Opinion ID: 1801902
Heading Depth: 4
Heading Rank: 1

Heading: Historical Evolution of the Treatment Request Process

Text: The workers' compensation scheme makes the employer of an injured worker responsible for all medical treatment reasonably necessary to cure or relieve the worker from the effects of the injury. (§ 4600, subd. (a).) When a worker suffers an industrial injury, the worker reports the injury to his or her employer and then seeks medical care from his or her treating physician. After examining the worker, the treating physician recommends any medical treatment he or she believes is necessary and the employer is given a treatment request to approve or deny. The standards applied in evaluating these treatment requests and the process by which treatment requests are resolved have both been significantly modified in the recent past. For our purposes, the relevant periods are (1) the time preceding passage of Senate Bill No. 228, (2) after Senate Bill No. 228 went into effect on January 1, 2004, and (3) after Senate Bill No. 899 went into effect on April 19, 2004.
Before the passage of Senate Bill No. 228, there were no uniform medical treatment guidelines in effect. Whether a medical treatment request was necessary depended solely upon the opinion of the treating physician measured against the general standard that necessary treatment was that which was reasonably required to cure or relieve the injured worker of the effects of his or her injury. (Former § 4600, as amended by Stats. 1998, ch. 440, § 2.) Moreover, former section 4062.9 provided a rebuttable presumption that the findings of an injured employee's treating physician were correct. (Stats. 2002, ch. 6, § 53.) If an employer wanted to obtain a report from a doctor other than the treating physician regarding the necessity of certain medical treatment, essentially the only option for the employer was to initiate the rather cumbersome, lengthy, and potentially costly process under former section 4062, a catchall dispute resolution provision. Former section 4062, subdivision (a) provided that, [i]f either the employee or employer objects to a medical determination made by the treating physician concerning ... the extent and scope of medical treatment ... or any other medical issues not covered by Section 4060 or 4061, [7] the objecting party shall notify the other party in writing of the objection.... (Stats. 2002, ch. 6, § 52, italics added.) An employer objecting to a treatment request had to do so within 20 days if the injured employee was represented by counsel, and within 30 days if the employee was unrepresented, although the time limits could be extended for good cause. (Former § 4062, subd. (a), as amended by Stats. 2002, ch. 6, § 52.) In the case of a represented employee, the statute directed the parties to seek agreement on a physician to prepare a comprehensive medical evaluation resolving the disputed issue. ( Ibid. ) If the parties were unable to pick an agreed medical evaluator (AME) within 10 days (or 20 days if the parties agreed to extend the time), the parties could not thereafter select an AME. ( Ibid. ) After the time for reaching an agreement had expired, the objecting party could select a qualified medical evaluator (QME) to conduct a comprehensive medical evaluation. ( Ibid. ) The nonobjecting party could choose to rely on the treating physician's report or could select a QME of its own, to conduct an additional comprehensive evaluation. ( Ibid. ) [8] The employer was liable for the cost of a medical evaluation obtained by the employee pursuant to former section 4062. (§ 4064, subd. (a).) After the injured worker was examined, the scheduling of which often resulted in further delays, the AME or QME had 30 days in which to prepare an evaluation, addressing all contested medical issues, and serve the evaluation and a summary on the employee, employer, and the Administrative Director of the Division of Workers' Compensation (administrative director). [9] (Former § 139.2, subd. (j)(1), as amended by Stats. 2000, ch. 54, § 1; former § 4062, subd. (c), as amended by Stats. 2002, ch. 6, § 52.) If a dispute remained after the comprehensive medical evaluations were completed, either party could request an administrative hearing. (§ 5500.) If the hearing failed to satisfy the parties, they could seek reconsideration by the WCAB (§ 5900) and, ultimately, review by the Court of Appeal (§ 5950). There was also an administrative (rather than statutory) utilization review alternative to proceeding under former section 4062. (Cal. Code Regs., tit. 8, former § 9792.6, Register 98, No. 46 (Nov. 13, 1998).) However, use of the process was voluntary and, because the administrative process contained no uniform medical standards, interested employers had to first undertake a complicated effort to design and submit their own medically based criteria to the administrative director. ( Id., subds. (b), (c), (d) & (e).) [10] As a result, the administrative process was little used and most treatment requests were resolved via the procedures in former section 4062.
