In California, before treating an injured worker, a physician must obtain prior approval from the payer for all treatment. The California Division of Workers’ Compensation (CA DWC) wants to remind physicians that they must submit their Requests for Authorization (RFAs) using the required form, DWC Form RFA.

With apparently no sense of irony, the agency issued a Newsline stressing the importance of the form to “ensure clear, consistent communication between medical providers and claims administrators [aka payers].” This ignores that the CA DWC allows payers to respond to the RFAs in any format they choose, often resulting in unclear, vague, bloated, and occasionally unintelligible Utilization Review (UR) decisions.

daisyNews has chronicled multiple claims in which the payer’s response to an RFA fails to adequately (or legibly) address the treatment the provider requested, leading to delays in care and needless battles over reimbursement for that care.

It’s a perfect example of the regulatory double-standard in California workers’ comp. Providers must adhere to strict requirements when requesting permission to treat an injured worker, with swift and automatic consequences for non-compliance, while payers enjoy wide latitude when responding (and a payment dispute process that defaults to the payer’s advantage).

There’s an easy fix: the CA DWC should create a standardized UR decision form that payers must use for all RFAs, requiring them to clearly indicate whether they authorize the specific treatments the provider requested.

There are two participants in every California workers' comp treatment authorization: the provider requesting care and the payer deciding whether to approve that care. Only one of them has to follow strict rules about how to communicate. The other is essentially free to wing it.

As we frequently argue, unclear permissions to treat and unreliable guarantees of payment for supposedly authorized services drive providers out of the comp system. This hurts access to care, delays worker recovery, and increases disability costs. As providers flee the extraordinary administrative burden required to treat injured workers, employers pay the price with rising premiums as claims grow more expensive.

CA DWC: RFA Form Is Mandatory

The CA DWC claimed to have received multiple inquiries about whether the RFA form is mandatory following the agency’s adoption of new authorization UR regulations.

The CA DWC therefore reminds providers that California Code of Regulations Section 9792.6.1 requires providers to use DWC Form RFA (unless the payer agrees to accept a narrative report containing all the required information instead of the form).

The CA DWC describes the use of the RFA form as an imperative for improving access to treatment, ensuring “clear, consistent communication” and “reducing delays in the delivery of necessary medical care.”

Apparently, the same reasoning does not apply to payers issuing the treatment decisions.

Non-Standardized RFA Responses: Anything but “Clear”

daisyNews has documented multiple examples of how “clear” and “consistent” payer communication can be, and how effective the CA DWC’s one-sided requirement has been at reducing unnecessary delays in injured workers’ care.

• The Hartford sent a two-line authorization with missing details and placeholder text, asking the provider to reach out to an unspecified “claims handler” at an unspecified phone number to retrieve the full authorization letter.
  
  The Hartford subsequently denied reimbursement, claiming the service was unrelated to the injury (despite having previously paid for the same service on the same claim).
  
  
• Zurich North America authorized an unspecified amount of psychological counseling, subject to an arbitrary "certification period,” after which the authorization apparently expires (a condition with no basis in state law or regulations).
  
  Zurich also noted that their permission to treat was not a “guarantee of payment” for that authorized treatment, contradicting the legal definition of authorization.
  
  
• Applied Underwriters denied care for an injured worker with what can only be described as a string of unhinged, untrue statements. Applied Underwriters claimed that the valid procedure codes listed for the requested treatment were “invalid” and no longer in use, denying the RFA as “NOT COMPLETE.”
  
  
• Liberty Mutual sent a 23-page RFA response denying surgery, based on the ramblings of two outside UR vendors and at least one out-of-state UR physician. Liberty Mutual ultimately approved the exact same surgery through a different outside UR vendor, putting the injured worker through a nearly two-year ordeal.
  

The above are just a few examples from a system in which providers must request approval for all recommended treatments on a standardized form, with perfect compliance, while payers can communicate their decisions about an injured worker’s care through interpretive dance if they choose.

Of all the inequities in workers’ comp, this is one of the easiest to address.

We urge the CA DWC, as new leadership takes control, to apply the same standards of clarity to treatment decisions as to treatment requests.

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