First, it is important to note that securing medical
treatment under a workers’ compensation claim is procedurally quite different
than treating with one’s family doctor. When a patient receives a
prescription for medication or any other form of treatment under private insurance, the patient usually expects the pharmacy to fill the prescription
immediately. However, within the context of a workers’ compensation
claim, merely obtaining a prescription and presenting it to the pharmacy may
not be sufficient to ensure the employer will be responsible for
the cost of that prescription.
In fact, if one attempts to procure treatment for a
work injury as if it were a non-work-related condition, that persons runs the
risk of becoming financially responsible for the treatment at issue.
Naturally, steps should be taken, when possible, to
avoid that undesirable outcome.
Ensuring the employer’s insurance company is
financially responsible for medical treatment begins with adhering to and
considering the necessary steps of the mandatory Utilization Review process.
What
is Utilization Review?
For all work-related injuries occurring after January
01, 2013, pursuant to SB 863, all medical treatment requests under workers’ compensation claims
must be submitted to Utilization Review.
It should be noted that
Utilization Review has an extensive legislative history in the State of
California and is implicated by many sources of law. Those sources include but
are not limited, to Assembly Bill 749, Senate Bill 899, and are further codified
in California Labor Code Sections 4062 and 4610.
Utilization Review applies within the first 90 days of
filing a claim, also known as the investigation period allocated to the
Employer, but the Employer is only responsible for the cost of reasonable
medical treatment, up to $10,000.00, during that 90-day-period. After the first
90 days, the insurance company must have accepted liability for the claim/body
part for which treatment is being sought, prior to there being a possible application
of utilization review.
If your claim is denied or even if it has been
accepted, it may be an appropriate time to seek legal counsel to facilitate administration
of a claim for a workplace injury.
Initiating
Utilization Review
The purpose of utilization review is to answer the
question of whether treatment is medically necessary according to
the relevant treatment guidelines. The possible answers to that
question are: yes (“certified”); no (“non-certified”); or in-part yes or no
(“modified”).
If the Employer requests Utilization Review, that
request is first triggered based upon steps taken by an injured worker’s Primary
Treating Physician.
Primary Treating Physician (“PTP”) is
a defined term by law and is the doctor designated in advance with the Employer
to fulfill the duties indicated in California Code of Regulations Section 9785,
among others. Some of those duties will be outlined below and are much
different than those a private doctor would need to follow.
On that note, choosing a PTP may be an
appropriate topic of discussion with an attorney.
Further, if liability for a workers’ compensation
claim or any aspect thereof has been accepted, an injured worker’s PTP,
requesting treatment, must submit a Request for Authorization
(“RFA”) and Physician Progress Report (“PR-2”).
The RFA is a state required form specific to the purposes of requesting treatment under a workers’ compensation claim.
The RFA is mainly a claim demographic form, identifying the injured worker,
workers’ compensation insurance carrier, and the PTP. However,
and importantly, the RFA also includes the name and diagnostic codes of the specific
treatment being requested in terms of quantity, frequency, and duration. The PTP must sign the RFA and transmit it along with the PR-2
(progress report) to the workers’ compensation insurance carrier to request medical treatment.
It is important to note that those steps, although
necessary, do not guarantee whether the outcome of utilization review is certified;
non-certified; or a modification. Further, a utilization review decision
on the basis of any one RFA and PR-2 does not necessarily mean that future RFAs
and PR-2s will result in the same decision (i.e. certified; non-certified; or
modified).
Similarly, if treatment is approved or
approved-in-part, the workers’ compensation insurance carrier will be
financially responsible for the approved portions of request(s) associated with
a given RFA and PR-2. So, since any approved portions stem from one RFA and
PR-2, the PTP will have to complete subsequent RFAs and PR-2s for
any future treatment requests. Thus, once the PTP transmits a RFA/PR-2
to the workers’ compensation insurance carrier, timing issues must then be
considered.
Timing Under Utilization
Review:
The gist of these timing elements, for better or
worse, often amounts to delay in obtaining medical treatment. California Labor Code 4610(g)(1) provides that a utilization
review decision must be made within 5 working days from
the receipt of information reasonably necessary to make the determination, but
in no event more than 14 days from the date of the medical treatment
recommendation by the physician. Further, California Labor Code 4610(g)(3)(A) requires
that a decision be communicated to the physician within 24 hours
of the decision and in writing within two business days to the physician,
employee, and if represented, legal counsel as well.
These timing provisions apply to the workers’
compensation insurance carrier that receives an RFA and PR-2 from an injured
worker’s PTP. The timing provisions may seem a disadvantage to persons
who expect to obtain treatment in the same manner as from one’s family doctor. However, the timing issues presented by utilization
review may provide guidance in developing a treatment plan for a work injury.
Failure by a carrier
to timely respond to all RFA’s and PR-2s (i.e. to conduct utilization review)
means that medical necessity is an issue that may be properly
decided by the Workers’ Compensation Appeals Board, based upon substantial
evidence. Thus, if an injured worker believes that an RFA and PR-2 has
not received a timely response then it would be appropriate to seek legal
counsel to discuss the propriety of pursuing the matter further before the
Workers’ Compensation Appeals Board, or otherwise. However, if a utilization review decision is timely,
but the decision is denial of treatment or modification then an injured
worker’s sole remedy is to file for Independent Medical Review (a
topic to discuss further with an attorney).
Concluding
Remarks:
Obtaining medical treatment under a workers’
compensation claim is more complicated than simply taking a prescription to the
pharmacy and can often be a source of delay. However, working with one’s
workers’ compensation PTP and/or legal counsel are ways to help
facilitate treatment.
It is important to note that this article is not an
exhaustive explanation of all nuances pertaining to utilization review.
This article is intended to provide only general
information regarding the procedural steps and timing issues that must be
considered when pursuing medical treatment under workers’ compensation.
If you have suffered a work injury or are considering legal
representation related to workers’ compensation issues, please contact our
office at (916) 446-4692 for a free consultation.