What’s Wrong with this Picture?
WORKERS’ COMPENSATION INSURANCE VS. GROUP HEALTH:
39 Times more medical care denial appeals in comp
CAAA PRESS RELEASE FOR IMMEDIATE RELEASE: Thursday, October 23, 2014
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 “What’s Wrong with this Picture?” series comparing quality health care measures in California workers’ compensation insurance to group health insurance. The fourth release compares the frequency of Independent Medical Review (IMR) decisions regarding denied medical treatment. The 800,000 workers’ compensation insurance patients appealed IMR treatment denials 60,776 times during a twelve-month period, while the vastly greater number of group health patients (16,000,000) filed just 1,558 appeals. This is one IMR decision for every 10,000 patients in group health vs. one for every 131 workers’ compensation patients. The IMR landslide of IMR appeals reflects a fundamental flaw in workers’ compensation: insurers send 3,500,000 doctors’ recommendations for care to their own Utilization Review (UR) companies each year.
“Why do Californians hurt at work have to file 39 times as many IMR appeals of denied care as group health patients?” asked CAAA President Bernardo de la Torre. “Because insurers use UR to deny their own doctors’ recommended medical treatment. Patients appeal to IMR because if the denial stands, it denies care for one year. Because of UR abuse, denying 84% of doctors' recommended treatment, IMR appeals in workers’ compensation insurance are filed 39 times more often than in group health. 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. The delays in returning to work harm both patients and their employers, who lose their productivity. 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. The contrast between medical care denials in the two systems is striking.”
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.
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