California Workers Compensation has very specific rules for how any kind of treatment will be approved – the doctor’s request must go through “Utilization Review” (UR). Just because your doctor requests treatment or writes a prescription during your visit, does not mean it will be approved. Doctors must follow the “Medical Treatment Utilization Schedule” which includes the “American College of Occupational and Environmental Medicine” (ACOEM) Guidelines, as well as the “Official Disability Guidelines” (ODG). These guidelines outline exactly how all kinds of injuries must be treated based on nationally recognized peer reviewed evidence based medicine. In order for treatment to be approved, it must be supported in these guidelines or the doctor must explain (with citations to studies) why they are not following the guidelines.
In addition, remember that the insurance company only pays/approves for up to $10,000 in medical treatment during the delay/decision period (up to first 90 days), and only pays/approves treatment on accepted cases. So if your case is denied, or if the insurance company is disputing whether a certain body part is related to your work injury – they will defer UR and will not approve/authorize anything requested.
In work comp there are three types of UR with different time limits. Note that all time limits can be extended by up to 5+ days each way for mailing time (so 10-12 total). In addition, most doctor offices do not send out the Request for Authorization Form and medical report the same day as your appointment. Some send them out within a couple days, some take 1-2 weeks. Also note that the rule says “working days” – which does not include Saturdays/Sundays or any state/federal holidays.
- Concurrent review: this is during an impatient stay like in a hospital
- Five (5) working days from receipt of the information reasonably necessary to make the determination, but in no event more than 14 days from the date of the medical treatment recommendations by the physician
- Prospective review: this is any review prior to the delivery of medical services. This is the most common
- Five (5) working days from receipt of the information reasonably necessary to make the determination, but in no event more than 14 days from the date of the medical treatment recommendations by the physician
- Retrospective review: this is review done after the medical services have already been given
- Thirty (30) days from receipt of the information reasonably necessary to make the determination
- Expedited Review: this is only in an emergency situation where there is imminent and serious threat such as loss of limb
- Decision must be done within timely fashion appropriate to nature of condition, but no more than 72 hours
It is important to know these timelines, and know that often the decision period is towards the longest range. Here are the most common scenarios/questions we get from clients:
- My doctor gave me a prescription today and I dropped it off at the pharmacy, but they said its not approved! Why not?
- The timelines apply for medication as well. Even some basic medication can take the full 14 days for review + 5 days mailing each way = 24+ working days for approval. With weekends and holidays this means you may have to wait roughly a month for even basic treatment to apply
- My doctor said they sent the request for treatment and its been 5/14/24/30 days since my appointment! Why hasn’t insurance sent the review yet?
- Remember that your doctor often does not send the “Request for Authorization” paperwork with the medical report the same day they see you. Some offices take a few days, some offices take up to 2 weeks. So that can mean the insurance company didn’t get the request until 14-20 days after your appointment, and it can take another 24+ working days for a response. In these scenarios approval can take 1.5months even for basic prescriptions, X-rays, MRIs, referrals, etc.
- The insurance denied my doctor’s request/treatment, what do we do next?
- We will review the Utilization Review documents, and determine if an appeal to Independent Medical Review (court doctors) is appropriate. However, statistically studies have shown that IMR upholds UR decisions 90.7-91.2% of the time. So most of the time it is your doctor that is not following the guidelines/rules, not the insurance company.
- If we do appeal to IMR, typically it takes 2-6 weeks to get a decision. This depends on the type of request, how many volumes of medical reports the IMR doctors have to review, and how quickly the insurance company sends those records (rule is within 10 days)
If you feel you need help in your workers compensation case, please contact us immediately for a free consultation!
