Hi WCC Forum Members:

The DWC has introduced an new complaint form to criticize UR malfeasance. This form can be filled out by an IW, an AA, or a treatment provider (TP) --- then either mailed, faxed, or delivered by email, to the DWC Medical Unit. A copy of the UR COMPLAINT FORM can be obtained by clicking on the paperclip at the bottom of this post. This UR COMPLAINT FORM is written in MS Word and is a 'form-field' document that only allows users to fill in the blanks, without changing the text.

This form has a check-off box format for the most common complaints. However, there is a box for "other" complaints about UR malfeasance.

Some suggested "other" complaints commonly encountered when a prospective request is submitted by the treating physician, and UR either issues a Modification, Delay, or Denial are as follows:

MDD decision not communicated to TP and/or IW, within 24 hours, per LC 4610(g)(3)(A).

Untimely request for additional information, request for consultation with expert reviewer, or request for additional examination or test, per LC 4610(g)(5) and CCR 9792.7(b)(3).

Claims Administrator failed/refused to electronically make available the complete utilization review plan, per CCR 9792.7(d) and/or (d)(1).

The criteria or guidelines used to MDD were not disclosed in written form to the IW, the TP, other provider, and/or the AA, per CCR 9792.8(a)(3) and/or (a)(3)(B).

Untimely retrospective UR report issued, absent timely compliance with CCR 9792.9(b)(2), CCR 9792.9(g)(1) or (g)(2), when prospective request ignored.

No response by UR to prospective request issued by TP, and QME dispute resolution process initiated untimely per LC 4062(a).

UR report unlawfully included determination of work-relatedness of injury or disease, per CCR 9792.6(n).

UR report unlawfully included determination of accuracy of billing, or reasonableness of charges, per CCR 9792.6(n).

Expedited UR response to expedited prospective request made by TP not responded to within 72 hours, per CCR 9792.9(d).

The DWC is very concerned about UR abuse, and the fact they have issued this electronic complaint form is significant. It is quite important that the IW, AA, or TP complaining about UR abuse also provides a brief description of the complaint and attaches all supporting documentation to the form.

Be the eyes and ears of the DWC and file a complaint.

York McGavin
ymcgavin@socal.rr.com

UR COMPLAINT FORM.doc  (41 KB)