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Why the RFA System Is Broken

August 4, 2017 by Catherine Montgomery

California-State-Capitol-buildingjpg.jpgEvery day, we hear from frustrated providers across California who are struggling with their Requests for Authorization (RFAs). Their RFAs take too long to submit, and often go unresponded to, or are contingent upon MPN membership (which is against the rules). Here’s how we see it: The RFA system in workers’ comp is bad for medical providers, plain and simple. By extension, it’s bad for injured employees, too.

One look at the convoluted mechanics of the current RFA process backs this up. Prior to providing care to an injured employee, the treating physician must first receive authorization from the employer’s utilization review company. To request authorization, the physician must complete and submit a long and tedious form including pages of supporting documentation. That form is forwarded to the employer’s utilization review company. Meanwhile, the physician – and their injured worker patient – are forced to wait (and wait) for a response.

This goes for any treatment. Every single prescription, x-ray, injection, splint, blood test or surgery is subject to this arduous process. If a physician fails to obtain the mandatory authorization, no payment is due for any treatment provided to the injured employee.

True, an exception exists for emergency treatment. In these special cases, the physician must receive authorization after providing the emergency care. But even then, the care is subject to denial by the employer’s utilization review. In which case, the employer would owe no money for the urgent care rendered to their injured employee.

Bearing this in mind, it’s easy to see that the premise of California’s workers' comp system is inherently flawed: The employer, who caused the injury, is also allowed to decide whether to pay for care. This sets up an impossible conflict of interest. In order to believe that the current system is working – or indeed fair on any level – one must trust that every employer’s moral conscience outweighs their interest in their own financial stakes.

To make matters worse, the utilization review entities hired by employers to decide whether to pay for medical treatment are typically private firms with no direct knowledge of the case in question. These companies are often hired based on the frequency with which they deny treatment. (And even when treatment is authorized, dozens of other complications may arise to add friction to the system – we’ll explore more of these in the weeks ahead.)

It’s no wonder that so many providers across the state voluntarily check out of the workers’ comp system. Would you stay in a job that seems designed to prevent you from helping people in need?


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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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