Monday, February 10, 2014

Don't Use a Bigger Hammer

The California Applicant's Attorneys Association has issued a report keeping Utilization Review and Independent Medical Review in the spotlight.

CAAA says that the Division of Workers' Compensation and other industry group's measurements of the rates of denial and delay on medical treatment can't be trusted.

The various industry reports by the California Workers' Compensation Institute and The Rand Corporation indicate that somewhere between 65% and 70% of all treatment requests are approved without resort to UR, much less getting elevated into the system.

Somewhere around 20+% are denied, another 6+% are modified prior to approval, and the balance gets delayed to some other disposition.

The year examined affects the statistics and the actual ratios, but the above generalizations are close enough for argument.

Adding the CWCI 2012 and 2013 figures to the numbers provided by Rand would show between 2007 and 2013, of the 8,524 treatment requests submitted, 5,908 or (69.3%) were approved without modification or delay and 1,914 (22.5%) were denied.

CAAA states that the variability in the percentage of treatment requests that are approved and denied “suggests that the practices of the claims administrator have a major influence on the approval rate.”

CAAA also takes issue with mixing treatment requests from medical only claims along with indemnity claims.

The statisticians take issue with CAAA's claims of course.

Alex Swedlow, president of CWCI and a co-author of the UR report, said differentiating between medical-only and indemnity claims when examining how claims adjusters handle treatment requests would be inappropriate. It suggests there are different standards of appropriate care depending on whether an injured worker lost time or not, he said.

“The standard of care is the standard of care,” he said. “To try to make the case that you have to have time off work as a test just doesn't make any sense.”

He also says that if every carrier sent every request for treatment to UR would increase cost management expenses dramatically and it would easily be distinguished in carrier expense reporting.

CWCI's study concluded that between adjusters approving requests and utilization-review companies authorizing treatments, 94.1% of treatment requests by physicians are ultimately approved.

CAAA's experience may be different, but there are explanations for that difference.

According to CWCI, an analysis of claims from accident years 2005 to 2010 found an attorney was involved in 80.4% of permanent disability claims and 38.1% of all indemnity claims.

Ergo, the CAAA attorney's experience is already significantly influenced by the fact that these claims already are in a disputed status, and one of the big disputes is going to be medical treatment.

In other words, the CAAA experience is a microcosm of the total workers' compensation environment.

For example, according to CWCI, the average cost of an indemnity claim in Los Angeles was $64,399 if an attorney was involved and $8,193 with no attorney. In Orange County, indemnity claims involving attorneys cost an average $65,681, compared to $9,168 for claims that weren't litigated.

In Sacramento, the average cost for a litigated claim was $66,627 while the cost for a non-represented claim was $8,540.

These numbers of course don't account for severity of injury, the extent of treatment requests, the amount of defense fees, the expense of UR, and a whole host of other unanswered questions that may factor into the total expense experience of a litigated versus non-litigated case.

But CAAA attorneys get cases that aren't entirely representative of the average workers' compensation experience. Their cases already are involved in dispute, are already on a path towards more significant severity (both medical and indemnity), and probably most importantly in the distinction, another set of eyes and hands are meddling in the control of the case.

I had opined earlier that IF there was a problem with treatment requests and out of control UR that the parties need to get together and HONESTLY disclose their numbers and experiences, without the interference of emotion or agenda, to see if there really is a problem and if so what to do about it.

The posturing by constituencies at odds with each other doesn't further the discussion and only makes participants dig in deeper to protect their positions and their opinions.

For instance, how many claimants go to an attorney as a consequence of the UR/IMR process?

Or, how many treatment denials get elevated in attorney involved cases versus non-represented?

And of those, how many are driven by an MPN doctor versus cases that are outside an MPN?

I could go on and on. There are so many unanswered questions surrounding the debate regarding the efficacy and efficiency of UR and IMR that industry statements from any position, party or constituency are almost meaningless, and seem to foster distrust and posturing.

In other words, OF COURSE attorneys are going to question the numbers posited by CWCI, Rand, DWC and others - because their experience on a case-by-case basis is at the extreme end of all claims. Applicant attorneys are, rightfully, going to question and act upon that experience - it is what they know and understand.

And these cases ARE a problem - as noted above litigated claims represent a huge expense over and above non-litigated cases. But they get litigated for a reason which is not easily quantified, and thus not easily understood.

We know anecdotally why claims "lawyer up" and one of the reasons is because medical treatment may have been delayed or denied.

To say that these cases are representative of an entire system is incorrect, just as it is incorrect to say that the overall UR/IMR experience is representative of litigated claims.

We can debate all of this endlessly but to no avail.

The volume of IMR requests had alarmed me, as it had many others in California workers' compensation.

I'm not so sure now. Perhaps it was just reaching equilibrium.

Bottom line - I'm not ready to declare that the present experience with UR/IMR is any overall industry problem. There may be specific issues that need to be addressed, but not on a wholesale basis.

My grandfather lived with us when I was growing up. He was a "master mechanic" back in the days when there was respect for the trades and such designations meant something.

My favorite quote of his is, "if it doesn't fit, use a bigger hammer."

He was of course being facetious.

Let's not let his facetious maxim drive workers' compensation policy.

No comments:

Post a Comment