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Insurance industry lobbyists on Tuesday answered charges that claims adjusters are routinely denying care for injuries that are not covered by medical guidelines by saying that workers in many cases are expecting treatment when none is warranted. Theo Pahos, a lobbyist for the Association of California Insurance Companies, said in a conference call with reporters that the American College of Occupational and Environmental Medicine (ACOEM) guidelines do not call for treatment for many...

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Comments (12):
“Pahos completely misses the point, and basically supports the problem - carriers are relying solely on ACOEM when the law CLEARLY states that ACOEM is NOT the ONLY criteria... WAKE UP CARRIERS!”
By: Anonymous, 03/16/2005 02:28:21 pm

“Believe it or not, I completely agree. Many of the denials handed down by utilization review are ludicrous. I'm frustrated too! My company gives me a small amount of power to override the denials but I better have plenty of documentation as to the reason. Part of the problem with treatment denials by utilization review companies or departments is the fact that most physicians send a brief, one line request such as "Request right carpal tunnel release". The reviewers are not mind readers. They must have the supporting documentation such as a positive EMG/NCV study before they can make an appropriate determination. It's extra work for the medical provider but it's a necessity. Utilization review has been a wonderful tool in those cases with two years of physical therapy or chiropractic treatment. If the modalities haven't healed the injury by now, will it ever? I would love to have massages three times per week!”
By: Mary Jones, 03/16/2005 03:43:52 pm
“Being an examiner I also agree. I happen to work for a company that still gives the examiner the ability to decide what will go through the u/r department. Why would I want my account to pay for a $200 u/r review on a back brace that costs $40, and then turn around and pay thousands of dollars in legal fees to fight it. This is senseless, and companies that have a policy of carte blanche u/r reviews are forcing either the court or legislature to take immediate a.s.a.p. Foolish strategy! Additionally, a fascinating question implied is whether injured workers are entitled to better care than the rest of us in the HMO and PPO worlds of txmt. I sure am not happy with the treatment or service that I've received through this Dept of Corp. run system and would find it unacceptable that people legitimately injured by work for their employer would be subjected to this sub-par level of treatment. Furthermore, I would go as far to hypothesis that sub-par treatment and increasingly excessive cost burden being placed on patients creates an atmosphere in which folks that are injured either have to risk bankruptcy to pay for necessary treatment or take their chances by filing a w/c claim. Congress recently passed a bill that even takes away bankruptcy protection for many of us, thus I would expect a gradual increase in claim filing as employed citizens realize they have more and more to lose by not having their treatment administered through the laws of the w/c system. Perhaps we'd be wise to look at many of the problems in the w/c system actually being a symptom of a much larger problem and stop all this counterproductive mud slinging! ”
By: Broadspire RCO1, 03/16/2005 04:22:08 pm
“What about the numerous cases where doctors spend the time to write the supporting reasons and the requests are denied? Also how are they supposed to get the approval for the "positive" carpal tunnel test in the first place? Diagnostic tests are not guaranteed approved. They are getting turned down right and left under the new guidelines also. Maybe not by your co but they are with others.This new system is ready for a meltdown if the carriers don't change fast.”
By: Barb Londee, 03/16/2005 04:25:29 pm
“As a treating chiropractor in the workers compensation field, I have been totally frustrated by the UR currently employed. Most of my patients are law enforcement officers with acceptd claims. As you are aware they are subjected to injuries most of us will never know. Sam Browne Syndrome, multiple traffic accidents, altercations, arrest and control school, Stress, prolonged sitting with up to 32 lbs, patrol cars with terrible seats and numerous other micro traumas on a daily basis. I have a good relationship with most adjusters and really don't put the blame on them. Chiropractors and M.D.s who are hired to do UR make easy money without any accountability or reprecussions. Most UR are canned and relate to the ACOEM guidelines which have nothing to do with chronic pain. Attorneys hate to take these cases to court because they are not paid. I write rebuttals several times many 6-10 pages with references and recent studies. What are we suppose to do? ”
By: seth goldstein, 03/16/2005 06:35:29 pm
“I am an injured worker. I waqs hurt in 1998. My insurance company denied everything, the employer threw away the hurt on the job form I filled out. I went to their doctors three times, then they suspended me for one day--supposedly for refusing to work as I was at the emergency hospital-then they denied, saying I had filed a fraudulant work comp case in retaliation for getting suspended. I had worked there three years, was planning on working there a lot more years. Then a year later, when we finally went to court, they said I hurt my back on previous job, I hurt my back in a small car accident, andor I hurt my back scuba diving. And they also said that if I did hurt myself it was not very much. The facts were far different from their accusations. I have told the truth for the last six years, and as far as I can see the insurance company has denied, their doctor has lied more than once,they called up my doctor that did my two disk lumbar surgery four times and wanted him to take away the physical therapy, refused to pay physical therapy and now there are over 13 penalties against them. One of my doctors said they are basically comitting medical malpractice in denying. Also they want 7 different reasons --including notes and reports, just to get a referral. MY PAIN LEVEL IS GETTING WORSE, i AM TAKING THE SAME MEDICATION A DYING CANCER PATIENT TAKES, and now we have to go to court again, this time--I think--because they never sent a letter back after my treating dr asked for me to see a nerologist, and also to get nerve conduction test, as now my condition is getting worse, I have nonfusion in neck, 5 lumbar disks are now bad, and now 5 facets are bad, and all insurance co does is deny, saying they have to go to comittee, deny for 11 months, then approve, deny for 3 12 years, then even when their own doctor says he feels I need a disk replacement and another neck surgery, they keep on stalling. I feel this is criminal behavior, and if there is any way I can file a civil suit I will. and it seems all the insurance company wants is for me to commit suicide, or go away. Now I am stuck with pain levels of 7 to 10 every day, body deterioating, having high blood pressure, heart condition, diabetes, all from the effects of getting hurt, surgeries, supervisor creating so much stress that all my body can deo is react to all this stress. So what this injured workewr has tried to do is to get fixed, and having all these denials or delays has just streched out my pain, causing more complications like fibromyalgia, and I will be lucky to come out of this alive. Is Bill SB899 supposed to help me? All it does is give the insurance company more ways to screw the injured worker. They put me on p&s one time, then just before court appearance they said--oh we were not supposed to do that, and sent me a check for the difference. Meanwhile I had to borrow $3000 from my credit cards. Now my treating doctor is threating to refuse me treatment because the insuranc company had delayed $28,000 in expenses, they just sent a check for one day, and this is for years. I even had to go to the VA hospital for a redo of lumbar surgery 3 12 years ago as insurance co delayed, wanted me to wait one year for approval of surgery, and I was taking 8 vicodin a day for pain. So trust us, the injured workers, all we want is to get rid of pain without taking morphine, vicodin, dilaudis, and now all kind of heart medication for stress, plus prozac.”
By: Donald Kottler, 03/17/2005 08:59:40 pm
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“Normally I'm a gadfly that takes the insurer view, but in this case I have to ask: Did this guy say this with a straight face? "Oh, no. We're not denying solely based on the lack of ACOEM Guidelines." I don't think ANYBODY actually believes that. This is symptomatic of a larger problem that insurers have: the knee jerk tendency to put off care, or at best, to slavishly push conservative care even when it is clear more aggressive care is needed up front. When will insurers learn that postponing the dime costs them a dollar? ”
By: Skip Simonds, 03/16/2005 04:37:17 pm

