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  1. #1
    Join Date
    Mar 2008
    Location
    CA
    Posts
    4

    Default Untimely 'UR' Response

    HI ALL,

    This is only my second post. I have already been in trouble by the way I posted my first one. HOPE THIS WILL BE OK!!!

    When the Utilization Review sends back it's determination and answer and it is NOT within the time guidelines set forth in LC, WHAT SHOULD HAPPEN?

    Scenario: PTP sends request to see specialist to CA on 10/5/06---CA denies and sends to UR.---UR denies authorization to see specialist as not medically necessary on 12/18/06---Approx. 44 days later.

    It is unknown whether or not any extensions were filed.
    Does this scenario automatically trigger the PQME process

    If in fact, there were no extensions filed, and nothing interfered with the process, would I be permitted to make appt. with specialist based on presumptive approval because of UR's untimeliness?

    How can I investigate to see if extension or ???? were filed that could possibly stretch this out to 44 days??

    Any opinions will be most welcome. THANKS!!!!

  2. #2
    Join Date
    Oct 2006
    Posts
    9,078

    Default Re: Untimely 'ur' Response

    No. you put the issue before the judge. File for an expidited hearing.
    basic UR info:
    http://www.dir.ca.gov/dwc/FactSheets/FactSheet_A.pdf

    contact an I&A officer for help with filing for a hearing
    http://www.dir.ca.gov/dwc/IandA.html

    general UR information
    http://www.dir.ca.gov/dwc/UR_Main.htm

    contact the doctor about the status of an extension.

  3. #3
    Join Date
    Feb 2007
    Posts
    550

    Default Re: Untimely 'ur' Response

    This link gives you one of the best non lawyer explanations for CA UR that you will see. It was penned by York McGavin (his dad, Darrin was the lead actor, in Night Stalker, and Ralphie's Dad in A Christmas Story!)

    http://www.workcompforums.com/ca/iw/...&threadid=2590

    If you can't figure out where to go next, let us know.


    LA

  4. #4
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    17,943

    Default Re: Untimely 'ur' Response

    If you'll get into the rules governing UR, I think you'll find that the UR process even with 'extensions'...(The UR process is to be completed within 5 days...if the IC needs additional time to complete the UR they can take up to 14 days)...In NO EVENT can the UR process take longer than 21 days to complete and issue a 'modification, delay or denial' of the requested treatment, OR the treatment is presumed to be ''approved''...as the FAQ provides, file a DOR for expediated hearing...and while addressing the untimely provision of benefits, ask for 5814's/sanctions, and file a Audit Unit AND UR complaint with the DWC.

    I haven't seen in the UR rules where there are provisions for actual ''extensions'', there are time lines for your PTP to appeal a 'timely' denial in the process. UR depts are required by the labor code, and are an "in-house'', or contracted facility used by an IC. There wouldn't be any place to 'file' an extension. The labor code requires that the ER/IC have a UR review plan in place.

    But UR is not something the CA can play with, nor can the UR doctors cause frivilous delay in issuing a determination. The CA's cannot 'deny' a requested treatment, they can only approve, or refer to UR for review, within the guidelines as provided in the rules. The initial answer to your PTP must be done within 72 hours with the hard copy to follow.
    UR is there to expediate the IW receiving appropriate medically necessary treatment.

    There has also been some discussion to UR doctors ''recommending'' to CA' to deny claims, refer to AME/PQME and just plain getting their noses into the process of adjusting a claim where they don't belong. Problems arise where the PTP, in requesting a treatment, provides his/her narrative in validating the need for the treatment, along with some description of the cause/injury and a UR doctor makes a AOE/COE determination based on the PTP information....
    UR doctors are there ONLY to address a formal request for treatment...period.

    So, learin... based on your post at WCC, and here, I think I'd have to agree with the others that once you get in front of a judge, you will have the WCAB on your side here.
    The only possible difficulty I see would be the 'untimely' dispute to the UR denial...or how the appeals process was handled by your PTP...
    The PTP is the one to dispute a UR denial, not the IW.

  5. #5
    Join Date
    May 2007
    Posts
    170

    Default Re: Untimely 'ur' Response

    BvIA,

    What happens when the IC issues a letter stating the a decision is being withheld pending medical justification from the PTP as to show casual relationship to the injury? On Ferb. 15 that is exactly what the letter I recieved stated when my PTP requested a neurological consultation. Here it is March the 18th and still no denial or approval letter. Would I be correct in assuming that it is approved? BTW I am in West Virginia and my understanding of the rules or laws that a one time consult for a specilaist is not required. Am I misunderstanding the rule?

