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Workman Compensation Utilization Review Baord

Sacramento, CA |

Utilization Review Board authorized me a very expensive Restoration Function Process but It expired due to a delay by the old insurance company. Now the new insurance company old records to their Utilization Review Board and they denied it. My QME said I needed the program in two reports but they didn't send that to their Utilization Review Board and they want me to do a Independent Medical Review to Dispute it. What are my other options here. They are refusing to send me my file so I can send in the proper paper work

Attorney Answers 5

Posted

There is no such animal as a Utilization Review Board ... there is only a Utilization Review process.

The Treating Physician issues a written request for treatment, the insurer hires a Utilization Review company who pays a doctor (who never sees you) to either 'certify' or 'non-certify' the treating doc's request.

WHEN a Utilization Review doc writes that the requesting physician is wrong, the treatment is non-certified, ONLY THEN do you go to the Independent Medical Review. ANd there's a deadline for that, which I strongly suspect has long passed.

YOU HAD A PIECE OF GOLD in your hand: you had a Utilization Review doc saying "Certified" to a QME suggestion. GET THAT LETTER/NOTICE and go to a Workers Comp judge and get it ordered.

The insurer/third-party administrator has no duty to send you your file. Adjusters were forced -- by law and threat of penalties == to send you notices to comply with the law.

IT WAS YOUR DUTY to save the notices and letters. IT'S not the adjuster's responsibility to 'replenish' these when you lose them. Your Attorney -- which you WILL hire shortly, correct? -- can subpoena these notices.

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Asker

Posted

Thank You. The time for IMR has not long passed. I just go the notice on Friday of the denial. However, Fort'e is giving me 10 days to send in supporting documents to appeal their decision. They have an internal appeals process and I sent all the supporting documents via over night mail today. The adjuster sent three ambiguous letters picked from my file to make it seem like the program wasn't necessary. Since the UR Doctor denied me because he said based on the three letters that my adjuster sent, it didn't seem as if I qualify. Believe me, I sent my QME report and much more..although older information but still useful. I was represented by an Administrative Law attorney fr 15 years that wanted me to be her first WC and offered t o only charge me 10% instead of 15. Well, she messed up my case horribly. She filed multiple DOR's back to back and incorrectly, she filed the request for reconsideration in 35 days instead of 20. What she wrote was good but the judge plowed her for all her mistakes and asked the appeals board not to consider my file due to untimely filing. I had to fire her and I asked that they would hear my case anyway because my attorney thought she had 30 days to file my request for reconsideration. I have been calling her to return my call but I guess she has refused to call me back so I am at the mercy of the insurance company in order to get access to my files.

Posted

It should be clear that you need an attorney ASAP. If you had one from the beginning, you almost certainly would not be asking this question.

If this information has been helpful, please indicate by providing feedback that the answer was either "helpful" or "best answer" as appropriate. Legal Disclaimer: Mr. Candiano is licensed to practice law in Illinois and Indiana. The response herein is not legal advice and does not create an attorney/client relationship. The response is in the form of legal education and is intended to provide general information about the matter within the question.

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Posted

I made hired a attorney who was in Administrative law for years and she messed up my case by incorrectly filing D.O.R's, riled my request for reconsideration in 35 days and even though everything was correct the judge requested it be denied due to untimely filing. At this point no attorney would touch my case and out of respect I wont say who she is even though is has been with AVO for a long time. She messed me up because she is a single attorney who took on a lot of cases and lost paperwork and did foolish things. Based on that can you just help ME by telling me what I can do. I don't think doing the reconsideration with Forte's is smart because their website is employer focused and not employee focused at all

Charles Joseph Michael Candiano

Charles Joseph Michael Candiano

Posted

You have RESPECT for someone who "messed you up," ... "took on a lot of cases and lost paperwork and did foolish things"?

Asker

Posted

I am torn. The public deserves to know how bad she messed up my case so they won't make the same mistake in hiring her but she is a small law firm and get's all her business from avvo clients. I know she is very poor and if I do that then it could send her over the edge. I am still considering the right thing to do. Anyways, Forte Ur gave me 10 days to send them supporting paperwork to appeal their decision. The adjuster sent three ambiguous notes from my file to prove that I didn't need the program. I still had my QME report where the qme said I need the program. I also sent a few other supporting documents. The files I sent were a little old but useful. I also explained that i don't have any of the new information because the insurance company is refusing to send me my updated file.

