Wednesday, June 27, 2007

DWC MEDICAL UNIT CLARIFICATION ON UR

It is important to keep in mind that all requests for authorization and all approvals as well as denials, delays and modifications are part of the UR process described in LC 4610 and the UR regs. An employer must have a UR plan with an appropriately credentialed and empowered medical director. Empowered to assure all decisions made in the UR process conform to the UR plan standards which must conform to LC 4610 and the UR regulations. The employer can contract out the UR responsibility thru h/h insurer, through a TPA or directly to a URO. If the employer just gets WC insurance or a TPA which, as part of the contract with the employer provides UR services (whether directly or through a subcontractor URO), that can satisfy the LC 4610 and the regs. However, it's the employer's responsibility to make sure that the contract documents cover the employer's duties under LC 4610 and the UR regs. It's the employer's responsibilities that the process is working.
As long as the Medical Director of the UR plan devises a way to ensure that the employer's claims adjusters (whether in house for a self insured employer or external through a TPA or WC insurer) are applying the standards of the UR plan (the plan the employer relies on to satisfy h/h LC 4610 and 8 CCR 9792.6 et seq responsibilities), the claims adjusters can approve medical treatment authorization requests. In so doing, they will be held to the same standards (timeliness, contents of communications) we would hold the URO to in complying with LC 4610 and 8 CCR 9792.6 for approvals.

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