  6. #6
    Join Date
    Feb 2007
    Location
    Calif
    Posts
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    Default Re: Untimely 'ur' Response

    patch,
    Different states have different rules pertaining to how they govern a request for treatment from a treating physican... I don't know how WV handles their UR process...
    Have you reviewed the state web site that deals with WC and how the process is to be handled...?

    I do know that most IC's use a UR process to determine IF a requested treatment is ''medically necessary'' per the guidelines in affect at the time...I don't know what guides WV uses. IC's use the UR process for ''regular'' health insurance coverage... Medicare uses a UR process... no one gets all the treatment/tests etc that their doctor would like to do... it is not a 'research' facility...and that is how costs are contained...
    Is that a ''fair'' system...?, probably not. Is it a good way to see IW's return to work asap... ? Probably not...
    But, that's what we have to work with.

  7. #7
    Join Date
    Mar 2008
    Location
    CA
    Posts
    4

    Default Re: Untimely 'ur' Response

    HELLO AGAIN,------THANK ALL OF YOU FOR YOUR RESPONSES!!!!!!

    SH--I will be putting this in front of a judge
    I have a hearing date scheduled for 4/8/08

    PrincessLA---Thanks PLA for the link. This is an outstanding article. Was very surprised to hear that York is Darrin McGavin's son. How did he get into this line of work? Sure glad he is.

    BvIA---Thank you for your extensive input.
    I have been studying all the links that PLA and SH provided most of the day.
    With the additional input you have supplied I have a much better understanding of the process.---

    One thing I have missed somewhere is the 21 days from start to finish. Perhaps it is 21 calender days. I was under the impression week ends did not count.

    The only possible difficulty I see would be the 'untimely' dispute to the UR denial...or how the appeals process was handled by your PTP...
    The PTP is the one to dispute a UR denial, not the IW.

    In either case I think I am covered. The PTP disputed within 4 days. Date of the denial letter 12/18/06 PTP disputed on 12/22/06. I also disputed on 1/7/07.

    I haven't seen in the UR rules where there are provisions for actual ''extensions'',

    I just wondered if there would be any legitimate reason that would cause this to take so long. EXP: needing additional info. from PTP and UR having to wait for the info. or??? I don't want the DA to present something that I am unaware of that would blow the case.

    is presumed to be ''approved''...as the FAQ provides,
    Are these FAQ's on the DWC page?

    ask for 5814's/sanctions,
    Is this something I bring up at the hearing and ask the judge for,OR do I need to file something?

    AND THANKS FOR THE EDUCATION

  8. #8
    Join Date
    Feb 2007
    Location
    Calif
    Posts
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    Default Re: Untimely 'ur' Response

    One thing I have missed somewhere is the 21 days from start to finish. Perhaps it is 21 calender days. I was under the impression week ends did not count.

    The time frame has been changed since I last read the reg's on the max timeframe...it is now 14 days (30 for retro UR)...
    ''4610(1) Prospective or concurrent decisions shall be made in a timely
    fashion that is appropriate for the nature of the employee's
    condition, not to exceed five working days from the receipt of the
    information reasonably necessary to make the determination, but in no
    event more than 14 days from the date of the medical treatment
    recommendation by the physician. In cases where the review is
    retrospective, the decision shall be communicated to the individual
    who received services, or to the individual's designee, within 30
    days of receipt of information that is reasonably necessary to make
    this determination.''

    In either case I think I am covered. The PTP disputed within 4 days. Date of the denial letter 12/18/06 PTP disputed on 12/22/06. I also disputed on 1/7/07.

    You can forget about 'your appeal', it will have no bearing on this...
    Did/have you received a timely denial, per the code/regs on the requested treatment...? A UR review cannot just linger. You're in March now, what happened after your PTP appealed the denial...?

    ask for 5814's/sanctions,
    Is this something I bring up at the hearing and ask the judge for,OR do I need to file something?


    That I'm not sure about, I think you have to include a Petition for Penalties along with the DOR for the expediated hearing...
    ''4610.1. An employee shall not be entitled to an increase in
    compensation under Section 5814 for unreasonable delay in the
    provision of medical treatment for periods of time necessary to
    complete the utilization review process in compliance with Section
    4610. A determination by the appeals board that medical treatment is
    appropriate shall not be conclusive evidence that medical treatment
    was unreasonably delayed or denied for purposes of penalties under
    Section 5814. In no case shall this section preclude an employee
    from entitlement to an increase in compensation under Section 5814
    when an employer has unreasonably delayed or denied medical treatment
    due to an unreasonable delay in completion of the utilization review
    process set forth in Section 4610.''

