BILL NUMBER: AB 2503 AMENDED
BILL TEXT
AMENDED IN SENATE AUGUST 19, 2016
AMENDED IN ASSEMBLY APRIL 19, 2016
AMENDED IN ASSEMBLY MARCH 29, 2016
INTRODUCED BY Assembly Member Obernolte
FEBRUARY 19, 2016
An act to amend Section 4610 of the Labor Code, relating to
workers' compensation.
LEGISLATIVE COUNSEL'S DIGEST
AB 2503, as amended, Obernolte. Workers' compensation: utilization
review.
Existing law establishes a workers' compensation system,
administered by the Administrative Director of the Division of
Workers' Compensation, to compensate an employee for injuries
sustained in the course of his or her employment. Existing law
requires every employer, for purposes of workers' compensation, to
establish a utilization review process to prospectively,
retrospectively, or concurrently review and approve, modify, delay,
or deny, based in whole or in part on medical necessity to cure and
relieve, treatment recommendations by physicians prior to,
retrospectively, or concurrent with the provision of medical
treatment services, as provided. Existing law requires prospective or
concurrent decisions to be made in a timely fashion that are
appropriate for the nature of the employee's condition. Existing law
also requires that decisions to approve, modify, delay, or deny
requests by physicians for authorization prior to, or concurrent
with, the provision of medical treatment services to employees be
communicated to the requesting physician within 24 hours of the
decision.
This bill would require, when an employee is referred to
a physician by an employer, insurer, or other entity that is subject
to the provisions governing utilization review, the physician to send
any request for authorization for medical treatment to the claims
administrator for the employer, insurer, or other entity.
This bill would require a physician providing treatment to an
injured worker to send any request for authorization for medical
treatment, with supporting documentation, to the claims administrator
for the employer, insurer, or other entity according to rules
adopted by the administrative director. The bill
would also make technical changes.
Vote: majority. Appropriation: no. Fiscal committee: no
yes . State-mandated local program: no.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 4610 of the Labor Code is amended to read:
4610. (a) For purposes of this section, "utilization review"
means utilization review or utilization management functions that
prospectively, retrospectively, or concurrently review and approve,
modify, delay, or deny, based in whole or in part on medical
necessity to cure and relieve, treatment recommendations by
physicians, as defined in Section 3209.3, prior to, retrospectively,
or concurrent with the provision of medical treatment services
pursuant to Section 4600.
(b) Each employer shall establish a utilization review process in
compliance with this section, either directly or through its insurer
or an entity with which an employer or insurer contracts for these
services.
(c) Each utilization review process shall be governed by written
policies and procedures. These policies and procedures shall ensure
that decisions based on the medical necessity to cure and relieve of
proposed medical treatment services are consistent with the schedule
for medical treatment utilization adopted pursuant to Section
5307.27. These policies and procedures, and a description of the
utilization process, shall be filed with the administrative director
and shall be disclosed by the employer to employees, physicians, and
the public upon request.
(d) When an employee is referred to a physician by an
employer, insurer, or other entity subject to this section, the
physician shall send any request for authorization for medical
treatment Unless otherwise indicated in this section,
a physician providing treatment under Section 4600 shall send any
request for authorization for medical treatment, with supporting
documentation, to the claims administrator for the employer,
insurer, or other entity. entity according to
rules adopted by the administrative director. If an employer,
insurer, or other entity subject to this section requests medical
information from a physician in order to determine whether to
approve, modify, delay, or deny requests for authorization, that
employer, insurer, or other entity shall request only the information
reasonably necessary to make the determination. The employer,
insurer, or other entity shall employ or designate a medical director
who holds an unrestricted license to practice medicine in this state
issued pursuant to Section 2050 or Section 2450
of the Business and Professions Code. The medical director shall
ensure that the process by which the employer or other entity reviews
and approves, modifies, delays, or denies requests by physicians
prior to, retrospectively, or concurrent with the provision of
medical treatment services, complies with the requirements of this
section. Nothing in this section shall be construed as restricting
the existing authority of the Medical Board of California.
(e) A person other than a licensed physician who is competent to
evaluate the specific clinical issues involved in the medical
treatment services, and where if these
services are within the scope of the physician's practice, requested
by the physician physician, shall not
modify, delay, or deny requests for authorization of medical
treatment for reasons of medical necessity to cure and relieve.
(f) The criteria or guidelines used in the utilization review
process to determine whether to approve, modify, delay, or deny
medical treatment services shall be all of the following:
(1) Developed with involvement from actively practicing
physicians.
(2) Consistent with the schedule for medical treatment utilization
adopted pursuant to Section 5307.27.
(3) Evaluated at least annually, and updated if necessary.
(4) Disclosed to the physician and the employee, if used as the
basis of a decision to modify, delay, or deny services in a specified
case under review.
(5) Available to the public upon request. An employer shall only
be required to disclose the criteria or guidelines for the specific
procedures or conditions requested. An employer may charge members of
the public reasonable copying and postage expenses related to
disclosing criteria or guidelines pursuant to this paragraph.
Criteria or guidelines may also be made available through electronic
means. A charge shall not be required for an employee whose physician'
s request for medical treatment services is under review.
