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Appellate Judge Brings SCIF Back into Case Alleging Blanket UR Denials

  • State: California
  • Topic: Top
  • - Popular with: Legal
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California's State Compensation Insurance Fund has been dragged back into a lawsuit over allegat…

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Anonymous Nov 3, 2016 a 7:58 am PDT

Finally someone has proven that at least one UR company is not doing UR, they are merely selling denials that the carrier instructs. That is sad since so much weight and power is given to a UR denial. Hopefully SCIF and EK fry over this. The fact the defendants in the case are on the MEEAC and also on the ODG board really makes the guidelines themselves loose credibility and also shows the behavior is malicious and still exists. Hopefully this case can get to the bottom of that. Look forward to more reporting on this.

Anonymous Nov 3, 2016 a 7:58 am PDT

"UR review is medical rather than legal and informal rather than formal". What the heck does that mean? Obamacare 101. Too many times SCIF will send UR denials for services not covered by UR as simply a way to try and get out of paying for services. Seems like the claims examiner can't find a SCIF policy that gives them a legal reason to deny payment so they run home to momma and they send in turn send out blanket denials. Wonder if this practice by SCIF/Elk goes deeper.... just asking.

Anonymous Nov 3, 2016 a 7:58 am PDT

Lie Detector: No... EK Health is owned by SCIF. SCIF used to do their own in-house and just few years ago spinned off EK Health in order to appeal to have 3rd party vendor. You call EK Health and ask about their relationship with SCIF and they will give you run around. Any other companies will tell you exactly who they work for or contract with. SCIF has always been helmed by ethically challenged people.

As for the Shockwave, well, in this case SCIF and EK Health mishandled this one...but still H-wave is a scam. They are making a big mistake to side with these people who are selling H-wave. Just like any device scam, they've been contracting with PTP's, illegally, and have been billing for it massively by prescribing to just about every patient a PTP might have. They charge $2000 for a 10 minute procedure with a machine that costs around $20,000. A technician would go to a site and see 30-60 patients in one particular day. Even if some do not get paid, because it's over charged so much, they still make a lot of money. Denied ones go to lien. This lawsuit if won by Hwave people will give those scam artists green light for the likes. They have another one like this currently which an MD brought it into the system back in 2012 and has already billed over $70 million. They "rent" the device and technician to a group and get percentage of collection or pay "rent" to the clinic for using their room (e.g. $5000/month which would cover the referral fee or kickback) for the exchange of getting all the PTP's patients referred to them. That scam was developed with H-wave and now have moved onto another device. Anything that has any kind of studies, but isn't addressed by MTUS or ODG are game for them. That's the loophole. This lawsuit may make the hole much bigger if it proceeds the way it is right now. People... get a clue. Why do these devices only sell in California WC? Especially concentrated in Southern Cal... That's where these guys who brought in this devices reside. They make so much money just working locally they don't feel the need to spread to other parts of the country. That's how screwed up our system is.

JAMES BADER Nov 3, 2016 a 7:58 am PDT

It seems pretty clear that the relationship of the insurance industry and the UR companies creates a strong partnership to effectively deny workers reasonable and timely medical care in accepted claims when the injured worker is treating within an MPN. What is really scary is that the carriers and administrators hire UR companies that they have effectively direct control over. There is no independence between the two "companies," and in reality they are acting as the same entity. Doesn't these seem to be a massive scheme to deny injured workers the reasonable medical care the doctors on the carriers MPN request based on their multiple years of experience and often board certification in their medical specialties. Oh, and of course their is profit involved and the insurance carriers effectively profit thought the earnings of the UR companies, which are effectively owned by the carriers. Maybe one day there will be a real expose of this UR business.

Feb 13, 2015 a 10:02 am PST

This comment is private

Feb 13, 2015 a 10:02 am PST

This comment is private

Steve Cattolica Nov 3, 2016 a 7:58 am PDT

Good job, Jim.

Anonymous Nov 3, 2016 a 7:58 am PDT

Correction

It looks like you need to make some corrections my friend. Did you purposely lie, or are you really that confused???

Michael Carmenita Nov 3, 2016 a 7:58 am PDT

Correction "is a di**"

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