San Bernardino Approves $100,000 to Hire 'Claim Expediter'

Published on 12/08/2016 by WorkCompCentral, authored by Greg Jones

The San Bernardino County, California, Board of Supervisors earmarked $100,000 to hire an outside firm to ensure survivors of the Dec. 2, 2015, terrorist attack receive necessary medical treatments as quickly as possible.

Survivors of last year’s shooting at the Inland Regional Center that killed 14 and injured 22 others reported to WorkCompCentral and other media that the county is using the utilization review process to deny treatments for physical and psychological care, as well as prescriptions for drugs to treat anxiety and depression. The county says treatment is being denied because either it is not receiving documentation to substantiate the medical efficacy of the request, or the state’s workers’ compensation medical treatment guidelines do not recommend the requested procedure.

In an effort to address the concerns raised by county workers, the Board of Supervisors on Tuesday created a $100,000 “December 2nd Workers’ Comp Claim Expediter Reserve” fund. According to a statement the county released after the meeting, the fund “will pay for an outside firm to provide proactive review of workers’ compensation claims, status and outreach to help minimize treatment delays and interruptions” for victims of the attack.

The county has been talking with prospective vendors since the middle of November and could execute a contract as early as the end of the week, public information officer David Wert said in an email Wednesday.

Wert said the county’s plans for the firm to focus on only claims filed by survivors of the attack. To date, staff in the county’s risk management division have handled the terrorist attack claims along with a caseload of about 2,500 other claims, limiting the time they can dedicate to trying to contact doctors and track down medical records, he said.

Wert said the most pervasive problem the county has been dealing with in reviewing and approving treatment requests has been not receiving medical documentation to support requested treatments. These problems are isolated to employees being treated by providers who do not regularly treat patients covered by work comp, and are not familiar with the rules and regulations in California.

“If the county had been able to call a provider requesting paperwork only once a day, the firm will be able to call three or four times a day,” he said. “If the county had only been able to reach out to a patient once every two weeks, the firm will be able to reach out once or twice a week. The firm won’t have to divide its attention across 2,500 cases. It will concentrate solely on the 54 Dec. 2 cases. And they will have the expertise in California workers’ comp needed to navigate swiftly between patients, providers, adjustors and utilization review, and work with all parties to reach solutions when a particular case or request hits a roadblock.”

Christine Baker, director of the California Department of Industrial Relations, said on Wednesday that she thinks the county is taking appropriate steps to address concerns about treatment denials.

In the first couple of months following the attack, the county did a good job in approving treatment for injured workers, she said. But over time the county became overly rigid in how it interpreted the state’s utilization review and independent medical review requirements.

“It shouldn’t be that bureaucratic in a situation like this,” she said.

Baker said the county could have done more to reach out to injured workers and their physicians. She said the new firm the county is hiring will allow it to provide that personal touch that is more more appropriate for terrorism victims.

The DIR is in the process of reviewing UR decisions from San Bernardino County to determine what was denied and what was approved. She said that statewide, more than 90% of treatment requests are approved through UR or IMR. Given what the county approved in the months immediately following the attack, Baker said she wouldn’t be surprised if it approved more than 90% of requested medical services.

Baker also said the county could have approved requests for services that utilization review determined weren’t necessary. But she does understand why county officials would be reluctant to overrule the decision of a doctor.

“It’s important to keep in mind that UR/IMR is not in place to deny treatment requests but is there to ensure treatments are appropriate,” she said.

Baker said the department made available an information and assistance officer who was to hold a meeting with survivors of the terrorism attack and explain the ins and outs of the comp system. The director said none of the survivors reached out to the I&A officer asking for help with their claims.

Lolita Harper, a spokeswoman for the union representing San Bernardino deputy sheriffs and district attorney investigators, said she believes the county ultimately viewed claims filed by survivors of the terrorist attack with the same skepticism it views all other claims. She said members of the Sheriff’s Employees Benefit Association regularly report problems getting treatment for work-related injuries.

Harper said she thinks its standard practice for the county to “deny first, ask questions later and make the person appeal” when dealing with workers’ compensation claims.

“I think it is strategic,” she said. “I think they’re using the right to utilization review as a cover and not looking at things. Whether it’s malicious in strategic intent to save money or not, we can’t judge.”

She also said the decision to dedicate $100,000 to hire a firm to help expedite treatment for survivors of the terrorist attack is an appropriate short-term solution, but she hopes the county will take additional steps to ensure its employees receive appropriate care for workplace injuries.

Alan Gurvey, managing partner of applicants’ firm Rowen, Gurvey & Win, was less charitable and characterized what the county is doing as “unadulterated hogwash.”

“If the latest media propaganda move by the county had any substance to it, and was not simply a smokescreen and an attempt to manipulate the bad press that has recently come to light in this situation, then apparently every workers’ compensation defendant would require a $100,000 firm to expedite treatment requests,” he said in an email.

Gurvey’s firm is representing three of the survivors of the attack.

He said there are some good adjusters and companies that ensure injured workers get treatment they need, regardless of UR and deficient or inadequate requests for authorization. And they don’t have to pay $100,000 to hire an outside firm to review those requests, he said.

Further, just because an employer can use UR to deny a treatment request doesn’t necessarily mean it should, he said.

 “On the contrary, in order to facilitate efficient and effective treatment, the adjusters and risk managers can simply authorize what appears to be legitimate treatment request by doctors who have a license to practice medicine and we assume for the most part are trying to help people,” he said. “If the request seems outlandish, or duplicative, then that is a different story. However, is it asking too much to authorize a medication that is commonly known to be taken for a given condition?”