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Too many hands in the pot excluding the most important player
I had a UR denial for surgery that can be considered “major procedural defects” (Invalid), medical records were not forwarded to the surgeon for a surgical consult that was authorized by UR and the surgeon was authorized by the adjuster, this surgeon only had the tests results and films I gave him, the UR reviewing doctor denied the surgery because there were no documentation of conservative treatment and it’s failure although the report from the consulting surgeon did state that all conservative treatment failed, I would think when the UR doctor seen that he would have asked for those records before denying treatment.

Dubon vs World Restoration
"Material defects include failure to adhere to time requirements or to provide all “relevant medical records” to the UR physician. Such “material defects” renders the UR decision invalid.
The WCAB noted that the major UR flaw in Dubon was the limited medical file provided to UR in addition to a failure to specifically identify the medical records reviewed. The Board deemed both actions as major procedural defects. It clarified that all “relevant medical records to the issue being decided by UR” must be provided. At the same time, it noted claims examiners do not have the burden of providing the complete medical file for every UR determination – yet, if the examiners don’t, the UR decision is in danger of being deemed inadequate."

Messages In This Thread
RE: Too many hands in the pot excluding the most important player - kev_b - 04-16-2014, 10:17 AM

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