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We developed simple, powerful protocols for helping people get a doctor and the medicine they were entitled to!

Benefits provided under the Workers’ Compensation System have always been at the mercy of larger than life politicians and the cigar-smoking fat cats that got them elected. My clients continually get caught in the cross fire of their misguided efforts at cost control. Following the enactment of SB-899 in 2004, we witnessed wholesale patient dumping by doctors and occupational health centers treating our people. Many folks, who were on powerful pain killers, were essentially issued their  last  script  and  told  to  fend  for  themselves. Some went through life threatening withdrawals alone; cold turkey. So much for the Hippocratic Oath! It was a painful thing to witness.

Things got much worse in 2012 after Mr. Brown signed SB-863 into law. Now we have Independent Medical Review (IMR); a 750 million dollar a year juggernaut, which purports to remove judges from the treatment decision making process, leaving “medical decisions up to doctors not lawyers.” IMR strictly bases its decisions on the stingy, complex, narrowly drafted Medical Treatment Utilization Schedule (MTUS). This is an insurance company’s dream.

Furthermore, individuals will never see the secret “doctor” from “Maximums,” the mega firm that is now making the medical treatment decisions that will be good for an entire year. Now even the most basic medical decisions require treating doctors to struggle through complex algorithms to justify treatment recommendations, and have burdensome “peer to peer” phone chats with feisty UR doctors, or face a denial of treatment for their patients. Since the beginning of the year, we have seen eight local comp physicians simply close up shop and move on to greener pastures. Why would any professional want to deal with this crap? The process had become socialized medicine’s evil twin; it is all about saving money for insurance companies now.

Without question, the most insidious thing the insurance industry is currently doing is making medical decisions for people on long-term pain control without physician oversight. Emboldened by the reforms, they start by obtaining a multi-page UR denial from an out of state vendor from some hell hole like Texas (where they lynch comp attorneys) and then only  authorize tapering doses of medications over a 90 day period. Thereafter, they simply cut the patient off their meds pending a final IMR decision. IMR decisions, by the way, are upholding 80% of the underlying UR denials.

So what is your attorney doing about this anyway?

I will be the first one to admit there were some desperate years after 2004 that we were just wondering how we were going to keep our doors open. There was a tsunami of medical treatment issues presented to us and it was, as my father used to say, “like drinking water out of a fire hose.” Many clients simply gave up and stopped treating or hooked up with State or Federal medical coverage. Those were dark times indeed. However, after the dust had settled a bit, we sat down and came up with a plan. On a succession of Saturdays, the scrappy troops here at LLG were mustered. Hundreds of dusty file boxes were wrested in from storage, sleeves were rolled up and many large pizzas consumed. We punched through each and every file with open medical treatment rights in an effort to reach out to clients and help them to get the treatment they were entitled to, or alternatively get them safely out of the system.

Thereafter, we developed simple, powerful protocols for helping people get a doctor and the medicines they were entitled to. To make all this happen, we created a unique position in the office for the sole purpose of securing treatment rights for clients. We filled this position with our über law student/ paralegal, Keya Bartlett. She became the North State’s first Medical Enforcement Specialist. So effective was Keya in getting people hooked back up with treating doctors and securing appropriate medical treatment that clients started calling her “Guido the Enforcer.”

Never underestimate the power of determined women on a mission. With the help of Senior Paralegal Miller and Case Manager Sypnicki, Keya developed “The Drill.” The Drill provides effective, time-tested techniques for securing the services of a doctor and streamlining treatment requests for clients. You will find the printed version of the procedure at our web site in “Articles” under “The Drill (Getting a doctor and medical treatment in the California Workers’ Compensation System).”

As far as the specific treatment algorithms laid out in the MTUS go, I will warn you that reading them will give you a headache. You can access the 2009 edit at our website as well under “Articles”, entitled “MTUS Guidelines”. The MEEAC commission plans on recommending a much more conservative version dealing with pain killers soon. Brace yourselves, as the insurance industry is dead-set on using these protocols to cut you off your meds. 

The good news for my clients:

There are blazing spots of good news on the horizon regarding all of this. After years of waiting, on April 3rd one brave firm has filed a Writ of Mandamus with the First District Court of Appeal taking on the IMR system as the blatantly unconstitutional denial of due process that it really is. At last! Also, under Jose Dubon v W.C.A.B., the IMR process can be unplugged and we can go straight to a judge on medical treatment issues if the UR decision is untimely or suffers from “material procedural defects that undermine its integrity.” Wow, this is big folks. This dam is starting to crack.

My prediction is that it is going to get worse before it gets better. The stark reality is that insurance companies control the doctors in the system and how they prescribe treatment. As they say, nature abhors a vacuum, and I think that there will be a new breed of physician that will find a way to make a buck by having the savvy to deal with MTUS protocols; much like the billing departments they have to wrangle payment out of health insurance companies, Medicare, and Medical. Let me stress the fact that you can get doctors and treatment in the workers’ compensation system. Be prepared to travel and have the patience of Job; sometimes the process is like watching a tree grow in your backyard. Just remember, you are not in this fight alone. You got questions? I got answers: tledgerwood@ledgerwoodlegal.com


Thomas Ledgerwood
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Proprietor Ledgerwood Law Group