Utilization Review UR - Denied
UTILIZATION REVIEW (UR) IS OUT OF CONTROL
A campaign to bring out-of-control Utilization Review (UR) to heel.
“Why does the State of California allow unacceptable treatment of Californians injured on their jobs?”
Insurers’ Utilization Review routinely delays and denies doctors’ legitimate requests for appropriate medical treatment. This is unnecessary and expensive, and has got to change. CAAA members see the evidence of out-of-control delay and denial in the 15,000 appeals to the new Independent Medical Review (IMR) program in just one month.
CAAA is working to fix California’s broken UR system, and stop insurance carriers from using it as a routine roadblock to needed care and compensation.
We seek stories that show both how delay affects injured workers, and how the delays add unnecessary costs. Reducing UR delays and denials will help workers and reduce costs. Are you aware of egregious cases by insurers engaging in a pattern of misconduct?
4/27/2015. I worked for Pan Pacific Petroleum as a truck driver. On Oct. 27, 2013, I was driving a big rig tanker truck in the City of Commerce. A bus being towed in front of me lost its rear axle. The axle knocked the tanker to the edge of the roadway, it jackknifed and...To see his story click here: UR Denied Story Donovan Dixon
3/6/2015. I worked for Quality Timber as a logger. I felled trees on most days. In July 2003, I had felled a sugar pine, which pushed over a smaller tree that was now leaning at a dangerous 45° angle. I was sawing off the danger- ous limbs when my saw got stuck in the tree. As I yanked it loose, I strained my back. I continued working, but...To see his story click here: UR Denied Story Doug Lee
2/27/2015. On Oct. 26, 2011, I injured my left knee while trying to secure a wheelchair for a passenger on my bus. When I knelt down to lock the wheelchair in, I heard a pop and felt pain. I reported the injury... To see his story click here: UR Denied Story Cleveland Waters.
12/2/2014. I fell at work and ended up 100% permanently and totally disabled. I’m confined to a wheelchair and in constant pain. An anonymous IMR doctor who never examined or treated me, overruled the doctor and cut off my medications and home health care aide. How can this be constitutional?.... To see her story click here: UR Denied Story Frances Stevens.
11/13/2014. I’m a traveling nurse. I tripped and fell in a patient’s room. The insurer delayed and denied the doctor’s treatment plan. I was terminated after my injury. My unemployment and temporary disability insurance ran out. I owe rent to the hotel where I live. I’m an insurance company hostage.... To see his story click here: UR Denied Story Althea Hart.
10/28/2014. I needed spinal surgery, but UR denied it. The insurance adjuster failed to send my medical records to the UR doctor, who therefore saw no need for my surgery. IMR upheld the UR denial. How can UR and IMR deny surgery without seeing my MRIs & medical records?... To see his story click here: UR Denied Story José Dubon.
09/02/2014. I was Catholic chaplain at Chino Youth Authority prison, serving inmates. The prison hired a former San Quentin inmate, who harassed me for being Catholic. I developed stress injuries and won medical treatment. SCIF has cut off my medicine over my doctor’s protest.... To see his story click here: UR Denied Story Fr. Vince Connor.
08/19/2014. I’m an R.N. in an Intensive Care Unit. I got a MRSA infection at work and Sedgwick denied my claim. They claimed I got MRSA from my dog! Nurses care for patients, risking our own health. We deserve protections for work injuries, so we can worry about the patient and not fear our injuries will be denied.... To see her story click here: UR Denied Story Kathryn Donahue.
08/15/2014. I supervised home supportive living services for the disabled. I fell down a flight of stairs at work and suffered a traumatic brain injury. The insurance company’s UR has denied home support services for me using the wrong guidelines. This is no luxury. I’ll die if left alone. ... To see his story and to get a glimpse of his daily life after his workplace injury click here: UR Denied Story Lee Griffith.
