Getting the Medical Treatment You Deserve: Understanding Medical Benefits and Utilization Review in Massachusetts Workers' Compensation Claims

If you’ve been injured on the job in Massachusetts, you have the right to receive reasonable and necessary medical treatment for your work-related injuries. However, navigating the workers’ compensation system and obtaining the care you need is rarely straightforward. Insurance companies in Massachusetts use what is often considered a complex process called “utilization review” to control and sometimes limit the medical treatment injured workers receive.

Understanding this process and knowing when you need the help of an experienced workers’ compensation attorney can make the difference between getting the treatment you deserve and being denied the care you need to recover. If you or a loved one is being denied medical treatment for a work-related injury, you do not have to accept that decision or endure the consequences alone. Experienced Framingham workers’ compensation attorney Chuck Pappas is prepared to evaluate your claim, protect your rights, and pursue the full medical benefits to which you are entitled under Massachusetts law.

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What Are Medical Benefits in Massachusetts Workers’ Compensation?

Under Massachusetts law, if you suffer a work-related injury or illness, your employer’s workers’ compensation insurance must provide you with reasonable, necessary, and appropriate medical care. This includes:

• Doctor visits and consultations
• Hospital care and emergency treatment
• Physical therapy and rehabilitation
• Prescription medications
• Medical equipment and supplies
• Necessary surgeries and procedures
• Diagnostic tests and imaging

The law is clear: you should not have to pay out of pocket for medical care related to your work injury. However, insurance companies frequently deny medical treatment and create obstacles to receiving this care through a process called utilization review.

What Is Utilization Review and How Does It Affect You?

Utilization review is a legal oversight process in Massachusetts designed, in theory, to help ensure that the medical services, treatments, prescriptions, and other related medical care provided to an injured worker meets the statutory requirement of being reasonable, necessary, and appropriate. However, in practice, it often becomes a tool for insurance companies to delay, deny, or limit the medical treatment recommended by your own doctors.

How Utilization Review Works

After you’ve been injured at work and the insurance company begins paying benefits, they must send you a utilization review card. This card contains critical information you’ll need whenever you seek medical treatment:

• Your name and identification number
• The name and phone number of the utilization review agent
• The name of the insurance company

Here’s the catch: before you can receive most medical treatments (except emergencies), your doctor must contact the utilization review agent and get approval. This applies to everything from physical therapy sessions to specialist consultations to necessary surgeries.

When Insurance Companies Can Deny Your Treatment

The utilization review process gives insurance companies multiple opportunities to deny or delay the medical care your doctor recommends. The insurance company’s utilization review agent will review your doctor’s treatment request and determine whether it meets their guidelines. If they decide it doesn’t, they can issue an “adverse determination” denying authorization for the treatment.

The Hidden Problems with Utilization Review

Several troubling aspects of the utilization review process put injured workers at a significant disadvantage:

1. The Doctor Reviewing Your Case May Not Be a Specialist

Massachusetts regulations only require that adverse determinations be made by a practitioner from the same “school” as your treating doctor – meaning they must have the same type of degree (MD, DO, etc.), but not necessarily the same specialty. This means a general practitioner working for the insurance company could deny treatment recommended by a specialist who treats your specific condition every day.

For example, if a hand surgeon recommends a specific surgical procedure for your work-related hand injury, the insurance company’s utilization review could be conducted by any medical doctor, even one with no specialized training in hand surgery. This doctor may rely on general treatment guidelines rather than understanding the nuances of your specific condition.

2. Insurance Companies Use Treatment Guidelines to Deny Care

The Massachusetts Department of Industrial Accidents has adopted 28 treatment guidelines that utilization review agents must consider. While these guidelines are based on medical evidence, they’re not meant to be rigid rules that apply to every patient. Every injured worker’s situation is unique, and your doctor should have the flexibility to recommend treatment that’s right for your specific needs.

However, insurance companies often use these guidelines as a reason to deny any treatment that doesn’t fit perfectly within them, even when your doctor believes the treatment is medically necessary. What the insurance company won’t tell you is that Massachusetts law specifically recognizes that reasonable and adequate medical care can include treatment outside these guidelines.

