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15. Self-Referrals/Cross Referrals – The Rules
In 1993, the legislature enacted the Workers’ Compensation Reform Act (AB 110) which contained sweeping changes that went to the heart of the way the compensation system functioned. One of the basic aims of the 1993 amendments in the fraud area was to curb potential abuses in the fee for direct service structure, which is built into physicians’ solo or group practices. In order to accomplish this, the legislature made disclosure a central component where a financial interest is involved in referrals for physician consultations, testing or treatment. As part of the new legislation, the legislature added far more specific prohibitions against self-referrals and cross-referrals than existed at that point and also added accompanying disclosure requirements to require the physician to declare under penalty of perjury that no such illicit actions were taking place. Unfortunately, these statutes, Labor Code sections 139.3 and 139.31, as written and rewritten by the legislature, are confusing to almost everyone and are often misinterpreted, even by attorneys. This article will clarify many of the confusing aspects of the legislation.
19. AMA Guides - Introduction
The AMA Guides are the most widely used basis for defining permanent impairment. They are used in most workers’ compensation jurisdictions in the United States, and often used in personal injury and automobile casualty cases to quantify the impact of an injury. Impairment and disability are not synonymous. The Guides only assess impairment. Impairment is defined as the â€œloss, loss of use, or derangement of any body part, organ system or organ function.â€ In this article, the concepts of impairment evaluation and the appropriate application of the Guides are reviewed. This article specifically addresses Chapters 1 and 2 of the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition.
28. Substantial Evidence of Causation Apportionment
The issue of apportionment of permanent disability has always presented a problem in workers’ compensation. Then, SB 899 came along. Apportionment would no longer be measured by the disability that the injured worker would have had if he had not been injured at work. From now on the focus would be on causation of disability rather than disability itself. Labor Code sections 4750 and 4750.5, which had governed apportionment of disabilities that developed before or after the industrial injury, were repealed. Labor Code section 4663, the former “natural progression” statute, was re-enacted in a different form with the introductory statement that “Apportionment of permanent disability shall be based on causation.” New Labor Code section 4664 gave a conclusive presumption of the continued existence of disabilities that were the subject of prior awards. Determining the underlying causes of a disability can be a formidable task. In pre-SB 899 days, a physician’s inability to come up with a definitive answer was not crucial. The defendant had the burden of proof and if it did not carry that burden, the applicant was entitled to an unapportioned award. The Legislature eliminated this “escape clause” by providing that if the doctor doesn’t make an apportionment determination, the report can’t be used as evidence of permanent disability. This article addresses the intricacies of Causation Apportionment.
29. Cumulative Trauma Injuries (CTs)
Cumulative injury is one of the most difficult concepts for physicians in the workers’ compensation field. Physicians often must address the long term harmful effects of work exposure to the psyche, the back and internal organs and must do so while simultaneously explaining (to the satisfaction of a workers’ compensation judge) why some elements of the exposure contributed more to the overall snapshot of a worker’s disability while others did not. They also must deal with claims and denials over whether there were, in fact, any periods of harmful exposure or, where more than one cumulative injury may have occurred to the same individual over a lengthy period of time; or where the injury slowly occurred with different employers over a period of time. Cumulative injuries have been described as a series of “micro-traumas” and “degenerative conditions” that occur slowly through repetition of some physical or mental stress to the body. This article covers date of injury, multiple injury case and multiple employer case issues.
30. QME Sanction Guidelines
The purpose of these guidelines is to provide a framework of the Department of Worker’s Compensation-Medical Unit (DWC-MU) disciplinary process for those affected by it – Qualified Medical Evaluators, the DWC-MU administrative law judges with the Office of Administrative Hearings, licensing boards and other interested parties. These guidelines are not intended to be an exhaustive list of violations or disciplinary actions that the DWC-MU may consider against any QME. These guidelines set out the parameters for discipline for misconduct considered serious. This article is taken directly from the DWC-MU guidelines.
40. Privacy Compliance for Work Related Medical Issues
Privacy is one of our most important and fundamental freedoms, and yet we are watching its erosion like the sand on a fading beach. In addition to our unique and specific state constitutional provision on the right to privacy, the legislature has enacted various statutes to protect privacy in California which help afford a measure of protection against unwanted intrusions. Under current employment law, there is a great deal of uncertainty with respect to when disclosure of medical information is proper and when the disclosure or inquiry may result in a successful action against the physician. Obviously the physician is an integral part of the disclosure chain, and whether he or she makes disclosure is an area filled with potential ramifications for both the physician and his or her patient.
