UR/IMR Decisions Considered “Valid” without Medical Records, or Addressing Wrong Body Part
CAAA PRESS RELEASE FOR IMMEDIATE RELEASE: Wednesday, March 25, 2015
Contact: Steve Hopcraft 916/457-5546, Steve@hopcraft.com; Twitter: @shopcraft
SACRAMENTO, CA - The California Applicants’ Attorneys Association (CAAA), whose members represent Californians injured on the job, today told the Senate Labor & Industrial Relations Committee that promised improvements in resolving medical treatment disputes from SB 863 are not materializing, as insurers fail to provide necessary medical records, and dispute five million treatment recommendations each year, mostly from their own chosen physicians. CAAA pointed out that not one insurance claims administrator has been penalized for withholding medical records, even though thousands of cases where treatment was denied are missing required medical records. CAAA also noted that employers’ workers’ compensation costs are at their lowest level in decades, and that insurers are shifting much of the actual cost of work injuries to group health, taxpayer-funded health and disability programs, and to injured workers and their families.
“Tens of thousands, if not hundreds of thousands, of injured workers have had their medical care denied by utilization review and IMR. The most recent DWC data for 2013 shows that 28% of treatment requests were denied in that year. If there are up to 20 million treatment requests annually, and a 28% denial in UR that means there are over 5 million denials of treatment requests annually,” said CAAA President Bernardo de la Torre. “Ninety-one percent of these denials that go to IMR are being upheld. When the system doesn’t work for injured workers, it can have devastating consequences and require families to go on public assistance. These workers deserve better and collectively we all have a duty to fix problems that arise.”
“Injured workers are waiting months to find out if their treatment request will be approved by Independent Medical Review (IMR) so they can get back to work, and recover from their injuries. Many injured workers have given up waiting, or received denials of care, and are going to their group health plans, union trust funds, Medicare, or Medi-Cal to get their treatment. The costs of this medical treatment are being shifted to these other plans,” said de la Torre.
“We see the cases, and we know that workers are being improperly denied. This is medical treatment usually recommended by the company’s own chosen doctor in their Managed Provider Network. This has real impacts on injured workers and real consequences to employers who are waiting to have their employees return to work,” de la Torre told the committee.
“California policy makers can no longer ignore that our system is not working well, or that employees injured doing their jobs are receiving the medical care and disability compensation they deserve in return for giving up their right to sue,” said Bernardo de la Torre.
De la Torre told the committee that even the most faulty UR and IMR decisions are considered “valid” by IMR if they meet the time schedule and are signed by a physician. “Even if a UR reviewer denies the requested treatment without reviewing the appropriate medical records, as long as that determination is signed by a physician and delivered within the time limits, it would be considered a valid UR decision. In September 2014, there were 18,756 IMR cases missing records based on Maximus data.”
“Similarly, if the UR physician cites the wrong medical guideline, or even cites the incorrect body part, there is no violation as long as that decision is signed and timely delivered,” said de la Torre. “Nor is there any violation – again assuming the decision is correctly signed and timely delivered – if the determination of the UR reviewer is just plain wrong, where all the medical experts, including the insurance carrier’s support the treatment recommendation.”
“The current process provides little or no protection for workers. It is being used against injured workers to assist with denying medical care, rather than to assist injured workers to get access to appropriate medical treatment. I think all of us can agree we rarely see an injured worker get better with no medical treatment being authorized while being off work,” said de la Torre.
CAAA noted that with limited rights of appeal and no penalties, insurers have little incentive to provide timely and effective medical treatments. “Without consequences or effective penalties for violating statutory or regulatory requirements in the UR or IMR process, a large percentage of California’s workforce is being wrongfully denied access to medical treatment for their injuries,” said de la Torre. “Why would an insurance carrier, who saves money by denying treatment, approve their own doctor’s recommended treatments when there is little or no consequence for denial?”
CAAA noted a recent national series of articles by Pro Publica and National Public Radio documenting deplorable delays and denials of medical care, inadequate permanent disability compensation, and cost shifting by workers’ compensation insurers. That series included California cases where home health care was cut off by insurers without justification.
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