Access to quality healthcare is a necessary component of the Colorado workers’ compensation system. The most cost effective medical care for our injured workers is care that maximizes recovery and opportunities for return to work. While a number of disciplines are involved in the provision of quality care to our injured workers, an understanding of the treatment goals for this patient population is extremely important. At the same time, healthcare is a significant driver of the overall cost of workers’ compensation. As such, the workers’ compensation system cannot maintain access to quality care without being competitively priced.
The Colorado legislature incorporated several programs, which, taken as a whole, give the workers’ compensation system the tools to create a balance between reasonable cost and access to quality health care.
The cornerstones of the medical policy programs include:
- Medical Treatment Guidelines
- Medical Fee Schedule
- Utilization Standards / Medical Billing Dispute Resolution
- Physicians' Accreditation
These programs are designed to identify and enforce the appropriate medical services and number of treatments, control the costs of individual services, create administrative procedures that keep friction costs as low as possible, and educate health care providers to understand and effectively navigate Colorado's workers' compensation system.
Medical Utilization Review
Medical Utilization Review was established to reduce the costs of medical care and litigation. It provides a mechanism to review and remedy medical services that may not be reasonable and necessary. Enacted in 1988, it is a peer review program designed to evaluate a health care provider's treatment of an injured worker.
Any insurer, self-insured employer, or claimant may request a medical utilization review. Utilization review (UR) proceedings may result in a change of provider, a retroactive denial of fees charged by the provider, and/or a revocation of the provider's accreditation from the Division. The results of a UR proceeding are set forth in an order by the Director based on the recommendations of a panel of peer health care providers.
If you have questions, please contact Timiann at 303-318-8769 for more information.
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