Can’t get medical treatment?

You may need an attorney to fight Utilization Review.

Under California Labor Code Law related to Workers Compensation cases, only a physician is allowed to deny medical treatment (LC§4610).

However, to allow a non physician claims adjuster to administer the workers comp claim, a process of Utilization Review (UR) has been established. With UR, the adjuster can rely on a doctor’s opinion to determine whether the workers’ compensation insurance must be utilized for the treatment expense recommended by the treating physician.

Many things can go wrong with this scheme, and many things are continuing to go wrong with it.

The applicant attorneys association has fought back against unreasonable denial of medical care that has become a rampant epidemic in California workers compensation.

The following is a brief look at treatment denial problems and the current status of the potential remedies.

First, we should observe that no rational worker’s compensation practitioner will deny that there needs to be a primary treating physician (PTP) assigned to each work injury claim. This is not the subject of UR and is seldom debated. It is the subject of a host of other problems, however, where the workers compensation insurer has a medical provider network that includes doctors who are not taking new patients, that changes the roster of names of doctors who are on the list, and where access to the list of doctors is sometimes not intelligible. These issues are addressed by recent regulations and revisions and are the subject of another article.

Assume that there is a valid MPN in place and that the applicant has managed to obtain medical treatment from a physician. Let’s also assume that the treating doctor has requested medications, a course of physical therapy and an MRI for conservative care of your work injury. How do you actually get the recommended medical care?

The treating doctor is required to complete a form called “request for authorization” (RFA) for each requested medical procedure. If the RFA is submitted, then the adjuster is obligated to either provide the authorization for the treatment or, if they object to the treatment, they must obtain a report from a UR physician that recommends against the treatment (non-certifies). If the UR report certifies, the treatment must be provided.

If the UR report “non-certifies”, the claims administrator may notify the treating doctor that the expense will not be permitted. There are strict timeliness requirements for the UR report and denial, and there has been some new law regarding the admissibility of a report that is not timely. However, even if the UR report is late, the treatment is likely to be denied until a judge at the appeals board makes a ruling that the report is late and the injured worker has proved that the requested treatment is still necessary.

When UR reports are timely, the only way to overturn a denial of treatment is to submit the dispute to Independent Medical Review.(IMR) The treatment is not provided until the dispute is “resolved”, and there are no adequate remedies challenge the IMR process or to enforce that it is an adequate or fair review of the UR determination.

Either way, a denial of treatment takes time to overturn, takes time to be reviewed, and puts the burden on the injured worker to prove medical necessity. The support of the treating doctor is needed for this process. Yes, the doctor provided to the injured worker from a list provided by the insurance company, the doctor who cannot get paid for appealing a denial of treatment, must provide the information necessary to win an appeal of the denial of treatment.

There is certainly a lot wrong with this picture. Attorneys can help. We don’t work miracles, and we work hard to help our clients with these issues, but without help it is likely that treatment for serious injuries will be less than adequate or reasonable. If you are an injured worker, I hope your injury is not serious and wish you a speedy recovery.