Monday, August 11, 2014

HOW UTILIZATION REVIEW AND INDEPENDENT MEDICAL REVIEW WORK TOGETHER TO DEPRIVE INJURED WORKERS OF CARE


The Medical Board of California is not at this time placing high priority on reform of either Utilization Review (UR) or Independent Medical Review (IMR).  

UR is required before Primary Treating Physicians (PTPs) or consultants can initiate diagnostic studies and/or institute treatment. UR physicians can deny or modify diagnostic or treatment requests by treating doctors. For instance, in one case we're studying, an orthopedic surgeon asked for authorization to do a preliminary treatment and if that treatment failed to go ahead with a fusion. The UR consultant authorized the preliminary treatment, not the fusion. Trouble is the authorized preliminary treatment failed. Since the request to do a fusion should the preliminary fail was denied, this injured worker will now go without the recommended follow-up fusion advised by the expert opinion of the evaluating orthopedic surgeon. The inherent absurdity in the program is that the UR doctor did not interview or examine the patient and reviewed only whatever records were given him by the insurance company. 


A current case that has come under our review concerns a patient who has lifetime medical care and who from time to time when symptoms recur gets physical therapy -- not this time, though! The request for physical therapy, reviewed by Doctor Unctious (his real name is kept secret by the Independent Medical Review Service run by Maximus) denied the request for physical therapy. The treating doctor won't be able to quiz Doctor Unctious because his real name is "protected" by Maximus. This kind of secret denial harkens back to the French Revolution when secret "lettres de cachet" filed by nobles enabled imprisonment of named victims without having to disclose who wrote the "lettre de cachet" in the first place. Perhaps it's better that Untious' real name isn't known. So far our review suggests that Dr. Unctious' professional conduct deserves disciplinary review by the Medical Board.

Aye, but there's the rub! Unctious does not have a California license and under California law does not need to be licensed in this state to practice UR in California. He is free to deny or modify care without a California  license to practice medicine. The official letter denying care trumpets that Unctious is licensed in Ohio and Texas, but those boards can't review Unctious' clinical conduct because those boards don't have jurisdiction in California. 

The California legislature has passed three bills requiring UR doctors to be licensed in California. All were vigorously  protested by the insurance industry. All three bills were vetoed, twice by Schwarzenegger (no surprise) and once by Brown (big surprise). The meaning of this quirk is that non-California licensed doctors do not come under the jurisdiction of the MBC whereas the  PTPs who  are left holding the bag when treatment isn't authorized remain subject to discipline by the MBC.

Texas requires doctors who do UR on Texas patients to be licensed in Texas.  The upshot is that Texas doctors may do UR in California without being licensed in this state whereas California doctors who want to do UR in Texas must first get a Texas license.

So here's how the "double whammy' works: first, UR denies treatment. Then, instead of judicial review by the WCAB, the case gets turned over to Maximus with its cadre of anonymous doctors who have in common with their UR counterparts that they also don't have to be licensed in California.


Epilogue: In the case at hand the patient is getting the P.T. he needs. He's just paying for it himself.  We regret that the Medial Board of California doesn't see enough inequity in this desultory situation to demand that UR and IMR doctors be licensed in California.

7 comments:

  1. The issue not only concerns Physician utilization managers but also 'Utilization specialist nurses"
    State MediCal and MediCal HMOS use them extensively and override attending Physicians routinely
    This has become a big industry and State is also deeply involved
    Bottom line is to spare the money spent.

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  2. Thank you, Dr. Rao -- see our next article and find out what the California Medical Association and the California Society of Physical Medicine and Rehabilitation reported about who has "authority to discipline utilization review physicians."

    RLW, Editor

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  3. This comment has been removed by a blog administrator.

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  4. شركة تنظيف الكنب بالرياض
    افضل شركة تنظيف خزانات بالدمام
    شركة تنظيف المنازل
    افضل شركة مكافحة النمل الابيض بجازان
    افضل شركة مكافحة حشرات بابها
    شركة مكافحة الحشرات بمكة
    افضل شركة تسليك مجارى بالدمام
    شركات رش مبيدات بجدة
    يبدء الفريق بتنظيف الواجهات بعناية فائقة وجيدة وبعد الانتهاء من عملية التنظيف وتفحص العميل للعمل يقوم الفريق باعطاء العميل شهادة ضمان وايضا تقدم الشركة متابعة دورية
    وهنا يا عزيزى العميل قد وصلنا لنهاية موضوعنا عن شركة تنظيف الواجهات بالدمام, وهذا بعد ان قمت بتوضيح كل شى عن الشركة ولو اردت الاستفسار عن اى شى او حل اى مشكلة تواجهك بالنسبة لتنظيف واجهات زجاج وحجر بالدمام يجب عليك التواصل مع شركة وادى الرياض على الرقم الموحد فى الدمام
    كلمات تسهل عليك البحث عن الشركة على الانترنت
    شركات مكافحة الحشرات بجازان

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