Utilization Review Update: Notice and Requestor
There has been quite a bit of case law recently outlining the timeliness and deadlines associated with Utilization Review (UR) and Independent Medical Review (IMR). However there is new case law on other aspects of UR including the form, author and notice of the Request for Authorization (RFA).
When a RFA is received with several requests for treatment, the deadlines for response are linked to the entirety of the RFA request, not the individual treatments. As you know, a UR decision is to issue 5 days after receipt of the RFA unless additional information is needed. If additional information is requested, a UR decision is extended to 14 days. For example, an RFA requests medication, physical therapy and an orthopedic referral. The UR physician requires additional time to review the need for an orthopedic referral but does not need additional time on the medication or physical therapy. The UR physician is not required to issue a 5 day decision on the medication and physical therapy. The UR physician has 14 days to issue a decision on all items since all items were part of the same RFA. This was confirmed in the February 16, 2016 panel decision of Cerna Romero v. Stones and Traditions, (ADJ7803069).
When a secondary physician issues an RFA for treatment, the RFA is subject to the same standards and deadlines as any other RFA request. There is no requirement that an RFA must only be submitted by the Primary Treating Physician (PTP). Requiring the PTP to review the secondary physician’s report and issue a separate RFA for treatment based on the secondary physician’s opinions would lead to delay in treatment. Furthermore, if the UR physician required further information regarding the services requested, it would be best to contact the secondary physician making the request rather than the PTP. Per the May 11, 2016 panel decision of Lopez v. City and County of San Francisco, (ADJ8505079), if an RFA is received on the RFA form from any physician providing treatment on a claim, the RFA must be submitted to UR for review.
Notice of RFA
There are instances when an RFA is not sent to the claims adjuster or UR department for review. Sometimes the RFA is sent to applicant’s attorney who in turn provides it to the defense attorney. According to May 31, 2016 panel decision of Czech v. Bank of America, (ADJ8917716), the defense attorney has an affirmative duty to provide the RFA to the claims adjuster or UR department. Since the defense attorney had knowledge of the RFA, he should have sent the RFA to the claims adjuster to obtain a review. Since he failed to do so, the treatment within the RFA was authorized.
The trouble with this decision is that 8 CCR section 9792.6(a) specifically requires that an RFA be transmitted to the claims adjuster or its UR provider by the PTP. The PTP in this case failed to follow the code requirements. The Judge however focused on the relationship between the attorney and claims adjuster. The attorney is classified as an agent for the claims adjuster and the attorney has an affirmative duty to conduct a good faith investigation of the claim and benefits due. When an RFA is obtained by the attorney, it is his duty to provide it to the adjuster within a reasonable time.
The argument however can be made that although it is the duty of the defense attorney to provide the RFA to the claims adjuster, there is no definition of what is considered a “reasonable time” to do so. 8 CCR 9792.9.1(a)(1) confirms that action on the RFA is not required until it is received by the claims adjuster or UR provider. Thus until the defense attorney, or applicant’s attorney, provides the RFA to the claims adjuster, no UR action is required. However it is in the best interest for all involved to relay the RFA to the claims adjuster as soon as possible. So if either applicant’s attorney or defense attorney obtains an RFA, it would be a good practice to send the RFA to the claims adjuster right away. Failure of the defense attorney to do so may result in the automatic authorization of the requested treatment.