Utilization Review Treatment Guidelines

1. Utilization ReviewTreatment Guidelines

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

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

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

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

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

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

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

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

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

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

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

13. Delay • Decisions should be made in the first 5 days • A non-physician may request more info and wait for it for the first 14 days • Then a physician reviewer may put it on delay and inform the requesting physician/IW what additional info is needed in writing • Provide estimate of additional time necessary • 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 • 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 • In-patient treatment only • PT that was started doesn’t count • Treatment shall not be discontinued until a plan is agreed upon • Insurer is only liable to care that is medically necessary to cure and relieve • Disputes under LC §4062

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