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Sedgwick Claims Management / unethical behavior

1 Wichita KS, United States

DOI: 04/16/16
Claim #[protected]
Patient: Lynn Everitt
Contact at Treating Facility:
Sarah Detrick- [protected]

This patient was evaluated at our facility, Advanced Physical Therapy, on 09/21/16 for a lesion in her ulnar nerve causing pain in her right wrist. The script from her physician requested she be seen 2-3 times per week for 6 weeks until her follow-up appointment with him on 10/20/16. However, the original authorization was only for 6 visits.
The patient's evaluation note and script were submitted to Medrisk for an additional 6 visits on 9/27/16.
On 10/4/16 the authorization request was resubmitted because we were told that the original had been misplaced.
Sedgwick CMS denied the proposed treatment plan from her referring physician, and only authorized 6 visits for the patient. After denying the authorization request no one informed the third-party claims company Medrisk of the denial, nor did they contact the physician, or treating facility.
On 10/17 we tried to contact the patient's adjuster from Sedgwick CMS, Arielle Richards, but her voicemail stated that she was gone on vacation and to contact her supervisor instead.
We contacted her supervisor, Brandi, who informed us that the issue with the authorization request, according to the Utilization Review nurse's notes, was that the script wasn't "Up-to-date". I informed her that we also had a signed plan of care approval from the referring physician that should also act as an additional more "up-to-date" script, but she wasn't certain what I should do with it. She forwarded me to the UR nurse, Dana, who informed me that a plan of care request isn't a script, even though it is signed by the doctor, would "possibly not be approved", if submitted with an authorization request.
Submitted new authorization request to UR, the case manager, and Medrisk on 10/20 with plan of care signed by the physician for an additional 8-12 visits.
Patient had a follow-up with her referring physician on 10/20/16 where he wrote a new prescription for an additional 18 visits.
Submitted new authorization request on 10/26/16 as well as contacted Brandi, the adjuster supervisor, to see if there had been any updates at all on this matter. She informed us that all of the previous authorization requests had been denied because the UR nurse had labeled them all as "duplicates". Left a message for the UR nurse to call us back to resolve the issue.
Dana, the UR nurse called back on 10/28/16 to let us know that the newest authorization request had been denied due to them not being able to talk to the referring physician for a peer-to-peer review.
We then called Dr. Gwyn, the referring physician, whose nurse informed us that he had tried to call Dana back several times but was never able to get a hold of her.

Resolution: This patient is, and has been in a considerable amount of pain since the DOI, and would greatly benefit from therapy according to her referring physician and our occupational therapist who is treating her. We are asking that her physician's scripts be honored, and ultimately be authorized for her 10 current visits to be covered, as well as the additional 20 visits requested by her physician. Please feel free to contact Sarah in referrals with any questions or if any additional information is needed.

Nov 8, 2016

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