The following findings are from the Medical Necessity Dispute Resolution Trends 2014-2020:
- From January 2014 to December 2020, health care providers and injured employees filed a total of 13,210 medical necessity disputes.
- About 550 health care providers submitted 80% of these disputes.
- Medical necessity disputes have declined since 2005, with the trend continuing in recent years.
- From 2014 to 2020, the number of medical disputes received by DWC declined from 2,826 to 1,357, which is an approximate 52% reduction.
- A DWC report credits fewer compensation claims filed, the adoption of health care networks in 2006, and DWC’s adoption of evidence-based treatment guidelines in 2007 as factors in the decline.
- Although almost half of new workers’ compensation claims are treated in networks, network medical necessity disputes are less frequent in network (16% in 2020).
- 9 out of 10 medical necessity disputes in recent years were associated with preauthorization denials.
- In 2020, about 70% of disputes involving network claims and 79% of disputes involving non-network claims upheld the insurance carrier’s utilization review decision.
- Most medical necessity disputes were resolved between 18 and 20 days.
