What’s the most absurd, bureaucratic, procedurally abusive excuse a claims administrator ever used to deny care to an injured worker?

We’ve seen our share of bad-faith denials—but Affirmative Risk Management (also known as Prime Administrators) may have just set a new bar for audacity.

A California provider faxed Affirmative a Request for Authorization (RFA) form requesting physical therapy and other care for an injured worker. The Third-Party Administrator (TPA) denied the care…because the RFA form listed Affirmative’s mailing address incorrectly.

The RFA was faxed, not mailed, and the required medical information was complete. Nevertheless, Affirmative denied the care—not because the requested treatment was unnecessary or excessive, but because the printed address was incorrect.

Affirmative didn’t pretend to comply with California UR laws and regulations that require denials to be issued by a physician qualified to evaluate the specific clinical issues. Instead, they invoked a bogus technicality to avoid care recommended by a treating physician.

This kind of care denial has nothing to do with medicine. This is a TPA non-compliantly exploiting a technicality to impose pointless, punitive administrative friction on a provider—potentially impeding a patient’s recovery.

Is it any wonder California workers’ comp takes twice as long to close claims as the national average, at twice the cost, and that physicians are fleeing the system, sick of wasting time and energy fighting this kind of red tape?

We’ve said it before: California’s UR system is functionally broken and morally bankrupt. But frankly, no amount of reporting can make the case as clearly as Affirmative just did.

Weaponized Bureaucracy, Not Medical Review

The RFA form below shows that the provider spent considerable administrative resources to complete a request for physical therapy and other measures to address an injured worker’s back issues.

The provider submitted the RFA via fax, using the correct fax number for Affirmative (as we can tell by the fact that Affirmative received it). But instead of conducting UR (as required by California law) to determine whether the treatments on the RFA were appropriate for the injury, Affirmative took a more creative approach and checked the “Denied” box, offering the following explanation:

“Carrier address is incorrect - please resubmit corrected RFA so we can process your request.”

While the injured worker waits—presumably in some amount of pain—for treatment, Affirmative is taking a bold stand in defense of bureaucratic minutiae to delay care the worker’s doctor recommends.

Affirmative delayed a human being’s medical treatment to impose the most useless kind of accountability on a provider—in a system notoriously empty of accountability for TPAs like Affirmative.

Meanwhile, TPAs, vendors, and private equity investors continue profiting handsomely from the lucrative friction that defines Utilization Review and California’s workers’ comp system.

This happens in a system run amok, completely devoid of meaningful regulatory oversight.

There are no consequences for bad actors who delay or deny care based on technicalities. There is no enforcement when TPAs break the rules. In the end, injured workers and their employers pay the price—as care is delayed, recovery is derailed, and physicians walk away from treating injured workers altogether.

This is beyond inefficiency. It’s more evidence of the destruction of access to care for California’s injured workers.

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