Posted

IMR is a nightmare. It's a brand new process and no one understands it. It is buried in IMR requests far beyond anything they ever expected. You only have 30 days to request IMR after that you're out of luck for one year....maybe. You may also want to file to go to court if the U/R is defective. Very complicated stuff. If the lawyers are having problems figuring it out, you don't stand a chance. Get a lawyer ASAP.

Plenty of excellent WC lawyers in Sacramento. Find a good one here at www.avvo.com or at www.caaa.org. CAAA is the association for attorneys here in CA who represent injured workers.

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Posted

I made hired a attorney who was in Administrative law for years and she messed up my case by incorrectly filing D.O.R's, riled my request for reconsideration in 35 days and even though everything was correct the judge requested it be denied due to untimely filing. At this point no attorney would touch my case and out of respect I wont say who she is even though is has been with AVO for a long time. She messed me up because she is a single attorney who took on a lot of cases and lost paperwork and did foolish things. Based on that can you just help ME by telling me what I can do. I don't think doing the reconsideration with Forte's is smart because their website is employer focused and not employee focused at all

Brett A. Borah

Brett A. Borah

Posted

All I can suggest is that you keep calling attorneys so see if they'll take your case.

Asker

Posted

OMG! forgot I have an expedited Hearing on file before July 2013. S.F Insurance intentionally held up the program. Now Y R Services hired an employer focused UR baord to deny it. HA HA! so , I can still go ahead with that since it is already on file..right? After the my file comes back from Recon Department

Posted

I agree with Mr. Borah that the new Independent Medical Review process that you can elect if utilization review delays, denies or modifies the treating physician's request is a nightmare. See topics http://www.wcwebzine.com/a-z/utilizationreview.htm and http://www.wcwebzine.com/a-z/independentmedicalreview.htm for more information.

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Posted

Well, can I just go to court by filing ut a DOR Forte's is employer focused so I wont be asking them for a reconsideration program. Do I need to give any notice other than filing out the forms that I just want to go to court

Marjory Harris

Marjory Harris

Posted

You cannot dispute the UR and IMR processes except in a limited way. The appeals board does not have the power to order a specific treatment, just to find there is a right to treatment. The specifics are established by the UR-IMR process. Did you read the topic pages I recommended?

Asker

Posted

Yes, I did. However, I forgot that I already have an expedited hearing on file. When the Ur Board at SF Insurance company granted me the program, my adjuster at first denied it because he thought it was not according to fee schedule but when he discovered that it was he said he isn't denying the program but just what company gives it to me. There are a total of three medical groups that offer the Functional program and he never called and scheduled me for anywhere else so my attorney at that time filed an expedited hearing before 07/13. I am just waiting for the a decision form the Recon dept which should be before 11/04/13. I just remembered that it was still on file

Asker

Posted

Oh, one last question. Who can request a UR? York attorney did and sent them old documentation and sent them nothing from my QME who said I needed the program. Can they do that?

Posted

You should be sure to sign/date the IMR application you were mailed and fax it to IMR. Keep a copy of the fax confirmation. You should also consider filing for an Expedited Hearing and I would suggest you either consult an attorney who is willing to file for the Expedited Hearing on your behalf or talk with the Information and Assistance Officer at the WCAB. Some judges will allow you to go to trial on the issue of defective UR and some are not allowing complaints about UR to go to trial saying the IMR is your sole remedy. The process is so new that no appelate court has addressed it yet. Good luck!

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Posted

Thank You. I have an Expedited Hearing that was filed in June because SF insurance lied to delay the program until it expired and refused to send it to the UR Board again for an extension. I am waiting for a response from the Reconsideration Department so I can go forward with the Expedited hearing. It was filed before July 2013. What kind of weight does that have?

Daniel W Epperly

Daniel W Epperly

Posted

As I' sure you are aware, for dates of injury before 2013 parties were still allowed to litigate a UR dispute rather than go to IMR until July 2013. It is sad the judge at your first Expedited Hearing would not go to trial on the issue. I hope the panel allows you to go to trial, but I cannot predict how that will play out. Sorry.

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