How does utilization review work in Nevada workers’ comp cases?

Workers’ compensation insurers in Nevada may use “utilization review boards” (UR) to look over your proposed medical treatment plan following a work injury. Depending on what the board says, the workers’ comp insurer can then either:

• accept,
• modify, or
• deny

your treating physician’s requests for authorization (RFA).¹

In practice, URs tend to either pare down your treatment plan so that it is less expensive for the insurer. Even though the physicians on the UR board have never met you in person, they can override all your doctor’s recommendations based on a quick review.

How long does the process take?

After you submit your workers’ comp claim, the insurer has 30 days to conduct a utilization review and give you a decision. You will be notified of their decision by mail or (if requested) by email.²

Can I appeal?

Yes, you have 70 days to appeal when your employer’s workers’ comp insurer denies you coverage or approves insufficient coverage. If both you and the workers’ comp insurer agree, an “independent review organization” can review your proposed treatment plan.

In Nevada, independent review organizations have five business days after a request to:

• review all the documents and materials submitted; and
• notify you, your employer, and the insurer whether any additional information is necessary.

Once the organization receives all the information necessary, it has 15 days to make a decision. It must take into consideration the following three factors:

1. Your medical records;
2. Your treating physician’s recommendations; and
3. Any other information approved by the Nevada Commissioner of Insurance.

Once the board reaches a decision, it will send a copy of it to:

• you,
• your employer,
• the workers’ comp insurer, and
• the appeals officer.

Note that the decisions of the independent review organization are not binding. Also note that the workers’ comp insurer pays for all costs associated with the independent review organization.³

Can I go ahead with medical treatment during the appeals process?

If your workers’ compensation claim is denied, you would have to pay for any medical treatment you receive during the appeals process.

Then if you win the appeal, you could get reimbursed. But if you lose, you are responsible for the medical costs you incurred.

What people make up utilization review boards?

UR boards are typically comprised of:

• claims adjusters, and
• physicians

What medical treatment can I ask for?

Depending on your injuries and your doctor’s recommendations, you can seek workers’ compensation coverage to pay for:

• outpatient doctor’s visits,
• surgery,
• hospital stays,
• stays at rehabilitation hospitals or skilled nursing facilities,
• home health care,
• prescription and over-the-counter medications,
• physical therapy,
• medical equipment, and
• mileage reimbursement for driving to and from treatment.

In addition to medical treatment, you can also seek temporary– or permanent disability payments as well as vocational rehabilitation.⁴

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