Hey, Utilization Review….Do You Have A Plan?

You could have heard a pin drop. I was speaking to 100’s of lawyers at the January 2020 CAAA Convention about the legal requirements that Utilization Review companies must meet before they can issue valid denials of medical treatment requests. Judging by the comments afterward, there were big concerns from the defense bar about whether the paperwork masquerading as Utilization Review is even admissible as evidence.

There are significant reasons for claims administrators and their lawyers to be concerned – the legal requirements are mandatory:

Labor Code Section 4610 requires that every Utilization Review company have a “Utilization Review Process” that complies with the law before treatment requests can be legally denied or modified. The Utilization Review Process shall:

• Be consistent with the Medical Treatment Utilization Schedule ( MTUS )
• Be accredited by URAC before 7/1/18
• Be submitted to the Administrative Director for approval
• Be developed with involvement with actively practicing physicians
• Be evaluated annually, and updated as necessary
• Disclosed to the physician that is requesting the treatment and to the injured worker

These requirements are IN ADDITION to all the other legal mandates that apply to Utilization Review, including communicating the Utilization Review decision in a timely manner. 

Is this a big deal? The California Supreme Court thinks so. In its decision Sandhagen vs. State Compensation Insurance Fund, the court regarded the Utilization Review Process as the “most significant” standard for evaluating treatment requests. 

Here is the bottom line – if a Utilization Review company denies or delays a medical treatment request, the defense attorney better shows up to court with proof that a legally valid Utilization Review Process was in place. 

Good luck with that. See you in court.