Medical treatment being denied – even under a prior WC award? Here’s why…..

Were you awarded medical care “for life” as a result of a stipulated award from your work injury?

And now, years after the settlement, your medical treatment is being denied?

Do you have an open work injury claim and the doctors tell you everything they request is being denied?

Here’s why…….

Reforms in 2004 under then-Governor Arnold Schwarzenegger took place as “emergency legislation,” to cap the medical and indemnity costs of worker’s compensation in California. The emergency? Companies, and their payroll taxes, were leaving California in droves because of the high costs of worker’s compensation insurance.  Expenses and costs were climbing and hundreds of insurance companies went bankrupt. Reforms were pushed through the legislature with little or no thought as to how it would affect people, the sole focus was on creating a business-friendly environment.

The reforms in 2004 slashed the value of worker’s compensation awards, eliminated Vocational Rehabilitation indemnity benefits, capped temporary disability (wage loss) benefits to two years, and imposed a myriad of “gate-keeper” systems.

The reforms included no longer being able to choose your own doctor, capping physical therapy and chiropractic visits, establishing networks of “approved” doctors (MPNs) and a bunch of other changes designed to put greater controls on worker’s compensation costs to the employer.  None of the improvements benefited injured workers in any way. The laws passed stated simply “This applies to all dates of injury.”  That means even if you received a Stipulated Award before these reforms were put into place, all these new requirements also apply to you. The California Supreme Court and Appeals Courts rejected challenges to these sweeping reforms, creating a patchwork of new laws, regulations, government departments and a massive overhaul of how injuries were valued.

Reforms continued, each trying to “improve” the system in some way, and inevitably creating more problems.  The result is a confusing bramble bush of regulations, statutes and case law.  In 2003, if your doctor wanted to give you an injection, for example, they would give you the injection and then bill the insurance carrier. The carrier then paid the doctor according to the medical fee schedule.  Done.

Now, the doctor has to be within the carrier’s “approved” network (an MPN).  They have to write a report to accompany the request for the injection, explaining why it is necessary and outlining all the treatments tried previously and the history of your injury.  Then they have to fill out an “RFA” (Request for authorization) detailing the procedure code, the specific treatment recommended, then wait for a response from the insurance company’s “Utilization Review” (UR) department on whether it is approved or not.

If the Utilization Review (UR) doctor looking at the request thinks that there is a question about the treatment, they can delay “to get more information.”  So the UR person calls the doctor’s office, and if the doctor is with a patient, or in surgery, or simply not able to drop everything to take a phone call, the treatment is denied based on “we attempted to contact the doctor for more information and they weren’t available.”   And that denial of treatment is VALID FOR ONE YEAR.

Think of it this way. If you were in charge of your own workload, and you were paid upwards of $350-$500 PER DECISION, you could simply rubber-stamp “denied” on everything without bothering to review it.  That would be a pretty sweet job, wouldn’t it? And the UR reviewers are not held liable for improper denials of treatment, or stopping prescriptions suddenly, causing withdrawals, because there is no physician-patient relationship (yet they are denying medical care).

There is no accountability.

Recently, NBC news aired a series of investigative reports addressing how the system of “Utilization Review” results in treatments being denied and delayed for months while injured workers languish without care or benefits.  The NBC series is linked on our website, and can be viewed here:

“Dozens of San Jose Firefighters denied treatment”  August 13, 2016

“Worker’s Comp Drags Out Medical Care to the Detriment of Workers – Doctors Say” August 22, 2016

“Injured Workers Face Stacked Deck on Denials of Medical Treatment” August 24, 2016

An earlier investigation in 2015 showed how an injury can devastate a family’s finances:

“Workplace Injuries Pushing more Americans into Poverty”

It is a safety net full of gaping holes, and people lose their jobs, their homes, their careers, and their health. I strongly urge every injured worker to watch this series to understand that the best thing your attorney can do for you — is get you out of the worker’s compensation system entirely.

Contact your legislative representative: Find your Legislative Representative