Your best option for better medical care is to choose a doctor who knows the system and how to get care approved. However, your Medical Provider Network (MPN) may not include such a doctor or you may not know which doctor(s) in the MPN are best able to navigate the system. Sometimes a lawyer who has dealt with a lot of doctors can help you, but the rest of this article will assume that you have a doctor who cares about his patients but is overwhelmed by the system. Odds are that will be your situation whether you have a lawyer or not.
Establish a good relationship with the doctor’s staff
The system requires a lot of paperwork. While the doctor’s input is critical to the paperwork, his staff actually produces and distributes that paperwork. You should be friendly with everyone you meet in the doctor’s office. Find out who is the person from whom you can obtain copies of whatever forms are provided to the workers’ compensation insurance and to your employer. Find out if anyone will be submitting paperwork to your attorney, if you have one. You especially want to know who sends the Requests for Authorization (RFAs) to the insurance. In order for the doctor to provide treatment there has to be a request (RFA) sent to the insurance, usually by fax. Make sure there is someone at the doctor’s office who knows the correct fax number to submit those requests. If you know who is your adjuster and what is your claim number, you or the doctor’s office can find out where the RFA should be sent.
If the doctor has proof that an RFA was faxed to the appropriate fax number to request that treatment be authorized and that request is not either approved or denied within the time limits, then the treatment is supposed to be approved. Usually, a doctor will not go ahead on that basis, but an attorney can obtain an “Expedited Hearing” where a judge can order the insurance to pay for the treatment. This is still not all that fast but it keeps the pressure on.
If a doctor is not especially familiar with the system, he might tell a patient that he is “still waiting for authorization” for a particular procedure a long time after he has told the patient that it will be requested. Sometimes it turns out that the doctor’s office has never actually submitted the request, even though the doctor told his staff to make the request or thought they had made the request. If you know who to ask, you can go to that person and find out when the request was made. If the response really is late then getting a copy of the request and the proof of fax to your attorney can help set up the pre-requisites for an Expedited Hearing. Even if the staff won’t talk to you, if you know the name of the person in charge, your attorney’s office can try to obtain the proof of fax and the request.
Talk to your doctor about the process
From the beginning it is good to establish with your doctor what is his attitude about Utilization Review. Some doctors seem to be quite confident that they can get most treatment approved. Others may feel defeated. It is good to know if your doctor is familiar with the Medical Treatment Utilization Schedule and other references for “evidence based medicine.” If the doctor knows what the hoops are that she has to jump through to get a treatment approved that is half the battle. If she tells you “we can’t get that approved until we have tried this,” she probably understands the checklist mentality of the reviewing doctor.
It is ok to ask your doctor, “Do you have a time when you call back UR reviewers?” Find out what the office procedure is for responding to UR reviewers when they call with questions. Maybe the doctor has a Physician Assistant or a nurse who deals with those calls or maybe the office has no procedure. The better prepared they are to deal with UR the more likely they are to get your recommended treatment authorized. If the doctor considers UR review calls to be a nuisance that he avoids, you may find that he has a harder time getting his recommendations approved, even though I suspect that most of the calls are a nuisance to the doctors.
We invite your Comments on this article.
I suggest to doctors that they keep a simple log on one page of what treatment you had when and what the result was. If that was kept up to date and submitted with every RFA I think it would answer a lot of the questions that the reviewers ask. So far, I haven’t found a doctor who does that, but it wouldn’t hurt for you to suggest it to your doctor.
Ask your doctor what he does when a UR denial comes in. Will he appeal it within the short window that appeals are allowed? Will he submit a request for Independent Review on your behalf? Will he read the UR denial and try to address the deficiencies claimed by the reviewer? Sometimes a procedure, test, or drug will be denied because some other procedure, test or drug has not yet been tried. It that is the case, will the doctor request the other precursor test, drug or procedure? He has to read and understand the denial in order to do that.
Keep your attorney informed.
If you have an attorney, keep the attorney’s office informed of your situation. If you were told that the next step for you is some particular procedure, follow up with the doctor’s office and tell your attorney’s staff that you are waiting for approval for that procedure. If the doctor’s office doesn’t call you to schedule the procedure call them.
If things seem to be taking too long, ask the doctor’s staff “Is this normal delay or is this taking too long?” Follow up with the attorney’s staff. You only have 104 weeks of Temporary Disability benefits maximum. In most cases that will be more than enough but your goal should always be to do all you can to recover as fully as you can and return to work. Don’t get complacent and used to not working. Getting better is your job now so get involved with your recovery team, the doctor and his staff. They are the primary people concerned, but if things are getting off track your attorney and his staff can sometimes provide the extra boost that is needed.
I want to repeat what I said in the beginning. Be friendly (or at least polite) with everyone you meet in the doctor’s office. If they are happy to see you, they will want to help you. The same goes for the attorney’s office. Remember, the doctor, the lawyer and all their staff are very busy, so being “friendly” shouldn’t take any more time than necessary. Respect their time and don’t expect a long chat about your situation. Give them the facts and let them tell you the facts. You won’t always like what you learn, but don’t take your disappointment out on the messenger. The system is not responsive to individuals. Your doctor and your lawyer and their staff see this all day every day. They have to work in that system as it is. Just because they tell you, “that can’t be done,” doesn’t mean they think it is right.
Let your legislator know
If you have a bad experience with the California Workers’ Compensation system, you should complain to your California Legislators and to the Governor’s office. They are the ones who created the system while ignoring input from injured workers and their representatives. Let them know how the system failed you. If you had treatment denied or delayed that would have allowed you to recover and return to work sooner, they need to know. The “links” on Hurtworker.com include a link to help you find your State Senator and State Assembly representative as well as Voters Injured at Work, a lobbying group of injured workers. Get involved in your own recovery and get involved in improving the legal system.