50, 51, 52. The Comprehensive Medical Legal Evaluation: Why and How - A Step-by Step Tool
Counts for 3 articles for 4.5 credits (must be taken together)
How can an AME or QME best fulfill the purpose of a medical-legal evaluation, and minimize the time required to bring a workers’ compensation claim to a proper resolution? The best way to do that is to not only perform a complete, thorough and excellent evaluation; but to prepare and issue a report that indicates how complete, thorough and excellent the evaluation actually was. This article contains a comprehensive outline and template, focusing on orthopedic injuries, but helpful with all specialties, ensuring that a physician fulfills the required elements of a medical-legal report. With a complete, thorough and excellent report, the parties will know what you concluded represents your best assessment of the issues, based on reasonable medical probability given the evidence that was available to you. Such a report will also assist in perceptions of the physician’s credibility; reduce the need for post-evaluation depositions; and assist all parties in resolving the disputed issues in a more-timely manner than might otherwise be possible with a less complete and thorough report.
56. Senate Bill 863 – Highlights for Qualified Medical Examiners
SB 863, signed into law at the end of 2012 by Governor Jerry Brown, contained many sweeping changes to workers’ compensation law that will directly impact physicians in the California workers’ compensation system. This article is a breakdown of some of the rules and regulations impacting doctors relative to both treatment of injured workers and forensic evaluation of industrial injury claims.
58. The Medical-Legal Evaluation Process under California Workers Compensation Law - After S.B. 863
The AME/QME process currently remains the method by which medical-legal evaluations are obtained and disputes are resolved under the California workers’ compensation system. Over the past decade, the legislature amended the relevant sections and the result has been a new system designed to limit the expenses of continued litigation under the process while keeping most of its unique characteristics. Nonetheless, Labor Code section 139.2 (appointment of QMEs) remains on the books as do several of the original QME statutes, albeit, in many respects, unrecognizable from their original form. With additional changes brought about to the AME/QME process first under SB 899, AB 749 and last year under SB 863, the current system, although still resembling the original QME process enacted in 1989, is vastly different. This article is intended to assist the physician in understanding his or her role within the larger context of the medical-legal process and will address this process as it now exists after the most recent legislative changes.
60. INDEPENDENT MEDICAL REVIEW: Navigating the New Industrial Medicine Matrix
As of July 1, 2013 all current medical treatment disputes in the workers’ compensation arena are subject to Independent Medical Review [IMR]. MAXIMUS Federal Services, Inc. [Maximus] has been given a two year contract as the sole entity in the State of California to oversee the implementation of this dispute resolution process, applying the evidence-based medicine protocols as delineated in the Labor Code and attendant regulations.
This article will describe the new treatment matrix implemented by the State and provide guidance on how to successfully navigate a patient’s care through the system. The changes necessary to successfully obtain medical care will not come easy; yet, once implemented into the medical practice, they will turn chronic UR denials into approvals.
Carriers, patients and attorneys are all looking for medical practitioners who can navigate the new system to get medical care approved. Using the techniques described in Article 60 will raise the effectiveness of the medical practice and provide opportunities for growth and expansion.
64. Medical Provider Networks After SB 863
Under the Reform Act passed in 2004, (SB 899) medical control under section 4600 was by and large returned to employers via the newly established Medical Provider Networks (MPNs) (Labor Code section 4613 – 4616.7) provided the insurance carriers elected to have their own MPN. The MPNs, as with any other change in the system, were criticized by some for unavailability of physicians, delays in treatment, and lack of sufficient specialists. Others pointed to the accessibility of medical care, successful return to work ratios and costs savings to the system. In a 2013 Reform Bill (SB 863) the legislature further refined the MPN networks. This article highlights changes to the MPN system as a result of SB 863.
68. Causation in California Workers’ Compensation
The intent of this article is to provide a common sense understanding of the issues associated with causation in California workers’ compensation. The article will review the following terms and the intent behind these terms in the medical legal context of CA Workers’ Compensation. Causation, AOE/COE, Aggravation, Exacerbation, Derivative effect, Compensable consequence, Specific injury, CT injury, Presumptive injury.
72. Apportionment - An Update
Article #72 is an update of apportionment. Apportionment is defined for purposes of workers’ compensation as the separating out of the part or parts of a disability or condition that are the result of an industrial injury from the part or parts of the disability or condition that are the result of other industrial or non-industrial injuries, conditions, or diseases. When different body parts are injured at the same time, apportionment is termed “duplication.”
73. Appropriate Use Of Almaraz-Guzman Case Law and Analogy
This article addresses the appropriate use of the Almaraz-Guzman cases, as well as when an “analogy” can be used in the absence of that case law. In California, use of the 5th Edition of the AMA Guides to the Evaluation of Permanent Impairment is mandated by the 2005 Permanent Disability Rating Schedule. As such, this article addresses only this edition of the Guides. When a worker is injured in California and they are determined to have reached maximum medical improvement with treatment, it is at this point the issue of permanent impairment is to be addressed in a permanent and stationary report by the primary treating physician, or a Qualified Medical Evaluator.If there is residual impairment, an impairment rating is required. The physician is directed to provide a rating based on the direct application of the instructions in the Guides. There are times, however, when an evaluator may opine that the impairment rating is either an inaccurate reflection of the impact a particular condition has on an injured worker’s ability to perform activities of daily living, or that a particular condition is simply not addressed in the Guides.This article addresses how to appropriately address this situation.
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