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California WC, Adjuster refuses to fill UR Certified Meds.
#1
Since January my adjuster has started to refuse to fill medications the UR has approved. Its not just me and UR authorizations, their being evil. I found a opened letter outside a doctor's office where a lawyer is threatening to take one of the nastier insurance carriers to court because they will not fill medications the IMR overturned for the IW. If adjusters will not follow the rules of the utilization review and IMR process, what can we do? What is the process for getting medications because California Adjusters are not playing by the rules they created themselves.

I am having to pay for medications out of pocket that are UR Certified, what is needed to make them follow the law? The new trick my adjuster started using was to not send my doctor's request to the UR, no paperwork is being sent so the Adjuster can lie and say "I never got your paperwork". What would you do? Thank you for your help.
 
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#2
Rules for appealing IMR
http://www.dir.ca.gov/t8/10957_1.html
Delay or denial of benefits is grounds for requesting that he court award penalty.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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#3
(04-01-2018, 10:04 PM)Billy Miller Wrote: Since January my adjuster has started to refuse to fill medications the UR has approved. Its not just me and UR authorizations, their being evil. I found a opened letter outside a doctor's office where a lawyer is threatening to take one of the nastier insurance carriers to court because they will not fill medications the IMR overturned for the IW. If adjusters will not follow the rules of the utilization review and IMR process, what can we do? What is the process for getting medications because California Adjusters are not playing by the rules they created themselves.

I am having to pay for medications out of pocket that are UR Certified, what is needed to make them follow the law? The new trick my adjuster started using was to not send my doctor's request to the UR, no paperwork is being sent so the Adjuster can lie and say "I never got your paperwork". What would you do? Thank you for your help.

Sometimes it can be the pharmacy and not adjuster. If it is CVS for example it can take a few times to run the prescription through. If it is denied ask the pharmacist for a print out of the denial. If you are not represented you should then call your adjuster or their supervisor if they do not respond. If this does not work you can file for an expedited hearing. If you have an attorney ask your attorney to file for an expedited hearing.

If your adjuster is not sending requests through UR, you need proof. How you get this proof is ask your doctors office for a copy of the RFA, request, proof of service page with fax or mail confirmation. This shows the request was sent. I cant tell you how many times injured workers thought their doctors requested something and then when they got the RFA they found it was not requested. You will need this paperwork for you or your attorney to file for an expedited hearing if your doctors requests are being ignored. If UR previously denied the request then they do not have to send through UR for 12 months unless change of condition.

In the mean time if you have insurance or Medicare you should be able to use that or pay cash.

If you do not have an attorney try to get help with this from an I&A officer. If you do have an attorney ask them for help. Either way getting the documents I mentioned above will help you. Try asking your pharmacy to run it again if you have not done so already. Also, your adjuster can approve a request and then does not have to send it through UR. Not sure what is going on here. Hope I gave you some ideas.

Best to you.
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.
 
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#4
Read his prior posts--hes not the injured.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
Reply
#5
(04-01-2018, 10:04 PM)Billy Miller Wrote: Since January my adjuster has started to refuse to fill medications the UR has approved. Its not just me and UR authorizations, their being evil. I found a opened letter outside a doctor's office where a lawyer is threatening to take one of the nastier insurance carriers to court because they will not fill medications the IMR overturned for the IW. If adjusters will not follow the rules of the utilization review and IMR process, what can we do? What is the process for getting medications because California Adjusters are not playing by the rules they created themselves.

I am having to pay for medications out of pocket that are UR Certified, what is needed to make them follow the law? The new trick my adjuster started using was to not send my doctor's request to the UR, no paperwork is being sent so the Adjuster can lie and say "I never got your paperwork". What would you do? Thank you for your help.

P.S.
Law changed 1/1/2018. New drug formulary applies.
http://www.dir.ca.gov/dwc/MTUS/MTUS-Formulary.html
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
Reply
#6
(04-01-2018, 10:55 PM)California_Help Wrote:
(04-01-2018, 10:04 PM)Billy Miller Wrote: Since January my adjuster has started to refuse to fill medications the UR has approved. Its not just me and UR authorizations, their being evil. I found a opened letter outside a doctor's office where a lawyer is threatening to take one of the nastier insurance carriers to court because they will not fill medications the IMR overturned for the IW. If adjusters will not follow the rules of the utilization review and IMR process, what can we do? What is the process for getting medications because California Adjusters are not playing by the rules they created themselves.

