Monday, August 27, 2012

California UR: Constitutionality Aside, On the Right Track

Catching my breath after WCI last week.  Excellent conference.  Thanks to all those that took time to meet with our team or just swing by the booth. 

While digging through all of the news I missed from last week, I wasn't at all surprised to find a lot of back and forth on California work comp reform.  Of specific interest, however, was the proposal that would allow injured workers to appeal utilization review decisions only through an independent medical review process (and limiting the judiciary's ability to overturn such decisions of the independent review only to cases of fraud or conflict of interest). 

Much of the coverage on this topic has been dominated by questions of constitutionality, legal analysis, memos of such analysis that may or may not have been sent to certain people, etc. All good questions that need to be answered.

But let's look at the practical implications.  The CA UR system is fraught with gamesmanship.  If a UR request results in a non-certification, delivered in an accurate and timely fashion, the response on the part of the injured worker (and his attorney) is often predictable: Request it again... and again... and again... hoping each time that the carrier/employer screws up on a technicality (the decision is a day late or the correspondence isn't sent to all appropriate parties), thus creating an allowance for the care in question.  Obviously, we see this with medication therapy on a daily basis.

While the proposal to subject such cases to an independent medical review that has real teeth (i.e., the ability to truly shut down payment for clearly inappropriate care) is a breath of fresh air, even PRIUM's own internal counsel tells me this doesn't pass constitutional muster. 


So let's amend the proposal to allow for slightly more expansive judicial review.  I'm not smart enough to figure out exactly what that means, but I do know that the guiding principle here is a good one: don't overburden the system and the WCAB with frequent and unnecessary review of obviously inappropriate care.

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1 comment:

  1. Agreed Michael - TX has a review process as proposed in CA, but there is review up through the courts. According to my sources, appellate review is almost never taken, so allowing for review in CA should not cause much concern. Eliminate the constitutional issue, permit appeal up the chain, and get the IMR system running.