Treatment Authorization (California)

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Treatment Authorization (California)

Postby grossmanburn on Tue Dec 18, 2012 9:03 am

It is my understanding from reading about the most recent incarnation of California Work Comp "reform" that a specific authorization form will have to be used when requesting authorization for treatment, and that the carrier has THIRTY DAYS to respond. As providers, we have been sent nothing by the State explaining the new rules and what we have to do to comply. Can someone confirm these two issues, please? It is most vexing, because in burn care, even five days can be too long, and we usually are able to get authorization within hours for needed treatment. Delays in authorization often result in dismal outcomes for the burn survivors we treat. :?
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Re: Treatment Authorization (California)

Postby on Tue Dec 18, 2012 6:20 pm


Well it might be from the lack of response that some in the healthcare world are leaving WC. I think the answer to your question is yes on a special new form. The last new form was the PR2 that was designed to make finding what you are requesting user friendly, the new form in another form where you will restate what you are stating in the pr2. In regards to care and authorization I guess you are supposed to file each tx request expedited or urgent and wait for a response within 3 days. The WC system does seem to recongnize the need for timely care in an acute injury setting. If you care is not authorized and your bill is denied you can now pay $150 for a lien or $325 for a bill review. No other provision to address your concern exists that I know of. Some see this as a better world or the real world. I think everyone is waiting for rules and regs and clarification regarding the process and the specific additional forms to be used after Jan 1. Good luck.


In the real world outside the Comp Dreamland, no doctor, no dentist, no psychiatrist, no "H-Wave" provider, no EMG specialist, not even a sign painter, would ever dream of performing work until the party responsible said "I'd like you to do this," and agreed to pay (and to be clear, there is an implied in law agreement that when I walk into a dentist or whatever, that I will pay for services even though I did not sit down and discuss the contract with the doctor, barber, dentist, whatver.)

Why would a medical provider just assume they could make the employer or insurance company pay? Because the system was grossly flawed, and allowed them to do that. Because they could.

Welcome to the real world, just like everyone else now.
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Re: Treatment Authorization (California)

Postby suekarp on Wed Dec 19, 2012 7:52 am

As a claims adjuster, if I have an injured worker who is severely injured (and I handle firefighters, so burn injuries are a significant possibility in my caseload), my opinion is that if the care required is time-sensetive, get in touch with me by phone, or anyone else in my office, if I was not available. Get the needed care rendered, and even if there is an argument about AOE/COE or anything else, we'll decide that after the emergency is passed. I know that not all adjusters have the same attitude, and working with a self-insured government entitiy, I suppose that I have more freedom to do what is right, not just what is economically expediant.

Having said that, of course I would expect that after such a phone call requesting authorization for emergency care was made, follow up information documenting the contents of the phone call from the provider would be expected, just as the provider would expect that I provide a fax copy documenting the authorization.

I really think that there are many with my attitude out in the claims administration community.

If rtuly an emergency, get a hold of someone at the employer, insurance company, etc. Tell them that you have an emergency. Try for a supervisor or above, if you are having issues getting through to an adjuster immediately. Tell the receptionist that you have an EMERGENCY. I know that it takes time, but I'll bet that it beats just sitting around for someone to return your call or faxing you a response, while you just provide pallitiave care to the patient waiting in front of you.

Also, there are regulations that allow for greatly expedited decisions to be made for UR.
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Re: Treatment Authorization (California)

Postby chirple on Thu Dec 20, 2012 10:24 pm

It is surely a difficult position to be in, as a medical provider of emergency services, to consider denying a patient treatment you believe is necessary because you fear the insurance carrier will not authorize or not pay.

I'm not advocating that medical providers should have to give away their services, but at what point do you say no to a patient when they can't pay or guarantee payment? Is it when the treatment is optional? Is it when the treatment is expensive? Is it when it is not life threatening?

Outside of WC, what do you do with such a patient who has no insurance at all? Or, one that has insurance but can't get authorization there?
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Re: Treatment Authorization (California)

Postby grossmanburn on Mon Feb 11, 2013 8:55 am

We request authorization for something nearly every day, yet on Friday, for the first time, we were told we had to use the new request for authorization form: RFA 9785.5. Seems the insurance/UR community isn't taking it very seriously.

What I found interesting, though, is that this form is required for all requests for authorization, yet it seems no one notified the providers. We were directed to it by Genex Services.
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