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One of the emerging successes of the Division of Workers’ Compensation under Jerry Brown is that the Medical Unit appears to be whittling down the backlog of requests for QME panels for both represented and unrepresented workers.

DWC Administrative Director was recently quoted in an article by Greg Jones of workcompcentral.com on the topic of medical panels. According to Jones, “When she started as administrative director in July, the unit was almost 10 months behind in issuing panels. Moran said Monday that the unit is now working on requests dating back to December 27, 2011.” This progress was also hailed by Jim Fisher of the DWC Medical Unit in recent remarks at the Los Angeles and Oakland DWC conference.

But will this progress be crushed by a potential tsunami that lurks on the horizon?

Huh, you say. What?

The tsunami could be triggered if the WCAB clarifies the law on whether represented workers must appeal utilization review treatment denials by going through the QME process.

Although some of my readers may have strong opinions about what procedures the law does or does not require, the fact is that there many judges and attorneys who believe that the QME process is permitted but not mandatory where a represented worker seeks to appeal a UR non-certification of a treatment request.

Since the 2003/2004 reforms, many a treatment dispute has been resolved by settlement or trial where the attorney challenged the utilization review physician denial by filing a declaration of readiness, relying on a report by the treating physician.

In some of those instances there were issues regarding whether the defendant had met statutory requirements for a valid utilization review:
-was the UR physician competent to evaluate the treatment request
(see Labor Code 4610(e))?
-was the treatment request within the scope of the physician’s practice (see labor Code 4610(e)?
-was the UR review timely (see 4610(g)(1))?
-would delay be detrimental to the employee’s health, triggering stricter timeframes (see 4610(g)(2)?

TO BE CONTINUED IN PART 2………

Julius Young
www.workerscompzone.com
www.boxerlaw.com

Category: Medical treatment under WC

Julius Young

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