UR Denials and the PQMR Dance

Saturday, March 25, 2006 | 0

By York McGavin

- TIMEFRAMES AND OBLIGATIONS -

THE GROUND RULES FOR UR

Treating physicians are required to submit requests for authorization for a proposed course of treatment on certain specifically delineated documents. One is called the Doctor's First Report of Occupational Injury or Illness. (formal name: Form 5021, Rev. 4, Doctor's First Report of Occupational Injury or Illness - informal name: DFR) The other is called a Primary Treating Physician Progress Report. (formal name: progress report - informal name: PR-2)

The DFR must be filed "with the employer's insurer, or with the employer, if self-insured" "within five days after initial examination." (See CCR 14003(a).) "When continuing medical treatment is provided, a progress report (PR-2) shall be made no later than forty-five days from the last report of any type..." (See CCR 9785(f)(8).)

The "treatment plan" section of both a DFR and a PR-2 is defined as a "request for authorization" for a proposed "course of treatment." (See CCR 9792.6(d) and (k).) These are called "prospective" requests for authorization.

Upon receipt of a DFR or a PR-2, the employer's insurer or the employer, if self-insured, must respond within five (5) working days. (See CCR 9792.9(b)(1).) "If appropriate information which is necessary to render a decision is not provided with the original request for authorization, such information may be requested within five (5) working days from the date of receipt of the written request for authorization to make the proper determination." (See CCR 9792.9(b)(2).)

The insurer or self-insured employer must make the request to the treating physician for additional "appropriate information" necessary to make a determination, "an additional examination or test be performed," or "a specialized consultation and review of medical information by an expert reviewer" (See CCR 9792.9(g)(1)(A-C).) within that "five (5) working day" time period contemplated by CCR 9792.9(b)(2).

If the insurer or self-insured employer does timely respond to the prospective request for authorization ("five (5) working days") and requests additional "appropriate information" and the treating physician provides it prior to fourteen (14) days from receipt of the original DFR or PR-2, the insurer or self-insured employer must reply by either authorizing, modifying, or denying the proposed course of treatment within "five (5) working days." (See CCR 9792.9(g)(3).)

If the treating physician provides the additional "appropriate information" after fourteen (14) days from receipt of the original prospective request, or the insurer or self-insured employer has timely requested "an additional examination or test be performed," or "a specialized consultation and review of medical information by an expert reviewer," the insurer or self-insured employer can conduct a "retrospective review" but must make a decision to approve, modify, or approve the request for authorization within thirty (30) days from receipt of the "appropriate information," the results of "an additional examination or test," or receipt of the report from the "specialized consultation and review of medical information by an expert reviewer." (See CCR 9792.9(g)(4).)

A claims administrator, a claims adjuster (CA), or any other "non-physician reviewer" can request additional "appropriate information." (See CCR 9792.7(b)(3) and CCR 9792.9(b)(2).) However, "No person, other than a licensed physician who is competent to evaluate the specific clinical issues involved in the medical treatment services, and where these services are within the licensure and scope of the physician's practice ..." may "delay, modify or deny, requests for authorization of medical treatment for reasons of medical necessity to cure or relieve the effects of the industrial injury." (See CCR 9792.7(b)(2).)

If the treatment plan in the DFR or PR-2 containing a proposed course of treatment is not authorized in full, then the UR physician must deny it within fourteen (14) days from receipt of the DFR or PR-2. If the UR physician issues the denial more than fourteen (14) days after receipt of the DFR or PR-2, the UR denial is inadmissible in court, and a panel qualified medical evaluator (PQME) is not to be provided with a copy of the untimely UR denial. (See Sandhagen I - side bar at right.)

- THE PQME DANCE -

Regardless of whether the insurer or self-insured employer complies with the above mandated time frames, if a prospective request for authorization for a proposed course of treatment is denied by UR, the PQME process to resolve the dispute can be triggered by either the IW or the employer (ER).

