Understanding Medical Treatment Guidelines for Workers' Comp

Gilbert Fisher: In 2013, the legislature in California changed the rules regarding how and when an insurance company has to authorize medical treatment in a workers' compensation case. Prior to that, the insurance companies claimed that they were spending way too much money on unnecessary treatment. So as part of that legislation, a couple of things changed dramatically. One of those was that they only have to authorize treatment that is spelled out or listed in certain guidelines. They use the MTUS is an acronym for a set of guidelines that they use. So for example, if a physician diagnoses a certain injury and describes what findings they have, you can look at these guidelines, and it'll say, "Okay, this is the recommended treatment." When a physician asks for something that's not on that list, you generally don't get it. In my opinion, I think this kind of limits the role of a doctor, because the doctor is the one who is in-person with the injured worker, looking at the problem. And any time you then limit that doctor in his/her medical opinion -- that's what they went to medical school for -- I think you're just tying their hands. But nevertheless, we have these very specific treatment guidelines that limit what the doctors can do. Secondly, even though the doctor may have correctly diagnosed the problem, in the report writing, if the doctor doesn't list specific findings, that might be a basis for the utilization review physician reviewing the treatment request to deny it. Because the utilization review treatment guidelines say, for example, that, "With this condition, there has to be finding A, finding B, finding C," and the doctor only mentioned two of the findings, so boom, it gets denied. Crazy, but that's the system we live in. So it really puts the responsibility with the treating doctor to make sure that they're also familiar with those guides, and when they find something that they believe this is the reasonable treatment for, that they write the reports in a way that are going to pass that utilization review. Another problem that we have under the current system is that doctors . . . insurance companies are required by the law to authorize or give a written reason for the denial within five business days of a treatment request. The problem is, is that the law also specifies that a treatment request, in order for it to be valid, must be done on a specific form, a DWC Form RFA with a report attached. And it has to be very specific. Completely filled out. All of this kind of stuff. So it gives the insurance company all kinds of technicalities that they can look for and deny based on those technicalities. Again, this shifts a real burden on the doctor. And a lot of times, we see that there are doctors who treat with private health insurance that doesn't require anything near this specific in the reporting, or in the discussion of the treatment requested to get the authorization. But in the work comp system, it's very specific. And the reporting burden on the doctor is pretty significant. So you have a doctor, who maybe for example, wants to prescribe some medication, and he writes it out on a prescription pad, and he faxes over the prescription pad. It's your private health insurance. And they authorize it in a minute. But in work comp, if he does the same thing, it gets denied. And why? Simply because it wasn't on the DWC Form RFA. So the current state of the law really puts, I think, an undue burden on the physician and their reporting requirements in order to get treatment authorized. Oftentimes, people turn to their attorneys to solve those problems. And the current law also very specifically states that we cannot appeal these delays and denials to a judge. As long as the insurance company acts within a time frame, the only avenue of appeal is to another independent medical review doctor, who, again, is just going to apply those same technicalities. And it makes for a frustrating system for an attorney because we're used to being able to get results for our clients, and currently getting medical treatment authorized may be the biggest obstacle an attorney faces in helping a client move forward with their case. I'm of the opinion that this really needs to change, but for the time being, that's the system we're in. And so what I recommend people is that we try to work with the doctors. If the doctors can't or don't understand the work comp system, we may need to look for a doctor who does it better. Also, we want to try and work with the doctor. We tell our clients, "Let your doctor know that if he or she makes a treatment request, we're happy to try and follow up with it. But they need to fax over to us a copy of the treatment request, so that we can chase it down." And if they made the treatment request wrong, no clock has started, the insurance company can ignore it, and nothing ever happens. And the doctor may be telling you, "Well, we requested it. We requested it," but what we recommend is that our clients get a copy of that request. The minute the doctor makes it, bring it to us, and we'll chase it down. But those are some of the obstacles that we face in the medical treatment, and why insurance companies just delay and deny things constantly. Narrator: If you, or a loved one, need help with a workers' compensation issue, call our office today.