Note: This is one in a series of blogs addressing the most common questions we receive regarding workers compensation in California. It is not meant to be legal advice nor does the information provided her apply to all situations. For information on your particular case, you should contact an attorney.
This is the number one question we get asked. We understand your confusion. You are left scratching your head wondering why the insurance company or employer (from here on out we will refer to both as the insurance company) sent you to this doctor if the same insurance company will not provide the treatment the doctor recommends for you?
You're thinking, "Heck, they sent me to this doctor (or provided me a list of doctors to choose from that the insurance company approved to treat me). Why don't they trust the physician then and give me the treatment?" Not only is this conduct difficult to understand; it is also very frustrating because you are not getting the medical care you need to get better. And really, that is all you want.
The reason for this denial of your medical care is part of a process called utilization review and independent medical review. This process was made into law by the California legislature in 2013 and as of July 1, 2013, applies to all injured workers, regardless of whether the worker was injured in 1980 or 2013. In the lingo of the workers compensation world, we refer to utilization review as 'UR' and independent medical review as 'IMR.'
Here is how the UR process works:
When your doctor recommends medical treatment for your work injury, your doctor must use a form called a Request For Authorization form (often referred to as an 'RFA'). The doctor inserts the information required and indicates his or her diagnosis as well as the treatment he or she is requesting. The doctor also encloses with the RFA any supporting information, such as medical reports on you, that supports the treatment the physician has requested for you. That request is then submitted to the insurance company for review to determine if it will authorize the recommended medical treatment.
Generally, the insurance company has 5 business days to review the RFA and supporting medical records and determine whether to authorize, deny or modify the treatment recommended. The insurance company is looking at the requested treatment and comparing it to treatment guidelines which were developed to treat your type of injury - that is, back sprain/strain injury, shoulder tendon tear injury, heart valve injury, etc. These guidelines are part of the law and are called the Medical Treatment Utilization Schedule or MTUS. If the treatment is not addressed by the MTUS, the law states that other evidence-based medical treatment guidelines should be reviewed to make the determination.
If the insurance company denies the recommended medical care, the doctor performing the UR must be competent to evaluate the specific clinical issues involved, and the treatment requested must be within the scope of practice of the doctor. In addition to other procedural requirements, the doctor is to be provided all of the necessary medical records regarding you so that the doctor performing the UR can make a fully informed decision.
The doctor performing the UR must not only complete the review within 5 business days, but also notify your doctor by either telephone or email regarding the UR doctor's decision within 24 hours of the decision. The doctor hired by the insurance company to perform UR is to provide a reason for his or her decision in simple terms and reference to the guidelines as to why the medical care is appropriate or not. The written UR decision is to be mailed to you and your doctor within 2 business days of the decision.
If the UR is not completed within 5 business days or the UR doctor fails to notify your doctor of his or her decision within 24 hours of the decision, you may be able to go to an Administrative Law Judge (ALJ) to request that the medical care requested by your doctor be provided by the insurance company. However, you and your doctor still have to show to the ALJ that the medical treatment requested meets the treatment guidelines (MTUS or other evidence based medicine guidelines) or the ALJ cannot order the insurance company to provide you the medical care requested by your doctor.
If the doctor performing the UR lacks the appropriate qualifications to do the review, or there are other procedural defects, under the current law in California your only way to deal with these mistakes is to request an Independent Medical Review (IMR). You may not go to the ALJ on these issues. Therefore, if a neurosurgeon recommends brain surgery and a podiatrist denies the treatment requested, as unfair as that is, you may not go to an ALJ for a ruling; you can only request an IMR.
In addition, if you and/or your doctor disagree with the decision of the insurance company to deny or modify the treatment your doctor recommended for you because you and/or your doctor believe the guidelines indicate the treatment should be provided, your only course of action is to request a review by IMR.
Unfortunately, the treatment guidelines are not black and white, but open to interpretation. It always seems like the insurance company's doctors hired to perform UR interpret the guidelines in a manner most beneficial to the insurance company - that is, in a manner intended to save the insurance company money by denying the medical care requested by their own handpicked doctors assigned to treat you.
All requests for an IMR must be made within 30 days of the insurance company's UR decision.
If you have a case and need assistance with obtaining your medical care, please call us at 866-324-9558. We will be more than happy to discuss your case with you.
In our next blog, we will discuss the second part of this process, the Independent Medical Review (IMR).