The Effect of Senate Bill 863 On California’s Workers’ Compensation System

The passage of Senate Bill 863 has stripped California workers' compensation judges of the right to award workers' compensation benefits for treatment they determine reasonably medically necessary for an injured employee. Previously, the court had jurisdiction with regard to awards for reasonable medical necessity. Typically, a doctor would prescribe a certain kind of treatment for the employee's work-related injuries, but before the treatment could be authorized by the insurer responsible for paying out workers' compensation benefits, the treatment would have to be approved by the insurer's utilization review department. Utilization review departments are generally composed of doctors hired by the insurance company. When reviewing a request for authorization of treatment sent by the injured employee's physician, the insurance company doctors will approve or deny the request, and also determine the treatment to be either certified or uncertified. Before the passage of Senate Bill 863, when a request for authorization of treatment was denied, an injured employee's attorney could petition the court to overturn the denial. This is no longer the case. In addition to this restriction of jurisdiction, Senate Bill 863 has introduced independent medical review as the new standard.

What is an independent medical review?

An independent medical review seeks to introduce a neutral, third-party doctor to review an insurance company's denial of the employee's request for authorization of medical treatment, and determine whether the denial was proper or not. The thinking behind the change in law is that an independent review panel will be free from bias to both the employee's physician and the insurance company's doctor-composed review department.

Why an Attorney is Necessary

Even under the new independent medical review standard, injured employees who have been denied treatment by an insurer's utilization review department will benefit from the experience of a skilled California workers' compensation attorney. An attorney will explain to the employee's physician the importance of properly drafting a medical treatment utilization schedule to show that the denied treatment is necessary, and that other treatment avenues have been exhausted. If the employee's current physician is incapable of systematically showing why the denied treatment is in fact necessary, an attorney will search for a doctor who can.

In other words, to overcome a denial of a request for authorization of treatment under the new independent medical review standard introduced by Senate Bill 863, there must be skilled and detailed presentation of evidence. Utilizing presentation of evidence to make a strong argument for the independent panel to overturn the utilization department's denial of the request is what an experienced California workers' compensation attorney does. Furthermore, an attorney will be able navigate procedural elements that remain in the jurisdiction of the court even after the passage of Senate Bill 863. For example, if an insurer did not make its denial of request within the time allotted by state law, an attorney will discover it and petition the court to overturn the denial on procedural grounds.

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