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Wednesday, March 30, 2016

Lawmakers Gearing Up for Review of UR

  • By Greg Jones
  • State: California
  • Topic: Top
  • - Popular with: Legal
  • -  0 shares
The leader of a Senate committee that hears workers' comp issues has introduced legislation that…

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Mar 30, 2016 a 10:03 am PDT

This comment is private

Anonymous Nov 3, 2016 a 2:58 pm PDT

Ab 2503 makes no sense. Labor code and regs state the request goes to claims administrator. Adjusters have the right to authorize. The adjuster receiving it is when UR starts. If they then don't know if they should approve they pic a vendor to send it to. It needs to stay that way. Instructing physicians to send requests directly to a UR vendor that the payer uses is ridiculous and cuts out the first stage of UR.

Stacy Balbona Nov 3, 2016 a 2:58 pm PDT

The entire UR process needs to be abolished! It's a complete farce and provides the adjusters with a place to run and hide behind in lieu of doing their jobs! Presently UR is being completely abused by the insurance companies and utilized for cost containment purposes. Further, it is NOT the doctors responsibility to make UR submissions; the adjuster should be properly adjusting his/her file and only submitting requests that require a review and authorizing reasonable treatment inclusive of medications. Exercise of a little common sense on behalf of the carrier is apparently asking too much. Furthermore, the bigger issue is that the proper care of the injured worker and wrongful denials of not only conservative care but surgeries and medications. This system is a complete travesty and the ONLY ones benefitting from it are the insurers. Appalling to think the UR physicians are receiving kick-backs and, not only that, but are the same individuals who knowingly deny opiate medications to IW's who have been provided with same even though they know that medically speaking they cannot be abruptly stopped - yet they do it anyway!!! That is criminal in and of itself yet it is continues and nobody cares, except for the IW and his/her family. Also, the UR system is completely lopsided - how is that approval is only valid for 3 months but a denial for 12? Who other than the insurance company does that benefit? There needs to be strict regulations in effect to disallow the denial and abrupt cessation of any medications which have historically been utilized for the care and relief of symptoms of industrial injury especially in cases of chronic pain and psychiatric injuries - the weaning or terminations of any such medications need to be left to the physician who is providing the care, not some quack being paid or receiving kick-backs. That just proves that the corruptness of this system are spread equally across the game table. Not to mention that there is responsibility of the certifying physician and insurer who wrongfully deny treatment/surgeries - I believe all physicians took the Hippocratic Oath, but I guess that doesn't count at all in this so-called no fault system. Leaving the IW to fend for themselves, pay for their medical care out of their own pockets (if they can afford it) or suffer is absolutely disgusting. Anyone in favor of this system better pray he or she or their most precious loved one never falls victim to it. I have worked in this system since before SB899 and unfortunately it's no longer about getting someone better and back to work, but about the bottom line - at the cost of the IW. The IW's are human beings and deserve to be treated with dignity and provided the care THEIR DOCTORS (who are MPN doctors by the way) recommend. In the end, PUT THE CARE OF THE PATIENT BACK IN THE HANDS OF THE DOCTORS AND PROPERLY ADJUST YOUR FILES AND STOP PLAYING GOD WITH OTHER PEOPLES' LIVES!

George Rothwell Nov 3, 2016 a 2:58 pm PDT

Some people forget that UR was put in place, in part, as the result of massive abuse of the WC system by a very small number of medical providers. They forget the times when some "multi-special" medical groups sent cappers to the lines outside unemployment offices to sign up warm bodies and then provided bonuses to a few unethical attorneys to file "skin and contents" applications. Sometimes applicants with legitimate injuries were ignored by these groups, if they had injuries that did not fall under the specialties of the group's members. In more recent times we have doctors taking bribes to send there patients to a hospital where phony medical devices were being implanted. Instead of claiming that one side or the other is evil and abusing the system, people should realize that there are abuses on both sides. Greed is not limited to applicants, attorneys, insurance companies, employers or medical providers, no humans are perfect. UR can provide a positive tool to prevent unreasonable medical treatment, but can also be subject to abuse. We should applaud any efforts to improve the system. I would suggest that one way would be to remove any financial connection between the UR provider and the carrier. The fact that some UR providers are also owned by the carrier who uses them would appear to me to be a clear conflict of interest, just as it is a conflict of interest for a doctor to send his or her patients for testing or P/T to a group owned by the doctor.

