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September 19, 2005
More Workers' Comp Upheaval in California

Last year, California overhauled its troubled workers' comp system by giving insurance companies the right to ask outside medical experts for second opinions if they disagreed with courses of treatment prescribed for injured workers.

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But answering the question of who should be allowed to give that second opinion has touched off another debate among doctors, insurers and regulators, according to the Los Angeles Times.

Regulators have proposed rules that would allow insurers to seek second opinions from out-of-state doctors, including those not licensed to practice medicine in California.

Doctors, represented by the California Medical Association, among others, contend that state law allows only physicians licensed by the state to make those decisions. Out-of-state physicians, they say, often lack specific expertise in California's workers' comp law and medical protocols designed to get those injured back on the job.

"We can't talk to [reviewing doctors] when they are far away; we have no way of evaluating whether they are competent or not, and we can't complain" to state regulators, said Jack Lewin, the medical association's chief executive.

The Medical Board of California, a government panel that licenses and disciplines physicians and surgeons, has raised similar alarms. In several letters to fellow regulators at the Division of Workers' Compensation, the board said the proposed regulations were illegal because they would allow out-of-state physicians to practice medicine in California without a license.

But Andrea Hoch, the state's top workers' comp administrator, says "the fact that [the reviewing doctors] are not licensed in California does not mean they are not capable of reviewing treatment requests and applying guidelines that are national. A broken bone is a broken bone."

Hoch said workers' compensation medical directors, who are licensed in California, would remain responsible for all treatment decisions made by reviewers in their networks. The doctors' complaints, she suggested to the Times, have more to do with protecting turf and making money than with ensuring top-notch treatment for patients.

The doctors are joined by advocates for injured workers, who say Californians who need medical care may not get it if decisions are made by out-of-state doctors working for insurers.


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