A treating doctor submitted the following question about problems he has had referring injured workers to specialists for surgical consultations. My answer follows:
Q: I keep having problems making referrals for orthopedic or surgical consults when...
A treating doctor submitted the following question about problems he has had referring injured workers to specialists for surgical consultations. My answer follows:
Q: I keep having problems making referrals for orthopedic or surgical consults when taking over as treating doctor after the patient first treats at an employer or carrier-recommended facility. That facility made a previous referral but the patient doesn't want to continue care with these doctors. What can I do?
A: This is a preauthorization issue. The Official Disability Guidelines do recommend orthopedic and surgical consultations. For a low back injury, the ODG suggests such a referral on the second visit in some cases; for a neck injury the referral is recommended as early as the first visit if there are neurological symptoms. The issue here is not whether the consult itself is necessary. The problem is that it has already occurred as a referral from the company doctor.
Division Rule 137.100 indicates that insurance companies are not liable for treatment that exceeds the ODG recommendations unless they are preauthorized. The ODG allows for a consult, say for the necessity of spinal surgery, but it does not allow for two such consults. The second consult must be preauthorized.
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Most of the time, the second treating doctor makes the referral and the referral doctor can't get the adjuster to "approve" the office visit. Someone at the doctor's office keeps calling the adjuster to see if the carrier will pay for the visit. When the doctor is told no, or is ignored, the referral doctor tells the treating doctor and the patient that they can't do the exam because it is not approved.
The problem with this scenario is that there is no way to resolve the situation, and the patient suffers as a result. The patient is left in limbo, often for long periods of time and there is nothing that can be done for them. The next step in the treatment plan is usually riding on the question of surgery.
The solution to this problem is to submit a written request for preauthorization of the referral for the surgical consult. Rule 134.600 requires the carrier to respond to this request within three business days, and send written notice of the decision within one day of making the decision. This approach allows for the use of the IRO process to obtain the surgical consult, and a hearing after that if necessary.
The important part of this process will be the explanation for the referral. There should be more than a prescription pad referral. There should be a chart note of some kind to explain the reason for the referral, ODG criteria for the referral, and the medical necessity of the referral pursuant to ODG and the doctor's own clinical judgment.
No longer is the patient left in limbo, complaining to the doctor about the lack of treatment. There is a decision with a defined appeals process. There is a response for the treating doctor to give the patient when asked about status of the referral. There's no angst for the patient over weeks of calling the carrier with no response while they sit in pain, waiting to see a doctor. There can be a solution other than the patient looking for a new treating doctor, one who can make a referral happen.
