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California Post SB 899: Should Out-Of-State Doctors Be Allowed To Perform Med-Evals?
By Pauline Grant - September 21, 2005

The latest tug-of-war in the California Work Comp system is about whether out-of-state doctors should be allowed to perform medical evaluations on claimants. 

 

SB899 gave insurance companies and self-insured employers the right to ask outside physicians for second opinions if an insurer/employer disagreed with a course of treatment prescribed. 

 

California state regulators are proposing rules that would allow insurers to contract with out-of-state doctors not licensed to practice medicine in California to render judgments—which could result in disapproval, modification and/or delay of treatment ordered by the physician caring for the claimant. 

 

The California Medical Association as well as professional groups representing California podiatrist and chiropractors, complain that insurance companies and self-insureds are already hiring out-of-state doctors to evaluate treatment plans.  The doctors contend that state law allows only physicians licensed by the state to make those decisions. 

 

Injured worker advocates assert that the practice of allowing out-of-state doctors to pass judgment of expensive treatments is depriving Californians of needed medical care.  The escalating conflict is the latest in a series of increasingly bitter disappointments among businesses, insurers, labor unions and doctors about how best to turn last year’s legislative overhaul into detailed rules about benefits and claimant care. 

 

The regulations proposed by the state Division of Workers’ Compensation would put the state’s stamp of approval on the practice, which Andrea Hoch, the state’s top workers’ comp administrator, says is consistent with review procedures used by health maintenance organizations for non-work-related care. 

 

But California doctors say that out-of-state physicians often lack the expertise in  California’s work comp law and medical protocols.

 

“We can’t talk to (reviewing doctors) when they are far away; we have no way of evaluating whether they are competent or not, and we can’t complain” to state regulators, said Jack Lewin, the medical association’s chief executive. 

 

The Medical Board of California, a government panel that licenses and disciplines physicians and surgeons, has raised similar alarms.  In several letters to fellow regulators at the Division of Workers’ Compensation, the board said the proposed regulations were illegal because they would allow out-of-state physicians to practice medicine in California without a license. 

 

Linda K. Whitney, the medical board’s chief of legislation, said state law specifically required that anyone who evaluates a California patient’s case and makes a decision on treatment, even someone thousands of miles away, must be licensed here.

 

In Hoch’s view, however, “the fact that (the reviewing doctors) are not licensed in California does not mean they are not capable of reviewing treatment requests and applying guidelines that are national.” 

 

Hoch said workers’ compensation medical directors, who are licensed in California, would remain responsible for all treatment decisions made by reviewers in their networks.  The doctors’ complaints, she suggested, have more to do with protecting turf and making money than with ensuring top-notch treatment for their patients.

 

Insurers and self-insured companies contend that keeping all medical review work in the state could substantially raise claims cost and lead to higher premiums or direct costs for self-insured employers.    

 

Advocates for injured workers counter argue that insurance and self-insured companies concern for their bottom lines put strong pressure on contracted doctors, who are beyond the reach of California regulators, to reject treatment plans. 

 

“The economic incentive for the (reviewing physicians) is to deny more often than they approve – or they won’t be used again,” said Peggy Sugarman, executive director of VotersInjuredAtWork.org, a Sacramento-based organization of workers’ compensation claimants.  

 

"Routine denials and modifications of treatment requests already are taking a toll on patients," said Franklin Case, a Burbank podiatrist and past president of the California Podiatric Medical Association.  Case said he recently prescribed custom shoe inserts for a laborer suffering from work-related heel and ankle pain in his right foot.

 

“The request was sent to Texas, and they said that if the patient only had pain in one foot, they could only authorize an insert for one foot,” Case said.   He went on to explain that using an insert in only one shoe could cause instability and create back problems.  “Someone out of state was making a ridiculous adjudication, and I don’t think he was a podiatrist.”     

 
 

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