UR reviewer of the same specialty (California)

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UR reviewer of the same specialty (California)

Postby rider001 on Wed May 12, 2010 1:33 pm

I have heard from several people that a UR reviewer must be of the same speicalty as the requesting physician. What is the authority. All i can find is that it has to be in their scope of practice.
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Re: UR reviewer of the same specialty (California)

Postby gaiassoul1@yahoo.com on Wed May 12, 2010 3:29 pm

same thing, scope of practice means you have to have the same specialty....we get internists reviewing orthopedic surgeons, we get occupational doctors reviewing neurologists....just different words that mean the same thing...

your authority is LC4610 (e)

(e) No person other than a licensed physician who is competent to
evaluate the specific clinical issues involved in the medical
treatment services, and where these services are within the scope of
the physician's practice, requested by the physician may modify,
delay, or deny requests for authorization of medical treatment for
reasons of medical necessity to cure and relieve.
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Re: UR reviewer of the same specialty (California)

Postby rider001 on Wed May 12, 2010 6:01 pm

I guess i got hung up on the wording "licensed physician who is competent". I thought every licensed physican should be able to apply MTUS to a treatment request whether it is in their specific specailty or not.
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Re: UR reviewer of the same specialty (California)

Postby gaiassoul1@yahoo.com on Thu May 13, 2010 1:12 pm

absolutely not, consider it in a legal analogy, would you let a work comp lawyer defend you in a criminal case?

Doubtful.....so seriously you would let an orthopedic surgeon operate on your anneurysm (sp) ?

People who do it day in and day out naturally know more, they are on the front lines their continuing education is slanted to them having a "specialty", they work side by side with others who share knowledge.
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Re: UR reviewer of the same specialty (California)

Postby stevepsca on Fri May 14, 2010 10:38 am

I glad this question has been posed.
So... how does one/IW, demand proof the UR Dr is of the specialty, and competence to evaluate to MTUS/ACOEM ?
I know one could demand the “curriculum vitae" of the expert medical reviewer... beyond that, what real recourse is there to dispute a UR decision ? (realizing the process exsists under LC 4062).
I'm trying to imagine a CA agreeing to resubmit a request for treatment to the appropriate specialty... ie pain management vs sports medicine, or occupational medicine. Certainly making the arguement "it doesn't matter...."
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Re: UR reviewer of the same specialty (California)

Postby gaiassoul1@yahoo.com on Fri May 14, 2010 1:35 pm

The Board does not license physicians by specialty so we have no information about the doctor's practice specialty. However, the American Board of Medical Specialties (ABMS) has a Web site that lists all physicians certified by ABMS member boards. This service allows the public to verify the board certification status, location by city and state and specialty of any physician certified by one or more of the 24 ABMS Member Boards.

www.abms.org
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Re: UR reviewer of the same specialty (California) (California)

Postby Barney5 on Sun May 16, 2010 7:20 am

I see UR denials come from Orange County; however the MD that these UR nurses work under is located in Texas. How does that work?
Last edited by Barney5 on Sat Jan 25, 2014 5:15 pm, edited 2 times in total.
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Re: UR reviewer of the same specialty (California)

Postby gaiassoul1@yahoo.com on Sun May 16, 2010 9:54 am

wow, if you could get the nurse to put that in writing or sign a declaration to that effect....there would be trouble...lots of trouble....I would still report this to the DWC for an investigation, the nurses cannot work "under his license", they can assist in writing it but if the doctor is not reviewing and signing, so wrong..I don't even know where to start.
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Re: UR reviewer of the same specialty (California)

Postby stevepsca on Sun May 16, 2010 2:28 pm

Getting that RN to put anything in writing would be beyond 'difficult'... but, you could depose the RN who stated this as fact. Get her under oath and let her sing...
This would be a terrific beginning to get this 'stuff' on the table.
They are using computer generated signatures... RN are not permitted to modify/delay/deny a valid requst for treatment. The ccrs are clear in that only a ''doctor'' can do this.

There is no problem with the UR Dr being out of state... but there surely is with the scenario you present.
This calls for audit unit after audit unif after audit unit referral... and UR complaint on every notice you receive from the UR contractor.
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Re: UR reviewer of the same specialty (California) (California)

Postby Barney5 on Sun May 16, 2010 3:33 pm

Thank you for the input.
Last edited by Barney5 on Sat Jan 25, 2014 5:16 pm, edited 3 times in total.
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