Is utilization review required in every case?
A. While the DWC has interpreted LC 4610(a) to require that all requests for authorization are subject to the UR time requirements and procedures, claims administrators are allowed and encouraged to establish guidelines within their utilization review plans under which certain requests for treatment are not required to go through a third party UR process. The DWC supports the establishment of “UR best practices” that allow claims administrators to approve appropriate levels of care for injured workers at the lowest possible levels within the claims organization, without having to send those requests through a third party process. Additionally, the UR regulations provide a way to give physicians authority to treat their patients without requesting authorization at all. This process is called “prior authorization.” “Each utilization review process shall be set forth in a utilization review plan which shall contain: “… a description of the claims administrator’s practice, if applicable, o
A. Yes. The California Supreme Court held in State Comp. Ins. Fund v. Workers’ Comp. Appeals Board. (Sandhagen) (2008) 44 Cal. 4th 230, 73 Cal. Comp. Cas 981, that utilization review must be used for every medical treatment request in the California workers’ compensation system. In Sandhagen, the court also held that approving requested treatment without physician review is part of utilization review (UR), and only reviewing physicians may decide to delay, deny or modify requested treatment. The court explained that employers/insurers may not skip UR by simply objecting to a medical report and starting the AME/QME process to dispute a medical treatment request. UR is the employer’s only avenue to reject a requested treatment. The UR regulations allow an employer to reduce the cost of physician review in UR by designing a “prior authorization” program within the employer’s UR plan. (See section below, ‘About prior authorization.’) DWC supports the establishment of “UR best practices” th
Related Questions
- Do utilization review companies and case management companies require a license in order to contract with a Workers Compensation Managed Care Organization (WCMCO) or any other entity?
- Once a continued stay review is certified, will the same case ever be selected for retrospective post-payment review?
- Is utilization review required in every case?
