20 Reasons how UR and IMR are committing fraud (California)

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20 Reasons how UR and IMR are committing fraud (California)

Postby Barney5 on Wed Dec 13, 2017 10:58 am

20 Reasons how UR and IMR are inappropriately denying requests that are warranted or committing fraud through their paper review system:
 

 These treatment guidelines (MTUS, Chronic Pain, ODG, ACOEM 2nd edition) are not always being used to promote the best treatment for patients. They are being used as cost containment for insurers.I do not group every UR reviewer doing these things I am listing below, unfortunately there are many who are.


1. Treatment requests are most often being denied due to lack of records sent to the UR reviewer:

For older claims it can take an enormous amount of time to dig through a patients file and pull all of the documents needed for the song and dance that the guidelines demand. Do physicians get paid to do this? I have no idea, however when I do internal UR appeals it can be very time consuming to provide the documents needed. On top of this the UR companies to not appear to keep these records, so in many cases I am sending the SAME documents over and over if they send requests such as medications through UR every month!

2. Incorrect use of treatment guidelines:
 I have seen partial guidelines quoted as a means to deny, even mid sentence. When I looked up the entire guideline it actually approved the request. This is absolute fraud in my opinion.

3. Minimizing a condition or listing incorrect condition as a means to deny:

 For example a patient was denied pain medication stating post laminectomy and quoted that guideline as a means to deny. The patients actual condition was post 3 level 360 lumbar fusion that failed to fuse, spine is unstable, combined with cauda equine syndrome. This again is absolute fraud to do this to a patient and this misuse of guidelines, and happens often. If this is a mistake then why have I never seen a guideline used to approve a request with the patient having a minimal condition but guideline used to deny was for a more substantial condition?

4. Incorrect guideline used:

Guideline used for wrong body part or condition as a means to deny treatment.

5. Guideline used to deny treatment of one body part when patient has numerous injuries:

This happens with everything, but often times medications. UR reviewer will use guideline for example shoulder strain as a means to deny medications when the patient has many body parts injured, but are not taken into account.

6. UR reviewer blatantly ignores records sent and denies request even though report, request, treatments guidelines and records verify everything needed to approve the request
. This is absolute fraud IMO.

7. Documents and guidelines sent show request is warranted however UR reviewer will find other treatment guidelines as a means to deny. For example ODG guidelines were provided and UR doctor uses MTUS (not chronic pain guideline) even though patient is chronic. 

8. UR reviewer uses MTUS guidelines as a means to deny when the patients condition is chronic.


9. Scientific studies and peer reviews quoted to make guidelines are sometimes incorrectly quoted as a means to make a treatment guideline
. It is worth it to look up what is quoted in a guideline as far as studies used to see if the study actually states what is being used in a guideline as a means to deny treatment.

10. Medical treatment guidelines made from reviews or studies that have financial ties to industry, biased and not based upon well reasoned science.


9. Scientific studies and peer reviews quoted to make guidelines are sometimes incorrectly quoted as a means to make a treatment guideline
. It is worth it to look up what is quoted in a guideline as far as studies used to see if the study actually states what is being used in a guideline as a means to deny treatment.

10. Medical treatment guidelines made from reviews or studies that have financial ties to industry, biased and not based upon well reasoned science.


11. UR reviewers claims to attempt to call physician for clarification but either did not call or called during when office is closed.

12. UR doctor approved the request however UR nurse writes up a denial. Yes I have found this happens
.(fraud)

13.UR internal rules limit amount of records allowed to submit and will only review over that amount if approved by the claims adjuster.


14. UR company will speak to claims adjuster but refuses to talk to injured worker or their advocate about internal appeal
.

[b]15. UR company has nurses and not doctors doing the reviews.
This is legal if treatment is approved but not legal if a nurse denied request[/b]. In one instance I was told by a UR nurse this is legal to do by working under umbrella of doctors electronic signature.

16. Incorrect specialty reviewing the request. I have seen an acupuncturist deny a bone scan. This is why I always google the reviewer after I get a denial.

17. Conflict of interests with UR physicians.
If UR physician has financial ties to anything related to the request he should not be making decisions on the request. How will we ever know with IMR reviewers as they do not provide their name?

18. UR denies treatment request because MTUS remains silent on request (meaning it is not listing in MTUS)
.

19. IMR physicians do not read or are not forwarded cover letters sent by injured workers or patient advocate: I have yet to see my cover letters listed in the records in an IMR response. In the cover letter I address everything that was stated in the UR denial and send appropriate guidelines. I have contacted Maximus and was told a middleman at Maximus forwards records sent in and decides what is forwarded to the IMR physician for review. I have yet to get an answer if cover letters are accepted or not and if not why.

20. IMR reviewers are not reading records sent:
I have sent records to IMR that address everything used in the UR denial to show the request is warranted , and while they list these records (not my cover letter) they are either not reading the records sent or just ignoring them. This is why physicians and their advocates should take advantage of the internal UR appeal process as you have a much better chance for an approval than with IMR. I believe IMR reviewers are getting away with this as they do not have to provide their name.


I also do not like the obvious copy and past jobs I am seeing in boilerplate denials, sometimes forgetting to change the patients gender from she to he. Yes that lazy and obvious.

On a separate note:I also do not like in field nurse case managers who work for same company who is doing UR determinations.In my opinion this is a conflict.


Treatment guidelines should not be used for every patient and should be considered a guideline, not end all. If it is then injured workers no longer need doctors and can just input their symptoms in a computer and receive a boilerplate answer.

Insurance carriers are taking advantage by doing the things I listed above. It is a pattern of practice and I believe wide scale fraud in certain instances.

Many patients conditions are complex and do not fall under ODG, MTUS, Chronic Pain and ACOEM guidelines. You can go outside of these guidelines and find other guidelines that are more appropriate for your patients.This of course takes time and research.

I know how to combat the shenanigans I listed above but it is a complete pain in the a$$, takes time etc. I cannot see how it could be cost effective for a physicians to do what is needed for every request, and then have to write appeals due to the shenanigans I listed above, over and over again. This is why the entire UR and IMR system can be very difficult for patients to receive appropriate treatment. And patients are suffering and sometimes becoming permanently disabled due to lack of appropriate treatment. I am heartbroken when I see patients unjustly suffer.

Patient Advocate for California injured workers.
Barney5
 
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Re: 20 Reasons how UR and IMR are committing fraud (California)

Postby injured7825 on Wed Dec 13, 2017 1:06 pm

I had a surgeon request one type of surgery only to get denied, the guidelines used by the UR doctor was for another type of surgery for a completely different condition, so UR used the guidelines for something my surgeon never requested to deny the request. 5 months later a new request for the same kind of surgery was approved by a different UR doctor.
Another time a fusion surgery was requested and denied by a doctor only to be approved the next day by a UR nurse and again ignored by the insurer, I am actually thankful for that one as the fusion was to be done by a surgeon connected with Pacific Hospital of Long Beach and the fake hardware.
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Re: 20 Reasons how UR and IMR are committing fraud (California)

Postby vampireinthenight on Mon Dec 18, 2017 9:13 am

I think the current situation is a real shame. QMEs could be in a great position to resolve many of these issues. Unfortunately, they didn't step up to the plate in time.
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