Recently, a DaisyBill client reached out with questions regarding automatic authorization. The source of the confusion was a slideshow presentation from the California Coalition on Workers’ Compensation (CCWC)’s 15th annual conference, held last July. The presentation contained no outright falsehoods, but used puzzling language and left out a key point regarding billing deadlines.

Tellingly, the conference was sponsored by Sedgwick, the third-party claims administrator. Given claims administrators’ interest in keeping providers in the dark regarding the new rules, we thought we’d clear up some confusion.

1. Different entities use different terms for automatic authorization.

Workers’ comp stakeholders and authorities have yet to agree on a catch-all term for the process by which providers can bypass prospective utilization review (UR).  It’s been variously described as “automatic authorization,” “fast-track UR,” and “UR exemption.” In their conference presentation, CCWC used the term “pass-through treatment.”

Neither CA Senate Bill 1160, which mandated automatic authorization, nor Labor Code Section 4610 (as amended by SB 1160) contain any specific term for treatments that meet the 6 qualifying conditions for automatic authorization. The regulations only refer to these treatments as “authorized without prospective utilization review.”

In this case, the semantics matter, if only so all stakeholders can get on the same page. While “treatment authorized without prospective utilization review” doesn’t earn points for brevity, it’s the only way the regulations describe it, leaving the rest of us to come up with snappier — if inconsistent — terminology.

2. RFA Required

One of the biggest incorrect assumptions about automatic authorization is that providers do not need to submit Requests for Authorization using DWC Form RFA when treatment is automatically authorized. It’s an understandable assumption, but also an incorrect assumption. The treatment is authorized automatically, so why should the provider bother requesting authorization?

However, the regulations still require providers to submit a compliant RFA for automatically authorized treatment, even though authorization is a foregone conclusion.

Providers must submit the RFA and Doctor’s First Report of Initial Injury or Illness within 5 days. The CCWC presentation emphasizes this, reminding the audience that  “the physician can be precluded from providing 'pass through' treatment for the employee whose Doctor's 1st report and RFA were not submitted within 5 days.”

That said, the claims administrator must treat the RFA, for all intents and purposes, as an approved retrospective RFA. The claims administrator has absolutely no say regarding the authorization’s approval. The claims administrator cannot modify, deny, or rescind automatic authorization.

The RFA is required, but it isn’t really a “request” in practice. So why require this largely ceremonial RFA?

Claims administrators may still conduct retrospective Utilization Review — not to approve, deny, or modify the requested treatment, but to check whether the treatment complies with the Medical Treatment Utilization Schedule (MTUS). This allows payors to deter abuse of automatic authorization by applying consequences like removing the provider from the MPN, or withdrawing their right to provide automatically authorized treatment.

3. Provider non-compliance is not grounds for denial of payment.

We’ve hammered this one home again and again, but it bears repeating. As they were sure to point out at the payor-sponsored CCWC conference, bill submission deadlines are much tighter. Providers have 30 days to submit bills for automatically authorized non-emergency services. For emergency treatment, the deadline is 180 days.

But for the love of workers’ comp, missing those deadlines does not preclude payment.

If the DWC creates new regulations that bar payment for untimeliness (as is the case with bills under the standard, non-automatic authorization rules), we’ll be the first to let readers know. Until then, claims administrators are not off the hook for payment unless the bill arrives a full year after the date of service. As it stands, only SB 1175’s 365-day deadline warrants non-payment if violated.

We hope this clears things up. Providers, stay compliant but know your rights. For a thorough, accurate primer on automatic authorization, see our 2018 Complete Guide to Automatic Authorization, and download our recent free webinar.

Dealing with the complexity of workers’ comp billing requires expertise and specialized technology. DaisyBill’s Billing Software takes the burden off providers, making authorization, billing, and appeals easier. Schedule a free demonstration today.

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