Data: CA UR Decisions 2022

February 15, 2023 7 min read

By: the daisyNews Team

One of the great sources of friction in California workers’ comp is the Utilization Review (UR) and treatment authorization process — the critical process that determines whether injured workers get the care deemed medically necessary by their doctors.

daisyBill data from 2022 suggest that some claims administrators make this process more frictious than others.

To treat an injured worker, the doctor must obtain authorization from the claims administrator’s UR organization. Below, we share data on the rates at which claims administrators approved and denied treatments, in response to Requests for Authorization (RFAs) submitted by California providers via daisyBill in 2022.

Data Summary: CA UR Decisions 2022

The data in this article reflect:

Prospective UR decisions,
Received and posted by providers in daisyBill’s system,
In 2022,
From claims administrators to which 100 or more RFA treatments were submitted

Overall, the 299 claims administrators in this data set approved the requested treatment 71% of the time, and denied the requested treatment 21% of the time. The remaining 8% reflects decisions in which the claims administrator modified the requested treatment, contested liability, or deferred their decision (to be discussed in a future article).

Utilization Review (UR) Decisions	Count / %
Total Posted UR Decisions	122,829
Decisions Approving Requested Treatment	86,916
% of UR Decisions Approving Requested Treatment	71%
Decisions Denying Requested Treatment	26,328
% of UR Decisions Denying Requested Treatment	21%

These numbers should ignite an important conversation. If the UR/authorization process was designed to prevent fraud or over-treatment, is it plausible that:

Over a fifth of requested treatments were fraudulent, or medically unwarranted?
California doctors requested legitimately necessary treatment only 71% of the time?

When an employer’s claims administrator denies the treatment requested by a physician, the doctor cannot repeat the request until 12 months have elapsed since the date of the denial, or there has been a change in the injured workers' condition. Only the injured worker may initiate Independent Medical Review (IMR) to contest a denial.

CA Claims Admins: Lowest Approval/Highest Denial Rates

Below we list the 36 claims administrators whose approval rates were lower than the 71% overall approval rate, and whose denial rates were higher than the overall 21% denial rate.

Of particularly troubling note:

Sedgwick, the largest claims administrator in our system by far, denied over a quarter of treatment requests submitted by daisyBill doctors. That’s 9,038 times Sedgwick said “no” to something a doctor asserted was necessary for an injured worker to recover.
Athens, another large entity, denied 36% of treatment requests submitted by daisyBill doctors. That’s 901 times Athens said “no” to something a doctor asserted was needed for an injured worker to recover.
Sutter Health denied 45% of treatment requests submitted by daisyBill doctors. Yes, almost half.

Claims Administrator	Approve UR Decision Count	Approve UR Decision %	Deny UR Decision Count	Deny UR Decision %
Sedgwick Claims Management Services	22,252	65%	9,038	26%
Gallagher Bassett	4,685	66%	1,974	28%
Broadspire	1,950	68%	669	23%
Athens Administrators	1,333	53%	901	36%
AmTrust North America	1,420	62%	739	32%
Liberty Mutual Insurance	1,071	59%	436	24%
The Hartford	952	58%	506	31%
Berkshire Hathaway Homestate Companies	685	61%	315	28%
Cannon Cochran Management Services Inc.	729	67%	251	23%
Preferred Employers Insurance Company	624	65%	239	25%
AIG Claims, Inc.	444	62%	211	30%
Farmers Insurance	402	58%	193	28%
Employers Compensation Insurance Company	346	60%	168	29%
Benchmark Insurance Company	385	69%	149	27%
City of Los Angeles Department of Water and Power (CA)	292	66%	111	25%
Pacific Gas & Electric	221	57%	154	39%
CNA Insurance	239	62%	89	23%
Southern California Edison	254	68%	89	24%
Next Level Administrators	163	45%	105	29%
Crum & Forster	187	63%	80	27%
Enstar Group	162	61%	70	26%
Omaha National Group	167	66%	57	22%
National Interstate Insurance	156	62%	84	34%
Hazelrigg Claims Management Services	123	60%	64	31%
City of Riverside (CA)	128	64%	66	33%
Guard Insurance Group	85	47%	59	33%
Disneyland Resorts California	121	69%	46	26%
QBE North American	89	55%	58	36%
AmeriTrust Group, Inc.	100	63%	49	31%
GuideOne Insurance	87	57%	64	42%
Beta Healthcare Group Risk Management Authority	68	48%	42	30%
Allianz	89	65%	37	27%
Mitsui Sumitomo Insurance	81	62%	42	32%
Matrix Absence Management	77	67%	28	24%
Sutter Health	59	53%	50	45%
ClaimQuest, Inc.	72	67%	29	27%

UR Data: All CA Claims Admins

Below we list all claims administrators from which daisyBill providers received and posted 100 or more UR decisions in 2022, listed in order of the volume of UR decisions posted.

We encourage providers, and also state legislators and regulators, to peruse these data and consider the implications for the health of injured workers across the state.

