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Posted on: Oct 29, 2018

Senate Bill 1160, signed into law in 2016, increased control of medical lien claims in exchange for less restrictive Utilization Review (UR) at the start of the claim.

It also required accreditation by July 1, 2018, for any utilization review organization operating in California to ensure they issue timely decisions, review all pertinent medical records, have peer-to-peer and internal appeal procedures, and have adopted policies prohibiting financial incentives for doctors denying treatment requests.

The bill directed the DWC to adopt rules for selecting an accrediting agency, but said the Utilization Review Accreditation Commission will perform that function until rules are in place.

Immediately following the passage of SB 1160, the DWC kicked into high gear to implement the new changes relating to medical lien claims - a win for insurance companies.

But over two years later, public rule-making has not even started to implement the UR changes intended to protect injured workers.

As a result, with no rules or penalties in place, a large number of treatment requests - exempt from UR in the first 30 days - continue to be denied through UR despite the changes in the law.

And while some UR companies are complying with the mandate for accreditation, others are subcontracting UR services to unaccredited, out-of-state reviewers who are denying treatment.

Where is the oversight to ensure the "necessary safeguards to provide sufficient incentives for competent and careful utilization review" are put into place?

We're still waiting...