Getting medical treatment has become an emotionally exhausting nightmare for most injured workers. So what can be done about it, how can we fight back? Part A & B of "The Drill" can help.
Ask most injured workers in the California comp system what it was like trying to get medical treatment before 7/1/13 and they would likely tell you that it was it was a constant battle. Basic treatment was frequently interrupted with Utilization Review (UR) denials. This got worse in 2012 when SB - 863 was passed. People with pending cases and those who settled with rights to receive future medical treatment all fall under this new law. Getting medical treatment has become an emotionally exhausting nightmare for most injured workers. So what can be done about it, how can we fight back? One way is to take care of medical problems before they come up. If you are treating with an unauthorized provider you will normally not be able to get your treatment requests authorized. How you fix that is laid out in part A (Getting a Treating Doctor on Board). The other way we fight back is with persistence when treatment is denied. How to fix that is laid out in part B (Getting Medical Treatment Authorized).
Things can go quickly, or you can be in for a long wait. Make sure you have applied for State Disability insurance as a back up to your Temporary Disability (TD) benefits. TD will only last two years. You are not in this fight alone, we will help you out.
PART A (Getting a Treating Doctor on Board)
There are many reasons people in the work-comp system find themselves without a doctor: They may not have needed treatment for a while and now need a doctor. Their doctor may no longer be part of their insurance company’s Medical Provider Network (MPN). Most recently, their doctor has decided they’ve had enough with work-comp and are no longer taking work-comp patients.
So what do you do when you need to get a treating physician on board? Things sometimes go easily and you get a doctor without much fuss, other times you need to steel yourself to the idea that we are going to have to go to court and get a judge to force the insurance company to authorize a doctor. Be prepared to travel, as many local doctor’s who once did workers’ compensation work, are getting out of the field because of the red tape. Here’s the Drill:
1) Get a copy of your insurance company’s MPN list and call the doctors listed. We can help you with that. You are looking for a doctor that takes Workers’ Compensation and is willing to be a primary treating physician (PTP). Often the MPN lists will be filled with surgeons and specialists who take work-comp but because they are specialists they are not willing to be a PTP. In comp you need a PTP who is going to oversee all of your industrial injuries and make appropriate requests. A PTP can refer you out to specialists. Non-PTPs usually get denied, unless your adjuster knows the ins and outs of your treatment requests. Combing through these lists is frustrating as you will get far more “no” responses than “yes” responses. Some doctors don’t take “old comp cases,” some “don’t do comp,” some are dead. Don’t let this stop you. It is all about persistence. It is very important to take notes on your MPN list about what the people you spoke with told you about why that doctor doesn’t take comp or won’t be a PTP. You will have to prove you did this leg work to a judge down the road. You want to make sure you are fully documented and confirmed that no one will take you on this first list.
2) If you are successful and find a doctor on the list a Change of PTP request needs to be done. We send this form to the insurance company asking that they authorize the doctor you have selected and that they send that doctor records so the doctor can determine if he will take you on as a patient. Once this is done, we wait for the records and authorization to get to the doctor then you see if you can make an appointment. Once you have an appointment, you treat with that doctor and let us know if you are struggling to get any of the treatments that doctor is requesting.
3) If you are unsuccessful with the MPN list and do not find a provider both willing to take work-comp and be a PTP (rest assured even on large lists this is common) then we either go for a wider MPN list, depending on the distance you originally looked at, or if we have gone the max distance then we attempt to go off the MPN list. Going off the MPN list can be great or miserable experience depending on the circumstances. Going off the MPN list is great if you have a doctor you really like that is willing to take work-comp and is willing to be a PTP. However, sometimes we have to go to court to get that doctor approved that is why you want to take good notes on all the denials you get from doctors on the list.
