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UTILIZATION REVIEW

Utilization review "means utilization review or utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, delay, or deny, based in whole or in part on medical necessity to cure and relieve, treatment recommendations by physicians, as defined in Section 3209.3, prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to Section 4600." Labor Code §4610(a).

SB 863 made some tweaks, including adding subsection (g)(6): "A utilization review decision to modify, delay, or deny a treatment recommendation shall remain effective for 12 months from the date of the decision without further action by the employer with regard to any further recommendation by the same physician for the same treatment unless the further recommendation is supported by a documented change in the facts material to the basis of the utilization review decision."

Subsection (g)(7) was added to restrict UR to accepted claims or body parts or conditions: "review of a treatment recommendation shall not be required while the employer is disputing liability for injury or treatment of the condition for which treatment is recommended pursuant to Section 4062."

In sum, the Utilization Review (UR) and Independent Medical Review (IMR) processes are for accepted claims. Treatment issues arising from denied claims must follow a different process (see Priority Conference and Liens).

To initiate UR, a doctor must submit a signed Request for Authorization (RFA) form. Under new 8 CCR §9792.1(a), use of the form is mandatory. Further definition is provided in §9792.6.1 (t):

"Request for authorization" means a written request for a specific course of proposed medical treatment. A request for authorization must be set forth on a “Request for Authorization for Medical Treatment (DWC Form RFA),” completed by a treating physician, as contained in California Code of Regulations, title 8, section 9785.5. “Completed,” for the purpose of this section and for purposes of investigations and penalties, means that information specific to the request has been provided by the requesting treating physician for all fields indicated on the DWC Form RFA. The form must be signed by the physician and may be mailed, faxed or emailed.

No longer can a Primary Treating Physician fill out a PR-2, mark a box at the top, and have made an effective RFA. Failure to follow the detailed instructions on the form and in the new regs can result in a delay, since the request will be deemed incomplete. The UR time period is not triggered until a complete RFA is received. Also, the instructions announce:

For requested medical treatment that is: (a) inconsistent with the Medical Treatment Utilization Schedule (MTUS) found at California Code of Regulations, title 8, section 9792.20, et seq.; or (b) for a condition or injury not addressed by the MTUS, include scientifically based evidence published in peer-reviewed, nationally recognized journals to recommend specific medical treatment or diagnostic services.

Will the Primary Treating Physicians take the time to do this, given the limited fees and rolls of red tape that increasingly complicate the workers' compensation system? Or will treatment recommendations be more "cookie cutter" oriented, with complicated cases getting neglected?

If the RFA is approved, the requested treatment then is available; if denied, delayed or modified, for injuries on or after 1/1/13, the next step is governed by the new Independent Medical Review (IMR) process. For all other injuries, UR denials, delays, or modifications on or after 7/1/13 go to IMR.

If the RFA is rejected because the employer is denying liability altogether, the injured worker needs to seek a priority conference. If the claim was accepted but a body part or condition is being disputed, the injured worker can proceed to an expedited hearing.

If UR is invalid because it is untimely, the worker can file for an expedited hearing as well as appeal to IMR. Note that failure to undertake utilization review or untimely UR does not relieve the injured worker from the burden of proving that the requested treatment is reasonably required to cure or relieve and is either presumed correct under the MTUS or that the presumption was rebutted (Labor Code §4604.5). See Dubon case below.

Label Item Links Comments
Labor Code Labor Code §4610  LC §4610   
Regulations/Rules Utilization Review Standards

Final regs
UR Regs

Final regs
 
Cases

State Compensation Ins. Fund v. WCAB (Sandhagen): "in light of the clear statutory language and the Legislature’s purpose in enacting the utilization review process in section 4610, we conclude the Legislature intended to require employers to conduct utilization review when considering employees’ requests for medical treatment. Employers may not use section 4062 as an alternative method for disputing employees’ treatment requests."

In the en banc decision Jose Dubon v. World Restoration, Inc.; and State Compensation Insurance Fund (2014), the Board held that If a defendant’s UR is found invalid because untimely, the issue of medical necessity is not subject to IMR but is to be determined by the WCAB based upon substantial medical evidence, with the employee having the burden of proving the treatment is reasonably required.

Sandhagen - Supreme Ct

 

 

 

 

 

Dubon v. World Restoration

Under SB 863, injured workers will likewise be precluded from using LC §4062 for disputing denials of treatment. See IMR
Forms Request for Authorization

UR Complaint Form (Note: If you want to save this form to your computer and email it to the DWC Medical Unit, you MUST use the Word version. The PDF version cannot be saved to your computer once filled)
RFA

Complaint form (pdf)

Complaint form (doc)
 
Websites DWC Utilization Review

Answers to frequently asked questions about utilization review (UR) for claims administrators
UR

FAQ
 
Practice Tips     
Articles
UR handout from DWC 20th annual educational conference 2/13 (pp. 1-4)

Ten Litigation Tips: handout from DWC 20th annual educational conference 2/13 (pp. 9-14)

Challenging Utilization Review at an Expedited Hearing by Mark Kahn (Associate Chief Judge, Retired)

UR and the Five Day Rules (Watch Out!) by Mark L. Kahn (Associate Chief Judge retired)

UR & IMR Regulations: handout from DWC 21st annual educational conference 2/14

UR changes post SB 863 pp. 1-4

Litigation tips pp. 9-14

 

UR at EH-Kahn

 

Kahn on UR & 5-day rule

 

UR & IMR Regs
 
Magazine Articles  
 
Roundtable    
Miscellaneous      

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