The Fix is in (California) (California) (California) (Califo

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The Fix is in (California) (California) (California) (Califo

Postby spreare on Sun Aug 12, 2012 3:39 pm



SB 863 Page 1
PROPOSED AMENDMENTS TO SB 863 Legislative Counsel No. 1221520 Set # 1.0 (Solorio)
The proposed amendments enact major reforms to the workers' compensation system. Specifically, the amendments:
1) Eliminate the special examination for chiropractors to qualify as Qualified Medical Evaluators (QME) (thus requiring chiropractors to pass the standard QME examination.)
2) Limit the number of office locations that a QME may file with the Division of Workers' Compensation (DWC) to 10.
3) Reduce the scope of evaluations that QMEs perform by establishing an Independent Medical Review system (IMR), patterned after the existing IMR process implemented by the Department of Managed Health Care (DMHC) for resolving health insurance disputes, to resolve medical treatment issues.
4) Establish a hierarchy of standards that are to be applied by IMR, with the Medical Treatment Utilization Schedule adopted by the AD as the highest source for evaluating the appropriateness of medical treatment, followed by lesser standards in the event a higher standard does not address the medical question at issue.
5) Eliminate the WCAB's authority to adjudicate medical treatment disputes that are directed to the IMR process.
6) Require a second utilization review (UR) determination prior to an IMR if either party has new or different information to present to the IMR that was not presented to the employer or insurer at the time of the initial UR process resulted in the delay, denial or modification of requested medical treatment.
7) Make the results of the IMR process binding on all parties, absent clear and convincing evidence of fraud.
8) Provide that a reversal of a Utilization Review (UR) decision by IMR is not necessarily an unreasonable delay in providing treatment within the meaning of the provisions that penalize an insurer or employer for unreasonably denied treatment.
9) Establish an Independent Bill Review (IBR) process to take mere billing disagreements out of the jurisdiction of the Workers' Compensation Appeals Board (WCAB) adjudication system under rules similar to the IMR process.
10) Provide for the Administrative Director (AD) of the DWC to contract with qualified organizations to implement the IMR and IBR functions, subject to detailed conflict of interest rules and substantive responsibilities, as specified.
11) Repeal several outdated annual reporting requirements.

SS 863 Page 2
12) Prohibit Professional Employer Organizations (PEOs) and temporary staffing agencies from becoming self-insured for workers' compensation purposes, and requires any of these entities that are currently self-insured to become insured by January 1, 2015.
13) Require public agencies that are self-insured to submit specified data to the Department of Industrial Relations (DIR) for purposes of policy analysis, and directs the Commission on Health and Safety and Workers' Compensation (CHSWC) to conduct a study of public sector self-insured programs.
14) Provide that the costs incurred by DIR in administering the public sector workers' compensation program are to be paid from the Workers' Compensation Administration Revolving Fund (user funding as opposed to General Fund.)
15) Repeal the requirement that a second opinion be obtained in cases of spinal surgery, and instead would resolve questions of appropriateness of spinal surgery in the IMR process.
16) Streamline the Agreed Medical Evaluator (AME) and QME process to eliminate unnecessary delays and friction in the system.
17) Provide that a report by a physician procured independently by an injured worker cannot be the sole basis of an award for compensation, but that a QME or authorized treating physician, when the QME or authorized treating physician is preparing a report, shall address any such report and indicate whether he or she agrees with the findings or conclusions of the independently procured physician, and there reasons therefore.
18) Establish a prohibition for any interested party in the workers' compensation system to have a financial interest in another entity to which it is referring a party for services, or for which is paying or receiving compensation, if the employer is paying the charges; provided that financial interests in affiliated entities in claims handling are subject to mandatory disclosure rather than prohibition.
19) Increase aggregate Permanent Disability (PD) benefits by approximately $720 million per year, phased in over a two-year period, and adjust the formula for calculating the number of weeks and weekly benefit amount so that compensation amounts more accurately reflect loss of future earnings.
20) Provide a modification of these new PD rules to ensure that no class of injured worker "loses" benefits as a result of the new formula.
21) Eliminate the future earning capacity and age modifier factors in the disability formula for injuries that occur on or after January 1, 2013.
22) Eliminate sleep disorder, sexual dysfunction, and psychological "add-ons" to primary injuries that do not include these injuries.
23) Clarify that an insurer or employer can pay for physical medicine treatments in excess of the 24-visit cap without that payment constituting a blanket waiver of the cap.

SB 863 Page 3
24) Provide that a chiropractor who has reached the 24-visit cap cannot serve as the injured worker's primary treating physician.
25) Eliminate the requirement that a Medical Provider Network (MPN) have non-occupational medicine specialists constitute at least 25% of the physicians in the network.
26) Require all MPNs to have a "medical assistance" staff person or persons, who need not be employees, but who must be located within the United States, to aid injured workers in obtaining appointments or referrals within the MPN.
27) Allow the AD to generically approve an MPN, as opposed to requiring a separate approval for each employer.
28) Provide that the approval of an MPN by the AD is conclusive in a matter before the WCAB that the MPN is valid, subject to proof that there was a specific failure as to a specific injured worker.
29) Require periodic administrative audits of MPNs.
30) Authorize discretionary administrative audits of MPNs.
31) Limit the reasons that can be used to avoid obtaining treatment within an MPN, and establish an expedited process to resolve any disputes about whether the injured worker is required to be treated within the MPN.
32) Require a physician who knows or should know that the patient is suffering from an occupational injury to notify the employer that the injured worker is being treated outside the MPN, and prohibits payment by an employer or insurer for any treatment provided to the injured worker when the notice requirements have not been complied with.
33) Provide that where interpreter services are needed, the injured worker shall make a request to the employer or insurer, and the employer or insurer shall arrange for and pay for the interpreter services.
34) Require that interpreters be certified, and authorizes the AD to establish or operate or contract for an interpreter certification program.
35) Modify the Supplemental Job Displacement Benefit (SJDB) rules to:
a) Change the point in time the benefit is triggered;
b) Prohibit "cashing out" the voucher in settlements;
c) Establish which schools are qualified to be paid by the retaining voucher;
d) Limit the time period during which the voucher is valid to 2 years; and
e) Specify that an injury that occurs during retraining does not constitute a compensable injury.
36) Prohibit the filing of a lien against an award for matters that are subject to 1MR and IBR dispute resolution.

