Every state has an obligation to ensure injured workers can access the care they need with as few roadblocks as possible. That means empowering doctors to furnish treatment with minimal friction.

For a great example, look to the streamlined process physicians in the State of New York use to obtain authorization for treatment.

New York has a simple rule: Generally, treatment is automatically authorized if the state’s Medical Treatment Guidelines (MTG) recommend the treatment. No payer authorization is required because New York allows the MTG—rather than payers—to dictate care.

Further, when authorization is required, the New York Workers’ Compensation Board (WCB) provides a portal for physicians to submit treatment requests (and for payers to respond). This seamless, abuse-resistant process allows the NY WCB to monitor and collect data about physicians’ requests and payers’ responses.

Contrast this with states like California, where every treatment (down to a Tylenol) for an injured worker is subject to a convoluted Utilization Review (UR) process, even when the California Medical Treatment Utilization Schedule (MTUS) supports the treating physician’s recommendations.

Annually, California physicians fax millions of Request for Authorization (RFA) forms to thousands of payers requesting approval for millions of treatments. Even more alarming, the California Division of Workers’ Compensation (CA DWC) exercises zero regulatory oversight, allowing payers to ignore these (faxed) RFAs or non-compliantly deny them with no consequences.

The costs of needless, redundant UR ultimately fall on California employers, whose workers’ comp premiums pay for the micro-mismanagement of their employees’ treatment.

New York is committed to quickly returning injured workers to work and containing employers' costs. California is entrenched in delaying care and preventing quick returns to work—while driving up costs for employers (and profits for UR organizations).

NY vs. CA Treatment Authorization

California and New York maintain similar state-approved treatment guidelines (both draw from the American College of Occupational and Environmental Medicine’s guidelines). However, there’s a crucial difference between the two states’ approaches to authorization:

• California physicians must fax a Request for Authorization (RFA) for every recommended treatment.
• Physicians in New York can provide treatment without asking for authorization as long as the physician adheres to the Medical Treatment Guidelines (MTG).

In California, if a claims administrator fails to respond to a physician’s RFA, the physician must re-fax (and re-fax) the RFA. There is no regulatory oversight to enforce timely decisions. Further, there is no regulatory oversight to prevent claims administrators from non-compliantly denying medically necessary treatment.

In New York, providers only submit Prior Authorization Requests (PARs) using the state-monitored WCB portal for the following:

• Treatments that are not listed in the MTGs
• Variances from the MTG
• Non-formulary medications
• Some Durable Medical Equipment
• “Special Services” as defined in the MTGs

In most cases, New York providers don’t need the claims administrator’s—or anyone else’s—permission to treat an injured worker in adherence to the MTG. This means physicians (and New York employers) are not burdened by the administrative costs and resources of submitting excessive PARs.

In New York, if the claims administrator fails to respond to a PAR, treatment is deemed approved. Further, all PARs are submitted and responded to in the NY WCB On-Board system, enabling the WCB to closely monitor claims administrator compliance.

Of note, many New York physicians submit PARs using the On-Board system to receive confirmation that a treatment adheres to the MTG to avoid non-compliant payment denials. However, such PARs are optional.

CA Workers’ Comp: Digging Its Own Grave Through UR

The consequences of California’s payer-controlled authorization approach manifest in injured workers' delayed recovery and (much) higher employer costs.

According to the Workers’ Compensation Insurance Rating Bureau, work injuries in California take twice as long to resolve as the national median. California employers also spend twice as much to settle injury claims as the national median, mainly due to “frictional costs” like UR and legal battles over authorization.

These dismal and costly results reflect the obstacles to delivering medically necessary care, and the absence of CA DWC oversight which allows claims administrators to delay and deny care without consequences.

In California, why does it take two doctors (one working for the payer) to determine if every recommended treatment adheres to state guidelines? Could California benefit from New York’s example and simply let doctors treat injured workers according to evidence-based guidelines?

Without argument, injured workers and employers would benefit from a functioning regulatory agency (like the NY WCB) that protects injured workers and providers, and by extension, employers.

Unfortunately, the apparent benefits of the New York approach conflict with California's profit motive, which apparently informs the CA DWC and California legislators more than the welfare of injured workers. In California, the longer it takes to heal an injured worker, the more the cash register rings for certain companies (and their private equity owners).

Nationwide, daisyBill increases revenue and decreases hassle for providers who treat injured workers. Get a free demonstration below.

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