California: Home Health Care: A Long and Winding Road

In Orozco v. Southland Framers, 2019 Cal. Wrk. Comp. P.D. LEXIS --, the WCAB, affirming the WCJ, held that the defendant did not conduct a timely utilization review (UR) of applicant’s 5/9/2012 and 11/25/2014 requests for authorization for home health care services, thereby giving the WCJ jurisdiction to determine the medical necessity of the disputed treatment. The WCAB further found that there was substantial evidence to support the WCJ’s determination that the defendant was liable for home health care services after 5/1/2012 for up to 12 hours per day, seven days per week, based on the opinions of the applicant’s treating physician and the medical evidence establishing that the applicant was “homebound” and unable to leave home or to perform activities of daily living without help, i.e., use of walker. The WCAB noted that UR in this case applied the incorrect treatment guideline in determining the applicant’s need for home health care by relying on the 2009 Medical Treatment Utilization Schedule (MTUS) guideline for home health care, which was subsequently determined to be invalid, and was replaced with the new MTUS guideline in 2016, and although the new guideline was not applicable in this case, the WCAB found that it provided guidance regarding the review of home health care prescriptions.

Practice Point: Counsel is advised to read the Orozco decision carefully as it provides a detailed discussion about home health care from a physician's prescription to authorization to payment. This case originated before any clear-cut Medical Treatment Utilization Schedule (MTUS) existed for home health care. As indicated in the WCAB panel decision, the 2009 MTUS for home health care was deemed invalid in the Stevens case (241 Cal. App. 4th 1074, 80 Cal. Comp. Cases 1262). Claims administrators struggled with trying to determine when home health services included providing food preparation, laundry, and housekeeping services, rather than medically related services such as wound care, home-based physical therapy, toilet and bathing assistance, administration of medications, and the like. This case originated at the trial level before there was a clear MTUS for home health care. By the time this case reached the end of its journey to the WCAB panel decision in 2019, the MTUS had been updated. Counsel should subscribe to the MDGuidelines.com web site in order to access the current MTUS which is based on ACOEM. The home health care section of the MTUS is embedded in the Chronic Pain Guidelines.

Note: The PDF for Orozco can be found at the end of this post.

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