I am having to pay for medications out of pocket that are UR Certified, what is needed to make them follow the law? The new trick my adjuster started using was to not send my doctor's request to the UR, no paperwork is being sent so the Adjuster can lie and say "I never got your paperwork". What would you do? Thank you for your help.

Sometimes it can be the pharmacy and not adjuster. If it is CVS for example it can take a few times to run the prescription through. If it is denied ask the pharmacist for a print out of the denial. If you are not represented you should then call your adjuster or their supervisor if they do not respond. If this does not work you can file for an expedited hearing. If you have an attorney ask your attorney to file for an expedited hearing.

If your adjuster is not sending requests through UR, you need proof. How you get this proof is ask your doctors office for a copy of the RFA, request, proof of service page with fax or mail confirmation. This shows the request was sent. I cant tell you how many times injured workers thought their doctors requested something and then when they got the RFA they found it was not requested. You will need this paperwork for you or your attorney to file for an expedited hearing if your doctors requests are being ignored. If UR previously denied the request then they do not have to send through UR for 12 months unless change of condition.

In the mean time if you have insurance or Medicare you should be able to use that or pay cash.

If you do not have an attorney try to get help with this from an I&A officer. If you do have an attorney ask them for help. Either way getting the documents I mentioned above will help you. Try asking your pharmacy to run it again if you have not done so already. Also, your adjuster can approve a request and then does not have to send it through UR. Not sure what is going on here. Hope I gave you some ideas.

Best to you.




Hi, my lawyer is long gone after having a heart attack and stroke. The pharmacy has tried dozens of times on one of my medications. The adjuster saw that I did not fight on that medication so she started to wage war by cutting me off all my medications. Adjuster sends my doctors information to the UR except it stopped happening two months ago. The UR was approving my doctors "plan of treatment" agreeing with all the medications.



There is no need for a IMR if Utilization Review approves or certifies treatment, right? Can the Adjuster who ran my doctors RFA through UR decide not to follow the Utilization Review's approval? Do I need the RFA if I have copies of the UR Reports approving medical treatment? She stopped running my psyche doctor's request for treatment through the UR. Doctor has the state of the art certification software with receipt. Do I need copies of both the UR Approval and the Doctors RFAs to request a DOR so it show's the Adjuster is not following any of the rules?

Will Medicare get paid back if the UR agree's with doctor's treatment? I will go down to the DIR agent tomorrow. Thank you!
 
Reply
#7
(04-02-2018, 01:04 AM)Billy Miller Wrote:
(04-01-2018, 10:55 PM)California_Help Wrote:
(04-01-2018, 10:04 PM)Billy Miller Wrote: Since January my adjuster has started to refuse to fill medications the UR has approved. Its not just me and UR authorizations, their being evil. I found a opened letter outside a doctor's office where a lawyer is threatening to take one of the nastier insurance carriers to court because they will not fill medications the IMR overturned for the IW. If adjusters will not follow the rules of the utilization review and IMR process, what can we do? What is the process for getting medications because California Adjusters are not playing by the rules they created themselves.

I am having to pay for medications out of pocket that are UR Certified, what is needed to make them follow the law? The new trick my adjuster started using was to not send my doctor's request to the UR, no paperwork is being sent so the Adjuster can lie and say "I never got your paperwork". What would you do? Thank you for your help.

Sometimes it can be the pharmacy and not adjuster. If it is CVS for example it can take a few times to run the prescription through. If it is denied ask the pharmacist for a print out of the denial. If you are not represented you should then call your adjuster or their supervisor if they do not respond. If this does not work you can file for an expedited hearing. If you have an attorney ask your attorney to file for an expedited hearing.

If your adjuster is not sending requests through UR, you need proof. How you get this proof is ask your doctors office for a copy of the RFA, request, proof of service page with fax or mail confirmation. This shows the request was sent. I cant tell you how many times injured workers thought their doctors requested something and then when they got the RFA they found it was not requested. You will need this paperwork for you or your attorney to file for an expedited hearing if your doctors requests are being ignored. If UR previously denied the request then they do not have to send through UR for 12 months unless change of condition.

In the mean time if you have insurance or Medicare you should be able to use that or pay cash.

If you do not have an attorney try to get help with this from an I&A officer. If you do have an attorney ask them for help. Either way getting the documents I mentioned above will help you. Try asking your pharmacy to run it again if you have not done so already. Also, your adjuster can approve a request and then does not have to send it through UR. Not sure what is going on here. Hope I gave you some ideas.

