No UR Necessary After Denial Issues; Even for Pending RFAs
Alright dear readers, your humble blogger is going to give you some advice – and this advice is both free and priceless.
Normally, I would hold off on giving recommendations over a forum like a blog because of the whole potential for malpractice and sometimes it triggers a flood of e-mails telling me to mind my own business. But, nevertheless, here it goes.
Invest, heavily and consistently, in a calendar.
Yep, that’s it.
Dates matter. They mattered in high school, the mattered in college, and they matter even more in the whimsical world of workers’ compensation.
In the case of Ghattas v. O’Reilly Auto Parts, applicant’s claim was on delay while defendant conducted its investigation. During this time, an RFA was submitted, but, prior to the treatment being authorized, the claim was denied. Well, applicant reasoned that because the RFA was submitted before the denial date, and the $10k treatment cap had not yet been reached, then he was entitled to the treatment (surgery, in this case) because the RFA was not submitted to UR.
By contrast, defendant took the position that there’s no need to burn money on UR because the treatment will be denied regardless, based on the claim denial.
The parties proceeded to trial and the WCJ ordered defendant to provide the treatment. However, the WCAB reversed on defendant’s petition for reconsideration.
Relying on Labor Code section 5402(c), the WCAB noted that medical treatment is defendant’s obligation “until the date that liability for the claim is accepted or rejected.” Since liability was rejected, no further treatment is due (absent a finding of AOE/COE).
Calendars, dear readers, calendars.
But could we take this one step further?
California Code of Regulations section 9785(a) provides that a chiropractor cannot be the PTP after an applicant has had 24 chiropractic visits.
What happens to all the RFAs pending on the chiropractor’s 24th visit? What if the next PTP decides that the Chiropractor’s RFAs are rubbish and has a new treatment plan? Does defendant have to submit those RFAs to UR?
My thinking is: no. Only the PTP (or, possibly, a secondary physician) can submit RFAs, and the chiropractor is neither after the 24th visit.
What about you, readers? Has your experience been similar?