SECRET NEGOTIATIONS EXPOSED: MANAGEMENT COLLUDES WITH LABOR

by Robert L. Weinmann, MD

In an effort to put more money into Permanent Disability (PD), certain key lobbyists from powerful interests in organized labor have colluded with Big Business to draft secret proposals that will inevitably harm injured workers and their doctors while providing minimal palliation to the lingering PD crisis brought about by Gov. Schwarzenegger and his administration. The background for the current maneuvering is SB 899, the refusal of the current administration to reform utilization review, the refusal to let injured workers pre-designate their own Primary Treating Physician (PTP), and the recent Almaraz-Guzman decision that Big Biz and the insurance industry abhor.

An amendment to be heard in the Assembly this week may be offered to SB 186 (DeSaulnier). Here's the scoop:

Under current law the PTP may prescribe diagnostic testing and treatment. But the PTP's decision may be delayed or denied by Utilization Review (UR). If the PTP and UR disagree, one method of resolution is to get a Qualified Medical Evaluation (QME). The QME reviews the reports filed by both the PTP and UR, interviews and examines the injured worker, and makes a definitive conclusion. The amendment about to be offered would delete the QME step and would substitute a paper-review-process known as an Independent Medical Review (IMR). The IMR process does not include interview and examination of the patient. It is a less expensive process that is also more likely to result in denial of care. The money saved would ostensibly go into the PD pot. The IMR and the UR approaches are similar in that neither requires re-interview or further examination of the injured worker. Both are paper decisions. This process is favored by the private insurance industry because it reduces costs and adds to corporate profit.

The IMR process is laden with potential mischief because it takes away the injured worker's best chance to be heard and examined again. The IMR process carries with it a large dose of potential medical mischief not only for wrongful denials of injured workers but also for liability to the PTP for an accusation of malpractice for treatment recognized as needed but not provided.

The amendment also envisions lien changes. Under current law many doctors who know that treatment is indicated and will eventually be recognized as such simply provide it in timely fashion even though it has been denied by UR -- they seek reimbursement afterwards by lien. The amendment or amendments to be offered to SB 186 (DeSaulnier) would discourage liens and further reduce access to care for injured workers.

The recommendation of The Weinmann Report is to ask your state senator or assembly representative to oppose these proposed amendments. If you are not sure who that is, try http://www.leginfo.ca.gov/yourleg/html. You may want to copy Sen. DeSaulnier (senator.desaulnier@sen.ca.gov), the Senate Labor and Industrial Relations Committee (gideon.baum@sen.ca.gov) and The Assembly Insurance Committee (markrakich@asm.ca.gov).
Faxed copy has the advantage of being signed.