Kevin Kampschror, Esq.
If you were to see your own doctor under your own health insurance, would
you give consent to another doctor, who has never seen you or met you,
to look at your records and give a medical opinion about what you do and
do not need? Would you then consent to that mystery doctor being able
to modify your own doctor’s treatment plan, at times including things
like physical therapy or even a surgery?
workers’ compensation (WC) laws in Nevada, you do not have a choice. Some insurers use “utilization
review boards,” (UR) who will review the treating physician’s
medical opinion and then give their own medical opinion and recommendations.
Insurance companies can then simply disregard the treating physician’s
recommendation and justify it with the utilization review board. If your
treating physician has recommended knee surgery, and the UR has denied
it, you have no option but to wait and appeal the decision (and wait on
getting the surgery, so hopefully it is not anything you need fairly soon),
or use your own insurance, and then hope that your appeal goes your way.
There are several enormous problems with UR. First, some doctor in another
state is simply looking at a snapshot of your medical history, not meeting
you, not talking to you, and not examining you, and then issuing an opinion.
Second, what is the point of having only one treating physician under
WC if insurance companies can simply pay companies like this to issue
medical opinions, presumably ones in their favor? Third, what about your
health – is money more important to insurance companies? Lastly,
this is a possible HIPPA violation due to the insurance company sending
your medical information, without your consent, to an outside party during
your WC claim. This issue likely will need to be litigated.
Rest assured that UR is rarely used to modify the treating physician’s
medical opinion and recommendation to adjust treatment to be increased
or more expansive. It is almost always used to short change your physical
therapy sessions from twelve (12) to six (6), deny a recommended surgery,
deny post-operative treatment, deny things like TENS units, and deny much,
This is a very complex area of WC law. As always, it is always advised
you seek an experienced Las Vegas workers’ compensation attorney
who is able to assist in obtaining all benefits that you are entitled
to under Nevada law.