The current state of affairs for medical treatment for injured workers is without a doubt rigged in favor of insurers who game the system to deprive workers of needed medical treatment and to push the costs of reasonable medical treatment off onto private health insurers, Medicare and MediCal. First, 80% of all workers injured at work are required to treat with doctors listed in the workers’ compensation carrier’s Medical Provider Network (“MPN”); the MPN is created and maintained by the workers compensation insurers. If a physician who is on the MPN recommends care which the insurer feels costs the insurer too much money, those physicians are weeded out by the insurer through economic profiling and taken off the MPN list. This means that doctors are reluctant to provide care which would otherwise would be reasonably medically necessary. We have had client’s say that their doctor has said “I would prescribe ‘X’ treatment, but the carrier will bump me off the MPN.”
Where the workers’ compensation doctor does recommend treatment, all such recommendations are reviewed by another doctor who never sees the patient and who generally only sees some of the medical records submitted by the workers’ compensation carrier. This automatic review is called utilization review, and is often performed by doctors who are paid by a subsidiary of the insurance company. There is no requirement that the reviewing doctor even be in the same specialty as the doctor who recommends the treatment. Not surprisingly these reviews frequently deny needed treatment.
Thus, the insurance company representing the employer has two bites of the apple in its effort to limit the worker’s right to treatment. If this were not enough, the system only has a substandard appeals process with regard to a utilization review denial. An injured worker has to submit the issue to a third doctor in a process called Independent Medical Review. This third doctor also never sees the patient. This doctor never even discloses his name to the worker. Not surprisingly, these “independent” doctors uphold the utilization review decision 86% of the time. The worker has no right to appeal the Independent Medical Reviewers decision to a judge unless the worker can prove that the doctor, whose name and history the worker is not permitted to know can prove that the IMR doctor is biased.
I often get calls from clients who are angry at the way this system works to deprive them of needed treatment. If the worker has other health insurance, they often try and get the treatment paid for by their private health care insurer. In this fashion, the workers’ compensation carrier shifts its burden to private carriers. When I explain how rigged this system is, I explain that the only way the system can be changed is by contacting their legislators to complain. I provide them with the names and contact numbers for their Assemblypersons and State Senators. I also visit assembly members and senate members to explain and complain but they are often ignorant of the particulars and need to have the whole system described so that they can begin to understand what the legislature did in its most recent revision of the law with Assembly Bill 899 passed and signed by Governor Brown in 2012.