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Poor Communication Between Providers, Claims Examiners Hurts Workers, Observers Say

  • State: California
  • Topic: Top
  • - Popular with: Legal
  • -  12 shares
California’s workers’ comp system is rife with mistrust and a lack of communication betw…

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Anne Bazel Mar 30, 2021 a 1:09 am PDT

A lot of philosophy. The issue is very simple, current rules in place are placing barriers for treatment. UR/IMR dance does nothing for effective treatment, but definitely is great in denying it. Most UR guys just cut and paste “guidelines” which even remotely match the issue, great excuse to deny. IMR is just a rubber stamp. None of the reviewer reads the whole record. How could they, they hardly get paid for their time by Maximus.
And MPNs? Doctors get picked in random, PTP can’t just refer to a specialist he trusts and understand their logic. No the patient must see someone within MPN whose logic sometimes makes no sense since there’s no communication between physicians.
There’s only one solution, give steering wheel to the treaters. All those reforms in the name of fraud control created one thing, DELAY OF TREATMENT. It might’ve saved some money for the carrier, but has done nothing for the injured worker.

Steven Feinberg Mar 30, 2021 a 8:02 am PDT

Anne, while I totally feel that the system is not working well for injured workers, I suggest as an interim step not giving wholesale control to my doctor colleagues (that did not work before) but rather identify quality treaters and bypass UR & IMR for them. We would need an independent body to monitor as physicians should not be thrown out of MPNs without education as to how to improve.

Kelly Webb Apr 5, 2021 a 3:33 pm PDT

I agree, we should be focusing on building relationships and trust with our MPN doctors by communication and allowing their recommended treatment as long as it is according to Evidence Based medicine. Building your MPN with quality treaters and doing regular quality reviews to monitor those treaters is a must.

Steven Feinberg Mar 30, 2021 a 8:02 am PDT

Anne, while I totally feel that the system is not working well for injured workers, I suggest as an interim step not giving wholesale control to my doctor colleagues (that did not work before) but rather identify quality treaters and bypass UR & IMR for them. We would need an independent body to monitor as physicians should not be thrown out of MPNs without education as to how to improve.

Robert Bourne Mar 30, 2021 a 3:22 pm PDT

“And it was actually put in place to protect the injured worker, and it's proven to be quite successful.”
I have a lot of respect for Bill Zachery. And I frequently agree with him. As a claimant's attorney I would have to say UR and Guidelines have been a disaster for injured workers. It is just a tool for delay and denial. It is the tail wagging the dog. In Georgia the employer decides who the doctor will be. If you don't trust your doctor to know what is best for the patient then don't put that doctor on your panel of physicians. let's be honest. UR and Guidelines are about saving the insurance company money. But at whose cost? I probably should not be complaining because delay and denial is ,by far, the biggest source of new clients for me.. But the human cost of delay and denial can't be measured by dollars. It is sad.

Gary Nelson Mar 30, 2021 a 8:41 am PDT

Clearly starting with the Governator and extending to Downtown Brown's reforms, the crux of the issue is controlling the cost of medical care. And that is only done by denying necessary care in many instances where it is curtailed. Most injured workers first experience with medical care in the system is an occupational medicine clinic that treats them like liars, complainers, and fraudsters. It is there I think that most of the distrust begins.

Gary Tobia Mar 30, 2021 a 12:01 pm PDT

Workers Compensation is a joke. Thank God I have Veterans Administration they treat me for my 1988 injury etc. You'll never get me back into the crooked system of workers compenation. As far as I can see Workers Compensation should be abolished and let civil litigation prevail

Gary Tobia Mar 30, 2021 a 12:01 pm PDT

Workers Compensation is a joke. Thank God I have Veterans Administration they treat me for my 1988 injury etc. You'll never get me back into the crooked system of workers compenation. As far as I can see Workers Compensation should be abolished and let civil litigation prevail

Gary Tobia Mar 30, 2021 a 12:01 pm PDT

Workers Compensation is a joke. Thank God I have Veterans Administration they treat me for my 1988 injury etc. You'll never get me back into the crooked system of workers compenation. As far as I can see Workers Compensation should be abolished and let civil litigation prevail

Gary Tobia Mar 30, 2021 a 12:01 pm PDT

Workers Compensation is a joke. Thank God I have Veterans Administration they treat me for my 1988 injury etc. You'll never get me back into the crooked system of workers compenation. As far as I can see Workers Compensation should be abolished and let civil litigation prevail

Suzanne Separa Mar 30, 2021 a 12:53 pm PDT

I oversee claims for clients in over 30 states. The only other 2 states that have WC claims open as long as California are Illinois and New York, but even they are not that bad.

There are too many "necessary" evaluations in California; PQME, QME, AME, etc.... and one for each alleged injury/body part. In other states each side gets a separate IME, and they take those, negotiate the difference and settle.

There are also the "add on" injuries in California for psych, sexual dysfunction, head, multiple appendages, nerves, etc. Doesn't happen in other states to the extent it does in CA.

All of these things make the costs higher, the claims are open longer, and employees and employers are more frustrated as a result. I also find it laughable that it's recommended the adjusters and doctors call each other. Most of my clients can't even get paper reports via email or fax.

I don't have the answers, but honestly, the entire system needs a reboot.

Edwin Haronian Apr 3, 2021 a 2:02 pm PDT

Oh great, a repeat of SB 863, SB 899, SB 99999.... all manipulated one-sided language like the MPN, UR, IMR, IBR, endless paperwork leading to the ability of the carrier to just deny care, and dispute payments and treatment. Bills are signed at midnight by some bureaucrat like we see above with one-sided language, development of systems that are complicated that even the judges and attorneys have a hard time understanding. Carrier spend $1 to deny a $1 treatment. All this, while the profits and reserves expand to billions since the last set of reforms. Oh, and claims remain open longer as getting a simple treatment like PT or an MRI takes months to approve requiring tons of paperwork.

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