Articles Posted in Medical Benefits

We have discussed the Utilization Review (UR) process many times in this blog.  Indeed, UR is such a big issue in the world of Pennsylvania workers’ compensation that we have a section on our website devoted to just this topic.  Basically, UR is the tool used by either an injured worker, or the workers’ compensation insurance carrier (usually the latter) to determine whether medical treatment is “reasonable and necessary.”

A somewhat related process is that for Fee Review.  Since this is something that is done by healthcare providers (rather than the injured worker), we have rarely addressed Fee Review in this blog.  The healthcare providers often have their own legal counsel handle these matters (rather than obtaining relief through the efforts of the injured worker’s attorney, as in other areas of workers’ comp).  Fee Review is the means a healthcare provider uses to obtain payment for reasonable and necessary medical treatment, related to the work injury.  Recently, the Commonwealth Court of Pennsylvania issued a decision which dealt with both Utilization Review and Fee Review.

In Keystone Rx LLC v. Bureau of Workers’ Compensation Fee Review Hearing Office (Compservices Inc./AmeriHealth Casualty Services), the injured worker hurt his left knee.  As part of the treatment for the knee, the physician ordered medications, which were dispensed by Keystone Rx LLC.  The workers’ compensation insurance carrier filed for Utilization Review of the treatment rendered by the physician, including these prescriptions.  A Utilization Review Determination found all treatment of the physician, including the medications, to be unreasonable and unnecessary.  This meant the insurance company was not responsible for payment of the treatment found unreasonable and unnecessary (including the prescriptions).

How many times must an injured worker in PA hear something like, “Why are you still out of work – it was just a bruise?”  What is not widely understood is that a bruise, or a contusion, can, indeed, be a serious injury with very severe consequences.  Recently, we saw an example of this in the sports world.

Tyler Lockett, a wide receiver for the Seattle Seahawks in the NFL, suffered a bruised lower leg in a game on November 11, 2019.  According to an article in the Washington Post, Mr. Lockett was hospitalized overnight as a result of the injury.  In addition to causing pain and immobility, a bruise or contusion can also cause swelling.  This swelling, when in a small area, such as a lower leg, can instigate “compartment syndrome.”  According to the article, “Compartment syndrome is a rare but potentially dangerous condition in which pressure builds to extreme levels in a limb after it undergoes some sort of trauma, either from a big hit or simple exercise.”

On the website for the American Academy of Orthopaedic Surgeons (AAOS), it is reiterated that compartment syndrome can result from badly bruising a muscle, which we do often see in PA workers’ compensation cases.  When this compartment syndrome is the result of acute trauma, it is a medical emergency.  Immediate treatment is necessary to avoid permanent damage to muscle, nerve and tissue.  There is no non-surgical treatment for compartment syndrome.  Specifically, the treatment involved would be:

The vast majority of work injuries in Pennsylvania heal with conservative treatment, allowing the injured worker to return both to work, as well as to activities of normal life.  However, there are certainly the more serious injuries, where more invasive medical treatment is required.

Often the more invasive treatment options entail surgery.  When we are talking about work injuries to the neck and back, the procedures we usually see are laminectomy, microdiscectomy and traditional lumbar fusion.  For a description of each of these, and more information regarding these procedures, check out this post from Penn Medicine.  For our purposes today, we are looking at the traditional lumbar fusion.  As explained in the Penn Medicine article:

Traditional spinal fusions are used to treat instability of the spine, scoliosis, severe degeneration of the discs, or a combination of these issues.  A fusion involves using bone from the patient’s body to fuse one vertebrae to another.  Often, metal screws (pedicle screws) are placed into the vertebrae to assist with the fusion process.”

While we are very conscious of being available to our clients as much as possible, the practice of PA workers’ compensation law, and the litigation process, means we are not always in our offices.  Sometimes, in addition to being at workers’ compensation hearings and depositions, our attorneys attend events or presentations that may help us better perform our job protecting the injured worker in PA.

And, so it follows, our attorneys were invited by Rothman Institute to attend their Workers’ Compensation Conference, being held all day on Friday, October 24, 2019.  We sincerely apologize if this means we are not available to help our clients on that day directly, though our office staff certainly remains available (and can reach the attorneys for any emergencies).  As our clients know, it is the practice of Brilliant & Neiman LLC for the clients to speak directly to the attorney, rather than being forced to always speak to support staff.  We apologize for this deviation from our regular course of business.

The Workers’ Compensation Conference will no doubt provide our attorneys with additional tools to help us best protect the rights of injured workers in PA.  Topics being presented will include 3-D printing in orthopedic surgery, issues with complex rotator cuff surgery, as well as general updates regarding treatment options for injuries to the neck, back and knees.  The Workers’ Compensation Conference will be moderated by Dr. Nicholas Taweel, and will include presentations from Dr. Pedro Beredjiklian, Dr. Mark Lazarus, Dr. Michael Molter, Dr. Howard Yeon and Dr. Paul Steinfield.

As far back as 2008, our blog reported on a marked increase in the number of total knee replacements that were being performed.  This trend seems to have been continuing, and, perhaps, not for the best.  According to a recent article in The Intelligencer, a rather high number of patients who elected to have a total knee replacement performed, were dissatisfied with the results.  According to the article:

Research suggests that up to one-third of those who have knees replaced continue to experience chronic pain, while 1 in 5 are dissatisfied with the results. A study published last year in the BMJ found that knee replacement had “minimal effects on quality of life,” especially for patients with less severe arthritis.”

