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July 12, 2016

Petitions to Review

If you are currently receiving workers’ compensation benefits, a Petition to Review Utilization Review, a Petition to Review Medical Treatment and/or Billing, or a Petition to Review Compensation Benefits may be filed in order for the Judge to clarify wording on documents previously issued or to make a decision about the payment of certain bills.  A Petition to Review may be filed by either you or your employer to clear up “gray areas” regarding your benefits.

Your employer can seek to have your medical treatment reviewed by another doctor to determine if the treatment is reasonable or necessary by filing a Request for Utilization Review: Initial Determination.  Your employer can also file a Petition to Review Utilization Review if it does not agree that your medical treatment is necessary and related to your work injury or a Petition to Review Compensation Benefits if it believes that you are not receiving the correct compensation amount.

Utilization Review

While the medical treatment related to your work injury is being paid by the workers’ compensation insurance company, it can request what is known as a Utilization Review through the Bureau of Workers’ Compensation. Through this process, any and all of the medical treatment you receive in relation to your work injury can be questioned by the insurance carrier at any time by way of this process. The insurance carrier will use this process to receive a determination as to whether the medical treatment for your work injury is reasonable and necessary. If it is determined that any or all of your medical treatment is no longer reasonable or necessary, the insurance company will, likewise, no longer be responsible for the medical treatment related to your work injury.

The insurance carrier can request a Utilization Review or schedule an Independent Medical Examination (IME) at any time and on an ongoing basis under the Pennsylvania Workers’ Compensation Act.

Impairment Rating Evaluation

For employees injured on or after June 24, 1996, the carrier will be entitled to schedule an impairment evaluation.  The doctor performing this evaluation will not be assessing the employee’s degree of disability.  The doctor will give the employee an impairment rating based entirely on the AMA Guides to Evaluation of permanent impairment.

The impairment evaluation is designed to determine the degree of impairment that remains as a result of the work injury.  The impairment is determined following the evaluation by a board certified physician.  The physician must be licensed in the Commonwealth of Pennsylvania and maintain an active clinical practice for at least twenty (20) hours per week.  The physician will be selected by agreement of the parties. However, if an agreement cannot be reached, a physician will be designated by the Department of Labor to perform the evaluation.

Following the impairment evaluation, if the employee’s impairment is found to be equal or greater than 50%, the employee is presumed to be totally disabled and can continue to collect total disability benefits.  However, if the impairment rating is less than 50%, the employee is presumed to be partially disabled.

Petitions to Modify, Terminate or Suspends Benefits

As soon as you begin to receive workers’ compensation benefits, and at any time thereafter, your employer may file a Petition to Terminate, Petition to Suspend or Petition to Modify your benefits. Employers generally file one of these petitions:

  • if any doctor says that you are able to return to work and you refuse to return to work.
  • if you return to work but do not complete the proper paperwork.
  • if your employer believes that you are completely recovered.
  • if your employer believes that you can return to work at your old job at the same or greater pay level, but that you still have medical problems from your injury.
  • if your employer believes that you can return to work at light duty or at an easier job which pays you less money than your old job.

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