Workman Compensation Utilization Review Baord

Asked 12 months ago - 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)

  1. Nancy J Wallace

    Contributor Level 14

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    Best Answer
    chosen by asker

    Answered . 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.

  2. Brett A. Borah

    Contributor Level 20

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    Answered . 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.

  3. Marjory Harris

    Contributor Level 14

    5

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    Answered . 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/independentmedical... for more information.

  4. Daniel W Epperly

    Contributor Level 13

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    Answered . 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!

  5. Charles Joseph Michael Candiano

    Pro

    Contributor Level 20

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    Answered . 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"... more

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