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Workers' Compensation Medical Treatment Requests - Utilization Review

Utilization Review Overview

In California, medical treatment is one of the benefits that is allowed by workers’ compensation laws. Generally, when a worker is injured and the injury claim is accepted by the employer or employer’s insurance carrier, then medical treatment can be requested through a primary treating physician. In short, the injured worker selects a primary treating physician and then that doctor makes treatment requests (Request for Authorization) that the doctor feels are reasonably medically necessary. Generally, these treatment requests are submitted to the employer’s workers compensation insurance carrier and these treatment requests will go through what is called a utilization review.  Under the new law, if the utilization review denies the medical treatment requests by the injured worker’s primary treating physician, then the injured worker can appeal the decision to an independent medical review (IMR).  Independent medical review will be discussed next week. For this week, we will talk about utilization reviews. 

Utilization Review Process:

Utilization review (UR) is a program that employers or claims administrators are required to have for the purpose of reviewing whether treatment recommended by an injured workers’ physician is medically necessary. 

The UR time limit for responding to a treatment request begins when the Request For Authorization (RFA) is first received, whether by the employer, claims administrator or utilization review organization (URO). There are different rules for prospective, concurrent, retrospective reviews, and expedited reviews.

For UR reviews conducted before the medical service is rendered (prospective reviews), UR decision must be made within 5 business days from receipt of the request. If additional reasonable medical information is needed, then additional reasonable medical information must be requested by insurance carrier or employer by the 5th business day and notice must be sent. Then UR has 14 calendar days from the date of the receipt of the original RFA to  render a decision. If additional medical information is not received from the treating physician, then UR must either deny the RFA and state it will be considered when the information is received, or issue a notice of delay – within 14 calendar days of receipt of the original RFA.

Changes to Utilization Review Under New Law

Under Senate Bill 863, utilization review of a treatment recommendation is not required while the employer is disputing liability for injury or treatment of the condition for which treatment is recommended. Hence, the insurance company or employer may defer a UR decision of an RFA if it disputes liability for the occupational injury or liability of the recommended treatment itself for reasons other than medical necessity, within 5 days from receipt of the RFA by issuing a written decision deferring UR to the requesting physician, injured worker and injured workers’ attorney.

This means that for denied claims, utilization review can be deferred until liability is established because the employer is contesting liability. If liability is resolved, time for UR retrospective review begins on the date of employer’s liability and prospective review shall run from the date of employer’s receipt of a treatment request. 

Even for accepted claims, medical treatment disputes often arise from the question as to whether a certain treatment request made by the injured worker's physician is reasonably medically necessary. As discussed above, the insurance carrier or employer must have a UR program that processes medical treatment requests. If UR does not timely deny a treatment request, the denial is not valid. As such, if UR denies a treatment request, it is very important for the injured worker or injured workers' attorney to find out when the treatment request was received by the employer or their insurance carrier, and assess whether the decision to deny or defer was timely made. If the insurance carrier or employer denies receipt of the treatment request, then the proof of service accompanying the doctor's treatment request should be examined as to whether it can be used to create a presumption of service on a specific date. 

Joseph Lee