You already know Requests for Authorization (RFAs) as the single most effective tool for guaranteeing payment. Now RFAs play a vital role in lien declaration, as well.
Starting January 1, 2017, all medical treatment and med-legal lien claimants must file a lien declaration affirming that the claimant satisfies at least one of seven new lien claimant requirements set down by Section 8 of Senate Bill 1160. Of the seven, two prominently feature RFAs.
Part one of this blog series examined Subsection C, which states that authorized treatment guarantees the right to file a lien. Today, we examine Subsection E, which is concerned with liability and Labor Code 4600.
From Section 8 of Senate Bill 1160:
For liens filed on or after January 1, 2017, any lien claim for expenses under subdivision (b) of Section 4903 that is subject to a filing fee under this section shall be accompanied at the time of filing by a declaration stating, under penalty of perjury, that the dispute is not subject to an independent bill review and independent medical review under Sections 4603.6 and 4610.5, respectively, that the lien claimant satisfies one of the following:
- Is the employee’s treating physician providing care through a medical provider network
- Is the agreed medical evaluator or qualified medical evaluator.
- Has provided treatment authorized by the employer or claims administrator under Section 4610.
- Has made a diligent search and determined that the employer does not have a medical provider network in place.
- Has documentation that medical treatment has been neglected or unreasonably refused to the employee as provided by Section 4600.
- Can show that the expense was incurred for an emergency medical condition, as defined by subdivision (b) of Section 1317.1 of the Health and Safety Code.
- Is a certified interpreter rendering services during a medical-legal examination, a copy service providing medical-legal services, or has an expense allowed as a lien under rules adopted by the administrative director.
If the claims administrator disputes liability for the injury within 5 business days of receiving a compliant RFA, it must issue a written decision deferring utilization review of the requested treatment.
If liability for the injury is subsequently accepted, the claims administrator must meet another deadline: Within 30 days of accepting liability, it must issue utilization review decisions for all previously deferred RFAs. Requesting physicians do not need to resubmit their deferred RFAs to the claims administrator – the claims administrator is automatically required to issue the decisions.
If the retrospective utilization review denies the treatment, the claims administrator must issue a written communication to the physician denying the requested services which have already been provided to the injured worker.
With the exception of emergency treatment, a physician is not allowed to submit an application for Independent Medical Review to dispute the UR decision. Similarly, the injured worker cannot dispute the decision, as treatment has already been provided. For retrospective treatment utilization review denials, filing a lien is the only option available to the provider. In this case, the written retrospective denied UR decision serves as documentation that the employer neglected or unreasonably refused medical treatment.