The New Year will bring new changes to the workers’ compensation laws. SB863 will change the utilization review process to include an Independent Medical Review. The Independent Medical Review process is designed to allow the applicant the opportunity to challenge the decision of utilization review. Labor Code section 4610.5(e) specifically states a utilization review decision may be reviewed or appealed only by independent medical review. Therefore, it is important to know the basics on how the independent medical review will change how we proceed with providing medical treatment
When Is An Employee Entitled to An Independent Medical Review?
An employee is entitled to an independent medical review if utilization review issues a decision to deny, modify, or delay a treatment recommendation. (Labor Code section 4610.5(d))
How Long Does the Employee Have to Request An Independent Medical Review?
The employee has 30 days after service of the utilization review decision to request an independent medical review. (Labor Code section 4610.5 (h)(1)) However, there are exceptions which may extend the employee time to request an independent medical review.
Where Does the Employee Submit the Request For An Independent Medical Review?
The employee submits the request for an independent medical review to the administrative director. The administrative director will notify the parties whether the employee’s request has been approved. (Labor Code section 4610.5 (k))
What If There Are Other Reasons For Denying Medical Recommendations?
If the employer is disputing medical treatment for any reason besides medical necessity, the administrative director will defer issuing a decision. (Labor Code section 4610.5 (k)) Therefore, it will be important to provide a timely written notice to the administrative director listing disputed issues affecting the authorization of treatment which are unrelated to medical necessity.
How Long Does the Independent Medical Reviewer Have To Issue A Decision?
The independent medical review organization has 30 days from receipt of the supporting documents to issue his or her determination. (Labor Code section 4610.6(d))
What Is the Next Step After Receiving the Decision?
If the independent medical review approves the medical recommendations and services were previously provided then the employer must reimburse the provider within 20 days of receiving the decision. If the services were not provided, then the employer must issue authorization within five days of receiving the decision. (Labor Code section 4610.6 (j))
Is There Anything Else I Should Know About the Independent Medical Review Process?
Yes, there is a lot to know about the new process and the law governing it. One important fact to keep in mind is that an employer is not liable for medical treatment furnished without the authorization of the employer. If treatment is delayed, modified, or denied by utilization review, liability only incurs to the employer if the decision is overturned by independent medical review. (Labor Code section 4610.5 (e))
A word of warning: Providers may furnish treatment with the hopes that independent medical review will overturn the utilization review decision but it will be the responsibility of all to affirm the new regulations to create a consistent implementation of the independent medical review process.