Newsline No. 36-08 printer image Printer friendly

June 18, 2008

 

California Division of Workers’ Compensation posts results of utilization review investigations on its Web site

The Division of Workers’ Compensation (DWC) has posted the results of utilization review (UR) investigations of claims administrators on its Web site. The results, posted at http://www.dir.ca.gov/dwc/UtilizationReview/UR_InvestigationResults.htm in the form of performance ratings and a summary of violations, cover the time period between November 2007 and the present.

“This information shows how claims administrators and utilization review organizations performed and summarizes the type and number of violations found during our investigations,” said DWC Executive Medical Director Dr. Anne Searcy. “We’ll continue to post what we find on line to give employers a chance to choose a UR program that’s providing benefits correctly.”

Claims administrators and utilization review organizations (UROs) are subject to UR investigation and penalties if they aren’t complying with UR regulations written by the DWC, which lay out timeframes and other rules for conducting UR. Claims administrators are subject to what's known as "routine investigations" once every five years. These routine investigations are conducted as part of the existing audits done under Labor Code section 129. UROs are subject to routine investigations once every three years.

If the claims administrator or URO has failed a previous routine investigation, DWC can return for what's called a "target investigation." The DWC can also conduct a target investigation based on a credible complaint. Credible complaints are provided to the claims administrator for their response prior to investigation.

During an investigation, a random sample of requests for authorization taken from a three-month calendar period that occurred on or after June 7, 2007, along with additional records that may be needed, is reviewed. Claims administrators and UROs receive advance notice that they have been selected for investigation. After producing the information called for about the requests for authorization received during the three months prior to commencement of the investigation, the claims administrators and UROs receive a notice at least 14 days before the investigation begins. The investigation of claims administrators occurs at the adjusting location, while UROs provide copies of all requested documents to DWC.

The information regarding UR reviews is posted in compliance with Title 8, California Code of Regulations, section 9792.12(b)(6). The Web site will be updated with additional reports as the investigation findings become final.

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