Christopher Lear Nov 3, 2016 a 2:58 pm PDT

Apparently you're not seeing the crap reports from applicant attorney selected treating physicians that I do on a daily basis. The doctors can't justify their treatment recommendations. Often their treatment recommendations are a joke and if there were any real justice we would see these hack doctors with their licenses stripped from them. Let alone the damage they do to the general public by prescribing unnecessary drugs, unnecessary surgeries, unnecessary therapy, etc. I understand how the general public are easily manipulated into believing that the treatment recommendations of these hack doctors are being unjustly denied by evil insurance companies. I find it less understandable how supposedly intelligent attorneys buy into the game so much that they actually become indignant when carriers try to get a handle on the widespread abuse and implement a system that at least puts the decision on authorizing treatment into the hands of another medical professional, rather than placing it into the hands of an adjustor or administrative law judge. Then there are the attorneys that send their injured patients to a chiro or pain specialist as PTP when they would never consider sending their own loved ones to the same type of practitioner for the same type of injury. Why? Because their clients are only there as methods to make money and they could care less about sending them to a specialist that can actually do them some good. Save your righteous indignation for people out in the general public or your clients who might actually believe it.

KURT HOFFMAN Nov 3, 2016 a 2:58 pm PDT

I like the old days 1990...when doctors can order whatever they think is appropriate. Lets roll back the laws to 1990. Give treating physicians power. No more UR or QME....back to AME and IME. Miss the old days.... Today is a joke.

Jerry Wells Nov 3, 2016 a 2:58 pm PDT

Ah, the good old days...when chiropractors could treat 3 times a week for two or three years...or indefinitely, with no evidence that the treatment provided any benefit at all; when medical legal evaluators were selected not for their expertise, but for the dependability of their opinions--pro applicant or pro defense. When PD opinions could be based entirely on subjective complaints with no objective supporting evidence. When a psychiatric and cardiac claim could be based on an "honest perception" of stress-inducing harassment, even if that perception was clearly wrong. Anecdotally, when one applicant attorney provided an office in his own office suite for his father, a medical doctor, who performed medical legal evaluations for his son, and those were relied upon to support awards of benefits. Yes, those were the good old days.

Pete Thomas Nov 3, 2016 a 2:58 pm PDT

Jeffery if IIC has just ODG in its system this would mean that UR docs would use the ODG exclusively and not MTUS and ACOEM. This is blatantly in violation of California workers comp statutes, can that be changed? Of course but at what time line and at what cost to the injured worker.

Your proposed "patient portal" is assuming that all patient treatment will entered into the computer and correctly. I get 20 to 30% of my x-ray and MRI reports that I have to get the radiologist to produce an addendum (not an easy task) because of pathology missed. How long before those get put into the "patient portal"? UR would now have the "excuse" that sense the information is not in the "patient portal" I can not authorize this requested treatment, which means off to the denial machine titled IMR.

Anonymous is correct, taking the adjustor out of the equation is very counter productive and in the long run will cost the insurance industry more monies and would mean more UR denials, the system needs to continue to allow the adjustor in the decision making loop. Further this allows for direct conflict in the current laws which will ultimately mean more court time.

As many of us know "old days" is the system has been changed because 10 to 15% of the docs seeing workers comp patients have been stressing the system. They have not been practicing patient care but only practicing innovative billing techniques. It has hurt us all financially as well as hindering docs decision making abilities.

