Clarifications on the Utilization Review Process
Utilization review, as defined by the DIR, is the process used by employers or claims administrators to determine if a proposed treatment requested for an injured worker is medically necessary. In essence, a utilization review (UR) is a process for evaluating requested treatment and its necessity (or lack thereof). Having a UR program is necessary by law for employers and claims administrators, and all UR evaluations are measured against California’s medical treatment utilization schedule (MTUS). However, various decisions in Workers’ Comp Appeals Board (WCAB) cases have updated and clarified key components of the UR process, specifically for admitted and denied cases as well as UR denials.
URs in Admitted and Denied Cases
In the 2008 Sandhagen case, the Supreme Court had clarified that, in admitted cases, the utilization review must be enacted every time a request for medical treatment is made. If an employer does not enact a utilization review after requested treatment, the employer cannot use the medical-legal process to prove lack of medical necessity. If the employer has performed a timely utilization review and has authorized treatment, the medical provider will be paid. If the employer denies medical necessity through a timely UR, then only the requesting provider can initiate the medical-legal process.
In denied cases, the employer has 90 days from the date of claim filing to admit or deny the injury. If the employer does not deny within 90 days, the injury will be deemed as admitted, and the UR process can occur. A UR can be limitedly admitted for determining the need for the requested medical treatment, but it cannot be admitted to show that the industrial injury was caused or contributed to the need for treatment.
UR Denial Timeline
The WCAB had also clarified the timeline that a utilization review is measured against for its timeliness. In the recent 2015 Dubon II case, the WCAB found that, if a request for authorization (RFA) is marked as an “imminent and serious threat,” it subjects the RFA to an expedited review. If the imminent and serious threat box is marked within an RFA, the UR reviewer must apply an expedited and separate timeline and must issue a UR decision within 72 hours of receiving the necessary information.