Utilization review investigation results
Claims administrators and utilization review organizations (UROs) are subject to UR investigation and penalties. Claims administrators are subject to routine investigations once every five years. These routine investigations for claims administrators are carried out in conjunction with the profile audit review (PAR) audits conducted in accordance with Labor Code section 129. UROs are subject to routine investigations once every five years.
A random sample of requests for authorization is reviewed during an investigation. The sample is drawn from the requests submitted in the three-month calendar period prior to the commencement of the investigation. Of the entire population of requests submitted, only those meeting the regulatory definition of a request for authorization are used in the investigation.
The claims administrators and UROs receive notice that they have been selected for investigation. After producing the information requested for the investigation, the claims administrators and UROs receive a notice of investigation commencement at least 14 days before the investigation begins. The investigation of claims administrators takes place at the adjusting location, while the URO provides copies of all requested documents to the DWC Medical Unit. Once the investigation has concluded, a final investigation report (which includes a performance rating) is provided to the investigation subject.
If a claims administrator or URO fails a routine investigation, DWC can return for a target investigation. The DWC can also conduct a target investigation based on a credible complaint. Credible complaints may be provided to the claims administrator for their response prior to an investigation.
As each investigation is completed, the final performance rating and an analysis of penalties and/or violations cited are posted below. Any party with questions about UR should review the UR FAQ page for more information.
Utilization review organizations (UROs)