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Thread Title: Is UR Review mandatory or can Adjustor approve or modify PTP Rx?
Created On Thursday December 25, 2008 2:53 PM


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sunset estates
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Posts: 28
Joined: Feb 2005

Thursday December 25, 2008 2:53 PM

gaiassoul1@yahoo.com
Senior Member

Posts: 2155
Joined: Feb 2004

Friday December 26, 2008 7:43 AM

UR is not mandatory if the adjuster approves the treatment as written.

UR is mandatory if the treatment is delayed, denied or modified.

UR is not required for denied or disputed body parts.

-------------------------
Ginger

To know how to say what others only know how to think is what makes men poets or sages; and to dare to say what others only dare to think makes men martyrs or
reformers - or both. Elizabeth Charles

Edited: Friday December 26, 2008 at 7:44 AM by gaiassoul1@yahoo.com

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STEVEPSCA@YAHOO.COM
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Posts: 990
Joined: Jun 2002

Friday December 26, 2008 9:27 AM

While I am certainly not questioning your answer Ginger...
I understood that the ER/IC/TPA is required to have a UR plan filed with the DWC...in that, the CA is permitted to approve a treatment request "as per' that UR plan (actually I guess what the ER/IC/TPA permits a CA to do)...some things a CA can approve...some not, which would trigger the UR doctor review....(?)

So...every treatment request is subject to the UR process and ACOEM/MUTS/EBM guidelines.

My carrier requests ALL treatment requests to be faxed to the UR doctor/dept...CA doesn't even get a chance to view prior to a UR doctors review. And what they look for is not what is best interest of the IW... but whatever they can find to base a denial on.

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DoubleCrush
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Posts: 344
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Friday December 26, 2008 11:46 AM

I've been told that the CA can make medical decisions if the request is reasonable. Otherwise, the request has to go thru UR.

And, the CA can deny treatment, medications, etc., if the body part is not part of an accepted claim. UR never sees the request in these situations.

I think I've said the same thing as Ginger but I tend to get wordy in my questions and explanations.

Hope everyone had a Merry Christmas.

DC

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gaiassoul1@yahoo.com
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Posts: 2155
Joined: Feb 2004

Friday December 26, 2008 12:47 PM

I agree Steve, 100%, however in the past when I have given this answer, all it did was confuse people.

Yes Double you said exactly the same thing I did.

The Ins. Co. has a UR plan, within the UR plan should be a list of medical services the adjuster is not required to run through UR. Some examples I have seen include durable medical equipment (TENS units, crutches, Commodes - etc.) with a purchase price less then $500, medications less then $500 for a 30 day supply which are not triple scripts, the first 24 PT or Chiro visits pre-surgery, etc. etc.

While the carrier may request that all UR requests be FAXED, most medical providers have figured out that is the fastest way to a denial, which does not ultimately help the injured worker. The best thing the medical provider can do is mail them directly to the ins. carrier, await the time frames for the UR response to expire and provide the treatment under Sandhagen for failure to timely provide a UR response. Reduces the amount of litigation necessary for the injured worker to secure medical treatment and gets the injured worked the treatment needed.

Note the word request, not manadatory and mailing is the best thing going with a proof of service only -- all of the injured workers I work with send their physician a letter requesting that no treatment requests be faxed, that they all be sent with a proof of service only.

-------------------------
Ginger

To know how to say what others only know how to think is what makes men poets or sages; and to dare to say what others only dare to think makes men martyrs or
reformers - or both. Elizabeth Charles

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Backouttawack
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Posts: 60
Joined: Aug 2006

Saturday January 03, 2009 9:33 PM

What if someones AME and PTP both said that an IW is allowed to have a block of physical therapy treatments a few times a year as needed. How does one get the IC to pay for it? I've already been P&S'd and my case is in limbo for now. I have been going to PT on my own and paying for it and I sent the IA the receipts and she denied payment.

