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It’s a Crazy System

Currently, in most California Workers’ Compensation cases you are required to treat with a physician within the insurance carriers Medical Provider Network (MPN) – their list of doctor? Then, when a physician, within the defendant insurance carriers MPN, seeks authorization for a specific type of treatment, said request typically is then sent by the insurance carrier to Utilization Review (UR) for approval and review, resulting in partial approval or even total denial.

The difficulty with UR is that they contract with the individual insurance carrier that is asking for this medical review and, in addition, the UR physician who decides whether or not the treating doctor’s request for treatment are granted, does not see or examine the applicant.

Once the denial or partial denial is received, the next level of review is the Independent Medical Review (IMR). This is a physician who again does not see or examine the individual, who is provided by an independent agency through a contact with the State of California. According to a reliable source, and based on current statistics, the physician performing the IMR sides (agrees) 80% of the time with the UR physician who contracts with the insurance carrier.

If it’s not a crazy system, I don’t know what is. There are two levels of review for treatment requests, by physicians who never speak with or examine the injured worker who then can, and, often do, deny the injured worker medical care recommended by a treating physician – who, again, was within their medical network.

To top things off, the IMR decision can be appealed, but the current criteria for appeal are so limiting that there is, in most cases, essentially no means to appeal the decision and have the matter heard by a judge. Not to mention the fact that the injured worker’s attorney has no current right to take the deposition of the IMR physician to question the basis for his/her opinions and/or to try to convince him or her that their opinion is not correct.

This system was intended, in large part, to provide medical treatment that would cure or relieve the effect of an employee’s injuries – but, it certainly doesn’t sound like it, does it! A complex system has only managed to get more complex and more problematic.

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