Under Labor Code § 4600, the insurer or self-insured employer must provide medical treatment “reasonably required to cure or relieve the injured worker from the effects of his or her injury” or else face the risk of having to reimburse the employee for his or her visits to Dr. McOver-Prescribe.
But at what point do the adjuster’s duties of approving the treatment or undertaking the expense of Utilization Review kick in? For example, if a chiropractor calls the adjuster and says “Jim needs 100 more treatments of Placebo-tox” or “your employee Kathy would really benefit from my patented Medo-Widget,” must the adjuster act?
Or what if you open your mail and there is a note from a treating physician, simply saying “please authorize treatment X”?
Labor Code § 4603.2(a) states that the employee’s treating physician “shall submit a report to the employer within five working days of the initial examination and shall submit periodic reports at intervals that may be prescribed by rules and regulations adopted by the administrative director.”
So what regulations have been adopted by the administrative director? Take a look at 8 CCR § 9792.6 (o). This sets out the requirements for a request for treatment. If the request is made orally, such as in a telephone call, it must be followed by a written request within seventy-two hours.
The written requests (both as originals and as the follow-up) must be on forms PR-1 or PR-2. Otherwise, the request must be in a narrative, containing the same information as a PR-2, and “the document shall be clearly marked at the top that it is a request for authorization.”
In other words, if the proper procedure is not followed, no soup for you!
Greg, It might be helpful to remind your audience that the PR-1 is actually the DLSR 5021 or commonly known as the Doctor’s First Report of Injury.
Secondly, the Cervantes case is helpful here. The court made clear that a request for authorization must be marked as such as worded appropriately. It also made clear that service of the request on the claims adjuster begins the time frame for response regardless of the internal workflow or process between the claims administrator and its UR vendor. The time frame is not delayed if the requesting physician is asked to send the request to the UR vendor instead of the adjuster nor is the requesting physician required to comply with such a request in order for an otherwise valid written request to be considered properly served.
Steve:
You are absolutely right- the post has a link to the PR-1 form, but to be clear, it is the Doctor’s First Report of Injury form.
The Cervantes case (http://www.dir.ca.gov/wcab/wcab_enbanc.htm) had to do with spinal surgery and the imposition of the nearly impossible 10-day limit to UR and potentially deny the recommendation.
The language found there can be applied to any request for treatment, not just surgery, to the extent that a treating physician is required to clearly label the request for treatment as such.
Pingback: Sanctions for a Bad UR Report? Not in My CA! « wcdefenseca