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CHANGES TO UTILIZATION REVIEW AND INDEPENDENT MEDICAL REVIEW AS OF JANUARY 1, 2018

By Don Liebherr


Although the majority of the SB 1160/AB 1244 legislation became operative during 2017, a part of the legislation becomes effective as of January 1, 2018 and during the year. In this year, 2018, the following will be taking place:

  1. Prospective review of medical treatment will not be required within certain exceptions in the first 30 days following the date of injury occurring on or after January 1, 2018.

  2. Prospective decisions regarding requests for medications covered by the formulary shall be made no more than five working days from the date of receipt of the medical treatment request. There is no extension of the turnaround time to 14 days.

  3. A utilization review process that modifies or denies requests for authorization of medical treatment shall be accredited on or before July 1, 2018, and shall retain active accreditation while providing utilization review services by an independent, non profit organization to certify that utilization review process meets specific criteria.

  4. Electronic reporting of utilization review is mandated, requiring that claims administrations route all utilization review data to the Division of Workers' Compensation for increased monitoring. THE DIVISION OF WORKERS’ COMPENSATION CAN ALSO REVIEW THE FINANCIAL CONTRACTS BETWEEN THE EMPLOYER, UTILIZATION REVIEW ENTITY AND UTILIZATION REVIEW PHYSICIAN REVIEWERS.

  5. Third-party administrators are prohibited from referring utilization review services to any entity in which the insurer or third-party administrator has a financial interest, unless the insurer/third-party administrator discloses the name of the utilization review entity and the insurer or third-party administrator's financial interest in the entity to the employer and the Division of Workers’ Compensation. SB 1160 has the potential to help the Workers' Compensation Industry to maintain and control care costs and to deliver the medical care necessary faster. Payors and utilization review companies in the position of retrospectively monitoring the delivery of treatment and potentially disrupting that treatment well after the development of the physician-patient relationship. This law requires and makes it very prudent for the Workers' Compensation Community to understand the requirements for treating Workers' Compensation patients and to also understand the Medical Treatment Utilization Schedule recommended treatments for the injured worker.

    The intent is that there will not be any managed care cost increases due to the removal of utilization review in the first 30 days under those limited circumstances enumerated herein.



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