The California Applicant Attorney’s Association says there’s a BIG problem with UR in California, and a recent analysis by CWCI is flawed and inaccurate.
I don’t see it.
Greg Jones’ piece in yesterday’s edition of WorkCompCentral digs deep into the issue; here’s the brevitzed version of the disagreement.
CWCI analysis indicates about 75% of ALL treatment requests are approved by the adjuster or surrogate referring 25% on to an elevated physician-based UR process.
Elevated UR denies or modifies 23% of the treatment requests for an overall denial/modification rate of about 6% (.25 x .23 = 6%). The denial rate falls even further to less than 5% for claims that go through the state’s new medical dispute resolution process, independent medical review (IMR). CAAA’s consultant argues that the denial rate is higher, by:
- citing different studies from different years with different samples, thereby comparing apples to oranges;
- asserting that there’s a lot of variation in denial rates among payers, as if this was a bad thing or even meaningful (different employer types, different locations, different medical management strategies);
- claiming that CWCI’s analysis was in error because their study included medical-only and not just indemnity claims, as if a standard of care or UR should or could somehow be different for claims with lost time. Guidelines are guidelines; they apply to all injured workers and don’t vary by type of claim.
Moreover, the premise of CAAA’s argument – to the extent there is one – is fatally flawed.
A denial rate of 5% is hardly a catastrophe – especially when one considers where California was before the 2004 reforms – known as the physician’s presumption of correctness. Treating docs decided what treatment was appropriate, based almost exclusively on their personal opinion, or for a relative few, how they could generate the most revenue. Payers had few opportunities to challenge a treatment plan. Treatment costs exploded to over $12 billion a year.
Would anyone allow a vendor to completely determine what services they were going to provide at what cost to whom?
Of course not. This is completely at odds with every other payer system’s medical management methodology/process, because it is wildly illogical. Yet that appears to be the motivation behind CAAA’s “analysis”.
Today, about 5% of treatment requests are denied or modified, medical costs are half what they were and employer premiums are way down as well.
Let’s look a little deeper at the results.
CWCI found that 43% of elevated UR and a third of the IMR reviews were for drugs. About half of those RX reviews are for opioids and compound drugs. Most likely a relatively few docs have a disproportionate percentage of challenged treatments.
The key is what are they doing and why – if they are prescribing Oxys to patients not supported by medical evidence, that’s wrong. And, the current IMR process has begun to fix that problem.
Yes there are workflow problems, problems that will be resolved. Yes the process needs to get a LOT more efficient and less expensive. Yes guidelines need to be constantly updated.
And No, we don’t need to go back to the days of never ending treatment at the whim of the treating doc and bankrupt insurers.