Red Flag UR Decisions: A 60-Second Seminar in Workers’ Compensation Claims Handling

When industrial compensability is in dispute, either for an entire injury or for just a body part, claims administrators should act cautiously should a Request for Authority (RFA) be received. The RFA is not to be addressed by utilization review (UR).  Instead, pursuant to Labor Code §4610(l)&(m) and C.C.R. 9792.9.1(b)(1), the administrator should respond within 5 workdays deferring UR until after the issue of compensability is determined. 

A claims administrator takes an unnecessary risk when sending an RFA to UR for response in a claim where injury or a body part is in dispute.  Should UR authorize the requested treatment, case law requires the services be provided despite the denial of liability.  On the other hand, should UR deny the requested treatment, then the injured worker may appeal the denial to Independent Medical Review (IMR), where if overruled, the services must be provided despite the denial of compensability.

Have you ever wondered what happens if in a disputed claim the administrator decides not to respond to an RFA?  Fortunately, should the administrator not o anything, the issue is not forfeited.  However, should compensability later be resolved in favor of the injured worker, UR will not be allowed to address the issue because the RFA was never deferred.  In other words, by failing to issue a deferral to all parties in interest, the administrator gives up their right to conduct utilization review later.

A few years ago, an applicant attorney raised an interesting but unsuccessful challenge at the Board.  He argued that where services involving a disputed injury were submitted to UR, which then addressed but denied the requested services, the administrator’s act of addressing the RFA waived the denial of liability, like what occurs when UR approves an RFA in a disputed claim.  Fortunately, applicant attorney was unsuccessful in this argument.

The best practice when dealing with an RFA on a denied injury or disputed body part is to issue a timely deferral to avoid the multitude of problems that may arise should the RFA be submitted to UR for response. For additional details or assistance with RFA and UR issues feel free to reach out to experts here at F+B!