Injured workers who seek remedy through the appellate process often find themselves at odds with “independent medical examiners,” explains a recent report by NBC.

Although the report focuses mainly on cases from the Bay Area of California, this issue is applicable nationally, including here in Georgia. As our Atlanta workers’ compensation attorneys often need to explain, “independent” medical examiners aren’t exactly “independent.” These health care professionals are often on contract with the employer (or the insurance company) and have a vested interest in keeping the employer/insurer happy in order to retain these lucrative contracts. Claimants are sometimes required to undergo an independent medical exam as part of their case.

In the NBC analysis, reporters noted that updated procedures in California require injured workers who’ve been denied benefits to have their case reviewed by a state-contracted, for-profit company. These “Independent Medical Reviews” involve payment to anonymous doctors who never actually examine the patient one-on-one and who determine eligibility based on specific standard guidelines. The news report indicated that between 2013 and 2015, injured workers contested some 600,000 denials of medical treatment following work-related injuries. 90 percent of those denials were upheld following an appeal to the independent medical review. 

Critics say this is clear evidence that the appellate process is one-sided and these teams of doctors and commissioners are simply rubber-stamping rejections to deny injured workers treatment. However, the state argues that the low rate of overturning decisions on appeal means the decisions are being made correctly the first time around.

Although Georgia doesn’t exactly follow the same process – appeals can be heard before a judge – there are independent medical reviewers working for employers/insurance companies and they can make appealing a denial of benefits far more difficult. That is why our Atlanta workers’ compensation team always comes prepared for the appeals process. We make sure clients know what to expect with these exams and how best to navigate the system.

It’s not unusual for employers to agree to some modicum of treatment early on, but then fight further benefits as time wears on. One case that NBC highlighted involved a nurse who worked with women enduring at-risk pregnancies. She slipped and fell down a flight of stairs during a house call, suffering serious injuries. She underwent surgery, but that didn’t quell the excruciating and chronic pain. She sought continued workers’ compensation benefits for treatment of chronic pain and the depression that stemmed from it. Days before receiving word that her claim was denied following an independent medical review, she took her own life.

Her family members say that while her workers’ compensation insurer did provide her with assistance, the arbitrary cut-off wasn’t fair. At the time, her physician had been trying to obtain approval for ongoing treatment of her depression.

The controversy in California stems from several factors, including:

• The private company that is contracted with the state to conduct the reviews for between $345 and $515 per case is paid by the injured worker’s employer and/or their insurance company.
• The names and identities of the doctors are kept confidential.
• There is no requirement that the doctors be licensed to practice medicine in California. In fact, some are only licensed to contract out-of-state.
• Doctors are not required to actually examine the patient. They are only given the worker’s medical history to review and make a determination based on pre-determined standards.

Workers’ compensation lawyers are arguing that there is a lack of necessary transparency. Plus, money spent for a private company means less money going toward the medical care of workers.

For information on Atlanta work injury compensation, contact J. Franklin Burns, P.C., at 1-404-920-4708 .