Workers' Comp Reform

Reform Effects Causing Docs to Refuse Injured Workers

Physicians are displeased with sweeping changes to the California workers' compensation system since the passage of SB 863.
By: | March 2, 2015

“I no longer take workers’ comp cases due to the impossibility of getting paid in a timely or appropriate manner without huge amounts of extra work,” a physician reportedly wrote. Another said “expenditures appear to have shifted from patient care to a cumbersome administrative system, involving 2-4 steps in different locations across state lines, for authorization.”

Both are comments cited in a survey from the California Medical Association. The association released the responses from 231 physician practices to the changes included in workers’ comp reform legislation signed into law September 2012.

“Significant changes to the utilization review process, implementation of an independent medical review and independent bill review process along with migration to a resource-based relative value scale payment system are some of the substantial changes to the California workers’ compensation system since the passage of SB 863,” said the survey. “Feedback from the CMA physician members thus far indicates significant challenges with the workers’ compensation reforms implemented.”

The survey was conducted over a two-week period. Questions addressed utilization review, independent medical review, independent bill review, and the resource-based relative value scale fee schedule.

More than two-thirds of the respondents cited problems with the UR process in getting authorization for patient care, and more than half of those cited “inappropriate denials” of tests, procedures, or services they deemed necessary.

“The process was always difficult but has become hideous in recent months,” according to one physician’s comment. “It has become a series of denials for even the most elementary medications or tests,” said another.

“I no longer take workers’ comp cases due to the impossibility of getting paid in a timely or appropriate manner without huge amounts of extra work.” — a California physician surveyed about the impact or workers’ comp reform bill SB 863.

The IMR process was also cited as a challenge with two-thirds saying it “has been unsuccessful in ensuring approval” of care they said is medically necessary. Slow responses to IMR requests and “inappropriate denials” of medically necessary actions were cited as the biggest challenges. One-third of physicians said opioids/pain management was the type of service most frequently denied by payers. Commenters said “prescription drugs of many kinds, not just opioids” were the type of service most frequently denied.

The independent bill review process was utilized by 30 percent of respondents with 32 percent saying they “had no idea it existed.” Among those familiar with it, nearly half — 46 percent — said it was “not at all successful” in addressing issues involving payment discrepancies. The $250 submission cost per issue to use the independent bill review was cited as “cost prohibitive” by 39 percent of respondents.

The main challenge cited from the new RBRVS fee schedule was “down-coding of claims resulting in underpayment,” according to 55 percent of respondents. One said “lack of payment for non face-to-face time, telephone calls, supplemental reports. It is a nightmare.”

Meanwhile, the state Commission on Health and Safety and Workers’ Compensation is calling for a reexamination of the system in light of the passage of S.B. 863. The commission was created by legislation in 1993 to examine the health and safety and workers’ comp systems and recommend administrative or legislative changes.

In its annual report, the commission specifically cited “medical care quality, accessibility, timeliness and cost” and “timeliness and cost of dispute resolution” as two areas the legislature and administration should address.

While S.B. 863 “incorporated many of CHSWC’s previous recommendations for statutory improvements” in the workers’ comp system, the commission recommended a thorough reexamination.

“Significant changes in the medical care process for injured workers have resulted from the reforms enacted in 2012. One of the changes is that medical necessity disputes are now resolved through an IMR process,” the report said. “IMR is administered by the Division of Workers’ Compensation Administrative Director and requires that an injured worker’s objection to a UR decision be resolved through IMR.”

The CHSWC called for an evaluation of the impact of the changes on an individual provision-by-provision basis and in combination. It also suggested evaluating the impact of the new provisions “on cost, quality and access of injured workers to appropriate and timely medical care” and to “identify issues and make recommendations for addressing areas of potential concern.”

Nancy Grover is the president of NMG Consulting and the Editor of Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at [email protected].

More from Risk & Insurance