In workers’ comp, providers must fill out a Request for Authorization form (RFA) when requesting a service, treatment, or tests for a patient. The RFA must be filled out correctly in order to receive approval from the employer’s insurance.
This excerpt from our podcast on How To Submit an RFA features RateFast’s founder Dr. John Alchemy in conversation with Arun Croll and Claire Williams about the intricacies and limitations of the Request for Authorization process.
There are certain steps that providers can take to make an RFA likely to be accepted, such as making sure that appropriate ICD-10 codes are included on the form. Insurance carriers may deny an RFA for all kinds of reasons, so it’s imperative to be as thorough as possible.
If you’re a workers’ compensation provider, adjuster, or case manager check out RateFast Express: the service that writes your impairment reports for you!
Terms
Request for Authorization, RFA (noun) – a standardized form distributed by the Department of Industrial Relations to request treatment or diagnostic tests for an injured worker. You can view a copy here on California’s website.
ICD-10 Codes (noun) – the International Classification of Diseases, Tenth Revision, Clinical Modification is a system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care in the United States.
Interview Transcription
Narrator: Welcome to the California Work Comp Report, a podcast hosted by Arun Croll and Claire Williams, featuring Dr. John Alchemy.
Arun: Alright, hello everybody. This is Arun Croll with the California Work Comp Report, and today is Friday, November 28th. And we here are going to talk today about how to get treatment for injured workers.
Claire: And we have Dr. Alchemy on the line with us, whose qualifications we have outlined in our last podcast. John, what can you tell us first about what kind of worker needs this form for request for treatment? Is it every worker?
John: Yeah, hi, hi everyone. So today we’re going to talk about the RFA (Request for Authorization), and the RFA is something that came into being at the beginning of 2014. It’s a form to standardize the way that treatment and interventions are submitted for within California work comp. So up until then, everyone was writing things down, sometimes they’d call for authorization, it was a very confusing process. This form is there to kind of standardize the information so everyone’s getting the same information so a determination can be made.
Arun: Dr. Alchemy, can we back up a little bit? We’re talking about requesting authorization. Now, the doctor’s requesting authorization for treatment for an injured worker. Who does this request go to?
John: Okay, great. So, this is a form that’s found at the Division of Work Comp online, and this is the form that the treater, the doctor, chiropractor, what-have-you, has to fill out to make a submission and a request for the treatment. So it’s a standardized form and the treater’s office is required to fill this out, put in all the information, and then from there, it’s sent into the insurance company. And the insurance company has a group that they work with that actually does the utilization review, and that’s done by a medical doctor or a “peer” who is comparable to the treater, so they can make a determination, if the treatment’s necessary and really indicated.
Claire: In your experience, John, are there specific things that you need to include on this form, to get that process expedited or to get it approved? What sort of things go into getting the treatment to your patients?
John: So, some really common things that lead up to a form not being approved, the RFA, is that it’s just incomplete. Sections are left blank, the diagnosis isn’t written down. There’s something called an ICD-9 code for each diagnosis, it’s not on the form, or they just forget to put the doctor’s signature on it. So administrative reasons are probably, in my experience, the greatest cause of not getting the RFA approved. After that, then it’s sometimes up to the doctor, they’re not indicating the number of therapies that they want for physical therapy, they’re not indicating the strength of the medication that they want requested. And remember, when this form gets sent in, it has to go with the patient visit form. So they look to that form with that visit with the patient, those two things have to match up and they have to make sense to the utilization review doctors, as well as the insurance company.
Arun: So, if you’re a doctor, it sounds like the best thing that you can do to make sure that your patients are getting the treatment they need is to fill out each form completely, include as much detail about their condition, including the ICD-9 code and specifics about the kind of treatment that you’re ordering, and you sign it. You’ve got to sign it and send it in with your full report.
John: Absolutely. Those are the bare minimum if you’re going to be successful at getting the RFA approved.
