Utilization Review In California Workers Comp. and how to get your requests approved!

Transcription

1 Utilization Review In California Workers Comp. and how to get your requests approved! A. David Matian, D.O.

2 Positive Outcomes

3 Adapted from Mike Nolan, CWCI

4 CWCI Study Comparative Study of California Workers Comp. Treatment to EBM Norms Diagnostic Tests times more than norm PT/chiro % NOT supported Back surgeries 8/9 NOT supported Work time lost x longer than norm

5 Adapted from Mike Nolan, CWCI

6 chron-acut-ulitis

7 fuzzy math

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10 Medical Treatment Utilization Schedule Title 8 California Code of Regulations Sections Effective Jun. 15, Definitions Acupuncture Presumption of Correctness, Burden of Proof and Strength of Evidence Med. Evidence Eval. Cmte.

11 Acupuncture The Acupuncture Medical Treatment Guidelines set forth in this subdivision shall supersede the text in the ACOEM Practice Guidelines, Second Edition, relating to acupuncture, except for shoulder complaints, and shall address acupuncture treatment where not discussed in the ACOEM Practice Guidelines.

12 Acupuncture Frequency and duration of acupuncture or acupuncture with electrical stimulation may be performed as follows: (i) Time to produce functional improvement: 3 to 6 treatments. (ii) Frequency: 1 to 3 times per week (iii) Optimum duration: 1 to 2 months Acupuncture treatments may be extended if functional improvement is documented as defined in Section (e).

13 Penalties UR penalty regulations became effective June 7, 2007 UR regulations, 8 CCR , specify how to comply with LC 4610

14 Key Points Remain Timelines No non physician may modify, delay or deny (LC 4610(e)) Non physicians (claims adjusters, RNs) may approve, discuss and request reasonable information needed to make decision without referral to reviewing physician (8 CCR (b)(3))

15 Key Points Remain (cont.) UR physician can add comment questioning whether treatment is causally related (Simmons v State of California, SCIF) 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

16 Penalty Regulation Overview outlines investigation procedures sets out penalty schedule lists penalty adjustment factors addresses liability for penalties specifies how penalty assessments will be served, rights to contest and request a hearing, hearing procedures and appeal processes

17 Sites of Audits DWC has authority to investigate UR process of employer, insurer or other organization subject to LC 4610 (LC 4610(i); 8 CCR (a)) UR investigations may occur at any location where LC 4610 UR processes occur (8 CCR (c))

18 Types of UR Audits at URO Routine scheduled every 3 years or sooner Return Target 18 months after prior investigation if performance rating below 85% Special Target at any time based on credible complaint information

19 Types of UR Audits at Claims Adjusting Location Routine (8 CCR (c)(2)(A)) Once every 5 years concurrent with PAR (profile audit review) audit under LC 129 or Return Target and Special Target Same as for URO

20 Audit Process Any conduct on or after June 7, 2007 (8 CCR (i)) Notice of Utilization Review Investigation Requests for general UR system information Provide within 14 calendar days Notice of Investigation Commencement Identifies UR request files randomly selected for review 14 calendar days to provide true, correct copies of records

21 Audit Process (con t) On site investigation may request additional records Preliminary Investigation report provided to subject Performance rating calculated (8 CCR (b)(1)) Preliminary notice of penalty assessments, if any Conference to discuss preliminary report, if need, within 21 calendar days

22 Documents Analyzed Random sample of requests for authorization received in 3 most recent full calendar months starting with June 2007 Table in (d) all if 5 maximum = 59

23 Penalty Structure Overview Mandatory penalties No waiver; Discretionary abatement reduction Lesser penalties Only assessed if fail 85% threshold in routine investigation UR violations will carry UR penalty

24 Mandatory Penalties No UR plan filed - $ 50,000 No letter in lieu of filing UR plan - $ 10,000 No Medical Director - $ 50,000 Non-physician issues modify, delay or deny - $ 25,000 Scope of practice violation - $ 25,000 Late to expedited review - $ 15,000

25 Mandatory Penalties (con t) Concurrent review fail to discuss or attempt to discuss reasonable treatment options - $ 10,000 No approval solely because condition for which treatment requested not addressed by MTUS - $ 5,000 Fail to file material modification plan within 30 days - $ 5,000 Fail to respond to PTP s request in nonexpedited concurrent review - $ 2,000

26 Mandatory Penalties (con t) Fail to respond to non-expedited prospective request - $ 1,000 Non-physician reviewer who approves a modification does not possess the PTP s amended written request - $ 1,000 Fail to respond to retrospective review request - $ 500 Post investigation non-compliance - $ 500 ( (a)(16)-(17)) Not making UR information available if requested- $ 100 ( (a)(15))

27 Lesser Penalties Technical Errors $ 100 penalty No notice to parties of basis for extending decision date Denial for lack of information with no documentation of request for more information After receive requested information, fail to timely decide and communicate per (g)(3) for prospective or concurrent review

28 Lesser Penalties Technical Errors $ 50 penalty notify within 5 working days need for more info. to make decision communicate approval decision to requesting physician by phone or fax after 24 hours of making decision Fail to fax/mail written notice of decision to modify, delay or deny Fail to communicate decision on retrospective review within 30 days of receiving information needed to make decision

29 Timeline of Utilization Review

30 Claims Examiners, the Gatekeepers Within 5 days your claims examiner must... Deny treatment requests for non-admitted injuries. These requests should never be sent to UR Authorize treatment for admitted body part if treatment is compliant with ACOEM Delay and request supplemental information then send to UR Immediately send to UR

31 The Utilization Reviewer Within 5 days your reviewer must... Approve Modify (e.g.. limit number of therapy visits requested) Deny based on ACOEM or other EBM Delay because: Employer is not in receipt of all information necessary and requested Employer requires consultation by expert reviewer Employer asks that additional exam or test be performed on employee Within 14 days your reviewer must... Accept, deny or modify requests that were initially delayed

32 Dispute Resolution If a request is not approved in part or whole dispute resolved per LC Objection to be made within 20 days of receipt of UR decision (unless extended for good cause or by agreement of the parties).

33 Spinal Surgery Requests Initially processed in the usual UR process Employee may object to a denial of a surgery request within 20 days and request a second opinion evaluation from an agreed upon neurosurgeon or orthopedic surgeon.

34 Utilizing Utilization Review Example 1 Carpal Tunnel mimicked by other conditions Hypothyroidism Pregnancy Diabetic neuropathy Cervical radiculopathy

35 Utilizing Utilization Review Example 2 Back strain frivolous treatment Special mattresses Purchase of TENS unit Gym membership Routine, redundant epidurals Limousine transportation

36 Utilizing Utilization Review Example 3 Stipulated Award: lifetime chiropractic Should be reviewed for lasting functional benefit

37 ACOEM Chapters 8 neck 9 shoulder 10 elbow 11 wrist/hand 12 low back 13 knee 14 ankle 15 stress 16 eye

38 Physical Therapy Active Passive

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