By Dr. Robert L. Weinmann

Doctors not licensed to practice medicine in California are allowed to practice medicine in California as long they restrict their decisions to injured workers who claim on-the-job injuries. This convenient niche is favored by insurance companies and acquiescent utilization review companies retained by the insurance companies. They argue that utilization review doctors aren't practicing medicine.

Here's how the scheme works. Josephine Hardhead reaches for a box of records stashed on an overhead shelf. The box falls onto her head and neck. She develops headache and neck ache that won't quit. Her primary care physician prescribes MRI scanning. Instead of doing the prescribed scanning, the insurance company refers the prescription to a utilization review company where a doctor who may be in another state and who has been hired to do utilization review looks over the prescription.

The review doctor has authority to deny, delay or modify treatment. The doctor who does the review may refuse to authorize the MRI even though the review doctor will not have interviewed or examined the injured worker. Under California law, review doctors without California licenses are allowed to overrule treating doctors even though the treating doctor is licensed to practice medicine in California. This aspect of the law would be stopped dead with the signing into law of AB2969.

Meanwhile, Josephine can't wait for new laws. She can't shake the pain of constant headache (cephalalgia) and chronic neck ache (cervicalgia). She gets referred to a specialist in pain management who prescribes a course of treatment that her industrial insurance company thinks is too expensive. The Workers' Compensation insurer now refers this prescription to a utilization review doctor because, under California law, review doctors may deny authorization for treatment, especially if they do so based on a document known as the American College of Occupational and Environmental Medicine guidelines, which in California have the force of law. Josephine can go home and take another aspirin.

That's when the rubber meets the road. Because the ACOEM guidelines are not comprehensive, especially with reference to chronic pain, doctors licensed in California are also held responsible for 26 pages of single-spaced rules and regulations specific to California and are required to take a 12-hour course in pain management. Yet their decisions can be overruled by utilization review doctors without California licenses who are not responsible for either.

Utilization review doctors sometimes telephone the primary treating physician of an injured worker and recommend modifications or reduction of treatment. They may force the primary physician to cancel or reduce the frequency of physical therapy or other treatment. The primary treating physician, though caught between a rock and a hard place, still is not as bad off as the injured worker whose treatment got canceled.

A huge snag in the system is that utilization review doctors without California licenses cannot be disciplined by the Medical Board of California for unprofessional conduct because they aren't under board jurisdiction. Neither can they be prosecuted in the states in which they do have licenses, because those states don't have jurisdiction in California.

The Medical Board of California says that utilization review is the practice of medicine because "only a physician and surgeon licensed in California is allowed to override treatment decisions." The Medical Board of California, the Osteopathic Medical Board of California, the Board of Chiropractic Examiners, the Board of Podiatric Medicine, the California Medical Association, the California Labor Federation and the AFL-CIO are among many organizations that support AB2969 (authored by Assemblywoman Sally Lieber, D-Mountain View), which would require doctors who do utilization review for injured workers in California to be licensed in California. This legislation is sponsored by the California Society of Industrial Medicine and Surgery, the California Society of Physical Medicine and Rehabilitation and the Union of American Physicians and Dentists.

The bill awaits the governor's signature or veto - and be certain that insurance company interests are lobbying the governor to veto the bill. The general public understands that insurance companies decline coverage for frivolous reasons and should urge the governor to approve AB2969.

Dr. Robert L. Weinmann maintains a private practice in neurology in San Jose. He was formerly president of the Union of American Physicians and Dentists, AFSCME, AFL-CIO (1989-2006) and is currently president of the UAPD Independent Practice Association.