In workers comp cases, the UR process can be confusing and slow, making it difficult for providers to get their dues cleared on time. Let’s delve into how we secured our client’s payment in this case through careful abidance to RFA guidelines. 

A warehouse worker sustains a wrist injury while operating heavy machinery at her workplace. Her treating physician recommends a series of physical therapy sessions to aid in her recovery. 

Being the medical provider representative, we promptly submitted an RFA to the administrator, detailing and justifying the recommended physical therapy sessions. Although the administrator started their UR process to evaluate the medical necessity of the proposed treatments, they failed to follow the guidelines of the insurance company having to respond to an RFA within 5 working days, under Californian law. 

As a consequence of the insurance company’s failure to follow the timeline and respond within the specified timeframe, the requested treatment is automatically considered authorized as per Californian law. In this case, the worker’s prescribed physical therapy sessions are automatically accepted and approved for coverage under her workers compensation policy. 

Finally, when the administrator responded to the RFA, the services were stated as non-certified based on a lack of medical necessity. Along with that, the bills that the medical provider submitted were also dismissed for the services being unauthorized. This is where Medical Lien Management intervened. Our experts reviewed the case and negotiated our client’s dues based on the untimely response of the administrator to our RFA. 

According to California’s Law, if the insurer fails to respond to the RFA in the given timeframe, i.e. within 5 working days, the treatment is deemed authorized and the insurance company is obligated to pay for the approved services rendered by the medical providers. 

As authorized under the RFA timeline specified in California’s workers compensation law, medical providers initiated crucial physical therapy for the injured worker. Using our negotiation expertise, Medical Lien Management secured prompt confirmation and payment for the treatments through the UR process. Let us handle the complexities of workers comp for you so you can focus on patient care. Contact us or visit our website to learn how we can support your practice.