Dealing with UR in CA.. re WC..

[Mariaa]

I found this little tidbit of info while purusing a WC forum..


The way to defeat UR decisions is complex and difficult. Have your attorney or doctor demand a copy of the complete UR decision and the employers UR plan and name of CA. physician overseeing the treatment plan.

The physician that is rebutting the UR decision must use a scientific approach, with treatment plan protocols prescribed. Protocols offered by the Primary Treating Physician (PTP) need substancial medical reporting to rebut the UR decision with Evidence Based Medicine (EBM).

UR uses ACOEM Guidelines which are presumed to be correct treatment protocols....

*** then there was a mention of some flaws with the ACOEM however, this gives at least some guideline or format for one working with WC UR denials to rebutt decisions...

This would be me....

Wishing anyone else with this process going on good luck...

[Mariaa]

ACOEM Guidelines~ American College of Occupational and Environmental Medicine

For a price you can get an updated version of ACOEM Guidelines at www.workcompcentral.com

This website is full of great info that is pertinent not only to CA WC IW (Injured Worker) but to every state~

[ans]

Great information for WC people.

Reminds me that I was denied an ENT procedure by my insurance's Utilization Review headed by a proctologist.

[Mariaa]

Found out more today re spine surgery requests for authorization going thru UR process in CA.

First time goes to Spine surgeon for authorization.

If denied, surgeon that will be doing surgery can rebutt with scientific evidence (EBM), studies and so forth, treatment plan...

IF still denied ..

If turned down, appeal goes to group/panel of Spine Surgeons.

If denied here, goes to Arbitration.

Here is where the Insurance Co. stands to lose $$ if it's found that they are denying treatment as Penalties are attached and can be very significant.

** I once got to this point in my treatment w/lifetime future med benefits over an unpaid $500 pysch bill after my failed back surgery and the judge ruled in my favor to the tune of $7,000.

Arbitration is binding so decision rendered stands...

This is just a skeleton sketch ... mostly what I was told is if and when you go to Arbitration, you should have an attorney representing you as the package that is put on the table in terms of why one wants the surgery done almost has to be put in more in legal jargon than medical in terms of what the person stands to lose if the "prescribed treatment or care" isn't rendered... Still there has to be solid information (case) backing the request package for the desired treatment or surgery, procedure (whatever)..

*** I wanted to add that I remember there was a person at this forum who is a WC attorney, I'm sure he could give the "real deal" of what is entailed in this process, however, I'm going by what I've read at workcomp websites and what the Nurse Case Manager told me of the appeals process.

So if there is anyone out there that wants to clarify or correct anything, please do so~

[biffnoble]

Thanks for the info Maria!

[Mariaa]

ans~
A proctlogist .. for an ENT procedure.. wrong end?

Biffnoble,
your welcome!

[Mariaa]

Also people involved in litagation with WC, go to www.nolo.com and you can get a book that will help guide you thru the process so you know what is going on ~what to expect..