For California providers, obtaining authorization for workers’ compensation treatment requires substantial administrative resources. As COVID-19 strains those resources, priorities must shift. Claims administrators and state authorities can empower providers to focus their time and effort on patients’ benefit first, by lessening the administrative burdens of the authorization process.
Both claims administrators and the Division of Workers’ Compensation (DWC) have it in their power to cut some of the regulatory red tape that, in a time of crisis, benefits no one.
Hamstrung Providers Need Relief During COVID-19
Currently, workers’ comp providers have fewer resources than ever, at a time when their work is more vital than ever. Provider administrative staff is reduced to skeleton crews, systems are strained, and providers must pivot to new methods of delivering services overnight.
In such a climate, state authorities and claims administrators cannot reasonably expect provider staff to prioritize the generation, submission, and tracking of Requests for Authorization. Still less can injured workers be expected to timely navigate the complex Independent Medical Review (IMR) process.
Just as providers must be flexible, so should other stakeholders.
In these unique circumstances, it is currently impractical or impossible for providers to meet already burdensome authorization and UR requirements. In recognition of this fact, claims administrators should temporarily suspend financial disallowances until providers can return to normal staffing and procedures.
This flexibility should extend to telehealth services in particular, as providers scramble to adopt this new method and as the DWC moves to clarify the rules.
Excessive Authorization Requirements: An Unnecessary Barrier
The authorization process should be a simple procedure for ensuring workers receive appropriate care and providers receive proper reimbursement. Instead, it’s often an obstacle to care and reimbursement, taking up far too much provider bandwidth. This was true before the first case of coronavirus appeared in California.
Now is surely the time to reduce administrative friction, so providers can adapt to better serve workers during the pandemic.
Currently, to ensure reimbursement, providers must:
- Complete and submit the Request for Authorization
- Track and document the claim’s administrator’s Utilization Review (UR) decision
- Ensure that claims administrators timely respond
The above is a best-case scenario in which the claims administrator authorizes the requested treatment and adheres to response time requirements — not always the case. In addition, when the claims administrator denies or modifies the requested treatment, the burden shifts to the injured worker, who must grapple with IMR.
In the long term, a hard look at the inefficiency of the UR and authorization processes is warranted. But to meet the workers’ comp system’s immediate needs, some flexibility regarding adherence to these processes would have a significant positive impact.
A constructive response to the COVID-19 outbreak requires creativity, flexibility, and a focus on real priorities. California workers’ comp providers exemplify this, as doctors and other professionals seek new ways to continue treating injured workers while doing their part to flatten the curve.
If we’re truly in this together, all parties involved must follow suit.
For more on telehealth rules for Medicare, California health insurers, and California workers’ compensation, look through the free resources available on our COVID-10 page.