Senate Bill 1160 was passed by the California legislature in 2016 in a wide-ranging effort to reform the state’s Workers’ Comp billing system. It included changes to automatic authorization, utilization review, lien filing, billing deadlines and much more.
While most of the changes took effect in 2017, some did not start until January 1st, 2018.
One of the most significant changes was to the Resource Family Approval Program (RFA) with the establishment of a limited set of treatments/conditions that would qualify a workers’ comp claim for automatic authorization (requiring no prospective UR). However, a Retrospective RFA is still Required. Click to see the Retro Auth Map here. Also note, ALL 6 requirements for automatic authorization must be met to qualify for payment.
Changes this extensive mean compliance questions and opportunities for billing errors.
Here are the six required conditions for automatic authorization:
- The date of injury is on or after January 1, 2018.
- Any request for payment for treatment is submitted to the employer, or its insurer or claims administrator, within 30 days of the date the service was provided. Failure by the provider to properly report treatment can lead to revocation of the “no UR” rule for that provider.
- Body part or condition is accepted as compensable by the employer.
- The treatment is included in MTUS, (the Medical Treatment Utilization Schedule). The MTUS is a set of regulations that contain medical treatment guidelines and rules for determining what is reasonable and necessary medical care.
- Medical treatment is provided through a medical provider network (MPN) and health care organization (HCO), other employer-directed provider, or a pre-designated physician.
- The treatment is not ineligible. Ineligible treatments include non-emergency inpatient/outpatient surgery, medications not covered by the formulary, psychological treatment, electrodiagnostic medicine, imaging (but x-rays ARE eligible) and radiology, durable medical equipment (DME) if total costs for all DME exceeds $250 (DME totalling less than $250 ARE eligible), and home health services, and any other services designated by the administrative director.
While the purpose of Senate Bill 1160 is to cut costs and to get injured workers quicker access to medical treatment (which is great), it has also created some confusion as to when preauthorizations are necessary and what treatments are exempt from UR.
At Medical Billing & Collection Systems, we are experts at workers’ comp claims and partner with our physicians to make sure they’re up-to-date on the latest developments in legislation that affects their prompt and accurate reimbursement.
Call us today at (949) 863-0022 to find out how we can help you navigate the ever-changing legislation regarding workers’ compensation. We can help you better serve your patients while streamlining your billing and collections and improving your bottom line.