(g) In determining whether to approve, modify, delay, or deny
requests by physicians prior to, retrospectively, or concurrent with
the provisions of medical treatment services to employees all of the
following requirements shall be met:
(1) Prospective or concurrent decisions shall be made in a timely
fashion that are appropriate for the nature of the employee's
condition, not to exceed five working days from the receipt of the
information reasonably necessary to make the determination, but in no
event more than 14 days from the date of the medical treatment
recommendation by the physician. In cases where the review is
retrospective, a decision resulting in denial of all or part of the
medical treatment service shall be communicated to the individual who
received services, or to the individual's designee, within 30 days
of receipt of the information that is reasonably necessary to make
this determination. If payment for a medical treatment service is
made within the time prescribed by Section 4603.2, a retrospective
decision to approve the service need not otherwise be communicated.
(2) If the employee's condition is one where
in which the employee faces an imminent and serious threat
to his or her health, including, but not limited to, the potential
loss of life, limb, or other major bodily function, or the normal
timeframe for the decisionmaking process, as described in paragraph
(1), would be detrimental to the employee's life or health or could
jeopardize the employee's ability to regain maximum function,
decisions to approve, modify, delay, or deny requests by physicians
prior to, or concurrent with, the provision of medical treatment
services to employees shall be made in a timely fashion that is
appropriate for the nature of the employee's condition, but not to
exceed 72 hours after the receipt of the information reasonably
necessary to make the determination.
(3) (A) Decisions to approve, modify, delay, or deny requests by
physicians for authorization prior to, or concurrent with, the
provision of medical treatment services to employees shall be
communicated to the requesting physician within 24 hours of the
decision. Decisions resulting in modification, delay, or denial of
all or part of the requested health care service shall be
communicated to physicians initially by telephone or facsimile, and
to the physician and employee in writing within 24 hours for
concurrent review, or within two business days of the decision for
prospective review, as prescribed by the administrative director. If
the request is not approved in full, disputes shall be resolved in
accordance with Section 4610.5, if applicable, or otherwise in
accordance with Section 4062.
(B) In the case of concurrent review, medical care shall not be
discontinued until the employee's physician has been notified of the
decision and a care plan has been agreed upon by the physician that
is appropriate for the medical needs of the employee. Medical care
provided during a concurrent review shall be care that is medically
necessary to cure and relieve, and an insurer or self-insured
employer shall only be liable for those services determined medically
necessary to cure and relieve. If the insurer or self-insured
employer disputes whether or not one or more services offered
concurrently with a utilization review were medically necessary to
cure and relieve, the dispute shall be resolved pursuant to Section
4610.5, if applicable, or otherwise pursuant to Section 4062. A
compromise between the parties that an insurer or self-insured
employer believes may result in payment for services that were not
medically necessary to cure and relieve shall be reported by the
insurer or the self-insured employer to the licensing board of the
provider or providers who received the payments, in a manner set
forth by the respective board and in a way that minimizes reporting
costs both to the board and to the insurer or self-insured employer,
for evaluation as to possible violations of the statutes governing
appropriate professional practices. Fees shall not be levied upon
insurers or self-insured employers making reports required by this
section.
(4) Communications regarding decisions to approve requests by
physicians shall specify the specific medical treatment service
approved. Responses regarding decisions to modify, delay, or deny
medical treatment services requested by physicians shall include a
clear and concise explanation of the reasons for the employer's
decision, a description of the criteria or guidelines used, and the
clinical reasons for the decisions regarding medical necessity. If a
utilization review decision to deny or delay a medical service is due
to incomplete or insufficient information, the decision shall
specify the reason for the decision and specify the information that
is needed.
(5) If the employer, insurer, or other entity cannot make a
decision within the timeframes specified in paragraph (1) or (2)
because the employer or other entity is not in receipt of all of the
information reasonably necessary and requested, because the employer
requires consultation by an expert reviewer, or because the employer
has asked that an additional examination or test be performed upon
the employee that is reasonable and consistent with good medical
practice, the employer shall immediately notify the physician and the
employee, in writing, that the employer cannot make a decision
within the required timeframe, and specify the information requested
but not received, the expert reviewer to be consulted, or the
additional examinations or tests required. The employer shall also
notify the physician and employee of the anticipated date on which a
decision may be rendered. Upon receipt of all information reasonably
necessary and requested by the employer, the employer shall approve,
modify, or deny the request for authorization within the timeframes
specified in paragraph (1) or (2).
(6) A utilization review decision to modify, delay, or deny a
treatment recommendation shall remain effective for 12 months from
the date of the decision without further action by the employer with
regard to a further recommendation by the same physician for the same
treatment unless the further recommendation is supported by a
documented change in the facts material to the basis of the
utilization review decision.
(7) Utilization review of a treatment recommendation shall not be
required while the employer is disputing liability for injury or
treatment of the condition for which treatment is recommended
pursuant to Section 4062.
(8) If utilization review is deferred pursuant to paragraph (7),
and it is finally determined that the employer is liable for
treatment of the condition for which treatment is recommended, the
time for the employer to conduct retrospective utilization review in
accordance with paragraph (1) shall begin on the date the
determination of the employer's liability becomes final, and the time
for the employer to conduct prospective utilization review shall
commence from the date of the employer's receipt of a treatment
recommendation after the determination of the employer's liability.
(h) Each employer, insurer, or other entity subject to this
section shall maintain telephone access for physicians to request
authorization for health care services.
(i) If the administrative director determines that the employer,
insurer, or other entity subject to this section has failed to meet
any of the timeframes in this section, or has failed to meet any
other requirement of this section, the administrative director may
assess, by order, administrative penalties for each failure. A
proceeding for the issuance of an order assessing administrative
penalties shall be subject to appropriate notice to, and an
opportunity for a hearing with regard to, the person affected. The
administrative penalties shall not be deemed to be an exclusive
remedy for the administrative director. These penalties shall be
deposited in the Workers' Compensation Administration Revolving Fund.