UR Approval (California) (California) (California)

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UR Approval (California) (California) (California)

Postby injured7825 on Thu May 26, 2016 7:36 am

I have a UR question, I had spine surgery that had complications and before the surgeon released me from surgery he decided he wanted out of work comp and put in a transfer of care to a new neurosurgeon to replace him. It was approved but the 1st neurosurgeon I selected from the MPN after review of 2 years of my medical records declined to see me so I selected another surgeon, it was approved also. The UR was approved for transfer of care, there was also an approval for 1 internal consultation in the same UR authorization letter and in the authorization letter from the adjuster to the new surgeon as a secondary treater as stated in her letter the adjuster stated she was going to send 2 years of medical records.
This new surgeon never acted as a secondary treater and the report stated on the front page of his report consultation, he never released me from surgical care and in fact recommended a 2 level fusion and in his only report he stated “this was a onetime evaluation and no further follow-up will be provided to the patient” the 2 years of medical records the adjuster stated to the surgeon were never mentioned in this surgeon’s report, just the films and 2 reports I brought with me.
Would I be able to enforce this UR approval for transfer of care to replace the original surgeon after more than 1 year?
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Re: UR Approval (California) (California) (California)

Postby LawAdvocate on Fri May 27, 2016 8:47 am

Nope, code says UR is only good for 12 months. Plus, I have rarely seen one neurosurgeon recommend exactly the procedure another neurosurgeon recommended. So unless the new neurosurgeon is asking for EXACTLY the same thing as the first neurosurgeon, the RFA process starts all over.

Transfer of care does not require UR approval, it requires a valid election of a new PTP or a proper referral pursuant to Labor Code Section 4603.2(b)(1) from a validly elected physician. Was a consult with a different neurosurgeon authorized to your PTP, more likely.

So consider that one neurosurgeon didn't see you after a review of your records, meaning there were no surgical options. The second neurosurgeon who saw you for a one time follow-up, reporting is not enough, did that neurosurgeon submit a valid RFA with supporting medical documentation? If so and that neurosurgeon was in the MPN, why has there not be an expedited hearing on the denial of medical care or an IMR appeal? This is not making sense on a legal level and less on a medical level, but I realize I have limited facts.

Designate and elect a new neurosurgeon within the MPN as your PTP who is REPUTABLE. If you need help with picking decent neurosurgeon - think Southern California Orthopedic Institute and Kerlan Jobe if you are in Southern CA, they are on most MPNs.
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Re: UR Approval (California) (California) (California)

Postby injured7825 on Fri May 27, 2016 10:24 am

I guess I didn’t word it correctly, the surgeon who did the spine surgery never released me from his care or surgery, he submitted an RFA for a transfer of care to a new neurosurgeon to replace him. The RFA was approved, the second time after the first selected surgeon declined to see me I selected a new surgeon from the MPN who was also approved, the adjuster sent him a letter stating he was authorized as a secondary treater and that in a separate mailing that 2 years of records will be sent.
In the first UR approval it stated the request was for a transfer of care to replace the surgeon who did the surgery, the second UR approval the request was for a transfer of care to replace the original surgeon but it also has a request for 1 internal consult that was also approved, I do not know who made the request for the consultation as I never asked for it and nor did my PTP. Now the letter sent to this new surgeon never made any mention that this was for a consult, just transfer of care as a secondary treater to replace the original surgeon.
This new surgeon never received the 2 years of records the adjuster stated she/he was sending him; I have no clue who told this new surgeon to do just a 1 time consult when the letter he received from the adjuster clearly stated he was the secondary treater to replace the original surgeon.
I have another question related, if a surgeon has never released a patient from surgical care after surgery can there be an MMI in the claim? I do have a PTP but he is not a spine surgeon and so far has not made me MMI and kept me TTD until I am released from surgical care.
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Re: UR Approval (California) (California) (California)

Postby LawAdvocate on Thu Jun 02, 2016 4:38 pm

An adjuster can approve a secondary treater. However, technically it does not make that neurosurgeon a secondary treater. The only way a secondary provider can get in the case is through a PTP referring you or writing a prescription to a secondary provider, if the good or service requires UR via a valid RFA, then the PTP sends an RFA in relation to the requested goods or services from a secondary provider (LC 4903.2(b)(1)). Then you go for the neuro consult once it is approved. The secondary provider then writes a report and sends it to the PTP, the PTP is to adopt and incorporate that reporting (CCR 9785(e)(4)). If the secondary provider feels additional treatment or goods are required, they then send an RFA requesting authority for anything additional needed. I think therefore, there have been huge misunderstandings as an adjuster cannot just limit someone to a one time consult - there are too many exceptions to that idea. So if you wish to return to that neurosurgeon, have your PTP refer you to that neurosurgeon or someone else.

Your other question - surgeons do not have to release you from surgical care after surgery. Once you have surgery you are released from surgical care at the point you leave the hospital. The follow-up care is just straight up evaluation and management and your PTP has to refer you back to the surgeon via a valid RFA justifying why you need to see the surgeon again, sometimes there is no reason to keep seeing the surgeon. If your PTP has not found you to be MMI and says you remain TTD until you are released from surgical care and does not refer you to the surgeon to be seen for a release -- then the PTP has not done his/her job and the theory that you are TTD is not supported by substantial medical evidence. You can't just sit back and say you are TTD until "x" event occurs and then make no effort to assure that event occurs, that is not reasonable medical care and the medical reporting will not be found to be that a reasonable mind can accept - the standard for all medical reporting. We see this now in UR where the physician says - the Applicant will not be MMI until they have 3 epidural steroid injections. The RFA rolls in for the epidural steroid injections, UR denies it, IBR upholds the denial - --- guess what that medical care was not reasonable or necessary -- so the PTP can't just keep demanding a non-certified unreasonable treatment, if the judge gets that report they will determine the physician has not done their duty and the Applicant is hence MMI because what is being demanded as treatment is not necessary.
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