Claims Administrator	Approve UR Decision Count	Approve UR Decision %	Deny UR Decision Count	Deny UR Decision %
Sedgwick Claims Management Services	22,252	65%	9,038	26%
State Compensation Insurance Fund (CA)	10,065	78%	1,951	15%
Gallagher Bassett	4,685	66%	1,974	28%
CorVel	3,335	82%	540	13%
Zurich Insurance North America	2,331	73%	635	20%
ESIS, Inc.	2,398	76%	593	19%
Tristar Risk Management	2,270	79%	413	14%
Broadspire	1,950	68%	669	23%
Travelers	2,233	79%	400	14%
Intercare Holdings Insurance, Inc.	2,381	86%	255	9%
Athens Administrators	1,333	53%	901	36%
Insurance Company of the West	1,665	72%	424	18%
AmTrust North America	1,420	62%	739	32%
Keenan & Associates	1,506	74%	391	19%
Liberty Mutual Insurance	1,071	59%	436	24%
The Hartford	952	58%	506	31%
Adminsure, Inc.	1,231	84%	179	12%
Acclamation Insurance Management Services	1,111	77%	238	17%
Berkshire Hathaway Homestate Companies	685	61%	315	28%
Cannon Cochran Management Services Inc.	729	67%	251	23%
Nassco / General Dynamics	972	92%	81	8%
California Insurance Guarantee Association	713	70%	182	18%
Preferred Employers Insurance Company	624	65%	239	25%
CompWest Insurance Company	701	77%	110	12%
The Zenith	623	74%	177	21%
Republic Indemnity	694	82%	70	8%
Los Angeles County Metropolitan Transit Authority (CA)	737	88%	68	8%
Pacific Compensation Insurance Company	606	78%	129	17%
Chubb Group of Insurance Companies	589	82%	73	10%
AIG Claims, Inc.	444	62%	211	30%
Farmers Insurance	402	58%	193	28%
Sentry Insurance	545	82%	72	11%
Employers Compensation Insurance Company	346	60%	168	29%
Benchmark Insurance Company	385	69%	149	27%
Albertsons / Safeway / Vons	385	78%	76	15%
American Claims Management, Inc	359	74%	97	20%
City of Los Angeles Department of Water and Power (CA)	292	66%	111	25%
Alaska National Insurance	274	70%	58	15%
Pacific Gas & Electric	221	57%	154	39%
City of Los Angeles (CA)	332	86%	33	9%
CNA Insurance	239	62%	89	23%
Helmsman Management Services	260	70%	77	21%
Southern California Edison	254	68%	89	24%
Next Level Administrators	163	45%	105	29%
Midwest Insurance	251	71%	83	23%
LWP Claims Solutions	267	78%	48	14%
None	235	69%	91	27%
Fresno Unified School District (CA)	297	88%	27	8%
Barrett Business Services Inc.	235	70%	65	19%
County of Riverside (CA)	250	77%	69	21%
City of San Diego (CA)	295	96%	9	3%
Pacific Claims Management	269	89%	27	9%
Crum & Forster	187	63%	80	27%
Cottingham & Butler Claim Services, Inc.	218	74%	52	18%
Finish Line Self Insurance Group	241	82%	27	9%
Elite Claims Management	230	80%	45	16%
County of San Diego (CA)	235	87%	24	9%
Enstar Group	162	61%	70	26%
Marriott Claims Service Corp	191	72%	57	22%
Omaha National Group	167	66%	57	22%
National Interstate Insurance	156	62%	84	34%
Hazelrigg Claims Management Services	123	60%	64	31%
City of Riverside (CA)	128	64%	66	33%
Packard Claims Administration	109	60%	36	20%
Guard Insurance Group	85	47%	59	33%
Strategic Comp	107	60%	30	17%
Disneyland Resorts California	121	69%	46	26%
Workers Compensation Fund (Utah)	129	75%	33	19%
Affirmative	159	93%	10	6%
County of Sacramento (CA)	142	83%	20	12%
CopperPoint Mutual	162	97%	4	2%
County of San Bernardino (CA)	144	87%	16	10%
QBE North American	89	55%	58	36%
PMA Companies	107	67%	32	20%
AmeriTrust Group, Inc.	100	63%	49	31%
Risico Claims Management, Inc.	122	79%	11	7%
GuideOne Insurance	87	57%	64	42%
Protective Insurance	128	85%	11	7%
Loma Linda University (CA)	125	83%	18	12%
City of Glendale (CA)	122	81%	25	17%
Sempra Energy Employee Care Services	107	74%	31	22%
Beta Healthcare Group Risk Management Authority	68	48%	42	30%
Allianz	89	65%	37	27%
Mitsui Sumitomo Insurance	81	62%	42	32%
JT2 Integrated Resources	107	82%	23	18%
City of Long Beach (CA)	126	98%	2	2%
Innovative Claim Solutions, Inc.	99	78%	27	21%
Church Mutual Insurance Company	92	74%	17	14%
Tokio Marine Management	96	82%	20	17%
Contra Costa County Risk Management (CA)	107	93%	7	6%
Matrix Absence Management	77	67%	28	24%
Schools Insurance Authority (CA)	71	62%	22	19%
Markel First Comp Insurance	84	75%	13	12%
Sutter Health	59	53%	50	45%
ClaimQuest, Inc.	72	67%	29	27%
City and County of San Francisco (CA)	99	93%	5	5%

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