1. Early Engagement (by the network)  -  “The ability to connect with a patient quickly establishes a foundation of trust.”  If the PPO network comprises high-quality professionals the primary treating physician has already done that.  The Network’s job is to facilitate the PTP’s work, not replace it.
2. Accurate assessment of the injury (see #1)  -  The Network has nothing to add to communication between the PTP, the patient, claims professional and the physical therapist. – except another person.
3. Rapid scheduling accomplished by the PPO network’s staff rather than the patient or primary treating physician? Faster than providing a list of qualified PTs from which the patient and PTP can choose and make their own phone call?  Again, networks should put the choice of healthcare provider into the hands of the PTP and injured worker rather than the hands of a network customer service agent with access to the lowest contracted reimbursement rates.
4. Fostering a Positive Mindset (see #1)  -   “A patient with a favorable attitude tends to heal quicker, and with fewer complications.”  We would add that accurate, complete information and a sense of control also build a positive mindset.  Your loved one did not need a university study to know this when you fell down. Neither does the well qualified primary treating physician and physical therapist. The Network has nothing to add to this communication except provide incentives for it to take place and get out of the way.  The PTP is responsible for diagnosis and communication of this information – one would hope the diagnosis and need for care is first discovered by a physical therapist and not sequestered there.
5. Physical therapists (and primary treating physicians) who create a goal-oriented recovery experience enable patients to stay focused and positive while on their road to recovery. A truism. Except for enabling and incenting great communication among the health care provider team, the Network need not be the conduit for communication amongst team members.
6. Active Engagement (see #1, #2, #3, #4 and #5)  -  Engagement begins at the beginning with the PTP.  If the Network has contracted with quality providers, patient engagement is carried out to the extent possible throughout the downstream healthcare provider team.  During treatment, the physical therapist could be the person with the most frequent and highest quality contact with the injured worker’s level of “engagement.” Communication of changes – good and not so good – should be direct to the PTP and claims professional and not through the Network.
7. “Treating the patient not the injury” is the straightest path to the best healthcare outcome.  A network of the best providers, working closely with engaged claims professionals and unencumbered by extraneous network interference, is by far the best model to pave that path.

The network is a means to an end.  If the network contracts with highly qualified providers, those providers should know how to work with the PTP and how to communicate with other team members.

The patient must be able to choose the best provider possible, not be forced to go to a provider chosen instead by the network which has a built-in conflict of interest based on its contracted rate with that provider.  To assume it is the network’s responsibility to guide the treatment plan, places no faith in the quality of claims professional and other medical professionals who are available.

To download this article, please click here.

Here is a link to an Assembly floor analysis that was done on May 24:
http://leginfo.legislature.ca.gov/faces/billAnalysisClient.xhtml?bill_id=201920200AB5

An article on the bill by Carolyn Said, San Francisco Chronicle business reporter, can be seen here:
https://www.sfchronicle.com/business/article/California-Assembly-passes-gig-work-bill-13904777.php

Also interesting is a take on the issue written by seasoned California political reporter Dan Walters:
https://calmatters.org/articles/commentary/a-new-front-in-battle-over-gig-workers/

Walters notes that the gig economy issue is now playing out in disputes over whether public entities must make PERS contributions for certain temporary workers.

With almost every California union, business interest and public entity having a substantial stake in the outcome of how employment status is defined in California, AB 5 has the potential to be the mother of all legislative fights.

So far, however, the bill’s author, Lorena Gonzalez (D-San Diego), seems to be guiding the bill with a firm grip.


Stay tuned."

Link to original article.

"The UAN, a uniform naming convention to ensure that parties are properly associated to cases in EAMS, is currently used by attorneys, claims administrators and lien claimants. E-filers may confirm or obtain their UAN by checking the database, or by submitting a registration request on letterhead with an authorized signature by email to cru@dir.ca.gov. Emailed requests are processed and posted within 10 business days."

"The first document to require UAN validation is the application for adjudication of claim. DWC will update other e-forms in the coming months to include this upfront validation."

Link to original article here.

As a result of the fear that access to treatment might become too easy for injured workers the bill got amended in committee with the acquiescence of the author to narrow the proposal but to allow stakeholders to challenge UR conclusions, said challenges to include more legal wrangling with even less access to care since treatment will inevitably be delayed, postponed, or just not done while the wrangling process is in play. 

It is true that this proposal gives the applicant or patient an opportunity that wasn't previously available but it does not facilitate prescribed treatment by treating doctors -- and that, my friend, was supposed to have been the raison d'etre of AB 1107 in the first place. 

In the recent King v. CompPartners Inc case, August of 2018, a deserving patient was harmed by wrongful utilization review when authorization for his medication was  withdrawn. The injured worker tried to use "tort" law to sue the Utilization Review Provider but lost that battle when the California Supreme Court decided that work comp law provides  exclusive remedy for employees who allege injury because of treatment denial by UR. This decision in turn caused one of the Justices to say that the law for injured workers should be revisited.

