WORK COMP TIPS:
Utilization review and the agreed medical examiner- a "Catch 22" situation and is this an unreasonable delay in medical treatment subject to penalties?
Some adjusters are improperly sending AME reports to utilization review. CAAA recommends that the best way to resolve a medical dispute is set out in Labor Code section 4602(a), which reads in part:
(a) If either the employee or the employer objects to a medical determination made by the treating physician concerning other issues not covered by Section 4061 or 4062 and not subject to Section 4610, the objecting party shall notify the other party in writing of the objection...If the employee objects to a decision made pursuant to Section 4610 to modify, delay, or deny a treatment recommendation, the employee shall notify the employer of the objection in writing 20 days of the receipt of that decision.
This clearly shows that the utilization review is the first step in this process. If either party objects to a treatment recommendation that is subject to utilization review the 4062 " dance" does not begin until after utilization review has been completed. This is also confirmed by section 4610(g)(3)(A) which states ,in part, "If the request is not approved in full, disputes shall be resolved in accordance with Section 4062."
Thus, where a treatment recommendation is subject to UR, a medical dispute is not created until after utilization review has been completed. At that point, section 4062 requires an evaluation in a represented case to be obtained under section 4062.2 and states that "no other medical evaluation shall be obtained." Appointment of an AME under section 4062.2 is clearly the end of the dispute resolution process, and the recommendation of the AME should not be sent to utilization review.
Therefore , the referral of an AME recommendation to utilization review may constitute an unreasonable delay in the provision of the recommended medical treatment.
