RFA: The key to success in the new Work Comp

RFA: The key to thriving in the new Work Comp

In the post-SB863 Work Comp world, the margin for error or interpretation of treatment requests is gone. Reports must be thorough, requests must follow MTUS, and RFAs must be strong. Accuracy is key to getting treatment approved and, ultimately, to getting paid.

RFA Basics

The DWC’s Request for Authorization is, nominally, a form used to codify treatment requests for simplified review and authorization of medical treatment for injured workers.

In addition to basic information for the employee, requesting physician and claims administrator, the RFA form requires:
– Type of request (new request, resubmission, expedited review)
– Diagnosis, ICD-Code
– Service/Good requested.
– Additional information may include CPT/HCPCS code and details like frequency, duration and quantity.
The form and instructions can be found here: http://www.dir.ca.gov/dwc/DWCPropRegs/IMR/IMRFormRFAClean.pdf

Making an Effective RFA

A strong RFA begins with getting the basics right – correct claim numbers, ICD Codes that correspond to injured body parts, as well as clearly indicated treatment requests supported by detailed reports with physical findings, complaints and diagnostics, as appropriate per request.

RFAs should support treatment requests with the appropriate guidelines; in fact, the DWC’s instructions for Request for Authorization, Requested Treatment section, states: “Reference to specific guidelines used to support treatment should also be included.” Of course, this means using references from the Medical Treatment Utilization Schedule (MTUS) to support your requests.

Also, it’s important to document functional improvement, or lack thereof, upon which a treatment request is based. If a patient is improving under current treatment, it is a compelling argument for continuing that treatment.

Who Cares, Really?

You care – if you want to get paid. Adjudication of medical treatment is now independent, and carriers must pay for the Independent Medical Review process. What this really means is that it’s actually easier to get approved, if you follow MTUS guidelines. Accuracy in the RFA equates to making claims adjuster’s lives easier, and treatment authorizations much more efficient.

Your referral parties care as well – secondary providers and ancillary providers (like diagnostics) depend on strong treatment requests from the patient’s PTP.

RFA Market Leader

Practices who understand the new processes and implement them thoroughly will weather the current changing seas in Work Comp. An accurate RFA with MTUS references, supported by a detailed report that argues for your treatment recommendations, is a strong marketing tool for your practice.

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