Utilization Review Study

Recently, Utilization Review (UR) has become an increasingly notable area of concern from a variety of stakeholders. Specifically, both injured workers and medical providers report delays and denials of medical care due to the UR process. While existing research does not support the argument of significant delays or denials due to UR, other studies suggest that, while such delays and denials may not be system-wide, they may be specific to certain employers or UR entities. This signifies, in part, that the implementation of best practices across the system will lead to improvements for injured workers who are having their care delayed or denied.

Senate Bill 1160 and Assembly Bill 2848 requires the Division of Workers¿ Compensation (DWC) to contract with an outside independent research organization to evaluate and report on the impact of provision of medical treatment within the first 30 days after a claim is filed.

SB 1160 also requires employers to establish a utilization review process that, in addition to meeting specific criteria, shall prospectively, retrospectively, or concurrently review and approve, modify, delay or deny treatment recommendations by physicians. The bill reduces utilization review requirements in the first 30 days following a work-related injury. It also mandates electronic reporting of utilization review data by claims administrators to the DWC, which will enable the division to monitor claim processes and address problems.

SB 1160   seeks to address the reported challenges with UR in two ways. First, it  eases the requirements of UR within the first 30 days of a worker¿s injury, with certain exceptions. Employers are still able to conduct retrospective review, and SB 1160 provides tools to employers in the event that a medical provider abuses the workers¿ compensation system.

In relevant part, both SB 1160 and Assembly Bill 2848, as related to medical treatment that is provided through a medical provider network (MPN), a health care organization (HCO), other employer directed provider, or a pre-designated physician, requires that no prospective UR may be undertaken for the first 30 days of treatment and requires any treatment provided within the first 30 days to be reported to the employer or claims administrator.