Weinmann, MD: Insurance Industry Sabotages Injured Workers in California (Schwarzenegger's veto)

[Omaha Steve]

http://www.californiaprogressreport.com/2008/10/insurance_indus.html

By Robert L. Weinmann, MD

Governor Schwarzenegger's veto of AB 2969 (Lieber) protects insurance company profits at the expense of injured workers. This legislation, proposed by Assemblywoman Sally Lieber, would have put a stop to an insidious practice by the insurance industry that undermines injured workers, sabotages treatment prescribed by properly licensed doctors, and protects wrongful business practices by insurance interests. Here's how the protected scheme works:

Joe Sixpack or Soccer Mom Sarah incur an on-the-job injury. The injured worker goes to a clinic that accepts industrial injuries. The injury turns out to be complicated. Specialists are consulted. Treatment recommendations are made. Documents are filed according to law to make sure that treatment is covered by the insurance company. At this point insurance companies may retain Utilization Review (UR) companies to review the treatment that has been provided as well as the treatment that is being recommended or prescribed. These reviews are conducted in accordance with law, namely, the AMA Guides, 5th edition, and the ACOEM Guidelines, 2nd edition, both of which enjoy the force of law thanks to statutes pushed into law by the Schwarzenegger administration to reduce costs of industrial injuries to insurance companies and to employers.

The AMA and ACOEM cookbooks allow UR doctors who have not interviewed or examined injured workers to review treatment proposals and to delay, deny, or modify treatment. UR doctors are allowed to overrule properly licensed doctors who have spent hours with their patients. UR doctors who make decisions about workers injured in California do not need to be licensed in California. Any license will do. UR doctors do not have to interview or examine injured workers. UR doctors review paperwork to do their jobs. When these disturbing inequities were noticed in Texas, legislation was passed to put a stop to it -- UR doctors in Texas must now have Texas medical licenses. They're responsible to the Texas Medical Board.

In California UR doctors need not be responsible to any medical board at all. In one quizzical situation, an injured worker in California, under treatment by a California-licensed doctor, had his treatment stopped dead in its tracks based upon the UR decision of a doctor with only a Connecticut license. To add insult to injury, the Connecticut doctor reported his denial of care to a UR company based in Texas. The upshot was that the UR doctor licensed only in Connecticut and the UR company based in Texas effectively conspired to stop treatment prescribed by a California-licensed doctor and that was already underway in California.

Insurance companies and their compliant utilization review companies may use doctors whose bent is to deny as much care as possible. Because UR doctors are allowed to practice medicine in California without California licenses, UR doctors don’t need to worry about what the Medical Board of California might do when they cause harm to patients by wrongful denials, delays, or modifications of care.

FULL story at link.