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What’s New for Workers’ Comp in 2018: CA Senate Bill 1160

February 9, 2018 by Catherine Montgomery

CA Senate Bill 1160In 2016 California passed Senate Bill 1160, which heralded significant workers’ compensation reform. SB 1160 outlined major changes to authorization, utilization review, lien filing, billing deadlines, and more. Some changes took effect in 2017, while others are newly effective, as of January 1 this year.

Let’s take a look at the major changes SB 1160 brings to workers’ comp in 2018.

Authorization and Utilization Review

First and foremost, SB 1160 radically altered the RFA and UR processes by adding a streamlined “automatic” authorization for certain treatments under certain conditions. We’ve discussed those conditions and new submission timeframes at length on our blog and in our recent webinar. Entities conducting UR for all treatments are also subject to new requirements.

The changes are outlined in the new Labor Code Section 4610. SB 1160 repealed the previous § 4610 and replaced it with the current version, effective January 1.

Automatic Authorization
Rule/Procedure 2017 2018
Submit RFA Provider submits RFA for prospective utilization review before providing treatment. Treatments that meet 6 required conditions are automatically authorized. Provider submits RFA within 5 days of providing “automatically” authorized service.
Submit Original Bill Provider submits original bill within 12 months of date of service Provider submits original bill for automatically authorized services within 30 days of date of service for non-emergency treatment, or 180 days for emergency treatment (12 month deadline remains for non-automatically authorized services)
Utilization Review

Rule/Procedure

2017   

2018

Utilization Review Accreditation

No accreditation for UR entities or processes

Processes may be internal and undisclosed

Entities accredited and held to specific standards regarding timeliness, “medical material” used, and rules against financial incentives

Processes must be disclosed to employees, physicians, and the public

Financial incentives for UR decisions

Financial rewards for modify/deny decisions permissible

Financial rewards for modify/deny decisions barred

Financial relationships with entities conducting UR

Insurers and TPAs may refer UR to entities in which they have undisclosed financial interest

Insurers and TPA’s may only refer UR to entities in which they have financial interest after providing full written disclosure to the employer and the DWC Administrative Director

Independent Medical Review (IMR)

The official approval and adoption of an evidence-based drug formulary per Assembly Bill 1124 also affects the new rules under SB 1160. Previously, an injured worker could challenge a UR decision by filing for Independent Medical Review (IMR) within 30 days of receipt (providers may assist in this process, but only the patient can initiate the dispute).

Now, disputes regarding authorization for medication are subject to the drug formulary, and injured workers face tighter deadlines for requesting IMR..

Rule/Procedure

2017  

2018

Disputes regarding medical necessity of drugs

Injured workers must file for IMR within 30 days of receiving UR decision for all treatments

IMR within 10 days of receiving modify or deny UR decisions for drugs

UR and IMR decisions subject to drug formulary per MTUS

Denied Claims

SB 1160 also required the DWC to adopt rules for when an employer denies an employee’s workers’ compensation claim. Following denial, the employer must provide notice of the employee’s right to access medical treatment outside the worker’s comp system.

The notice must contain a DWC-approved statement outlining employee rights, found in California Code of Regulations (CCR) § 9812. Some (including ourselves here at DaisyBill) found the proposed required language unclear and potentially misleading, in spite of its stated aims.

Rule/Procedure

2017

2018

Denied Claim

No notice required

Following denial of a claim, the employer must issue notice of the employee’s right to seek treatment outside the workers’ comp system, worded per CCR § 9812

Interpreter Services

2018 brings new rules regarding the credentials and payment of language interpreters. SB 1160 standardizes payment and credentialing, while clarifying where the responsibility to reimburse interpreters falls.

Rule/Procedure

2017

2018

Interpreter credentials and identification No DWC- established credentials for interpreters DWC Administrative Director establishes criteria for interpreter credentials and identification.

Attorney Fees

The DWC Administrative Director is now empowered to determine a range of fees employers or insurers must pay to cover the cost of attorneys for deponents in appeals board cases, the specific fee in each case to be determined by the appeals board itself.

Rule/Procedure  2017   2018

Attorney fees for deponents in WCAB cases

No provision for determining acceptable range of attorney fees

DWC Administrative Director determines range of reasonable fees for deponent’s attorney. 


DaisyBill offers a full suite of cloud-based billing software to help providers easily obtain the correct reimbursement. Schedule a free demonstration today, and see how DaisyBill can improve your bottom line.

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DaisyBill is a trusted authority on workers’ comp billing. Thousands of work comp professionals attend our webinars and state agencies and professional organizations turn to us for our expertise. We created this blog to help everyone involved in workers’ compensation; sharing news, tips, and data of interest to the community.

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