EK HEALTH

by Steve Kline, Esq.
EK Health Services' Legal Counsel

Last April, the Department of Workers’ Compensation held a utilization stakeholder meeting in San Francisco. At that time there was discussion concerning the adoption of a Request for Authorization form that would be mandated by the DWC for ease-of-use by requesting physicians and utilization review organizations. Of course, many in the room had great trepidations about what kind of form would be created and the complications that such a form would create for all interested parties.

Recently, a draft of the form has been presented to the public for review.  A copy is located at the end of this article.

There are many positive aspects about this form. Certainly many primary treating physicians will not like this form, because it is something new that they have to deal with and change always cause problems.  However, overall the form & its accompanying instructions are encouraging from the EK Health perspective.

Near the top of the form it states, “Must be accompanied by a medical report substantiating the requested treatment.”  This admonition is certainly welcome as too often EK Health receives requests on prescription forms, notepaper and other miscellaneous documents that hardly substantiate or document the rationale behind the treatment request.  Incomplete requests causes considerable delays with requests for more information in order to provide an adequate review of the medical necessity for the request for treatment.

The instructions which will accompany the forms (copy not included in this article) sets out that requesting physician should include “reference to specific guidelines used to support treatment” requests.  They suggest that CPT codes be used and must be used for surgery requests.  With regard to requests for the continuation of treatment, “documentation of functional improvement” must be attached.

Another major part of the form that has already caused a great deal of comment is that there is to be only one request per form. This means that if, in fact, a primary treating physician is requesting three different treatment protocols, they must use three separate forms.  EK Health will be recommending to the DWC that the form provide for up to three treatment requests per form.

The clear message of this form is that there needs to an exact delineation of the treatment protocols that the physician is requesting.

After the public comment period closes, the DWC will review the comment, possibly make some changes.  The form and rule changes should be presented to the Office of Administrative Law to publish and establish the new form and the new regulations.

We’ll keep you updated, but change is slow and we my not see this form implemented until January, 2011, at the earliest.