Adjusters and nurse case managers frequently rely upon The Montana Utilization and Treatment Guidelines. More troubling is that the adjusters and nurse case managers, use the Guidelines to prevent a medical provider from pursuing treatment options.
The adjuster will try to manage your medical treatment using the Montana Utilization and Treatment Guidelines. During your healing period, the adjuster will expect the doctor to follow Montana’s Utilization and Treatment Guidelines (“U &T” Guidelines). Most doctors do so without question. They do so because they often rely upon a nurse case manager to learn what they can and can’t do in terms of treatment. In that regard, your doctor is failing you. Any statement by the adjuster or nurse case manager that the guidelines are mandatory or are “the law” is simply false.
The Utilization and Treatment Guidelines were put together by the Montana Department of Labor and Industry to make sure that claimants with similar conditions get similar treatment. The Guidelines also put limits on certain types of treatment like chiropractic care, acupuncture, and massage. According to the Administrative Rules of Montana, the purpose of the Guidelines is to assist injured workers in receiving prompt and appropriate care, assist injured workers in stay-at-work/return-to-work options, assist clinicians in making decisions for specific conditions, and help insurers make reimbursement determinations. Although the primary purpose of the guidelines is advisory and educational, the guidelines are enforceable for payment purposes.
The Guidelines require specific documents and dictate when certain procedures can happen. The focus is often on whether the treatment is effective or not. The effectiveness of the treatment is measured by much your physical function improves. They are also supposed to speed up treatment by allowing the doctor to go ahead and treat without asking authorization so long as the treatment is within the Guidelines. They are simply guidelines, and doctors are not required to follow the Guidelines.
Also, the Guidelines may function differently for older cases, and many adjusters don’t understand how to apply them properly. The Guidelines apply to all medical services provided on or after July 1, 2011. The Guidelines establish a presumption of compensability for injuries and occupational diseases occurring on or after July 1, 2007. For injury / occupational disease claims occurring on or before June 30, 2007, treatment in accordance with the guidelines constitutes reasonable primary or secondary medical treatment. That means if it is in the Guidelines, you can meet your burden of showing that the recommended treatment is “reasonable and necessary” just by pointing to the Guidelines.
If your doctor recommends a treatment that is outside the Guidelines and can justify it as reasonable and necessary, it can still happen. But it requires your doctor to put his opinion in writing and seek authorization. You may even need to mediate the issue if the adjuster doesn’t agree. The Guidelines are NOT the law. Most doctors do not realize these are not black and white rules.
“Reasonable and necessary” are the keywords.
If you want to read the actual Montana Utilization and Treatment Guidelines, you can find them at http://mtguidelines.com. If you want to learn more about the Guidelines and the Montana workers’ compensation system, you can download our free book, Hurt at Work: An Insider’s Guide to Understanding your Montana Work Comp Claim” by going to the main page of our website: https://mtworkcomplawyer.com.
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