Utilization Review: Hypocrisy in Velvet Gloves

Wednesday, March 26, 2014 | 2

Obvious bad faith in workers' comp re injured workers is revealed in this story about how an insurance company denied care without making any attempt to reach the primary treating physician before issuing a decision. We are not stating the patient's name for obvious reasons. We're not stating the name of the insurance company because they all do it, so there's no sense in just one taking today's hit. We're not naming the doctor because we don't have permission. But what we do have is full documentation, which can eventually be made available. In the meantime, we'll make this story and details known where it may do some good.

Setting the scene

A  request was made to prescribe hydrocodone, capsaicin, and lidoderm. The insurance company's utilization review doctor reviewed the request and called the prescribing doctor's office at 10 p.m. The UR doctor reported later than no one was there to take the call, so he left a message. The prescribing doctor asked later whether or not it was reasonable to make such a call at 10 p.m. and reported also that no message was left. In other words, the UR doc called at an unreasonable time and then faked or lied about having left a message. 

The bogus appeal denial

When the PTP became aware of the denial, an appeal was filed. The response by the UR doctor came by telephone at 4:34 a.m. This second UR doctor said that a message was left because there was no one present to take the 4:34 a.m. phone call. Once again no message was left; not that calling PTPs at 4 a.m. should be considered acceptable practice. 

Utilization review's standard of practice is woefully short on both ethics and knowledgeable practice. In the case at hand, the PTP is knowledgeable re the standards of care re managing pain. The UR doctor's response appeared knowledgeable from textbook information but was seriously flawed in its application to the now denied patient. The denial was rammed through without a good-faith effort to confer with the PTP. Two UR doctors made phone calls at unreasonable hours and then claimed to have left messages. The PTP doubts the latter assertion. So does this author. Our experience is that UR is repeatedly conducted in bad faith and to the best of our belief with the knowledge and connivance of the insurance companies.

The recent passage of Senate Bill 863 allows independent medical review to support bad or bogus UR decisions and then deny the patient not only treatment but also his day in court. Both UR and IMR are sties in the eye of medicine and need strict utilization control themselves. Better yet, both should be repealed.

Dr. Robert Weinmann is a neurologist in San Jose, Calif. This column was reprinted with his permission from his Politics of Healthcare blog.