tag:blogger.com,1999:blog-8489363879633129568.post833863171060902736..comments2023-11-13T11:54:56.769-08:00Comments on DePaolo's World: IMR, Records and The Unintended OversightAnonymoushttp://www.blogger.com/profile/02446191842560064784noreply@blogger.comBlogger4125tag:blogger.com,1999:blog-8489363879633129568.post-65535809815741523702013-08-15T10:37:58.541-07:002013-08-15T10:37:58.541-07:00I'm not sure what world Bill lives in but in t...I'm not sure what world Bill lives in but in the real world, it doesn't quite work the way it should work.<br /><br />If you can't get the records from your MD, attorney, or the adjuster, I suggest that you send a letter along with the IMR application explaining your disagrement with the UR denial. In that letter, list the records (Name of doctor, date of report/evaluation/request) that the IMR should review but that you are not able to secure. That way, the IMR reviewer will have to ask for it. If the adjuster does not send it, it will be grounds for appeal if IMR does not rule in your favor.<br /><br />Also, if the adjuster doesn't follow the law, I recommend you file written complaints. Failure to submit treatment requests to UR (with the exception of disputed body parts)is a violation of Labor Code 4610. Written complaints about UR violations can be submitted to the Medical Unit, the DWC website has the complaint form (DWC UR-1). Rouge adjusters not following the law can be reported to the Audit Unit. Again, the DWC website has the form (DWC AU-906).<br /><br />If either the Medical Unit or the Audit Unit gets enough complaints about a particular adjuster/insurance company, they may do an audit, and hopefully levy the appropriate sanctions/penalties, etc....<br /><br />If the employer is self-insured, there is a corresponding Office of the Director - Administration of Self-Insured Plans with similar complaint procedures.<br /><br />Unfortunately, rouge adjusters only learn when their files are audited and the company is penalized/sanctioned, and when their jobs are on the line.<br />Jhttps://www.blogger.com/profile/06341103736762275939noreply@blogger.comtag:blogger.com,1999:blog-8489363879633129568.post-41696573434913705452013-08-14T12:45:44.426-07:002013-08-14T12:45:44.426-07:00A couple of comments after having read you blog an...A couple of comments after having read you blog and the ‘Letter to the Editor’ – neither address the whole IMR / UR issue. But I do think it brings up some other salient points. Please bear with me.<br /><br />The first thing that struck me was that the ‘injured worker’ became (several times) an apologist for his Applicant Attorney (AA) – saying that he was ‘too busy’ and ‘didn’t get paid for that’.<br /><br />Actually, Yes – they do get paid for that. The AA’s compensation is different from the Defense Attorney’s (DA). The AA is paid on a contingency whereas the DA gets hourly compensation from the carrier. Whether it is ‘not enough’ or ‘too much’ is not the issue. It is the compensation scheme the AA agreed to – in fact eagerly sought out. The fact that the AA has to do extra work, and perhaps has a busy schedule otherwise, isn’t a factor. The AA has a professional duty to his client to represent him fully.<br /><br />Given the circumstances, it might serve the injured worker (IW) to substitute his attorney out and represent himself. I’m not sure how far he would get with that (I’m not versed in the legal side of work comp), but it seems to me it couldn’t be any worse. It is disappointing that the ‘system’ doesn’t provide an IW the outcomes they want, when they want them – but, it is a system that provides access and redress. Everyone has to work within the system. Some are better at it than others and some probably do ‘game’ the system to their advantage. But I think we could safely say the same about every other system – be it Social Security, MediCare, the IRS, or the DMV.<br /><br />Since the IW was anonymous, I don’t have the full picture. But, absent any concrete information, I would at least consider that the Letter to the Editor could be an AA’s political writings ala Ben Franklin’s ‘ Mrs. Silence Dogood’ – particularly give the ‘pass’ they gave the AA for poor performance. It sounded to me as though the AA was the ‘victim’ instead of the IW.<br /><br />Secondly, I understand it is difficult to get medical records from either the treating physicians or the adjusters. There’s no concrete rules on that and everyone tends to err on the side of safety – for themselves.<br /><br />I do have a suggestion on how the IW can achieve this – he can work on this in cooperation with his employer. The rights granted to an employer under Section 3762 of the Labor Code will be sufficient to obtain the medical documentation needed. An enlightened view by both the employer and the injured worker will serve both parties.<br /><br />I’ve used this many times in the past to obtain medical information from the insurance carrier that would help the employer understand and resolve an open work comp claim. Usually, I don’t get the information from the ‘front line’ personnel (adjusters). But a short hike up the chain of command has always gotten me the results I’m looking for.<br /><br />There is no reason both parties (including the AA) can’t have an open and honest dialogue given that everyone wants to resolve the claim, get the injured worker the benefits they are entitled to, and (most important for the employer) get the claim closed.<br /><br />Again, this is a bit ‘off message’, but I think the system isn’t quite as ‘broke’ as it might appear. Both parties – injured workers and employers – still have avenues to resolve these issues. Those avenues of recourse existed long before SB863 and SB899 and still prevail.<br /><br /><br />billhttps://www.blogger.com/profile/16030231757371541081noreply@blogger.comtag:blogger.com,1999:blog-8489363879633129568.post-20323126240568502342013-08-14T09:53:55.169-07:002013-08-14T09:53:55.169-07:00You can try, but legislating "good behavior&q...You can try, but legislating "good behavior" by the payers and providers is problematic.<br /><br />Steven Feinberg, MD Anonymoushttps://www.blogger.com/profile/05372563264859898991noreply@blogger.comtag:blogger.com,1999:blog-8489363879633129568.post-81696110176899923092013-08-14T09:15:48.577-07:002013-08-14T09:15:48.577-07:00This is the exact system the carriers and employer...This is the exact system the carriers and employers want. If it is to hard to get treatment, the injured worker will receive treatment through obamacare and not make a WC claim.JGhttps://www.blogger.com/profile/17065906167225801205noreply@blogger.com