San Bernardino survivors stymied by workers' comp denials

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One year after the terrorist attack in San Bernardino, several survivors are frustrated that the county has denied requests for medical and mental health care through its worker's compensation system.  Now, county and state officials say more should have done to help those injured in the shooting.

"Myself and my co-workers are not asking for anything that we're not entitled to or the doctors haven't ordered," says Valerie Kallis-Weber, who was shot in her shoulder and back in the Dec. 2, 2015 assault on a San Bernardino County Health Department training event and holiday party.

She spent a total of three months in the hospital after the attack, undergoing 20 surgeries and five blood transfusions in the first month alone. Although she's now home, she needs more surgery on her pelvis, her left arm is paralyzed from the elbow down, and she says she suffers from post-traumatic stress disorder.

"For our case, being a mass murder, shot by terrorists, one would think that the county would do everything it can to assist its workers to get better," she says. "To date, for me and for some of the coworkers I have spoken with, this is not the case."

San Bernardino County spokesman David Wert agrees the survivors’ cases are extraordinary and says the county has done its best to care for them. But he acknowledges it could have done more to shepherd the survivors' cases through the workers compensation system.

"That's something where the county thought it was doing a sufficient job, but it quickly became apparent that there were cases where we could be doing things better," Wert says.

The head of the state agency that oversees the worker’s compensation system also says that San Bernardino didn't do enough for its employees.

"In this situation, because of the major event and trauma and multiple people getting injured, they needed a little more attention to guiding the workers through that process," says Christine Baker, director of the California Department of Industrial Relations.

The county is now moving to hire an outside firm to expedite the survivors' workers' compensation claims. The county pledged to take this step after several survivors pleaded for help at Monday's county board of supervisors meeting.

"I've had all of these issues"

California's workers' compensation law requires that a doctor's recommendation of a medicine or other treatment go through a process called utilization review. As part of this process, a claims administrator reviews the provider’s recommendation to determine if it’s medically necessary.

This step is intended to prevent over-prescribing of opioids and unnecessary surgeries, as well as fraud, which is estimated to cost the state between $1 billion and $3 billion a year, according to California Insurance Commissioner Dave Jones. 

But Kallis-Weber says in her case, utilization review has become a barrier to care.

Her doctor says she needs the assistance of a home health care worker 12 hours a day. The worker helps her bathe, cook and put on her shoes, she says, explaining, "because of the injuries in my pelvis, I can not bend over and reach the ground, as well as I can't lift my legs up very high."

But Kallis-Weber says the utilization review claims administrator determined she won't need any home health care by the end of the month.

She says she's terrified by that possibility. Kallis-Weber has tried to fight the decision, but she says she needs a case worker to advocate for her. She's had a couple, but doesn't have one now and says she's asked the county for a new one.

"Since the time that my first case worker has left, I have had to take an active role, trying to get my medicine, trying to get my therapy, and so instead of me trying to recuperate and using all my energy doing that, I've had all of these issues," she says.

"Extenuating circumstances"

The majority of treatment requests are approved in more typical workers' compensation cases, says George Parisotto, acting administrative director of the state's Division of Workers' Compensation. He acknowledges that complex cases like Kallis-Weber's fall outside the system's guidelines.

"There are extenuating circumstances where I think you need to look at factors that go outside of the guidelines and in this situation … there's no guidelines, nothing, I think, that can help somebody deal with this type of situation," he says. "You have to look outside the guidelines; you have to look at everything."

Wert, the San Bernardino County spokesman, says the county will hire the outside contractor by the end of the month. The contractor will follow up on treatment requests, communicate with doctors and make sure the system works for the injured employees, he says.

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