UTILIZATION REVIEW AND THE CALIFORNIA PROFESSIONAL FIREFIGHTERS

On 14 February 2012 Assemblyman Paul Fong introduced AB 1687 at the request of California Professional Firefighters. The purpose of the bill is to improve how Utilization Review (UR) is applied in California's workers comp system. Currently the UR process may be used by insurance companies to delay and deny care to injured workers. Doctors retained by the insurance companies and their affiliated UR companies are not required to have California licenses. If these doctors make mistakes, wrongfully deny care, and cause harm to injured workers, they do not answer to the Medical Board of California as would treating doctors, known as PTPs or Primary Treating Physicians, who are licensed in the states in which they practice.

Non-California licensed doctors do not answer to their own state boards because out-of-state medical boards do not have jurisdiction in California. Insurance companies derive financial benefits from this method because they don't pay for care that has been disallowed by the unlicensed doctors even if the care was actually prescribed by licensed doctors. This form of retroactive denial of care has previously been discussed in these pages.

Efforts to pass legislation to correct this situation by requiring UR doctors to be licensed in California have been successfully opposed by insurance companies who easily convinced Gov. Schwarzenegger to deny access to care to injured workers but who also persuaded Gov. Brown to veto AB 584 in 2011 (AB 584, also by Paul Fong, would have required UR doctors who do California cases to be licensed in California).

Fong's current bill, AB 1687, says that

"communications or responses regarding decisions to modify, delay, or deny medical treatment services requested by physicians also shall include a clear and concise explanation of the available options for objecting to the modification, delay, or denial of those medical services."

It does not say that the UR doctors who make these decisions should be licensed in California. This omission is the Achilles' heel of AB 1687.

Without this provision the UR doctor and the medical director employed by the UR company, in turn retained by the insurance company, may assert that whatever reason is presented for delay or denial of care is "clear and concise." The change in language requested by the California Professional Firefighter is a step in the right direction and deserves support even though it isn't strong enough to challenge wrongful and harmful decisions by non-California licensed doctors who can simply state that their reasons for delaying or denying care are "clear and concise."

Rather than get involved in debates about whether or not language was "clear and concise," beleagured doctors who prefer to practice medicine will leave the system. The large clinics that see patients at breakneck speed will inherit the patients. Injured workers will once again inherit the wind.