3. Approval Doesn’t Guarantee Payment

Even if the utilization review agent approves your treatment, that doesn’t mean the insurance company will actually pay for it. This is one of the most frustrating aspects of the system. The utilization review process only determines whether the treatment meets medical necessity guidelines—it doesn’t resolve questions about whether the insurance company accepts liability for your injury or whether your condition is work-related.

Insurance companies frequently deny payment for approved treatments by claiming the injury isn’t work-related or that they’re contesting liability. This leaves injured workers in an impossible position: your doctor says you need treatment, the utilization review agent says the treatment is medically necessary, but the insurance company still won’t pay.

4. You Could Be Held Financially Responsible

This is crucial to understand: if you receive medical treatment after the insurance company has issued an adverse determination denying that treatment, you may be held personally liable for the cost. This means you could receive a bill for thousands of dollars for physical therapy or other treatments that your doctor recommended.

This threat of personal financial liability is one of the most effective tools insurance companies have to discourage injured workers from pursuing the medical care they need. Many injured workers simply cannot afford to risk being stuck with these bills, so they forgo necessary treatment.

What Happens When Treatment Is Denied

If the utilization review agent denies authorization for your treatment, they must send you an adverse determination letter. This letter should include:

• The treatment guideline used in making the decision
• The reason for denying the treatment
• Instructions for appealing the decision

Your Appeal Rights

You have the right to appeal an adverse determination, but the process is complicated and time-sensitive:

• For prospective or concurrent denials: You or your doctor can initiate an expedited appeal by phone, with the right to speak with a medical professional from the same school as your doctor. The utilization review agent must render a decision within two business days.
• For retrospective denials: The appeal must be made in writing within 30 days, and the decision must be made within 20 days.

If you’re unsuccessful in the utilization review appeal process, you can file a claim with the Department of Industrial Accidents. However, navigating this process without legal representation puts you at a severe disadvantage.

Why You Need an Experienced Workers’ Compensation Attorney

The utilization review process is intentionally complex, and insurance companies have teams of adjusters, nurses, and lawyers working to minimize what they pay out in medical benefits. Without an attorney who understands this system, you’re fighting an uphill battle. Here’s how an experienced workers’ compensation lawyer can help:

1. Holding Insurance Companies Accountable to Procedural Requirements

The insurance company must follow strict procedural rules throughout the utilization review process. If they fail to comply, they may lose their right to deny your medical claims. An attorney knows what to look for:

• Did the insurance company send you a utilization review card? If they didn’t, they may be barred from using utilization review as a defense against your medical claims.
• Did they meet the required timeframes? Delays in issuing determinations can work in your favor if properly challenged.
• Did they maintain proper phone access? The insurance company must provide toll-free phone access during business hours and have a system for after-hours calls.
• Is their utilization review program properly approved? If the insurer performs its own utilization review, the program must be approved by the Office of Health Policy.

The burden of proving compliance with these requirements falls on the insurance company. An experienced attorney knows how to challenge the insurer’s compliance and use any procedural failures to your advantage.

2. Fighting Denials Based on Liability or Causation

As mentioned earlier, insurance companies often approve treatment through utilization review but then refuse to pay by claiming the injury isn’t work-related or they’re contesting liability. This is a separate battle from the utilization review process, and it requires legal expertise to win.

An attorney can file a claim with the Department of Industrial Accidents and present evidence proving that your injury is work-related and that the disputed treatment is causally connected to your industrial accident. This often involves obtaining medical expert opinions, gathering workplace evidence, and presenting a compelling legal argument.

3. Navigating the Appeals Process Effectively

If your treatment has been denied, time is of the essence. The appeal deadlines are strict, and missing them could mean losing your right to challenge the denial. An experienced attorney can:

• Immediately initiate expedited appeals when appropriate
• Work directly with your treating physicians to provide the utilization review agent with the most compelling medical evidence
• Present arguments about why the treatment guidelines should be interpreted to support your care
• Escalate to the Department of Industrial Accidents when utilization review appeals are unsuccessful

4. Protecting You from Personal Financial Liability

One of the most valuable services an attorney provides is protecting you from being stuck with medical bills. When you have legal representation:

