For injured employees within California’s Workers’ Compensation system, the denial of care and/or denial of treatment by insurance companies is reaching epic proportions. Nearly two out every three potential client calls to our office involve employees upset by denied treatment. As you will see below, these frustrations are well grounded.
Through this two part blog, we will generally explain how insurance companies determine whether or not to allow treatment, and how best to ensure you receive the care you need.
Part 1: The first step in understanding how to get the right care is to understand the medical review system under California’s Workers’ Compensation scheme.
What is the role of a “Primary Treating Physician”?
Theoretically, the answer should be simple: Take care of you! Unfortunately, in California’s Workers’ Compensation system, their role is not that simple.
A “Primary Treating Physician” under the applicable regulations is defined as the “physician who is primarily responsible for managing the care of an employee, and who has examined the employee at least once for the purpose of rendering or prescribing treatment and has monitored the effect of the treatment thereafter.”
In perfect world, without insurance companies and aggressive Workers’ Compensation insurance adjusters trying to save a couple bucks, the primary treating physician would examine an injured employee, make a decision, and prescribe the proper care. That care would then be provided to the injured employee. Unfortunately, despite your Primary Treating Physician’s best judgment, treatment must first be approved, unless there is a medical emergency. The approval process is referred to as “Utilization Review”.
What is a “Utilization Review” and how does it work?
Utilization Review is the brainchild of your legislature, after heavy lobbying by the insurance industry. In a nutshell, a utilization review is an opportunity for the insurance companies to review your primary treating physician’s recommendation and decide if it is medically necessary.
Under the current Workers’ Compensation system in California, your doctor can spend hours examining you, consulting with other physicians and medical resources, and creating a plan to resolve your pain and get you back to work. After all that work, with the stroke of a pen or the punch of a keyboard, your treatment can be denied by a doctor that has never met you! This inequity in the workers’ compensation system is extremely frustrating to many injured workers.
When you are denied treatment, you are denied the chance to receive the care that your doctor thinks is best for you, get better, and return to work in a timely manner.
Fortunately, when your treatment has been denied, you are not without rights. The first formal step to remedy this denial is to request an “Independent Medical Review.”
What is an “Independent Medical Review?”
Historically, when your Primary Treating Physician recommended treatment, and your insurance company refused to provide that treatment, you had the right to go before a Workers’ Compensation Judge and present the reasons why your treatment was needed. The judge could then order that you be provided that treatment. The insurance companies did not like this system, as they were consistently ordered by a judge to provide you treatment, after a FAIR hearing.
After much lobbying, the insurance company convinced the legislature to take away your right to an impartial hearing before an independent judge. Instead, they created a system known as “Independent Medical Review.” Under this new system, a physician is randomly selected from a panel. This physician then reviews your file and makes a determination as to whether or not the treatment requested by your Primary Physician is medically necessary.
There are many problems with the Independent Medical Review process, not the least of which is that the reviewing physician has never, and never will, examine you in person. You do not have the right to meet with them, the right to explain to them your problems in your own words, the right to have them physically examine you, or even the right to ask them if they have all the information needed.
Under the Independent Medical Review system, the reviewers are paid a nominal flat fee per file, with the only variation being whether or not the claim is pharmacy related and/or expedited! They are not paid based on the amount of time they spend; they are not paid based on how complicated the problem is; they are simply paid a flat fee regardless of the seriousness or lack of seriousness of the issue. Consequently, the more complicated the case, the more likely it is that the medical examiner failed to actually do their job, especially in light of how little they are paid compared to what competent physicians charge for a similar review outside of the Workers’ Compensation system.
We have now reviewed the basic roles of the “Primary Treating Physician,” the Utilization Review process, and the Independent Review Process and its challenges. In part two of Denied Treatment for Workers Compensation Injury: How to Fight Back!, we will provide some tips and tricks to help increase your success in navigating the systems described above.
