Hello There, Guest! Login Register
Index    |     Search    |     Members    |     Help

Thread Rating:
  • 1 Vote(s) - 5 Average
  • 1
  • 2
  • 3
  • 4
  • 5
CA-California. IMR: Claims Administrator not sending medical files
#1
What remedies does a worker really have when IMR's are being UPHELD in the IC favor? Claims Adjuster sent no medical records for multiple reviews in my case.

Workers are at a complete disadvantage since it is a challenge to get necessary reports and write our own appeals based on MTUS, ODG guidelines. Good luck getting docs, lawyers to help much on all of this. It is incredibly time intensive and they aren't really interested in old clients with long term medical issues.
 
Reply
#2
contact your state legislator; they approved the process.
........Each state has their own comp system; POST YOUR STATE to get accurate information.........
 
Reply
#3
I think in about every state the laws are not in favor of the injured worker and CA is one of the worst. There is really nobody but the injured workers to fight for any change in the laws to help us out and the insurance companies have money to lobby for their side. In my state they even talk about how the high cost of thinks like WC hurts businesses. What they never really dig down and look at is that folks that really get hurt and need help get such a big run around and in many cases these companies spend more fighting them then they do providing the care we need.
Most people see WC injuries as lazy people that are just trying to get free money out of the employers and don't want to work and until it happens to them or somebody they know not much is going to change. And those out there that have used the system to get money they really need earn have killed it for those that truly need the care. You never turn on the news and see a story about how an employee got hurt on the job and because their employer fought them they lost their house and now live in daily pain but one person gets caught scamming the employer out of money because of a WC claim and it will make every news source out there.
 
Reply
#4
(02-19-2014, 01:14 PM)1171 Wrote: contact your state legislator; they approved the process.

Great! No penalties for the IC to openly break the law. Even when there are penalties, they are so small that the IC just ignores them too. Absolutely no teeth in the law to protect workers. This entire system in California is so hijacked it’s virtually impossible for workers to get the treatment they need to return to work and keep working.

Note to any and all workers injured in California: If you have private medical insurance you are far better off lying that you hurt yourself outside of work so you can actually get the medical care you need to survive, recover, and move on with your life. Yes, you will have to pay for it on your own. But at least then your private insurer can’t deny you care that work comp was SUPPOSE to be delivering and paying for. Once you file comp and your injuries are accepted, your private medical insurance for these injuries is worthless to you.

Don’t think for a minute the workcomp system is going to help you because it won’t! It will suck every last piece of life out of you and leave you to wither and die. You are not going to get better; you are not going to get treatment. You will likely end up jobless, homeless, and better off dead.

Off to take care of the last and final part of this…. can’t deal with it any longer.
 
Reply
#5
nothing happens as fast as you want it to.
other then going back to court to plead your case the only thing you can do is complain to your legislator.
whether penalties and or sanctions will be levied depends on the persuasiveness of your evidence.
........Each state has their own comp system; POST YOUR STATE to get accurate information.........
 
Reply
#6
(02-19-2014, 12:55 AM)SickOfTheProcess Wrote: What remedies does a worker really have when IMR's are being UPHELD in the IC favor? Claims Adjuster sent no medical records for multiple reviews in my case.

Workers are at a complete disadvantage since it is a challenge to get necessary reports and write our own appeals based on MTUS, ODG guidelines. Good luck getting docs, lawyers to help much on all of this. It is incredibly time intensive and they aren't really interested in old clients with long term medical issues.

If no records were sent by the claims adjuster your attorney can file for a hearing on this. The new regulations state the past 6 months worth of records should be sent by your claims adjuster.

You may also be able to get another UR for this issue on your own within the 12 month waiting period if the new request "is supported by a documented change of the facts material to the basis of the utilization review decision".

Regarding the question of whether there has been a change of the facts material of the original denial there shall be an opinion asserting such change exists and new review is required, unless there is a finding by a licensed health care provider has been no such change.

Such findings require that there be consideration of the supportive change in patients presentation has been:

Relevant supportive change in patient presentation; and/or
Relevant supportive findings from new diagnostic studies or imaging, and/or
Relevant support change in interval clerical history.

I would recommend printing this out and asking your doctor if your condition falls under this. This could mean if some testing's relevant to your doctors request such as MRI etc were NOT previously sent o UR, then you can request another UR stating the material facts of these records were not known to the UR reviewer.