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rosellavera
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Posts: 40
Joined: Jul 2005

Saturday January 03, 2009 11:11 PM

I would file a DOR with the Board who has jurisdiction over your case. I know based on experience, that the IC may reconsider paying for the recommended treatment if it has to pay its defense attorney to make an appearance. If you add up the attorney's fees which run about six hours at $165.00 per hour (be there, done that when I worked for defense firm), and the risk of having the WCJ order the treatment, they will see that in the long run it's cheaper to pay for it without Board intervention. Send them your receipts and tell them that you give them a deadline to pay. If they don't, file your DOR. If you need any help, send me a private email.

Rose Vera
rosellavera@yahoo.com

Edited: Saturday January 03, 2009 at 11:12 PM by rosellavera

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gaiassoul1@yahoo.com
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Joined: Feb 2004

Sunday January 04, 2009 11:01 AM

The recommendations Rose has given work only if your injury was prior to 1/1/04.

Otherwise you may be limited to 24 PT visits.

If you have had your 24 PT visits, it does not matter what the AME or the PTP say and you will not be reimbursed per Facuendo vs. WCAB.....the 24 visit cap is not negotiable, unless you had subsequent surgery.

Secondly if the AME and the PTP have failed to document with evidenced based medicine as to why extended PT is necessary and reasonable for your particular condition past the PT already given, their reports are not worth the paper they are written on. Gone are the days a physician can prescribe continuing PT, their is not much out there for continuing PT and home exercise is just as effective, so I would not hold my breath on getting reimbursed.

You should be on a daily home exercise program to build core body strength. If you are not, the physicians have done you a great disservice.

STOP paying for your own PT with the expectation that you will somehow be reimbursed. START a comprehensive home exercise program and keep your weight down to take care of yourself. Yoga, tai chi, walking are all exercise programs that are available for little or no money.

-------------------------
Ginger

To know how to say what others only know how to think is what makes men poets or sages; and to dare to say what others only dare to think makes men martyrs or
reformers - or both. Elizabeth Charles

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STEVEPSCA@YAHOO.COM
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Posts: 990
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Sunday January 04, 2009 3:23 PM

'What if someones AME and PTP both said that an IW is allowed to have a block of physical therapy treatments a few times a year as needed. How does one get the IC to pay for it? I've already been P&S'd and my case is in limbo for now.'

From the way you phrased that, you are talking about treatment in a Stipulated Award, and the AME/PTP has indicated PT in the future medical treatment box...(?)

Follow what Ginger has provided...

And I say that because, I have the same thing/issue. You have to go back to your PTP each time you feel the 'need', get a request for treatment ..."Per Dr AME, furture medical stipulation...." submitted to the CA, and go through the UR process. IF denied, back to the AME...on to the WCAB judge for an order to enforce the 'award'.

The PTP has to provide EBM, and well reasoned, substatantive medical opinion, with a goal of functional restoration, and a return to gainful employment to get the additional "block of PT a few times per year' authorized. EVEN IF you are not subject to the 24 visit cap.

That cap is so unconstitutional, there is no provision for ANY appeal to a non medical, 'lay persons',.. (the ER/CA's) 'legal' denial of additional PT/Chiro/OT visits...not even a UR doctor,... NOT EVEN a judge can over rule a determination made by the ER/IC/TPA.

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gaiassoul1@yahoo.com
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Posts: 2155
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Sunday January 04, 2009 7:51 PM

<< That cap is so unconstitutional, there is no provision for ANY appeal to a non medical, 'lay persons',.. (the ER/CA's) 'legal' denial of additional PT/Chiro/OT visits...not even a UR doctor,... NOT EVEN a judge can over rule a determination made by the ER/IC/TPA. >>

and that was the exact premise of Facuendo vs. WCAB which found despite the feelings of many that the cap was NOT unconstitutional

-------------------------
Ginger

To know how to say what others only know how to think is what makes men poets or sages; and to dare to say what others only dare to think makes men martyrs or
reformers - or both. Elizabeth Charles

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STEVEPSCA@YAHOO.COM
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Posts: 990
Joined: Jun 2002

Monday January 05, 2009 5:12 AM

Is that case going to appeal ?

Incredible how any issue can be left w/o judicial intervention. And a 'medical' issue left with non-medical personel.
I'll sure be glad when Arnold is gone...MAYBE someone in the legislature will finally step up to the plate and push that pendlum at least closer to the center.

