Rescinding Medical Authority: A 60-Second Seminar in Workers’ Compensation Claims Handling

Have you ever carefully read California Labor Code §4610.3(a), on the issue of rescinding a physician’s authority to treat an injured worker? As you might expect, like most procedures in the workers’ compensation context, recission ain’t that easy!  LC §4610.3(a) provides:

“. . . an employer that authorizes medical treatment shall not rescind or modify that authorization after the medical treatment has been provided based on that authorization for any reason . . .”

This statute has been interpreted to mean that once authorized medical treatment has been provided, the claims administrator is financially responsible for those services. We therefore truly wonder how many work comp adjusters are aware of this law, considering that the WCAB is inundated with lien disputes filed by medical providers seeking payment for services authorized in writing by the claims’ administrator. It’s as if this statute does not exist. 

Of particular importance we note that LC §4610.3(a), as written, implies that authorization may be withdrawn prior to the services being rendered, which appears to be contrary to a common belief that “once UR approves a procedure, the services must be provided.”  Interestingly, we are unable to find a statute in the Labor Code which supports this proposition. As further proof of this common belief being inaccurate, ask yourself, “What happens when a case settles after medical services are authorized – will the applicant still be entitled to treatment at the employer’s expense?” Of course not. As previously noted, LC §4610.3(a) implies that authorization may be withdrawn. Settlement of a case is a prime example of when UR authorization may be rescinded.  Other examples are:

1. when future credit rights are granted.
2. when a doctor or patient changes their mind about undergoing a procedure.
3. when an election is made against a different co-defendant.
4. when the requesting medical provider leaves the MPN.

Under all these circumstances the claims administrator may rescind UR approval, providing that notice of the rescission is served on the medical provider and all parties prior to services being provided.

If you have question about this topic, feel free to reach out to F+B for assistance.