As stated in the previus article, if you are an injured worker, proceed with caution in dealing with the claims examiner and the company’s doctor who is treating your work injury. Simply put.
One thing that always bothered me at my insurance company job was the tendency by Claims to deny basic medical care and then hide behind Utilization Review(UR) as a justification to do so. In fact, when UR was first introduced in California , Claims was told to put “everything” through UR since this was viewed as the solution to those “over-treating” doctors. Simple things such as aspirin, pain medications, physical therapy, X-rays or other diagnostic tests, were routinely denied because UR “said so”. The result was nothing less than a disaster since it seemed as though the whole medical treatment part of our cases came to screeching halt. Oftentimes it would get worse. The time frames for conducting a timely UR were rarely met. This would lead to medical care routinely denied because of a late UR. Of course, it took a while to correct this situation. After much litigation and years of delayed and denied medical care, the WCAB and the Courts made it clear that a late UR was invalid and could not be used to deny care. You would think that carriers would simply self-correct this problem and limit what treatment was put through UR. Some carriers did eventually make this move, to their credit. Better late than never!
Fast forward to today, and we still have an imperfect system for providing medical care to injured workers. Claims examiners still hide behind UR to deny medical care, even though the doctors who are requesting the treatment are basically selected by the insurance companies through a scheme called Medical Provider Networks. So you have a contract between the insurance company and the doctors that requires the doctor to provide care to injured workers within certain guidelines and with the goal of getting that injured worker back to work as soon as possible. On paper it sounds good, right? In practice, it’s bad detrimental to the injured worker. Why? Because, that doctor has an incentive to keep costs down at the expense of the patient/injured worker. Diagnostic tests tend to be limited. Workers are released from care right away especially in those Occupational Medicine clinics. Even with this incentive, some doctors may request certain types of treatment that truly is reasonable. Let them have it, you say. Well, not so simple. The claims examiner still has the right under current law to submit that request for care to their UR vendor. If UR says no, that’s it. Treatment denied. Lest I forget, even though we have an appeal process for UR denials called Independent Medical Review(IMR), the track record for this appeal system is appallingly in favor of carriers who deny treatment. Sort of like a rubber stamp.
Back to my point about hiding behind UR. Carriers like to point out that UR simply follows the Medical Treatment Utilization Schedule(MTUS) which is the law of the land in California for judging medical care. MTUS in turn follows the ACOEM guidelines in many cases. It is interesting to note that ACOEM provides the following disclaimer at the beginning of the book:” The American College of Occupational and Environmental Medicine provides this segment of guidelines for practitioners and notes that decisions to adopt particular courses of actions must be made by trained practitioners on the basis of the available resources and the particular circumstances presented by the individual patient. Accordingly, the American College of Occupational and Environmental Medicine and OEM Health Information, Inc. disclaims responsibility for any injuries or damage resulting from actions taken by practitioners after considering these guidelines.” In other words, go ahead and use the guidelines, but if things go wrong, don’t blame us!
The whole point to providing medical care to injured workers should be to heal them as much as possible so they can go back to work and live their lives. Sometimes this happens, but there are many cases where it does not. This is where I saw UR used as a tool to deny recommended medical care. What happens is that the treating doctor asks for a course of treatment—medications, diagnostic tests, therapy, surgery, and Claims sends it to UR, which then denies the request. Once denied, the claims examiner will not budge even though the requested treatment may appear to be reasonable and the treating doctor has explained why the treatment is appropriate. Keep in mind that Claims can authorize medical treatment without going through UR, if it wants. Claims examiners are trained and told not to override UR decisions. The result is a denial of medical care, even when it should be provided. The injured worker does not heal and may get worse. Recent case law (Hikada) found that any increase in permanent disability from improper medical care is actually compensable under workers' compensation law. What about the increase in PD due to a denial of medical care? I suspect this is a more frequent result than people realize. With IMR, things don’t change much due to IMR's tendency to uphold the denial of care. Even if the treatment dispute went before a judge, the examiner would usually say “Let the judge decide" instead of simply providing the treatment to keep the case moving forward. The result was even more delay in providing care. When I left my insurance job in 2016, the one thing I wanted to see improved was the unshackling of medical care from the restraints of UR. This would have allowed cases to proceed a lot quicker, with less administrative and litigation costs, and likely with better results for injured workers from the medical side as well. In the end, this would result in real cost savings for employers and carriers. Hopefully, in 2018, when the revised Labor Code 4610 goes into effect, more insurance companies will realize it is cheaper to simply authorize the majority of medical care requested by their MPN doctors without going through UR.