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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.
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.
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
58. The Medical-Legal Evaluation Process under California Workers Compensation Law - After S.B. 863
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
68. Causation in California Workers’ Compensation
73. Appropriate Use Of Almaraz-Guzman Case Law and Analogy
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