Today’s News You Can Use | Tuesday, January 28, 2020
In This Alert: What is the safest method of service of Utilization Review Determinations denying or modifying requests for authorization of medical treatment?
California regulation §9792.9(c)(4) indicates that utilization reviews to modify, delay or deny a healthcare provider’s request for authorization prior to or concurrent with the provision of medical services to the injured worker “shall be communicated to the requesting physician initially by telephone or facsimile. The communication by telephone shall be followed by written notice to the requesting physician, the injured worker, and if the injured worker is represented by counsel, the injured worker’s attorney within 24 hours of the decision for concurrent review”...
Regulation §10505(a) states “This section shall apply when a document is served by a party, a lien claimant, or their attorney or other agent of record”. Subsection (b) states: “Except when a document is personally served, service of any document shall be made by first-class mail or by an alternative method that will affect service that is equivalent to or more expeditious than first-class mail, unless: (b)(1) the party, lien claimant, attorney or agent being served has previously specified that a designated preferred method of service other than first-class mail may be used for any service”…
In other words the applicant, applicant’s attorney, lien claimant or other agent must have previously agreed that service by any method other than United States mail is acceptable (such as fax or email).
At the California Applicant’s Attorneys Association convention last week during a panel discussing utilization review, one applicant’s attorney commented that he will not accept service of utilization review determinations by anything other than United States mail.
The question arises then as follows: when utilization review denials have been issued and the applicant’s attorney has not previously agreed to be served by any method other than United States mail, is the utilization review determination valid? This attorney’s argument was that it is not valid therefore any treatment requested has not been validly denied therefore it must be provided.
WHAT THIS MEANS TO YOU
While this is just an argument raised by one applicant attorney at a CAAA convention, it is troublesome and could lead to litigation over the timeliness and validity of utilization review modifications and/or denials. If the issue is promoted by applicant's attorneys there will have to be a judicial determination regarding valid service of UR determinations.
If you are not already doing this it is therefore recommended that all parties and their attorneys be served by United States first-class mail with UR denials, modifications and/or delays of requests for authorization of medical treatment.