Claire: And what sort of treatment do you find most often you’re requesting?
John: Well, often what you’re looking at at the beginning of the claim, in most orthopedic injuries, are two things. One, you want to get the medication going, and help them feel better and control the pain, and then two is you want to do some type of strengthening and mobility, which is usually physical therapy, sometimes acupuncture, sometimes some chiropractic. So those are most often the first RFA’s that you’ll submit on a case. When you’re submitting for medications, you want to try to make sure that you’re using a generic, if possible. Because as we all know, health care is very expensive. So if you’re going to try to use something that’s not a generic, you need to be very specific as to why you’re doing that. Maybe the patient has an allergy, or the patient has an underlying medical condition with their kidneys, their liver, and they have to select one medication over another. And that’s great. But that information has to be in your visit note, or the insurance company’s not going to understand that, and they may not approve it. So medications, again, if you’re not going to use a generic or a common medication, spell it out in no uncertain terms in that visit [form] that gets attached, as to why you’re doing that.
Arun: Sounds like some great advice for ordering medication. Is there a set of similar tips that you have for people that are ordering some sort of therapy? Like physical therapy or acupuncture?
John: I, along with a lot of other doctors that learned this through trial and error, I think the biggest mistake that gets made is that in the note, the body part that’s going to receive the physical therapy is not clearly mentioned. Some cases have two or three body parts, and if you just write down there, “send to physical therapy,” people are scratching their head. Well is it the shoulders, is it the knee, is it the ankle, is it for all of them? So that needs to be very clear in the treatment section of the note, and then also on the RFA, there’s the section for frequency. You want to put down how many times a week, how many weeks is the therapy. So for example, a common one is two times a week for three weeks, a total of six visits. And again, you want to put down that that’s for the low back, as an example. And the more specific you can be, the more likely the determination can be done quickly and hopefully approved, if indicated for the patient.
Arun: It sounds to me like that’s the ultimate moral of the story here. Be as specific as possible, so that people who are reviewing this form understand exactly why that they should need this or that treatment, and exactly what that treatment will be.
John: That’s right, exactly. And the doctor wants to subsequently show, if they’re going to be requesting more treatment of the same, add it to “how are we going to measure success?” If I’m going to ask for more therapy, what things need to be in my visit note after the therapy’s been completed, showing that more therapy is warranted and that it’s a good investment of the injured worker’s time and of the insurance company’s resources?
Claire: And John, you mentioned that this was for the first round of RFA’s. Is it very often that you find that you need a second round of treatment for your patients?
John: Yeah, that’s a great point. Often you have to do a refill of a medication, or the first visit of physical therapy got him on the road to recovery, but he still needs some more strengthening and some direct supervision by the physical therapist. So, when commenting a report in preparation for a second RFA for the same treatment, it’s important to put down the following: Did it work? Does the patient feel better? Is the patient able to do more things at home? Have the work restrictions changed in any way, meaning they can do more at work now than they could before they had the treatment? And then finally, in the physical exam, which is often missed, is objectively on the exam, are they moving better? Do they appear in less pain? Has their strength improved? Are they no longer limping? Are they not using a cane any more? All of those things need to go together to make the story to support the request. And if it’s written effectively, you’re not going to get problems with getting the RFA approved. But if it’s vague and non-specific, there are going to be problems, understandably so.
Claire: So, it sounds like it’s much more about the work that you as a physician put into the RFA that determines whether a patient receives a second round of treatment, as opposed to the patient themselves and the work that they’re doing in trying to heal.
John: That’s right. Because the doctor is basically telling a story, and they’re talking about, here’s the situation in the story, here’s an element that we introduced to it that’s a treatment or a therapy, and here’s the outcome, and the more engaging that that story is, the more compelling it is for the utilization review doc to go ahead and approve that.
Claire: Would you say overall the RFA system is working better than the sort of lack of system it sounds like there was before this?
