UR reviewer of the same specialty (California)

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Re: UR reviewer of the same specialty (California)

Postby stevepsca on Tue May 18, 2010 1:22 pm

I would like to know if there have been any investigations or studies that have shown the percentage of approvals vs. denials for requests made to UR. This is something that should be looked at
There are studies, currently being done. But you/we shouldn't expect there to be anything done until at the very least after the November elections.

You can't even get the Adm Dir to comply with the law requiring a review of the 2005 PDRS...and it IS THE LAW. Arnold said she didn't have to. But, even though the legislative committes have demanded a valid reason, and order to comply... what recourse or penalties are there...? Is someone going to empanel a grand jury and bring Carrie Nevins and Arnold to task? Doubtful...The very people who take the oath to uphold the state constitution and enforce the laws as enacted by the legislature are the very ones disobeying the laws, and acting outside that oath... yet there is no action to be taken but charge them with being "morally bankrupt". Arnold is termed out... what the hell does he care.
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Re: UR reviewer of the same specialty (California) (California)

Postby yogibear on Sun May 30, 2010 10:10 am

Here is a "new twist" on just what some QME physicians seem to rely on when attempting to justify their " 'qualifications" to opine "out of their specialty of expertise' ", which I suspect may be a similar "line" made by some UR physicians:

Recently, my attorney had a very interesting discussion with another AA, who just happened to use the same QME in his case, as my attorney had used. This AA stated that he deposed this particular QME "Dr. W", a Board Certified Internal Medicine Doctor, when she was selected by the DA to evaluate the IW for his Diabetes, when his PTP opined that the Diabetes was interfering with the IW's need for treatment for his accepted Orthopaedic injuries.

This QME "Dr. W", had opined in her report that not only was the diabetes not interfering with the IWs need for Orthopaedic treatment, she further "opined" that the IWs previously accepted Orthopaedic injuries were most emphaticaly NOT an INDUSTRIAL INJURY.

When the AA questioned QME "Dr. W" about her qualifications to opine as an "expert" regarding Orthopaedic injuries, when she was a Board Certified Internal Medicine Doctor, and not a Board Certified Orthopedic Doctor OR Sugeon, the QME testified that she was indeed "qualified to opine in the specialty of Orthopaedics" because she was a MEDICAL DOCTOR, and had "taken courses in Orthopaedics during Medcal School in order to BECOME a licensed Medical Doctor"....

This AA's case is still pending, so he does not know how the Judge will determine this QME's "qualifications" to opine as an alledged "expert in the specialty of Orthopaedics". when the AA asks that her report be thrown out, as it pertains to this QNEs "opinion" as it relates to the IWs Orthopaedic Injuries and the need for treatment, which included surgery as recommended by the IW's Board Certified Orthopedic Surgeon PTP.

It would therefore be extremely interesting and useful to know if there is any actual Case Law that addresses this issue, whether or not it applies to UR Doctors or to QME/AMEs, and it would be greatly appreciated if such Case Law exists, that the Pros here would kindly post it.

Thank you in advance,

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Re: UR reviewer of the same specialty (California)

Postby swan@comppartners.com on Thu Mar 31, 2011 7:36 am

The Reviewer has to be a license Doctor. Best Practice is Specialty matched provider. Someone who would treat the injury in their normal practice. Best practice is to call and discuss the request with the treating provider so that if there are issues that fall outside MTUS their is the opportunity for compromise. An appeal process should be available for denials that a requesting provider may take issue with. Having a Nurse prepare the report the reviewer dictated and attach his signature after his review is a non issue. As in everything communication is key. There is no rule against providers treating using MTUS as a guideline. I know a very successful MPN that only retroactively audits the providers for UR compliance.
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Re: UR reviewer of the same specialty (California)

Postby gaiassoul1@yahoo.com on Sat Apr 02, 2011 8:24 pm

Having a Nurse prepare the report the reviewer dictated and attach his signature after his review is a non issue.

agreed, the issue is that utilization reveiw nurses end up on work comp too, and we all know WAY TOO many nurses are preparing everything a physician never sees.

The problem is that these nurses will need to work again so getting them to go public is difficult.
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Re: UR reviewer of the same specialty (California)

Postby dontdenyme on Wed Mar 21, 2012 10:05 pm

OK. Let me clarify a few things. Nurses CANNOT deny anything. They can only approve. If anything is in question of denial, it needs to be referred to a physician. And the physician doesn't have to be same profession, but needs to have the scope. For example, DC cannot peer review LAC because they do not have training in acupuncture. But DC can do review of MD's for MRI or other special study requests because they also perform it. They cannot do review on surgery due to lack of training. But OT, even though they do not perform surgery, can opine on medical necessity of surgery if they have enough training on the issue. I hope I didn't confuse you guys more.

Anyway, I perform UR and nurses prepare summary for me. I use it to get a gist and review the entire medical records provided to make determination. I make my own determination and write the rationale. Nurses may edit for grammars and spelling. But they do not change the determination or alter the rationale.
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