This ought to be good news - Merry Christmas and Happy New Year.

Of course, it remains to be seen how effective the steps acknowledged by State Auditor, Elaine Howell, will be in practice.  The community will need to work together to reach any level of success and there remains much work to be done fine-tuning QME recruitment, testing and report quality improvement.  Oh yeah - and the med-legal fee schedule.

It's up to the community.  The DWC cannot do this alone.  It is apparent without a full court press nothing will work and injured workers and their employers will bear the brunt of failure.

It is very important to note one area in which proof has yet to be found in the pudding.  In fact, the pudding seems hard to find.  I draw attention to the admonishment from Ms. Howell regarding "written policies for reinstating disciplined QMEs or how the process will unfold if investigations are pending." (see highlighted section). 

The DIR's insistence it has implemented written policies apparently has not met muster with the auditor's office.  Not surprising since the underground regulations causing the "mess" began as unwarranted and unpublished "policies." 

These new DIR written policies must be published to the community and perhaps hearings undertaken in advance of implementation in order to avoid an outcome similar to the previous underground scenario.  If the corps of evaluators do not have full knowledge of these policies and their enforcement, it seems a stretch to expect compliance or any level of understanding when the policies cause action to be taken.

We wish all of you respite, relaxation and some breathing room (literally) during these holidays as well as a New Year worth waiting for.  Stay safe, be healthy.

PS - The attached article is distributed with permission from Workcompcentral.  Consulting clients are reminded that discounted services from Workcompcentral are among your benefits.  Look for more information after the holidays.

Steve  Cattolica
12/23/20

DIR Has Met Most Recommendations From 2019 - Workcompcentral 

Yesterday's public hearing (zooming) yielded few surprises including the quality of testimony from the physician community itself which was extremely well done – thoughtful and insightful.

Our written input is attached in two parts.  The first, authored before the hearing, concentrated on one somewhat overlooked topic and one not raised until yesterday:

1. A COLA and the Division's position it does not have the authority to place one into the fee schedule, and
2. Training/educating Maximus how to resolve IMR issues under a new (or any) fee schedule.  This critical issue must be part of the Division’s focus going forward regardless of the final language of a revised MLFS.

It was heartening to hear so many propose rather than installing a completely, new, untried, and potentially friction-filled fee schedule, that the current MLFS could be clarified, and a raise given so reports would continue to be reimbursed based on complexity rather than how many pages of records are delivered – a variable the brunt of which under the proposal would fall squarely on the shoulders of the evaluator. 
 
The immense friction anticipated from the page count “innovation” has both providers and payors on edge – and rightfully so.  Plus, copy services do not seem very eager to take on any additional responsibility.
 
The second point must be thrust to the forefront regardless of how the MLFS is updated.  I urge readers to peruse the testimony dated December 9, 2020 for background on this issue which arose during the QME Inquisition that wreaked havoc and did much damage among the Corps of QMEs a few years ago.  The main point is the Division's Medical Unit trains (educates?) Maximus staff how to review IBR requests.  If the Division does this by itself, Maximus knows only one viewpoint.  By definition, a medical-legal IBR has at least two such viewpoints.  Since Maximus staff otherwise has only the Division’s viewpoint to draw from and given the inherently vague and ambiguous language of both the current and proposed fee schedules, from now on the Division must utilize a team approach to properly and completely train/educate the Maximus reviewers.

Back to the point made by many regarding improving the current fee schedule, readers will find also attached the CSIMS 2015 MLFS white paper entitled, “Physician Reporting in the California Workers’ Compensation System” wherein Dr. Rick Newton and his team of CSIMS members came to the same conclusion as many of yesterday’s witnesses, a position little heeded…perhaps until now.
 
Has the fun just begun (over again)?

CWCSA MLFS Comments
CWCSA MLFS Additional Comments
CSIMS Position Paper - Physician Reporting in the CA Workers' Compensation System

June 13, 2019 DWC Newsline Update

From the article: "The Division of Workers’ Compensation (DWC) has posted an order adjusting the Official Medical Fee Schedule (OMFS) to conform to changes in the Medicare payment system as required by Labor Code section 5307.1."

