Utilization Review and California workers compensation
Utilization Review (UR) regulates medical treatment in California workers compensation cases. It effectively removes litigation of treatment disputes from the Workers Compensation Appeals Board (WCAB). Under current statutes all requests for medical treatment must be sent to Utilization Review unless the adjusting agency approves the treatment request outright. If the Request For Authorization (RFA) from the Primary Treating Physician is not on the proper form, a Primary Treating Physician Progress Report, or PR-2, it is invalid and can be denied on its face even before being sent to Utilization Review. It is therefore imperative that an injured worker in California finds a physician who knows and understands the reporting requirements mandated by the California Code of Regulations and MTUS (Mandatory Treatment Utilization Schedule). Even physicians in other states who are providing treatment for a California workers compensation claim must comply with California reporting requirements.
Once a Primary Treating Physician has made a proper treatment request on a PR-2, Utilization Review must be performed within five days of receipt of the treatment request. From an litigation standpoint, it can be difficult to obtain solid confirmation that the PR-2 was actually submitted to the workers compensation carrier and this has thwarted many attempts to enforce untimely Utilization Review denials.
The WCAB reviewed the matter of timeliness of UR treatment denials in a Significant Panel Decision in 2014 – Timothy Bodham vs San Bernadino County. In that decision the WCAB stated a defendant is obligated to comply with all time requirements when conducting Utilization Review, including communicating the decision to the interested parties. That would be the injured worker and treating physician. For a represented injured worker, it includes the Applicant attorney. A UR decision that is timely made, but not timely communicated is untimely. When a UR decision is untimely and therefore invalid, the treatment request is then subject to WCAB jurisdiction. The necessity of the treatment request subject to judicial review. The burden of proof is on the employee to prove the medical treatment requested is reasonably necessary. Again, if there is no proof the treatment request was submitted, the injured worker fails to meet the burden of proof regarding timeliness. .
For clarification the WCAB held in Puni Pa’u vs SCIF in 2019 that Saturday is not considered a working day when counting the days for completion of Utilization Review. However, the Code of Civil Procedure section 12a, extends the deadline for performance of acts that fall due on a Saturday.
If the UR that denies medical treatment in an RFA is timely, then the only remedy is to request Independent Medical Review (IMR). Whenever UR denies or modifies treatment, statutes provide the injured worker must be informed of the reasons for the denial or modification. Further the injured worker must be provided the the forms to appeal to IMR. Typically this is done by sending a copy of the Utilization Review denial along with the IMR appeal forms and the information necessary to file an appeal. It is a simple process of signing the appeal form and mailing or faxing it to Maximus who conducts all Independent Medical Review in California. I always recommend by clients fax the materials because it is free over the Internet and they get a fax confirmation that the appeal was sent and received by IMR.
A decision by Maximus is supposed to issue within 30 days of submission per LC 4610.6(d). However, as is usually the case in California workers compensation the District
Court of Appeals in SCIF vs WCAB, Margaris (2016) the statute “directory” not mandatory, which means the 30 day time frame can be essentially be ignored. Further, the Court held that the proper remedy for a failure to timely issue IMR is to file a writ of mandate under California Code of Civil Procedure 1085.
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