There I was at the Acme School for Workers' Compensation Claims Adjusters. It was the first class of the first approved vendor for the new claims training authorized by the Department of Insurance. The various insurer, self-insured and TPA employees had about them an air of anticipation, as though they were about to be part of something special.

The teacher approached the podium, the epitome of authority, no hesitation in her voice and no doubt that what she proclaimed was in fact the Truth. The course outline indicated that the subject was the medical utilization schedule.

"The schedule is the law!" the teacher all but bellowed to the earnest students. Immediately, a hand was raised.

"But aren't these supposed to be guidelines?" a student asked hesitantly.

"Yes, you are supposed to use your best judgment. Obviously, you have to use common sense when looking at a claim. This is especially the case for claims before April 19, 2004 when SB 899 was signed into law," the teacher said, seemingly satisfied with her answer, although at least one student was not.

"But are the guidelines presumptively correct?" asked another student.

"And aren't they defined as treatment necessary to cure or relieve in Section 4600?" asked another.

"Yes, that's all true. But you should not be automatically denying medical treatment just because it is contrary to the schedule," the teacher warned.

Seemed simple enough.

While most of the students were writing this guidance down, a few remained skeptical.

"Excuse me, but doesn't the new utilization review procedure require us to enforce the treatment guidelines?" someone asked.

Suddenly, all pens and pencils were set down.

"Yes, it does," the teacher agreed. The answer seemed too simple, but after all, this was the curriculum approved by the Insurance Commissioner.

"And doesn't the new law allow the Division of Workers' Compensation to assess penalties if we fail to follow the utilization schedule in our UR process?" the student asked. Clearly, he had done his homework.

"Yes, it does," the teacher agreed.

"So, how exactly is it that I am supposed to authorize treatment that doesn't fall within the guidelines?" the student continued.

"Use your judgment," the teacher answered, beginning to sound like a broken record.

"But don't the new medical provider networks have to provide treatment in accordance with the medical treatment utilization schedule?" said another student who apparently had read the Labor Code before coming to class.

"Yes, they do," the teacher agreed.

"So what are we supposed to do when an injured worker whose date of injury is before April 19, 2004 asks us to approve treatment that was ongoing from the date of injury and not consistent with the new treatment guidelines?" the student asked.

"Use your judgment," the teacher advised.

The class seemed to be at an impasse.

"What judgment? Are we supposed to approve treatment that is inconsistent with the guidelines, or aren't we?" the student asked with a tone of exasperation in his voice.

"Yes and no," the teacher waffled.

"Huh?" the student said.

"Look, the answer is that you need to look at each case on the merits. If the injured worker has a course of treatment that isn't too over the top, just keep providing it. It will be cheaper than litigating it and all you wind up with anyway is a dissatisfied claimant," the teacher tried to explain.

There was silence in the room. Then yet another hand went up.

"So let me get this straight - we have presumptively correct treatment guidelines, we have a UR process that is supposed to enforce these guidelines, we have medical networks that are supposed to provide treatment in accordance with these guidelines and you are saying that if it doesn't cost too much, we should go ahead and approve treatment outside the guidelines? Do I hear that right?" the student asked with a note of incredulity in his voice.

"That's correct," she affirmed.

"Then what good are the guidelines?" he asked.

"Well, you have to use your judgment on whether to approve treatment. Most cases will be pretty clear-cut," she said, trying to make the best of a rapidly deteriorating situation.

"But I thought the Commissioner said that the old system - before SB 899 - was full of provider abuse and that the old law permitted excessive and improper use of treatments," he said.

You could have heard a pin drop.

"Well, yes, he did. But that doesn't mean that everything that happened before SB 899 was wrong, it only meant that some of it was," she replied.

"Like what?" asked yet another student.

"I think it is time to move on to the issue of chiropractic, physical and occupational therapy services. The law says that more than 24 treatments or services requires approval from the claims payer," the teacher said with a sigh of relief, thinking she had moved to a less controversial subject.

Immediately a hand popped up.

"How does this relate to the utilization schedule?" a student asked.

"The law states that approval is required notwithstanding the schedule," the teacher said.

"Oh, so that means that we don't have to do UR when it is a request for a chiropractor or PT?" the student asked.

Seemed logical enough.

"Well, not really. The reference to the utilization schedule really only applies if the schedule states that more than 24 visits or treatments are appropriate," said the teacher, uncomfortable again.

"Where does it say that?" the student persisted.

"Well, that is the interpretation that makes the most sense," she offered, hoping that would satisfy the inquisitive group.

"OK, maybe I am missing something here. If the utilization schedule says, for example, that eight chiropractic visits are appropriate, I have to authorize eight, right?" the student asked.

"Yes, that would be correct," said the teacher, thinking maybe there was a breakthrough.

"But the statute says that you can have up to 24 visits before approval is required. Right?" asked the student.

"Well, I think you have to look at this logically. If the guidelines say eight, then that is the presumptively correct number," the teacher said.

"And according to what you said, if the guidelines were to say 30, then the statute would say there still has to be authorization after 24 visits. But even before that, if the doctor and the patient agreed on, say, 18 visits, then we should use our judgment to approve that even though the guidelines say eight and there doesn't appear to be authority to disapprove treatments until there are more than 24," the student observed.

"That could be an acceptable outcome," the teacher answered. It was almost time for a break and the teacher now looked intently at her watch.

Silence fell upon the classroom.

"Well, before we break for 10 minutes, are there any questions?" the teached asked.

Of course, there were none.