State Data Shows Injured Workers Face Uphill Battle During Workers’ Comp Appeals Process

This article originally appeared as a segment of an NBC Bay Area investigation into California's Workers' Compensation System. The original article can be read in it's entirety here: NBC Bay Area Workers Compensation Investigation Part III .

Injured workers face an uphill, long-odds battle if they want to appeal the denial of medical care through California’s workers’ compensation system, state data shows.

Since reforms made in 2013 under Senate Bill 863, injured workers can no longer appeal treatment denials in front of a judge. Now, the state contracts with a private, for-profit corporation that reviews appeals under a process called “Independent Medical Review.” The company pays anonymous doctors, who have never examined the patient in person, to make those decisions based on a standard set of guidelines.

Patients don’t stand much of a chance under the new system, the data shows. Between 2013 and 2015, injured workers contested almost 600,000 denials of medical treatment. Those denials were upheld nearly 90 percent of the time when reviewed on appeal by independent medical review doctors.

The UR/IMR system is biased against injured workers and their doctors. While proponents of the UR/IMR system would claim that IMR’s upholding 90 percent of the denials is evidence that most treatment requests were unnecessary, those who witness the results of the denials of treatment on a daily basis know differently. Medical professionals understand that the practice of medicine is an art that should not be reduced to arbitrary standards of “old” medicine. UR/IMR prevents the physician from treating his patient effectively.

The bizarre irony is that in a majority of instances, the cost of denial of treatment is more than the cost of the treatment denied. The big savings to employers and insurance companies is found in the area of denials of medications and treatment for the chronic pain patient and in the denials of surgical treatment and effective after-care.

Most physicians simply desire to treat their patients as effectively as possible. Most injured workers simply want effective treatment that will return them to their jobs as soon as possible. Under the UR/IMR system, frustrated physicians are looking elsewhere for patients to treat and undertreated injured workers are often unable to return to work, at all.

But employers benefit and insurance company profits are at record highs.

Read the original article here. ​