GO to Injured Worker Forum

Replying to Thread: UR Determinations as Substantial Evidence
Created On Wednesday 31, December, 2008 12:23 PM by spreare

New forums at: http://forums.workcompcentral.com

Remember my login

Forget your login information?


Posts: 91
Joined: Mar 2006

Wednesday December 31, 2008 12:23 PM

User is offline View thread in raw text format

I think it has been well established that when UR determinations are not timely, then they cannot be presented as substantial evidence. We agree on this, yes?

However, when UR determinations are timely, they are presentable as substantial evidence.. And we have seen that among claims professionals, even on this board, they are willing to challenge liens up to a higher level, defending on the basis of negative UR determinations..... For me, as someone with hundreds of un-paid, and thereofre liened treatment bills, a signigicant question is this: does the timely UR determination bare equal evidence against my reports and reccomendations for treatment? IE, when I go to argue why treatment was within ACOEM guidelines (that which was self-procured as timely denied by UR), are my reports, findings, reccomendations, etc, on an equal footing of those UR determinations non-certifying treatment?

Fortunately, few of my mailed out POS treatment recc's are timely responded to, but there are some that are timely that I am concerend about.



Posts: 53
Joined: Aug 2005

Monday January 05, 2009 10:41 AM

User is offline View thread in raw text format

IC will hang their hat on the UR determination as substantial evidence although most UR determiation are made with blinders and are generic in nature. UR determinations leave themselves quite open to rebutal. Substantial evidence is the key phraze. Who holds the better report or evidence? Is the entire medical record taken into account? How many pages were reviewed to make a determination?

You could strengthen your position and make your question obsolete by requesting a supplemental report from the QME commenting on necessity.

You might consider taking another look at UR determination and issue another report commenting further and put it back up for retro auth. I have had postive results in getting treatment authorized via retro auth. After the denied treament has been completed with several ptp reports in hand stating the positive outcome. Who knows maybe the IC will then approve it or maybe they will default by not responding within in the 30 days allowed for retro auth requests.


You are in message post mode [ FORUMS : THREADS ]

FuseTalk 3.0 - Copyright © 1999-2002 e-Zone Media Inc. All rights reserved.
© 2013 WorkCompCentral Workers Compensation Forums