• Your attorney can negotiate with medical providers to delay billing while your case is being resolved
• Many medical providers understand the workers’ compensation system and are willing to work with attorneys they trust
• If you ultimately win your case, the insurance company must pay the medical bills—you won’t be left holding them
• Your attorney can advise you on whether it’s worth the risk to proceed with treatment that’s been denied

5. Leveraging Utilization Review Approval in Litigation

When the utilization review agent has approved treatment but the insurance company refuses to pay, an attorney can use that approval as powerful evidence in litigation. While the insurance company will argue that liability and causation are separate issues, the fact that their own medical reviewer found the treatment medically necessary and reasonable carries significant weight with administrative judges.

6. Understanding the Nuances of Treatment Guidelines

Massachusetts law recognizes that treatment guidelines are not absolute rules. The regulations specifically state that the guidelines “should not be construed as including all proper methods of care reasonably directed to obtaining the same results.” An experienced attorney knows how to argue that your doctor’s recommended treatment, even if it falls outside the standard guidelines, is reasonable and necessary for your unique situation.

Red Flags That You Need Legal Help Immediately

You should consult with a workers’ compensation attorney as soon as possible if any of the following occur:

• The insurance company denies a treatment your doctor says you need
• You receive an adverse determination letter from a utilization review agent
• The insurance company approves treatment through utilization review but refuses to pay for it
• You’re being threatened with personal liability for medical bills
• The insurance company is delaying decisions on treatment requests beyond the required timeframes
• You never received a utilization review card after benefits began
• A general practitioner working for the insurance company has denied treatment recommended by your specialist
• The insurance company contests whether your injury is work-related
• You’re confused about the utilization review process or your rights

The sooner you get legal representation, the better your chances of obtaining the medical care you need. Many of the procedural requirements and deadlines work against injured workers who try to navigate the system alone.

The First 12 Weeks: A Critical Window

It’s important to understand that Massachusetts law requires utilization review for all medical treatment provided after 12 weeks from the date of injury. During the first 12 weeks, the insurance company may choose whether to conduct utilization review, but they must do so before denying any request for medical services.

This 12-week period is crucial. If the insurance company doesn’t properly initiate utilization review during this time but then tries to deny treatment, they may have waived their right to use utilization review as a basis for denial. An attorney can identify these situations and use them to your advantage.

Your Right to Choose Your Doctor

While utilization review controls which treatments are approved, it’s worth knowing that you generally have the right to choose your own treating physician under Massachusetts workers’ compensation law. The insurance company cannot force you to see their doctor for treatment, although they can require you to attend independent medical examinations.

Having a doctor you trust who is willing to advocate for the treatment you need is essential. Your attorney can help ensure that your doctor provides the utilization review agent with comprehensive medical documentation supporting the recommended treatment.

Don’t Let the Insurance Company Dictate Your Recovery

The utilization review process is designed to control costs for insurance companies, not to ensure you get the best possible medical care. While the regulations exist to prevent unnecessary treatment, in practice, they’re often used to create barriers to the care you legitimately need.

Remember these key points:

• You have the right to necessary medical treatment for your work-related injury
• The insurance company must follow strict procedural rules in conducting utilization review
• Treatment can be reasonable and necessary even if it falls outside standard guidelines
• You have appeal rights when treatment is denied
• An experienced attorney can level the playing field against insurance company tactics

Get the Help You Deserve

If you’ve been injured at work and are facing challenges getting the medical treatment you need, don’t try to navigate the utilization review process alone. The system is complex, the stakes are high, and the insurance company has professionals working to minimize what they pay.

An experienced Massachusetts workers’ compensation attorney can protect your rights, hold the insurance company accountable, and fight to ensure you receive the medical care necessary for your recovery. Most workers’ compensation attorneys work on a contingency basis, meaning you don’t pay attorney fees unless you win your case.

The sooner you have an experienced attorney on your side, the better your chances of getting the full benefits you deserve. Reach out to Chuck Pappas by calling (508) 879-3500 or contact him online now and take the first step toward securing your financial future while you heal.

Your health and recovery are too important to leave to chance. Get experienced legal representation on your side and focus on what matters most – getting better.