MICHAEL SULLIVAN & ASSOCIATES BLOG

The doctrines of res judicata and collateral estoppel can bar parties from re-litigating claims and issues that were decided previously in workers' compensation proceedings. Res judicata, or claim preclusion, acts to bar claims that were, or should have been, advanced in a previous suit involving the same parties. It arises if a second suit: (1) involves the same cause of action; (2) is between the same parties; and (3) occurs after a final judgment on the merits. (DKN Holdings LLC v. Faerber (2015) 61 Cal. 4th 813, 824.)

The utilization review (UR) process begins when a claims administrator receives a completed request for authorization from a treating physician. Under the updated UR regulations that became effective April 1, 2026, California Code of Regulations (CCR), Title 8, § 9792.6.1(u) defines what constitutes a valid "request for authorization," and specifies the conditions under which a request is deemed "completed" for purposes of triggering the UR clock. CCR 9792.9.1(b) addresses the claims administrator's obligations on receipt of a request that does not meet the definition of a completed request.

Once a qualified medical evaluator (QME) has been selected in a represented case, California Code of Regulation (CCR) 34(b) explains that any subsequent evaluation may be performed at a different medical office of the selected QME if that office is listed with the medical director and is "within a reasonable geographic distance from the injured worker's residence." Labor Code § 4062.3(k) further directs that, after a medical evaluation is prepared, the parties "shall utilize the same medical evaluator who prepared the previous evaluation to resolve the medical dispute" to the extent possible. Together, those provisions reflect a strong preference for continuity of the medical-legal evaluator, and they set the framework for disputes that arise when a QME relocates his or her practice.

In accepted cases, Labor Codes 4061 and 4062 establish the procedures by which parties may dispute a medical determination made by a primary treating physician (PTP) and, when the employee is represented by an attorney, obtain a comprehensive medical evaluation through the qualified medical evaluator (QME) panel process under LC 4062.2. Under LC 4061(b), a valid objection may be raised to a PTP's medical determination "concerning the existence or extent of permanent impairment and limitations or the need for future medical care." Under LC 4062(a), objections to medical determinations may be raised to issues not covered by LC 4061 (for example, ongoing temporary disability, body parts injured, work restriction).

Labor Code § 4610(l) allows an employer to defer conducting utilization review (UR) of a request for medical treatment "while the employer is disputing liability for injury or treatment of the condition for which treatment is recommended pursuant to Section 4062." Former California Code of Regulation (CCR) 9792.9.1(b) and new CCR 9792.9.2(a), effective April 1, 2026, state that a request for authorization "may be deferred if the claims administrator disputes liability for either the occupational injury for which the treatment is recommended or the recommended treatment itself on grounds other than medical necessity." That procedure protects defendants from having to immediately determine the medical necessity of treatment for a potentially nonindustrial condition.

Effective April 1, 2026, the Division of Workers’ Compensation (DWC) adopts a comprehensive and extensive set of new regulations governing utilization review (UR), independent medical review (IMR) and physician reporting. The regulations are available on the DWC's rulemaking page.

The changes are primarily driven by the legislative mandates of Assembly Bill (AB) 1124 and Senate Bill (SB) 1160, which were enacted to address complaints of excessive UR delays and denials. The overarching goals of the new regulations are to align the review process with SB 1160 and AB 1124, and to improve the process of the delivering medical treatment within workers’ compensation.

Labor Code § 4062.2 establishes the rules for requesting a panel of qualified medical evaluators (QMEs) when an employee is represented by an attorney. After a panel is obtained, LC 4062.2(c) states, "Within 10 days of assignment of the panel by the administrative director, each party may strike one name from the panel." The statute does not describe the appropriate method for exercising a strike, but it adds, "The administrative director may prescribe the form, the manner, or both, by which the parties shall conduct the selection process." Although the administrative director has adopted regulations related to the QME selection process in the California Code of Regulations (CCR) 29 et seq, none of the regulations discusses the striking process.

Labor Code § 4062.2 establishes the rules for requesting a panel of qualified medical evaluators (QMEs) when an employee is represented by an attorney. After a panel is obtained, LC 4062.2(c) states, "Within 10 days of assignment of the panel by the administrative director, each party may strike one name from the panel." The statute does not describe the appropriate method for exercising a strike, but it adds, "The administrative director may prescribe the form, the manner, or both, by which the parties shall conduct the selection process." Although the administrative director has adopted regulations related to the QME selection process in the California Code of Regulations (CCR) 29 et seq, none of the regulations discusses the striking process.