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No Half Measures on Improper Treatment Requests

July 12th, 2013

So, as this humble blogger’s beloved readers are very well aware, California Code of Regulations section 9792.6, subsection o, requires a primary treating physician’s “Request for Authorization” of medical treatment to be made on a PR-2 form “or in narrative form containing the same information required in the PR-2 form.”  In fact, the Workers’ Compensation Appeals Board, in Cervantes v. El Aguila Food Products (2009; en banc) held that, at least for spinal surgery, a request for authorization “must comply with AD Rule 9792.6(o)”.

So then, consider, the curious case of Stefano Musetti (Musetti v. Golden Gate Disposal & Recycling).  There, applicant’s primary treating physician requested authorization for total knee replacement surgery.  Although the PTP used the PR-2 form, he did not check “surgery or hospitalization” or “request for authorization.”

The report, dated September 20, 2012, was served on defendant by applicant’s counsel on October 26, 2012, and then the defendant objected, and wrote to the panel QME requesting his opinion, on December 4, 2012.  So, assuming 5 days for mailing, defendant received the “request for authorization” on October 31, and waited until December 4, 2012 to request a report from the PQME.

The WCJ, over defendant’s objection, allowed an expedited trial on the issue to go forward, and then found that “Defendant has been in receipt of this report and has delayed in forwarding the report to the panel QME,” and awarded the surgery.

So, in short, the primary treating physician didn’t properly fill out a PR-2 form, and the defendant took too long, by waiting one month, in forwarding the report to the PQME.

In reviewing the case and denying defendant’s petition for reconsideration, the WCAB reasoned that the issue of whether one month was too long to wait should not have been reached, because defendant did not first conduct Utilization Review.  But was there an obligation to refer the faulty request for authorization to UR in the first place?  After all, if the doctor had faxed a post-it note with the applicant’s name, the doctor’s signature and the word “TKA” (Total Knee Anthroplasty) to the defendant… would that have counted as a valid request for authorization?

Well, the WCAB noted that “by the time of defendant’s November 18, 2012 [objection] letter, however, defendant had apparently examined Dr. Forster’s request and realized that he was seeking authorization for surgery.”

So, what do you do when you have a faulty request for authorization?  According to this panel opinion, what you DON’T do is engage in half-measures: Either ignore it like you would a post-it note faxed to your office, or process it through Utilization Review and proceed with IMR.

By writing an objection or going to a PQME, or doing anything that would seem prudent in a reasonable world and a fair system, you are acknowledging that you understand that this is a request for authorization of treatment, and the reasoning of Cervantes falls away (“Rule 9792.6(o) … recognizes that claims adjusters routinely receive numerous medical reports from treating physician.  Therefore, if in a spinal surgery case a particular report might trigger the 10-day deadline for a defendant to both complete UR and make a section 4062(b) objection, then the defendant should be given clear notice that authorization for spinal surgery is being requested.”)

But, remember, dear readers, the WCAB also bent over backwards to accommodate an applicant in the matter of Valerie Morales v. General Design Concept, where the WCAB treated the applicant’s DOR as an objection to Utilization Review, allowing the applicant to then request a PQME opinion on the issue of medical treatment, even though the time to make a specific objection to the UR determination had gone the way your humble blogger’s youth and optimism.

So, no “gamesmanship” – once you realize this is a request for authorization, put it through UR before you do anything else.  And, if your claims office or defense firm has a long procedure before incoming mail reaches the desk of the adjuster or attorney handling it, perhaps protocols should be put in place to highlight PR-2s or medical reports that request authorization.

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