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Receipt of a Request for Authorization by a Defense Attorney

Posted by Sure S. Log on Sep 21, 2022 3:00:00 PM
Sure S. Log

Labor Code § 4600(g)(2)(A) states, "Unless otherwise indicated in this section, a physician providing treatment under Section 4600 shall send any request for authorization for medical treatment, with supporting documentation, to the claims administrator for the employer, insurer, or other entity according to rules adopted by the administrative director." The statute directs that a request for authorization for medical treatment (RFA) must be sent to a claims administrator, rather than somewhere else, although the claims administrator may designate where the RFA is sent (CCR 9792.6.1(t)(3)).

That language was added effective Jan. 1, 2017, by AB 2503. Pursuant to the Senate Floor Analysis, "[I]t is often difficult for health care providers in the workers' compensation system to obtain timely approval for treatment of injured workers because it is difficult to know where to send RFAs." So, the bill was "intended to clarify where the RFA and related materials must be sent, so that the time frames specified in statute will be more effective." Pursuant to the Assembly Floor Analysis, "AB 2503 requires that a RFA is submitted directly to a claims administrator, rather than a UR vendor or some other third party."

Despite that language, the WCAB has held in two recent cases that a defendant cannot rely on LC 4600(g)(2)(A) to avoid conducting utilization review just because the RFA was not received by the claims administrator. In both cases, the WCAB held that a defense attorney's receipt of an RFA form also required the attorney to act timely and reasonably.

In Erhardt v. U.S. Concrete dba Central Concrete Supply Co., Inc., 2022 Cal. Wrk. Comp. P.D. LEXIS 198, an applicant's attorney emailed a treating physician's report and RFA to the defense attorney after the treating physician reported that the applicant was still awaiting authorization for surgery. Two months later, the parties proceeded to trial, and the defendant still had not performed a utilization review. The WCAB concluded the that defendant's attorney should have transmitted the RFA to the claims administrator for review within a reasonable time. It also found that the claims adjuster's receipt of reports indicating that the applicant was "still" awaiting authorization for surgery provided notice that a further investigation was necessary under CCR 10109. The WCAB concluded that the defendant did not timely submit the RFA for UR, and that it could determine whether the requested treatment was medically necessary.



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Similarly, in Sevillan v. Kore 1 Inc., 2022 Cal. Wrk. Comp. P.D. LEXIS 205, the WCAB held that it had jurisdiction to determine the medical necessity of a physician’s request for an outpatient rehabilitation program because the defendant’s UR determination was untimely. Although the request for authorization was not transmitted to the claims adjuster, the WCAB found that the defense attorney did not act with reasonable diligence after receiving it. It explained that the duty to conduct a good-faith investigation under CCR 10109 required the defense attorney to transmit a copy of the RFA to the adjuster within a reasonable time after the attorney received it, and it was unclear whether the adjuster received it. Because the defense attorney did not submit the report to the adjuster (or UR provider), or otherwise take affirmative steps to investigate the treatment for approximately 2 1/2 months after receiving it, the WCAB concluded that the UR determination was untimely. It also concluded that the request for treatment was supported by substantial medical evidence.

So, although LC 4600(g)(2)(A) requires an RFA form to be submitted directly to a claims administrator, a defendant cannot dodge its responsibility to perform utilization review just because an RFA is not directly submitted to a claims administrator. If an RFA form is received by a defense attorney, he or she has a duty to transmit it to the claims administrator so that UR can be performed.

Neither case holds that a defense attorney's receipt of the RFA form triggers the time limits for utilization review. Instead, if an attorney sends the RFA to the claims administrator within a reasonable time, the time limit for UR will be triggered by the claims administrator's receipt of the RFA. (See Bissett-Garcia v. Peace and Joy Center, 2016 Cal. Wrk. Comp. P.D. LEXIS 174.) Moreover, neither case requires a defense attorney to send the RFA form to the claims administrator immediately. They require the attorney to transmit it only within a reasonable time. That gives the WCAB jurisdiction to review case-specific circumstances to determine whether the defense attorney acted reasonably.

Nevertheless, it's clear that defense attorneys also have a duty to act diligently in making sure that treatment issues are timely resolved. Although most RFAs will be sent directly to a claims administrator or the designated utilization review organization, if an RFA is sent directly to a defense attorney, she or he should either confirm that it was also sent to the claims administrator, or simply forward the RFA to the claims administrator. For further discussion on this topic, see "Sullivan on Comp" Section 7.34 Utilization Review –– Request for Authorization.

Topics: Utilization Review, RFA, defense