Division of Workers' Compensation posts revised draft utilization review regulations to online forum for public comment
The Division of Workers' Compensation (DWC) has revised the utilization review (UR) regulations and posted them to the online forum where members of the public may review and comment on the proposal. UR is required by Labor Code section 4610 and the regulations are contained in Title 8 of the California Code of Regulations, sections 9792.6 through 9792.15.
Amending the UR regulations to streamline procedures and reduce administrative costs is part of the division’s 12-point plan to help control medical costs. The revisions include:
- Posting a list of pre-approved UR plans on the DWC Web site. Claims administrators will be required to send revised plans for approval annually or inform the division annually that there are no changes.
- UR plans will be reviewed separately from the UR investigations and claims administrators will receive a notice of approval or disapproval within 60 days.
- A UR plan template will be posted on the DWC Web site.
- UR organizations will be investigated once every five years instead of once every three years.
- Section 9792.9, which sets forth the timelines for responding to requests for authorizations, is reorganized for clarity.
- A claims administrator or utilization review organization will either pass if it receives a performance rating above 85 percent, or fail if the rating is below 85 percent. If it passes, only the mandatory "(a) penalties" will have to be paid. If it fails, the $100 or $50 "(b) penalties" will be increased depending on the requests for authorization sample size. The abatement section has been deleted.
- A request for authorization form must be used by the physician requesting treatment approval. DWC will only look at forms in which the mandatory fields have been completed when conducting an investigation or assessing penalties.
- The new request for authorization form makes the sample selection more efficient and helps simplify the UR process for claims administrators and physicians.
The forum can be found at: http://www.dir.ca.gov/Wcjudicial.htm. Click on "current forums" at the top of the page.
Comments will be accepted on the forum until 5:00 p.m. Thursday, Oct. 7, 2010. Please feel free to participate in this important process.