1. Utilization Review Treatment Guidelines

2. Utilization Review n As of 1/1/04 each employer had to file a program with the AD n Plans are listed at: http://www.dir.ca.gov/dwc/urplans.pdf http://www.dir.ca.gov/dwc/urplans.pdf n For treatment on or after 1/1/04 regardless of the date of injury

3. Request for Authorization n Means a written confirmation within 72 hours of a verbal request n Doctor’s First Report of Injury/Illness n Primary Treating Physician’s Progress Report (PR-2) or narrative that is marked as a request

4. Communication Requirements n Telephone access for physician requests 9:00 AM to 5:30 PM PST 9:00 AM to 5:30 PM PST n Facsimile available for physician requests

5. NON-PHYSICIAN REVIEW n Non-physicians may approve request n A non-physician reviewer may discuss request with the treating physician. n The treating physician can voluntarily withdraw the request and modify it and the non-physician may approve the modified request. n May request additional information also

6. Review Criteria n Review criteria is to be consistent with ACOEM or schedule adopted pursuant to LC section 5307.27 n If outside of those guidelines, then evidence- based, recognized by national medical community n Can give pre-authorization

7. Treatment Guidelines n RAND Study n AD proposes to adopt the second edition of ACOEM n AD is not proposing adoption of the American Academy of Orthopedic Surgeons’ guideline for spinal surgery n Evidence committee

8. ACOEM n Has a utilization management tool that is coming out shortly n APG Insights n Updating of second edition

9. Authorization n Means assurance that appropriate reimbursement will be made for the specific course of treatment n Bill review can look at the level of payment, but should not deny n Must specify what was authorized

10. Physician Involvement n Medical Director must hold an unrestricted California license and ensure compliance with law n Reviewing physicians don’t have to have CA license n Specific issues in review must be within the reviewer’s scope of practice n Only a physician can delay, deny, modify

11. Criteria Disclosure for Delayed, Denied, Modified n Written copy of relevant part of guideline shall be given to the physician, provider of goods, the IW, and the attorney (if represented). n Simply stating ACOEM was used is not sufficient n Form letter? n Contact information of reviewer with 4 hours of availability

12. UR Process Timetable Concurrent or Prospective n Not to exceed 5 days from receipt of info n If need more information, should not be more than 14 days from request n Must be communicated to physician within 24 hours by phone or fax n Followed by written confirmation within 48 hours for prospective/24 for concurrent

13. Delay n Decisions should be made in the first 5 days n A non-physician may request more info and wait for it for the first 14 days n Then a physician reviewer may put it on delay and inform the requesting physician/IW what additional info is needed in writing n Provide estimate of additional time necessary n Inability to talk to requestor is not sufficient

14. Retrospective –Must be communicated within 30 days of receipt of info –Failure to ask for authorization in an emergency is not a basis to deny

15. Timeframe (cont.) Expedited Review n Serious threat to health (loss of life, limb, bodily function) –Decision must be made in “a timely fashion” –Not to exceed 72 hours from receipt of info

16. Concurrent Review n In-patient treatment only n PT that was started doesn’t count n Treatment shall not be discontinued until a plan is agreed upon n Insurer is only liable to care that is medically necessary to cure and relieve n Disputes under LC § 4062

17. Failure to Comply? n Court decisions (e.g.Sandhagen) n Sanctions