Alan Gurvey, an applicants’ attorney and managing partner at the law firm of Rowen, Gurvey & Win, said the recommendation to disallow modifications from IMR is not “fair.” “When a doctor makes a recommendation for treatment, he or she obviously does it because he or she believes that it’s in the best interest from a medical perspective for his or her patient...”
Originally published by WorkCompCentral authored by Tonika Reed
Advocates for injured workers said a recommendation by the California Workers’ Compensation Institute to exempt treatment modifications from independent medical review is potentially unnecessary with the falling number of treatment disputes.
Such a recommendation would also be unfair to injured workers who would be left with no avenue to challenge utilization review modifications, they said.
The California Workers’ Compensation Institute in an Oct. 29 Research Update titled “Post-Reform Medical Service Approval Rates in California Workers’ Compensation,” reported 94.1% of all treatment requests submitted between January and October of 2018 were either approved or approved with modifications.
In the report, CWCI suggests in order to cut “administration burden and costs,” the state could exempt from independent medical review “treatment modifications in which the UR physician approves the treatment but reduces the volume of services to the (Medical Treatment Utilization Schedule) -recommended level.”
CWCI reports that modifications account for 12% of IMR decisions, and cutting them would save money without undermining the goal of utilization review of ensuring injured workers receive medically appropriate care.
Bob Young, communications director for CWCI, said rather than approving two dozen visits up front, the guidelines in the Medical Treatment Utilization Schedule dictate the appropriate number of visits.
“These guidelines are based on the fact that history has shown that a certain number of visits is appropriate for that specific type of injury,” he said. “So, the modification simply ratchets it back down to the level that is recommended based on a historically proven success rate.”
Young elaborated on the recommendation saying it provides more time to evaluate success of treatment.
“Rather than approving more treatments beyond what the treatment guidelines recommend, it allows for the evaluation to see if the treatment is working or not,” says Young.
Diane Worley, director of policy implementation for the California Applicants’ Attorneys Association said CWCI should, “Be careful what they ask for.”
“What’s facing injured workers now is that if they don't appeal the decision, that denies or modifies the treatment, they’re out of luck for 12 months,” she said. “If they don't do it timely and they don't appeal it to IMR, they’re out of luck.”
Before Senate Bill 863 created the independent medical review process that took effect in 2013, an injured worker could go to the Workers’ Compensation Appeals Board and dispute issues treatment denials. The WCAB now only reviews these types of disputes under very limited circumstances.
Worley also said the suggestion to eliminate IMR eligible requests with modifications “just won’t work,” and there absolutely must be some additional type of review process. Worley asserts such a recommendation is “extremely premature”, because the current data states IMR filings have gone down at the beginning of 2019.
“In everything you have to have some kind of recourse,” she said. “So I think the friction is coming from the fact that the statute and regulations makes that decision final unless you appeal it timely.”
Alan Gurvey, an applicants’ attorney and managing partner at the law firm of Rowen, Gurvey & Win, said the recommendation to disallow modifications from IMR is not “fair.”
“When a doctor makes a recommendation for treatment, he or she obviously does it because he or she believes that it’s in the best interest from a medical perspective for his or her patient,” Gurvey said. “So, if they say that someone needs 12 hours of home care a day, if he thought or she thought that the injured worker only needed six hours, then he would have said, or she would have said, six hours. So there is a reason for the medical opinion and the request for authorization for that amount of treatment, or if it’s a certain medication, for that particular medication, or if it’s a certain modality of treatment, for that particular modality.”
Applicants’ attorney Julius Young, a partner at Boxer Gerson Attorneys at Law shared the opinion that injured workers should have access to proper, doctor-sanctioned care they need in a timely fashion. Young said there has been “sort of a disconnect” after UR and IMR were put into effect.
“The parties in comp may be looking at the same set of facts, but from very different lenses,” says Young.
Ultimately, the attorneys said they feel it’s in the best interest of the injured worker for there to be a way to dispute utilization review determinations.