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Audit shows delay in workers' compensation medical reviews

Workers' compensation in California is a vital aspect of injured employees receiving medical care and wages for the time they are unable to work. The key part of these benefits, however, is getting approved as quickly as possible. One aspect of this is when there is a disagreement with the employer as to whether the injury is work-related and how long the person should be out. This is when there will be a medical review. A problem that has recently surfaced with these reviews is that workers are waiting an inordinate amount of time to get a decision. Clerical problems can be a troublesome part of the workers' compensation claims process.

In the audit, the reviewer found that there are not enough doctors to conduct the reviews. There was a 37 percent increase in review requests between 2013 and 2018. Despite that, there was a reduction in doctors who were available to conduct them by 12 percent.

In a review, the worker receives an offer of three doctors on a panel. Frequently, they will not be available within 60 days. If that happens, there can be a new panel to expedite the case. The number of requests to speed up the case went up significantly in that five-year span. In 2017 and 2018, there were approximately 19,000. That is an increase from 4,600 from four years earlier.

There has not been a move to hire new doctors. In fact, it is believed that many doctors already employed to conduct the reviews have chosen to leave or were denied a reappointment due to billing disputes.

In addition, the Division of Workers' Compensation (DWC) does not regularly conduct a review of the reports the doctors provide. Some reviews found that 85 percent did not meet the necessary standards. The auditors want state lawmakers to improve how the doctors are paid and make other adjustments to reduce the wait time workers are facing.

Being injured on the job can be problematic enough without wondering whether the medical expenses will be paid and if an ongoing delay in a medical review can cause a negative outcome. These seemingly minor issues can sow concern in the worker's mind and be a distraction from getting the necessary treatment to recover.

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