Denied by Design: Navigating the Access to Workers’ Compensation Care in Chicago

Workers’ compensation (WC) was introduced as a no-fault system to provide injured workers with timely access to medical treatment and compensation for lost wages. When the treating physicians submit a care request to the third party insurer, these requests are often subjected to a utilization review process. Utilization Review (UR) is the process of comparing an injured worker’s case to evidence-based clinical guidelines that outline national standards for a patient with similar symptoms as the one being reviewed. UR often results in a delay or denial of treatment and access to care. Analyzing these disparities can help improve patients' access to appropriate and necessary medical care. A retrospective case series was utilized to analyze existing treatment plans of multiple patients subjected to the UR process. Consent was obtained from an orthopedic private practice located in the Greater Chicago Area to review a series of anonymous WC patient histories. Between January 1, 2024, to December 1, 2024, a total of 42 WC patients were subjected to the UR process. For each patient, their insurer, type of requested treatment, and dates of each UR denial were tracked. Then, the frequency of the total number of UR repeat submissions, total denials, and total approvals pertaining to each requested treatment type was collected. The analyzed requested treatments included the following: pharmacy, physical therapy, surgical, and durable medical equipment. The results displayed that 93.75% of the 42 patients’ UR submissions were denied with these patients facing a longer wait time of 124 days and more frequent UR resubmissions.