"The Physician and Non-Physician Practitioner Fee Schedule update order adopts the following Medicare changes:

• CMS Medicare National Physician Fee Schedule Relative Value File RVU19C July 1, 2019 quarterly update
  
• National Correct Coding Initiative Practitioner Procedure to Procedure (PTP) Edits July 1, 2019 quarterly update
  
• National Correct Coding Initiative Medically Unlikely Edits July 1, 2019 quarterly update (excluding MUE “0” value codes)
  
• CMS ZIP Code to Carrier Locality files July 1, 2019 quarterly update, for Geographic Practice Cost Index (GPCI) locality mapping"
  

"The order adopting the OMFS adjustments is effective for services rendered on or after July 1, 2019 and can be found on the DWC website."

"Treating the patient - not just the injury - works!"
by Steve Cattolica - June 4, 2019

Ms. Michelle Despres, P.T. recently discussed one of the most widely known secrets of healthcare since the biopsychosocial model of practicing medicine was first discovered by a mother, father, grandparent or other loving adult when their child fell and skinned their knee. Studies by universities have confirmed what they knew!  Treating the patient - not just the injury - works!

With zeal to put this age old “secret” into practice, workers’ compensation systems nationwide have developed complete infrastructures capturing and packaging and controlling their contracted providers on behalf of their client, the claims administrator.  That infrastructure, including the costs of the claims duties it is purported to replace as more efficient, is now the costliest component in the work comp system - not injured worker indemnity benefits and not the actual hands-on care.

Let’s quickly examine the components of the model:

Latest news by Julius Young in the Workers Comp Zone, published May 30, 2019.

From the article:
"AB 5 passed out of the California Assembly on May 29 and is now headed to the California Senate.

It’s a bill that would codify the ABC employment test used in California Supreme Court Dynamex case. In a recent post “Hard to Define”, I explored the background of several legislative approaches re defining employment status in a gig economy era:
http://www.workerscompzone.com/2019/05/06/hard-to-define/

The Assembly vote on AB 5 was 59 to 15, with 6 not voting.

While there will likely have to be further changes to AB 5 when it hits the California Senate, clearly the bill has momentum.
The stakes are enormous for some of the gig economy companies. The recent Wall Street debut of Uber and Lyft  was underwhelming, and passage of AB 5 could be a substantial if not fatal blow to the business model of some lesser gig economy platforms.

Passage would ensure that many more workers are covered under California’s workers’ compensation laws.

A research publication by Dr. Steven D. Feinberg, M.D., M.S., M.P.H.

From the introduction: "This article addresses prevention and management of work injury claims that result in a bad outcome for the injured worker and considerable costs to the payer. I examine the genesis of these claims and how the concerned parties, inadvertently or otherwise, contribute to their development and growth. I place special emphasis on the ways attorneys contribute to a positive or negative outcome for the injured worker and the claim."
Link to full article here.

by Mariellen Blue, national director of case management at Genex Services who specializes in nursing, case management and utilization review.  Published April 9, 2019 on the Risk & Insurance website.

From the introduction: "Delayed recovery is a challenge coming to the forefront of workers’ comp. It’s defined as a lack of anticipated functional recovery in a medically reasonable period of time. Recently, many organizations have been seeking new ways — whether through telephonic or field case management services — to identify injured employees who are at risk for delayed recovery."
​
Link to full PDF article here.

by Dr. Vanila M. Singh, M.D., MACM. Published May 10, 2019.

"Summary: Dr. Vanila Singh explains the work of the Pain Management Best Practices Inter-Agency Task Force." 

​Link to full interview with Dr. Vanila Singh on the task force's work here. 

May 15, 2019 Newsline Update

From the article: "The Division of Workers’ Compensation (DWC) has updated its EAMS system to require validation of uniform assigned names (UANs) when users e-file documents. Filers will receive an error if the document contains a faulty UAN, so they can correct the issue immediately. The new procedure is expected to reduce errors and processing delays."

The Workers' Compensation Appeals Board (WCAB) has said in a unanimous decision that the nature of an injury to a California worker — including those that may be severe or catastrophic — is an issue to be determined by a judge.  Read the full decision here.

by Dr. Robert Weinmann, MA - May 9, 2019 (Weinmann Report)

In its original form AB 1107 was supposed to give relief to injured workers who were being wrongly denied access to treatment. It was supposed to ease the administrative burden on treating physicians whose time for patient care was being diluted by unreasonable requests for documentation to entertain Utilization Review (UR). The main thrust of AB 1107 was to facilitate treatment by primary treating physicians by exempting them from UR under specific circumstances. This plank has now been removed and replaced by language that may actually increase legal costs.

