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Secondary Physician’s RFAs Must Be Submitted to UR As Well

Happy Friday, dear readers!

One of the cases making the rounds and being discussed at the proverbial water coolers is that of Lopez v. City of San Francisco.  To cut to the chase, the issue presented was whether a request for authorization submitted by a secondary treating physician was subject to Utilization Review.  Or, another way to ask it – is the insurer/employer free to ignore RFAs by secondary treating physicians.

As we all know, California Code of Regulations section 9785 provides that an injured worker can only have one “primary treating physician” at a time (subsection (b)(1)) and a “secondary physician” is any physician other than the PTP who examines or provides treatment to the employee.

The panel of commissioners held that even though the RFA comes from the secondary treating physician, unless the employer wants the determination of medical necessity made by a judge on the merits, the employer must timely conduct utilization review.

Unless there’s a statutory amendment on the horizon, defendants would be well served to submit secondary treating physician requests for authorization to Utilization Review.  The only mitigating factor is the fact that under Labor Code section 4610(g)(6), a UR determination will typically stand for one year, unless the RFA is submitted by a new physician or there is a change in circumstances.

One of the frustrating things about this decision, however, is that an applicant can have any number of secondary treating physicians, who could all take turns submitting the exact same treatment request until there is a late UR report or a UR physician finally agrees.  In the meantime, defendants have to keep paying for every UR.

One of the things that should be considered when trying to see the forest behind all those pesky trees is whether it’s worth it: whether the cost of UR and IMR and the litigation surrounding both is worth the cost of the treatment.

Sorry folks – no good news for the defense community today.

Have a great weekend!

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