Help for CA IW's after being denied medications 2018 (Califo

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Help for CA IW's after being denied medications 2018 (Califo

Postby Barney5 on Wed Jan 03, 2018 11:21 am

I am anticipating a large number of California injured workers are going to be weaned off of or in some case denied immediately medications due to recent guidelines. I understand patients are not supposed to be cut off certain medications cold turkey, but I have seen it enough in the past to continue to have this concern. I also understand there is a problem in some cases with over prescribing medications. My worry is for the majority of patients, who do not fall into this category.

Problems:

1.Weaning: Every patient is different and weaning protocols should not be uniform to be placed on EVERY patient (JMO).

2.Many patients do not understand the internal UR appeal process, the IMR process and what is needed to appeal denials correctly. Many physicians who are not well versed in the CA WC system do not either.

3. Patients may receive a determination of weaning and not understand it and believe it is a denial. I have seen this many times. Also, if the patients prescription they received from their doctor is denied by their pharmacy, they may not be aware they need to get another prescription or how to obtain another prescription with lower dose before their next office visit (could be 4 weeks away, could be 3 months away).

4. Patients may be unaware that denials for medication in the work comp system, may be covered by private insurance or Medicare.

There is a lot of information on the states website, but many patients are unaware of it, how to access it, how to navigate it and also what all of the info means. While while this information may seem easy to those who do this everyday, it is not for the average patient.

I am looking for ideas from others, perhaps coming up with a list to provide to patients on the internet on forum such this this one and/or medical providers not well versed in the work comp system, on what to do when medications are denied. Something that a patient can easily understand.

This can be very scary and stressful for patients to go through, especially those who have chronic, long term pain and have been on their medications for long periods of time, have no alternative insurance or monies to cover their denied prescriptions. I have had several patient write to me on anonymous message boards in the past stating they wanted to take their life after being denied their medications.


California Injured Worker Patient Advocate
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Re: Help for CA IW's after being denied medications 2018 (Califo

Postby vampireinthenight on Fri Jan 05, 2018 9:05 am

I'm kind of shooting from the hip here. Hopefully they have some other coverage, but maybe not. If it were me, I would want to have in my possession a current medical report and prescription to prove that I have been taking the meds. Coupled with the written denial cutting me off cold turkey. Then I could at least present an emergency room with something showing them the situation I am in so they don't think I am lying to get opiates or whatever.

Another ethically questionable recommendation would be to save a couple of pills from each refill of meds and stash them away in case of an emergency. Then at least I could try to wean myself in an emergency.
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Re: Help for CA IW's after being denied medications 2018 (Califo

Postby LawAdvocate on Fri Jan 05, 2018 9:40 am

If the injured worker has other medical insurance, once treatment is denied under workers' comp, they can legally proceed to their regular physician. The insurance companies then duke it out when the group health carrier files their lien.
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Re: Help for CA IW's after being denied medications 2018 (Califo

Postby Barney5 on Fri Jan 05, 2018 12:49 pm

Thank you both. These are helpful ideas.

I understand not all patients are aware they can use alternative insurance or pay for medications themselves (if they have the money) after receiving a denial. I have seen an issue so far only with one private insurance, starting with a "K". According to the injured worker "K" private insurance refused to fill a prescription written by a physician outside of their network. The WC physician was not in the IW's "K" private insurance network. When the injured worker went to his "K" doctor and asked him to write his pain medication prescriptions and told him the issue with UR denial, the "K" doctor replied he could not write a prescription for a work related injury.

Injured workers should bring info recommended by Vampireinthenight to ER, including workers compensation carrier claim info to provide to the hospital. The hospital may try to bill the IW for ER visit, however CA department of Insurance has stated this it is not legal to bill an IW who has an accepted WC claim. If this happens the injured worker could respond to a ER hospital bill to send bill to WC carrier and state billing IW for treatment for accepted WC claim can result in a fine from CA State Dept of Insurance for up to 3 times the amount of bill.(just an idea)
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Re: Help for CA IW's after being denied medications 2018 (Califo

Postby mytwocents on Sun Jan 07, 2018 12:03 pm

It is my understanding that in general, a K pharmacy will not fill a prescription from a non-K doctor. This is not just in connection with WC cases but also in situations where, for example, a dentist writes a prescription for pain medication following oral surgery. It is also my understanding that group insurance is required to provide self-procured treatment on a lien basis if the claim is denied. However, I don’t know about a denial of specific treatment based on medical necessity. I would suggest that your K member go to membership services and discuss the problem to see what is or is not covered under the contract. K has its own internal UR/IMR. It is possible that the K doctor may not have accurate information.

