You may have noticed that the insurance company is not authorizing most, if not all, of your medical care recommended by the doctor. This occurs even if the doctor is one of the doctors you have been forced to see who is on their list of approved doctors or Medical Provider Networks.
The reason for this is that the State Legislature, who makes workers’ compensation laws and rules, decided that your doctor wasn’t either smart enough or competent enough to make determinations about your medical care. What they have done is taken away the doctor’s right to determine your course of care and given it to two levels of new insurance company-selected people, who examine the medical records to see if the doctor complied with all the published requirements and recommendations they have imposed.
First, your doctor, although he or she has examined you and knows you, cannot prescribe any treatment or diagnostic test without first getting written authorization from the insurance company. If he does not get this, he will not be paid and his report could be excluded from evidence. Even a telephonic okay from an adjuster is NOT sufficient, as later adjusters have denied agreeing to the treatment.
Second, the insurance companies have determined that you should only be treated according to the guidelines of ACOEM (the Academy of Occupational and Environmental Medicine) and then by the Medical Treatment Utilization Schedule (MTUS) and the ODG (Occupational Disability Guidelines), all drafted and run by insurance company surrogates. This means that your treatment is going to what the “average person”, according to the Guidelines will allow. Your treatment cannot exceed the “average” approved level of treatment.
Treatment approval is determined by two levels of “review.” The first is called Utilization Review (or UR). State law provides that every insurance company or self-insured employer must have a program in place to review medical treatment requests. It was supposed to be used for non-traditional or excessive treatments; however, the UR lobbyists have convinced the carriers that they must do UR on all requests, despite the Supreme Court having told them differently. This also allows the carrier to hire adjusters who do not have any real knowledge or experience with the usual medical treatment progressions.
Once the doctor decides on a treatment, get a test or change your medications, he or she must complete a PR-2, or Physician’s Report 2, in which he is supposed set forth the nature of your injury and what he or she wants to do in the way of treatment. With the PR-2, the doctor must also send a Request for Authorization (RFA), which re-states what was requested in the PR-2. Unless both forms are sent, the Legislature has determined that the insurance carrier does not have to read or even acknowledge the request. The treatment request must be justified and based upon ACOEM, the ODG or the MTUS. It isn’t sufficient that the doctor states for example, that you have pain and will benefit from the specific treatment. The doctor must provide proof that it might be helpful.
The requests are then sent to the insurance carriers (Some carriers are demanding that the doctors send them directly to Utilization Review, which again is not in the law.) and the adjuster can either approve the treatment or send it to UR. The insurance carrier has, for the most part, five (5) business days after receipt of the request to make a determination. The adjusters are the ones that select and send the materials to the UR people for review. The UR company must notify the doctor of the determination or request additional information from the doctor. The request extends the period of allowed review to no more than fourteen (14)days.
The UR department allegedly calls your doctor’s office to get additional information about the requested treatment or about what information is needed. Doctors are busy and therefore are rarely available to talk to the UR doctor at that time.
You, as well as our office, are supposed to be sent the denial within forty-eight (48) hours of the determination being made. It is amazing how long it takes for letters to go from Santa Ana, for example, to San Diego these days, for we often get the letters of denial a week later.
If we disagree with the determination, we request Independent Medical Review (IMR). This is a new level of insurance company-selected people to decide if the UR was appropriate. They too, do not examine you and make the decision based upon the records that are sent to them. Our experience has been that at least 95% or more of UR determinations that we appeal are upheld by the IMR. There is no time line on the Independent Medical Review determinations and we are not allowed to know who made them or depose them.
We cannot appeal these decisions. The legislature has taken the courts out of the decision-making process regarding medical care. The courts are not allowed to be involved, unless in the very limited circumstance that the UR denial was in someway defective. In that event, the if for example the UR determination is late, we can go to court and the UR denial is then held to be invalid, but the judge then must look to the report and confirm that the doctor complied with the Guidelines. All of these things cost the insurance company money; often more than the treatment being requested! That false economy makes little sense to anyone outside of the insurance industry.
THEREFORE if your doctor writes you a prescription, or says he is going to request some treatment or test, remember that it will take at least five (5) business days for the insurance company to do ANYTHING after they get the doctor’s written request. We cannot do anything during that period as our hands are tied by the law.
We know this is frustrating for you and seems cruel. It is frustrating for us as we are constantly being bombarded with denials for no apparent reason and no real way to help you out this mess.
So please be patient with us when you are not getting medical care. Know that we are trying to keep the insurance carriers “feet to the fire” by checking all timelines to make sure they have complied with the rules.
If you are as incensed at this as we are, we strongly suggest that you call and write your state Senator and Assembly person as well as the Governor (https://govnews.ca.gov/gov39mail/mail.php). Tell them what is going in and how you are not getting care or getting care delayed and demand that they do something about it. You can also contact the Department of Industrial Relations, in particular Destie Overpeek , the Director, at firstname.lastname@example.org and complain to them as well.