California-Worker's Comp Hell

[Disciple]

Need some input from the experienced pain docs:

Intradiscal procedures are near impossible to get authorized in my state through Worker's comp.

1. Denied per AECOM guidelines which do not support the use of such procedures

2. In the event I'm able to get the reviewing physician to see my point of view and provide him/her with literature references, they usually tell me they have to deny the procedure based on the insurance carrier's underlying policy which labels the procedure as "experimental" (Blue Cross of CA is one who has such as policy. Anyone know which insurers do not?).

3. Should the carrier have no such policy, the insurer's UR dept will often attempt to block my attempts to appeal the denials by classifying my request as a request for "spine surgery" thereby invoking a section of the California Labor Code stating that denials for "spine surgery" may not be appealed and must be recommended in second opinion by a Neurosurgeon or Orthopaedic spine surgeon, which pretty much destroys any chance that the procedure will be authorized.

Do I have any viable recourse? I'm considering setting up practice in another state due to this BS.

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[Aether2000]

There is little you can do about these "guidelines" that basically attempt to divert patients to non-interventional non-treatments. Only at the pain society level can there be any viable battle of these sham guidelines that were set up by occupational physicians without any knowledge or recognition of other treatment modalities outside their own limited field. WC has adopted these guidelines because it shunts patients into very inexpensive extremely conservative therapies that may not work at all, but cost so little that it makes the WC carriers happy.

 

[Mister Mxyzptlk]

You can thank Dr. Carragee for this, and keep him in mind when someone tries to sell you on the "functional discography" system he is trying to market. The entire discussion of discography focuses mainly on his publications. They don't mention that he still does them.

ODG does not totally prohibit discography. It is simply "not recommended". Here is the "yes, but . . ." part to use in your appeal:

While not recommended, patient selection criteria if discography is to be performed, requiring ALL of the following:

o Back pain of at least 3 months duration

o Failure of conservative treatment

o Satisfactory results from detailed psychosocial assessment (discography in subjects with emotional and chronic pain problems has been linked to reports of significant back pain for prolonged periods after injection, and therefore should be avoided)

o Candidate for surgery

o Briefed on potential risks and benefits from discography and surgery

I'd make sure the patient jumps all these hurdles and then ask for reconsideration based on the above.

Moral of the story: know your enemy and hoist him on his own petard.

 

[paz5559]

You can thank Dr. Carragee for this, and keep him in mind when someone tries to sell you on the "functional discography" system he is trying to market. The entire discussion of discography focuses mainly on his publications. They don't mention that he still does them.

ODG does not totally prohibit discography. It is simply "not recommended". Here is the "yes, but . . ." part to use in your appeal:

While not recommended, patient selection criteria if discography is to be performed, requiring ALL of the following:

o Back pain of at least 3 months duration

o Failure of conservative treatment

o Satisfactory results from detailed psychosocial assessment (discography in subjects with emotional and chronic pain problems has been linked to reports of significant back pain for prolonged periods after injection, and therefore should be avoided)

o Candidate for surgery

o Briefed on potential risks and benefits from discography and surgery

I'd make sure the patient jumps all these hurdles and then ask for reconsideration based on the above.

Moral of the story: know your enemy and hoist him on his own petard.

I have often found that pointing out that discography generally is used to rule out levels, or rule patients out altogether, from undergoing surgical procedures, will ultimately save insurer's money.

Mind you, if you are doing a discogram to justify your own intradiscal procedure in follow-up (i.e. IDET or your favorite PDD) this is not a reasonable argument.

 

[lobelsteve]

Mind you, if you are doing a discogram to justify your own intradiscal procedure in follow-up (i.e. IDET or your favorite PDD) this is not a reasonable argument.

Unless you are a fellow in a training program?

 

[Aether2000]

PAZ...I would agree that it may raise some eyebrows doing your own discogram then procedures based on that outcome, but the surgeons do not share in such trivial details. They are happily doing their own discograms (sometimes quite poorly) and are content to obtain their training from NA$$ to perform lumbar injection procedures as a prelude to their surgical interventions. I am not sure if we can take the high road when surgeons increasingly will not.

 

[Disciple]

You can thank Dr. Carragee for this, and keep him in mind when someone tries to sell you on the "functional discography" system he is trying to market. The entire discussion of discography focuses mainly on his publications. They don't mention that he still does them.

ODG does not totally prohibit discography. It is simply "not recommended". Here is the "yes, but . . ." part to use in your appeal:

While not recommended, patient selection criteria if discography is to be performed, requiring ALL of the following:

o Back pain of at least 3 months duration

o Failure of conservative treatment

o Satisfactory results from detailed psychosocial assessment (discography in subjects with emotional and chronic pain problems has been linked to reports of significant back pain for prolonged periods after injection, and therefore should be avoided)

o Candidate for surgery

o Briefed on potential risks and benefits from discography and surgery

I'd make sure the patient jumps all these hurdles and then ask for reconsideration based on the above.