    I just wondered if there would be any legitimate reason that would cause this to take so long. EXP: needing additional info. from PTP and UR having to wait for the info. or??? I don't want the DA to present something that I am unaware of that would blow the case.

    4610 (5) If the employer, insurer, or other entity cannot make a
    decision within the timeframes specified in paragraph (1) or (2)
    because the employer or other entity is not in receipt of all of the
    information reasonably necessary and requested, because the employer
    requires consultation by an expert reviewer, or because the employer
    has asked that an additional examination or test be performed upon
    the employee that is reasonable and consistent with good medical
    practice, the employer shall immediately notify the physician and the
    employee, in writing, that the employer cannot make a decision
    within the required timeframe, and specify the information requested
    but not received, the expert reviewer to be consulted, or the
    additional examinations or tests required. The employer shall also
    notify the physician and employee of the anticipated date on which a
    decision may be rendered.


    Here are the Utilization Review Standards, as applied by Title 8..blah blah blah...http://www.dir.ca.gov/dwc/DWCPropReg...egulations.pdf

    It would be a rarity to find that a requested treatment was not acted upon within the legal timeframes, and the "presumption'' applied.
    There are 'extensions' allowed, as specified by the UR Standards...find those on page 8, and must be submitted to the parties in writing.

  9. #9
    Join Date
    Mar 2008
    Location
    CA
    Posts
    4

    Default Re: Untimely 'ur' Response

    In either case I think I am covered. The PTP disputed within 4 days. Date of the denial letter 12/18/06 PTP disputed on 12/22/06. I also disputed on 1/7/07.

    You can forget about 'your appeal', it will have no bearing on this...
    Did/have you received a timely denial, per the code/regs on the requested treatment...? A UR review cannot just linger. You're in March now, what happened after your PTP appealed the denial...?

    BvIA--I assumed that the letter from the UR, dated 12/18/06 was the denial. It sounds as though I should have received something in addition to that. I believe the denial was UNtimely because, unless I am missing something, PTP requested referral on 10/5/06 and UR denied on 12/18/06.

    Back in 2004 I had a PQME. After the PTP disputed the denial, the CA said that she could not authorize and the only other option was to send it on to the PQME for an opinion. On 3/23/07 CA submitted this letter to PQME.

    Dear Dr. PQME------March 23, 2007

    You previously examined Mr. IW in the capacity of a Panel Qualified Medical Examiner and you issued your P&S report dated 3/8/05

    Enclosed are medical reports for your review. Although you previously reviewed the internal report of Dr.(defense doc.) dated 1/2/03, I am attaching it again. In summary, he was of the opinion that the patient's dizziness and vertigo were not work-related.

    In Dr. PTP's report of 10/5/06, he requested referral to an ENT for evaluation of dizziness. This was denied by Utilization Review on 12/18/06.

    On 1/31/07, Dr PTP issued a subsequent report stating that the patient should self-procure an ENT consultation with Dr.XXX to determine if it is work-related. (Dr.XXX is my preferred doc. and PTP recommended doc. in Riverside Ca.) .

    Mr. IW is emphatic that his dizziness is industrial in nature and would like the consult to be covered under workers compensation.

    In your report of 3/8/05, you indicate the patient underwent a neurological evaluation through Dr.(defense doc.) on 10/7/04 and that she stated the vertigo (dizziness) was unrelated to the 7/2/02 injury.

    Please issue a supplemental report addressing whether the ENT consult should be administered on an industrial vs. non-industrial basis

    Sincerely-----CA

    ANSWER FROM PQME:---5/15/07
    I can assure that ear, nose, and throat doctors and neurologists are specialists in cross-over fields when it comes to the exact diagnosis of dizziness or vertigo and the exact diagnosis has not been diagnosed in reference to evidence based tests which would include an ear, nose, and throat evaluation for abnormalities of the middle and inner ear
    I am an orthopedic doctor. I did not pursue the patient's complaints of dizziness and headaches stated to occur with repetitive head and neck rotation, I therefor believe the patient should undergo an ear, nose, and throat consultation.

    At this point the CA realizes that she has to authorize but once again refuses to authorize because she does not want me to see Dr.XXX. (he is too liberal) I assumed that Dr.XXX was authorized also since he was the only one mentioned, and the PQME did NOT refer to any other.

    Any thoughts??

  10. #10
    Join Date
    Feb 2007
    Location
    Calif
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    Default Re: Untimely 'ur' Response

    All of that has already been asked and answered on one of your other posts... I don't have anything to add here.

    It probably would be a good idea to stick with the issues on ONE forum where you will get the best responses to your questions...using this and the other could result in some confusing information, at the very least, no one will answer one or the other, as some of us frequent both.

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