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Claims Administrators far Exceed minimum Compliance Score for UR Timeliness, CWCI Reports

  • State: California
  • Topic: WEST
  • - Popular with: Legal
Claims administrators on average scored a 97.2% in utilization-review performance ratings conducted …

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7 Comments (10 Replies)

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Anonymous Nov 3, 2016 a 7:58 am PDT

Are we on the same planet? My experience is just the opposite. All of you out there, am I wrong?

Steven Dewberry Nov 3, 2016 a 7:58 am PDT

This sounds reasonable. Claims rarely uses their experience training or discretion with regard to medical care anymore. They simply and immediately send all requests to UR. That delays matters, and generally results in a denial based upon some arcane provision of or interpretation of MTUS. The result of course that medical costs are down. If UR denies everything, and Maximus upholds, Claims has learned to work the system of denials. The Administration loves it, says everything is working. Maximus and the UR companies are getting rich.

Garry Crosby Nov 3, 2016 a 7:58 am PDT

amazing news!!!! between the DWC/Claims administartors, I do not know who deserves an award of excellence and the IWs get a kick!!

WILLIAM YATTAW Nov 3, 2016 a 7:58 am PDT

SSK not really quite sure what your saying. Did you mean the word "back" in your response; if so it would make no sense either.

Anonymous Nov 21, 2016 a 10:49 am PST

Just saying I believe he means injured workers are getting screwed, or a kick in the balls or kick in the ass or kicked to the curb. I am just assuming...

Manila Manila Nov 3, 2016 a 7:58 am PDT

What is this? The fox rating the henhouse?

WILLIAM YATTAW Nov 3, 2016 a 7:58 am PDT

Your comment is not reality; as the administrators/TPAs' get more strict penalties for not being timely, thus their high score.

John De Vasure Nov 3, 2016 a 7:58 am PDT

First one must read Labor Code 4610(g)(1) and understand that it is 5 workings days to comply. The physician providing the utilization Review must use the State's Guidelines to support his medical opinion.

WILLIAM YATTAW Nov 3, 2016 a 7:58 am PDT

Possibly workdoc you may have problems with UR.

Anne Bazel Nov 3, 2016 a 7:58 am PDT

I don't know where they got the data from. Most UR's I get is much more than 5 days late from the time they receive it, even the reviewer states it. Sometimes, they chose to do inappropriate "retroactive" review on requests from few months ago.

D C Nov 3, 2016 a 7:58 am PDT

You are not wrong Workdoc.

Many injured workers, doctors and AA's are not aware they can send in a UR complaint if the UR is late etc. I have sent a ton of UR complaints throughout my claim and believe my TPA can just get away with it. The audit unit does nothing to the adjusters doing this.

From my understanding these insurance carriers are alerted before they have an audit, and get their files in order before the audit comes. Does anyone know if this is true?

I have had late UR or no ignored within the last year.

I agree with the comment below is that this system is completely set up as a denial machine. It begins with a UR denial that is denying based on lack of information and/or they are using MTUS incorrectly. If the injured worker does not have someone very well versed in appealing the bullshit, the denial will be rubber stamped by another IMR denial.

Christopher Lear Nov 3, 2016 a 7:58 am PDT

The claims file is documented through claim notes, UR reports, UR submission documents, documents, documents, documents, dates, dates, dates. When adjustors get audited, the auditors only select a percentage of the files and the adjustors do not know which ones will be audited. It would be completely impossible, due to time constraints, to do what you suggest and go through each and every file to fix them up. Plus, the way the files are documented makes that almost impossible. No. When the adjustor makes a decision and documents it, it is pretty much set in stone and they have to live or die by that decision. Plus, if they did lie about dates, the auditors could check the other end of the document (AA office, doctor office, etc.), and if they did find any falsification, the adjustor would probably lose their job, let alone possible prosecution and perhaps a very, very hefty audit penalty assessed against the carrier. Here is the gigantic elephant in the room that those on the applicant side (IWs, AAs and PTPs) wish to ignore. The PTP is supposed to draft his report and RFA in compliance with certain statutory provisions, which they repeatedly ignore. MTUS. RR 10606. etc. etc. etc. The reality is that doctors hate insurance companies, or anyone else for that matter, questioning their judgment. The doctor may actually be correct in his request for treatment. But if he is incompetent in submitting his request, his request will fail. So, the problem for AAs and IWs is to find a doctor that knows how to write a report which complies with the MTUS and report writing statutes and regulations. I have absolutely no recommendation on how a person might do that. Frankly, the doctor probably is not at fault as much as the staff he hires to write the reports, fax them in, respond to requests for further info, etc.

Anonymous Nov 21, 2016 a 10:49 am PST

Thank you defense attorney for clarifying how the audit is conducted. I have yet to find such a doctor who will do as you wrote above. David DePoalo wrote a blog story about how many MPN doctors did not know the system well. He got some flack for it in a response. I personally think he was spot on. My current PTP did not know what that term meant (primary treating physician). I had to e-mail his secretary IMR forms and directions how to fill them out. I have to appeal all of his denials. The surgeon is one of the top spine surgeons in the state. I was shocked he was on my MPN. I was happy to have him as my surgeon, but I would not receive any treatment if I did not appeal the denials. I absolutely believe my top surgeon knows what he is doing as far as my treatment. I do not think many realize how specialized work comp is. It is a very complicated system. They have set it up in such a way that a doctor would absolutely need special training to know the paperwork side of it. In the end the one who suffers is the injured workers.

Anonymous Nov 21, 2016 a 10:49 am PST

Correction, I had to e-mail RFA forms not IMR forms to the secretary.

Frank Huljev Nov 3, 2016 a 7:58 am PDT

The DWC lives in a dream world. Took them from 2005 to 2012 to realize that MPN was ghost lists of DOCs that don't take WC or are not even around any more. Now that the lists are certified what has changed, nothing. I am sure it will take them a decade to figure out UR is what it is. Part the of the administrative chess match, with includes deceiving the DWC>

Christopher Lear Nov 3, 2016 a 7:58 am PDT

Perhaps the PTP should read CCR §9785, or simply check the WCAB website, which includes several articles regarding the reporting requirements of reporting physicians. Those who are QMEs certainly have little excuse, since they are supposed to be "experts" in comp. As far as IW indicating that the doctor treats well, but appears to be confused by the comp system reporting requirements, that is perhaps somewhat understandable. The solution is also simple. Doctors don't know, for example, how to submit paperwork to Anthem, AETNA, or other non-comp insurance carriers. Their solution is to hire someone who does, or train them. The problem for the doctors is that those people are also trained experts and command a reasonable salary. If you are a greedy doctor who wants to horde all of the profits for yourself, then you hire an untrained 18 year old right out of high school and they know less than the doctor does about submitting the correct paperwork, submitting appeals, etc. The doctor gets frustrated, but the problem is caused by his own incompetence and greed. Your PTP may be one of the best surgeons in the State, but if he cannot get the treatment authorized, you suffer. So, while it's easier to find a doctor who is competent as a doctor, it's much more difficult to find a doctor's office that is competent in working with the insurance companies. I have no advice to offer on that score.

David Coe Nov 3, 2016 a 7:58 am PDT



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