I'm back with a blog post on yet another one of those favorite topics: utilization review.  The case at hand is Holguin v. First United Methodist Church, a panel decision.

Gregory Grinberg

The basic facts are these: Applicant’s primary treating physician on an accepted case submitted a request for authorization for a functional restoration program, which UR non-certified. Less than a month after the original RFA, the PTP submitted a second RFA, noting a “change in material facts.” It appears that no UR report issued for the second RFA.

However, in the section provided on the RFA to document the material change in facts (“include documentation supporting your claim”), the PTP apparently did NOT provide documentation of a change in material facts but argued with the reasoning of the original UR determination.

After trial, the judge issued an order that applicant was entitled to the functional restoration program.

On appeal, the Workers' Compensation Appeals Board panel first noted that Labor Code Section 4610(k) provides that a UR determination stands for 12 months unless “the further recommendation is supported by a documented change in the facts material to the basis of the [UR] decision.” Since the PTP failed to provide documentation of changes in material facts, the WCAB opined that the original UR decision stood and that no further action or response was required by the defendant.

How many times have you seen the exact same thing happen? “Resubmission — Change in Material Facts” is checked, but no change in facts is provided with the RFA. I see it a-plenty. Of course, it’s always safer to run UR again, but sometimes things slip through the cracks.

The Holguin case is not earth-shattering and doesn’t change the landscape for us dramatically, but it is an excellent reminder of a potential defense if UR fails to catch every single RFA.

Gregory Grinberg is managing partner of Gale, Sutow & Associates’ S.F. Bay South office and a certified specialist in workers’ compensation law. This post is reprinted with permission from Grinberg’s WCDefenseCA blog.