John: Well, I would say from an organizational standpoint, it is better. Because I’ve also served as a utilization review doctor myself, looking at medical requests, and it does clarify what are we looking at to approve, what body part, and why are we doing it. And the RFA has just introduced a standardization of the presentation of that material, if you will. So I think it’s still a pretty busy form, information is necessary, but in the long run, it’s not too burdensome that you can’t work with it. So I would have to say that it’s probably a step forward from what we had before, which was nothing.
Arun: Great. And it’s a pretty recent change, so a lot of professionals, I would imagine, are still getting used to this process.
John: Yeah, that’s a good observation. It is still going through its first year. I think the bigger change for everyone was when the utilization review process came in and doing that, and going through that acceptance. The RFA is, it’s just a way to streamline the information and focus the discussion. Yeah, I think it is helpful for everyone when they have something to look at.
Arun: So, Dr. Alchemy, if you’ve got an injured worker who comes into your clinic and it’s the first time they’ve seen a doctor after sustaining a work injury, and they hurt their neck and they’re in pain, and you want to give them painkillers, you want to give them a brace, you want to give them something, right? You’ll give them their care that day, correct?
John: Yes, the patient always gets the appropriate care and timely care, so if they need a medication or they need an urgent or an emergent treatment, that’s going to happen. We always want to do what’s best for the injured worker, and then in retrospect, you can look at it with the RFA as to whether or not it was absolutely medically appropriate or not. For the major things, fractures, surgeries, trauma, usually not a problem at all. Problems with the RFA usually come in when it’s either an elective procedure, again, it’s a non-generic medication, or you’re going for physical therapy rounds number four, five and six, further into the care. Remember, we do have guidelines that the RFA is applied to, so those guidelines are obviously available to the treaters, to the insurance carriers, and to the utilization review doctors, so everyone has an understanding about what is “available care,” and once you start to go in-between what the guidelines say or beyond what the guidelines might expect for the duration of treatment, that peer review process, and again the RFA, and the visit note along with it become very important to help navigate that grey area.
Claire: Now, have you submitted any real wild requests for treatment? People wanting like hot tubs for their sore back or something?
John: I think that’s an example of a little non-standard RFA request. More often you’ll maybe see some patients who come in and they read about something, or there’s a new treatment that they’d like, and they want to see if we can get that approved. Now, I don’t have a problem submitting for non-standard requests. However, I always tell the patient that look, what we want is we want to make sure that we’re giving you something that’s beneficial, and that we know is helpful. So usually that’s a medication that’s been around a while, or what we say is accepted by peer review literature, or studies have been done appropriately to show that there is a benefit. Usually after explaining to the patient that way, they’re kind of like “Okay, well I understand.” So I tend to not submit too many of them, but if I do submit a non-standard RFA request, I’m always careful to put it in there for that utilization review doctor or the insurance company to read, that the discussion was carried out with the patient that this is not a standardized, acceptable treatment, and therefore may not be authorized. And so I try to set the expectations early, that hey, if we try everything else, do you really want to see if this will work? I’m happy to consider it and present it to the insurance company, but I am going to put on there the disclaimer that this is not widely accepted or carefully studied with results to how much it’s going to help.
Claire: Great. Wow, thanks so much for enlightening us on this next process of computing a work comp claim.
John: Absolutely.
Arun: Yeah, thank you for joining us today, Dr. Alchemy. If you’re a doctor out there, whether you’re giving treatment to a patient, requesting treatment for a patient, or reviewing somebody else’s request, it seems like the bottom line is you need to communicate clearly and look out for reasons that justify why this or that treatment should be given to this patient.
John: Absolutely.
Arun: Alright, thanks everybody. Join us next time on the California Work Comp Report, hope to talk to you then.
Narrator: Thank you for joining us for this episode of the California Work Comp Report. We look forward to next week in continuing our discussion of work comp claims in California. Questions or comments? Got a great workers compensation story to share? Find us on Twitter at @ratefast or at rate-fast.com.