Franz v. Industrial Claim Appeals Office

250 P.3d 755
CourtColorado Court of Appeals
DecidedMay 13, 2010
Docket09CA0298
StatusPublished

This text of 250 P.3d 755 (Franz v. Industrial Claim Appeals Office) is published on Counsel Stack Legal Research, covering Colorado Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Franz v. Industrial Claim Appeals Office, 250 P.3d 755 (Colo. Ct. App. 2010).

Opinion

250 P.3d 755 (2010)

Vincent S. FRANZ, Petitioner,
v.
INDUSTRIAL CLAIM APPEALS OFFICE of the State of Colorado, Brookharts, Inc., and Pinnacol Assurance, Respondents.

No. 09CA0298.

Colorado Court of Appeals, Div. III.

May 13, 2010.

*756 Steven U. Mullens, P.C., Steven U. Mullens, Pattie J. Ragland, Colorado Springs, Colorado, for Petitioner.

John W. Suthers, Attorney General, A.A. Lee Hegner, Assistant Attorney General, Denver, Colorado, for Respondent Industrial Claim Appeals Office.

Harvey D. Flewelling, Denver, Colorado, for Respondents Brookharts, Inc. and Pinnacol Assurance.

Opinion by Judge RICHMAN.

In this workers' compensation action, claimant, Vincent S. Franz, seeks review of the final order of the Industrial Claim Appeals Office, affirming the order of the administrative law judge (ALJ) who affirmed the Director's medical utilization review (MUR) order directing a change of treating physician and found that no physicians appointed to claimant's MUR committee had any disqualifying conflicts of interest. We conclude that the review process did not violate claimant's rights to due process and that no disqualifying conflict exists under the applicable rule. Consequently, we affirm the Panel's order.

I. Background

Claimant sustained an admitted work-related injury in 1989. In 1997, employer, Brookharts, Inc., and its insurer, Pinnacol Assurance (collectively employer), admitted claimant was permanently and totally disabled as a result of the injury.

Under the care of claimant's authorized treating physician (ATP), his medication and narcotics use increased and he was reported to be "maxed out on medication." When the ATP first examined claimant and reviewed the medical records, he diagnosed claimant with "chronic narcotic use." As he continued to treat claimant, the ATP reported that claimant's narcotics dependence and use had various detrimental physical effects and that, despite the medications, claimant remained "quite miserable," was "not doing very well," and was "quite dysfunctional."

After the ATP had treated claimant for several years, employer requested an MUR pursuant to section 8-43-501, C.R.S.2009. As stated in the statute, the purpose of the MUR, which may be requested by a claimant, employer, or insurer, is to provide a mechanism to review and remedy services rendered under the Workers' Compensation Act which may not be reasonably necessary or reasonably appropriate according to accepted professional standards. § 8-43-501(1), C.R.S.2009.

Upon receiving employer's request for an MUR and a licensed medical professional's report reviewing claimant's medical records, the Director appointed three physicians to the MUR committee and provided the parties with notice of the committee members' identities. See § 8-43-501(2)-(3), C.R.S. 2009.

After receiving notice of the formation of an MUR committee, claimant first moved to stay the MUR on the ground that the medical professional who performed the review had a conflict of interest due to a financial relationship with insurer. The Director determined that the medical professional had no conflict and permitted the MUR to continue.

Thereafter, claimant submitted a written objection to the members of the MUR committee itself, claiming that the physicians had conflicts because of their affiliation with insurer and SelectNet, a provider network. Despite claimant's concerns, the MUR committee proceeded to review claimant's treatment without addressing the conflict of interest question. Each committee member concluded that the ATP was severely over-medicating *757 claimant and recommended that claimant's medical provider be changed. Thereafter, the Director adopted the committee's recommendation and ordered claimant's medical provider changed.

After receiving the order, claimant questioned why his objection to the committee members had apparently been disregarded. The Director ordered the MUR recommendation held in abeyance until the conflict of interest issue could be resolved. He gave the parties the opportunity to submit position statements on that issue. The Director ultimately adopted the position propounded by employer that no disqualifying conflicts existed, vacated the abeyance order, and again accepted the recommendation of the MUR committee directing a change of treating physician.

Claimant sought an ALJ's review of the Director's order that claimant's medical provider be changed. The ALJ affirmed the Director's order, finding that neither the licensed medical professional who reviewed claimant's medical records nor the members of the MUR committee had a disqualifying conflict of interest and that claimant had not overcome the MUR's findings by clear and convincing evidence. The Panel affirmed the ALJ's order, and this appeal followed.

II. Claimant's Appeal

Claimant contends that the Panel erred in affirming the ALJ's decision to uphold the MUR and change his medical provider. He first argues that his due process rights were violated because he was denied an opportunity both to conduct discovery and to present evidence to the MUR committee at a hearing before the recommendation to change his physician was entered. He also contends that the MUR committee members' associations with insurer and SelectNet created inherent conflicts of interest which should have precluded their participation in the process, but that because he was not permitted to conduct discovery into the committee members' affiliations, the extent of their alleged conflicts of interest could not be determined. We are not persuaded by either contention. He does not argue on appeal that the licensed medical professional who provided the review of the medical records had a conflict of interest, and we do not reach that issue.

III. Applicable Law

A party may request an MUR to determine if the care provided to a claimant is "reasonably necessary" and "reasonably appropriate according to accepted professional standards." § 8-43-501(1); see Colorado Comp. Ins. Auth. v. Nofio, 886 P.2d 714, 716 (Colo.1994). The Director has authority to appoint members to an MUR committee, who are charged with reviewing a claimant's care and determining, by majority vote, whether a change in provider should be ordered. § 8-43-501(3)(a)-(c), C.R.S.2009; Nofio, 886 P.2d at 717.

No statutory provision addresses conflicts of interest applicable to an MUR committee. However, division regulations provide that within ten days of notification of the committee members' identities, a party may submit written objections based on a committee member's alleged conflict of interest. Dep't of Labor & Employment Rule 10-5(E), 7 Code Colo. Regs. 1101-3. Workers' Compensation Rule of Procedure 10-5(E) specifies that a conflict "will be presumed to exist when the provider under review and a member of the review committee have a relationship which involves a direct or substantial financial interest." Id. Subsections of the rule define "direct or substantial financial interest," but the rule does not otherwise delineate situations constituting a conflict of interest.

The conclusions of the MUR committee are "afforded great weight," and any party disputing the committee's recommendation must overcome its "finding[s] by clear and convincing evidence." § 8-43-501(5)(a), C.R.S.2009; see Carlson v. Indus. Claim Appeals Office,

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