California Supreme Court Rebuts Court Ruling On UR Physician Liability

April 29, 2016
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Medical reviewers and workers’ compensation providers can breathe a sigh of relief – at least for now.

Last week the California Supreme Court ruled to officially depublicize a lower court’s previous ruling on the utilization review (UR) and workers’ compensation industries that would have set a precedent by holding UR physicians responsible for the care of patients whose cases the physicians review.

Medical reviewers and workers’ compensation providers can breathe a sigh of relief – at least for now.

Last week the California Supreme Court ruled to officially depublicize a lower court’s previous ruling on the utilization review (UR) and workers’ compensation industries that would have set a precedent by holding UR physicians responsible for the care of patients whose cases the physicians review.

The prior court ruling in the case King v. CompPartners issued by the California 4th District Court of Appeal revolved around the issue of duty of care for UR physicians, subsequently placing UR physicians at increased malpractice risk.

In that decision, the court ruled that a UR physician could be held liable for civil damages because the physician had established a doctor-patient relationship with the plaintiff and thus owed the patient a duty of care.

But the ruling will be dismissed, at least temporarily, now that the Supreme Court has decided to depublicize the earlier decision.

“The Supreme Court made the correct decision to overturn the court of appeal’s ruling,” says Aja Ogzewalla, Director of Regulatory Compliance, Medical Review Institute of America, Salt Lake City.

“The court of appeal’s ruling negated the purpose of the utilization review system, which is to provide a mechanism for ensuring quality of care by obtaining an objective opinion by a qualified professional that services provided are medically necessary and based on established medical treatment guidelines,” she adds.

Overcoming a ‘seriously flawed’ decision

In the wake of the court of appeal’s decision, several groups, including NAIRO, submitted evidence to the California Supreme Court that called into question the merit of the decision, and those groups issued several formal letters calling for depublication.

Calling the court’s opinion “seriously flawed,” NAIRO partnered with another organization to submit a request for depublication to the California Supreme Court in February, citing numerous practical considerations and legal precedents that support a revocation of the Court of Appeal’s ruling.

NAIRO and its partners refuted the Court of Appeal’s ruling on the following grounds, among others:

  • The physician-patient relationship, as described in King v. CompPartners, does not exist. While the Court of Appeals concluded that a physician contracted with an independent review organization (IRO) to perform UR enters into the realm of a physician-patient relationship, NAIRO contends that such a relationship does not exist, as defined by the physician’s role and interaction with the patient. Unlike a patient visiting a doctor’s office, for instance, a physician providing UR services does not meet, care for, examine, diagnose or treat a patient. UR physicians are only reviewing the records associated with the case and providing an opinion based on those records.
  • The opinion runs contrary to prior case law. Not only does the Court of Appeals’ decision oppose previous rulings defining the physician-patient relationship, it also bypasses previous rulings detailing the nature of “duty of care” as characterized in this context. Even more, the court’s decision fails to consider the so-called “compensation bargain” that’s at the core of California workers’ compensation. The compensation bargain is a longstanding policy, supported by case law, that defines the relationship between employers and workers as it pertains to work-related injury, responsibility and compensation. Essentially, the compensation bargain revolves around no-fault coverage for work-related injuries, which limits liability on the employer’s side and financial dividends in the case of an injury on the worker’s side.

Ultimately, the appeal court’s decision would have set a dangerous precedent. Specifically, it would have exposed “UR physicians and IROs to unlimited exposure to claims for medical malpractice by persons who are not their patients,” according to the depublication request filed by NAIRO.

The California Workers’ Compensation Institute (CWCI) also issued a request to the Supreme Court for depublication, citing a “foundational lack of full awareness of the unique nature of the workers’ compensation utilization review process” among the 4th Court of Appeal, according to the depublication request.

In its request, the CWCI warned that the decision of the appeals court “may become a blunt instrument to dismantle the decades of legislative reforms leading up to the adoption of UR as a means to enforce high-quality medical decision-making,” according to the depublication documents.

For now, UR will continue in California without interruption. Stay tuned to NAIRO for further updates.

For comments, feedback or additional information, please contact admin@nairo.org.

The original article can be found here