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Tuesday, January 5, 2016

Sedgwick Agrees to Pay $1.129 Million for UR Violations

  • By Greg Jones
  • State: California
  • Topic: Top
  • - Popular with: Legal
  • -  0 shares
Sedgwick Claims Management Services agreed to pay a fine of $1,129,600 to settle allegations of Labo…

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Anonymous Nov 3, 2016 a 7:58 am PDT

Could this be the turning point we hjave been waiting for? Hopefully the DWC will now order more audits and see what is really occurring.

M. Hollie Rutkowski Nov 3, 2016 a 7:58 am PDT

I have posted the Sedgwick UR Plan to a bunch of people. It is going out as attachment to e-mail. Anyone who wants it, e-mail me at Hollie@TCLC.org. Procedure for concurrent UR starts at page 30 and is 2 pages long. This is important – I had a Trial in which Sedgwick Claims Examiner was required to appear – issue was UR and IMR Appeal. On the day of Trial, before Trial, WCJ asked Sedgwick CE why she only provided UR Reviewer with one report from PTP, the one report that requested the treatment, then Sedgwick denied because lack information that was in PTP’s three prior reports. Why didn’t she provide the UR Reviewer with several of the PTP’s report? Sedgwick CE said that Sedgwick CMS and Sedgwick UR are the same company, that Sedgwick UR has complete and unfettered access to Sedgwick claims file and can get any medical info necessary. (All this I gathered before I ever saw the UR Plan.) This is important for a couple reasons. Sedgwick CMS and Sedgwick UR are the same company. Sedgwick has Sedgwick deny treatment so Sedgwick controls exactly what treatment is denied. I do not know why this is not a conflict of interest – but I could not find where UR conflict of interest is defined. I thought it was LC 139.3 but that is IMR conflict.

Sedgwick UR has access to all medical info – the UR Plan does not say this. But if true (UR plan was revised 11/11/15, so perhaps this was taken out?) then Sedgwick UR cannot ever say that treatment denied because the one report from the PTP does not contain all the required info.

See Subsection d. on page 30 – “if CE thinks more info is needed” for UR, CE “contacts the ordering physician by phone” to ask for that info. Yeah, right. Why is the CE the one who is decided what info the UR Doc needs to review???




Dr. Edwin Haronian Nov 3, 2016 a 7:58 am PDT

UR doctors are bound by medical board of California. It has been established that by providing treatment recommendations they form physician-patient relationship. Once that occurs the medical board has jurisdiction to investigate. They can not simply change a treatment that is detrimental to the patient for the benefit of the carrier. Physicians have obligations to the patient. Simply file a complaint against the UR doctor with medical Board. It's a simple one page document. The quake UR doctors will stop denying everything once they are looked at closely.

Dr. Edwin Haronian Nov 3, 2016 a 7:58 am PDT

File a complaint against the ur doctors
http://www.mbc.ca.gov/forms/07i-61.pdf

Cliff Bernstein Nov 3, 2016 a 7:58 am PDT

OMG. This happens on a regular basis, but there is no incentive for the AA to get into this dog fight. Winning penalty money goes to the AD, not the applicant (injured party)
I caught a UR company "nurse" (red handed) denying a UR request before the MD even saw it. The MD was angry and willing to testify but no incentive for AA to pursue. UR company "nurse's" routinely sum up reports for the doctors leaving out what they want and making the determination for them. UR doctors don't even get the requesting MD's report. WHEN WILL THIS BECOME A CLASS ACTION LAW SUIT OR RICO CASE???
I had a denial for home health care, which was upheld on appeal, for a lady discharged form hospital after spine surgery complicated with a T4 paraplegia. UR only gave 3 days care 8 hours/day
Ever notice how some patients are black balled?Everything is denied no matter what, no matter which doctor reviews the case.

TINA DYCK Nov 3, 2016 a 7:58 am PDT

I agree we need to do something as lien claimants. I have started to send the audit unit any reconsideration I do on a denied bill. If the audit unit keeps receiving complaints, someone is going to notice and do something. Gallagher Basset is another carrier who routinely denies bills as well as AIG, ESIS etc for authorized treatment without a valid reason. So lets bombard the audit unit with complaints.

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

Youdaman, I also caught a UR nurse red handed doing same. They sent the UR to a nurse in Texas (usually they have a CA nurse handle it). Since relevant information was not included in the original request I had the IW's doctor make the request again. It was denied by the UR doctor stating it had previously been approved. The previous UR response was a denial so this did not make sense. I called the UR company directly (name of UR company starts with a G and ends with a letter x).The person on the phone stated the previous UR doctors notes approved the request but for some reason the UR came out as a denial.It was not a typo as the denial contained guidelines and rational to deny. Apparently UR doctors write notes at G--- and it is up to their nurses if they want to type out an approval or denial. I still have all of the paperwork on this. This company also has in field nurse case mangers. I believe this is a conflict of interest as the in field nurse case managers goal often times is cost containment, and UR is supposed to be unbiased. How is it a fair UR review if the employer is hiring the in field NCM's directly from the same company? Cost containment is advertised in marketing materials for these companies and they state what they are doing publically. I do notice how some patients are blackballed while others do not have anything sent to UR and get everything approved. A patient who was a former high ranking position in the fire dept has never had anything sent through UR and gets everything approved, on the other hand a mechanic who filed one complaint against his claims adjuster now has EVERYTHING sent through UR with 90% denial rate. A change of condition will warrant another UR review for your patient, Youdaman.

