In California workers’ compensation, Utilization Review (UR) evaluates the medical necessity of treatments for injured workers based on the Request for Authorization (RFA) submitted by medical providers. UR can be prospective, beginning upon receipt of a DWC Form RFA, or retrospective, starting after a liability determination. Understanding the role of retro UR in workers’ comp is crucial, as administrators must follow UR guidelines per Title 8, California Code of Regulations, Section 9792.9.1. Insurers must respond to RFAs within five working days and have 30 days to file for retrospective UR after a liability determination. Failing to adhere to these guidelines forfeits the right to perform retrospective UR.
Utilization Review in Workers’ Compensation plays a critical role in managing costs and ensuring that only medically necessary treatments are approved.
For instance, according to a study by III in 2021, the total workers’ compensation benefits paid in the U.S. amounted to $60 billion, with $28.5 billion allocated specifically to medical benefits.
This highlights the significant financial impact of effectively managing workers’ comp claims through processes like UR.
However, failing to comply with UR timelines, such as the mandatory five-day response period for RFAs, can lead to automatic approval of treatments, potentially escalating insurers’ costs (ACOEM, Work Injury Help). The Workers’ Compensation Insurance Rating Bureau of California (WCIRB) has noted that improper handling of UR processes, including retro UR, can result in significant financial losses due to unapproved or unnecessary treatments being authorised (WCIRB).
In recent cases, an Acme Corporation employee injured her lower back while working and reported it to her employer. Due to her severe injuries, she had to undergo multiple treatments over six months. MLM timely filed the RFA, but the UR process did not happen timely. As per California’s law, our client’s services were deemed approved due to the 5-business days rule. When the patient’s attorney requested a PQME evaluation, the PQME on the case accepted the injury and resolved it in favour of the worker. Once liability was accepted, they refused to bill treatment based on retro UR.
Market Trends and Impact: As the U.S. Workers’ Compensation market faces rising medical costs and increasing claim severity, efficient UR processes have become more crucial than ever. Despite declining rates and premiums, the market remains profitable due to tight control measures like UR (RPSIns).
In response, MLM professionals explained how retro UR ensures workers’ comp payments by adhering to DWC guidelines regarding UR and the Retro UR process. Further, the PQME evaluation supported the validity of the services. Our professional billers continuously tracked the case, providing crucial follow-ups. Through our expert negotiations and professionalism, we made sure there were no gaps that would cost our clients their revenue. We have expertise in how to increase workers’ comp payments for our clients through a swift process. Let the experts at MLM manage the intricate details of workers’ compensation claims while you focus on providing the best possible care to your patients.
