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Industry Waits for UR Regulations to Answer Unresolved Issues

  • State: California
  • Topic: Top
  • - Average time spent on item: 72 minutes
  • - Popular with: Legal
Utilization review requirements in California are in a state of limbo, with mandates from a 2016 ref…

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2 Comments (3 Replies)

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Kimberley J Pryor Aug 16, 2019 a 7:08 am PDT

Utilization Review is designed to shift the burden of medical treatment for injured workers to the public coffers such as Medicare, Medi-cal, and to private insurance, which means it's borne by the taxpayers, instead it out of the pockets of the billion-dollar insurance companies, their CEOs, and shareholders. No one is talking about the 800-pound gorilla in the room. Injured Workers lucky enough to have other insurance are getting treatment, it's just that Sedgwick, Corvel, AmTrust, Church Mutual, Gallagher Bassett, AIG, etc. are not paying for it. Those without other insurance get to suffer in silence.
Same old story...The rich are stealing from the poor.

Steven Chandler Aug 16, 2019 a 8:08 am PDT

Sadly, Ms. Pryor's seemingly biased comments do not represent the WC community as a whole but perhaps represents her personal situation or experience. As a former IW, WC subsequent Claims Adjuster, and presently a Risk Manager, I can attest that the CA WC process is the most regulated insurance/benefit delivery system of its' kind. While no system is perfect, it's also not a free-for-all and with so many payers and takers, there's bound to be disputes at any given time. Just because you want something doesn't necessarily mean you are entitled to it. Ms. Pryor may wish to focus her concerns on medical necessity as well as understanding the issues of nature and extent. This would go further than just bellowing such gripes about TPAs, insurance companies, CEOs, and shareholders. Obligations of the employer are essentially to pay no more nor no less than what is required. Sorry, but I've known plenty who certainly did not 'suffer in silence' because they had no other insurance. They filed for a QME, met with the I&A, hired an attorney, filed UR appeals and IMR's, changed PTP's and Specialists, and most even focused on receiving the treatment so they could get better and get on with their lives!

James Bader Aug 16, 2019 a 9:08 am PDT

Have to agree with Kimberly. Although no one wants to say, everyone knows the system of denial of medical treatment in California Workers Compensation is draconian. Sure seems we could do better for our injured workers.

Vesta Armstrong Aug 16, 2019 a 3:08 pm PDT

I also agree with Kimberly. UR denials are often based on reasons such as "no documentation of conservative care" when the injury was more that 2 years prior. Obviously there was conservative care. My office IMRs every denial and the majority are upheld even when we point out that there is a clear exception within the guidelines. It doesn't matter what a QME or AME has to say about medical treatment. I have seen denials when all treaters and a QME say that the treatment should be afforded the injured worker. In addition, Judges are reluctant to hear the case when IMR is appealed. My clients with private insurance are the ones who can move forward with the healing process in spite of this one-sided system.

Dr Aug 17, 2019 a 2:08 pm PDT

See "Now Comes SB 1160 Unreasonable Denials," by the undersigned, published as a column on workcompcentral, 23 September 2016 -- that so much indicated medical care gets rejected by UR and by IMR is scandalous. But since UR and IMR docs don't have a Duty of Care they get away with it (see also my editorials on Duty of Care, my blog or workcompcentral columns).

robert L. weinmann, MD, Editor, www.politicsofhealthcare.com

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