08/01/2014. The company-approved surgeon recommended surgery on both shoulders for the same injuries. Before IMR, one was approved. When IMR took effect, the insurer’s UR denied surgery, and IMR upheld it. I’ve lost a year fighting to overturn denials..... UR Denied Story Art Conrad - Insurance companies use Utilization Review (UR) to deny and delay needed medical care. The care is usually recommended by the company’s own chosen doctor. Without consequences or effective penalties, insurers’ UR is out of control. It has real impacts on injured workers. Here is one of their stories.
06/20/2014 - I want to die. This is no life. The insurance company has spent four years fighting to keep me from getting treatment for my stroke and the psychological trauma from the injury. They’ve ignored court orders without penalty. UR Denied Story Juan Mora - Insurance companies use Utilization Review (UR) to deny and delay needed medical care. Workers’ compensation insurers deny 1 in 5 doctors’ treatment requests, up to 3,500,000 denials per year. The care is usually recommended by the company’s own chosen network doctor. Without consequences or effective penalties, insurers’ UR is out of control. Here is one of their stories.
05/20/2014 - I had carpal tunnel surgery. The insurance company’s UR denied post-surgical hot/cold therapy. IMR said the therapy was appropriate, but denied it as no longer useful since IMR took 3 months to rule and the time when the therapy would be effective had run out. UR Denied Story Katrina Quach Workers’ Compensation was supposed to provide appropriate and timely medical treatment to help me heal and return to work as quickly as possible. I had surgery, but the workers’ compensation insurance company denied post-surgical therapy. When I appealed to IMR, they agreed the treatment was needed, but ruled that the months’ delay going through UR and IMR had rendered it ineffective any longer. The insurer delayed and denied the treatment until it was no longer helpful. They didn’t have to pay, but I paid a high price.
05/16/2014 - I was denied Physical Therapy, a contrast MRI, pain medication, surgery for my hip, and chiropractic care for my back... UR Denied Story Gregory Vlastelica Workers’ Compensation was supposed to provide compensation for lost future earnings caused by my work injuries. The system was supposed to provide appropriate and timely medical treatment to help me return to work as quickly as possible. Instead, inordinate delays precede each medical decision made by my employer’s insurance claims examiner 2,000 miles away, and their UR company.
04/25/2014 - The Care I've Been Denied: I requested epidural injections to avoid risky back disc fusion surgery. UR and IMR said I must have surgery that’s as likely to fail as to succeed.. UR Denied Story Jacinto Fonseca - Treatment is supposed to follow a “conservative” model, with the least invasive treatments tried first. The opposite is being required of me. Instead of trying epidural injections, I am being forced to have surgery that likely won’t work.
04/14/2014 - The Care I've Been Denied: A Florida ANESTHESIOLOGIST overruled a California Audiologist! I need hearing aids that work - UR Denied Story Arthur "Bud" Nowell - Insurance companies use Utilization Review (UR) to deny and delay needed medical care. The care is usually recommended by the company’s own chosen doctor. Without consequences or effective penalties, insurers’ UR is out of control. It has real impacts on injured workers. Here is one of their stories.
02/07/2014 - Round 5: Sedgwick v. Juan Jose Gonzalez SEDGWICK VS. THE PEOPLE “DENY & DELAY CARE TO DRIVE INJURED WORKERS AWAY” - X-Ray Technician’s Injury Tests Insurer, Sedgwick Fails: Defies Judge’s Order, Refuses to Provide Medical Care FOR IMMEDIATE RELEASE: Friday, February 7, 2014 Sacramento, CA – The California Applicants’ Attorneys Association (CAAA), whose members represent Californians injured on the job, today released the fifth in their “Sedgwick vs. the People” series detailing Utilization Review (UR) abuses by insurance companies. The largest workers’ compensation insurer in North America, Sedgwick Claims Services, has failed to provide needed medical treatment and disability compensation to an injured X-Ray technician, despite a judge’s order finding his injury was work-related.
