Access to Medical Records in Workers Compensation Utilization Review

Date: May 18, 2010
Posted In: DLP Law

The Pennsylvania Commonwealth Court has recently ruled that a medical provider\’s failure to provide a password to access medical records contained on a CD-ROM amounts to non-compliance with a medical records request and supports a finding that the treatment that was the subject of a Utilization Review (UR) was not reasonable or necessary. In Shaw v. WCAB (Melgrath Gasket Co.), the facts indicated that the employer filed a UR regarding medications prescribed for the Claimant, Mr. Shaw. The Workers Compensation Bureau assigned the UR request to a Utilization Review Organization (URO). The treating physician timely mailed a CD-ROM, purportedly containing Claimant’s medical records, to the URO but failed to either inform the URO of the encrypted password or provide directions on how the URO could gain access to the records. The Commonwealth Court ruled that the failure to provide the URO the password to the CD-ROM rendered the records contained on the CD-ROM useless since, without access to those records, the URO could not properly perform a records review. In essence, as the CD-ROM could not be accessed, the CD-ROM received by the URO was the equivalent of a blank CD-ROM. The Court acknowledged that there is no rule or regulation prohibiting the medical provider from sending the medical records on CD-ROM and that the provider did nothing improper by securing the contents of the CD-ROM by password. However, the Court concluded that the medical provider under review acted unreasonably by failing to inform the URO about how it could open the file. Despite being contacted by the UR, the provider did nothing; as such, the URO had no other option than to issue a determination finding the medical treatment unreasonable and unnecessary under 34 Pa.Code § 127.464 because of the medical provider\’s failure to mail medical records, in a useable form, to the URO.

Tom Cummings
Thomas P. Cummings has been a Partner with Dougherty Leventhal & Price, LLP since 1996 and has been with the firm since 1991. He focuses his practice on workers’ compensation, Social Security Disability and personal injury cases.