NeuroTalk Support Groups - Work Comp? Utilization Reviews

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Work Comp? Utilization Reviews - Anyone Being Abused?

Is anyone having these problems ?
A member is asking on the wc forum.

[Utilization Reviews - Anyone Being Abused?
Everybody:

I need your help. Is anyone being harrassed or abused by multiple filings of Utilization Reviews?

I believe this is California only.

I need people who are being harrassed or retaliated against, and in CA, they are using these URs to delay or end treatment on even the admitted / accepted cases.

Also, they are "doctor shopping" where they send you to one doctor and they don't like the report, so they then send you to more and more.

Is ANYONE else being treated like this? Because, I am contacting the media. ]

the link to the post on wc forum if this applies for you -
http://neurotalk.psychcentral.com/thread117947.html

to pass along...California has been doing this since the beginning of time. My 11 years with the SHUFFLE has been quite a story. Unfortunately, the attorneys know of the physicians to send you to that will all collborate the incorrect diagnosis and paid thousands of dollars. Which is why Master P started the foundation to help others. Nowadays, its the UR case worker or a physician brought in to deny procedures who have no education or experience in the direct field. As one physician says it is unethical practicing and to get your attorney on it. We are hooked up and collaborating with all.

This is most likely going on in every state and has gone on for years. When my husband got hurt back in the 70's here in Colorado, the Dr. he was sent to told him that he needed back surgery and what was wrong with him, when he went to the hearing his Dr. actually said he'd never seen Bill. I had went with him to see this Dr. so I knew he had. I just thought it was the wierdest thing. Since we had no paperwork to prove different we were just stuck. I guess the Dr. most likely got rid of his file also.

I am always shocked by what WC can get by with.

Ada

Quote:

Originally Posted by Jo*mar (Post 638440)

It is even more sinister than you think. Prior to 1/1/05 (generally) in CA, the treating Dr was presumbed to be most correct when a med-legal issue arose. And if it became litigated, then the judge would have to error in favor of the patient. Since then the "good book," the ACOEM Guidelines is now the presumption of correctness (that's right, a book, not a person). It is heavily based on the AMA Guidelines for Impairment 5th ed., So if it isn't in the books, forget it, you're not getting it!

UR is a seperate issue. It is now mandated that the insurer must have UR analyse the claim before authorization to treat is given or money paid. All treatment must abide by the insurer/UR's interpretation of the "good books," no exceptions. UR companies have been anywhere from a branch of the insurer (by a different name) or a situation where several UR companies, usually out of state, clamor to the insurer bidding for thier UR services. The lowest bidder (and one who denies the most claims) gets the job. An associated tier of WC in CA has to do with the fact that mostly only MPN (multi-physican network) docs can treat the patient-can't see your own doc. And guess who butters the bread of the MPN doc?

The main reason this was done was because all of the employers were complaining that WC insurance was sooo expensive. So enter the 2005 reform. It cut cost of WC health care by 50%. It also cut the ability to treat a patient by 50% too as treating docs don't get authorized to treat, much, sometimes not at all. Needless to say, it was buyers remorse and there is some desire to revert somewhat back to days when injured workers got fairly treated (NPI). And some of you wanted universal care???

Quote:

Originally Posted by Dubious (Post 639239)

Yes, why? Insurance for profit, that's why. Take out the middle man. For profit health care delivery warps the system to the point of making money by denying, and gets worse as costs rise. The single payer can and should be in direct competition with private for profit insurance companies to keep them honest. The single payer does not have to be a federal program, it can be State driven or regional non-profits. It works all around the world in different arrangements with success. WC is no different than many other patch work affairs our system has been patching up for 60 years.

This wasn't meant to be a political or health care thread.
{limited political discussion as stated in NT guidelines}

Mainly was posted asking for info if others are getting these Utilization Reviews.

Quote:

Originally Posted by Jo*mar (Post 639472)

There are a couple level of appeals with UR that are possible for the patient and treating doc as first requests for authorization are frequently denied or are cut by UR to where the proposed treatment is meaningless. One can go outside of the system at some point for unauthorized and eventual litigated treatment, but options are even more slim there for quality care. There are few happy WC patients in CA! If you are in CA, your doc must be experienced in dealing with the ACOEM Guidelines and the appeals process.

But getting back to your original question, UR is mandated before treatment is authorized. Every darn case goes thru UR whether it is with a private insurer, self-insured or thru the state compensation insurance fund (state run insurance for those who cannot find a private WC insurer, but they are not cheap!)