Malpractice by Utilization Review?

Friday, December 19, 2014 | 6

Here's the story we're working on right now: a utilization-review physician with a California license is being challenged for a decision that is reported to have resulted in harm to a patient. As we go to press, here's what we know:

1) Patient X sustained a brain and spinal cord injury in 2001;
2) Patient X had a three-level cervical fusion;
3) Patient X had been on Lyrica since 2008;
4) Patient X reported relief of symptoms;
5) Patient X did not report adverse effects;
6) UR Doctor Y was referred the case for review;
7) As is the custom in these cases, UR Doctor Y did not interview or examine the patient since so doing is not required by California law covering utilization review;
8) As is the custom in these cases, UR Doctor Y reviewed the documents forwarded by the insurance company, three medical reports that purportedly covered the injured worker's 12-year medical and surgical history;
9) At this point one of the allegations against the UR doctor that could also be directed against the insurance company is that a paucity of medical records was reviewed by the doctor and/or submitted by the insurance company;
10) UR Doctor Y submitted a report advising that the dosage of Lyrica which had been prescribed for about 6 years be cut in half;
11) This recommended reduction in medication was accepted by the insurance company which then reportedly declined to authorize the next request for medication refill (we do not know at this time if the actual primary treating physician or PTP agreed, acquiesced or rewrote the prescription in accordance with the UR recommendation). We also do not know if the PTP filed an appeal;
12) Patient X did poorly with the reduced medication and experienced adverse effects;
13) In due course, a California licensed physician got the original dosage restored;
14) Patient X sustained adverse effects that were short-lived and reversed once the original dosage was restored;
15) Patient X now has a lawyer who has instituted proceedings to report UR Doctor Y to the Medical Board of California and to initiate a malpractice complaint.

In summary, although we believe we know more, the facts as stated above can safely be stated with reasonable medical probability. In previous op-eds, we've pointed out that Dr. Frantozzi as president of the MBC submitted a letter stating that UR was part of the practice of medicine and required a California medical license – in this case, the offending UR doctor does in fact have a California medical license, which is why the MBC retains jurisdiction in this case. In other cases where the UR doctor does not have a California medical license, there would be no sense in even submitting this complaint to the MBC. Malpractice litigation would be the only choice. In this case, it appears that both options are open. We'll follow up when we know more. Stay tuned.

MORE, A LITTLE MORE, IS HEREWITH REPORTED: Repeal of SB 863 is indicated.

If you stayed tuned as requested, here's the next bits of information we've gleaned about this patient's plight. The PTP in this case reportedly filed an updated RFA which dutifully got referred back to Utilization Review. A different UR doctor than the one who nixed the original prescription then opined in favor of the original Lyrica prescription. The medication was then reauthorized. We're also advised that the Medical Board has now been advised about this case and has been asked to comment on it. This method of medical practice owes its existence to SB 863. The solution is repeal of SB 863. Stay tuned, this fight has just begun.

References

"Medical Board Asserts Jurisdiction Over Utilization Review," Workcompcentral.com, by Greg Jones, 2013-06-12.

"Utilization Review Hypocrisy in Velvet Gloves," Workcompcentral.com, by Robert Weinmann, MD, 2014-03-26.

"Is Utilization Review in the Cards for 2015?" Workcompcentral.com, by Robert Weinmann, MD, 2014-12-03.

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