The IW gets the first opportunity to trigger the PQME process, but if the IW fails to timely object to an adverse determination by UR, than the ER can trigger the PQME process. The Labor Code (LC) is instructive of how the PQME process works. LC 4062(a) is germane to this issue, and directs the unrepresented IW to LC 4062.1.

If a treating physician's prospective request for authorization is denied by UR, then the IW must object in writing within twenty (20) days. (See LC 4062(a).) This written objection should be sent via certified, return-receipt mail, or faxed to the insurer or self-insured employer. (Be sure to keep all the certified, return-receipt documentation or the proof of receipt by fax.)

Upon receipt of the objection by the IW, the insurer or self-insured employer, there is an obligation to "immediately provide the employee with a form prescribed by the medical director with which to request assignment of a panel of three qualified medical evaluators, the evaluation shall be obtained as provided in Section 4062.1, and no other medical evaluation shall be obtained." (See LC 4062(a).)

However, the IW need not wait for the insurer or self-insured employer to provide this form. The form to request assignment of a panel of three qualified medical evaluators (QMEs) is available on the Division of Workers' Compensation (DWC) website that can be filled out and printed on your computer. Click here to obtain the PQME panel request form from the DWC website.

As mentioned above, the insurer's or self-insured employer's receipt of the objection to UR made by the IW triggers an obligation to provide a copy of this form immediately. Upon receipt of the form to request a PQME panel, the IW only has ten (10) days to select a physician specialty of choice, and submit the form to the DWC Medical Unit. If the IW fails to select a physician specialty and submit the form to the DWC Medical Unit within ten (10) days, the ER can select the physician specialty and submit the form. (See LC 4062.1(b).)

(Being as the PQME chosen to resolve the dispute will be the same PQME to resolve any future disputes for the life of the claim (See LC 4062.3(j).), it behooves the IW to be proactive by timely objecting to an adverse UR denial, timely selecting a physician specialty of choice, and timely submitting the PQME panel request form to the DWC Medical Unit.)

Once the DWC Medical Unit receives the PQME request form, it must issue a randomly selected panel of three (3) QME physicians of the chosen specialty, in the geographic area where the IW lives, within fifteen (15) working days. (See LC 139.2(h)(1) and (h)(4).) If the DWC Medical Unit fails to issue a PQME panel list within fifteen (15) days, the IW may select any QME to resolve the dispute. (See LC 139.2(h)(1).)

Upon receipt of the PQME panel list containing the names of three (3) physicians in the specialty chosen, the IW gets first pick, regardless of whether the IW or the ER submitted the PQME panel request form to the DWC Medical Unit.

However, the IW only has ten (10) days from the date of issuance by the DWC Medical Unit, to pick a physician from the list, make an appointment, and notify the ER of the selection.

If the IW fails to notify the ER of the selection within ten (10) days, the ER can pick which QME will resolve the dispute. (See LC 4062.1(c).)

Once the date and time of appointment with the PQME has been made, both the ER and the IW have an obligation to furnish each other with a list of proposed medical and non-medical information to be provided the PQME no later than twenty (20) days in advance of the scheduled appointment. (See LC 4062.3(b) and (e).)

If the IW or ER objects to any non-medical documentation proposed to be provided the PQME (e.g. witness statements, letters, depositions, sub-rosa videos, or photographs), then an objection must be issued within ten (10) days from receipt of the list, and the non-medical documentation shall not be provided to the PQME. (See LC 4062.3(b).)

Once the IW has begun the evaluation by the selected PQME, the IW can say anything to the PQME, and provide the PQME with additional documentation (e.g. evidence-based medicine [EBM] studies or other treatment guidelines) supporting the treatment plan that was denied by UR. (See LC 4062.3(h).)

