Archive for January, 2017

They say that Workers’ Compensation is supposed to help get the injured worker back to pre-injury condition, but as this injured worker has learned there’s no guarantee when or if that care will even be provided.

In my last post, I wrote about waiting for my treating physician’s request for physical therapy (PT) to get the green light. Of course the Adventist Health (that religious hospital/healthcare corporation) claims adjuster decided that maybe my treating physician’s diagnosis that I needed PT was somehow inappropriate, not the standard of care, a shot in the dark diagnosis, etc. So, off she went and sent the request to utilization review (UR) – you know any excuse not to pay for medical care or at the very least delay shelling out the greenbacks to pay for care for as long as Adventist Health (that religious hospital/healthcare corporation) can hold out, or better yet wear out the injured worker so that they either give up on seeking the care or pay for it out of pocket.

This time it only took just under three months to actually get a PT appointment scheduled. To accomplish this goal it only took numerous calls from my treating physician to the Adventist Health (that religious hospital/healthcare corporation) claims adjuster, approval of their handpicked UR company and my attorney. All this effort and time for four PT appointments with a system like this, it’s a wonder that injured worker’s get any medical treatment at all.

More to follow . . .


Plural sequelae


  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.

When I suffered my work-related injury being represented by an attorney was the furthest thing from my mind that is until I felt that Adventist Health (that religious hospital/healthcare corporation) was “messing” with my care.

After my fall on the wet floor of the restroom at the hospital I was sent to our employer’s workers’ compensation clinic/physician for care. While I was somewhat underwhelmed by the physician’s level of knowledge he seemed attentive and taking the appropriate steps to evaluate and treat my numerous injuries. The problem arose several weeks later when I found myself unable to place any weight on my right leg. While I had injured this leg in my fall the physician found primarily soft tissue/strain-like injuries, so I couldn’t understand why I couldn’t bear weight on my right leg. Stumped, I returned to the clinic for re-evaluation and surprise, surprise, I had a fracture that the physician had overlooked.

The physician ordered a cast walker, better known as a moonboot. Unfortunately, he didn’t have one he could fit me with so it was up to me to call around and find a store where I could purchase one. I was expected to pay for it out-of-pocket for which Adventist Health (that religious hospital/healthcare corporation) would reimburse me, which they eventually did thanks to a very professional and compassionate employee in Human Resources at Glendale Adventist Medical Center (GAMC). However, you’d think that a health organization would have such materials on hand or have a relationship with vendors/suppliers that could get them what they needed them stat – but I guess not.

So with the moonboot found and fitted I prepared myself to “wait-out” the almost six weeks that the physician estimated it would take to ensure full healing. In the meantime I began a series of physician visits to treat my other assorted injuries, including consulting with an orthopedic surgeon to fix the torn meniscus in my left knee, another injury that was the result of the same workplace accident. During one of my orthopedic appointments the surgeon agreed that I was a good candidate for surgery and we discussed the surgical plans. It was at this point that I asked him that if I had surgery immediately and considering that my right leg was currently in a moonboot this would leave me confined to my bed if I had surgery before my moonboot was removed. The orthopedic surgeon thought about this for about a minute and asked when the moonboot was to be removed and I replied in two more weeks. After some additional discussion he decided that since I was a diabetic we should wait until my moonboot was removed so I’d have at least “one good” leg to get around on while recuperating from left knee surgery. Since being confined to a bed for two or more weeks was not sound medicine for a diabetic such as myself and could lead to more dire consequences. I left his office that day not only with a treatment plan, but an appointment two weeks out for surgery. Everything was set, or so I thought.

Shortly before my surgery date I received a letter from the Adventist Health (that religious hospital/healthcare corporation) claims adjuster, Mr. CA, informing me that since I had refused surgery I had been deem “permanent and stable”. This designation would also affect my workers’ compensation payments and I would now be receiving permanent disability (PD) since I was no longer eligible for total temporary disability (TTD). Shocked by this change I contacted Mr. CA (I could do this since I had no attorney at that time) and asked him about the status change, since when I left the surgeon’s office two weeks earlier I was deemed TTD. Mr. CA went on to explained that he had contacted the surgeon and asked him to review his opinion, which the surgeon did and it was decided that I was now PD. I explained to Mr. CA that, at least in California, a physician cannot change a medical diagnosis of a patient without reexamining that patient which, hadn’t occurred in my case and any way I had a surgery date set and would be having surgery shortly, so how could I have refused surgery?

It was at that time the Mr. CA would utter those fatal words “we do it all the time”. I asked him to hold on for a moment so I could get my daughter in the room to listen to our conversation on the speakerphone. Once there I asked him to repeat his response to my question of the legality of having a physician changing a medical diagnosis without reexamining the patient, and Mr. CA repeated once again “we do it all the time”.

It was at that time that I knew I would need an attorney to sort this situation all out, and the search for a shark began.

More to follow. . .

Let’s talk about pain

A while back I published several articles on pain and opioid use.  I wrote these article to shed light on the other side of the pain and opioid use debate that seemed to me to be very one-sided.  And while opioid abuse has undoubtedly destroyed many lives, what concerned me most was the focus on opioid abuse without equal time being given to the estimate 25.3 million Americans suffering from chronic pain (8/11/15 NIH press release).

That said you can find my articles on the issue here

Nov. 2011 – Working Nurse Magazine – Chronic Pain: What nurses don’t know about pain management WNM Chronic Pain1 copy

Sept. 2012 – Working Nurse Magazine – The Great Opioid Debate: Balancing the need for pain management with the potential for abuse — WNM The Great Opioid Debate1 copy

May – Apr. 2014 – Working Nurse Magazine — The Opioid “Epidemic”: Why we need to dial back the sensationalism and find common-sense solutions — WNM Opioid Epidemic1 copy

The other day I read an interesting post written by Dr. Kathleen Kozak a physician from Hawaii who has a column in Honolulu Civil Beat. Her column, which can be read here bolstered my own personal theory that has been germinating for quite some time now. I’ve often wondered over the past many years if we looked objectively at both care models, Workers’ Compensation and the private, which model would have the injured worker back to pre-injury condition (or at least as close to it as possible) faster? Based on my own experience (both nursing and personal) I think we’d find that an injured person would “recuperate” more quickly if provided care through their private insurance.

I think this story from Hawaii illustrates the problem quite well. Reading about Bonnie Chan’s struggle to get appropriate care for her work-related injury struck a chord with me, especially in her fight to get timely care. When I underwent ankle bone graft and partial fusion/surgery, I suffered an unexpected outcome and consequently developed Complex regional pain syndrome (CRPS) and though my orthopedic surgeon made numerous requests for physical therapy, which by the way is one of the treatment of choice for CRPS his request were continually denied. At least one of the reasons given was that I had already had the maximum number of physical therapy allowed by our state’s WC regulations. While I had had physical therapy, it was ordered for my elbow as part of my recovery post-surgery elbow surgery. To this health professional it makes little sense that the physical therapy ordered for my ankle would be denied because I had “used” up my allotted physical therapy on my elbow. One would think that if physical therapy is the treatment of choice then that should supersede some arbitrarily set limit.

But then again we are talking about WC, a bureaucratic, governmental system that by definition is not always known for being logical. All thanks to the self-insured Adventist Health (that religious hospital/healthcare corporation).

More to follow. .