(09-24-2015, 09:07 PM)neckpain101 Wrote: Thank you Calif.
This is a notice of hearing, and the reason is for status conference, that's all it said in the notice. No, none of the atty. indicate why they need this conference.
In regard to the UR's denials, yes, the atty did go thru the IMR request, but they upheld it. And, said they did all they could.
(09-30-2015, 12:56 AM)neckpain101 Wrote: Calif,
If I have questions about not understanding the UR or the IMR, who should I talk to, my atty or my PTP? In another word, who is obligated to explain it to me?
Thanks again!
Hopefully if you have questions either your doctor or attorney will help you. I think if you are having difficulties obtaining medical treatment it would be beneficial to learn the basics of this system. Every WC board has a monthly one hour training class for injured workers but this system is extremely complicated.
I recommend to request a free guidebook from this link. You can also read the guidebook directly from the link. This gives a very basic explanation to the UR and IMR process and you can also use the search box of this link to review UR and IMR process. You can also search your questions by placing the topic in the search engine of this link.
http://www.dir.ca.gov/dwc/InjuredWorker.htm
The basics of UR and IMR:
1. Your doctor makes a request on a form called RFA form. If the request is not sent in on this form your adjuster can ignore it. If you are seeing a doctor outside of an MPN your adjuster can ignore his RFA requests and also if a body part is in dispute.
The best way to get approvals is if your doctor sends medical treatment guidelines and rational to get the request approved. Many doctors are not doing this which results in denials. California workers compensation uses specific medical treatment guidelines to approve and deny requests.If your condition does not fall within the medical treatment guidelines used with CA WC you can use any scientifically accepted guidelines. I know this sounds complicated. You will see these guidelines quoted in your UR denials and they look like this for example "MUTS chronic pain for lumbar strain states".
2. Your claims adjuster can approve the request OR send it to UR. A claims adjuster cannot ever deny a request as she is not a MD.
3. Within 5 business days (not counting the day it was sent) the decision must be made to approve or deny the request UNLESS UR needs additional information from your doctor. If this happens the UR company has 14 days (not business days without counting the day sent) to approve or deny.
4. Once you get a UR denial look to see if the UR company has an internal UR appeal process. Most of them do and the information about this is on the last few pages of the UR denial. This is NOT IMR. It is not mandatory for a UR company to have an internal UR appeal process, but most do. If your UR company has this available your doctor, your attorney, or you need to submit the appeal usually within 10 days (usually but every UR company has different rules so check what it states on the UR denial). In my opinion it is much easier to get an approval this way than by IMR. I do recommend doing both UR internal appeal and IMR because there are timelines for this and if you miss one you are SOL for 12 months. A doctor can appeal this the best, and some will while others will not. This is because they do not get paid for this, are very busy and many are not familiar with the guidelines or how to do a internal UR appeal (just FYI). I would recommend to ask your doctor if he appeals UR denials by internal UR appeal process. If he states he will do UR appeals I would recommend to call his office to ensure he is aware of the denial so he will appeal it. Often times these denials are not shown to the doctor and just placed in your medical file.
I recommend reading the UR denial to see WHY it was denied. For example surgery may be denied based on conservative treatment such as physical therapy was not attempted first. If you did do PT then this would be something easy for your doctor to appeal. If your doctor will not appeal the UR denial you can do it as well. You can write a letter stating you did the PT and send a report or record showing you did it. Most denials are not this easy to appeal. I am just giving an example.
5. Once you get a UR denial you have 30 days to request an IMR. You, your doctor or attorney can request the IMR. Many attorney's are doing this for their clients and proving records but that is it. This can result in another denial by IMR because 90-95% of IMR determinations are denials and if no one is addressing the REASONS for the original denial and are just sending records it is often times not enough to get an approval. This is why sending a good appeal to IMR is better than just sending records which may or may not be read especially if a lot of records are sent.
6. If you get an IMR denial or do not send in an IMR after a UR denial it stands for 12 months before your doctor can request it again UNLESS you have a change of condition or if material facts not known for example relevant records were not sent to the UR doctor your doctor can make the request again before the 12 month period, but must check off the box on the new RFA request that states change of condition or material facts etc.
You can also ask an information and assistance officer for help explaining this process. Some state they cannot help if you are represented by an attorney, but I have been told that is not correct.
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.
