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The Workers’ Compensation System Is Broke-Still!

I should probably apologize for discussing an issue that I had discussed in a previous BLOG – but I won’t.  It’s time for me to vent again.

The vast majority of the time an injured worker has to choose his/her primary treating physician form a medical Provider Network (MPN) provided by the defendant employer and/or insurer.  This is a listing of doctors by specialty.

The Workers’ Compensation System Is Broke-Still!For example, an injured worker with a back and knee injury might select an orthopedic doctor from the defendant’s MPN list and then request authorization to see and treat with the doctor. Assuming the authorization is given, there still may be a question as to whether a particular doctor (even on the MPN) will see the injured worker.  Often, these doctors, through their staff, refuse to take the case if, for example, their medical records are more than ½” thick, if they have already had a surgery, if their case is over two years old or if their case involves multiple dates of injury.  The result of such a screening process by these physicians is that it often takes much longer than it should to find and get the injured worker to an appointment with a newly-elected primary treating physician.

As much as this process is tedious, time-consuming and frustrating – it doesn’t compare to the even greater travesty of actually obtaining medical treatment after being seen and evaluated by their new primary treating physician (PTP).  In such cases, after an injured worker is seen by their PTP, it is incumbent on the PTP to request treatment via an RFA (Request for Authorization) form.  You would think that once you have chosen a physician from the employer’s/insurer’s own MPN list, you would think that the treatment request would be approved.  After all, the physician is one of their approved providers, so wouldn’t it be reasonable to expect that the recommendation of their approved provider would be approved and followed?  No such luck.

What happens next is truly amazing.  The RFA (Request for Authorization) is funneled by the employer and/or insurer to a Utilization Review (UR) physician who never examines, meets with or communicates with the injured employee in any way.  The majority of the time that doctor (based upon our experience) denies the treatment as medically necessary based upon certain medical guidelines, studies, or information.  Granted they rely on procedures enacted by the State Legislature, but it seems as if the approach lends itself to looking for a reason to deny the request from the primary (or secondary) treating physician, rather than finding a reason to support such a request.

After all, this system was set up for the benefit of the injured workers in California and yet when one of the most critical issues (treatment) facing the injured worker is sought, the State Legislature put a system in effect that allows doctors that never see, examine, or speak with the injured worker to decide whether (or not) they should get the treatment recommended by the doctor who did examine and treat the injured worker.  And, don’t forget – the requested treatment was based upon the recommendation and request for authorization by a doctor from the defendant’s list.

Based upon over thirty-five (35) years in this business, I can tell you it is harder than ever to get necessary treatment in this system, especially in comparison to private insurance. When the inquiry is whether or not to authorize treatment, it seems that the vast majority of my clients who have gone through their private medical provider (after being denied by Workers’ Compensation multiple times for a particular requested treatment) have been able to get that treatment in a fraction of the time.

You’ve got to love a system that was put into place for injured workers that creates more roadblocks than pathways to the treatment of individuals who were injured while performing services for the benefit of another person or company – right? I don’t think so.

Thank you State Legislature.

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