Calif. Providers to Make a Case for Changes: Politics 03/31/06

[Guest guest]

CA -- Calif. Providers to Make a Case for Changes: Politics 03/31/06

Lobbyists for medical providers are mobilizing California physicians for a

Capitol hearing in May that promises to focus on the quality and delivery of

care to injured workers under the reforms implemented since 2005.

The Senate Labor and Industrial Relations Committee tentatively plans to

hold an informational hearing May 3. The California Society of Industrial

Medicine and Surgery (CSIMS) urged members this week to testify about their

experiences in treating claimants since the adoption of Senate Bill 228,

Assembly

Bill 227 and Senate Bill 899.

One area under scrutiny is the use of American College of Occupational and

Environmental Medicine (ACOEM) treatment guidelines, which CSIMS claims should

have been replaced by now. The Division of Workers' Compensation admits that

while the ACOEM guidelines have created some gaps, they meet the legislative

requirements set forth under the reforms.

" The DWC is convening a guideline-evaluation committee under our new medical

director (Anne Searcy) that will look at possible solutions for gaps in

ACOEM that doctors may be struggling with, " DWC spokeswoman Gard said

Thursday.

CSIMS urged physicians to attend the hearing and testify about a litany of

issues involving ACOEM treatment guidlines, claims denials, delays or

modifications of proposed treatment guidelines. The group also wants to hear

from

providers who've experienced a failure to respond timely to prior-authorization

request, CSIMS said.

Bryce Docherty, lobbyist for the California Ambulatory Surgery Association

(CASA), said that his group objects to how prior authorizations are being

handled, sometimes by out-of-state physicians or nonphysicians.

CASA represents about 180 surgical centers in the state.

" Prior authorizations being done by out-of-state physicians or out-of-state

individuals who may not be physicians ... were not the intent of SB 899, "

Docherty said.

Secondly, surgical providers view the medical provider networks as a new

" profit center " that is not going to benefit injured workers, Docherty said. He

calls MPNs " the great experiment. "

" Some MPNs are demanding a 30% discount, " he said. " The intent was medical

control and how it was determined ... never to create a profit center. "

The schedule created under SB 228 set ambulatory center fees at 120% of

Medicare, an already low reimbursement level, Docherty said. Asking for a 30%

discount on top of that puts surgery centers in a position of having to decide

whether they can afford to continue to take workers' compensation cases, he

said.

The California Ambulatory Surgical Association does not believe the

discounts being demanded of providers is consistent with the letter of the

reform

law, he said.

CSIMS also asked members to relay to the Senate Labor and Industrial

Relations Committee, chaired by Alarcon, D-San Valley, how

care has

been delayed or denied because of preauthorizations moving out of state.

Difficulties dealing with out-of-state utilization review (UR) doctors are

said to include time-zone problems, narrow windows of opportunity for the

treating physician to speak with the person handling the UR review, UR doctors

calling at inconvenient times and insisting that the doctor come to phone or

risk having a proposed treatment plan denied, according to the CSIMS notice to

members.

Docherty said the issues of preauthorization and MPNs have definitely led to

delays in delivering timely medical care to injured workers.

CSIMS also charged this week that California Division of Workers'

Compensation Administrative Director Hoch failed to replace ACOEM

treatment

guidelines with other scientific, evidenced-based guidelines by a Dec. 1. 2004,

deadline.

DWC spokeswoman Gard, however, disputed CSIMS' interpretation that the ACOEM

guidelines were supposed to be replaced under the law.

" ACOEM guidelines were rated No. 1 by RAND in its study of potential

guidelines. Additionally the labor code requires that any guidelines adopted by

the

administrative director address duration, frequency and intensity of

treatment, which ACOEM guidelines do. "

Gard added, " It's also important for folks to remember that the statute

allows for the use of other evidence-based guidelines to justify treatments not

covered by ACOEM. "

There were some problems initially with how the guidelines got applied

because, as Gard said, they represent a fundamental shift in the way treatment

is

provided.

" However, we're hearing that those problems are lessening as providers and

claims administrators alike better understand how to apply guidelines. "

CSIMS also wants testimony on:

* The " use and abuse " of ACOEM guidelines;

* Failures to honor a preauthorization commitment;

* The inability for a physician to be admitted into a medical provider

network;

* Example of " compromised " patient care attributed to reform legislation or

how it was either implemented or not.

-- Rob McCarthy, WCC Editor