Eric Krouse Nov 3, 2016 a 2:58 pm PDT

Anyone step-back at California and think that it's too big to manage as one entity? That the answers in the North are not the answers in the South? That we need our management, for all people, existing closer to the scene. This State is too big. Look at the rest of the Country. We need to make a Northern California, Central California, and Southern California. Then, the dragons (i.e. issues) that need to be slayed will be smaller and less complex.

Alexander Zaks Nov 3, 2016 a 2:58 pm PDT

To get rid of the workers compensation system. It's a failure.

Too much money at stake and everyone in the entire industry is corrupted.

Abolish it and the sooner the better.

Anonymous Nov 3, 2016 a 2:58 pm PDT

My feeling is that we need to take the medical community of pay for service out of the picture. Put everyone into an HMO on a capitated basis. This takes run the bill to get the insurance company to pay more, out of the picture or just don't allow insurers to buy out future medical. With Medicare out there looking for every dime they can, this is probably something that will come down anyway. Thus carrier can't buy out future medical thus no reason for claimant to run a big bill besides to fatten up the compensation end. Once that's paid and SOL's running no motivation left and keeping them in the HMO capitated keeps all the costs under control through the internal HMO UR processes. Let the doctors shift their motivation to control costs. No predatory DME, compound medication, or facility kick backs to keep those doors open. But then again when it comes to doctors and bills they always find someway to make WC pay more. Throwing in some co-pays or deductibles would also provide some incentive for injured workers to avoid regular doctor visits. The days of seeing a doctor as much as you can just for the same RX refills would fade away fast. Only reason to go is for obvious changes in condition or medication changes. Just my opinion.

Jeffrey Stevenson Nov 3, 2016 a 2:58 pm PDT

Reply,

I agree with all of you.

The description above is necessarily brief.

Toss out UR and go with a good MPN and give them what they ask for, when they ask for it. That is what the MPN was all about so the employer could direct their workers to good value physicians.
Good value for the employer was not always good value for the insurance carrier.
Enter UR.

I got tired of complaining and figured it was faster to drive to Sacramento or Silicone Valley for some meetings and back then to do long ineffectual appeals for Dr.No.

SB 2883 is looking to improve our work flow and efficiency.

Excellent case management is a pleasure with a good adjuster.
The broke piece here is playing Battle Ship for authorizations with the other side constantly changing until you get an honest UR Doc that gives you what you need.
Often enough my report was in fact missing key information and the denial was reasonable, ..sort of.
All unfunded of course.

A portal pushing the algorithm to me would help reduce this type of deficiency.

The goal of the paperless piece is for real time authorizations.
Imagine being able to schedule the patient for the PT, ortho or MRI while in your office.
No excuses. You save 2-6 weeks of TTD here and there x the life of the claim and the patient stays motivated and moving forward.

Algorithms are part of the EBM mantra we have to chant.
We only have good EBM-guidelines for 35% of our imaging studies using Medicare guidelines per a recent RAND study.

The portal concept is to make easy things easy and allow real time communication such as supporting reports and special circumstance comments and authorizations where appropriate.
Spine surgery among other things deserves a careful review beyond a couple days, but you can upload documents and complete prepopulated forms or whatever in the interface/portal.

Algorithms are part of the EBM mantra we have to chant.

If someone is frauding the system call the AG and let them deal with it. Don't use it as an excuse to strangle us.

Dr. skin in the game makes sense but beware of the HMO hot potato discharge game with a complex injury.

Keep the comments coming.
Suggestions welcome.

Jeff

Gary Tobia Nov 3, 2016 a 2:58 pm PDT

UR is a joke - especially when there is a F & A. Just delays treatment. Thank goodness I have VA - I don't have to put up with the BS. Yes, BS. VA gives and provides BETTER QUALITY AND TIMELY MEDICAL TREATMENT then does the WC System. UR ALWAYS denies which is okay as DAs and carriers get the bill to pay and WC Lost medical control. At least on a few cases I know about anyway.

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