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State Official Assails Insurers: Hearing on Workers' Comp Considers Delays Doctors Face After Their Diagnoses.

Posted on: Thursday, 4 May 2006, 12:04 CDT

By Gilbert Chan, The Sacramento Bee, Calif.

May 4--A top state regulator Wednesday faulted insurance companies for going "too far" in questioning medical evaluations by doctors and slowing treatment for severely injured workers.

"Many insurers have gone too far with (reviews)," said Carrie Nevans, acting administrative director of the Division of Workers' Compensation.

Speaking to a standing-room audience attending a special hearing of the Senate Labor and Industrial Relations Committee, Nevans said, "I don't particularly understand, if you selected your doctor through a (medical provider network), why can't you trust those doctors enough to give them some authority ... to provide treatment?"

Nevans said new penalties are in the works to levy $5,000 fines against carriers who unduly reject treatment to injured workers.

Critics, though, put the blame on Gov. Arnold Schwarzenegger's administration for failing to act sooner on broadening medical treatment guidelines for insurers and doctors and for not cracking down on carriers breaking the law.

"Two years is inexcusable. We ought to come up with another system to get them (injured workers) treated faster. We are losing good workers forever," said Sen. Richard Alarcon, D-Sun Valley, committee chairman and an architect of a key workers' compensation law passed in 2003.

Alarcon's measure and the governor's landmark 2004 law, SB 899, required insurers to use guidelines developed by the American College of Occupational and Environmental Medicine when determining whether to approve treatment for injured workers. The goal was to bring uniformity to care and give doctors a scientific way to determine a course of treatment for job-related injuries.

But state officials and physicians admit the ACOEM guidelines are far from comprehensive and don't address all medical conditions or specialties. The state is convening a special committee to consider expanded guidelines to cover areas such as chronic conditions and chiropractic care.

Critics have accused insurers of being too rigid in following the current standards and denying much-needed care - even for workers who had been awarded lifetime treatment.

Nevans, though, pointed to a state-commissioned study that found 76 percent of requests for treatment were authorized by insurers.

Yet, a parade of doctors and injured workers Wednesday accused insurers of dragging out decisions and delaying reimbursements by insurers.

Dr. Daniel Silver, an orthopedic surgeon with offices in Bakersfield and Encino, said insurers reject about 70 percent of his initial requests for treatment.

"It takes 20 percent more effort ... to get the approval. There is no trust. Every doctor is presumed to be dishonest or incompetent," Silver said.

Dr. Bernyce Peplowski, national medical director for Zenith Insurance Co. in Woodland Hills, said her company approves 80 percent of requests without requiring a review. About half of the appeals end up being granted, she said.

Mark Webb, a spokesman for Employers Direct Insurance Co. in Thousand Oaks, defended the insurance industry and traced the problems to confusion over sweeping changes within the workers' compensation system during the past two years.

"We don't benefit from denial of appropriate medical care," Webb said.

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Copyright (c) 2006, The Sacramento Bee, Calif.

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Source: The Sacramento Bee

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