Blog: Daisy News

The RAND Corporation thinks California workers’ comp providers are spending too much time on redundant paperwork — and getting too little compensation in return.

The state frequently taps the international research firm to analyze the workers’ comp system. A new report from RAND calls for greater efficiency in workers’ comp reporting by digitizing forms like the Doctor’s First Report of Injury or Illness (Form 5021) and eliminating redundant overlaps between reports and other forms like the Request for Authorization (RFA).

The report also proposes new and increased reimbursements for workers’ comp reporting.

First, let’s be clear that providers never have to wait for authorization before providing emergency treatment an acute medical condition. Never.

However, the provider must ultimately obtain authorization for all services, even when the injury is time-sensitive or a medical emergency. While the authorization and utilization review (UR) process should never be an obstacle to such treatment, there are mandated procedures and timelines for submitting the official Request for Authorization (RFA).

Medical Provider Networks (MPNs) are a drag on California workers’ compensation. Nominally designed to help employers control costs, MPNs rarely achieve more than throwing up obstacles to the treatment of injured workers, and cheating providers out of reimbursement — even for authorized services.

Authorization, of course, is supposed to be final. But when claims administrators grant authorization on the condition that the treating physician be included in the employer’s MPN, they create opportunities to deny payment.

Recently, a DaisyBill client reached out with questions regarding automatic authorization. The source of the confusion was a slideshow presentation from the California Coalition on Workers’ Compensation (CCWC)’s 15th annual conference, held last July. The presentation contained no outright falsehoods, but used puzzling language and left out a key point regarding billing deadlines.

Tellingly, the conference was sponsored by Sedgwick, the third-party claims administrator. Given claims administrators’ interest in keeping providers in the dark regarding the new rules, we thought we’d clear up some confusion.

Over the last several months, we blogged extensively (and hosted a free comprehensive webinar) on the new automatic authorization process for California workers’ comp. Here, we’ve assembled the most important rules and procedures into one convenient guide. Use this for quick and easy reference, and feel free to download and print the PDF version below:

There’s been lots to say about authorization and utilization review (UR) this year, especially given the major changes to the process. However, one UR rule that remains the same in 2018 also remains sadly overlooked: those conducting UR on behalf of employers or insurers should not telephone providers for further information needed to make a UR decision.

This practice is non-compliant, wasteful, and has the potential to compromise the integrity of a decision to approve, modify, or deny the requested treatment.

In 2016 California passed Senate Bill 1160, which heralded significant workers’ compensation reform. SB 1160 outlined major changes to authorization, utilization review, lien filing, billing deadlines, and more. Some changes took effect in 2017, while others are newly effective, as of January 1 this year.

Let’s take a look at the major changes SB 1160 brings to workers’ comp in 2018.

Automatic authorization for California workers’ comp is in effect, but not all treatments qualify.

In fact, the Division of Workers’ Compensation (DWC) has specifically barred certain treatments from automatic authorization. In these cases, the usual Request for Authorization (RFA) and prospective utilization review remains required — with some exceptions. Since many of our recent webinar attendees asked about specific services, we thought a review of ineligible treatments was in order.