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Showing posts with label Utilization management. Show all posts
Showing posts with label Utilization management. Show all posts

Thursday, August 7, 2014

ROTTEN IN DENMARK

Today's post was shared by Julius Young and comes from www.workerscompzone.com

July 29 2014
You might have thought that news of bad behavior in California’s workers’ comp system was hitting bottom.
After all, could it get worse? Allegations of legislators taking money to help charlatans who profited off of the backs of injured workers (literally). Scads of doctors alleged to have taken kickbacks for prescribing questionable compound medicines one of which allegedly killed a baby.
It appears that law enforcement authorities are now focusing on relationships between some applicant attorney firms and medical groups.
In Southern California the Riverside County DA has executed a search warrant against a workers’ comp firm, California Injury Lawyers (CIL). Apparently this is a result of a long investigation into suspected workers’ comp fraud,  targeting operations allegedly connected to an individual named Peyman Heidary who is said to have a financial interest in as many as nine medical clinics in the Los Angeles area.
The details of the alleged bad behavior or fraud is unclear, and it must be noted that any allegations are currently just that, allegations.
But this case has the potential to involve a number of  Southern California health care providers as well as some lawyers.
Meanwhile, last year’s workers’ comp bill AB 1309 seems to be the focus of new allegations in the federal case against State Senator Leland Yee. A grand jury indictment contains allegations that Yee suggested that in...
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Saturday, July 19, 2014

California Dreamer: Recent Reform Too Good To Be True

California IMR-Source: CA DIR (7-2014)
Reading it is one thing, and believing it is another. As lawyers we all know that there are at least 2 sides to every story.

This week the California Division of Industrial Relations (CA DIR) published a report of the implementation status of recent workers' compensation reform legislation commonly referred to as SB 863 (2012 enactment).

The report concludes that it is still too early to determine whether or not the legislation produced a positive impact on the system. If delay and denial of benefits is what was intended, then from what has been heard on The Street, the legislation is a win.

Basically, the latest round of reform, crafted with very little public input and enacted in "the dead of night," was intended to curb and contain costs. The "innovative process" to limit escalating medical costs, probably the largest ticket item in the entire package, was to be limited going forward through a process termed Independent Medical Review (IMR). A theoretically system that removes the medical delivery decision from the adversary system, ie. get rid of the lawyers approach.

While it sounded great on paper, the process turned out to be a constitutionally challenged nightmare that ultimately delayed and denied benefits and added insult to injury for disabled workers. Employers and carriers started to challenge everything. No one wanted to take responsibility for medical care and the system suffered from compounding delay as everything seemed to be tossed in the IMR bucket.

California is particularly important as a model for workers' compensation.  It is a national testing ground for innovation. It is a very large and extremely complex system, where even the exceptions to the rule have multiple exceptions. Luckily the California workers' compensation bar  is well organized, educated, knowledgeable and skilled. Unfortunately, the numbers of expert workers' compensation lawyers continues to become fewer as firms backout of the system for lack of economic incentive to participate.

The CA DIR report released this week basically answers nothing about whether the system improved since the SB 863 was enacted. A few charts loaded with caveats only reflect a statistical vision of political hope for improvement that is diluted with a conclusion that it is too soon to tell if it is really working as promised.

The "promise" made by Industry to Labor in 1911 for system of remedial social legislation, ie. workers' compensation, seems broken. Recognizably the cycle after cycle in California of repeated efforts to readjust the system through major systemic efforts continue to compound failures.

It is far time that California stopped dreaming about improvements that appear too good to be true and start thinking creatively on how to craft an innovative system that meets the needs of ALL the stakeholders.

….

Jon L. Gelman of Wayne NJ is the author of NJ Workers’ Compensation Law (West-Thompson-Reuters) and co-author of the national treatise, Modern Workers’ Compensation Law (West-Thompson-Reuters). For over 4 decades the Law Offices of Jon L Gelman  1.973.696.7900  jon@gelmans.com  have been representing injured workers and their families who have suffered occupational accidents and illnesses.

