The workers’ compensation system is designed to be a benefit delivery system to make the injured worker “whole” from their work-related injury, which includes medical treatment. Pursuant to Labor Code section 4600, medical treatment that is reasonably required to cure or relieve the injured worker from the injury shall be provided by the employer.
How do we determine if treatment is medically necessary? For starters, there must be a treatment report made by the injured worker’s doctor which outlines the plan of treatment. Typically, these reports often includes recommendations for certain services (for example, physical therapy, acupuncture, chiropractor visits), procedures (surgical and non-surgical treatment), medications, and referrals for specialists to address more complex medical issues or issues that are outside the expertise of the primary care doctor.
Request for Authorization (RFA)
How does that doctor go about requesting those additional services or treatment? First, they must submit a request for authorization (RFA) for treatment to the insurance company.
What is an RFA? Glad you asked! An RFA is a request for additional treatment/services to be authorized by the insurance company so that the treatment is covered under the Workers’ Compensation system.
The RFA must include: the treatment requested, the guidelines for treatment, what the treatment is for, and why the treatment is medically necessary.
Utilization Review (UR)
What happens next? When the defendant receives the RFA, they have two options: (1) they can approve the RFA, so treatment is approved immediately without further review; or (2) they can submit the RFA to utilization review (UR), which is where an independent doctor must review the RFA and determine if the request for treatment is medically necessary.
The UR doctor can either approve, deny or modify the treatment request. That decision is then submitted to the treating doctor.
Deadlines
Keep in mind, both the insurance company and the UR doctor have FIVE days from receipt of the RFA to approve, deny, or modify the request.
Meaning, the clock starts running the minute the insurance company receives the RFA from the initial doctor. They must submit it to UR immediately, and UR must make a decision within 5 days.
If they miss this deadline, then the defendant has two options: 1) they can either authorize the treatment, or 2) they can dispute it as not being reasonable and necessary if they truly believe it is not reasonable and necessary. However, please be forewarned that if the defendant goes with the second option, the applicant’s attorney will often file a DOR for an expedited hearing. At these expedited hearings, judges tend to lean toward approving the treatment and rejecting defendants’ arguments under the second option.
What if the UR doctor receives the RFA timely, but still needs additional information and requires more than 5 days to make a determination? For example, the UR doctor looks at the request for authorization for a knee surgery. However, the UR doctor needs an MRI to determine whether the RFA should be approved. In that scenario, the UR doctor has up to 14 days to make a determination on the RFA.
Also keep in mind, the UR decision is valid for one year from the date of decision. If a new UR is submitted within a year, it must have new or additional information to be considered for approval.
UR Denial/Non-Certification
Oftentimes, the UR doctor will not approve the RFA. This is only where UR made a timely decision within 5 days (or 14 days if they requested additional information within that first 5 days).
Again, if the UR denial was untimely, the defendant has the two options we discussed earlier – approving the treatment or disputing it as unreasonable and unnecessary. (And judges lean against that second option.)
What happens if the timely RFA is denied? The injured worker is unable to move forward with the initial doctor’s request for treatment. This often results in the applicant proceeding with more conservative care.
Independent Medical Review (IMR)
In the case of a UR denial, the injured worker can appeal the denial through IMR. An independent medical doctor will review the UR decision and determine whether the UR denial should be upheld or overturned. The injured worker must submit the request for IMR within 30 days of the UR denial. The IMR doctor has 30 days to make a decision on the UR denial, and can either uphold the UR denial or overturn the denial, or modify the UR denial (for example, partial approval and partial denial). If the IMR overturns the UR denial, then the treatment must be approved. If IMR upholds the UR denial, then treatment should be denied.
Retrospective UR decisions
What if medical services were already provided and UR had not been conducted yet or approval was not received?
For example, the injured worker received the knee surgery and an MRI but did not submit the RFA for surgery through the insurance company first? In that scenario, the insurance company has to provide written notice to deny all or part of the RFA within 30 days of receipt of the RFA.
Alternatively, the insurance company has to approve the services within 30 days of receipt of the RFA.
Keep in mind, failure to respond to a retrospective request can subject the insurance company to a $500 penalty for each failure.
Conclusion
There you have it, RFA/UR/IMR in a nutshell! Please note, this article only refers to the standards and procedures after 2013. Pre-2013 requests are subject to different procedures. Always be sure to check when the date of injury occurred.
Lastly, it’s worth noting that if an injured worker does not like the UR process, they should consider settling via Compromise and Release. Many people prefer not being subject to UR, and that’s okay – that’s why settlement via Compromise and Release exists.
Jessica E. Bair is an associate attorney at Bradford and Barthel’s San Jose office. If you have questions about workers’ compensation defense issues, please feel free to contact Jessica at 408.392.8202 or via email at jbair@bradfordbarthel.com.
Viewing this website does not form an attorney/client relationship between you and Bradford & Barthel, LLP or any of its attorneys. This website is for informational purposes only and does not contain legal advice. Please do not act or refrain from acting based on anything you read on this site. This document is not a substitute for legal advice and may not address every factual scenario. If you have a legal question, we encourage you to contact your favorite Bradford & Barthel, LLP attorney to discuss the legal issues applicable to your unique case. No website is entirely secure, so please be cautious with information provided through the contact form or email. Do not assume confidentiality exists in anything you send through this website or email, until an attorney/client relationship is formed.