The PTP, Secondary Treater, and Pre-Authorization

Saturday, February 14, 2004 | 0

The WorkCompCentral Professional Forums recently hosted a question on pre-authorization of medical care. The following dialogue has been heavily edited for readability and the answers have been combined for a cohesive explanation.

Question:

My understanding is that neither the California Labor Code nor Title 8 requires a primary treating physician (PTP) to obtain authorization to refer the patient to a 2nd party for either treatment or evaluation (consultation); however, if either the PTP or 2nd party physician does request authorization, again, my understanding is that the insurer/employer has a certain amount of time to deny authorization or else the treatment/evaluation is considered authorized. My question is, is this so and if it is, what is the Labor Code or Title 8 section that deals with this issue and how many days or weeks does the insurer/employer have to respond or deny a request for authorization?

Answer:

There is no requirement for obtaining pre-authorization for provision of medical treatment. LC 4603.2 provides that the PTP "authorizes" medical treatment. However the problem with proceeding without authorization from the defendant is the potential that the treatment will not be considered "reasonably necessary" to cure or relieve from the effects of the injury and therefore will not be paid for by defendant. This can be particularly true for treatment after 1/1/04 when employers are required to implement utilization review guidelines using the ACOEM treatment guidelines.

There is no provision in the Labor Code or Administrative Regulations that makes a failure to deny treatment within any specific time frame the same as authorization. Even if the defendant fails to object to properly documented medical bills within the time frames of LC 4603.2, the KUNZ (Kunz vs. Patterson Floor Coverings, 67 Cal.Comp.Cases 1588 (2002)) case holds that the defendant may still raise issues as to the reasonableness and necessity of the treatment (although they may have waived issues as to the amount of charges if the treatment is found reasonable).

Obtaining pre-authorization for medical care will eliminate the possibility that the treatment, once provided, will not be paid for on the grounds that the treatment was not reasonable or necessary.

LC 4603.2 works in conjunction with California Code of Regulations section 9792.6.

When section 9792.6 first issued there was a provision that stated, "Failure to respond timely to a request for authorization constitutes a de facto authorization." However this provision was deleted.

9792.6 requires the payor to respond, IN WRITING, to a request for authorization (DLSR 5021- Doctors First Report of Injury / PR-2 - Primary Treating Physician's Progress Report).

This is true regardless of whether the payor chooses to (1) authorize the proposed course of treatment, (2) issue a delay letter requesting additional information necessary to determine the efficacy of the proposed course of treatment, or (3) issue a denial (which must be AUTHORED BY A PHYSICIAN).

Failure to timely respond to a DLSR 5021/PR-2 request for authorization is a violation of the section 9792.6 and subjects the payor to possible penalties from the Audit Unit. If the failure to respond is found to be pervasive, and demonstrates a pattern, this can mean a conviction for violating LC 129.5(d) resulting in a $100,000.00 penalty assessment for the first conviction, and a possible revocation of the certificate of authority to provide coverage upon a second or subsequent conviction.

Now, in 2004, one should look to newly created LC 4610 for guidance. This Code, which of course trumps the regulation, will certainly create much litigation in the coming years. There is a 'time frame' outlined in created LC 4610 for prospective Utilization Review of no more than fourteen (14) days.

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