California’s Division of Workers’ Compensation (DWC) is supposed to have a critical role in enforcing state laws and regulations. Just as critically, the DWC has a duty to keep all stakeholders informed.

This is especially true when it comes to authorization and Utilization Review (UR), the complex processes by which claims administrators approve or deny treating providers’ recommendations for medical care. For that reason, the DWC maintains a dedicated UR FAQ page.

However, some critical UR FAQs have vanished from the DWC page over the last several months.

For example, one of the missing FAQs addresses claims administrators’ obligations to pay for Medical-Legal diagnostic tests. The DWC removed important clarifications that physicians need in order to successfully dispute improper reimbursement denials or reductions for diagnostic testing conducted as part of a Medical-Legal evaluation.

Below, see this particularly glaring (and galling) example and ask yourself why the DWC would remove this FAQ. Providers cannot (and should not) trust a regulatory system in which regulators quietly delete the information necessary to protect them.

Med-Legal Diagnostic Tests FAQ: DELETED

The November 28, 2023 version of the DWC UR FAQ page included the section below, which explains that diagnostic testing is a valid Medical-Legal expense, and that such testing does not require authorization as long as the following conditions are present:

1. Subjective complaints and physician findings make the tests necessary to complete the evaluation.
2. The medical documentation provided to the evaluator lacks “adequate medical information” that would otherwise make the test unnecessary.

As this previous version of the FAQ stated, when a diagnostic test is ordered “as part of the medical/legal evaluation,” the claims administrator may not “put that request through utilization review.” Such tests are considered Medical-Legal expenses rather than treatment.

This FAQ is not just some random regulatory minutiae. It is critical information for Medical-Legal physicians given that claims administrators improperly deny or reduce payment for Medical-Legal diagnostic testing.

Yet the FAQ is no longer on the DWC’s page.

We cannot know what factors went into the DWC’s decision—assuming it was the DWC’s decision—to make this information less readily available. But without this information, physicians may be subject to improper payment denials without knowing.

Who benefits from such a retreat from transparency? The answer is undoubtedly not providers, to say nothing of injured workers.

Wayback Machine Reveals DWC’s Stealth Edits

The Internet Archive allows visitors to see previously saved versions of various websites, including the DWC UR FAQ page. The version of the FAQ page saved in November 2023 featured helpful information on a dozen specific topics related to authorization and UR, as shown below.

As of this writing, the same page (current version below) has been stripped down to just six topics, with the following topics removed:

• Requests for authorization
• Timelines and timing
• UR replies
• UR and AME/QME reports
• UR and medical provider networks (MPNs)

Two other topics, ‘Different types of UR’ and ‘Prior authorization,’ seem to have been combined into a single topic, ‘Types of UR and prior authorization.’

At a glance, the above could reflect a simple reorganization or streamlining of content. However, this does not explain why certain FAQs were entirely deleted—the answers to which are crucial to providers seeking payment for services rendered.

We have to wonder if by quietly removing information critical to providers, the DWC has inadvertently signaled that it prefers to keep only some stakeholders informed.

To learn more about the Medical-Legal Fee Schedule (MLFS)—including reimbursement for diagnostic testing—watch our recent webinar below.

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