All employers have an obligation to issue treatment decisions in connection to requests for authorization for treatment in a “timely fashion.” This duty arises in part pursuant to Labor Code § 4610, which sets forth that every employer is required to establish a utilization review process for assessment and determination of requests for treatment authorization by an injured worker’s physician.
The timeframes for utilization review decisions are specified under the Labor Code, and clarified under the California Code of Regulations. The timeframe allowed for UR determinations varies depending on whether the treatment in question is being requested prospectively or concurrently, retrospectively, or in relation to request for expedited review.
For prospective of concurrent decisions, the labor code provides that a decision shall be made in a “timely fashion” that is appropriate for the nature of the employee’s condition, not to exceed 5 working days from the receipt of the information reasonably necessary to make the determination, but no later than 14 days from the date of issuance of the treatment recommendation. (LC §4610 (i)(1))
Regarding prospective/concurrent decisions- Note the hard decision deadline of 14 days from treatment recommendation. The decision shall issue no later than 14 days of receipt. However, while a decision is generally required within 5 working days from date of receipt by UR, there is some discretion allowed when information “reasonably necessary” to make the decision in light of the nature of the condition in question. Reasonable minds may disagree on what information may be “reasonably necessary” in order to make a determination. Read: potential dispute issue.
Retrospective decisions to approve modify, delay, or deny a request for authorization must be made within 30 days of receipt of the medical information necessary to make the determination. What’s reasonably necessary? Again, subject to argument. (LC § 4610 (i)(2))
In regards to request submitted for expedited review, decision shall be made in a timely fashion that is appropriate for the nature of the employee’s condition, but not to exceed 72 hours after the receipt of the information reasonably necessary to make the decision. But what’s reasonable? What’s necessary? Arguable. (LC 4601 § (i)(3))
Absent issuance of a treatment determination in a “timely fashion,” employers face possible penalties for each failure to meet any of the statutory timeframes which may impose penalties as provided under Title 8 California Code of Regulations § 9792.12, at the discretion of the Administrative Director.
In addition to possibility of administrative penalties, untimely utilization review decisions may be challenged by injured workers to the Board as invalid. The Board would then have jurisdiction, or in other words, the power to determine the prima facie issue of whether the UR decision was in fact statutorily untimely.
Only where the Board finds that a utilization review decision is untimely, does the Board have jurisdiction, or power, to address the pertinent substantive medical issues.
In such a case, the Board must then make a determination on the disputed medical treatment, based upon substantial medical evidence, with the applicant having the burden of proof.
The injured employee is nevertheless entitled only to “reasonably required” medical treatment (§ 4600(a)) and it is the employee’s burden to establish his or her entitlement to any particular treatment (§§ 3202.5, 5705), including showing either that the treatment falls within the presumptively correct MTUS or that this presumption has been rebutted. (§ 4604.5; see also § 5307.27.) The employee must present substantial medical evidence. (Dubon v. World Restoration, (2014) 79 Cal. Comp. Cases 1298, 1312)
Appropriate utilization review procedural compliance is crucial to the administration of claims. Compliance with timelines helps ensure prompt provision of information vital to the execution medical treatment plans necessary for progression towards maximum medical improvement, and the ultimate resolution of claims.
Additional information and FAQs regarding Utilization Review can be obtained through the California Department of Industrial Relations website: http://www.dir.ca.gov/dwc/utilizationreview/ur_faq.htm