DePaolo's Work Comp World: Mandatory UR?
By David DePaolo
October 29, 2014
CAAA PRESS RELEASE FOR IMMEDIATE RELEASE: Friday, October 31, 2014
Contact: Steve Hopcraft 916/457-5546, Steve@hopcraft.com; Twitter: @shopcraft
“Perhaps one of the reasons that the California workers' compensation system spends so much on cost containment services is because there are no incentives not to spend so much.
“In other words, the folks that benefit the most from cost containment services are the folks that are charged with overseeing such utilization - the proverbial fox in the henhouse.
“I heard from one claims insider that some companies, including the one she worked at, use utilization review as a cost containment system, rather than a treatment control system.
“According to this lore, the philosophy is tied to quotas; claims adjusters are told that they are measured on denial volumes, the intent that a certain percentage of treatment requests essentially will just go away after a series of UR denials, and whatever is left over now goes to independent medical review.
“IMR upholds the few UR denials three quarters of the time because either the request in fact fails to meet Medical Treatment Utilization Schedule protocol, records are incomplete, or requests aren't timely.
“Again, I don't know if this is true, but this is what I'm hearing on the street. …”
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