By: Omar Behnawa, LFLM San Diego
Senate Bill 1160 was signed into law on 9/30/16. The Bill seeks to address concerns by both defendants and claimants/applicants. The Bill increases control of liens, a concern for defendants, in exchange for less restrictive Utilization Review (UR) at the start of the claim – a concern for claimants/ applicants.
For dates of injury on or after 1/1/18, there is no requirement for UR, subject to some exceptions. Treatment requests within the first 30 days following the initial date of injury must be authorized, unless the treatment request is for any of the following:
Surgery, psychological treatment, imaging/ radiology services other than X-rays, medical equipment costing more than $250.00, home health care, or medications not covered in the prescription formulary.
If the treatment requested within the first 30 days of the claim is for any of the foregoing treatment modality (not subject to the 30-day UR exemption), it is imperative that defendants submit the treatment request to UR for a determination as to reasonableness. Otherwise, claimants/applicants will be able to proceed to an Expedited Hearing on the issue, likely obtain the treatment and thereby subvert the UR and Independent Medical Review (IMR) process altogether.
The treatment rendered within the first 30 days of the claim must still be reported to the claims administrator and a provider may be forced to go through retroactive UR – to ensure the treatment rendered was within evidence based medical standards. Labor Code Section 4610(f) allows retroactive UR for the sole purpose of determining whether a provider is consistent with the Medical Treatment Utilization Schedule (MTUS). A provider may be removed from the Medical Provider Network (MPN) if there is a “pattern and practice” of treatment inconsistent with the MTUS. If providers are non-compliant with the reporting requirements, the providers’ 30-day exemption from UR may be removed.
UR decisions covered by the medication formulary must be made within 5 business days. The 14-calendar day timeframe to obtain additional information prior to issuing a UR decision is inapplicable to the medication formulary. Formulary disputes must be submitted to IMR within 10 days (still 30 days for all other disputes). IMR must decide medication formulary disputes within 5 days (all other disputes still to be decided within 30 days, though per case law no real remedy for untimely IMR decision).
As part of Senate Bill 1160’s lien/anti-fraud provisions, Labor Code Section 4615 requires an immediate stay on the liens of medical providers criminally charged with fraud against the workers’ compensation system, medical billing fraud, or fraud against the Medicare/Medi-Cal programs, until the criminal proceedings are resolved.
The Bill also requires lien claimants to file a Declaration stating that they are within the employer’s MPN, have searched and do not believe the employer has an MPN, or have proof of denial of care. The Declaration is required for any lien filed after 1/1/17. All liens filed prior to 1/1/17 were to file the foregoing Declaration by 7/1/17. Lien claimants that failed to file the Declaration by 7/1/17 are dismissed by operation of law.
© Copyright 2018 Laughlin, Falbo, Levy & Moresi. All rights reserved. Reprinted with permission