Utilization review physicians should be held accountable for medical decisions

February 03, 2017
Area(s) of Interest: Professional Liability Workers' Compensation 

The California Medical Association (CMA) has filed an amicus brief with the Supreme Court of California, discussing the nature of utilization review and the real-world impact utilization review decisions can have on injured workers under California’s current workers’ compensation system.

In this case, King v. CompPartners, Inc., a worker sued a third-party utilization review company and its utilization review physician for injuries that arose when they abruptly cut off his prescription for Klonopin, an antidepressant drug. The defendants deemed the drug to be not medically necessary following the workers' compensation utilization review process; however, the worker claimed they were negligent in failing to consider and address the potential harm of immediately taking him off Klonopin, rather than weaning off the drug.

A key issue brought before the court is whether a workers ’ compensation utilization review physician and the third-party utilization review companies contracted by employers owe a duty of care to the injured worker.

CMA’s amicus brief argues that utilization review constitutes the practice of medicine — an opinion supported by the Medical Board of California and the American Medical Association. CMA believes that utilization review physicians should owe some duty or obligation to injured workers in the same manner that other physicians practicing medicine are held accountable. Absolving utilization review physicians of all responsibility for the foreseeable consequences of their medical decisions facilitates a workers’ compensation system that can systematically deny and delay care to the detriment of real people.

This case comes to the court at a time when the workers’ compensation system is changing more rapidly than ever. Like in commercial health plans, employers use third party companies to conduct utilization reviews and approve, modify, delay, or deny care requested by an injured workers’ treating physician. Coverage decisions by utilization review are heavily determined by standardized medical treatment guidelines, rapidly departing from previous standards of reasonable care.

CMA is concerned that utilization review decisions, when there is little accountability and room for appeal, can result in the denial and delay of medically necessary care. In a 2014 survey of California physicians, conducted by CMA, two-thirds of participating physicians reported difficulties obtaining authorization for patient care through utilization review. Responding physicians also identified inappropriate denial of medically necessary care through utilization review, and denials or care and slow response times while using the independent medical review process, as significant issues in the current workers’ compensation system.

Click here to read the brief.


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