The LA County Observer

Observations of a LA County Resident

Sequela

Written By: raconte - Jan• 10•17
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Plural sequelae

\-?kwe-(?)l?\

  1. An aftereffect of a disease, condition, or injury
  2. A secondary result

As defined in the Merriam-Webster dictionary

As I sit here at home waiting to learn when I’ll finally have my physical therapy (PT) appointment, I wondered how many other injured workers’ suffer from sequela/ae due to the foot dragging, oops I mean the review process, that’s used so very often by the Workers’ Compensation (W/C) claims adjuster to verify that the treatment recommended by the injured worker’s treating physician is “reasonable”.

On November 14, 2016 my physician submitted the form PR-2, aka Primary Treating Physician’s Progress Report, followed on November 28, 2016 a formal request for authorization to my claims adjuster (Ms. CA). So before Ms. CA could give my physician the green light off to utilization review (UR) it went and after a couple of back and forth UR approved albeit it was a “modified” approval but my physician’s PT request was authorized. Yet here I sit more than one month later still waiting to begin my PT. Why? You may ask, all because Ms. CA has yet to respond to my physician to approve the actual physical therapist facility/person. So without her green light, here I sit waiting in pain.

Under a traditional healthcare plan there’s usually a 5 to 7 day window for the plan to approve a referral, and the member then receives a referral letter that either shows the referral is approved with the name of the specialist or therapist to call. If the referral is declined the member can appeal and again there is a set period of time for which this must occur. Unfortunately, with W/C this is very often not the case with the treating physician being required by the claims adjuster through the use of UR to “justify” that the injured worker is indeed in need of the specialized care, treatment or tests. Should UR approve the request then the treating physician can refer the patient, but the claims adjuster can throw a monkey wrench in things if the specialist or request treatment still requires approval from the claims adjuster for the injured worker to see the specialist.

When this kind of foot dragging occurs the only recourse is to go back to the W/C “court” and seek the intervention of an administrative law judge. Even when the attorney makes this request for a hearing the injured worker can expect to wait 30 days or months for a hearing date. In the meantime the injured worker’s injury is left to endure an extended period of time without appropriate treatment for their injury. Meanwhile if that injured worker had been treated through the traditional medical track one can reasonably conclude that the injured person would’ve received treatment more quickly and thus be at a lesser risk of suffering additional sequela/ae.

I think that much of this waiting and foot-dragging is directly related to the adversarial system that has become rooted in our W/C system. It would appear that many employers in order to “manage the claim” come to see the injured worker as someone who is out to take advantage of the system, and while this may be true in a small number of cases it’s not so for the majority of the cases. The majority of injured workers simply wish to get back to pre-injury condition (as much as is medically possible) and back to work. But when the injured worker and treating physician have to plead and fight for treatment and then wait for the W/C courts to sort it out essential progress in healing is delayed and to some great extent denied. What I find outrageous is that even when there’s a court order that supports the injured worker the employer, through the claims adjuster, can decide to simply ignore it; leaving the injured worker with no recourse but to go back to court waiting again sometimes for months for another hearing, which stretches things out even more. And around and around it goes when it’ll stop nobody knows.

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