In workers compensation, workers have historically had the statutory right to all medical care reasonably necessary to cure or relieve from the effects of an injury. This unfettered right to reasonable medical treatment has been greatly restricted by legislative reforms in 2005 (Senate Bill 899) and 2012 (Senate Bill 863).
The first reform, Senate Bill 899 put into place a system of medical provider networks where the insurer hand picks “company doctors”. The injured worker is required to go to one of these doctors to get treatment. That bill also instituted a system of Utilization Review, so that when one of the doctors who has been hand picked by the insurer recommends any medical treatment, a second doctor also selected by the insurance company reviews the prescription for treatment and approves or disapproves it. This allows insurance companies a second bite of the apple meaning a second chance to deny treatment by a doctor selected by the insurance company. That doctor would never meet with the patient and would only review the records selected by the insurance company. This reform eliminated the system where judges could decide if treatment was reasonable in the event an insurance company denied the treatment. Although, it did allow for doctors agreed to by both sides (what are called Agreed Medical Evaluators) or doctors selected by the state (what are called Qualified Medical Evaluators) to review denials of care and determine if the treatment was reasonably medically necessary.
Then in 2012 further “reforms” which benefit insurance companies were enacted. That bill put into place a system of so called Independent Medical Review (IMR). Under the IMR system, an additional doctor would review the decision of the Utilization Review doctor and the basis for denial and decide whether the treatment was appropriate. That doctor also never meets with the patient or examines the patient and only reviews what the adjuster submitted to the utilization review doctor.The worker or his attorney is not even allowed to know the name of the IMR doctor. Not surprisingly, the statistics compiled after this second system was put in place show that the IMR doctors upheld the Utilization Review doctor’s denial 91% of the time. The only way the worker can overturn that decision in court is by showing bias or fraud on the part of the IMR doctor (this is impossible to prove because you don’t even know the doctor’s name).
Opioids are very much in the news these days from the addiction epidemic to the death of prominent stars like Prince. What doctors use to treat pain are a variety of tools, the selection of which in a group health context are based on the experience, training and education of the individual doctor. These tools consist of treatment such as physical therapy, chiropractic treatment, acupuncture, as well as nonsteroidal anti-inflammatory and opiate medications. Unfortunately, most of these treatments are routinely denied by Utilization Review doctors. Often treating physicians are shocked and frustrated by the constant denial of normal methods of treating pain whether it is post surgical or chronic pain. One of the results of these reforms is that often the only methods not denied are opiate medications. In turn, responsible doctors who treat patients with pain following injury use opioids to treat the pain when everything else is prohibited.
BusinessWire reports that, “the use of opioids in California workers’ compensation has declined in recent years, along with the associated payments, yet these potentially addictive painkillers remain the number one therapeutic drug group used in the system according to a new California Workers’ Compensation Institute (CWCI) study” (http://bit.ly/1WWlP1c). This data is indicative of the failure of past W.C. reforms which have made it harder for injured workers to recover from their industrial injuries. If the WC carriers stopped denying so much restorative and diagnostic care, then injured workers’ might actually get better or see more improvement. And, if that were the case, there would be less need for opiates and the problem with same would not be as large as it is. The carriers should stop blaming injured workers and the medical providers and take a closer look at the consequences of their own conduct.
By: James G. Butler