Some Workers’ Compensation Claimants Say Treatment Guidelines Limit Care Options
Some injured workers say new rules that allow workers' compensation insurers to evaluate treatment requests based on a series of guidelines by the American College of Occupational and Environmental Medicine are preventing them from receiving needed care, the San Francisco Chronicle reports. Some experts also say that misinterpretation of the guidelines and the exclusion of certain treatments from the guidelines are leading to wrongful denials of care (Abate, San Francisco Chronicle, 2/6).
The administration of Gov. Arnold Schwarzenegger (R) on Dec. 23, 2004, issued an emergency regulation to change the guidelines for determining workers' compensation insurance payments for permanently injured workers starting Jan. 1.
Under the regulation, workers' compensation payments are determined using guidelines to assess the extent of injuries. Classifications include such factors as age, job and "diminished future earning capacity." Injured workers can appeal their awards in court (California Healthline, 1/3).
Lachlan Taylor, an administrative law judge with the Workers' Compensation Appeals Board, said reports of care denials are "so consisten[t] that we believe it is consistently happening," but he added that there is no way to determine the number of legitimate claims that are denied.
Doug Benner, who oversees 31 Kaiser Permanente occupational health clinics, said that the guidelines are used correctly in 80% to 85% of cases, adding that "the process of the regulations may not be followed" in the remainder of cases and the guidelines are incorrectly applied to some cases.
Mark Gerlach, a consultant to the California Applicants' Attorneys Associations, said that workers' compensation insurers are using the guidelines to approve or deny treatments, which is outside of their intended purpose.
Washington state physician John Holland, who helped write the guidelines, said they are not "meant to provide hard-and-fast, black-and-white rules about what types of treatments are appropriate and how much of it."
Andrea Hoch, director of the Division of Workers' Compensation, said the agency is revising the guidelines, after a RAND report in November 2004 found the guidelines lacking in such areas as medical devices, home health care, medical equipment durability and toxicology. She said DWC also is considering levying fines against companies who delay coverage decision or fail to alert injured workers to denials promptly.
"We are achieving more stringent review on the overutilization. Whether we're throwing out the baby with the bath water, it's too soon to tell yet," Hoch said (San Francisco Chronicle, 2/7).
Some doctors say they have been "swamped with paper work and denials of care" since the guidelines were introduced, and others are moving to states where workers' compensation laws are "less cumbersome," the AP/Riverside Press-Enterprise reports.
Nicole Mahrt, a spokesperson for the American Insurance Association, said, "Change is hard; that doesn't mean it's wrong. It was certainly no one's intention to drive doctors out of the business. At the same time, abuse was going on in the system, and we needed to bring in new rules."
Spine surgeon Jeffery Coe said that although some services may have been overused, the "pendulum has swung too far." He added, "Instead of providing care you're paying people to deny care" (Lawrence, AP/Riverside Press-Enterprise, 2/7).