TREAT ME AS YOU WOULD TREAT YOURSELF
Sometimes referred to as the “Golden Rule,” one should treat others as one would like others to treat oneself. That same principle should apply to workers’ compensation treatment. Unfortunately, it doesn’t always work out that way.
With the passage of workers’ compensation reform in 2004, spearheaded by the governor, Arnold Schwarzenegger, injured workers lost their “free choice” of treating doctors. Now the law permits the defendant, which may be an insurance company, self-insured entity or a third party administrator (TPA), to have a Medical Provider Network (MPN). AN MPN is essentially a group of doctors pre-selected by the defendant who renders treatment for injured workers. In most case, the injured worker must treat within the MPN.
Fortunately, we have found that there are often a number of competent and caring doctors in MPNs and we are able to find our clients doctors who are on the MPN list. Moreover, since there are usually a number of choices for a treating doctor on any given MPN, physician changes can usually be made without penalty. We maintain an unwavering belief that proper treatment should not be a political decision, but a medical one.
Once a doctor/patient relationship is established, it is important that the injured worker discuss all of his or her symptoms with the doctor to ensure that the doctor has the entire picture. This should provide the doctor with the ability to address all of the patient’s symptoms and conditions, and then document them in reports to substantiate the need for the recommended treatment. A doctor should recommend a consultation with another specialist if the symptoms the patient is experiencing are outside the scope of the doctor’s specialty. This way you receive comprehensive medical treatment addressing all of your symptoms and complaints.
Based on an injured worker’s symptoms, the doctor will request necessary diagnostic testing (x-ray, MRI, echocardiogram, etc.) or treatment (medications, physical therapy, chiropractic manipulation, acupuncture, surgery, etc.) documented in a treating doctor report. The doctor will then forward this report to the defendant and your attorney. The defendant will submit the doctor’s reports to utilization review (UR). The UR company is theoretically a separate entity “hired” by the defendant to review the doctor’s requests and determine whether or not the request, in the UR’s opinion, is medically necessary.
We have seen many instances where the utilization review is misguided and ineffective. Often times, we find that the requests are being review by nurses and doctors who are not in the specialty of the treating physician and who are not licensed in California.
Under the current system, the defendant often denies the treatment requests of the treating doctor. If the treatment denial is timely provided, the issue may end up going to Independent Medical Review (IMR) the final step in the appeal process for medical treatment. If we, as attorneys, believe that we can prove that the defendant did not follow proper UR procedure, we will usually file for a court hearing on the issue.
It is important that your attorney receive all doctor reports, all utilization reviews and all doctor appeals before filing for a court hearing because we typically need all of the information to prevail at court.
One of the arguments against utilization review is the reviewing doctor, nurse or administrative reviewer does not have the benefit of actually examining the patient. Moreover, many times they are no furnished with all of the necessary information to make an informed decision about a person’s treatment. Clearly, there are a number of intangibles that come into play when making decision about treating an injury. Many doctors dislike the utilization review process because they feel that it is taking their clinical judgement, experience, specific knowledge and relations ship with their patients out of the equation. Again, medicine is not an exact science and there are a number of different approaches to treatment. For now, we are stuck with the utilization review system and must work within it.
If a workers’ compensation case sis denied in its entirety, or if a specific body part or condition is denied, as the injured worker’s attorney, we will ensure that the injured worker treats with a doctor who has agreed to treat on a lien basis. This means that the doctor will treat the injured worker without receiving payment from the defendant until the case is accepted, settled or the court provides a ruling. The patient is no responsible for payment to the doctor.
As you can see, it is not always east to get treatment for your workers’ compensation case. But, there are many quality doctors who really care about your well-being and do, in fact follow the “Golden Rule.” At the Law Firm of Rowen, Gurvey & Win, we have a commitment to the “Golden Rule,” and continuously work toward the goal of treating you as we would like to be treated ourselves.
CASE RESULTS PERTAINING TO TREATMENT ISSUES
A 53 year-old female aviation structure mechanic filed a workers’ compensation claim due to injury sustained affecting her bilateral upper extremities, left knee and for depression, chronic fatigue and headaches occurring as a result of continuous trauma. The self-insured employer ceased the payment of temporary disability and denied many treatment recommendations made by the primary treating doctor. The employer took the deposition of the Agreed Medical Evaluator asking the doctor whether the treatment to date had been appropriate. When it was his turn to inquire, Mr. Gurvey was able to elicit testimony from the AME indicating that treatment to date had not been adequate, that more aggressive treatment was necessary and that due to the employer’s delays in treatment, applicant continued to be temporarily disabled. The resulting level of permanent disability was at a high level than it would have been had treatment been provided without unsubstantiated objections. To avoid paying what would have been a large sum of retroactive benefits and then a potentially large permanent disability award, the employer entered into Stipulations with Request for Award at 100% total permanent disability.
A 52 year-old instructional aide suffered injury to her low back as a result of her occupational duties associated with assisting disabled children. As a result of this injury, the injured worker developed atypical urinary incontinence requiring a specialized surgical procedure to address the symptoms. The insurance company refuse to accept the liability for the urological condition. The Agreed Medical Examiner in urology provided comprehensive testimony explaining the link between the industrial injury and the need for this specialized procedure. The insurance company was unable to convince the Agreed Medical Evaluator that the work-related injury was not the cause of the urinary incontinence and was forced to authorize the treatment, ultimately improving the applicant’s quality of life.
In the case of a 50 year-old teacher for the L.A. Unified School District, the injured worker claimed injury to her head, neck and back, which resulted in a diagnosis of fibromyalgia. The fibromyalgia severely restricted this injured worker’s activities of daily living effecting her ability to reach above shoulder level and tend to grooming needs. As a result the Law Firm of Rowen, Gurvey & Win was able to obtain an award for treatment that includes grooming in a hair salon. Other treatment modalities obtained for this injured worker include holistic treatment, such as chiropractic, acupuncture, yoga, Pilates and nutritional supplements.
A 37 year-old department manager/maintenance worker suffered injury to his back, neck, upper extremities with a secondary psyche component. Back surgery was recommended, however, the injured worker’s weight was in issue and the surgery could not be performed unless a significant amount of weight was lost. The Law Firm of Rowen, Gurvey & Win, through the use of specialized medical opinions was able to establish that bariatric surgery was needed prior to back surgery. The injured worker was provided the bariatric surgery and necessary follow-up care as part of the treatment for the underlying industrial injury. The applicant has now undergone successful back surgery and his weight has remained in the normal range for his size and stature.
Making a false or fraudulent worker’s compensation claim is a felony subject to up to 5 years in prison or fines of up to $150,000.00 or double the value of the fraud, whichever is greater, or by both imprisonment and fine.