Utilization Review in Workers Comp by Non-licensed Doctors

Utilization Review by doctors without California licenses continues to bedevil California physicians and rob injured workers of indicated care.

Here's what happened recently to an orthopedist in San Jose and his patient. The orthopedist found that his patient had evidence of an osteoid osteoma or similar lesion. The orthopedist stated in his report that "there is clear-cut pathology ... with a dye leak from the mid-carpal joint to the radiocarpal joint through the scapholunate and triquetro-hamate intervals."

The treating orthopedic surgeon sought authorization for left wrist arthroscopy and excision of the lesion in the distal radius. The insurance company handed over this request for authorization to a doctor without a California license. The proposed medical treatment was then deemed "not certified" and denied.

In a formal affirmation of the denied authorization, the Utilization Review doctor asserted he'd had "peer-to-peer discussion" with the treating orthopedist. This description stretches the truth. The out-of-state doctor may call himself a peer but, truth is, the California-licensed orthopedist completed a 12 hour course in pain management as required by the Medical Board of California whereas the out-of-state doctors isn't required to meet this requirement. He is exempt. But he is useful to insurance companies that want surgery delayed or denied.

When the treating orthopedist reviewed the non-California licensed doctor's negative report, he found that the non-California licensed doctor had not reviewed the X-rays. Nonetheless, the non-California licensed doctor turned a patient away from needed and indicated arthroscopy.

The treating orthopedist, duly licensed to practice medicine in California, stated in his own rebuttal, that "it is reasonable to proceed with a surgical arthroscopy " and, "prior to a final decision regarding surgery, to proceed with a limited bone scan to evaluate the bone lesion seen on CT."

This effort was initially thwarted by the Schwarzenegger administration's application of law. A non-California licensed doctor was allowed to overrule a licensed California doctor. In this case, harm was done because necessary and needed surgical intervention was delayed and initially denied. The treating doctor had to take on an insurance company and their non-California licensed doctor. Readers will be glad to know the arthroscopy was eventually done thanks to the fighting spirit of the treating doctor. The lesion was excised and the patient is a happy camper (no thanks to the Schwarzenegger administration and its distortion of Utilization Review).

The fault lies with the Office of Administrative Law and the Schwarzenegger administration. Both have cow-towed to insurance company interests. Both have made it possible for carpetbaggers to practice medicine in California. AB 933 (Fong) would put a stop to this nonsense. AB 933 (Fong) will require that doctors who do Utilization Review for injured workers in California be licensed in California.

The latest amendments to AB 933 (Fong) include provisions to govern how Medical Provider Networks function so that the perception that MPNs drop physicians from their rosters on an arbitrary basis can be corrected.

AB 933 (Fong) is up for hearing in Senate Appropriations on Monday, August 2nd. E-mail your concerns to committee staff, bob.franzoia@sen.ca.gov, and copy to assemblymember.fong@asm.ca.gov