Best to you.




Hi, my lawyer is long gone after having a heart attack and stroke. The pharmacy has tried dozens of times on one of my medications. The adjuster saw that I did not fight on that medication so she started to wage war by cutting me off all my medications. Adjuster sends my doctors information to the UR except it stopped happening two months ago. The UR was approving my doctors "plan of treatment" agreeing with all the medications.



There is no need for a IMR if Utilization Review approves or certifies treatment, right? Can the Adjuster who ran my doctors RFA through UR decide not to follow the Utilization Review's approval? Do I need the RFA if I have copies of the UR Reports approving medical treatment? She stopped running my psyche doctor's request for treatment through the UR. Doctor has the state of the art certification software with receipt. Do I need copies of both the UR Approval and the Doctors RFAs to request a DOR so it show's the Adjuster is not following any of the rules?

Will Medicare get paid back if the UR agree's with doctor's treatment? I will go down to the DIR agent tomorrow. Thank you!

For the requests that were not sent through UR and ignored I recommend getting the paperwork I mentioned above to prove they were sent but ignored if you or your attorney is going to take the issue to expedited hearing.

I don't know what you mean by your attorney is long gone. Are you still represented by him? If you do not have an attorney you can file for an expedited hearing. If you are still represented by an attorney he will have to file for a hearing.

If you are not represented by an attorney you can call your adjuster and talk to he/she about it. If they do not respond you can go above them and request to speak to their supervisor. You should contact an information and assistance officer for help if you are not represented.

As 1171 wrote above there are new guidelines for medications.
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
#8
(04-02-2018, 12:17 AM)1171 Wrote: Read his prior posts--hes not the injured.

Thanks.
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
#9
File for a hearing claiming Unreasonable delay, if UR and IMR deemed the medication medically necessary then the claims administrator MUST authorize, I would also file an audit complaint with the DWC.

https://www.dir.ca.gov/dwc/educonf12/5814/Penalty.pdf

A. Unreasonable delay: 5814. When payment of compensation has been
unreasonably delayed or refused, either prior to or subsequent to the issuance of
an award, the amount of the payment unreasonably delayed or refused shall be
increased up to 25 percent or up to Ten Thousand Dollars ($10,000), whichever
is less. In any proceeding under this section, the appeals board shall use its
discretion to accomplish a fair balance and substantial justice between the parties.

II. Audit penalty: Any employer or insurer that knowingly violates section 5814
with a frequency that indicates a general business practice is liable for administrative
penalties of not to exceed four hundred thousand dollars ($400,000). Penalty
payments shall be imposed by the administrative direction and deposited into the
return-to-work fund established pursuant to section 139.48. The administrative
director may impose a penalty under either this section or subdivision (e) of section
129.5.
 
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#10
(04-02-2018, 08:49 AM)kev_b Wrote: File for a hearing claiming Unreasonable delay, if UR and IMR deemed the medication medically necessary then the claims administrator MUST authorize, I would also file an audit complaint with the DWC.

https://www.dir.ca.gov/dwc/educonf12/5814/Penalty.pdf

A. Unreasonable delay: 5814. When payment of compensation has been
unreasonably delayed or refused, either prior to or subsequent to the issuance of
an award, the amount of the payment unreasonably delayed or refused shall be
increased up to 25 percent or up to Ten Thousand Dollars ($10,000), whichever
is less. In any proceeding under this section, the appeals board shall use its
discretion to accomplish a fair balance and substantial justice between the parties.

II. Audit penalty: Any employer or insurer that knowingly violates section 5814
with a frequency that indicates a general business practice is liable for administrative
penalties of not to exceed four hundred thousand dollars ($400,000). Penalty
payments shall be imposed by the administrative direction and deposited into the
return-to-work fund established pursuant to section 139.48. The administrative
director may impose a penalty under either this section or subdivision (e) of section
129.5.


DIR employee called and left a message saying they were filing a "DOR" even though the UR had certified the medication. Is there another form to fill out when the adjusters are not adhering to their own UR forms?


The UR approved a medication from Jan to March 2018 and my adjuster refused to fill that medication. The UR finally denied this particular medication on April 3, are there forms I can fill out because the adjuster refused to fill UR Certified Medications? I want the company to get a penalty because they play lots of games, it gets so old having them deny medications that were approved by their doctors.
 
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