Getting Authorization for Treatment in California Workers Comp


Requests for Authorization

RFA.    Learn that phrase.  Request for Authorization.  RFA, for short.   

Workers Comp doctors who don't make requests for authorization are not really helping you.   Workers Comp doctors who do not know how to do RFAs properly and send them out carefully can't help you.

In California, you can pick ANY physician from the insurer's Medical Provider Network, the ' MPN ' for short.   So when you are stuck with a doctor who says they are 'waiting' for an Okay on your treatment, they are lying to you, so go to the MPN website and find a new doctor, one who can show you the Request For Authorization and knows how to send it out.

How RFAs Work

The Treating Doctor starts by writing a report, and making any Treatment suggestions in a Request for Authorization, that RFA.   The doctor sends that RFA to the adjuster, typically by fax (but some still mail it... and some email it).   

The insurance adjuster has just 5 'business' days to answer each request for authorization.   So if your doctor's staff faxes his RFA on Tuesday, you and he should get an answer to the RFA by the next Tuesday.

The Answer comes in the form of Utilization Review (UR).   Mostly, the reviewing physician finds the treatment 'non-certified'... a gentler way of saying "No you don't get this requested treatment'.    If your doctor never sends an RFA, then you don't get the UR denying treatment... so if you are not receiving any Utilization Review letters, then either your doctor is not sending out any RFAs for your treatment or the insurer has a bad address for you.

RFA Denials

So, your doctor requested treatment and UR denied your treatment. What should you do?

Late Denials

If the RFA was denied late, you can ask a WCAB Judge to hear your request for treatment at an Expedited Hearing... first showing the specific date the doctor delivered the RFA to the insurer and the specific date the denial was received (so if your doctor cannot give you proof of the date an RFA was faxed or sent, you can't proof it was late).    You should have an attorney for this, most unrepresented workers cannot get this to a judge and get the evidence together for the judge to order the treatment.

Getting Help from Your Physician

Another strategy is to help your physician 'appeal' the denial.   Workers comp doctors interested in really helping their patients take the time to answer the reasons for the denial and appeal the denial directly to the UR physician... and it has to be done in a day or two.   If your treatment is denied, you can contact your doctor to confirm an appeal of the 'non-certification' decision is going out in a day or two... at which time you will find out if the doctor received a timely denial.

Seeking an Independent Medical Review

The Labor Code suggests your remedy is the Independent Medical Review (IMR).   The IMR sends the denial to a nameless, faceless 'physician' for evaluation, and the vast majority of IMRs support the denial.   There is no way to know if a real physician even sees your medical records.   The denials are unsigned.    You can do this just to see if it is returned late, but do not expect an IMR to overturn treatment denials.    If you get a late response, you again can go to the WCAB to request a WCAB Judge order the treatment in an Expedited Hearing.   WCAB Judge's are hesitant to overturn IMRs, so your evidence has to be indisputable and complete (so most are going to need a lawyer).

Most people give up, finding the system in place at present impossible.   Most get as much cash as they can and try to find private insurance covering pre-existing conditions to use to get the treatment they need, and mostly more than a year after the requesting physician suggested the treatment.   Sadly, almost nobody in your State Legislature wants to re-write the laws letter the Insurance Companies deny treatment – not even to the San Bernardino terrorist shooting victims! – so until injured workers actively oust state assemblymen and state senators supporting the current law, be prepared to go without treatment many many months and getting the treatment after you close your case.

Copyright © 2017 Nancy Wallace, All rights reserved. No portion of this article may be reproduced without the express written permission of the copyright holder. If you use a quotation, excerpt or paraphrase of this article, except as otherwise authorized in writing by the author of the article you must cite this article as a source for your work and include a link back to the original article from any online materials that incorporate or are derived from the content of this article.

This article was last reviewed or amended on Mar 10, 2017.