LC 4603.2(b) Question (California)

[paduanow@yahoo.com]

Two Questions:

1.
I have an Ortho PTP in the MPN and it is getting paid, refers patinet to RPT for Treatment
with a prescription. RPT is within MPN but does not get paid because he did not
request authorization. LC 4603.2 states "payment for medical treatment provided or
authorized by the treating physician." The PTP authorized the treatment which I interpret
as being approved. Is my thinking wrong?

2. Same question but the RPT is not within the MPN. I still believe the RPT should get paid.
Is my thinking off here too!

Thanks


4603.2. (a) Upon selecting a physician pursuant to Section 4600,
the employee or physician shall forthwith notify the employer of the
name and address of the physician. The physician shall submit a
report to the employer within five working days from the date of the
initial examination and shall submit periodic reports at intervals
that may be prescribed by rules and regulations adopted by the
administrative director.
(b) (1) Except as provided in subdivision (d) of Section 4603.4,
or under contracts authorized under Section 5307.11, payment for
medical treatment provided or authorized by the treating physician
selected by the employee or designated by the employer shall be made
at reasonable maximum amounts in the official medical fee schedule,
pursuant to Section 5307.1, in effect on the date of service.

[rider001]

1. No. Treament still has to conform to ACOEM or MTUS and be authorized.
2. Depends. If the ptp was not in the MPN then they can refer outside of the MPN. If the ptp is in the MPN then one must refer in the MPN. Regardless of MPN status stills need auth.

[jakelast@aol.com]

I think you are correct that the PTP actually authorizes medical treatment. If the employer wishes to contest, the methodology is through UR. there is simply no requirement to obtain authorization for treatment to be paid. However if authorization is not sought the RPT runs the risk the treatment will be denied in retrospective review and will have bought litigation to try and get paid.

If the RPT is outside the MPN and the employee is in the MPN, the RPT is out of luck. The PTP is obligated to refer the employee to a medical provider within the network and the employer does not have to pay for Tx outside the MPN.

The failure to obtain authorization for the RPT in the MPN is not fatal to getting paid, but runs the risk of non-payment. Outside the network, you are out of luck. Providing Tx without seeking authorization also runs the risk the 24 visit cap will be gone and the Tx is legally not collectable.

The moral of the story is if the RPT is inteersted in getting paid, seek authorization

[paduanow@yahoo.com]

Thanks for all your answers.
I want to clarify my fisrt question.

Most of the time we only have a couple of days notice to fax over the request for authorization before the first visit. Most of the time we do not get a reply, but when we do it is after the first and/or second visit. We always send the request for authorization with the first billing along with PR2 and prescription. But this seem not to be enough. We get a denial letter for the IC stating it was not pre-authorized. The L.C. 4603.2(b) "authorized by the treating physician selected by the employee" does not say anything about authorization by the IC. In addition, "Payments shall be made by the employer within 45 working days after receipt of each separate, itemization of medical services provided, together with any required reports and any written authorization for services that may have been received by the physician." We are sending the authorization with the billing here. But it is not pre-authorized.

[rider001]

I didn't see a question here more of an explanation. Anyways, you can not read one section or subsection of a law to get the complete story. You must take all laws into cosideration. All carriers have to have set up an authorization process that has been approved for treatment request. 9792.9 will give you the time frames.

Options from least to most invovled
1. stop scheduleing so fast or until you get authoriation.
2. after treating a few sessions request retro authuorization.
3. fax authorization request and keep the fax transmittals as this may help you collect on a lien when resposnes are not generate within the appropriate time frames.
4. treat without authorization and get a good lien rep.

It all depends on how hard you want to work to get paid and how balloned you want your A/R to be.