Joined: Aug 2006
Monday November 20, 2006 8:48 AM
Gotta love that common sense angle. If we actually used that in this industry on a widespread basis, I think I might just fall out of my chair and end up needing a DWC-1... :-)
Most of my medical providers and nurse case managers love dealing with me for one simple reason: If it sounds logical, I authorize it. A doctor tells me he's going to operate on someone's shoulder but forgets to mention that a specific immobilizer sling is going to be needed. UR approves the surgery and the doctor comes back saying, "Oh, by the way, she needs this very specific sling" and my response has always been, "Go through this vendor and get it. If they give you any grief, speak to Xxxxxx and just mention my name." I cannot even begin to tell you how many braindead adjusters will send the file *BACK* to UR... Remember, UR costs money people. Why spend $90 on one review when the item in question is $10? Jeez...
Oh yeah, let me incur $100+ for a supplemental AME report just to see if someone needs a crutch or a sling. Those things are obvious. It's not like the doctor is asking for a motorized wheelchair on an ankle sprain (yes, I've received such a request with such a diagnosis).
Finally, let's not forget one of the *MAJOR* provisions of the Sandhagen case law (and another example of how SCIF makes bad case law a daily reality): Utilization Review is ***OPTIONAL***!!! You miss the time frame for UR and your only back-up is a 4062 objection. Uh, are you really going to waste a Med-Legal eval. on something as simple as a cervical MRI or a pair of crutches?
Employers should take a close look at what their insurance companies are doing. And if the employer is directly to blame for this nonsense, then I really don't want to hear them bitching about their spiralling X-Mods or losses. Since when did filing a workers' comp injury equate to trying to defraud and abuse the system??
Since you mentioned Swift, I just can't bear to keep this under my hat any longer. This is Claim Monkey reform, henceforth to be known as AB(c)123.
1. Utilization review shall be conducted on three levels: common sense, logic, and necessity.
2. If anything requested by a medical provider does not exceed the cost of the review, then the adjuster or employer shall authorize or deny based on the common sense principles previously indicated. For instance: wounds require bandages, sprains require immobilization or splinting, broken bones require casts, and lower extremity injuries often require crutches.
3. Should an adjuster or employer deny any one of these common sense items or submit said request to utilization review, then the requesting physician may issue an automatic subpoena for personal appearance at his/her offices. When the adjuster or employer arrives under said subpoena, the physician is then authorized to conduct a "cerebral excess particle removal," defined herein as a slap across the back of one's head intended to clear the "excess particles" or "dust" from the top of one's brain (or lack therein).
4. Should an adjuster or employer receive three or more brain dusters, then the physician may issue an immediate request for a posterial kinetic application of tarsal structures (or PKATS) procedure to be conducted against said adjuster or employer. This may be carried out by the physician himself or his patient's counsel or otherwise designated agent, as this is a common and easy to carry out lay procedure. Of note, this is literally only a kick in the ass.
5. Should an adjuster or employer be injured in this Utilization Retribution process, they shall be barred from receiving compensation, as this is a natural consequence of their ignorance.
Nonetheless, I know this probably comes nowhere near the biting wit of Swift, but still, something really needs to be done about this obnoxious use of UR and medical-legal examinations. Are people already forgetting about that huge supreme court case a few years ago? Schaeffer Ambulance v. SCIF? If UR were to start coming out of insurers' "Loss Expense" lines, then they'll probably be a bit more judicious in the usage of UR and actually start authorizing stuff because the costs of UR could be considered the "cost of doing business" for the insurance company, much like sub rosa, medical-legal evaluations, and legal/expert expenses. But for now, it's being billed as medical costs and the employers are going to get hit one way or another with increased loss ratios, inflated X-Mods, and excessive expenses. Much like the 4061/4062 AME/QME tracks of old, UR is the same beast, but with different spots. UR companies can hire infamous doctors who will find *any* way possible to deny treatment, deny AOE/COE, deny everything. Wait a sec. It's a right-wing administration! I knew it. Anyone working at one of these UR brothels will tell the adjuster what they want to hear because the adjuster is paying for the review...