Senator Cortese Bill Would Stop Medical Coverage Denials by Physicians Not Licensed in California

A bill introduced Thursday by Senator Dave Cortese would stop insurance companies from enlisting out-of-state doctors to cancel medical treatment plans proposed by California doctor for workers’ compensation claims for certain patients.

Under current law, insurance companies can change or deny a recommended medical treatment made by a California-licensed doctor by ordering a “utilization review” by another doctor. The doctor performing the review might deem the original doctor’s proposed treatment as not medically necessary — and modify or deny the treatment, despite having never examined or even communicated with the patient. SB 636 would require doctors performing a utilization review on private sector patients to be licensed in California.

“When an insurance company steps in to deny a surgery or any medical treatment plan, it can be a nightmare scenario for the patient,” said Senator Cortese (D-San Jose). “Medical treatment is stressful enough without insurance stepping in to deny coverage. If insurance companies feel compelled to perform a utilization review, SB 636 would at least make sure the review doctor is licensed and accountable in California.”

Physicians who are not licensed in California operate in these instances without a regulatory structure to hold them accountable. The Division of Workers’ Compensation and the Medical Board of California lack the jurisdiction to discipline out-of-state doctors for medical malpractice. The review physician can’t even be prosecuted in their home state, because outside states don’t have relevant jurisdiction in California.

 

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