The Division of Workers’ Compensation (DWC) has posted a 15-day notice of modification to the proposed utilization review (UR) and independent medical review (IMR) regulations to the DWC website. Members of the public are invited to present written comments regarding the proposed modifications to email@example.com until 5 p.m. on October 11. The number of proposed changes are extensive. The following are some examples.
The new proposed rules set forth a revised Request for Authorization form (DWC Form RFA), emphasizing that it must be signed by the employee’s treating physician. There is a statement on the DWC Form RFA that it is not a separately reimbursable report under the Official Medical Fee Schedule.
One of the proposed changes that may be of concern to claim administrators is Section 9792.9.1(c)(2), Under this proposed language, a non-conforming request for authorization (i.e., an incomplete Form RFA or request that does not use the form) must be returned to the requesting physician within three business days or else be considered as complete and subject to all applicable timeframes and requirements. This provisions would seem to place a substantial burden on claim administrators. It would seem that a Request for Authorization buried in any document forwarded by a treating physician would have to be identified (by reading carefully every single word in the document) and then this obscure language would rise to the level of an official Request for Authorization unless the administrator objected in three days. It is difficult to see how a claim department could meet this burden.
Section 9792.10.4 of the proposed changes allow the independent review organization delegated the responsibility by the Administrative Director to conduct independent medical review pursuant to Labor Code section 139.5 (IMRO) may consolidate two or more eligible applications for independent medical review by a single employee for resolution in a single determination if the applications involve the same requesting physician and the same date of injury.
The new proposed regulations implement new procedures to impose sanctions. Section 9792.10.6(j) provides that upon receipt of credible information that the claims administrator has failed to has failed to comply with its obligations under the independent medical review requirements the Administrative Director shall, concurrent or subsequent to the issuance of the final determination issued by the independent review organization, issue an order to show cause for the assessment of administrative penalties against the claims administrator under new section 9792.12(c). Section Section 9792.10.7 provides that upon receipt of credible information that the claims administrator has failed to implement the final determination, the Administrative Director shall issue an order to show cause for the assessment of administrative penalties against the claims administrator under new section 9792.12(c).
Section 9792.12(c) is a new subdivision to provide for Independent Medical Review Administrative Penalties. The subdivision lists specific violations and the amount to be assessed as an administrative penalty for each.
The notice, text of the regulations, and forms can be found on the proposed regulations page.