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Is the Workers’ Compensation System Broken In California?

In a word, yes, it is. By far, the number one way the workers’ compensation system is broken is how medical care is authorized.

First of all, injured workers have to treat within the insurance company’s medical provider network of doctors. That is called an MPN (Medical Provider Network). An injured worker is limited to this network, with few exceptions, and can rarely seek treatment with a doctor outside of the network. In addition to that, the way medical care is authorized is, far and away, the worst part of the system. The MPN doctors have to use what is known as an RFA (Request For Authorization) form, for any treatment modality or diagnostic study that they want for the injured worker.

For example, if the doctor wants an MRI, medications, or a referral out for psychical therapy, all of those modalities of diagnostic study/treatment need to be requested on an RFA form and sent to the insurance company. The insurance company at that point sends the RFA to its utilization review department. The utilization review department then reviews the request using a book of averages to determine whether or not to authorize that medical care. And, if the request doesn’t fall within that specific average, that care is denied.

At this point, a California workers’ compensation attorney makes sure that the denial from the utilization review department was done in a timely manner. If it was, the only other recourse is to send the denial to a government agency called Independent Medical Review (IMR) for a second look. The frequency of the IMR agreeing with the insurance company’s utilization review board is over 90%.

The problem is that everyone has become an average in workers’ compensation. Let’s say we have an injured worker with a low back injury and their doctor wants to get an MRI. The doctor fills out an RFA form, sends it to utilization review, utilization review opens up their handy-dandy book of averages. The book says, on average, most low back pain resolves within 90 days. Is the insurance company going to authorize an expensive MRI within the first 90 days of treatment? No. They are hoping that the injured worker falls within the average regardless of what the treating doctor requests. What Utilization Review will authorize though are opiate medications to mask pain and physical therapy because both are a lot cheaper than an MRI.

There are countless examples of workers’ compensation attorneys that have injured workers sitting across from them, telling the attorney how their doctor can’t get an MRI authorized but they got physical therapy authorized. Then the injured worker is laid out on the PT’s table and the physical therapist does a straight leg raise and it sends the injured worker’s pain level through the roof. (Note: a straight leg raise is a common test for a herniated disc.) The physical therapist steps back and says I’m not touching this person with a ten-foot pole, they need an MRI. And yet, an MRI can’t get authorized for another three months.

This is a big problem. Doctors are not allowed to be doctors. The Workers’ Compensation arena is losing a lot of good physicians because they are frustrated with the system. They know what their patient needs and yet they can’t get it authorized from the insurance company.

Permanent Disability:

In addition to how medical treatment is authorized, another way the system is broken is in evaluating Permanent Disability. Permanent Disability is expressed in a percentage, from 0% to 100%. Zero percent is equivalent to the injured worker being entirely healed, as if the injury never happened. 100% Permanent Disability is a catastrophic injury such that the injured can no longer work in any capacity. Permanent Disability is typically based on diagnostic evidence, e.g., an MRI showing a disc herniation. What the permanent disability rating system does not take adequately into account is the level of pain that many injured workers experience.

When rating Permanent Disability doctors use a book called the American Medical Association Guides to Whole Person Impairment. Under the AMA guides, if the doctor opines a standard level of Permanent Disability, yet the injured worker is experiencing significant pain, the doctor can only add an additional 3 percentage points for pain. And yet, any doctor will tell you that it’s the pain experienced by injured workers that keeps them from going back to their usual and customary occupations. Pain it what keeps injured workers from engaging in the activities of daily living.

Nine times out of 10, an injured worker will do far better getting a just and reasonable permanent disability rating working with a seasoned workers’ compensation attorney than if they litigated their case themselves. Good workers’ compensation attorneys are aware of case law, they are aware of alternative ways of rating permanent disability, and they will ask the medical legal evaluator about those alternative ways to rate disability. A good workers’ compensation attorney is familiar with the AMA Guides to Whole Person Impairment.  They understand how the book is used and they understand alternative ways in which the book can be used to get the injured worker a higher level of permanent disability.

If an injured worker goes to a medical legal evaluator without representation, the insurance company will typically write to that medical legal evaluator and the injured worker will not. The insurance company is not going to ask a medical legal evaluator about alternative ways of rating disability that may result in a higher level of disability for the injured worker. They won’t do it because it’s not in their best interests. They want to save money. Good applicant attorneys always write to the medical legal evaluator prior to the evaluation date and specifically ask the evaluator to consider alternative ratings if they believe the standard rating insufficient.

So in conclusion; yes, the system is broken. Doctors are not allowed to be doctors. The Workers’ Compensation arena is losing a lot of good physicians because they are frustrated with the system. They know what their patients need and yet they can’t get it authorized from the insurance company. Injured workers who represent themselves, i.e., In proper, do not have the knowledge to find the right medical legal evaluator, cannot call the insurance company directly to get an Agreed Medical Evaluator (AME), and cannot dismiss a Nurse Case Manager assigned to their case by the insurance company if they feel the Nurse Case Manager is looking out for the insurance company instead of them.

That said, a highly skilled workers’ compensation attorney can still help you navigate your way through to the best possible outcome.

Sacramento Workers’ Compenation Lawyer:

We hope this answers some questions you may have about the flaws in the workers’ compensation system in California. For any additional questions please call The Law Office of Alice A. Strömbom at 916-444-7557 for a free consultation. We’re here for you.


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