RateFast Podcast: RFA’s and Utilization Review

This article is a transcription of an episode of the RateFast podcast, which you can listen to by searching “RateFast” in iTunes or the iOS podcast store.

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In the work comp world, it is important for doctors to fill out accurate reports and justify the reasons they need different equipment or treatments for their patients. For example, if a durable medical equipment is being requested, it’s important to include information such as the number of equipment pieces needed.


Or if a medication is requested, the doctor must list such information as the strength of medication, type, the number to be dispensed, and the amount of allowable refills.


This kind of information is all necessary for a doctor to fill out a report called a request for authorization (RFA). If any of this information is missing, the RFA may be sent back to the provider as either ambiguous or incomplete, which ends up taking more time than if it were just filled out correctly in the first place. It’s best to take your time and make sure everything is correct!





ADL (noun) – activities of daily living – routine activities people that people tend do every day without assistance


RFA (noun) – request for authorization


Peer-to-peer call (noun) – when a utilization review provider or doctor calls to get additional information to certify or non-certify the RFA.


Utilization review doctor (noun) – the role of the UR doctor is to ensure that the medical treatment requested is appropriate and will help the injured worker based on evidence-based medicine.



Interview Transcription



Dr. John Alchemy:Hello, and welcome to the California Work Comp Report. My name’s Dr. John Alchemy, and today we are going to be talking about the RFA approval system in California workers’ compensation. Our talk will consist of some of the basics of the RFA approval process, what the utilization review people are looking for when they do an approval, and how medical providers can create RFA’s and compelling reports that will increase the probability that their requests will be approved.


First of all, what is an RFA, or a request for authorization? The RFA in California is a standardized form that outlines the basics of the claim information, includes a diagnostic code, and what is being requested. If a durable medical equipment is being requested, the number of the durable medical equipment pieces need to be identified. Likewise, if a medication is being requested, the strength, type of medication, the number to be dispensed, and the refills are all included in the information for the RFA. Failure to include any of this information may result in the RFA being sent back to the provider as ambiguous or incomplete.


So, RFA’s are created as a sister document, if you will, with the actual medical report, such as the doctor’s first, PR-2 or a PR-4. An RFA by itself is very difficult to authorize because there’s no medical context provided with it. Therefore, typically the report is created and sent with the RFA to give it context and give the reviewer the information they need to do the approval process.


Now, when the office creates the RFA, this can be an incredibly tedious process, very frustrating, and fraught with errors. In products such as RateFast, the RFA is automatically created from the content of the report, when it is actually ordered in the software. And this is a great example of how efficiency and accuracy work together when trying to create and generate timely, accurate and fast referrals for the injured worker. Simply hit a button, the report’s finished, and the RFA is all paired up with it, ready to go.


So now you’ve got this RFA, and you’ve got your PR-2 report as an example. Now what happens?


The RFA and the report need to be sent in to the carrier. Usually there is a separate fax that receives utilization review requests, also known as UR, for the insurance carrier. Most UR services are third parties that are contracted by the insurance company with the sole purpose to review the medical necessity for the treatment being requested. So when an RFA is received, the utilization review, by law, has to apply certain sets of guidelines. This is the ACOEM (American College of Occupational and Environmental Medicine) Practice Guidelines, Second Edition, and the California Medical Treatment Utilization Schedule, MTUS. Now as you can imagine, not every single guideline can cover every single type of request or medical condition, and therefore, sometimes another set of guidelines, called the Official Disability Guidelines, ODG, are used in instances where the ACOEM Guidelines or MTUS are ambiguous or do not address.


So let’s review: We’ve got an RFA, we’ve got a medical report to go with it, it’s now been sent in to the utilization review fax, now what happens? The utilization review provider is going to now be applying the guidelines, and reading that note. It’s very important that the note have all the pertinent information in it so a peer-to-peer call is not necessary.


What’s a peer-to-peer call? A peer-to-peer call is when you get a call from the utilization review provider or doctor and they need additional information to certify or non-certify the request.


Here’s a simple example: Physical therapy. The provider is requesting on an RFA, six visits of physical therapy. However, in the note, it’s not clear if this is the first six visits, the second, or the third round of physical therapy being requested. As a result, the reviewer has incomplete information, and therefore needs to make an attempt to contact the clinic and speak with the provider or a provider designate to clarify the information. If they’re unable to speak with the provider or a provider designate, it is possible that the report may be non-certified due to insufficient information being available to apply the guidelines.


