RFA: UR Decision Data 2023

August 15, 2023 6 min read

By: the daisyNews Team

On Friday, a California Workers’ Compensation Institute (CWCI) representative reportedly cited a 95% approval rate for medical treatments requested by California providers. This statistic would indicate that, for the most part, claims administrators approve the care doctors determine necessary and appropriate to heal injured workers.

However, daisyBill Utilization Review (UR) data (and the reported experience of many providers) doesn’t jibe with the CWCI’S claim.

The data from doctors submitting Requests for Authorization (RFAs) through daisyAuth show a much lower approval rate of 70%.

Below, we share Utilization Review (UR) data from tens of thousands of decisions for 2023 so far. We encourage all employers to peruse our data and ponder whether denial of care prevents injured workers from returning to work. Employers must know that each denial of the care a doctor recommends potentially means delayed recovery, increased costs, and higher insurance premiums or fees.

According to the CWCI website, its members are “insurers licensed to write workers’ compensation in California, as well as public and private self-insured employers who serve as associate members.” In other words, the organization exists to support payers’ interests — a factor that must be considered when weighing these data.

Taking CWCI data as gospel, or citing it without considering non-payer sources of data, is a disservice to California workers’ comp. Stakeholders should also refer to other available, verifiable data from the provider side of the equation.

Admittedly, we are (proud) advocates for providers and injured workers. That acknowledged, our data are publicly available and independently verifiable for anyone who wishes to examine them. We are happy to share these data, as we do below.

Data Summary: CA UR Decisions January-July 2023

The UR data in this article reflect prospective UR decisions doctors received in response to Requests for Authorization (RFAs) sent between 1/1/2023 and 7/31/2023.

Overall, the 77 claims administrators listed below approved only 70% of requested treatments while denying 22%. The remaining 8% reflects UR decisions in which the claims administrator modified the requested treatment, contested liability, or deferred the UR decision.

Utilization Review (UR) Decisions	Count / %
Total Posted UR Decisions	82,036
UR Decisions Approving Requested Treatment	57,615
% of UR Decisions Approving Requested Treatment	70%
UR Decisions Denying Requested Treatment	17,656
% of UR Decisions Denying Requested Treatment	22%

These data do not suggest a workers’ comp environment in which providers are free to treat their patients as they see fit. Rather, the data suggest a much stronger influence on injured worker care by claims administrators, whose UR organizations have the final say.

UR Data: All CA Claims Admins

Below, we list all claims administrators from which daisyBill providers received and posted 100 or more UR decisions for RFAs sent between January 1, 2023, and July 31, 2023, in order of the volume of UR decisions posted.

We encourage providers, state legislators, regulators, and employers to review these data and consider the implications for the health of injured workers across the state. We also urge everyone sincerely invested in improving workers’ comp to consider the sources of all data.

Too many openly insurer-run entities like the CWCI, the Workers’ Compensation Insurance Ratings Bureau (WCIRB), and others contribute payer-friendly charts and graphs to the conversation, which are often parroted without critical analysis. This lack of objectivity precludes real solutions to the challenges faced by doctors, injured workers, and employers.

