JOSÉ DUBON: The Human Face Behind WCAB Decision

Imagine if this was you or your spouse. The California Legislature passed SB 863 and the recent Dubon case has taken the Workers’ Compensation courts out of deciding medical issues. This has effectively denied crucial medical care for thousands if not hundreds of thousands of California citizens. If the Insurance company denies a treatment and does not follow the law, you will likely not get your day in court to challenge the violations. Read the full story from C.A.A.A below:

California Applicants’ Attorneys Association (CAAA): JOSÉ DUBON: The Human Face Behind WCAB Decision; Consequences of Insurers Gaming UR System, Withholding Medical Records

The California Applicants’ Attorneys Association (CAAA), whose members represent Californians injured on the job, today released a UR DENIED story on José Dubon, the injured laborer whose case has resulted in three different Workers’ Compensation Appeals Board decisions, addressing what insurers are required to provide to Utilization Review (UR) to make the UR valid. Insurance carriers’ Utilization Review (UR) denies one in five physicians’ requests for medical treatment – up to 3,500,000 per year. The Dubon v. World Restoration case is an excellent example of the widespread failure of claims administrators to provide adequate medical records to the UR reviewer. “José Dubon’s case has produced a WCAB decision that addresses insurers’ withholding of key medical records. Today, we are releasing the human story behind the Dubon I and II decisions,” CAAA President Bernardo de la Torre. “José waited more than a
decade for back surgery for his work injury. That is unacceptable and outrageous and shows what is wrong with the abuse of Utilization Review (UR). The law requires that injured workers receive medical care in a timely and just fashion.”
“I needed spinal surgery, but UR denied it,” said José Dubon, 56, of Anaheim, who was a laborer for World Restoration for seventeen years before hurting his back in 2004 lifting a toolbox. “The insurance adjustor failed to send my medical records to the UR doctor, who therefore saw no need for my surgery. IMR upheld the UR denial. How can UR and IMR deny surgery without seeing my MRIs & medical records?”
“Insurers’ UR companies blatantly and willfully ignore and violate the law by issuing UR denials that fail to comply with the law, yet there are no effective sanctions or consequences for doing so,” said de la Torre. “In José’s case, the key medical records weren’t sent, the records UR reviewed were woefully incomplete, and were not even itemized. José has been left to twist in the wind with no treatment while the interminable and opaque IMR review process allowed insurers
to avoid their responsibility to provide the doctor’s recommended treatment.”
The WCAB’s decisions allow insurers to game the system by failing to send UR reviewers adequate medical records to support the doctor’s recommended medical treatment, so UR denies the claim. “It takes injured workers years to go through the maze of UR and IMR obstacles. At the end of the maze, IMR Reviewers continue to uphold 84% of the UR denials of doctors’ recommended care – even doing so without examining the key medical records, as in José’s case. If this happened in group health, there would be a patients’ riot,” said de la Torre. See José Dubon’s story here:
http://www.caaa.org/index.cfm?pg=UR_Denied_Jose_Dubon

–Contributed by Brett G.

Doctors’ Recommended Treatment for Injured Workers is Denied 84% of the Time

Part Four in CAAA’s “What’s Wrong With This Picture?” Infographic on the contrast between the use of IMR decision in Workers’ Compensation vs. Group Health. Read the full article from CAAA below and let us know what you think in the comments section.

From C.A.A.A:

Sacramento, CA – The California Applicants’ Attorneys Association (CAAA), whose members represent Californians injured on the job, today continued its “What’s Wrong with this Picture?” series comparing quality health care measures in California workers’ compensation insurance to group health insurance. The fourth release compares the frequency of Independent Medical Review (IMR) decisions regarding denied medical treatment. The 800,000 workers’ compensation insurance patients appealed IMR treatment denials 60,776 times during a twelve-month period, while the vastly greater number of group health patients (16,000,000) filed just 1,558 appeals. This is one IMR decision for every 10,000 patients in group health vs. one for every 131 workers’ compensation patients. The IMR landslide of IMR appeals reflects a fundamental flaw in workers’ compensation: insurers send 3,500,000 doctors’ recommendations for care to their own Utilization Review (UR) companies each year.

“Why do Californians hurt at work have to file 39 times as many IMR appeals of denied care as group health patients?” asked CAAA President Bernardo de la Torre. “Because insurers use UR to deny their own doctors’ recommended medical treatment. Patients appeal to IMR because if the denial stands, it denies care for one year. Because of UR abuse, denying 84% of doctors’ recommended treatment, IMR appeals in workers’ compensation insurance are filed 39 times more often than in group health. There are no meaningful penalties in workers’ compensation insurance, so insurers are free to deny legitimate treatment without consequence. The deck is stacked against patients in workers’ compensation.”

“Hundreds of millions of dollars are spent denying doctors’ recommended medical treatment. The delays in returning to work harm both patients and their employers, who lose their productivity. The disparity between IMR group health and workers’ compensation clearly shows the system is stacked against patients in workers’ compensation insurance,” said de la Torre.

UR has almost quadrupled since 2005, and is one of the fastest-growing costs in California workers’ compensation insurance, costing several hundred million dollars per year. CAAA is urging a thorough overhaul of the UR process. “Overused and costly UR continues to penalize Californians hurt at work,” de la Torre said. “Californians hurt at work are trapped in a system where delay and denial is the norm. The contrast between medical care denials in the two systems is striking.”

CAAA based its report on information from the Division of Workers’ Compensation (DWC) and the Department of Managed Health Care, comparing twelve months’ experience in each of the two systems.