After more than six months of reporting by the Investigative Unit, the director tasked with administering California’s workers’ compensation system responded to criticism from injured workers and doctors who say obtaining authorization for medical treatment has never been more difficult. Many claim critical medical care needed to get employees back to work has been delayed or outright denied by employers and insurance companies.
Christine Baker, the director of the Department of Industrial Relations, defended the system, saying reforms made four years ago improved access to medical treatment and helped contain costs. She also credits a new law enacted in January for further strengthening the system. Although the new legislation will speed up care to workers with new injuries, it won’t directly benefit employees with long and complex injuries who feel stuck in the system.
Director Defends Workers’ Comp Reforms
The major changes launched in 2013 under SB 863 emphasized evidence-based medicine and shifted treatment decisions from the courts to medical reviewers using state-approved guidelines to authorize or deny treatment requests. According to Baker, the changes are paying off.
“Benefits are going to workers, treatment has been sped up and appropriate treatment is being approved,” she said. “It is overall an improvement to the workers’ comp system, which is very complex.”
According to recent estimates, the reforms also cut costs to the nation’s most expensive workers’ comp system by more than a billion dollars per year.
But many doctors and attorneys who represent injured workers told NBC Bay Area the savings have come at a price. They say denials have reached all-time highs. They believe the guidelines touted by state administrators are too rigid and don’t always keep up with modern treatment techniques.
Baker rejects those claims.
“Ninety-five percent of medical care decisions are approved,” Baker said. “There are a few that don’t get approved and it could be that it’s inappropriate care or the doctor didn’t document the requirements for care.”
Lack of Data Called Into Question
But the data cited by Baker is impossible to verify. Until this year as a result of new reforms, the state has not collected data on the number of medical treatment requests that are approved or denied by insurers.
Instead, state administrators point to studies published by the California Workers’ Compensation Institute. The research group relies on data voluntarily provided by its members – insurance companies – which is not made available for public inspection.
More than a dozen doctors that spoke to NBC Bay Area say the denial rate for workers’ comp medical treatment requests made by their respective practices is substantially higher than what those studies reported.
In 2014, the California Medical Association surveyed doctors about the 2013 reforms Baker said improved the system. Sixty-seven percent of physicians reported difficulties obtaining treatment authorization and more than half said the greatest problem was the denial of “medically necessary tests, procedures or services.”
The new law, authored by State Senator Tony Mendoza (D)-Artesia, requires the state to track approvals and denials of medical treatment though a process known as utilization review. Doctors working on behalf of insurance companies and employers review requests for medical treatment made by an injured worker’s treating physician. They approve or deny treatment based on a standard set of guidelines.
Mendoza chaired the Senate Labor and Industrial Relations Committee for the past two years. During hearings concerning workers’ comp, Mendoza said injured workers repeatedly complained about treatment denials. He said the database of treatment decisions will bring transparency to the process and accountability to insurance companies.
“Why are injured workers being denied and for what reasons,” Mendoza said. “It will really begin to shed light on what’s going on in our state.”
Injured Workers Battle System for Medical Care
Many injured workers who shared their stories with NBC Bay Area had similar concerns. They say they’ve been stuck in the system for years, still hurting and off the job. For many of them, like former paramedic Chuck Hood, the pain is not just physical.
“It’s been the most frustrating three years of my life,” Hood said.
Prior to 2014, Hood says his life was full of meaning. As a paramedic, he answered the call to help on 9/11. For seven days after the attack, he performed search and recovery operations in the south tower of the World Trade Center.
Most recently, Hood worked at Oracle Arena catering Warriors games. He loved the job, especially interacting with fans. But three years ago, a hot box he was wheeling inside the arena tipped and crushed his arm against a post. The injury caused severe nerve damage. The pain, he said, is unrelenting.
His doctor requested a series of treatments, including surgery, to improve his condition. Hood said medical reviewers denied about 80 percent of those requests. At 48, he is headed toward permanent disability.
“Being caught in the system is not much fun, I wouldn’t wish it on my own worst enemy,” Hood said. “It feels like you are a prisoner in your own body.”
New Law Speeds Up Care
A new reform made under Mendoza’s legislation would speed up care to workers with new injuries beginning next year. In the first 30 days of an injury, workers will no longer be subjected to the utilization review process many blame for denying treatment.
Mendoza is hopeful the reform will expedite treatment and get workers back on the job faster. But he admitted his legislation may not go far enough to help people feeling forgotten after spending months and years fighting for treatment.
When asked about those injured workers who feel like they’ve been strung along with no resolution, Baker pointed to the state’s independent medical review process.
When medical care is denied, workers can ask the state for a second look at the decision. But an NBC Bay Area analysis of decisions found reviewers uphold treatment denials nearly 90 percent of the time.
Hood said the red tape and roadblocks are exhausting.
“It’s gotten to the point some days where I’ve felt so beaten down by the system I have contemplated suicide,” he said.
Delays, Denials and Endless Frustration
Last year, NBC Bay Area reported more stories like Hood’s.
Lorrie Mays was a nurse who dealt with chronic pain and depression after being badly injured on the job. Medical reviewers abruptly stopped approving the only treatment her family said provided her any relief. She committed suicide shortly after her appeal was denied. A note she left behind said, “We treat our employees while injured worse than we treat our veterans.”
Then there was California Highway Patrol Officer Ryan Snyder, hit by a drunk driver in 2013 while patrolling the Napa area on his motorcycle. Snyder was launched from his bike and landed chin-first on the asphalt. He has yet to return to work fulltime and suffers from chronic neck and back pain. Snyder and his doctors say requests for medical care on constantly denied, even for basic items such as a $30 heating pad.
Marty Hoenisch, a San Jose firefighter, was crushed under a toppling wall during a massive warehouse fire. His injuries, including a fractured pelvis, were severe. But San Jose city administrators had to step in and overrule the city’s third party workers’ comp administrator, Athens Administration, when reviewers denied treatment requests made by Hoenisch’s doctor.
Baker said she’d have to look at these individual cases to understand why they faced denials, but reiterated the majority of the 250,000 workers who go through the system each year get satisfactory results.
“Most people are not stuck,” Baker said. “Most get back to work. Most people are getting their treatment.”
New Oversight of Insurance Industry
Mendoza’s legislation will also require more oversight of insurance companies and third party administrators. The medical treatment guidelines that many doctors said were outdated and overly rigid will also be revamped.
Baker said the state is also coordinating an outreach effort to help doctors understand how to properly document a request for a specific course of treatment, which she expects to further reduce denials.
“It’s an education piece and the Division of Workers’ Compensation is working hard at getting information and educational information about treatment guidelines on our website and how to use them,” Baker said. “We’re hoping the holistic approach will overall really make improvements to workers’ comp in California.”
Hood is hopeful the changes will make life better for him and other injured workers. But he’s cautious.
“People don’t understand the pain, the disappointment, the false hope and the lies that you are going to be treated,” he said. “Basically you aren’t.”