Source: https://www.lexisnexis.com/LegalNewsRoom/workers-compensation/b/recent-cases-news-trends-developments/posts/california-ur-and-the-five-day-rules-watch-out
Timestamp: 2019-02-20 14:27:32
Document Index: 65336239

Matched Legal Cases: ['§ 4610', '§ 4603', '§ 4603', '§ 5402', '§ 5402', '§ 4610', '§ 4610', '§ 4610', '§ 4603']

California: UR and the Five Day Rules (Watch Out!) - Recent Cases, News, Trends & Developments - Workers' Compensation - LexisNexis® Legal Newsroom
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The time frames are changed if the request is for expedited review. Expedited review for prospective or concurrent request for treatment shall not exceed 72 hours from receipt. (Rule 9792.9.1(c)(3)(A))
The claims administrator (non-physician reviewer) has five business days to take one of the following actions:
2. Negotiate: The proposed regulations provide that the claims administrator can contact the requesting physician and negotiate an agreement on the treatment that will be approved by the claims administrator. (See Proposed Rule 9792.7(b)(3) at http://www.dir.ca.gov/DWC/DWCPropRegs/IMR/IMR_Regulations/IMR_Regulation.pdf) If this procedure is followed, the physician will withdraw the RFA and file a new RFA consistent with the agreement, which will then be approved by the claims administrator within five business days.
Note: Most defendants are already using this procedure today. The proposed change makes it clear in the new regulations that this is is a permissible procedure.
Commentary: Contrary to the belief of many, UR is only mandatory if the claims administrator wishes a physician reviewer to review the request for treatment in order to determine if the treatment should be approved, delayed, modified or denied.
Does the claims administrator have more than five days to approve or negotiate a proper treatment request? I would suggest that at this time the claims administrator complete the approval or negotiating process within five business days of receipt of the RFA. See the discussion below under timely UR.
3. Reject the RFA form as not being properly completed: If the RFA is not completed (as defined in Rule 9792.6.1(t)), a non-physician reviewer or the reviewer can either treat the form as complete and comply with the time frames or mark the form as not complete and no later than five business days return the request for authorization to the provider marked as not complete and the process will begin anew upon receipt of a new completed form RFA. (Rule 9792.9.1(c)(2))
Commentary: If the request for treatment is properly deferred, UR can be conducted retroactively when the threshold issue is finally determined. What if the Claims Administrator does not timely or properly issue the deferral? Has the defendant lost their right to retroactively conduct UR after the threshold issue is finally determined? Is the failure to defer in a timely manner similar to failure to conduct the initial UR review in a timely or proper manner that results in the defendant being liable for the treatment? (See Sandhagen v. WCAB (2008) 44 Cal.4th 230, 73 Cal.Comp.Cases 981 [73 CCC 981]) That is an issue to be determined by the courts in the future.
Practice Tip: Until this issue is decided, it is recommended that deferral be timely made within five business days and properly accomplished as outlined in the regulations. (See Rule 9792.9.1(b)(1))
6. Referring the matter to UR: The non-physician reviewer may refer the matter to UR which either approves the treatment request, denies, delays or modifies the treatment request. (Rule 9792.9.1(c) and (e)
If the treatment is approved by UR, defendants have no appeal rights and treatment is provided. (LC § 4610.3(a)-(c) [4610.3])
Practice Tip: Until this issue is finally determined by the courts, I believe it would be best practice to make sure that within five business days of receipt of the RFA, defendants make the decisions whether or not to refer the treatment request to UR.
Medical Control Issues: Related to the issue of utilization review is the issue of medical control. When the RFA is received, and if the treatment request is from a non-MPN physician, the defendants can issue a denial for the request for treatment, notifying the doctor he is not within the MPN. The issue of medical control is an issue to be determined by the WCAB at an expedited hearing. (LC 5502(b) and LC 5502(b)(B) [5502]) If the defendants prevail at the medical control hearing before the WCAB, they are not liable for any treatment of the non-MPN physician or any referrals made by the non-MPN physician. (LC § 4603.2(a)(3) [4603.2]) If the applicant prevails at the expedited hearing and was permitted to treat outside the MPN, applicant may continue to treat with that physician and defendants lose medical control for that physician. (LC § 4603.2(a)(2))
Can the defendants UR the treatment requests made by the non-MPN physician prior to the expedited hearing on medical control? In my opinion, the defendants can issue a timely deferral of UR of the non-MPN physician’s treatment request within five business days of receipt based on the threshold issue of medical control. Defendants, if they were to lose the medical control issue at the expedited hearing, could then claim the right to retroactive UR of the physician treatment requests based on their timely deferral. This issue will have to be decided by the courts.
Do not forget about LC § 5402(c) [5402] in which defendants are liable for up to $10,000 in medical treatment until liability is accepted or rejected. Defendants would be wise to apply the UR procedure to this treatment. Defendants can dispute medical necessity of the treatment, but they may be liable for up to $10,000 pursuant to LC § 5402(c).
The applicant can contest that the UR decision was timely or not properly conducted by defendant and request an expedited hearing on this issue. If the applicant prevails at the expedited hearing and proves that the UR was not timely or not conducted properly (in accordance with the regulations), the WCJ can award the applicant medical treatment if the applicant has introduced at the expedited hearing a medical report that is substantial evidence supporting the treatment. (LC § 4610.5, Rule 9792.9.1, Rule 9792.10.1, Corona v. Los Aptos, 2011 Cal. Wrk. Comp. P.D. LEXIS 156, Becerra v. Jack’s Bindery, 2012 Cal. Wrk. Comp. P.D. LEXIS 451)
If the defendants prevail at the expedited hearing, the UR will become final unless the applicant has timely and alternatively requested IMR. (See LC § 4610.5, Rule 9792.9.1, Rule 9792.10.1(b)) Most of the time, if the applicant is contesting whether the UR is timely and proper by expedited hearing, the applicant should also timely request IMR in case they do not prevail in the expedited hearing, in which case they can then proceed to IMR.
A utilization review decision to modify delay or deny a request for authorization of medical treatment shall remain effective for 12 months from the date of the decision without further action by the claims administrator with regard to any further recommendation by the same physician for the same treatment unless the further recommendation is supported by a documented change in the facts material to the basis for the UR decision. (LC § 4610(g)(6) [4610], Rule 9792.9.1(g))
Note: Independent Bill Review (IBR) applies to all treatment requests ultimately approved and have separate procedures and time frames, including delay procedures pending the outcome of threshold issues. Independent Bill Review is not discussed in this article but must be taken into account in handling receipt of bills for medical treatment including disputed medical treatment. (LC §§ 4603.2, 4603.6, 4622 and 139.5 [4603.2, 4603.6, 4622, 139.5]) For further discussion of IBR, see Rassp & Herlick, California Workers’ Compensation Law, Ch. 17, Liens [Ch. 17] (LexisNexis).
© Copyright 2013 LexisNexis. All rights reserved. This article will appear in an upcoming issue of California WCAB Noteworthy Panel Decisions Reporter (LexisNexis).