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WCAB RFA Cases and Why They Matter

March 12, 2015 by Catherine Montgomery

The WCAB in several recent cases carved out exceptions to the rule that medical necessity can only be decided by claims administrators’ UR. Along the way, the WCAB makes sure that claims administrators adhere to RFA timelines.

If you’ve attended any of our Request for Authorization (RFA) webinars, you know that we believe RFAs are incredibly important for proper workers’ comp bill payment. We might even be a bit obsessed and I’ll tell you why in this post.

First, authorization via RFA guarantees payment.

Why this matters: Claims administrators cannot later deny payment for treatment that they authorize through the RFA process.

Second, under certain circumstances, the Workers’ Compensation Appeals Board (WCAB)--instead of a claims administrator--can make medical necessity decisions.

Why this matters: Because the WCAB is less likely to uphold a claims administrator’s denial or modification of a provider’s RFA. Normally, only claims administrators’ Utilization Review (UR) or the Independent Medical Review process makes decisions about the medical necessity of treatment.

Third, the circumstances under which the WCAB can make medical necessity decisions are those where the claims administrator fail to meet RFA timeliness requirements.

Why this matters: The WCAB is essentially telling claims administrators that they need to be on time with RFA decisions, or else. In addition, all elements must be timely: making the RFA decision, initial communication of the decision to a provider and written communication of the decision.

Next post: grisly details of the WCAB decisions, for those who secretly wish to be lawyers.

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