THAT was what AB 1107 initially sought to do. Instead, we have a compromise which does not help injured workers when they need treatment but which provides them and their lawyers a way to challenge UR decisions later. This solution is another in the sordid list of "too little, too late." This writer recommends revisiting the bill again to review the circumstances under which Utilization Review can be set aside so that injured workers get needed care in timely fashion. There is still time to amend the recent amendment. 

Reports reviewed for this editorial include:

"Will AB 1107 Trim the Claws of UR," workcompcentral column, 2019-04-18 by Robert Weinmann;

"Turning the Clock Back on State's Workers' Compensation System, workcompcentral column, 2019-04-24 by Carlos Luna; 

"Utilization Review Physicians May Owe Duty of Care to Applicants, King v. Comp Partners, 2016, 243 Cal. App. 4th 685, Mullen and Filippi. 

Posted by Robert Weinmann at 10:17:00 PM

​"Every employer wants to keep their workers safe and healthy. But some of the latest data suggests their efforts are falling short, and it comes at a steep cost.

The Bureau of Labor Statistics (BLS) shows that 2.9 workplace injuries occurred for every 100 full-time employees in 2017, totaling about 3.3 million nationally.  Collectively, workplace injuries cost the U.S. economy roughly $52 billion to $60 billion per year — that’s at least $1 billion per week.

The impact comes not just from expensive medical treatment, but from absenteeism,
decreased productivity, and increased employee turnover as well."

Download the full article here.

The “2018 Independent Bill Review (IBR) Report: Analysis of 2013-2017 Application Filings” summarizes the activity of an essential component of Senate Bill 863, providing an evaluation of the program during the first five years following its enactment. The report accounts for all applications filed to dispute payments not resolved through Second Bill Review during this time period.
Highlights of the report include:

• The number of IBR applications received averaged 165 filings per month.
  
• Seven of 10 decided cases resulted in additional payment for the provider.
  
• Nearly $12.3 million was awarded in overturned case decisions.

“We hope the findings of this report will encourage health care providers to consider using IBR for some of their payment disputes,” said DWC Administrative Director George Parisotto.

The progress report is posted on the DIR website. 

​​I believe in the concept that short lines of direct communication work best.  Injured worker to/from employer; employer to/from claims; employers and claims to/from medical providers; medical providers to/from each other.  Of course, the legal profession is included.  Name the exchange and shorter is always faster, better and costs less.

There’s no better example than what is now called “revenue cycle management.”  A process ultimately between only two entities – provider and customer – that has grown into a complex industry of its own.  It is part of an industrial complex of inordinate proportions; all for the sake of efficiency, accuracy and return-on-investment.  Yet these three factors remain elusive and in the latter case, often undefinable in concrete terms.

It’s as if, in the kids’ game of “telephone,” a longer line of kids (or adults) passing along the message assures the message is more accurate and timelier.  If there is any truth to this analogy, it disappears completely when responsibility for vital communication is allowed to occur without strong implementation of the maxim “trust and verify.”

Nowhere is this truer than with the proliferation of medical provider networks and the subsequent consolidation of these networks under single management conglomerates. 

Please do not misunderstand, provider networks of all types are ubiquitous and for good reason.  Maintaining hundreds, if not thousands of direct contract relationships is costly and time consuming.  However, it is asking for trouble to abdicate responsibility for the quality of claimants’ health care, diagnostic testing, application of pseudo utilization review, interpreting services, transportation and who knows what else to mega corporations; one-stop shops whose business model puts them in the cashflow between their payor/customer and all those providers – without appropriate transparency regarding the specific services provided, their true costs, how the bills for those services are generated and where the money ends up.

There is a reason why the costs of claims have, at least in California, become an outsized proportion of the premium dollar.  It’s not because lines of communication are shorter or systems more efficient.  A proliferation of cottage industries has spawned on both the payor and provider side.  In some instances, the ‘cottages’ are more like glass enclosed office towers.

‘Efficient’ can be defined as, “achieving maximum productivity with minimum wasted effort and expense.” One can add, “preventing the wasteful use of a particular resource.”
Premium dollars (the particular resource) are presumed to be held in trust for the benefit of the at-risk employer that paid the premium (or set the money aside if self-insured) and their legitimately injured workers.  However, the telephone message about efficiency and waste has become garbled.  “Minimum wasted effort and expense” and “wasteful use of a particular resource” becomes defined by whose “effort” and “resources” one is speaking about.  The conversation has morphed from one benefiting the employer to one benefiting the cottage.  Are there too many people on the “telephone” line?

Those who provide network and other services have the great opportunity to participate in maximizing efficiency and minimizing the effort and expense it takes to deliver benefits. 

However, when delivery of services is engineered to be opaque and costs are disproportionate compared to the benefits delivered to the two main constituents - the employer and injured worker - something must change.

Published Feb. 21, 2019, by Steve Cattolica on WCC'S Work Comp World.