Workers Comp Zone


One of the ironies of the California workers’ comp system is the lack of education treating and evaluating doctors have.

The AMA Guidelines, 5th Edition became the touchstone of disability evaluations in 2005. But QMEs were not required to be schooled in use of those guidelines.

Many QMEs have by now delved deeply into the Guides, taking various seminars. But some QMEs still have a tenuous grip on the Guides.

And what about treating doctors? Have they mastered state-mandated treatment rules?

California adopted the ACOEM Guidelines as treatment standards and later adopted the MTUS, the Medical Treatment Utilization Schedule. Proffered treatments are required to be supported by the MTUS (found at Title 8, California Code of Regulations 9792.20 to 9792.2). Treatments not addressed by MTUS may be authorized on a rebuttal basis “if such treatment is in accordance with other scientifically and evidence-based, peer reviewed, medical treatment guidelines that are nationally recognized by the medical community” and “a variance from the schedule is reasonably required to cure of relieve the injured worker from the effects of his or her injury” (see 8 CCR 9792.25)

Could it be that few doctors are familiar with the MTUS? Have few workers’ comp treating doctors even read the MTUS?

That may well be the case.

So is the argument made by Dr. Robert R. Kutzner, a Los Angeles area based
pain specialist. Writing in comments on proposed MPN regs in a DWC sponsored forum, Kutzner charges that:
“I am consternated that we write more and more laws to enforce the MTUS law when we haven’t spent any effort to ensure that those whom are responsible to implement it, KNOW ABOUT IT. This is outrageously shocking and easily substantiated: Just ask any provider, any WC Insurance Adjuster, or just about anyone at the Medical Board outside the Div of WC about the MTUS and they won’t know what you’re talking about. To prove my point simply look at the video recording of the Med. and Pharm. Brd. joint forum on Prescription Overdose, Feb 2013, where I asked hundreds of attending WC Providers and Insurance Adjusters, to include the Professional Panel, if they knew about the MTUS only to receive a blank look where no one knew what the MTUS was. No one, not Adjusters, not TPA’s, not the Providers who are supposed to implement the WC Program know anything about the MTUS. Why should they when they are not even required to read it to participate.”

Kutzner defines the problem thusly:
“Providers are not required to know or implement the MTUS. Shockingly most Providers don’t know what the MTUS is let alone read it. That’s right, Insurance Companies don’t require Providers to even read the MTUS to get on their MPN list.
In addition, Insurance Adjusters are not required to know or implement the MTUS. The State does not require Insurance Companies to even read the MTUS to get approval to offer Workers Compensation Insurance.
Third Party Administrators (TPA’s) are not required to know or implement the MTUS. The State does not require Third Party Administrators (TPA’s) to even read the MTUS to get approval to participate in Workers Compensation.”

His solution?

“Doctors that want to be on a Provider Network SHOULD HAVE TO AKNOWLEDGE THAT THEY HAVE AT LEAST READ THE MTUS.
Insurance Carriers and TPA’s that want to participate in Workers Compensation SHOULD HAVE TO AKNOWLEDGE THAT THEY HAVE AT LEAST READ THE MTUS. They should also acknowledge that they will ensure that their Providers have also read the MTUS.”

Kutzner has identified a very basic problem. California workers’ comp has become ever more complicated.

Substantive changes in the law, procedural changes, regulatory changes.

The volume of rules and regulations that apply to stakeholders is massive.

It’s likely that many of the physicians and stakeholders either are too distracted or too busy to pay attention to the details. Any the DWC currently has no way to monitor training that those stakeholders receive on the basics.

It’s a problem.

Stay tuned,

Julius Young

Category: Medical treatment under WC