After the evaluation is completed, the chosen PQME usually only has thirty (30) days to issue his or her report. (See LC 139.2(j)(1)(A).) However, the PQME can seek an extension of time to issue his or her report from the DWC Medical Unit because the PQME has not received test results or a report from a consulting physician. (See LC 139.2(j)(1)(A)(i).)

This is not unusual, particularly if there is a claim for multiple body parts to have been injured. (e.g. an orthopedic PQME cannot comment on a psyche claim, so the orthopedic PQME must refer the IW to a psychologist or a psychiatrist of the PQME's choice and has to wait for the report by the consulting psychologist or psychiatrist to be issued.)

If a PQME needs additional time to finish his or her report because he is awaiting test results or the report from a consulting physician, the PQME must seek an extension of time from the DWC Medical Unit. The PQME must submit a Form 112 to the DWC Medical Unit no later than five (5) days before the report is due to be issued. This means no later than twenty-five (25) days after the date of the evaluation.

If the PQME issues a report that resolves the dispute in favor of the IW, the ER must provide or pay for the treatment previously requested, and previously denied by UR. If the ER refuses to provide the treatment, or denies reimbursement for the treatment, the IW should file a "Declaration of Readiness to Proceed to Expedited Hearing."

UR DENIALS AND THE PQME DANCE MADE SIMPLE

OBLIGATIONS AND SUGGESTIONS:

Your treating physician must seek authorization for a proposed course of treatment on a DFR or a PR-2. It should be supported by EBM.

The ER/UR must respond within 5 working days.

If UR denies or modifies the proposed course of treatment plan, the IW should trigger the PQME process by objecting to the UR denial in writing within 20 days. The IW should consult with their treating physician on which specialty to pick to conduct the PQME evaluation. Upon selecting a specialty, the IW should submit the request for a PQME to the DWC Medical Unit ASAP, but in no event later than 10 days after the insurer or self-insured employer has provided the PQME request form to the IW.

The DWC Medical Unit must issue a panel of 3 physicians from the specialty selected within 15 working days, or else the IW gets to pick any QME to resolve the UR dispute.

The IW and the ER must exchange a list of proposed medical and non-medical documentation to be provided the PQME no later than 20 days before the evaluation.

If the IW or ER objects to any non-medical information proposed to be provided the PQME, the objection must issue within 10 days from receipt of the list. If non-medical documentation is objected to, it shall not be provided the PQME.

If the UR denial was issued more than 14 days after receipt of the DFR or PR-2, it is inadmissible and should not be provided to the PQME.

The IW and the ER are to provide the allowed documentation to the PQME prior to the evaluation.

The IW can provide non-medical documentation to the PQME at the time of the evaluation.

The PQME must issue the report no later than 30 days after the evaluation, or timely request an extension of time from the DWC Medical Unit.

If the PQME report approves of the proposed course of treatment that was previously denied by UR, the ER must provide or pay for it.

If the ER refuses to provide or pay for the treatment, the IW should file a "Declaration of Readiness to Proceed to Expedited Hearing."

At the Expedited Hearing, which is a trial, the IW should file a copy of the DFR or PR-2 requesting the proposed course of treatment, and any medical reports and EBM supporting the proposed course of treatment, as well as a copy of the PQME report, and any denials from the ER that issued prior to the PQME as well as after the PQME report issued.

If the initial UR denial was untimely, the IW should object to it being introduced into evidence by the defense attorney for the ER on the basis it was untimely.

The IW should be prepared to testify as to how the treatment assists in increasing range of motion (ROM), and increases function in that the treatment makes it easier to stretch, exercise, get dressed, cook, and/or work, as well as reducing pain. The trial judge must understand that the treatment will assist the IW in returning to the workplace.

The trial judge will issue an opinion on an expedited basis that resolves the dispute(s).

My analysis of UR denials and the PQME dance is based on the WCAB en banc decision called Willette v. AU Electric. (Side bar at right.)

by York McGavin - ymcgavin@socal.rr.com



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