If you have an off the MPN doctor that is willing to treat you sometimes it is as simple as doing a Change of PTP for that doctor and request they be authorized. You never know, you might get lucky. If you do not have a doctor in mind it is difficult to go off the MPN because you essentially have to cold-call doctor's offices out of the phone book to find one. We are always compiling a list of doctor’s that we know take work-comp and are willing to be a PTP. So if we get to this point we can give you a list of a few names (very few) in each area that are usually “sure things” so you don’t have to go through the phone book. You pick one you like, we request they be authorized and then if they’ll see you, you set up an appointment and we wait for a problem.
4) If all the above fails, we proceed to court and get a judge to order that you be able to treat with the non-MPN physician. Insurance companies are duty bound to provide you medical treatment. This is where we will all be happy that you took really good notes as you went through the underlying lists.
PART B (Getting Medical Treatment Authorized)
So you’ve made sure your doctor is authorized to oversee your treatment by going through Part A. He is treating you and he is requesting treatment he thinks will improve your functionality, health and quality of life. Everything is going swimmingly until: 1) You go to pick up your prescription and the pharmacy tells you they can’t be filled 2) Your doctor tells you they requested treatment or therapies with a different provider but you haven’t heard anything from anyone or 3) You get a denial in the mail outlining why your requested treatment is being denied by Utilization Review. What do you do next?
1) For starters, you need to be treating with a PTP, authorized by your insurance carrier. If you are not treating with an authorized PTP, please see the MPN drill above on how to resolve that issue first.
2) Your PTP needs to request the treatment he believes you should have (this includes prescriptions) on a Request for Authorization (RFA) Form, this is a form put out by the division of Workers’ Compensation. If treatment is not requested on an RFA form it is not reviewed. Unfortunately it is that simple for the insurance company and that can be devastating.
We ask clients to kindly request that their doctors fax us a copy of the RFA they send into workers’ compensation. Utilization Review has 5 business days from when they receive the RFA to issue an approval or denial (they can have more time if they need more information, but that is limited as well and they have to notify us if that is the case). If we are consistently getting copies of the RFA forms from doctors we can follow-up on the decisions to make sure they are occurring timely, or when they do not occur timely, and the treatment is denied (not timely) the decision can be rendered invalid.
If you are not able to fill your prescription it could be because the RFA was never sent in so the carrier. If this is the case, then the prescription vendor never got the authorization to give you the medicines. If you haven’t heard anything regarding treatment requests it could be because an RFA was not sent in, or not sent in properly. Many problems can be easily solved with a few phone calls. Alternatively your PTP could have sent in a valid RFA and for whatever reason your insurance company is not responding or doesn’t have it. This is when it is very important for us to have a copy of the RFA because a subsequent denial can be determined invalid as being untimely.
3) Once we have a UR decision, if it is approved – Great! You have medical treatment (for now). Much more common though is that UR denies the treatment, this is the paper you will get a copy of in the mail saying the treatment is authorized or denied, certified or non-certified. When that happens, a couple things spring into motion.
a. We send off the IMR application on your behalf, requesting that IMR reviews the treatment to see if they will overturn the UR decision or uphold the decision. The bad news is that IMR currently upholds 80% of the UR denials.
b. If this is treatment you strongly feel you need, you will want to contact your doctor and request that they appeal the denial, they only have 20 days to do this, so you will want to call them right away upon receiving the denial.If their appeal is approved we can withdraw the IMR request and you will have treatment (for now).
c. If their appeal is not approved, we still have our IMR application pending, but unfortunately there is more bad news with IMR.Currently it is a very lengthy process, taking months, so it will be a while before we know what IMR’s decision is, and we know that there is a 80% chance it will uphold the UR decision…so what do you do knowing all that?The next step if your doctor has appealed the denial is to talk to him about what else he thinks may provide you similar relief that he thinks you meet medical necessity for.Hopefully that treatment gets approved and you have treatment (for now). If not though we will repeat steps 3a-3c until we find treatment that UR is willing to authorize for you.
d. The most import thing is not to lose hope.You are entitled to appropriate medical treatment under the Labor Code. The IMR process is very new. Treating doctors need to learn how to make appropriate requests that fit within the guidelines of the Medical Treatment Utilization Schedule.