Utilization Review Enforcement Regulations

New Regulations That All Claims Administrators and Employers Should be Aware of:

The California Administrative Director filed the final version of the utilization review enforcement regulations with the Office of Administrative Law on April 26, 2007 with an effective date of May 26, 2007. The regulations carry high dollar monetary penalties for failure to meet any of the provisions of the utilization review regulations. The following are examples of the penalties in the most recent version of the regulations:



$50,000 for failure to establish a utilization review plan
$5,000 for failure to include all of the plan requirements
$10,000 for failure to file the utilization review plan or a letter in lieu of the plan
$5,000 for failure to file a modified utilization review plan after a material modification
$50,000 for failure to employ or designate a physician as a medical director
$25,000 for issuance of a decision to modify or deny a request for authorization regarding a medical treatment, procedure, service or product where the requested treatment, procedure or service is not within the reviewer’s scope of practice
$25,000 for failure to comply with the requirement that only a licensed physician may modify, delay or deny requests for authorization of medical treatment for reasons of medical necessity
$15,000 for failure to communicate the decision in response to a request for an expedited review
$5,000 for failure to approve the request for authorization solely on the basis that the condition for which treatment was requested is not addressed by ACOEM
$10,000 for failure to discuss reasonable options for a care plan with the requesting physician prior to denying authorization of or discontinuing medical care, in the case of concurrent review