Independent medical review and medical claims review for workers’ compensation ensure that there is a cost-efficient, non-judicial way to solve disputes between injured workers and employers/workers’ compensation insurers. When a request for medical treatment is denied, delayed or modified by a workers’ comp claims administrator on the grounds that the treatment does not meet medical necessity, an independent medical review may be utilized. During the review process, the claim will be reviewed by an objective, third party physician who will make a determination either to agree with the initial finding or disagree with it. If claims disputes are settled outside the courtroom, considerable money can be saved while also allowing the patients a second opinion regarding their case – a decision that is objective, timely and provided by a highly qualified physician.
Rulings and decisions related to workers’ comp cases have to be closely followed and understood. Recently, the Pennsylvania Supreme Court struck down an important part of the workers’ compensation law that has governed how the state evaluates workplace injuries for the past 20 years. Attorneys say that this ruling could enable thousands of severely injured workers to receive benefits more accurately in keeping with the extent of their injuries. This ruling was made in connection with Mary Ann Protz who was employed as a hall monitor for the Derry Area School District, near Pittsburgh in 2011. The court’s decision eliminated the practice of using AMA guidelines to place a cap on benefits paid out to severely injured workers.
Under a section of workers’ compensation law signed by former Gov. Tom Ridge in 1996, insurance companies can require injured workers to see a physician after receiving benefits for 2 years. The physician had to use guidelines from the AMA (American Medical Association) to rate the workers’ injury as a percentage. If a workers’ injury didn’t meet 50% of the guidelines as determined by the AMA, insurance companies could reduce the payments to reflect a partial injury and cap benefits at 500 weeks or nearly 10 years.
In Protz’s case, she received a 10% rating for her knee injury and related surgical complications in 2010. Her lawyer Thomas C. Baumann appealed for a higher rating arguing that the entire 1996 provision was illegal. He argued that citing a private medical group in workers’ comp injury ratings for two decades was an illegal “delegation” of power by the General Assembly. In a majority opinion dated June 20, Justice David Wecht said that while the General Assembly can in some instances enlist other groups to carry out laws, the legislature could not properly control the methodology of the AMA. The General Assembly did not require that the AMA hold hearings, accept public comments, or explain the basis for its methodology in a reasoned opinion that could then be subject to judicial review. The AMA was given de facto, unrestricted control over a formula that determined state benefits. This was not acceptable practice.
Workers’ rights advocates have welcomed the decision, though business groups fear havoc and increased healthcare costs. Small businesses with limited staff may be worst hit because this ruling prevents a doctor’s review of the worker’s progress and his/her ability to return to work. The court has left open the possibility that any injured worker over the past 20 years who has let the 500-week cap run out or has settled a workers’ compensation case before reaching that cap could be eligible to refile.
It is not clear how influential AMA guides are in other state workers’ comp systems but it is inferred that around 31 states use some form of AMA standards.
Insurance companies could use other ways of capping benefits such as providing evidence that the worker can perform some duties or offering a settlement. However, as Baumann points out, in the absence of AMA guidelines, there is likely to be some amount of confusion until the General Assembly introduces new guidelines or the judicial system clarifies whether severely injured workers can reopen old cases.