Senate Bill No. 228, effective January 1, 2004, enacted comprehensive workers' compensation reform. The Legislature, reacting to escalating costs, made a number of critical changes to the statutory scheme. Particularly relevant here are changes to the standards used in evaluating medical treatment requests as well as alterations to the process for resolving the treatment requests. The Legislature added section 5307.27, directing the administrative director to adopt a medical treatment utilization schedule to establish uniform guidelines for evaluating treatment requests. (Stats. 2003, ch. 639, § 41.) The provision further provides that this schedule shall incorporate evidencebased, peer-reviewed, nationally recognized standards of care and address the appropriateness of all treatment procedures ... commonly performed in workers' compensation cases. (§ 5307.27.) The Legislature also amended section 4062.9, limiting the presumption of correctness that had previously applied to a treating physician's opinion (Stats. 2003, ch. 639, § 20), and added section 4604.5, which created a rebuttable presumption that the treatment guidelines in the utilization schedule were correct on the issue of extent and scope of medical treatment. [11] (Stats. 2003, ch. 639, § 27.) (3) In addition to changing the standards for evaluating treatment requests, Senate Bill No. 228 also made a number of important changes to the process of resolving treatment requests. Most significantly, the Legislature enacted a statutory utilization review process in section 4610. (Stats. 2003, ch. 639, § 28.) In addition to requiring every employer to establish a utilization review process (§ 4610, subd. (b)), section 4610 also enacted a number of procedural and substantive requirements. Most notably, subdivision (e) of section 4610 allows only a licensed physician, who is competent to evaluate the specific clinical issues involved, to modify, delay, or deny requests for treatment. Accordingly, while medical review is not required if the employer approves the treatment request, section 4610 requires that a licensed doctor deny, delay, or modify the request. This represents a significant departure from the process in former section 4062, which permitted an employer or claims adjuster (without review by a physician) to object to a treatment request. (§ 4062, as amended by Stats. 2002, ch. 6, § 52.) Section 4610, subdivision (g) imposes a number of additional requirements that must be met as part of the utilization review process. Among them are: (1) treatment decisions must be made in a timely fashion, not to exceed five working days from the receipt of information reasonably necessary to make the determination, and in no event more than 14 days from the date of the request for treatment (§ 4610, subd. (g)(1)); (2) if the request is not approved in full, disputes shall be resolved in accordance with section 4062 (§ 4610, subd. (g)(3)(A)); and (3) if an employer cannot make a decision within the specified timeframes because it (a) is not in receipt of all the information reasonably necessary and requested, (b) requires consultation by an expert reviewer, or (c) has asked that an additional examination be performed on the employee that is reasonable and consistent with good medical practice, the employer must immediately notify the physician and the employee. ( Id., subd. (g)(5).) Upon receipt of all information reasonably necessary and requested by the employer, the employer shall approve, modify, or deny the request for authorization within the specified time frames. ( Ibid. ) (4) As the Court of Appeal here recognized, the Legislature intended utilization review to ensure quality, standardized medical care for workers in a prompt and expeditious manner. To that end, the Legislature enacted a comprehensive process that balances the dual interests of speed and accuracy, emphasizing the quick resolution of treatment requests, while allowing employers to seek more time if more information is needed to make a decision. (§ 4610, subd. (g).) If the treatment request is straightforward and uncontroversial, the employer can quickly approve the requestutilization review is completed without any need for additional medical review of the request. If the request is more complicated, the employer can forward the request to its utilization review doctor for review, since the statute requires that the employer seek a medical opinion before modifying, delaying, or denying an employee's request for medical treatment. ( Id., subd. (e).) [12] This ensures that a physician, rather than a claims adjuster with no medical training, makes the decision to deny, delay, or modify treatment.
