Doctors, claims examiners, injured workers and many others whose fortunes rest with moving the opinions of legislators or regulators are all in angst about utilization review, fondly referred to in California workers’ comp circles as UR. Elected officials loathe it. Appointed officials revile it. Labor advocates argue that insurance companies profit obscenely from it, and somehow self-insured employers are immune from it. Advocates who hate medical provider networks question why doctors should have their treatment requests reviewed at all. But there’s a secret.
A concept first born when Gray Davis was governor, somehow the SB 899 version of UR is far more vile than the SB 228 version, even though the operative language was not changed between the pre- and post-Schwarzenegger reforms.
Providers chafe under requirements of seeking authorization for treatment and, not surprisingly, there are those in the medical community who do not feel constrained to be limited either by the UR process or the medical treatment utilization schedule, a set of prescriptive guidelines first conceived in SB 228 and strengthened, or at least made more prescriptive, in SB 899.
Therein lies the rub. The most closely guarded secret in workers’ comp is that by and large UR is doing what it is supposed to do. You won’t hear any regulators say that unless it’s dragged out of them. The vision of those who originally placed UR in the workers’ comp system formally – the sponsors of SB 228 (that’s organized labor and applicant attorneys) – envisioned a group health type of system, where doctors are given guidelines outlining best medical practices but ultimately would be free to exercise their best medical judgment as long as it was supported by a certain degree of medical evidence. In that environment, UR was conceived.
In the group health context, there are no prescriptive guidelines. Instead, there is the concept of “medical necessity.” UR is a process whereby the payer, in the case of group health either a health care service organization or an insurer, can determine whether requested treatment is medically necessary. It involves peer-to-peer dialog among medical professionals and, if there is a dispute, a process called independent medical review, in which a certified doctor makes a decision based on the patient’s medical records and not a physical exam.
When the authors of SB 228 and SB 899 looked at reforming delivery of medical care in workers’ comp, reform of handling medical treatment disputes was left out. For those who have angst over UR and its costs, look no further than your own desire to preserve a medical dispute process that left decision making in the hands of judges, not doctors, as the cause. That judges regularly overturn UR decisions should not come as a surprise, given that medical evaluators, especially AMEs, feel unconstrained by the treatment schedule. Lien claimants, whose treatments were both unauthorized and beyond the scope of either the treatment schedule or the physical medicine caps, still can find a sympathetic ear from a judge who simply wants the lien to go away. Want to take a poll of how many payers feel that the judges basically say, “Just give them something”?
If providers want to have more discretion in the workers’ comp system and stakeholders want to lower the costs of UR, then put independent medical review back on the table. Take the resolution of medical treatment disputes out of the hands of judges, QMEs and AMEs. Require lien claimants to show their treatment was appropriate and that it was ultimately authorized through the review process. Finally, and this is to the judges and commissioners of the WCAB, if an injured worker secures the services of an attending physician as authorized by the Labor Code, don’t let that become a back door for letting bad medicine back into the system and never, ever, compel the employer to pay for it. This last recommendation has the added advantage of being the law, although that seems seldom to be dispositive in such matters.
Oh, and by the way, while you are at it, make the official medical fee schedule mandatory and require providers to bill in accordance with the schedule to get paid. For those who decry the costs of bill review, it would be more beneficial to advocate for additional reform than simply bashing “insurance companies” for the costs of maintaining the system that you in large part created.