Claims Administrator	Total UR Decision Count	Days to UR Decision Average	Approve UR Decision Count	Approve UR Decision %	Deny UR Decision Count	Deny UR Decision %
Sedgwick Claims Management Services, Inc.	22,855	7.1	14,954	65%	5,843	26%
State Compensation Insurance Fund (CA)	8,916	5.1	6,889	77%	1,345	15%
Gallagher Bassett Services Inc.	5,387	8.5	3,713	69%	1,312	24%
CorVel	3,352	8.3	2,828	84%	387	12%
Intercare Holdings Insurance Services, Inc.	2,839	5	2,490	88%	246	9%
Athens Administrators	2,195	7.1	1,122	51%	817	37%
Insurance Company of the West	2,095	4.4	1,341	64%	475	23%
ESIS, Inc.	2,086	8.5	1,453	70%	512	25%
Zurich Insurance North America	2,080	6.5	1,374	66%	564	27%
Travelers	1,886	5.4	1,497	79%	285	15%
Broadspire Services, Inc.	1,833	8.5	1,279	70%	433	24%
Tristar Risk Management	1,692	5.4	1,274	75%	276	16%
AmTrust North America, Inc.	1,692	6.4	982	58%	565	33%
Liberty Mutual Insurance	1,598	7.4	937	59%	376	24%
The Hartford	1,293	8.6	741	57%	374	29%
Keenan & Associates	1,211	7	840	69%	293	24%
Berkshire Hathaway Homestate Companies	947	6	570	60%	271	29%
CompWest Insurance Company	841	4.8	668	79%	59	7%
Adminsure, Inc.	784	5.2	668	85%	84	11%
Acclamation Insurance Management Services	741	5.9	503	68%	192	26%
Republic Indemnity	729	3.3	571	78%	105	14%
Cannon Cochran Management Services, Inc.	692	9.5	459	66%	164	24%
Los Angeles County Metropolitan Transit Authority (CA)	619	4.5	528	85%	62	10%
The Zenith	599	4.9	439	73%	134	22%
Sentry Insurance	592	6	468	79%	84	14%
Chubb Group of Insurance Companies	574	6.4	525	91%	26	5%
Nassco / General Dynamics	530	10.9	426	80%	93	18%
California Insurance Guarantee Association	529	6.2	417	79%	63	12%
American Claims Management, Inc	427	4.5	347	81%	65	15%
Pacific Compensation Insurance Company	426	5.5	306	72%	73	17%
City of Los Angeles Department of Water and Power (CA)	415	3.6	290	70%	88	21%
Farmers Insurance	415	4.2	252	61%	113	27%
LWP Claims Solutions, Inc.	395	4.7	327	83%	30	8%
Employers Compensation Insurance Company	385	4.6	176	46%	106	28%
Benchmark Insurance Company	384	6.8	228	59%	131	34%
Preferred Employers Insurance Company	376	7.3	254	68%	79	21%
Pacific Gas & Electric	374	6.7	179	48%	182	49%
Next Level Administrators	338	4.2	165	49%	97	29%
City of Los Angeles (CA)	308	6.4	235	76%	54	18%
Helmsman Management Services LLC	305	11.3	201	66%	68	22%
CopperPoint Mutual	298	5.6	230	77%	48	16%
Midwest Insurance	286	5.7	218	76%	55	19%
Cottingham & Butler Claims Services, Inc.	273	10.4	212	78%	41	15%
Fresno Unified School District (CA)	250	4.6	238	95%	9	4%
Southern California Edison	232	6.9	189	81%	33	14%
County of Riverside (CA)	205	3.9	139	68%	41	20%
Santa Ana Unified School District (CA)	204	9	146	72%	51	25%
Alaska National Insurance	204	5.1	140	69%	22	11%
City of Glendale (CA)	204	3.2	140	69%	60	29%
Marriott Claims Service Corp	189	4.8	147	78%	28	15%
Omaha National Group	183	4.2	96	52%	65	36%
Loma Linda University (CA)	179	4	128	72%	34	19%
Elite Claims Management, Inc.	176	4.7	145	82%	27	15%
Pacific Claims Management	174	5.4	148	85%	23	13%
Crum & Forster	172	5.7	101	59%	49	28%
ClaimQuest, Inc.	171	5.2	120	70%	41	24%
City of San Diego (CA)	168	1.8	164	98%	3	2%
Finish Line Self Insurance Group, Inc	168	5.5	145	86%	10	6%
County of San Diego (CA)	167	4.6	156	93%	5	3%
Strategic Comp	161	5.4	107	66%	20	12%
AmeriTrust Group, Inc.	158	4.6	87	55%	51	32%
Guard Insurance Group	157	5.2	84	54%	43	27%
City of Riverside (CA)	152	4.2	118	78%	33	22%
National Interstate Insurance	152	8.8	84	55%	52	34%
WCF Insurance	151	7.2	105	70%	31	21%
PMA Companies	134	8	101	75%	21	16%
CNA Insurance	134	7.1	92	69%	31	23%
Workers' Compensation Administrators, LLC	132	4.7	112	85%	14	11%
MedRisk Network	131	8.8	68	52%	41	31%
County of San Bernardino (CA)	127	6.1	110	87%	17	13%
National Casualty Company	126	4.7	94	75%	27	21%
Albertsons / Safeway / Vons	121	3.8	103	85%	12	10%
The Walt Disney Company	116	2.9	109	94%	5	4%
Contra Costa County Risk Management (CA)	116	7.1	101	87%	13	11%
Affirmative	115	4.8	93	81%	18	16%
Packard Claims Administration	110	7.2	64	58%	24	22%
GuideOne Insurance	105	5.5	65	62%	32	30%

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1 Reader Comments

Chris

It would be interesting to see this data broken down by provider specialty.

Published 02:08PM August 15, 2023

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