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California workers compensation claims administrators who conduct utilization reviews received a 97% performance rating for 2013, surpassing the 85% benchmark that state insurance regulators consider a passing grade for such reviews, the California Workers' Compensation Institute said.
A review of 280 workers comp claim administrator offices conducted in the past several years by the California Division of Workers' Compensation Audit Unit showed that utilization reviewers received a 97.1% overall score in 2013, a 97.5% score in 2012 and a 97.1% score in 2011, the Oakland, California-based CWCI said in a report released Tuesday.
The CWCI noted that the high score for utilization reviewers was based on timeliness in responding to treatment requests — meaning decisions were made within five working days — as well as substantiated content in utilization review determinations and adequate delivery of written notices related to utilization review decisions.
The study concluded that the data shows that California utilization review processes “have been working efficiently,” despite concerns from “some in the workers compensation community ... that claims (the state's) administrators have performed poorly in meeting their obligations in responding to treatment requests.”
Arguments will be presented to the California Supreme Court next month in the case of an injured worker whose death from a prescription drug overdose was ruled noncompensable under California workers compensation law.