If your condition gets worse, then this may be grounds for new UR.

An IMR denial does not necessarily mean you are stuck for 12 months.

I recommend asking your attorney about your IMR and can he file a hearing over issue that no records were sent.

I recommend being at a doctor who writes reports with medical back up, AND who will do a UR appeal if denied AND who will also help you with IMR if needed. This is the number one reason I see patients stuck. Their doctor is not doing what they should to get the patient the requested treatment. This is a VERY complicated system and unfortunately if the doctor is not well versed in it, the patient can suffer. Even when the doctor is well versed, it is an uphill battle. I do not know if this is your situation. Your attorney should be able to tell how well your doctors requests are being written.

You should also take the initiative and request your records. You can also send UR records, as well as your doctor, as well as your attorney. If no one is looking out for you, this may become a regular problem.

So the answer to your question is yes there are things you can do about this. File for a hearing over the lack of records sent to IMR, get your doctor to write another request if your condition and or medical records warrant a new UR (any savvy doctor could find a reason in most cases IMO). Look at what was sent to UR in the request. Was it just the doctors request, and no MRI's etc....well then that may be cause for new UR. I don't know, but discuss this with your doctor and attorney.

If your doctor is not cutting the mustard get someone who can.

I have not seen the fat lady sing yet in your case, and this means it ant over.

Good luck to you. Don't let this litigation process get you down. That is their intent.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
Reply
#7
(02-19-2014, 05:08 PM)Manley2 Wrote: I think in about every state the laws are not in favor of the injured worker and CA is one of the worst. There is really nobody but the injured workers to fight for any change in the laws to help us out and the insurance companies have money to lobby for their side.

In my state they even talk about how the high cost of thinks like WC hurts businesses. What they never really dig down and look at is that folks that really get hurt and need help get such a big run around and in many cases these companies spend more fighting them then they do providing the care we need.
Most people see WC injuries as lazy people that are just trying to get free money out of the employers and don't want to work and until it happens to them or somebody they know not much is going to change. And those out there that have used the system to get money they really need earn have killed it for those that truly need the care. You never turn on the news and see a story about how an employee got hurt on the job and because their employer fought them they lost their house and now live in daily pain but one person gets caught scamming the employer out of money because of a WC claim and it will make every news source out there.

The insurance company does a good job with giving people the impression there is a lot of injured workers who are committing fraud, however that is not true. In California for example less than 1% of workers compensation fraud is committed by the injured worker. MOST fraud is employer, medical provider, and insurance company fraud.

I agree that the insurance company does have a big lobby. That is why it is very important for injured workers to lobby for their goals. This is the way to change the system.

It is not true that in California there is no one looking out for injured workers. There are injured workers who are lobbyist as well as organizations who lobby for the welfare of California injured workers. Injured workers in California, you are not alone.

I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
Reply
  


Possibly Related Threads...
Thread Author Replies Views Last Post
  2018 rate increases for California claims 1171 2 542 12-30-2017, 08:48 PM
Last Post: chrischris
  Desperate for answers California IC offered me cash to buy my life medical Sugarpuss44 5 961 08-23-2017, 09:29 PM
Last Post: California_Help
  Has anyone successfully moved out of California with lifetime Medical? TreadingWater 10 2,173 07-15-2017, 04:23 PM
Last Post: California_Help
  Claims Manager Accessed All Medical Records? shefallsdown 5 1,459 02-10-2017, 10:35 PM
Last Post: California_Help
  *no names please* is sending me for 2nd IME and want to settle before lumbar hearing CheriLovesJesus7 10 12,246 01-26-2014, 02:48 PM
Last Post: bronco54501
  Workers Comp sending me back to Dr. Cathy 14 12,436 10-26-2013, 02:11 PM
Last Post: CheriLovesJesus7
  IC is sending me 2 checks??? Bobby 2 4,331 06-18-2013, 01:20 AM
Last Post: darruda66
Rolleyes WC sending me back to doc lonelylib81 1 1,863 06-09-2013, 11:08 PM
Last Post: Cervical_Fusion
  Worker comp company wants to offer medical trust instead of lifetime medical benfits de88iet 1 7,800 10-20-2012, 12:36 AM
Last Post: 1171
  california and using medical cannibus while on workers comp mrssleepy 2 3,529 10-13-2011, 03:06 PM
Last Post: mrssleepy

Forum Jump:


Browsing: 1 Guest(s)