If California’s Department of Industrial Relations (DIR) had taken $300,000 of taxpayer money, thrown it into a gravel pit, and set it on fire, it would have been only slightly less wasteful than paying RAND to produce its newly released study on Utilization Review (UR).

UR is the process by which workers’ comp claims administrators (aka payers) determine whether to approve the care that injured workers’ physicians recommend.

A burning pile of cash would at least have provided some warmth and light. Instead, California taxpayers gave RAND a small fortune to discover what anyone who reads daisyNews already knows: the state has no comprehensive UR data to inform a meaningful study.

Despite state laws requiring the California Division of Workers’ Compensation (CA DWC) to gather, analyze, and publicize UR data, the agency has blatantly declined to do so. As a result, RAND had to supplement the scraps of available data by simply...asking around for any payers willing to share their UR numbers.

The final product is a hundred pages of RAND’s best guesses about UR, with its central findings based largely on self-reported “data” from a grand total of two payers.

Through its tiny pinhole-sized view into California’s UR system, which must approve all treatment provided to an injured worker, RAND attempted to show the impact of Senate Bill 1160 on treatment during the first 30 days of a claim. However, as the study notes, RAND’s “ability to evaluate SB 1160’s impact was constrained by the absence of systemwide data…”

The RAND report summary concludes with a policy recommendation: “Invest in Utilization Review Data Infrastructure.” Of course, daisyNews has offered this exact recommendation for years (and never asked the taxpayers for a dime).

RAND reports that a “UR decision database” is in development. But given its track record of managing data, if the CA DWC has any hand in this database, it has a 99.9% chance of failing. The agency has already dropped the ball on the Workers’ Compensation Information System (WCIS), a Medical Provider Network database, and a UR decision database that’s years overdue.

If the DIR and CA DWC are truly building UR data infrastructure, it is critical that they face something to which they are not accustomed: genuine accountability for their execution of the project.

Meanwhile, daisyBill has already built the technology to track and manage RFAs and UR decisions, with over 500,000 RFAs flowing through our systems over the last several years. We are willing to share our data with stakeholders for free.  

RAND: Begging for Data to Study (and Coming Up Short)

To conduct the UR study, the state offered RAND data from:

• WCIS
• The Electronic Adjudication Management System (EAMS)
• CA DWC audits of randomly selected RFAs
• Independent Medical Review (IMR) cases

These data sources are, to be kind, of limited value in determining anything other than the fact that no comprehensive UR data exists.

• RAND “determined that the WCIS would not be a suitable data source to analyze UR decision patterns” because there is no RFA or UR information in “any fields in the medical billing data or other parts of the WCIS…” Moreover, the CA DWC considers reporting to WCIS “voluntary” for claims administrators.
• EAMS has no information on RFAs or UR, either.
• CA DWC audit data comprise only a few thousand randomly selected RFAs not necessarily restricted to the first 30 days of the claim.
• IMR upholds treatment denials in an implausible percentage of cases.

In an attempt to locate UR decisions, RAND reached out to six claims administrators and was able to get “individual-level RFA data on the outcome of RFAs” from just two claims administrators.

Rational readers may wonder if voluntarily supplied data from just two payers can offer a representative picture of a statewide system. The answer is no. As RAND acknowledged in its report, those data can only tell you so much (emphases ours):

“...the trends in UR outcomes measured in these data are not representative of the entire California workers’ compensation system. Furthermore, because participation was voluntary, it is possible that claims administrators who were willing to provide data are systematically different than others…”

In fact, RAND felt compelled to point out just how “systematically different” their volunteer payers are, noting that those payers had much higher treatment approval rates (above 90% both before and after SB 1160 took effect), compared to the approval rates reflected in the CA DWC audit data (emphases ours):

“We reiterate, however, that data were provided voluntarily by two claims administrators and may not be generalizable to the UR approval rates from all claims administrators. For example, approval rates in the audit data were lower (65–74 percent) than the data received from our two claims administrators.”

In other words, even RAND accepts that extrapolating two payers’ UR approval rates statewide would be a stretch.

In fact, daisyData show that historically, the hundreds of payers in our system collectively approve around 70% of physician-requested treatment, with wide variations in approval rates from payer to payer. The state’s largest Third-Party Administrator, Sedgwick, previously boasted of derailing more than 50% of treatment requests to produce a “return on investment” for its clients.

California workers’ comp stakeholders should be incensed that $300,000 was spent to analyze self-reported data from two nameless payers, making this very expensive report functionally worthless.

CA DWC Ignores the Law (but daisyBill Can Help)

California legislators have passed multiple laws intended to strengthen oversight and encourage transparency in UR. The CA DWC has either blatantly ignored or only nominally complied with all of them:

• Labor Code Section 4610 requires the CA DWC to establish a system for mandatory electronic reporting of all UR activity. The agency has implemented no such system.
• Labor Code Section 4610(q) requires the CA DWC to commission a comprehensive report evaluating medical treatment in the first 30 days post-injury by July 1, 2023. The agency finally commissioned this functionally useless RAND study in 2025.
• Labor Code Section 138.8 required the CA DWC to publish provider treatment and UR denial data by January 1, 2024, and annually thereafter. The agency has published no such data.

California didn’t need to spend $300,000 to realize that the obvious first step in meaningful UR reform would be to compel the CA DWC to follow the law. But since the taxpayer forked over so much money for this report, let’s take RAND’s primary recommendations seriously (emphases ours):

“DIR should require standardized reporting of all UR decisions, using the existing RFA form as a starting point. At a minimum, the [UR] database should capture standardized treatment and diagnosis codes (ICD-10 and the Healthcare Common Procedure Coding System), key dates (date of injury, RFA submission, and UR decision), and claim identifiers that enable linkage to the WCIS…”

“...When operational, this UR decision database covering all claims administrators and UROs [Utilization Review Organizations] will provide a clearer and more comprehensive picture of UR’s role in the workers’ compensation system.”

As the laws already on the books demonstrate, California legislators are way ahead of this. Unfortunately, the CA DWC is years behind.

In the meantime, there’s at least one large UR dataset available to any stakeholder who asks: ours. Through daisyAuth, we have RFA and UR data going back to 2014. These data cover:

• Over 1,200 California providers
• Over 1,200 claims administrators operating in the state
• Over 1.3 million RFAs
• Over 2.7 million requested treatments

These data already offer valuable insights. For example, the payers in our system collectively approved just 71% of over 215,00 treatments providers requested in 2025, with approval rates varying widely across payers. This is consistent with previous years’ data, suggesting that:

• Approval rates are implausibly low; who really believes that only ~70% of doctors’ requests are medically necessary or appropriate?
• Treatment approval may depend more on the payer making the decision than on medical necessity or appropriateness.

Moreover, RAND’s research on treatment approval in the wake of SB 1160 misses a key factor in how UR can delay care and lengthen claim durations: the administrative burden on providers.

Providers submit RFAs in accordance with strict requirements and must track responses carefully. Meanwhile, payers can respond to RFAs in any form or format they like, often resulting in bloated, unclear, illegible, or nonsensical UR decisions that can lead to disputes. We have the receipts.

In daisyBill, California has a significant source of data on UR, as well as workers’ comp billing and payment, for which we ask nothing in return. Next time the DIR reaches for the public purse, it should think more carefully about what taxpayers are getting for their money.

Submit compliant RFAs in seconds and track UR responses with daisyAuth. Click below to see how it works:

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