Why am I not getting the medical treatment my doctor is recommending?

The reason is almost always that the insurance company is refusing to authorize your doctor to provide the treatment because of a denial issued by utilization review (UR).  The failure of injured workers to get the treatment recommended by their doctors is the number one reason that injured workers retain our law firm. 

What is utilization review (UR)? 

Utilization review is a process by which your doctor's treatment recommendations for you will be reviewed by another physician to determine if the treatment being recommended for you is appropriate.  The physicians that perform the review are almost always out of state and not even licensed in the State of California.  The law requires that the utilization review only be performed by a physician in the same medical specialty as the doctor who is treating you (orthopedics, chiropractic, psychiatrist, orthopedic surgeon, etc.). Despite this law, the reviews are often performed by nurses and physician who are not in the same medical specialty as your treating doctor.

In addition, the review is supposed to be based on scientific medical evidence.  In the State of California the main text used for this is the American College of Occupational and Environmental Medicine Guidelines (ACOEM).  However, these outside physicians may also make references to other medical literature.  Often the review is not accurate and fails to look at the full reasons your doctor is recommending the treatment for you.

How can I get the treatment my doctor is recommending for me? 

First, you must speak with your treating doctor to see if he can appeal the utilization review which has denied your treatment.  However, the doctor must be able to write a report explaining to the insurance company and the utilization reviewer why the treatment being recommended for you does fall within the appropriate medical scientific literature such as the ACOEM Guidelines.  That is not always an easy task.

Secondly, you might have to go to Workers Compensation Appeals Board (WCABs) in order to have the treatment being recommended by your doctor ordered by a Workers' Compensation Judge.  This is not always an easy process for the uninitiated but there are Information and Assistance Officers at the local WCAB’s to help you in this process.

In conclusion, there are actions you can take to get the treatment that your doctor has recommended for you authorized by the insurance company.  Do not let the insurance companies become a "UR denial" machine.  This is often done by insurance companies in order to drag your cases out so that you will get so frustrated that you will accept any settlement proposal that they make to you just so that you can get the care that you are entitled to. 

For more information about utilization review and obtaining medical treatment for your work injury please check out our web page at www.personalinjurylawsandiego.com.

Atcherley & McLaughlin, LLP is a Southern California based law firm representing clients in the areas of personal injury, workers’ compensation, employment law, Longshore and Harbor Workers’ Compensation Act, Defense Base Act, immigration and family law.

The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for advice regarding your individual situation. We invite you to contact us and welcome your calls, letters and electronic mail. Contacting us does not create an attorney-client relationship. Please do not send any confidential information to us until such time as an attorney-client relationship has been established.

Making a false or fraudulent workers' compensation claim is a felony subject to up to 5 years in prison or a fine of up to $50,000 or double the value of the fraud, whichever is greater, or by both imprisonment and fine.