Labor Code 4600 & The Utilization Review Process
Labor Code 4600 and The Utilization Review Process
Did you know that under Labor Code section 4600, the employer’s workers’ compensation insurance carrier is responsible for all medical treatment “reasonably necessary to cure or relieve” the effects of the injury? Once the injury is reported to the employer, the employer should refer the injured worker for medical care. A physician recommends medical treatment that s/he believes necessary to “cure or relieve” the industrial injury. The physician must submit a treatment plan in the form of a Request for Authorization (“RFA”) for the employer to approve, deny, or modify. This falls under the Utilization Review (“UR”) process. The UR process serves as a body under which requests for medical treatment may be reviewed by the insurance carrier. Upon receipt of an RFA, UR has five (5) working days to issue a decision. If medical treatment is approved by UR, the insurance carrier must authorize it. What happens if UR denies medical treatment? First, if medical treatment is denied, UR must notify the injured worker, the physician recommending the treatment, and the injured worker’s attorney (if represented). Notice is important—failure to properly notify all parties of UR’s denial for treatment may render the UR denial defective! Second, assuming notice is timely and appropriate, an injured worker has the right to challenge the determination if medical treatment is denied or modified! To challenge a UR decision, an injured worker must request an Independent Medical Review (“IMR”) and appeal UR’s denial. The IMR Application should always be provided to the injured worker along with notice of UR’s denial for treatment.
Other important points to consider…
What happens if an Independent Medical Review upholds the Utilization Review’s decision?
If an Independent Medical Review agrees with UR’s initial denial, IMR notifies all parties in writing. Once IMR upholds UR’s denial, such a decision is valid for one (1) year, unless there is a change in circumstances. It is important that the injured worker’s physician documents the change in circumstance. Often, a change in medical condition may prompt the injured workers’ physician to renew an RFA for treatment recommended that was already subject to the UR process, where UR issued a denial and IMR upheld such UR denial.
What happens when a physician is outlining medical treatment for denied body parts?
When a physician is outlining medical treatment for denied body parts, then the Utilization Review must still issue a written response to any/all RFAs submitted within five (5) days. UR may defer on a decision as to whether the treatment is reasonably necessary to cure the effects of the injury if the employer is disputing liability for the industrial injury and/or body part.
There are many layers to the Utilization Review (UR) process and fact-based dependent. The attorneys at Ford & Wallach know your rights and will help you through every step of your workers’ compensation claim.
Ford & Wallach offers a free case evaluation. Contact us by email or call 213.380.3140.