It took about a year, but that's about how long these
things usually take. When SB 863 went
into effect, many parties, including PRIUM, expressed some concern around the
IMR process and whether or not it would
stand up to the challenges that we knew would come. Claimant attorneys in the state have been busy
and we are starting to see the expected results.
In Dubon v. World Restoration, Inc., (cite) the WCAB took
back much of the authority that the legislature tried to take away. UR determinations that suffer from a
material procedural defect that undermines the integrity of the utilization
review determination no longer fall under IMR's jurisdiction. Those determinations will now rest with judges and
as the WCAB so eloquently put it "a prudent employee" that wishes
"to challenge the [...] procedural validity of a UR decision before the
WCAB ... will also file a timely request for IMR. If the employee elects not to file ... the
employee does so at his or her own peril".
What does this mean? We are going to see more requests
for both IMR and hearings, as "prudent" attorneys will want to cover
all bases, and we will see additional confusion around what constitutes a
material defect. Another case decided
last week brought this point up as well.
In Weilmann v. United Temporary Service, the WCAB held
that UR decisions must be signed by the reviewer and that they must be provided
sufficient information necessary to make the determination on medical
necessity. In this case the insurance
carrier failed to provide the AME report to the UR reviewer, now whether or not
the burden rests on the physician requesting the treatment or the insurance
carrier is a post for another day. Based
on the totality of the circumstances in this case, the UR decision was found to
be invalid and the treatment request should be granted (if the judge finds it to
be reasonable and necessary).
Lastly, and potentially most impactful, is Stevens v. State Compensation Insurance Fund,
being heard by the First District Court of Appeals, in which Ms. Stevens, who
is 100% disabled, was denied medical care.
The underlying argument is the one that we were most concerned with
from the outset of SB863 and the IMR process: the inability of the injured worker to make an appeal
following an IMR denial.
It's been a busy few weeks in California and I don't
expect it to slow down. We will be
anxiously watching to see what's next.
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