Blog: Daisy News

In a much-anticipated ruling, California’s Supreme Court ruled that a secondary injury derived from an incorrect Utilization Review (UR) decision is compensable under workers’ comp.

The Supreme Court denied the injured worker’s right to sue the Utilization Review Organization (URO) and UR physician in civil court, affirming workers’ comp as the “sole and exclusive remedy” for all injuries that arise out of or occur in the course of employment — including additional injuries that result from improper UR decisions regarding accepted injuries.

When treating an injured worker, a provider must fax the Request for Authorization (RFA) to the fax number designated by the claims administrator. RFAs should never be sent with a bill.

Often claims administrators delegate bill review and utilization review (UR) to different entities. A provider who fails to fax RFAs to the correct destination is out of compliance with RFA regulations which require providers to fax these requests using the fax number issued by the claims administrator.

When a payor’s utilization review organization (URO) denies treatment recommended by an injured worker’s treating physician, the only recourse is for the injured worker to appeal the denial to Independent Medical Review (IMR) administered by Maximus Federal Services.

A recent analysis of Maximus’ IMR decisions by California Workers’ Compensation Institute (CWCI) found that Maximus upheld the overwhelming majority of payors’ utilization review decisions.

The notion of IMR as a largely futile pursuit works to the advantage of the CWCI, an insurers’ and employers’ group with the stated aim of analyzing data “to improve benefit delivery.”

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.

Payments for physician-dispensed drugs are some of the most misunderstood — and incorrectly denied — in workers’ compensation billing. Too often, the employer or insurer’s claims administrator denies payment based on inapplicable Physician Fee Schedule status code rules. Beyond that, the Division of Workers’ Compensation (DWC) and state legislature seem keen to discourage physician dispensing.

Regardless, physicians have permission to dispense pharmaceuticals, and to bill according to the Pharmacy Fee Schedule.

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.