IN-STATE V. OUT-OF-STATE UTILIZATION AND INDEPENDENT MEDICAL REVIEW

OPEN LETTER TO ASSEMBLYMAN RICHARD PAN, MD
Chair, Assembly Committee on Health
15 January 2013

Dear Doctor Pan,

I am asking you to carry or sponsor legislation to repeal language within SB 863 that allows doctors who are not even licensed to practice medicine in California but who are allowed to do utilization reivew here to have their names kept secret. This secrecy is a way of making it even more difficult than it already is for injured workers to appeal wrongful denials of care.

SB 863 became effective as of 1 January 2013. An injured worker who is victimized by a stupid and harmful denial of care will not be allowed to file an appeal unless fraud, bias, or conflict of interest is suspected. The trouble is that since the legislation allows these doctors' names to be concealed, it will be truly challenging to file an appeal based on fraud, bias, or conflict of interest. The real problem, actually, is that the WCAB is no longer empowered to reverse wrongful decisions that harm injured workers. As a doctor, I don't think you would favor denials of treatment you prescribed to be done by doctors whose reports and names are not fully known to you. Am I wrong about that?

As matters stand now traditional Utilization Review does not need to be done by doctors who are licensed in California and are therefore responsible to our state medical board. Insurance companies can scour the country in search of malleable and cooperative doctors who will deny care on a myriad of technicalities no matter how harmful these denials of care are to injured workers. This injustice cannot happen in Texas. In Texas if California doctors want to do utilization review the doctors must be licensed in Texas. Since each state's medical board's jurisdiction is limited to its own state, many of the  doctors doing utilization review or independent medical review in California may not come under the medical board jurisdiction of any state at all for their UR or IMR work in California.  This largesse is estimated to cost California $10,000,000 annually --  an unwise choice for a state with financial woes.

Richard Fantozzi, MD,  as president of the California Medical Board in 2008, told Governor Schwarzenegger that this step "would provide increased consumer protection over decisions that do not have patients as its primary concern." At the request of the insurance companies and the Chambers of Commerce, Gov. Schwarzenegger vetoed a bill that would have corrected this abuse. Under similar pressure, Gov. Brown also vetoed legislation that would have corrected this abuse. SB 863 now makes the denial process even more vicious since the IMR doctors' names will be protected.

That's why treating physicians and their patients need you and like minded colleagues to amend SB 863 so that injured workers get fair and equitable access to treatment. What say you?

Yours truly,

Robert L. Weinmann, MD,  Editor, www.politicsofhealthcare.com

References

WorkCompcentral, 1/12/13, Comment by this writer to News Article by John P. Kamin, Legal Editor

Work Compcentral, 1/10/13, "Out-of-state v. In-state Utilization Review," Robert Weinmann, MD

TotalCapitol.com, 3/11/12, "Utilization Review as a gift to insurance companies," Bob Weinmann

Assembly Bill 584 (Fong): stops the unlicensed practice of medicine

AB 584 (Fong) is an important step in the right direction and should be supported by physicians and by all of their organizations.

As matters stand now, injured workers may legally be denied access to diagnostic tests and treatment needed to diagnose and treat their injuries even when properly prescribed by duly licensed California doctors.

The legal maneuver used to deprive injured workers of indicated and necessary treatment is based on the Schwarzenegger adaptation of utilization review. Utilization review is required by California law -- it's supposed to be a way to supervise treating doctors and prevent overutilization of services. It is primarily a cost control measure.

In 2005 the Schwarzenegger administration persuaded the Office of Administrative Law to agree that utlization review wasn't medical practice and, therefore, did not require California state licensure. Never mind that the Medical Board of California stated that utilization review was certainly an aspect of medical practice. Once the leash was relaxed on the insurance companies, several insurance groups and their management cohorts hired doctors for utilization review who were not licensed in California and who would not, therefore, be required to take the special 12-hour course in pain management that is required of California licensed doctors.

The upshot is that under current law utilization review doctors who are not licensed in California are allowed to overrule California doctors who are licensed in California.

These non-California licensed doctors are not responsible for their mistakes before the Medical Board of California because they're not licensed in California. They're also not responsible to the medical boards of the states in which they are licensed because those states don't have jurisdiction in California.

The non-California licensed doctors are also not obliged to pay licensure fees to the Medical Board -- they get a free ride while their licensed colleagues are obliged not only to pay for licensure but also for a mandatory pain management course.

Injured workers in California are subjected to delays and denials of treatment by doctors who should not have been allowed to practice in California in the first place.

The Schwarzenegger workers comp policy has caused innumerable delays and denials of treatment and has caused countless workers to lose out on the treatment that could have returned them to work.

Physicians in California should reach out in support of AB 584 (Fong). The bill has already passed the Assembly. It should clear the Senate. Then Gov. Brown should sign it into law.