Reports to UR - whose responsibility? (California) (Californ

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Reports to UR - whose responsibility? (California) (Californ

Postby docwats on Tue Jan 18, 2011 10:34 am

As an MD I submit reports to the claims administrator, as required. When I request authorization for a service, and it goes to UR, I almost invariably find that little or no information has been provided the review MD. Many requests are denied on the basis of there being no supporting documentation.

It is my understanding that I must report only to the claims administrator, and for me to supply anyone else with reports I must be told to do so by the claims administrator, in writing. I am also supposedly reimbursed for doing so. Yet, despite having 12 hour turnaround from office visit to report in the hands of the claims departments, the information is almost always not supplied.

Am I missing something here?
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Re: Reports to UR - whose responsibility? (California) (Californ

Postby gaiassoul1@yahoo.com on Tue Jan 18, 2011 9:11 pm

yep, what you are missing is that your request for authorization is a self-contained stand alone document/statement.

You can refer to prior reports but the findings you are relying on to justify your authorization should be summarized within the request for authorization.
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Re: Reports to UR - whose responsibility? (California) (Californ

Postby docwats on Wed Jan 19, 2011 7:45 am

I'm looking at a document on line, from the DIR official website, which seem to be currently in effect. Can anyone reading this confirm this has gone into effect, with the new "California specific codes" like WC009 ?

Title 8, California Code of Regulations
Division 1, Chapter 4.5
ARTICLE 5.3
[§9789.10 unchanged.]
[§9789.11 unchanged.]
§ 9789.12.1 Physician Fee Schedule: Official Medical Fee Schedule for Physician and Non-Physician Professional Provider Services – For Services Rendered On or After 10/1/2010 January 1, 2011

On page 15:

(4) Provider Reports That Are Not Legally Mandated. When a claims administrator or its authorized agent requests that a provider complete a form that is not legally mandated or submit information in excess of that required pursuant to section 9785, the provider shall be separately reimbursed using code WC006. Maximum reimbursement is $37.98 for first page, plus $23.37, for each additional page. Maximum of six pages absent prior authorization mutual agreement. Maximum total reimbursement is $154.83.

on page 16:
(d) Duplicate Reports. A primary treating physician has fulfilled his or her reporting duties by sending one copy of a required report to the claims administrator

I don't see that reports to UR are legally mandated. UR seems an "authorized agent". It looks like WC006 is for this purpose.
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Re: Reports to UR - whose responsibility? (California) (Californ

Postby docwats on Wed Jan 19, 2011 7:51 am

The link to the document is http://www.dir.ca.gov/dwc/ForumDocs/Phy ... hedule.doc
or the PDF at http://www.dir.ca.gov/dwc/ForumDocs/Phy ... hedule.pdf

I believe it may still be open for public hearing and the implementation delayed.
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Re: Reports to UR - whose responsibility? (California) (Californ

Postby dontdenyme on Wed Mar 21, 2012 9:44 pm

Hmmm...OK...I"m a UR guy... and I do bill reviews. So I think I can help you on this.
Like the guy above said, you should have all the necessary information contained in the requests. If you need to write a narrative for this which I recommend, you can bill 99080 per page. Don't try to make it lengthy and include all kinds of garbage like some of the stuffs they teach you at seminar. Some idiots actually write threatening statements. That's really a red flag for us. Just be concise and be to the point. summarize the past treatments, current treatments outcome (current status) vs past status, etc...
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