Yesterday California’s Supreme Court fully supported the State’s workers’ comp UR/IMR process.
That is excellent news.
First, here’s the key takeaway – the Court ruled that workers’ comp remains the “exclusive remedy” for resolving disputes related to treatment approvals/UR/IMR.
Second, the California Legislature may well take up the issue and require payers to take into consideration the potential medical effects of a treatment decision, perhaps including weaning off medications that are no longer approved.
UR/IMR is an inherent part of the workers’ comp process, and therefore falls under the exclusive remedy provision of work comp. So, the plaintiff could not sue the IMR reviewer for an allegedly adverse treatment decision.
(Any treatment arising from the plaintiff’s medical care – which in this case was allegedly due to the suddenly stopping a medication – is part of the work comp claim.)
Here’s how CWCI General Counsel Ellen Sims Langille put it:
We have long contended that exclusive remedy was the beginning and end of the discussion in this case, inasmuch as the URO was acting in the capacity of the employer, and as a statutorily required part of the claims process, and now the Supreme Court has agreed. The URO was acting as the “alter ego” of the employer, and the utilization review itself is a statutorily required part of the claims process. That is the very definition of exclusive remedy.
The Court of Appeal had made an obvious error in finding that the seizures suffered by Mr. King were compensable outside of the workers’ compensation system because there were no allegations that he was working at the time he suffered the seizures. That is a fundamental misunderstanding of how compensable consequences work. As our Amicus brief argued, the injuries alleged by Mr. King were derivative of a compensable workplace injury, and the new compensable consequences injuries fall within the scope of the workers’ compensation bargain — and within exclusive remedy.
But there’s more, which may lead to additional legislative action to address the underlying event behind King…again from Langille:
Concurring Opinions were filed by two justices, and may prove to be the enduring legacy of the decision. Justice Liu frankly invites the Legislature to examine whether existing safeguards provide sufficient incentive for competent and careful utilization review, pointedly noting his skepticism that “a care plan… appropriate for the medical needs of the employee” was established before the Klonopin was discontinued. Even the Majority Opinion referenced the same language from §4610(i)(4)(C). Unfortunately, it does not appear that any of the justices understood that this subsection applies only to cases of concurrent review, which is defined under Reg. §9792.6(d) as “utilization review conducted during an inpatient stay” and thus inapplicable to the facts of this case. Be that as it may, it is likely that the next legislative session will include some effort to expand the safeguards for the injured worker under utilization review.
What does this mean for you?
Consider the impact of medical treatment decisions on the patient’s future condition.