The Audit and Enforcement Unit of the California Division of Workers’ Compensation (DWC) issued a press release recently indicating it will be conducting more target audits in 2016 to address utilization review (UR) complaints.

Under California law, all claims administrators are required to have a UR program governed by written policies and procedures, must utilize a medical director, and medical decisions that modify or deny a request for treatment must be made by a reviewing physician.

The DWC reminded claims administrators in its recent press release that the penalty for not responding to a request for authorization is $1,000 for each prospective review, and if a non-physician delays, denies or modifies a treatment request, there is a $25,000 penalty. The DWC advised claims administrators to review UR timeframes with their staff and utilization review organizations to ensure proper UR timeframes are met.

According to a recent article published by Business Insurance, the DWC also recently sought to assess large monetary penalties against several TPAs for allegedly failing to provide medical records in a timely manner for independent medical reviews. Specifically, the DWC recently issued orders to show cause against several TPAs, and the details of these orders are summarized below.

• One TPA was assessed penalties of $3.53 million for allegedly failing to provide medical records for 705 independent medical reviews within 15 calendar days of receiving notice from a company that conducts independent medical reviews.
• Another TPA was issued penalties of $1.21 million for 242 alleged violations.
• A third TPA was assessed $940,000 for 188 alleged violations.