It’s not very easy for a hurt California worker to appeal a denied medicare request through the workers’ compensation system. The reason is largely the result of 2013 reforms via Senate Bill 863; injured workers cannot appeal their denials of treatment before a judge anymore. These matters are decided — and many are saying unfairly so — by a private and profit-driven corporation contracted to review appeals.
The corporation pays anonymous physicians to review patient medical records, and not the patient him- or herself, in order to decide if the appeal will prevail based on standardized guidelines. The thing is, data shows that patients are not likely to win their appeals. Approximately 600,0000 patients have been denied medical treatment from 2013 through 2015, and 90 percent of the appeals associated with those denials are also rejected.
Critics are saying that this is real and direct evidence that the appeals process is nothing more than a “rubber stamping” of previous denials. However, proponents of the system say that the 90 percent appeals rejection figure points to the fact that the original denial decisions were spot on. Who is correct?
To answer the question of whether the California workers’ compensation appeals process is unfair is a difficult one to tackle. This will require months of review, investigation and analysis of a random sampling of hundreds of cases.
However, what this figure does tell us is the fact that, if a California worker decides to appeal a denial of benefits, he or she may want to ascertain whether a viable appeal can be made. Furthermore, the injured worker will want to organize the appeal and associated arguments in a way that makes the most watertight case possible. For this reason, and because so much is at stake, many California workers are turning to the aid of an experienced workers’ compensation lawyer, who can advocate on their behalf.
Source: NBC Bay Area, “Injured Workers Face Stacked Deck During Workers’ Comp Appeals Process, Critics Say,” Liz Wagner, Michael Bott and Jeremy Carroll, Aug. 25, 2016
