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I continue to be amazed - Printable Version

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I continue to be amazed - TripleP - 08-09-2010

Its been awhile since my last post...I hope everyones "Journies" in Workers Comp World are going well. I am located in PA and things in my case are progressing well, with the Insurance Carrier approaching my lawyer and I about settling...Thats the good..

The judge ruled in my favor for the Supersedeas continuing my comp & benefits..Thats good...

Now the bad and the rant......My utlization review came in....I sent my testimony in to the "Independent Review Panel" which clearly stated what was performed and when. I am so glad that these review groups are so proficient in the english language that they clearly misread my letter leaving out key points and even changing the facts. Not too mention that when this review process began they gave a drop dead date for the all materials to be submitted...Well my doctor which comes from a giant practice and is run like our federal bureacracy did not submit the forms as stated in the letter in a timely manner, but within the time frame stated overall.

This supposed independent panel used only materials benefical to the insurance companies...leaving out various other opinions, taking only those that were of favor of the insurance company...Its good to see they ruled that my treatment was viewed as not reasonable or ncessary.

I can not wait till I am free and clear of this Workers Comp nonsense!


RE: I continue to be amazed - Timothy Belt - 08-10-2010

If you want an interesting read, I pulled the paragraph below from seminar materials I resently prepared.

"Even if the records are produced by the provider under review within the proscribed time frames the URO may still issue a determination that the treatment is neither reasonable nor necessary if the required verification form signed by the doctor is not also provided in a timely manner. In Sexton v. WCAB (Forest Park Health Center), 974 A.2d 546 (Pa.Cmwlth. 2009) the provider under review did produce his records in a timely manner to the URO, but he failed to provide the signed verification form. As a result, the URO returned the records to the provider, failed to assign the UR to a reviewer and issued a determination that the treatments were neither reasonable nor necessary. A Petition to Review UR Determination was filed and the WCJ concluded that under Section 127.459© of the Workers’ Compensation Medical Cost Containment Regulations (Regulations), 34 Pa.Code § 127.459, a verification form was required, but the Regulations did not direct a URO to return timely received records for lack of verification. On appeal to the WCAB, the WCAB concluded failure to timely issue the verification form with the medical records to the URO was a failure to comply with the utilization review provisions."


RE: I continue to be amazed - TripleP - 08-10-2010

Thanks for the reply Mr. Belt...

Certainly something I will bring up with my lawyer.


Timothy Belt Wrote:If you want an interesting read, I pulled the paragraph below from seminar materials I resently prepared.

"Even if the records are produced by the provider under review within the proscribed time frames the URO may still issue a determination that the treatment is neither reasonable nor necessary if the required verification form signed by the doctor is not also provided in a timely manner. In Sexton v. WCAB (Forest Park Health Center), 974 A.2d 546 (Pa.Cmwlth. 2009) the provider under review did produce his records in a timely manner to the URO, but he failed to provide the signed verification form. As a result, the URO returned the records to the provider, failed to assign the UR to a reviewer and issued a determination that the treatments were neither reasonable nor necessary. A Petition to Review UR Determination was filed and the WCJ concluded that under Section 127.459© of the Workers’ Compensation Medical Cost Containment Regulations (Regulations), 34 Pa.Code § 127.459, a verification form was required, but the Regulations did not direct a URO to return timely received records for lack of verification. On appeal to the WCAB, the WCAB concluded failure to timely issue the verification form with the medical records to the URO was a failure to comply with the utilization review provisions."