Member, UMR Diversity Committe at University of Pennsylvania Occupational Medicine Residency
I respectfully disagree with some of your points. I do not discount there that there might be some "rogue" claims adjusters who might also be incompetent, and then some who are nice and just plain incompetent, but there are some simple truths about the post-SB 899 paradigm.
First medical decision-making was taken out of the hands of the claims adjuster only as far as denial of said treatment was concerned. The latter statement was an example of good reform. Yes it added a second bureaucratic and expensive administrative layer to determine medical necessity, but the intent was also to bring "rogue" physicians in line with evidence-based treatment of work-related injury and illness, to drive out the rogue physicians who enabled excessive treatment and unnecessary disability, and to take out of the courts adjudication for medical treatment.
SBC 899 also provided the overburdened adjuster a path to decrease their workload by sending all requests to UR, the path of least resistance, and created a path that allowed them to escape accountability of their work product. The claims adjuster could shift blame for denial of treatment to the UR people, whether UR was "inside" or a third party vendor, and whether or not UR "got it right". The adjuster was no longer accountable for medical decision-making.
There may very well be carriers out there who have an internal mechanism to perform UR and that system may be automated and computer-driven, but one unmistakable truth exists:
The treatment request must offer medical necessity, or contain the elements that demonstrate how the particular request for treatment for a particular patient in a particular situation meets MTUS guidelines.
At the end of the day the doctor's medical report must be read, and I don't care how good of OCR your computer may be capable of performing for doing the work of UR and letting a computer read the request and medical report, but the sad truth is that for most of the routine requests submitted to the carrier the doctor did not submit the necessary medical report. For most routine requests for treatment the treating physician does not know where to find the MTUS or how to check to see if their request meets MTUS criteria for medical necessity. Even for treatments that have been routinely authorized in the past because the injured worker has been awarded future medical treatment for an injury from before UR was codified, there has to be medical justification for the requested treatment and many physicians fail to document medical necessity.
Keep in mind that that community of attorneys and providers are by and large involved with the treatment of somewhere around 20% of all work-related injuries, and the perceived inadequacies your community talks about at your annual conference do not represent the tip of the iceberg. The other roughly 80% of injured workers resolve their industrial accidents and return to work. Their medications are authorized, their diagnostic tests are authorized, and they get better, but not because the system worked for them or got it right, but because they did not have serious injury and their treating physicians either documented how the injured workers' symptoms and findings met MTUS criteria for medical necessity, or the treating physician was willing enough to take the time to talk to the UR physician and discuss the medical necessity, and was able to articulate the medical justification that met MTUS criteria.
Yes I agree that some carriers are better than others and that some carriers blow it with some injured workers, but the system gets it right when everyone plays by the same rules. Everyone is accountable and it is easy to try to diffuse accountability, easy to shift responsibility to another party. It is easy for the treating physician to blame the carrier for denial of treatment, but did the treating physician submit in a timely manner the necessary medical documentation that showed how the requested treatment met MTUS criteria?
What about IMR? What percentage of reviews through IMR upheld the UR decision? IMR is demonstrating that UR got it right the first time around. Sure there was a backlog of requests for IMR, and one could also be critical of the 15-20% of IMR reviews that reversed the UR decision and led to unnecessary delays in treatment. What does not get published are the percent of IMR reversals where the carrier was procedurally at fault or incorrect, or the percent of IMR reversals where UR physician just plain got it wrong. But if 80% of the time IMR is validating that UR got it right, and most of those IMR decisions were for the litigated cases where the attorney pushed for IMR (thereby contributing to the backlog in IMR), something must be working in favor of the injured employee. Evidence-based medicine is prevailing.
Unfortunately currently there is no feedback loop from IMR that allows system errors to correct themselves through good case management, so the same faulty logic that denied treatment for one injured employee is likely to produce the same result for a different injured worker.
Yes the system is imperfect but the truth of the matter is that most workers' needs are being addressed through workers' compensation. All stakeholders need to be accountable to ensure that the 20% that end up as litigated cases also have their medical needs met and that their treatment follows evidence-based medical treatment guidelines. Just because you can order more physical therapy, chiropractic treatment, or acupuncture does not necessarily mean that it is medically necessary. Same goes for that prescription for OxyContin, topical compounded Lidocaine/Cyclobenzaprine/Amitriptyline/Gabapentin cream, or Valium. **************** My reply: Thanks for your opinion Ramon. I will post it for community response.
But you only deal with UR and IMR - that was not the point of my post. Please read more carefully. The point of my post was that medical care is being unreasonably DELAYED and this drives up costs.
Also you mention SB 899 - IMR was the product of SB 863.
Finally, UR starts with the adjuster. There is no requirement that an UR company perform that service.