So the phone rings in the office, and it’s a peer-to-peer call. You pick up the phone. On the other end is a doctor, and you’re going to talk to them, and they may have some very specific questions about the guidelines, or in general, they may simply need to know more about the case. How did the patient get hurt? What other treatments have been attempted? What imaging has been done? What has been the response to prior treatment? These are all critical and important questions. And if your report is not documenting that background information, you will probably get a lot of peer- to-peer calls. Peer-to-peer calls for a busy clinician is frustrating, because they can come at any time, the peer-to-peer doctor does not have a lot of time, and then you end up playing phone tag. Now, there is an end date set and time when these utilization review calls need to be complete, usually within five business days, and the determinations are technically supposed to be open until 5 p.m. in your timezone. Now, since some of the utilization review services are out of the East Coast, sometimes doctors are frustrated because determinations will close earlier than 5 p.m. in their timezone. What I always recommend is that if you are calling in before 5 p.m., end of deadline in your timezone, make a call, document it in the chart what time you called, and also let the voicemail know or the service person that you’re calling that you have called before 5 p.m., and the close of the determination. And this will be helpful if you have to re-submit, or if they need to go back and reconsider the determination because it was closed early.


So what is the content in the report that the utilization review doctor is looking for? Well, this varies somewhat from body part to body part, request to request, however, in general, they’re looking for some very basic information that every report should have to support an RFA. Some of the things they’re looking for, I’ve already mentioned. They want to know treatments to date, response to the treatment, self-care, home exercise program, and particularly when talking about response or benefit from treatment in the past, they want to know a couple things: 1. Is the patient feeling better? Is their pain less? 2. Are they functionally improved? Meaning, after they have had a treatment or a series of treatments, is it documented in the chart that their motion is better or their strength is better? Flexibility, neurovascular exam, et cetera, maybe some orthopedic tests. Those have to be also shown as improved, or at least it’s very helpful if you can show objectively that the patient’s not just feeling better, but also moving better with reproducible documentation, such as degrees of range of motion. 3. Is the patient being compliant with treatment? Are they doing a home exercise program? And are they taking all the medications that you’ve recommended, and are compliant? 4. How is the treatment, when beneficial, helping them with their activities of daily living? Crack open your AMA Guides, look at Table 1-2, and those are the activities of daily living. They are essential, and they are measurements of impairment put forth by the AMA Guides. They’re basically the standard currency used to describe functional activity as a result of an injury or a condition. Having an inventory of ADL’s (Activities of Daily Living), such as how they’re benefited, or how they’re not able to be met, is very compelling in a report when a utilization reviewer is looking at the evidence. And finally, if someone has a series of treatments or a benefit from a treatment that is now being recommended, but is currently on hold, it also can be helpful to show deterioration of ADL function, increase of pain, or loss of motion.


We might see this in a situation where someone is periodically in the future care of their claim, and they have chronic discomfort and problems, and they’re seeking to get six visits of chiropractic care every six months. So in this situation, what the provider needs to write in the note is what they’re seeking: six visits of chiropractic. When they last had it? Six months ago. How did it help the pain? Reduced it by 40%. Did it affect the need for medications? Yes, decreased medications for six months. Which ADL’s were benefited in the past? For example, self-care, lifting, dressing, bathing, preparing food, eating, standing, walking, sleeping. How long did they feel better for? Three to six months. And also, has the patient maintained a home exercise program? Yes. Have past benefits from treatments shown improvement in range of motion? Yes, place the exam from March 1st, 2015, as an example.


So if the PR-2 report I just described is now turned in with a chiropractic request, this is a very compelling argument for utilization review. And, it has all of the elements that the utilization review doctor will likely need. When you are creating supplemental reports, doctor’s first, or even PR-4 reports, and you’re requesting an RFA — Have a structured program that’s going to help you to remember to ask the right questions, document all the essential elements, and document the ranges of motion and physical exam accurately. This is the most compelling, efficient and likely way to get RFA requests approved.


Remember, the goal with the RFA is not to fight the insurance company or the utilization review doctor. That is not the goal. The goal is to understand what information they need and giving them all of the information in one report, if possible, so the questions are minimal and the time from authorization to determination is fast.