Moral of the story: know your enemy and hoist him on his own petard.

Thanks everybody for all the input.

To update, I actually got a PDD authorized today (Worker's comp). I had been harrassing the adjustor with phone messages the past few weeks and finally was able to speak with her today. She informed me that the request was about to be forwarded to an Ortho spine surgeon for a 2nd opinion. I explained to her that the requested procedure was not "spine surgery" ,and, by some act of God, she authorized it.

Granted, this was a smaller company that did not use Blue Cross for UR, but I guess I better hurry up and get the patient scheduled before the medical director finds out about it. Some of the pain UR docs I've been able to speak with have told me they haven't done a PDD in over 2 years.

To the next problem in this state, Medical Provider Networks (MPNs). From what I understand they are exclusive lists (like being on "the list" for the hottest night-club) that WC insurers create (based on how little money you waste and how quickly you get patient's back to work) to pick which physicians their insured may use.

How does one get on these lists?
Are they also common place with private insurance?
From what I understand the first contract or so is short term so they can evaluate your performance and make sure you are not over-treating?

Thanks.


Ignorance is bliss.

 

[Disciple]

You can thank Dr. Carragee for this, and keep him in mind when someone tries to sell you on the "functional discography" system he is trying to market.

The Kyphon rep is coming to the clinic tomorrow

 

[Disciple]

Well,

Another run in with UR today. So I had requested a Perc-DD for a patient with a L4/5 pos/lat herniation (failed 2 ESIs). It was denied and I appealed (with current references).

I spoke with a second reviewing physician today for peer review. He couldn't respond to any of the literature I referenced. His answer was basically, "Well, Blue Cross, ODG and ACOEM say it's experiemental, so, I just can't authorize it, but I guess you can appeal it again if you want."

To the experienced docs: Are there any options? Complain to the DWC? or have you found it's just not worth it to try to fight through this BS?

Another point. I've noticed that appeals are never reviewed by the same physician who wrote the denial. So, not only does this new physician not have to address your rebuttal to the denial, but he is able to interject his own original BS and deny it a second time with different rational. It's like getting a panel denial. If your request gets handed off enough to different UR physicians, you exhaust your alloted appeal attempts. Calculated move by the insurers/independent UR contractors?

Maybe I'm just getting cynical.

 

[Mister Mxyzptlk]

According to the great and wise Kenny Rogers, you have to know when to hold and when to fold. Sometimes you just can't fight the machine and this seems to be one of those times.

I have discharged all of my WC patients except for a small handful who I thought would not do well psychologically with the separation right now. This is the second time I have dropped off WC. I came back in last year when they "reformed" it but in reality nothing has changed, so I'm exiting for good.

Looking at it just in dollar terms, I figure it this way:

1. See a WC pt for 15 minutes and bill 99212.
2. Spend another 30 minutes (1) writing a precert letter, (2) arguing on the phone with a peer reviewer (usually a family practitioner with no knowledge of pain management except what ODG says), then (3) write an appeal letter on the denied precert, and (4) talk to yet another peer reviewer so you can do an ESI.
3. In Texas WC pays 125% of Medicare, so net = 125% of Medicare 99212 rate for 45 minutes of work.

OR,

See 3 Medicare patients for 99212 and make 3 x 100% of Medicare for the same amount of time, then do an ESI on each one of them while you wait for the appeal of the denied precert on the WC patient.

There's no "maybe" here - I am definitely cynical.

 

[Disciple]

Looking at it just in dollar terms, I figure it this way:

1. See a WC pt for 15 minutes and bill 99212.
2. Spend another 30 minutes (1) writing a precert letter, (2) arguing on the phone with a peer reviewer (usually a family practitioner with no knowledge of pain management except what ODG says), then (3) write an appeal letter on the denied precert, and (4) talk to yet another peer reviewer so you can do an ESI.
3. In Texas WC pays 125% of Medicare, so net = 125% of Medicare 99212 rate for 45 minutes of work.

OR,

See 3 Medicare patients for 99212 and make 3 x 100% of Medicare for the same amount of time, then do an ESI on each one of them while you wait for the appeal of the denied precert on the WC patient.

You're more convincing each time. As reported no WC mass exodus out here yet (surgeon wise), but more slowly leaving each year.

Some are predicting either the return of "work-comp mills" or major reform once all the doctors bail out. Wasn't there a situation in Florida like that some time ago?