Division of Workers' Compensation issues 15-day notice of revisions to proposed utilization review enforcement regulations

The Division of Workers' Compensation (DWC) has modified its regulations for utilization review enforcement. A 15-day notice of modification was distributed to interested parties and the revised regulations are posted to the DWC Web site. Members of the public may comment on the revisions until 5 p.m. on Tuesday, Feb. 22, 2007.

The proposed utilization review enforcement regulations are authorized by Labor Code section 4610, which requires every employer to have and use a utilization review process, and sets out timelines and conditions to be met whenever a request for authorization of medical treatment will be delayed, modified or denied.

The revisions include:

• A clarification that routine investigations of claims administrators will occur at least once every five years, concurrent with the profile audit review done pursuant to Labor Code sections 129 and 129.5
  
• A clarification that the routine investigations of utilization review organizations will occur at least once every three years
  
• A revision to the list of the information and records that must be made available during the investigation
  
• A performance rating of 85 percent on the "b" penalties (section 9792.12(b)). If the claims administrator or utilization review organization has a performance rating of 85 percent or better, the penalties listed in section 9792.12(b) will not be imposed
  
• A change to the method of calculating penalties imposed under section 9792.12(b) for a return target investigation.

Further information and the modified proposals can be found at http://www.dir.ca.gov/dwc/DWCPropRegs/UREnforcementRegulations/UR_EnforcementRegulations.htm.