02/05/2014 - California Applicants' Attorneys Association Report: Insurers Deny 1 in 5 Doctors’ Treatment Requests; Up to 3,500,000 Denied Per Year Significant UR Problems Undermine SB 863 FOR IMMEDIATE RELEASE: Wednesday, February 5, 2014
SACRAMENTO, CA - The California Applicants’ Attorneys Association (CAAA), whose members represent Californians injured on the job, today released a report estimating that insurance carriers’ Utilization Review (UR) denies one in five physicians’ requests for medical treatment - up to 3,500,000 per year. CAAA based its report on information from the Division of Workers’ Compensation (DWC), and rejected insurers’ estimates of UR denials as “incorrect and misleading.”
08/07/2013 - In case you missed it… The Fresno Bee Fresno workers' compensation case highlights statewide problems
06/20/2013 -Injured Workers’ Advocates Seek Criminal Penalties for Death After Insurer’s “Callous Indifference, Reckless Disregard of Care”Why is it not criminal when workers’ compensation insurance companies kill patients through delaying and denying medical care?
A series spotlighting the claims handling practices of insurers like Sedgwick Claims Management Services, the largest workers’ compensation claims handler in North America.
Current penalties are inconsequential to insurers, and do not deter illegitimate UR denails.
The Death of Charles Romano
This is evidenced by the Charles Romano case, in which Sedgwick denied critically needed care, thus helping cause Charles’ death.
02/05/2014 - Sedgwick vs. The People: Round 5: Sedgwick v. Juan Jose Gonzalez ““Sedgwick delayed and denied the care I need for my work injury. They treated me like a criminal, not an injured professional hurt doing his job. Despite a court order finding my injury was work-related, Sedgwick has refused to provide any medical care. How can they get away with that?” My name is Juan Jose Gonzalez. I’m 63 years old, and I live in Perris, in Riverside County. I’m married with two grown children: a daughter, 18, who is in college; and a son, 17, who is finishing high school. I went to school and studied to become a Radiologic Technologist. I loved my job, taking x-rays and other important tests for patients, and I excelled at it for 25 years. I worked at several hospitals, and they all loved my work. Until I was injured. Then, everything changed....
10/23/2013 - Sedgwick vs. The People: Round 4: Sedgwick v. Debbye Mazzucca “Deny & Delay Care to Drive Injured Workers Away” Operating Room Nurse’s Injury no Emergency to Kaiser, Insurer: Defy Judge’s Order, Refuse to Provide Urgent Medical Care Injured Workers’ Advocates to Seek Penalties, Investigation FOR IMMEDIATE RELEASE: Wednesday, October 23, 2013 SAN DIEGO, CA – The California Applicants’ Attorneys Association (CAAA), whose members represent Californians injured on the job, today held a news conference outside Kaiser Foundation Hospital with Debbye Mazzucca, a former operating room nurse who was injured while working there. They called for sanctions against Sedgwick Claims Services, Kaiser’s
09/16/2013 - Sedgwick vs. The People: “Deny, Delay and Drive Injured Workers Away” Round 3: Sedgwick v. Gabriel Padilla. The third in a series spotlighting the workers’ compensation claims handling practices of insurers like Sedgwick Claims Management Services, the largest workers’ compensation claims handler in North America. “Why does the State of California allow unacceptable treatment of Californians injured on their jobs?”
08/06/2013 - Injured Workers’ Advocates Call for Penalties, Investigation: Lyons Magnus Insurer Failed for Ten Years to Provide Medical Care, Disability Compensation Drove Fresno Woman into Homelessness, Lost Custody of Children Insurer Also Contributed to Death of Ventura Co. Man - Protest lack of effective penalties when workers’ compensation insurance companies harm patients through delaying and denying medical care
05/08/2013 - In case you missed it… Workers’ Compensation insurance carrier denies care, defies judge’s order to provide care, patient dies, WCAB orders an audit of Sedgwick to examine pattern and practice of denials of care. Article links from sources regarding the audit.