“ I have learned through bitter experience that U/R is not working as intended. Being on a claims desk has again proven that those who pass these changes to our comp law never ask those who have to make the system work, if there are viable changes. I'm old enough & hopefully wise enough to know when to disagree with U/R. If you have three MD's telling you someone needs surgery, you don't need a crystal ball to realize that the peer review is never going to hold up before the WCAB. What is missing from U/R is common sense. It is the one essential to claims adjusting that is neither encoded by law nor one which can be taught. I only hope that more people blessed with this trait, will know when to fight and when to concede. ”
By: Denise Vega, 03/16/2005 05:04:09 pm
“Excellent point. I have spent 30 years in employer/insurer defense in the Midwest, and since coming to California, and going over to the applicant side, have noted the insurers penchant for delaying and resisting needed treatment. From my experience, this only delays the innevitable, greatly extends TTD and lessens the chances for a successful return to work. This attitude of the insurers is totally wrong headed.”
By: John Wilson, 03/16/2005 05:14:26 pm
“I think that Mr. Wilson is making a very broad statement here. I do believe that he has also seen abuse of the system and while the ACOEM Guidelines are not a perfect tool at least this is an attempt to bring reasonability into play. As long time adjuster, with any number of jurisdictions under my belt, I have observed that CA doctors, claimants, and applicant attorneys are responsible for much of the reactionary decisions some adjusters are now making. This is unfortunate and is probably caused by either lack of adjuster experience, a need to deny what we don't understand, or simply growing pains that come with change. Unfortunately, it appears that the carrier is so constantly behind the eightball that sometimes adjusters may go overboard to attempt to level the playing field. ”
By: Jane Lehr, 03/16/2005 05:37:30 pm
“I agree with you Jane. It is hard sometimes to weed the legitimate, necessary requests out of the ridiculous ones. And I have to again as the question, why should Workers' Comp patients receive different different or more specialized treatment than those in the regular HMO/PPO system. I have a shoulder injury, and was told by two different doctors, even with MRI findings, that the best treatment was rest and no other intervention. Why is that not good enough for a person who was injured on the job? And, why would anyone want to treat or take medications if it wasn't necessary? Who would knowingly punish their body that way?”
By: Leroy DeLeon, 03/16/2005 06:23:57 pm
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“I have been an injured worker since nov 1998. I finally had to have back and neck and removal of right rib. I have mris and xrays showing 27% compression of cervix, now 5 lumbar disks bad-from two, due to insurance company denying and delaying, I need another surgery by ucla, I now have fibromyalgis, both feet are going numb, boths legs and hands and arms have shrunk 25 to 33% and still shrinking. They took away home care, laundry piling up, my treating doctor asked if I have health care since Zurich has not paid $28,000 for past medical treatment, I am seriously considering suicide as the only way out. All I wanted was to get fixed. All I got was insurance co. denying, telling surgeon to take away physical therapy after lumbar surgery, and having more than 12 penalties so far against them. Is this all we injured workers can expect? I have lost my life as it used to be. I used to be muscular, 190 lbs, went scuba diving, backpacking, skiing. hiked 10 to 15 miles a day. Now I am lucky to get out two hours a day, take Dilauded( stronger than morphine) and vicodin, and muscle relaxants and prozac, I need more surgeries, all I get from Zurich is delay and delay and deny, even tho what they are doing is illegal. I think we should go back to the days when we could sue for 5 to 10 million---maybe that would cause them to help us get back to some semblence of being human.”
By: Donald Kottler, 03/19/2005 10:27:00 am

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