Dear California Readers,
One of your neighbors experienced a significant head injury while repairing California highways. This individual has diminished cognitive abilities due to this unfortunate work accident.
Sadly, California’s indefensible Utilization Review (UR) system has empowered the workers’ comp insurer to halt this individual’s treatment.
Like everyone who keeps the state’s infrastructure functioning, this injured worker deserves every California resident’s respect and gratitude. More importantly, they deserve access to the medically necessary care to restore their health.
Yet instead of care, this person now suffers from the tragic ramifications of California’s broken UR system, which grants insurers virtually unregulated power to determine the medical treatment an injured worker receives (or does not receive).
Through a series of articles, we will demonstrate how an insurer can repeatedly botch (and arguably manipulate) California’s complex UR laws, regulations, forms, timelines, and medical guidelines and potentially withhold medically necessary care from employees injured while performing work duties.
With this exposé, daisyBill is not advocating eliminating UR in California. Instead, we are advocating for a reformed UR system.
daisyBill is uniquely positioned to demonstrate how California’s UR system makes it far too easy for insurers to withhold potentially necessary care from injured workers.
Daily, hundreds of physicians use daisyAuth to transmit over 1,000 Request for Authorization (RFA) forms and to receive UR decisions. This technology allows daisyBill to track the medical documentation faxed with each RFA and the UR decisions claims administrators and their Utilization Review Organizations (UROs) send to deny, approve, or modify the treatments requested by physicians.
Using our RFA and UR data, we will be writing extensively about the ways insurers (and Third-Party Administrators working on behalf of insurers and self-insured employers) can deny what may be medically necessary and appropriate care — with no fear of regulatory consequences for impeding an injured worker’s recovery.
Injured workers and their employers deserve a better system to guarantee medically necessary care for injured workers and employer protection from physicians providing unnecessary care.
If you missed our series' first article, read it now: SCIF: Inept Utilization Review Delays Care for Injured Worker.
California can do better. Let’s roll up our sleeves and fix this mess. The health of our neighbors and their families depends on all of us and our willingness to demand real change.
In the meantime, this series continues tomorrow with article #2. Stay tuned.
I don’t need to tell you how courageous, focused and competent you are as you lead the only charge (that I know of) at the unethical and utterly uncaring CA state WC system. What you do and what you’ve created with Daisy Bill are the only things that give providers and those we take care of, reason for good hope.
Does anyone remember the case of Charles Romano? Treatment delay after delay after delay resulting in an injured Workes death. Read the case here: https://www.workcompcentral.com/pdf/2013/misc/RomanovKroger.pdf
DaisyBill provides content as an insightful service to its readers and clients. It does not offer legal advice and cannot guarantee the accuracy or suitability of its content for a particular purpose.