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2018 Authorization/Utilization Review: Major Changes Effective 1/1/2018

December 1, 2017 by Catherine Montgomery

Senate Bill 1160 makes significant changes to the authorization and utilization review (UR) process starting in 2018. New “fast-track” UR takes effect on January 1.

Fast-track UR bypasses prospective utilization review by automatically approves the required treatment in many — but not all — circumstances. A set of specific conditions must exist in order for providers to bypass the usual UR process. The new process also changes the rules regarding authorization and billing for these encounters.

DaisyBill will host a webinar[a] on fast-track UR on January 23.

SB 1160 replaces Labor Code § 4610 in its current form with a new, revised § 4610, effective January 1, 2018. While much of the new § 4610 mirrors the current version, there are some big changes, including fast-track UR. As the new Labor Code states:

“Emergency treatment services and medical treatment...Shall be authorized without prospective utilization review.”

This new, “automatic” authorization looks like a boon to providers and patients at first glance. But like much else in workers’ comp, there’s more to the story. Complicated qualifiers, billing changes, and some mystery surrounding the Division of Workers’ Compensation (DWC)’s plans (or lack thereof) for promulgating new regulations muddy the waters.

What we know so far, and will cover in our comprehensive webinar, includes:

  • The 6 required conditions for fast-track UR
  • Requirements for the timing of treatment
  • Treatments that do/do not qualify for fast-track UR
  • Authorization requirements (it’s not quite “automatic”)
  • New, shorter billing deadlines

As of this writing, the DWC has not yet promulgated new regulations regarding fast-track UR, though the Division reserves the right to do so. Our webinar will include the latest updates, right up to the day itself.

In the weeks to come, in this blog we’ll discuss in detail the circumstances under which this new authorization process applies, how to apply it, and what providers can expect as a result. Meanwhile, we strongly encourage readers to sign up for our webinar[b]. On January 23rd, we’ll make sure that all attendees know everything there is to know about  this new twist in the work comp world.

CTA[c]

  1. Highlighted here, the new Labor Code 4610 states: “Emergency treatment services and medical treatment,” and at the bottom: “Shall be authorized without prospective utilization review.”
  2. In other words, effective January 1st, 2018, when the required conditions are true, treatment is automatically approved and does not require a utilization review decision.
  3. Automatic authorization only applies when all of the six conditions listed here are true.

  1. First, automatic authorization only applies to dates of injury on or after January 1, 2018.
  2. Second, automatic authorization only applies to treatments provided within the first 30 days of the injury. Automatic authorization does not apply to treatment rendered on or after day 31 of the injury.
  3. Third automatic, authorization is only allowed for accepted body parts or conditions. It does not apply if liability is a contested.
  4. Fourth, automatic authorization applies only when the treatment is addressed by California’s medical treatment utilization schedule, also known as the MTUS.
  5. Fifth, automatic  authorization applies only for MPN physicians or predesignated physicians.
  6. 6th, automatic authorization is not allowed for treatment listed in subdivision (c) of the new labor code 4610.

        In other words, Subdivision (c) lists treatment that is ALWAYS requires prospective utilization review. The treatment listed in subdivision (c) cannot be automatically authorized. This treatment includes some pharmaceuticals, nonemergency inpatient and outpatient surgery, psychological treatment, home health care….

Imaging and radiology services, excluding x-rays, DME exceeding $250 in value, electrodiagnostic medicine, and any other services designated by the administrative director.

  1. In a DWC Newsline, the DWC announced the passage of SB 1160 and stated, “SB 1160 reduces most utilization review in the first 30 days following a work-related injury.”
  2. The new Labor Code 4610 passed by SB 1160 only reduces prospective utilization review when all of these six required conditions are true. But, there’s a hitch, which I’ll discuss in a second.
  3. Now here’s the hitch for treatment that’s been automatically authorized -- a provider must submit a completed Request For Authorization within 5 days from the date of service. In other words, even though physicians are not required to submit a Prospective RFA BEFORE treatment, they must submit it after the treatment.
  4. To clarify, the new Labor Code 4610 does NOT eliminate the physician requirement to submit a completed request for authorization. In effect, it just shifts the timing of the RFA for automatically authorized services.
  5. In addition to the requirements to timely submit the DLSR and RFA, the new Labor Code 4610 requires the provider to submit the bill for services within 30 days of providing any treatment that is automatically authorized. This is a different deadline than the 12 month deadline for other workers’ comp bills that will took effect this year.

[a]I hate linking above the fold, but if it gets registrants...

[b]link

[c]No "below the fold" for this one. Let's just be honest about pushing the webinar.

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