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art
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Posts: 2111
Joined: Aug 2004

Monday January 05, 2009 8:21 AM

No, I believe the window to appeal has lapsed. York would know better.

FWIW: If I heard the report correctly the primary legacy of Bush #43 is that 2/3 rd's of the Federal Bench are his appointees. I guess we now know what he did with all his spare time while President Cheney and V.P Rove were busy running/ruining the country.

Sigh...

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gaiassoul1@yahoo.com
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Posts: 2155
Joined: Feb 2004

Monday January 05, 2009 12:54 PM

it was appealed all the way to the Supremes...they refused to hear it and every court found that the 24 PT and chiro cap was constitutional.....so given the expense of a constitutional challenge, I imagine that unless somebody else comes up with a completely different look, this is a moot issue.

So at this point, I don't see that happening and not sure what fact pattern would change the argument to succeed in the future.

-------------------------
Ginger

To know how to say what others only know how to think is what makes men poets or sages; and to dare to say what others only dare to think makes men martyrs or
reformers - or both. Elizabeth Charles

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STEVEPSCA@YAHOO.COM
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Posts: 990
Joined: Jun 2002

Monday January 05, 2009 5:47 PM

I'm sorry if I wasn't clear in my opposition to this issue. It's not the cap itself I have the difficulty with...24 visits seems logical barring EBM to the contrary...and I agree with the abuse of these treatements prior to the changes.

The part that I find unconstutional is the inability to take the matter beyond a ER /CA/TPA, at least to UR and a PQME/AME... and if necessary to a WCAB judge.

That a non-medical person is permitted, by law, to make a medical determination on treatment as outlined by a 'doctor' with out adequate judicial appeal, is in my mind 'unconstutional...the right to 'due process' has been taken away.

As I recall, York had a lot to say on this issue.
BTW...where is York...?
He is missed around here...

Edited: Monday January 05, 2009 at 5:50 PM by STEVEPSCA@YAHOO.COM

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gaiassoul1@yahoo.com
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Monday January 05, 2009 8:05 PM

Steve as you may or may not know I still work for York.

The exact issues you raised were issues in the constitutional challenge as well as the cap created two classes of injured workers, those injured prior to 1/1/04 and those injured after who therefore have two different PT "rights". So no go per the Supremes at this time, despite conventional wisdom from the trenches to the contrary.

As you will recall, York left the work comp arena in his business in 1/1/05. He is therefore building his private insurance end of the business and is well. He is trying to get rid of his liens as soon as possible. As you know building a business is very time consuming....so that is where York is.

-------------------------
Ginger

To know how to say what others only know how to think is what makes men poets or sages; and to dare to say what others only dare to think makes men martyrs or
reformers - or both. Elizabeth Charles

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postscript2
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Posts: 437
Joined: Sep 2006

Tuesday January 06, 2009 6:39 PM

I was "fishing" the net the other day and saw an add on a job finder site. I saw "York Insurance Co."

I was very curious about this and will inquire further. Thanks for the info!

LCS

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gaiassoul1@yahoo.com
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Posts: 2155
Joined: Feb 2004

Wednesday January 07, 2009 6:58 AM

York Ins. Co. is not one of York McGavin's companies. He is building his business as to providing durable medical equipment as to the patients in the private industry sector.

-------------------------
Ginger

To know how to say what others only know how to think is what makes men poets or sages; and to dare to say what others only dare to think makes men martyrs or
reformers - or both. Elizabeth Charles

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York
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Posts: 337
Joined: Mar 2006

Wednesday January 07, 2009 9:11 PM

Hi All,

Contrary to any rumors swirling around, I am still alive and well, and although there is an IC named York, I have no ownership interest. (Les, you should know that I would never fund an insurer that exalts profits over reasonable treatment, necessary to cure or relieve an IW.) As noted by Ginger, I have been as busy as can be. In addition to just running the day-to-day operations of my DME business, I have indeed been steadily increasing my percentage of individual and group heath insured patients --- as continuing to provide treatment to the IW community would have driven me into bankruptcy.

