When the claims administrator representing the insurance company, employer, or TPA denies a valid, compliant Request for Authorization (RFA), what’s a work comp provider to do?
The RFA and Utilization Review (UR) process leaves much to be desired, as we’ve pointed out before. But if the claim’s administrator’s UR decision is unsatisfactory, there is recourse: Independent Medical Review (IMR). However, California work comp rules severely limit providers’ ability to pursue IMR, leaving it mostly to the patient. That said, the provider can play an active role.
The Provider’s Role
When the utilization review denies or modifies requested treatment, DWC rules require the claims administrator to send the written utilization review decision to the injured worker along with a completed IMR application form. Only the employee can request IMR, not the provider, with one exception we’ll discuss below.
So what’s the provider’s role in the IMR process?
According to California Code of Regulations (CCR) § 9792.10.1, the physician who made the RFA in question “may join with or otherwise assist the employee” in requesting IMR, submitting relevant documents and responding to inquiries by the independent reviewers. However, the request must come from the worker, their attorney, or designee.
There is only one situation in which the provider may initiate the IMR request: for emergency treatment. On their own behalf, a provider may request IMR only when the RFA in question is retrospective for emergency medical treatment. § 9792.10.1 states:
A provider of emergency medical treatment when the employee faced an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life, limb, or other major bodily function, may submit an application for independent medical review under this section on its own behalf within 30 days after the service of the utilization review decision that either delays, denies, or modifies the provider's retrospective request for authorization of the emergency medical treatment.
Generally, we do not recommend providing medical treatment without authorization, but in the case of emergency treatment, a provider cannot obtain prior authorization. Once emergency treatment is provided, if the claims administrator denies treatment, the provider can submit a retrospective RFA for the necessary emergency services. To the extent the retrospective RFA is denied, the provider is free to pursue IMR on their own behalf.
The IMR Process
When the employee (or the provider, in the case of a retrospective RFA for emergency treatment) requests IMR, they must:
- Submit the completed, signed DWC Form IMR with a copy of the written UR determination modifying or denying the RFA to the DWC.
- Submit DWC Form IMR and UR determination within 30 days of service of the written UR determination.
- Submit DWC Form IMR and UR determination via mail, fax, or electronic transmission (mailing address available on DWC website).
- Concurrently send a copy (not the original) of the DWC Form IMR to the claims administrator.
Like Independent Bill Review (IBR), IMR is conducted by Maximus Federal Services. The Division of Workers’ Compensation (DWC) chose this private entity to resolve both billing and authorization disputes between providers and claims administrators. While Maximus hasn’t always earned our highest regards, they remain the state’s designated arbiter, for better or worse.
Once the DWC Administrative Director’s office reviews the IMR application and deems it eligible, Maximus informs both parties that the dispute is under review (either regular review or expedited). A qualified medical reviewer (or multiple reviewers, if necessary) examines the dispute by reviewing the documentation. The reviewer(s) then determine the medical necessity of the disputed treatment.
The reviewer’s findings are binding, and considered the determination of the Administrative Director. A decision is due:
- Within 30 days of receipt of DWC Form IMR and written UR determination for a non-expedited IMR
- Within 3 days of receipt of DWC Form IMR and written UR determination for an expedited IMR, when the disputed treatment has not yet been provided
- Within 30 days of receipt of DWC Form IMR and the written UR determination for an expedited review, when the disputed treatment has been provided
Except in cases of emergency, we cannot urge providers strongly enough: always obtain compliant authorization for treatment. The RFA and UR process is not perfect, but it is the only way to ensure payment for provider services. For more information on the IMR process, see the DWC website.
The best way to RFA? DaisyBill’s Billing Software. Our software allows providers to generate compliant RFA’s quickly, and tracks the response times, alerting providers when a decision from the claims administrator is due. Schedule a free demonstration, and see what DaisyBill can do for your office.