If there is one thing that leaves injured workers frustrated, it’s the procedures that frequently result in treatment denials.
Between 2005 and 2010, medical cost containment expenses almost quadrupled. That includes expenses for utilization review and bill review.
Insurers assert that without cost containment procedures, medical treatment costs would be even higher, resulting in unsustainable premium increases.
The chorus of complaints about UR is particularly loud from workers who settled cases years ago and were awarded “future medical” as part of their case resolution.
From the employee’s perspective, they bargained for medical as part of a settlement or as part of a court award. Not only may they be required to change doctors to a new physician on an employer network. Now they find that almost everything that is prescribed is either delayed or denied.
So the worker who had been represented years ago calls his former attorney, asking for help.
In some instances, the worker may find that his attorney has retired. But even where the attorney is still in practice, the worker may have trouble obtaining help.
The attorney is busy handling current cases. While some attorneys will get involved in treatment denial issues for clients whose cases were handled years ago, others simply are not staffed to take on these issues as a project unless they can be paid for doing so.
The problem here is that under current law, attorneys representing injured workers are not compensated in most situations.
An attorney who decides to help fight treatment denials may expend a substantial amount of time and effort on UR appeals. Time spent talking to the client, tracking down the medical reports and UR paperwork. Analyzing time frames to see if UR time limits were observed. Using the QME process to appeal denials. Possible court appearances.
And even if there’s a victory for the worker, the victory may be on one treatment issue.
But this may be repeated again and again with ongoing treatment issues for this worker.
And that’s only one worker.
Many applicant attorneys have represented thousands of workers over their career. So it’s not hard to see why some applicant firms limit their involvement in challenging treatment denials. There simply are not enough hours in the day for many firms.
And that’s probably fine with many insurers, who are happy that attorneys are not incentivized to fight denials on behalf of workers.
This is the problem that AB 1687 (Fong) seeks to address.
AB 1687 would require that when injured workers are given explanations as to why the insurance company modified, delayed or denied medical services, they also be given a description of available options to appeal such a decision.
Furthermore, AB 1687 would allow attorneys to be compensated a reasonable fee for their efforts on behalf of injured workers to enforce previously awarded medical treatment.
Supporters of the bill include the California Professional Firefighters and the California Labor Foundation.
The bill has already cleared the California Assembly Insurance Committee and the Assembly Appropriations Committee.
But with Governor Brown’s likely unwillingness to sign piecemeal workers’ comp changes, the bill’s future may depend on what occurs later this year with other components of workers’ comp reforms.
Here is a link the current text of AB 1687:
http://www.leginfo.ca.gov/pub/11-12/bil … sm_v98.pdf
Category: Medical treatment under WC