WHERE HAS TREATMENT GONE?
Frustration is abound in the Workers’ Compensation system!
Now, even after you select a physician from the insurance carrier’s list of physicians (politely known as their “Medical Provider Network”) and that physician recommends treatment which the physician feels is necessary, the insurance company typically forwards that request to the now-infamous “Utilization Review” physician for his/her decision as to the necessity of said treatment.
Unfortunately, the Utilization Review physician does not even see or examine the injured workeragain does not see or examine the injured worker! By rule, the identity of that physician is anonymous to all the involved parties, so the attorneys don’t even have the right to take the physician’s deposition and question him or her as to their findings or opinion.
Then, if you wish to appeal the decision of the unknown and unquestioned IMR physician, the basis for appeal is so limited as to be virtually non-existent. For example, you can appeal the decision if you can prove prejudice, bias or conflict of interest. How do you prove any of those basis for appeal when the identity of the doctor is unknown? Absent a statement in the IMR decision which is on it’s face evidence of bias, prejudice or conflict of interest (which won’t happen) you are left with the final two (2) basis for appeal. Without boring you further they, likewise, are so limiting as to be the equivalent of essentially no appeal rights.
The State of California apparently believes that although it is illegal to provide medical treatment to someone without seeing them, it is apparently legal to deny medical treatment to someone without ever seeing them, based upon that doctor’s review of records only – which may or may not contain all the information the IMR doctor would be able to obtain if he or she were permitted to examine the injured worker.
Can you imagine having a doctor who has treated you for months (sometimes years) having his/her medical care requests denied by a physician who has never seen you or examined you, whose opinions are, except in the rarest of circumstances, binding and not subject to further questioning or inquiry?
Again, where has all the treatment gone?