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Weinmann: Will AB 1107 Trim the Claws of UR?

  • State: California

Under current law, employers are obliged to establish utilization review panels whose purpose is to review, approve, modify or deny diagnostic and/or treatment recommendations.

Dr. Robert Weinmann

Dr. Robert Weinmann

Some doctors are felt to have a penchant for the task. Other doctors sometimes see these UR doctors as utilization review denial specialists.

Assembly Bill 1107 would take away some of the unbridled authority now enjoyed by UR panels. For instance, some of the denials seem outright arbitrary from the get-go: Physical therapy has a limit of 24 sessions per injury but there are no peer reviewed studies that show 24 as a reasonable cutoff limit. It is widely accepted that the limit of 24 is based on economics and has nothing to do with science or medical treatment.

Legislators who are often not familiar with health and safety issues may not know that utilization review doctors do not interview or examine the patients on whom their decisions fall. Patients are often astonished that this practice governs their lives and access to treatment. Patients usually believe that their doctors make the medical decisions. In fact, they do, but UR is allowed under the law to unmake these decisions.

So here is what AB 1107 would do:

  • The law would hold that medical treatment prescribed by a primary treating physician is no longer subject to Section 4610 or subject to dispute on the grounds of medical necessity.
  • If the employee suffers from a serious chronic condition, or if the requested treatment has been previously authorized by the employer but fails to establish that the treatment is no longer indicated, or if the employer has established a medical provider network pursuant to Section 4616, and that if there is a dispute, the appeals board shall resolve the dispute, and the employer is not precluded from objecting to a treatment protocol on grounds other than medical necessity.

While this legislation does not carry a duty of care provision, a provision that makes PTPs and UR doctors equally responsible under the law for their decisions, it carries enough clout to modify the sometimes arbitrary and arrogant conduct of the utilization review system.

An aye vote is warranted.

Dr. Robert Weinmann writes the Politics of Healthcare blog, from which this entry was taken with permission.

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