Friday, July 18, 2014

TOP 10 EVENTS IN CALIFORNIA WORKERS’ COMP 1ST HALF 2014

Today's post was shared by Julius Young and comes from www.workerscompzone.com

2014 is half done. What were the most significant events/themes in California workers’ comp in the first half of 2014?
Here, in no particular order, are my top picks:

1. CONTROVERSY OVER UTILIZATION REVIEW AND INDEPENDENT MEDICAL REVIEW CONTINUES

Utilization review and independent medical review continued to generate controversy during the first half of 2014. California injured workers, doctors, and applicant attorneys complained that it was increasingly hard to get consistent treatment for work injuries, as many adjusters used utilization review to deny treatments. Prominent attorney advocates called for reform of utilization review statutes and regulations.

However, there were disputes about the raw numbers. A January 2014 study by CWCI (the California Workers’ Comp Institute) (http://cwci.org/research.html) claimed that only about 4.7% of treatment requests are ultimately denied or modified.

According to the CWCI around 75% of treatment requests were approved without being sent to UR (“elevated review”). These numbers were in line with a 2011 study done by RAND. In response, a January 2014 analysis )of 2013 sample UR audit data prepared by CAAA consultant Mark Gerlach documented that some insurers were denying as much as two of every three treatment requests. Reviewing audit data, Gerlach noted that there was a wide range in approval rates of different claims administrators.

Overall,...


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Saturday, January 11, 2014

DWC's IMR Meetings Premature

The noise over the volume of Independent Medical Review requests and Maximus' inability to cope with that volume is at top level and the California Workers' Compensation Institute's latest research paper is certainly going to add to the fury.

The Division of Workers' Compensation has scheduled round table meetings with interested groups for Monday and Tuesday. CWCI's release couldn't be more timely.

CWCI says that basically IMR (and underlying Utilization Review) are working as intended.

The say that only 5.9% of requested medical procedures are delayed, denied or modified through utilization review, and that three out of every four medical treatment requests are approved by claims adjusters without the need for additional oversight.

Moreover, CWCI found 76.6% of the 919,370 treatment requests it evaluated that were sent out for physician review were approved, 6.6% were modified and 16.9% were denied.

One-in-four treatment requests being sent for physician review and one-in-four of those physician-reviewed requests denying or modifying the recommendation means that 94.1% of treatments are approved and 5.9% are denied.

CWCI also reviewed 1,141 independent medical-review decisions that had been issued as of Jan. 2 and found 78.9% of denials are upheld by the administrative review and 21.1% are overturned.

Of the 919,370 medical treatment requests reviewed by CWCi researchers, "pharmacy" garnered fully 43% of all events - this is an astounding number and debunks quite a...
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Saturday, December 14, 2013

IMR: DWC Get Out of the Way

Today's post was shared by WorkCompCentral and comes from daviddepaolo.blogspot.com

What is the purpose of California's Independent Medical Review?

I have to ask myself this question in light of the most recent proposed changes to Utilization Review/IMR rules published by the Division of Workers' Compensation (a whopping 75 pages long, albeit inclusive of all changes since origin).

What causes me to pause is that the new amendments would allow a medical reviewer to, “issue a determination as to whether the disputed medical treatment is medically necessary based on both a summary of medical records listed in the utilization review determination,” and additional documents submitted by the employee or requesting physician.

In addition, the latest amendments reverse the order in which documentation is mandated - prior versions of the regulations said the claims administrator shall provide the documents. This version provides that the IMR entity shall RECEIVE documents. I don't know why this was done, but to me it seems bass-ackwards.

Finally the pending amendments would allow the DWC administrative director to determine that an IMR decision is not valid because the case should not have been deemed eligible for review in the first place. The rules would say the director can vacate an IMR determination at any point unless an appeal has been filed with the Workers' Compensation Appeals Board or the time to file an appeal has expired.

IMR was statutorily authorized by Labor Code section 4610.5, added via SB 863.

LC 4610.5 provides a list of the documents...
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