The treble damages for billing an injured worker directly can be found in Labor Code section 3751(b) which provides “If an employee has filed a claim form pursuant to Section 5401, a provider of medical services shall not, with actual knowledge that a claim is pending, collect money directly from the employee for services to cure or relieve the effects of the injury for which the claim form was filed, unless the medical provider has received written notice that liability for the injury has been rejected by the employer and the medical provider has provided a copy of this notice to the employee. Any medical provider who violates this subdivision shall be liable for three times the amount unlawfully collected, plus reasonable attorney’s fees and costs.”

The statute says “liability for the injury” and not “liability for the treatment.” Furthermore, emergency treatment is an exception to the requirement for prior authorization. So, you may have an argument here. The hurdle might be to get the ER to provide more than a couple of pills to tide the person over until he can get to his regular doctor.
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Re: Help for CA IW's after being denied medications 2018 (Califo

Postby chirple on Sun Jan 07, 2018 3:36 pm

I am a K member. They will fill prescriptions from outside providers who are not of a classification of physician that K covers. ie....mytwocents mentions oral surgery. I have had pain meds and antibiotics prescribed by my dentist both filled at the K pharmacy with no issues at all.
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Re: Help for CA IW's after being denied medications 2018 (Califo

Postby mytwocents on Mon Jan 08, 2018 8:13 am

Thanks for correcting me on that. Now that I think about it, it was an outside MD whose prescription they wouldn't fill and I assumed that policy applied to any non-K prescription.
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Re: Help for CA IW's after being denied medications 2018 (Califo

Postby Barney5 on Tue Jan 09, 2018 7:42 am

Thank you both for the info about "k' and also specific labor code to help with emergency room bills.
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Re: Help for CA IW's after being denied medications 2018 (Califo

Postby jpod on Fri Jan 12, 2018 10:56 am

LawAdvocate can you explain further how a denied modality would be picked up by the health insurer in an otherwise accepted WC claim? I get that a health insurer would have to pick up treatment for a condition/injury that was denied as not having AOE/COE and later file a lien to recoup if it can prevail on injury AOE/COE.

I am less clear on how it works in practice when the condition/injury is admitted AOE/COE but a particular treatment modality is found to be unreasonable as defined in LC 4600.

In practice wouldn't the non WC PTP have to submit a bill and paperwork to the health insurer that certifies the billing is not for a workers' comp claim before the heath insurer would pay the doctor? In which case the insurer would seem to have a hurdle in proving up a WC lien. Conversely wouldn't the health insurer just deny payment to the doctor if paperwork indicated the billing is for a WC injury but the treatment was found to be unreasonable vis a vis UR/IMR?

Are you saying the health insurer has a contractual obligation to pick up the denied treatment modality even when the underlying condition is AOE/COE?
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Re: Help for CA IW's after being denied medications 2018 (Califo

Postby vampireinthenight on Tue Jan 16, 2018 9:43 am

I could be wrong about some of the fine points, but here is my understanding. It's some blend of case law, contract and the Knox-Keene Act. If you have coverage, your heath care cannot deny treatment simply because they have a dispute over whether WC is primary (whether WC should pay but won't). If WC will not cover something for whatever reason and the other healthcare provider agrees that the care is necessary, they must provide it. They cannot shirk their responsibility to treat by pointing to WC. If there is a dispute, their remedy is the lien process.

It is so well established I cannot even recall the case names. I think there was a big one involving Kaiser? Like a duty to defend argument?

Most AA firms have a letter to fire off when this happens, so you might check with them. It used to happen more often a few decades ago.
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