As we recently noted, Senate Bill No. 899 was passed as an urgency bill in response to a perceived crisis in skyrocketing workers' compensation costs. ( Brodie v. Workers' Comp. Appeals Bd. (2007) 40 Cal.4th 1313, 1329 [57 Cal.Rptr.3d 644, 156 P.3d 1100].) Like Senate Bill No. 228, Senate Bill No. 899 was an omnibus reform that made a number of significant changes to the workers' compensation scheme, including, as particularly relevant here, altering the standards used in evaluating workers' requests for medical treatment and the process for evaluating them. With Senate Bill No. 899, the Legislature amended section 4600 to define medical treatment that is reasonably required to cure or relieve the injured worker from the effects of his or her injury as treatment that is based upon the guidelines adopted by the administrative director pursuant to Section 5307.27 or, prior to the adoption of those guidelines, the updated American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines. (Stats. 2004, ch. 34, § 23.) Senate Bill No. 899 also repealed section 4062.9, which had contained a presumption of correctness for the findings of an injured employee's treating physician (Stats. 2004, ch. 34, § 22), while making slight modifications to section 4604.5, which contains a presumption of correctness for the treatment guidelines. (Stats. 2004, ch. 34, § 25.) The Legislature amended section 3202.5 to underscore that all parties, including injured workers, must meet the evidentiary burden of proof on all issues by a preponderance of the evidence. (Stats. 2004, ch. 34, § 9.) Accordingly, notwithstanding whatever an employer does (or does not do), an injured employee must still prove that the sought treatment is medically reasonable and necessary. That means demonstrating that the treatment request is consistent with the uniform guidelines (§ 4600, subd. (b)) or, alternatively, rebutting the application of the guidelines with a preponderance of scientific medical evidence (§ 4604.5). While Senate Bill No. 899 did not alter the section 4610 utilization review process, it made a number of changes to the dispute resolution process in section 4062 that are particularly relevant here. First, the prior version of section 4062, subdivision (a) (Stats. 2003, ch. 639, § 17) permitted an employee or employer to object to a treating physician's medical determination regarding the permanent and stationary status of the employee's medical condition, the employee's preclusion or likely preclusion to engage in his or her usual occupation, the extent and scope of medical treatment, the existence of new and further disability, or any other medical issues not covered by Section 4060 or 4061 .... (Italics added.) The Legislature amended section 4062, subdivision (a), eliminating the extent and scope of medical treatment from the list of things to which an employer may object. (Stats. 2004, ch. 34, § 14.) Subdivision (a) of section 4062 now permits an employer to object only to medical determinations regarding any medical issues not covered by Section 4060 or 4061 and not subject to Section 4610 .... (Italics added.) Second, Senate Bill No. 899 made another change to section 4062, subdivision (a), adding that [i]f the employee objects to a decision made pursuant to Section 4610 to modify, delay, or deny a treatment recommendation, the employee shall notify the employer of the objection in writing within 20 days of receipt of that decision. (Stats. 2004, ch. 34, § 14, italics added.) Senate Bill No. 899 also changed the AME/QME process, eliminating the competing comprehensive evaluations that often existed under former section 4062. In the case of represented employees, the bill repealed former section 4062.2 (Stats. 2004, ch. 34, § 17) and replaced it with new section 4062.2 (Stats. 2004, ch. 34, § 18). As with the procedure under former section 4062, new section 4062.2 instructs the parties to attempt to select an AME. If the parties cannot reach an agreement within 10 days (or 20 days if the parties agree to extend the time), either party may request a three-member panel of QME's be assigned. ( Ibid. ) The parties must then confer and attempt to agree on one of the QME's. ( Ibid. ) If the parties have not agreed on a medical evaluator from the panel by the 10th day after assignment of the panel, each party may then strike one name from the panel and [t]he remaining [QME] shall serve as the medical evaluator. ( Ibid. ) [13] [N]o other medical evaluation shall be obtained. (§ 4062, subd. (a).) [14]