What happens when the defense does not comply with Labor Code section 4610? Well, if you ask a lien claimant or one of their reps, the answer is pretty clear – there may be good in the world, there may be evil; some things may be right, or may be wrong; it’s even possible for the world to be flat… but if the employer fails to go through the UR dance, the lien claimant automatically gets paid and the adjuster has to watch the lien-claimant drink a delicious milkshake and isn’t allowed to ask for a sip.
The Workers’ Compensation Appeals Board has a slightly different take on the issue.
Labor Code section 4610 lays out the general rules regarding Utilization Review. In the case of Thomas Coffin v. Robert Munson, Inc., a lien claimant sought to have the employer’s insurance company pay out for various self-procured medical treatment items after the insurer declined to pay for Utilization Review.
Unimpressed with lien-claimant’s bill, the defendant allowed the matter to proceed to a trial and presented no evidence. Lien-claimant, on the other hand, presented evidence of various physicians prescribing the medications that lien-claiming provided over a 25-month period. As the trial was nearing a close, lien-claimant was dreaming of how it would spend its $27,411.35 as claimed in the lien… until that fantasy bubble was burst by the workers’ compensation Judge’s finding in favor of the defense.
Lien-claimant had failed to provide documentation that any of the prescribing physicians were applicant’s primary treating physician as required by Labor Code section 4600. In fact, lien-claimant failed to provide any documentation that any of the physicians prescribing the medication provided by lien-claimant were the primary treating physician at any point.
Furthermore, there was no evidence that the reports requesting the treatment were served on the defense or that they complied with California Code of Regulations section 9792.6(o).
In denying the lien-claimants petition for reconsideration, the WCAB incorporated the WCJ’s report.
Adjusters are often overworked and spend their days watching the piles of papers stack up around them as they scramble to keep up. So, naturally, it is often easy to send everything to Utilization Review. Sometimes, that doesn’t happen, but that doesn’t automatically mean that the defendant becomes liable for the requested treatment.
As this case shows, the burden is always on the lien-claimant to prove that the treatment was reasonable and necessary. And for treatment to be reasonable and necessary (read: paid for by the defense) the primary treating physician needs to be in the picture. That wasn’t the case here and the defense managed to dodge over $27,000 in bills.