What’s Wrong with this Picture?

Workers’ Compensation Insurance vs. Group Health:
Group Health Patients Win 61% of Medical Care Denial Appeals; Workers’ Compensation Patients Lose 84% of Appeals

What's Wrong with this Picture? Infographic #3

Insurers have Stacked the Deck Against Californians Hurt at Work

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 continued its series comparing quality health care measures in workers’ compensation insurance to group health insurance. The third release compares the frequency of Independent Medical Review (IMR) upholding Utilization Review (UR) denials of doctors’ recommended medical care. Workers’ compensation IMR denied 84% of patients’ appeals of denied medical treatments in one year, while group health IMR reviewers approved 61% of patients’ appeals. Group health patients win appeals of denied medical care nearly four times as often as California’s injured workers.

“Why do Californians hurt at work lose nearly four times as many appeals of denied medical care as group health patients?” asked CAAA President Bernardo de la Torre. “California firefighters, peace officers, nurses and others hurt doing their jobs are frequently denied recommended medical treatment. They appeal, and are almost always denied. But if you compare that to group health, there are so many fewer denials, and the patients win nearly two-thirds of their appeals. There are no meaningful penalties in workers’ compensation insurance, so insurers are free to deny legitimate treatment without consequence. The deck is stacked against patients in workers’ compensation.”
“Hundreds of millions of dollars are spent denying doctors’ recommended medical treatment. Insurers’ Utilization Review (UR) denies over 3.5 million treatment requests annually. Then, Independent Medical Reviewers rubber-stamp those denials. The disparity between IMR group health and workers’ compensation clearly shows the system is stacked against patients in workers’ compensation insurance,” said de la Torre.

UR has almost quadrupled since 2005, and is one of the fastest-growing costs in California workers’ compensation insurance, costing several hundred million dollars per year. CAAA is urging a thorough overhaul of the UR process. “Overused and costly UR continues to penalize Californians hurt at work,” de la Torre said. “Californians hurt at work are trapped in a system where delay and denial is the norm,” said de la Torre. “The contrast between medical care denials in the two systems is astounding.”

CAAA based its report on information from the Division of Workers’ Compensation (DWC) and the Department of Managed Health Care, comparing twelve months’ experience in each of the two systems.

The comparisons are posted on www.caaa.org.

For more information, visit: www.caaa.org

Click here to Download Documentthe press release.

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