Workers Comp Zone


Will many utilization review organizations miss the upcoming July 1, 2018 California deadline for UR accreditation?

That is looking increasingly likely.

Labor Code section 4610(g)(4) requires UR programs to be accredited by July 1, 2018. This provision, added as part of the SB 1160 reforms in 2016, provides that until the AD adopts rules selecting an independent nonprofit organization to do accreditation, the AD shall designate URAC as the accrediting organization.

URAC, based out of Washington D.C. , is an acronym for Utilization Review Accreditation Commission.

According to a June 18 Workcompcentral article, the DWC provided figures that as of last week only 35 of 62 UR organizations had received accreditation.

It is unclear how many others are in the approval process and when or whether their accreditation will be finalized.

I’ve been told that the accreditation process takes time and is fairly rigorous, so if UROs started the accreditation process late or failed to produce documentation there may be a problem getting certification.

Unless there is a flurry of last minute accreditations, this may mean that as of July 1 there will be UR organizations who are out of compliance. If so, the consequences are not clear.

Labor Code 4610(g)(4) says that there “shall” be accreditation before July 1, 2018, but provides no roadmap for how non-compliance is to be handled. There appears to be no current mechanism to assess a penalty for non-compliance, and it is unclear whether non-compliance will in fact be deemed by the courts as a procedurally defective and invalid UR.

I certainly expect that arguments will be advanced that a UR denial from a non-accredited UR organization is an invalid UR determination much the same as a late UR determination is an invalid UR determination. At a minimum that will be tested in the courts.

Perhaps this will be addressed in proposed regulations. But there are no regs out yet, though the DWC is said to be working on them.

The purpose of the accreditation requirement was clearly to elevate the standards of UR organizations. Labor Code 4610(g)(4) requires URAC to “certify that the utilization review organization meets specified criteria, including but not limited to, timeliness in issuing a utilization review decision, the scope of medical material used in issuing a utilization review decision, peer-to-peer consultation, internal appeal procedure, and requiring a policy preventing financial incentives to doctors and other providers based on the utilization review decision.”

Stay tuned for more on this.

Julius Young