How UR and IMR Work together to Deny Injured Workers Care
Monday, August 18, 2014 | 3
The Medical Board of California is not at this time placing high priority on reform of either utilization review (UR) or independent medical review (IMR).
Utilization review is required before primary treating physicians or consultants can initiate diagnostic studies and/or institute treatment. UR physicians can deny or modify diagnostic or treatment requests by treating doctors.
For instance, in one case we're studying, an orthopedic surgeon asked for authorization to do a preliminary treatment and if that treatment failed to go ahead with a fusion. The UR consultant authorized the preliminary treatment, but not the fusion. Trouble is, the authorized preliminary treatment failed. Since the request to do a fusion should the preliminary fail was denied, this injured worker will now go without the recommended follow-up fusion advised by the expert opinion of the evaluating orthopedic surgeon. The inherent absurdity in the program is that the UR doctor did not interview or examine the patient and reviewed only whatever records were given him by the insurance company.
A current case that has come under our review concerns a patient who has lifetime medical care and who from time to time, when symptoms recur, gets physical therapy -- not this time, though! The request for physical therapy, reviewed by Dr. Unctious (his real name is kept secret by the independent medical review service run by Maximus) denied the request for physical therapy. The treating doctor won't be able to quiz Dr. Unctious because his real name is "protected" by Maximus. This kind of secret denial harkens back to the French Revolution when secret "lettres de cachet" filed by nobles enabled imprisonment of named victims without having to disclose who wrote the "lettre de cachet" in the first place. Perhaps it's better that Untious' real name isn't known. So far our review suggests that Dr. Unctious' professional conduct deserves disciplinary review by the Medical Board.
Aye, but there's the rub! Unctious does not have a California license and under California law does not need to be licensed in this state to practice UR in California. He is free to deny or modify care without a California license to practice medicine. The official letter denying care trumpets that Unctious is licensed in Ohio and Texas, but those boards can't review Unctious' clinical conduct because those boards don't have jurisdiction in California.
The California Legislature has passed three bills requiring UR doctors to be licensed in California. All were vigorously protested by the insurance industry. All three bills were vetoed, twice by Gov. Arnold Schwarzenegger (no surprise) and once by Gov. Jerry Brown (big surprise). The meaning of this quirk is that non-California-licensed doctors do not come under the jurisdiction of the Medical Board whereas the primary treating physicians who are left holding the bag when treatment isn't authorized remain subject to discipline by the Medical Board.
Texas requires doctors who do UR on Texas patients to be licensed in Texas. The upshot is that Texas doctors may do UR in California without being licensed in this state whereas California doctors who want to do UR in Texas must first get a Texas license.
So here's how the "double whammy' works: First, UR denies treatment. Then, instead of judicial review by the Workers' Compensation Appeals Board, the case gets turned over to Maximus with its cadre of anonymous doctors who have in common with their UR counterparts that they also don't have to be licensed in California.
Epilogue: In the case at hand the patient is getting the physical therapy he needs. He's just paying for it himself. We regret that the Medical Board of California doesn't see enough inequity in this desultory situation to demand that UR and IMR doctors be licensed in California.
Dr. Robert L. Weinmann is a practicing neurologist in San Jose, California. This column was reprinted with his permission from his Politics of Healthcare blog.
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