California law requires insurers to honor authorization for medically necessary treatment as a legally binding, non-rescindable guarantee of reimbursement. The Hartford is either somehow unaware of California law or chooses to ignore it.

As daisyNews reported, The Hartford recently denied payment for treatment it had authorized, claiming the provider was not in the applicable Medical Provider Network (MPN). At the time of treatment, The Hartford’s MPN directory listed the provider as a member. More importantly, under California Labor Code Section 4610.3, MPN status became legally irrelevant the moment The Hartford granted authorization.

The provider filed a Second Review appeal. The Hartford denied that, too, forcing the provider to pay $195 and file for Independent Bill Review (IBR).

Now, the dispute hinges on whether the California Division of Workers’ Compensation (CA DWC) will allow IBR to proceed. The agency has repeatedly ruled MPN disputes "ineligible" for IBR, even when documented proof of authorization is present. If that happens here, the provider's only way forward is to file a lien with the Workers’ Compensation Appeals Board (WCAB), which could take months (or more) and be prohibitively expensive.

This is the system California providers must navigate every day. If this is how The Hartford treats its legal obligations to providers, imagine how it treats employers’ injured workers.

The Hartford Denies Second Review Appeal

The Hartford initially responded to the provider’s Request for Authorization (RFA) by granting authorization, but attempted to condition that authorization on membership in ‘The Hartford Select Network’ MPN.

Nothing in California law or regulations allows payers to condition authorization on MPN membership. Regardless, daisyBill confirmed that The Hartford Select MPN lists the provider and place of service.

Still, The Hartford denied payment for the bill and the subsequent Second Review appeal.

The Hartford twice denied payment despite the MPN in question listing the provider and (more importantly), the fact that MPN non-membership legally cannot nullify treatment authorization. The Hartford has shown that, at least sometimes, it will simply act as if its authorizations are not binding, state law be damned.

Worse, the state might do nothing about it.

The Facts About CA Authorization

When a provider submits an RFA to a workers’ comp payer, they are asking for something simple: a legal guarantee of reimbursement for the requested treatments. California Code of Regulations (CCR) Section 9792.6.1 defines "Authorization" as "assurance that appropriate reimbursement will be made” for the treatment.

California Labor Code (LAB) Section 4610.3 states that authorization is not rescindable, even if it turns out the provider wasn’t in the applicable MPN, as The Hartford incorrectly alleged (emphases ours):

“...an employer that authorizes medical treatment shall not rescind or modify that authorization after the medical treatment has been provided based on that authorization for any reason, including, but not limited to, the employer’s subsequent determination that the physician who treated the employee was not eligible to treat that injured employee…”

A (now-deleted) FAQ on the CA DWC website explicitly stated that MPN non-membership is not grounds for breaking the promise of payment. The Hartford is either implausibly unaware of these basic legal and regulatory facts, or, in this case, decided to ignore them.

The “Threshold” Loophole: How CA Hamstrings Providers

For payers, there’s effectively no reason not to issue denials like the one above, because the state will never impose consequences.

The outcome of a Second Review appeal is entirely under the payer’s control. The only thing that might compel a payer to reverse a denial or reduction is IBR. Unfortunately, there’s a loophole in the IBR process through which a payer could drive a Buick.

IBR can only determine how much a payer owes, not whether they are responsible to pay at all. So-called “threshold” issues, such as a provider’s MPN status and eligibility to treat, are outside the purview of IBR. On multiple occasions, the CA DWC determined that if the payer claims MPN non-membership as the denial reason, IBR cannot resolve the issue.

Of course, it defies all reason that the CA DWC does not consider documented proof of authorization sufficient to declare a dispute eligible for IBR. Authorization, by definition, eliminates any “threshold” issue regarding the payer’s obligation to reimburse.

Regardless, the CA DWC abandons providers the second a payer whispers a few magic words (MPN, compensability, liability, etc.) that make the threat of IBR disappear.

The result is that providers who treat injured workers have no truly reliable guarantee of payment, since the state repeatedly fails to defend the sanctity of authorization. Understandably, many providers would rather not bear the risk of operating in an environment where the laws protecting them are effectively optional.

Given the recent retirement of the previous CA DWC Administrative Director, we hope that the agency, under its new leadership, will allow IBR when undeniable proof of authorization is included in the IBR request, starting with this pending request against The Hartford.

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