My company is a low-dollar provider. In the last quarter of 2004, my accountant informed me that due to the expenses of maintaining proficient representation (and Ginger is a spectacular example of a super-proficient hearing rep), if I was not paid in full, with interest, by the time I or one of my reps made a second appearance, I was in the red. What an eye-opener --- as for many years we had been making 3, 4, 5, 6, or 7 appearances on a regular basis. My accountant told me that if it were not for the fact I work in 37 other States, I would have been BK many many years ago.

Thus, effective 1/1/05, I had to shut the door to new IW referrals. I now have my hands full growing my biz, expanding further nationwide; bringing a new device to market by having the FDA approve this device; expanding my network of sales reps; and today, despite the fact I shut the door to new IW referrals 1/1/05, some 4 years and 6 days ago, we are still making anywhere from 30-40 appearances before the WCAB on a weekly basis. Just this week, although I live in the LA area, I personally had to make appearances in San Diego Monday, Fresno Tuesday, and today, I am in Santa Rosa preparing to litigate a $652,000.00 lien. (No, I am not the lien claimant, but was requested to rep the lien claimant.)

In regards to the 24 visit cap for chiropractic or PT, for those IWs who sustained injury on or after 1/1/04, this is now carved in granite. I have to agree with Steve regarding how obnoxious it is for an adjuster to have more authority than an AME, a QME, or a WCJ --- when it comes to authorizing more than 24 visits. This point was made in the arguments contained in the briefing.

I did my best to have this 24 visit cap declared unconstitutional in Facundo-Guerrero v. WCAB, (Argonaut). For those of you who have an interest in reviewing the step-by-step proceedings, briefings, and arguments, I created a mini-website as a repository. Please feel free to review all that was done by clicking on 24 Visit Cap Constitutional Challenge.

Perhaps in 2011, after this damn governator is termed out, we may see some sanity return to the comp system. I'm keeping everything I have a pair of crossed that the damned deformed reforms brought about by SB 228 and SB 899 are mitigated.

Meanwhile, today, like so many an IW, I am striving to return to a normal lifestyle. In 2004 and 2005, we were often required to make 8 appearances at 6 venues --- on any given morning, and 8 more appearances at 6 different venues in the afternoon. Although the DA would refuse to negotiate with any lien claimants during the pendancy of the case-in-chief, if we did not appear, as sure as the sun will rise tomorrow, we would receive a notice of intent to disallow our lien. What a bunch of BS, and quite costly for me as well.

In reviewing so many of the briefs I have labored many weeks creating, I noted how many briefs were completed on Christmas day, New Years day, my wife's birthday, and on our wedding anniversary.

Today, I am spending more time with my wife, and doing my best to enjoy my life --- rather than wrestling with a DA over dollars. As we all know, time is far more valuable than money, as although money may come and go --- time just goes................

It is now after 9 pm, and I have to prepare the lien I am litigating tomorrow to be EAMS compliant. Grrrrr. More BS.

Although I am no longer a 'frequent flyer' here on the WCC Forums, my heart still goes out to the IW community. In fact, I still receive more than a few calls from IWs on a daily basis seeking advice and an understanding of how to navigate this maze we call workers' comp. As usual, I do my best to ensure each IW gets all to which they are entitled.

York McGavin
ymcgavin@socal.rr.com

-------------------------
I am not an attorney. My personal opinions, as to what I would do if I were standing in your shoes, are not to be considered legal advice.

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STEVEPSCA@YAHOO.COM
Senior Member

Posts: 990
Joined: Jun 2002

Thursday January 08, 2009 6:15 AM

Thanks for taking the time to visit us now...
And know that your efforts are very much appreciated, as well as you are thought of often....and missed.

Best wishes in your DME endeavors...hopefully the FDA won't drag you out for another 10 years !
S.

Posts: 62
Joined: Mar 2004

Thursday January 08, 2009 1:13 PM

York, although we have at times disagreed with each other, I want to say I have great respect for your integrity and depth of knowledge. Wish you, your employees and your family the best for the New Year and understand your business decisions. Please post whenever the mood strikes--I have learned more from you probably than you from me.

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