Denial of medical treatment in a workers’ compensation claim is the most common problem that brings injured workers to seek an attorney’s help. This often presents complex issues not easily understood and difficult to resolve even for experienced attorneys.
The adjuster who handles a work injury claim cannot modify, delay or deny medical treatment without the opinion of a qualified physician that supports that decision. This process is called Utilization Review, and UR has strict timelines to meet in order to be allowed as evidence in the claim.
The problem that attorneys and injured workers face is that the evidence needed to determine whether the UR report is on time relies on a document that is difficult to obtain. The rule works this way; the treating doctor requests treatment by using a required form, the Request for Authorization (RFA). If the UR report is prepared within 5 working days (usually 7 calendar days) and communicated to the doctor within one day from the time it is prepared, it is timely.
If the UR report is late, it can be excluded as evidence and the injured worker can have the judge review the medical evidence to see whether there is substantial evidence in support of the need for the requested treatment. This is often a reasonable remedy where the UR reviewer has not reviewed all of the relevant documents or made errors in reporting on the medical history or used the wrong criteria for decision.
We have found that a UR report that says the RFA was received within the allowed time frame in many instances is incorrect and that the RFA was actually received earlier than reported. Once we get the RFA and look at the date it was prepared and sent for review, we can establish the true facts. But there are two obstacles to getting the evidence.
Doctors are not required to notify the injured worker or the injured workers’ attorney of the date the RFA is submitted. Without the form and its date stamp for evidence, there is no way to know when it was submitted and when the 5 working day time clock actually starts.
The second obstacle to getting the RFA form is the form itself which, on page 2, at the top of the instructions, clearly says the form should be provided only to the adjuster or designated UR facility. Even when we subpoena records from the doctors, we have found the RFA forms missing from the medical records.
The bottom line is that injured workers can be denied treatment and the only recourse is to determine whether the UR is timely, or appeal the UR report for a review by Independent Medical Review conducted by Maximus, the rubber stamp agency that performs “independent” review in secret.
Getting the RFA form with the date stamp would be a simple matter that would resolve this procedural problem and assist injured workers in their efforts to return to work. When treatment is denied, the doctor may tell the represented injured worker to notify their attorney. But the first step in solving this problem is getting the RFA that the doctor has prepared and sent for review. We cannot as the court for review unless the UR report is late, and we need the RFA for proof. If we cannot prove the UR is late, we can only appeal to IMR, the reviewing agency, and apparently most appeals these days seem to fall on deaf ears.