Contrary to what some critics of the 2012 California's workers' compensation reform are saying, injured workers throughout the state are receiving the care they need. According to these critics, the changes to the system have established a review process that effectively denies medical treatments to injured workers.
But according to a recent study conducted by the California Workers' Compensation Institute--a nonprofit organization of insurers and self-insured employers--over 95 percent of requests for workers' compensation treatment are approved under the new process, which makes use of utilization review and independent medical review.
Utilization review, for those who don't know, is a when an insurer evaluates the appropriateness of health care services under a health benefits plan. In the context of workers' compensation, utilization review can remove coverage for health care services deemed to fall outside the scope of the worker's comp plan. California's workers' compensation system allows for appeals of utilization review decisions.
The way the process works is that the treating physician or injured worker requests payment authorization for health care services. If that request is met with an order for a utilization review and the payment is rejected after independent examination, the patient is able to appeal. Since the process was implemented, there have reportedly been a great number of requests for review. Of the roughly 70,000 requests sent in, over 5,000 have been decided. Sources didn't say how many of these decisions have been appealed.
Injured workers who experience trouble having their medical needs covered may benefit from speaking with an experienced attorney. Doing so may be the first step in having an intractable dispute resolved.
Source: Insurance Journal, "California Workers' Comp IMR Working: Study, California," Don Jergler, January 14, 2014.