How SB 1160 Impacts Utilization Review



Governor Jerry Brown Signed Senate Bill 1160, which primarily affects Utilization Review (UR) and liens. Changes will become effective on or after January 1, 2018. Medical treatment for injured workers may bypass formal UR for the initial 30 days of a claim with emergency treatment services, treatment related to an accepted body part(s), treatment rendered by a physician within the claims administrator’s Medical Provider Network (MPN), Health Care Organization (HCO), is a pre-designated physician, or is an employer selected physician.  Any of these situations will avoid the prospective utilization review process, resulting in more timely delivery of medically necessary care. The one caveat is that the providers must still operate within the boundaries of the presumptively correct Medical Treatment Utilization Schedule (MTUS). The final regulations have not been written yet.


In order to better define what constitutes appropriate care within the MTUS, a list of treatment exclusions has been defined, which includes Home Health Care, advanced imaging outside of x-rays, DME exceeding $250.00, electrodiagnostic studies (i.e. NCV/EMG), psyche treatment, non-emergency surgery and certain medications not on the formulary.


EK Health already implements a similar automated process through our Ahshay™ proprietary software called Express Approval™. Express Approval™ enables a systematic approach to quickly processing incoming Requests for Authorization (RFAs), and immediately authorizing treatments that fall within the guidelines and/or the claims administrator’s threshold for authorization. Express Approval™ tracks treatment requests and disposition historically for the life of the claim within Ahshay™. The defined list of non-UR treatment can easily be uploaded into Express Approval™ to meet SB 1160 requirements.


Ahshay™ also tracks the number of requests by provider and the types of treatment they request with outcomes. This will provide an automated platform to easily identify if providers are following SB 1160 and staying within the MTUS.  Should providers routinely request beyond the MTUS, they may be prevented from treating within the initial 30 days absent formal UR.

 

Dr. Glenn Crafts, Executive Director of Utilization Review