Injured workers often have difficulty getting treatment within the workers' compensation system. This guide offers an overview of the process by which medical treatment is, or is not, authorized.
What is Utilization Review and is it legal?
In 2012, the California State Legislature passed and Governor Jerry Brown signed into law Senate Bill 863 (SB 863). These new laws took effect for all injured workers on 7/01/13. Under the new laws, a workers' compensation treating physician is required to submit any proposed treatment on a Request for Authorization (RFA form). The RFA form must be accompanied with a narrative report explaining why the treatment is reasonable and necessary. Upon receipt of the RFA, the adjuster has 5 days to authorize or he/she can submit to Utilization Review (UR). UR is a process where a doctor is supposed to review the relevant medical records and decide if the treatment your doctor is recommending is reasonable and necessary under evidence based guidelines such as the Medical Treatment Utilization Schedule (MTUS).
How do I appeal a Utilization Review Decision?
If UR denies or modifies the treatment, you should be mailed that UR decision along with an Application for Independent Medical Review (IMR) within 2 days and the decision should be conveyed to your treating physician within 24 hours. To appeal a UR denial or modification, you file with Maximus the signed/dated IMR application either by fax or mail along with a full copy of the UR decision. I suggest sending the IMR application and UR via fax so you have a confirmation page showing how many pages were sent and when. IMR then reviews the UR decision and either upholds or overturns the UR physician's decision. This currently is your only appeal. An appeal to UR is time sensitive so you should submit the IMR application and the UR decision immediately as well as keep your fax confirmation showing your IMR Application and UR decision was faxed timely to start the IMR process.
What if the UR process is not being followed?
If the UR process above is not being done "timely," you can talk to your attorney or the Information and Assistance Officer at the Workers' Compensation Appeals Board (WCAB) about how to file for an Expedited Hearing and have a Workers' Compensation Judge review the matter. The injured worker has the burden of proving the UR process was not timely and the medical evidence shows the proposed treatment is reasonable and necessary. Whether or not a UR decision is timely depends upon whether the time frames of Labor Code section 4610 are met which include a decision or request for additional information within 5 days of the submission of the RFA form as well as timely notifications of the UR decision described in the preceding section. (Bodam v San Bernardino County (2014) 79 Cal.Comp.Cases 159).
What if my doctor says the treatment was denied but I never received a UR decision?
Often, injured workers complain the treatment their doctor is recommending is not being authorized. I advise my clients to ask the doctor, or his office, for: 1) the RFA, 2) the report that was submitted with the RFA, and 3) the fax confirmation showing when these materials were faxed to the claims adjuster. Many times, doctors will say the treatment was denied where in fact, the doctor failed to submit the necessary paperwork. Once an injured worker has documentation from the doctor's office showing their actually was a request for treatment submitted, it can then be determined if the UR process was timely.
What if treatment I need is not authorized by UR and IMR upholds the decision?
If the UR process above was followed timely, all you can do is follow the process and hope the treatment gets authorized through workers' comp. If the treatment you need is denied, you can use your private group health insurance and when they ask, is this a worker related injury, your answer is yes, but they are denying treatment.
How long is a UR decision binding?
Absent a change in circumstances, a UR decision is valid for 12 months. This means absent a documented change in your medical condition such as an updated diagnostic test, failure of conservative care, or some other change in circumstances, the adjuster does not need to review a new request for a previously denied treatment for a period of one year. Getting your treating physician to issue a new report documenting any change in circumstances is, again, difficult.
Does it help to write to the UR Physician asking for reconsideration?
Another avenue to get treatment authorized is the voluntary appeal process. Many UR vendors have a voluntary appeal process that allows the injured worker, the treating physician, and/or the injured worker's attorney to write to the UR physician requesting reconsideration. In my practice I have had some success in getting UR to authorize treatment that had previously been denied by providing medical reports that the adjuster had failed to send initially and/or writing an advocacy letter along with copies of medical studies showing why the treatment is necessary. Getting a treating physician to write an appeal letter is often difficult. Also the internal appeal process is voluntary and does not extend the injured worker's time to appeal to IMR.
What can I do to change this system?
Injured workers in California are currently stuck with what I believe is a broken system where treating physicians conduct a volume business in order to make a profit and despite this are required to deal with cumbersome red-tape just to get treatment authorized. Many doctors are now refusing to accept workers' comp cases. Legal challenges to the UR process and SB863 have had little success. I do not foresee this system changing absent the California Legislature taking action. If you have been harmed by this system or are outraged by it, please write to your State Legislators and explain how unfairly injured workers are being treated post SB 863. In this letter, ask for laws that allow injured workers to get the medical treatment they need. The insurance companies and major self-insured companies have fooled the public into believing that injured workers were milking the system, and SB 863 is the end result.
I hope the information contained in this guide is helpful. This is information only and under no circumstances should be consider legal or political advice. Every case is different, including yours. If you need further assistance, try calling the attorney who handled your workers' comp case or the Information and Assistance Officer at the WCAB where your case is venued.
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