Mary Miller Nov 3, 2016 a 7:58 am PDT

How is the person still employed????

Stacy Bickler Nov 3, 2016 a 7:58 am PDT

She is no longer employed there. Has not been for some time. i suspect it was because of this case in particular.

James Witkop Nov 3, 2016 a 7:58 am PDT

For this to be a viable RICO case you need it to be a conspiracy among co-conspirators. If McDivitt were simply mishandling the desk, there is no conspiracy. A class action requires the exact same wrongful conduct resulting in the same or similar damage to all plaintiffs (e.g., a plane crash; cable company overcharging). In these types of cases a class action is not effective due to the range of results from the improper denials.

It's hard to tell exactly what happened here but it looks like McDivitt was doing a bad job of managing her desk and ignoring RFAs. It looks like McDivitt herself was responsible for approximately 15% of all of the Long Beach office's discovered audit violations, so the violations may not be as prolific as the article suggests. I doubt this audit would have occurred but for her mishandling of this one case.

Brenda Jones Nov 3, 2016 a 7:58 am PDT

Theresa was the supervisor of Kroger claims, and it was no accident she did this. She held a lot of power with Kroger and these actions were routine by her. With over 25 years experience Theresa knew what she should of done, and her violations were routine. It just this time she got caught. Funny she did this for her employer to save them money for years, and as this case hit the fan they fired her.

Rhonda Wofford Nov 3, 2016 a 7:58 am PDT

The person who made the medical decision without a medical license incurred a criminal liability of "practicing medicine without a license;" however, I doubt that this well-documented instance of same, will ever be prosecuted as such.

KURT HOFFMAN Nov 3, 2016 a 7:58 am PDT

Lien Claimants must band together and file a class action law suit against all the major carriers for refusing to take phone calls, respond to messages and lack of good faith attempts to negotiate before forcing us to file a DOR. Lien Units are really BRICK WALLS. The insurance companies would rather use the resources of the court than deal directly with lien claimants. Denying payment to lien claimants may be fraud. Something must be done about it.

KURT HOFFMAN Nov 3, 2016 a 7:58 am PDT

All applicant doctors in the state should all donate 10K to a legal fund and file a class action law suit in 2016 against insurance company/TPA sneaky dirty tactics to delay payment which all amounts to fraud but never punished.

John Hoffman Nov 3, 2016 a 7:58 am PDT

Completely agreed & we are starting to do something about it. Let me know if you would like to discuss further.

Stacy Bickler Nov 3, 2016 a 7:58 am PDT

And what about the liens filed for improper care, unauthorized care, and for services billed in grossly excessive amounts? And then, attempts to collect on those services improperly? If you want to start slinging mud, it goes both ways.

Stacy Bickler Nov 3, 2016 a 7:58 am PDT

And what about the liens filed for improper care, unauthorized care, and for services billed in grossly excessive amounts? And then, attempts to collect on those services improperly? If you want to start slinging mud, it goes both ways.

M. Hollie Rutkowski Nov 3, 2016 a 7:58 am PDT

I have Sedgwick's UR Plan. Anybody want to see it? I have to convert it to a link or fax it because it is many pages -- most of which are filled with drivel. The Med Director is Robert Douglas Petrie of Bermuda Dunes, CA, age 67, CA Lic # C50893, said to be "retired", but one his responsibilities (listed in the UR Plan) is that he is responsible for all UR decisions AND he is a resource to claims personnel on "complex medical treatment issues" . His house is worth $932,000, a big 5 bedroom, 4 bath oasis in a large patch of dessert. He is an Occ Med specialist. Blame the claims examiner, sure, but the real culprit, the "doctor" responsible for Romano's death, is Petrie.

BILL CLABAUGH Nov 3, 2016 a 7:58 am PDT

Would love to have the info as I am fighting Sedgwicks UR--if yo do a link or you could email me at ylldone@gmail.com Thanks

Jan 5, 2016 a 2:01 pm PST

This comment is private

Anonymous Nov 21, 2016 a 10:49 am PST

Any injured worker can request a copy of their UR plan, and they should!

DEBORAH HALVERSON Nov 3, 2016 a 7:58 am PDT

Thank you, Work Comp Central, for publishing this article. This insurance fraud occurs on a daily basis in the healthcare provider community.
I have witnessed countless, daily articles on Work Comp employee/employer fraud. But in point of fact, there is an equal amount of insurance fraud. It all too rarely gets reported. There should be zero tolerance for both types of fraud, at all times.
I would like to see more such articles published and better pro-active pursuit by the DWC of ALL WC fraud.

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

Rutkowski should be commended for naming the person responsible. I hope his example spurs others to do the same when they can and should.

Charles Rondeau Nov 3, 2016 a 7:58 am PDT

So where are all of the posters who were so outraged yesterday about CAAA continuing to challenge the constitutionality of IMR .. crickets Yeah, I thought so.

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