In Pennsylvania workers’ compensation, a total knee replacement is a procedure with see with some regularity.  Whether the injured worker had a preexisting arthritic condition, which was aggravated by a work injury, or whether the work injury itself led directly to the procedure, a total knee replacement is not uncommon in a workers’ comp case.

Did you know that an injured worker in Pennsylvania can choose his or her own doctor?  There is a common misunderstanding in the general public that the workers’ compensation insurance carrier can dictate the medical treatment of an injured worker.  While a workers’ comp insurance company MAY be able to have some limitation on the choice of a doctor for an injured worker, that control is narrow.

If an employer posts a valid list of healthcare providers for an injured worker to select (called a “panel posting”), the workers’ compensation insurance carrier may only have to pay for treatment with one of the listed providers (for the first 90 days).  This would only be true if the list is a valid one (there are rules of what providers can or cannot be on a list), the list is posted in a prominent location, and the injured worker signs an acknowledgement that he or she has seen the list, both before and after the injury.  Employers frequently do not meet all of these requirements, allowing an injured worker to treat with a doctor of his or her own choosing (and having the workers’ comp insurance carrier responsible for payment).

As the PA Bureau of Workers’ Compensation notes on its website, “The PA Workers’ Compensation Act gives employers the right to establish a list of designated health care providers.”  Many Employers simply do not take advantage of this “right,” giving them no control over the medical treatment for an injured worker.  Again, even if an Employer has a properly posted “panel,” this control over medical treatment only lasts for the first 90 days of treatment.

Recently, we discussed the status of Senate Bill 936, which was passed by the House.  We are pleased to relate that Governor Thomas Wolf has vetoed this legislation, recognizing that it was a thinly disguised attack on injured workers and not a solution to any problem.

As discussed in the Morning Call, Gov. Wolf said:

Make no mistake, Senate Bill 936 is not a bill designed to fight the opioid crisis. Senate Bill 936 threatens health care for millions of workers who could be injured on the job, including police, corrections officers, and firefighters, who put their lives on the line every day, and whose injuries can be unique, debilitating and severe. It is wrong to sacrifice health care for our first responders to protect the bottom-line for insurance companies and corporations.”

Previously, we have warned of the pending legislation that will restrict the access of injured workers across the State of Pennsylvania to get medications they need.  Now, thanks to the House passing Senate Bill 936, the legislation heads to the Governor.  It is not bad enough that innocent people suffered injuries at work, now they have to deal with the reality that they will be treated different than patients who are not in the Pennsylvania workers’ compensation system.

As noted in an article on Pennlive.com, this legislation “was drawn up in response to reports in the Philadelphia Inquirer and Daily News about doctors and law firms specializing in worker’s compensation that were operating their own pharmacies.”  Perhaps someone would be kind enough to explain why the legislation did not simply prohibit the ownership of pharmacies by these groups?  Instead, this legislation does not even deal with this issue.  At all.  Rather, the legislation makes medications (all medications, not just the opioids that caused all of the supposed angst) more difficult for an injured worker in PA to obtain.

And, again we ask, is this fair?  Is this how our elected representatives protect us?  By making sure that we have difficulty getting medications if we are unlucky enough to be injured at work?  We urge all injured workers, those who care about injured workers and those who care about fairness and justice, to reach out to their legislators, and reach out to the Governor’s office, and let everyone know this will not be done without a fight!

Previously on this blog, we have discussed the rights held by injured workers in Pennsylvania to choose their own medical providers.  This is only one area of confusion in the wacky world of medical benefits under the Pennsylvania Workers’ Compensation Act (Act).

A common complaint we get from an injured worker is that, “They are denying my medical treatment.”  In this situation, “they” is almost always the workers’ compensation insurance carrier.  And the word “denying” may or may not be accurate.

Under the Act, the workers’ comp insurance carrier has 30 days to either pay a medical bill or institute Utilization Review (the tool used to challenge whether medical treatment is reasonable or necessary), provided the bill is properly submitted by the medical provider (including supporting documentation).  As you can see, this means the workers’ compensation insurance company need not give an opinion on how they view treatment until it is actually performed.

We have lamented the severe and draconian limits on the ability to challenge Utilization Reviews (URs) on this blog before.  We have seen a case where a healthcare provider sent a treatment summary and talked with the reviewer, and a case where records were actually submitted by the provider, but then returned by the reviewer due to a missing verification, both of which were deemed unreachable by appeal (finding that the Workers Compensation Judge (WCJ) lacked jurisdiction due to the failure to supply records).

Considering that UR is the process to limit medical treatment to an injured worker, and that the Supreme Court of Pennsylvania just told us, in Parker v. Workers’ Compensation Appeal Board (County of Allegheny), “we observe that the Workers’ Compensation Act is to be liberally construed in favor of workers in order to effectuate its remedial purpose,” these cases are hard to rationalize.  And, with this latest contribution from the Commonwealth Court of Pennsylvania, even more disappointing.

As noted above, the case law, and regulations, have told us that when a healthcare provider fails to provide records, no report is to be prepared by the Utilization Reviewer, and no challenge can be made from the Utilization Review to a Workers’ Compensation Judge (WCJ).  In fact, the Utilization Review Determination Face Sheet has a specific box to be checked for when no Determination can be issued due to the failure to supply records.