"A focus on prevention can dramatically cut the number of on-the-job injuries suffered every year."
​
A Risk & Insurance® e-newsletter article, in collaboration with Concentra©.  Published April 11, 2019.

April 9, 2019 DWC Newsline Update

From the article: ​The Department of Industrial Relations (DIR) and its Division of Workers’ Compensation (DWC) posted a progress report today on the department’s Independent Bill Review (IBR) program. IBR is a process used to resolve billing disputes for medical treatment and medical-legal services provided to injured workers.

Workers' Compensation Perspectives Blog Update

Posted March 12, 2019, by TerryB on his blog, Workers' Compensation Perspectives.
​

April 4, 2019 DWC Newsline Update

​From the article: The DWC has issued a notice of public hearing for proposed evidence-based updates to the MTUS, which can be found at California Code of Regulations, title 8, section 9792.23. 
 
The public hearing is scheduled for Monday, May 6 at 10 a.m. in the auditorium of the Elihu Harris Building, 1515 Clay Street, Oakland. Members of the public may review and comment on the proposed updates no later than Monday, May 6, 2019.
 
The proposed evidence-based updates to the MTUS incorporate by reference the latest published guidelines from American College of Occupational and Environmental Medicine (ACOEM) for the following:

• Low Back Disorders Guideline (ACOEM March 7, 2019)
• Introduction to the Workplace Mental Health Guideline (ACOEM March 13, 2019)​

​

March 26, 2019 DWC Newsline Update

From the article: "The Division of Workers’ Compensation (DWC) has posted an order adjusting the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) section of the Official Medical Fee Schedule to conform to the 2019 changes in the Medicare payment system as required by Labor Code section 5307.1.

The order, which is effective for services on or after April 1, 2019, adopts the Medicare DMEPOS fee schedule second quarter release for calendar year 2019."

The order adopting the adjustment can be found here.
​

by Steve Cattolica
​
“I can see clearly now the rain is gone; I can see all obstacles in my way….”
Johnny Nash, June 1972

For those of us around in 1972, Nash was speaking our language…rain gone, no dark clouds, nothing but blue skies, sunshiny days, bad feelings disappear, rainbows, a clear path…I better stop there.

‘Transparent’ can be defined as, “allowing light to pass through so that objects behind can be distinctly (clearly) seen.”  The opposite of transparent is opaque.

As the costs of claims handling rise, employers and policy makers look for the reason why.  Naming the causes - some are apparent, even obvious - does not fully answer the question.  The picture is opaque.  Individual contributors to the rise in costs are hidden.  More can be done.  More must be done.

Would-be explanations offer what could be boiled down to the adage, “be careful what you ask for.”  Recently, I read about pricing of prescription drugs and was left thinking that it wouldn’t matter how much buyers learn about pricing.  There’s almost nothing that can be done to change the outcome.  The buyer ends up paying the same amount regardless. 

Transparency should plainly show all the components of a service clearly and empower improvement, not reinforce the status quo.

by Dr. Robert Weinmann, MA - January 30, 2019 (Weinmann Report)
​
Duty of Care (King v. CompPartners) was reviewed in this column on 10/16/18.  The case involved the sudden discontinuation by a Utilization Review (UR) physician of patient Kirk King's klonopin. King filed suit based on negligence and malpractice because the UR doctor arbitrarily discontinued his medication and thereby caused him to have four epileptic seizures. Eventually the case went to the California Supreme Court which decided that "the exclusive remedy for disputes arising out of the UR process belongs to the workers comp system."  The case was remanded to the District Court. King was barred from pursuing a tort claim. 

We wrote in this column that the decision protects UR physicians from malpractice lawsuits. But Justice Mariano-Florentino Cuellar wrote in his opinion that it might be time for the California legislature to take a look at the law since it could now be argued that protections in the law for injured workers "may not be set at optimal levels and the legislature may find it makes sense to change them."

It makes no sense that treating doctors are subject to Duty of Care, a protective legal concept that protects patients from cavalier care, whereas by contrast UR doctors, who do not interview or examine the patients, are not. 

It makes sense to change the law so that both UR and IMR (Independent Medical Review) doctors can be brought under the same Duty of Care umbrella as their PTP (primary treating physician) counterparts. Legislative action is now an issue in Hawaii and California.