Now, sometimes the utilization review doctor will be very helpful. They’ll call, they’ll leave a voicemail, “We need to do a peer-to-peer.” But the very good utilization review doctors will tell you what they’re missing. They’ll say “Dr. Alchemy, I’ve reviewed your request for an additional six visits of chiropractic. However, I need to know when the patient last had chiropractic care,” for instance, had I forgotten to put that in the PR-2 report. In that situation, I can call back. If I get a voicemail, I can simply leave the information. Always give a good phone number for you to be contacted. I give my personal cell phone, and that tends to increase the likelihood that if there’s any additional questions, I can be contacted quickly and directly, and the utilization review doctor can get a hold of me immediately.


Once the utilization review doctor has made a determination on your RFA, a letter will be sent. It may be faxed or sent in the hard mail, but a letter will be sent with a determination of approval or denial. Now, these letters are opportunity for you to learn. If you receive a denial, read it carefully and find out what pieces of information were missing from the reviewer’s report. If there was a critical piece of information that was left out, next time you see the patient, be sure to clarify that missing piece of information in your report. Go out of your way to say “utilization review denied chiropractic care because of missing information on the last date of treatment.”


And then obviously, put in “I discussed with the patient today and verified in the chart that the last date of treatment was March 1st, 2015. Six visits obtained.” Then you can go back to your treatment section, create another RFA, and resubmit because new and additional information is now available, and the RFA can go through the process again and hopefully get approved. It is only in the treater’s best interest to carefully study the ACOEM, Second Edition, the MTUS, and also the official Disability Guidelines, as these three pieces of guideline information are used together most often to make a determination on approval for RFA. If you do not understand what these guidelines are looking for, it does make it more difficult to get request treatments authorized.


Finally, the role of the utilization review doctor is not necessarily to deny care. The role of the UR doctor is to ensure that the medical treatment requested is appropriate and will help the injured worker based on evidence-based medicine. And that’s what these guidelines are based upon: evidence-based medicine and literature. Now, here’s a great point: If you have evidence-based articles or literature you would like to be considered in addition to your clinic note and the RFA, please attach it and send it along with the request. The UR doctor is required to review any additional information included in helping them make their determination. As you may know, many new treatments are coming out constantly, and studies on those treatments are being released. And so, not every guideline can be up-to-date perfectly, and the UR doctor will welcome getting those records and those additional documents for consideration. If you are going to use a peer-reviewed literature article, be sure that you make some type of statement in your report as to why you’re including it, and what portions of the study you believe are relevant and support authorization for your request.


So in closing today, let’s review what we’ve learned: 1. The RFA form, Request for Authorization – make sure it’s complete and accurate, it includes a diagnosis, it includes the type of treatment being requested, the number of units being requested, and any refills, if necessary, for example, a medical. 2. Pair it up with a compelling, complete and accurate report. Make sure your report includes prior treatment attempts, response to prior treatments, benefits from the ADL’s, self-care, home exercise program, and anything else that the injured worker is doing to maintain themselves before requesting this treatment. Make sure that you are creating a supporting report with all the number of physical therapy that has been attempted to date, chiropractic, acupuncture, consultations, diagnostic imaging, et cetera. If you use an electronic documentation system, such as RateFast, this will all be taken care of for you, and you shouldn’t miss any essential questions or pieces of information or data in that report. Make sure the RFA and the report are sent to the utilization review fax, and then finally, be prepared for a peer-to-peer call. You might want to list in the report your direct contact phone number and also place it in the RFA to make yourself immediately available to the UR doctor. Remember, they are working under a timeline. When you call or you speak to anyone in the UR process, be sure you document who it is you spoke with, what time, and what phone number you called. If you receive a denial letter, read it carefully. Learn something from it. And bring the patient back in, create another documentation, and include specifically the new and additional information that was absent or missing in the UR doctor’s opinion, and resubmit your RFA.


Finally, remember, the UR doctor is not your enemy. They are there to make sure that resources are being used appropriately, and consistent with the evidence-based guidelines. If you have an article that you believe supports your request, be sure to include it and explain it in the report that’s going in with the RFA.


I hope you’ve enjoyed our RateFast California Work Comp Report today on RFA’s in the utilization review process. To learn more, please come visit us at rate-fast.com, and click on the blog. I’m Dr. John Alchemy, and again, I want to thank you for joining us today.


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