SB 863 Page 4
37) Establish a $150 filing fee in order to file a lien, recoverable if the lien claimant prevails.
38) Establish a $100 activation fee for legacy liens (unless the lien previously was subject to a since-sunsetted $100 filing fee), recoverable if the lien claimant prevails.
39) Adopt firm time limits within which liens must be filed.
40) Adopt a fee schedule for ambulatory surgery centers.
41) Require the AD to adopt a fee schedule methodology based on medicare's RBRVS system.
42) Clarify the rules that govern the fee schedule applicable to vocational expert compensation, and provide that written testimony, in lieu of live testimony, is proper.
43) Limit the home care services for which reimbursement is required where the services were already being provided prior to injury (i.e., no pay for cooking for the injured worker if a spouse was already doing that function prior to injury); authorize the AD to adopt a home care services utilization and fee schedule, and limit the re-opening of old cases where home care services are alleged to have been provided but were not authorized or ordered by a physician before the services were rendered.
44) Authorize the AD to adopt a fee schedule for copying services, and establish substantive rules to govern these services.
45) Eliminate the "double-payment" pass-through for implantable surgical hardware. Analysis Prepared by: Mark Rakich / INS. / (916) 319-2086
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Re: The Fix is in (California) (California) (California) (Califo

Postby suekarp on Mon Aug 13, 2012 6:53 am

You obviously have access to to the bill. Would you be so kind as to post a link where everyone can review the actual test of the bill?
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Re: The Fix is in (California) (California) (California) (Califo

Postby Elizabeth Howe on Mon Aug 13, 2012 7:06 am

Just type in the bill #, or the word-search (and make sure the year is correct), and you can have any bill that you want.

Suggest you look at the 'in progress' ones, as they show the deletions, and additions, while the final bill just shows what was actually enacted.
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Re: The Fix is in (California) (California) (California) (Califo

Postby ozzie on Mon Aug 13, 2012 12:04 pm

With all due respect, the bill as described (except for the elimination of the DFEC and age modifier, which I do not understand, not having seen the bill), appears to be a pretty moderate clean-up of some of the problems, focusing on just a couple of major areas:

1) It eliminates some needless yet expensive litigation over second opinions, UR/AME/IMR, etc., to get the worker medical treatment sooner and stop wasting time and money;
2) it closes up some major loopholes which have been used by a few to game the system;
3) puts the system on a much better path to being more reasonable.

Reduction of self-referrals to functional restoration programs, cleaning up the interpreter abuses, are a few things I see as being a whole lot better.
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Re: The Fix is in (California) (California) (California) (Califo

Postby spreare on Mon Aug 13, 2012 12:23 pm

With all due respect, you IMO are looking at a few items which obscure the remainder garbage in this bill.

Limiting chiro's to 24 to manage PTP is just prejudicial malice and is in condradicton to the Affordable Health Care Act which demands "provider non discrimination."
tightening up MPN's rather than opening them up to qualified doctors with the demand they play by the rules or get kicked out" , MPN's in of themselves are prejudicial, discriminatory, monopolistic, and predatory against small provider businesses which are excluded. What do they have to fear by opening them up to qualified doctors playing by the rules?

$150 lien fee, been there, done that. it is possbily a tool to be a malicious way to prevent doctors from treating patients that are being rail-roaded.
Carriers can deny pmt of a QME and now latter must file $150 fee?

It does nothing to raise PD, because too many other items are stripped away.

Decrease surgery ctr fees to 80% of medicare, closing that legitimate avenue of treatment.

I could go on and on but I am trying not to vomit on this keyboard!

Why doesn't ins industry clean up their own act and reduce costs?

IN Affordable healthcare Act 85% of revenues must be spent on treatment.

Why won't they do that here? Because insurers in work comp want huge profit margins rather than provision of care for workers and dignity to those that serve them.
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Re: The Fix is in (California) (California) (California) (Califo

Postby stewshe on Mon Aug 13, 2012 1:15 pm


If it passes, I don't believe I will be writing any new editions.

It is very sad day for California to see such a draconian bill even be proposed, much less seriously considered.

If it passes, I expect to see a dramatic increase in the number of suicides and even fewer doctors and hospitals accepting workers' comp patients except as emergencies.

The last I heard there were no psychiatrists or urologists in the Fresno area accepting workers' comp claims. No specilized hand surgery centers the state would accept a poor fellow with a claw of a hand after his "less than stellar treatment" by an "approved" physician. Neither Stanford, UCSF, UC Davis or several other well known specialized hand centers would !agree to treat because they only treated emergency W/C cases.

I wonder how other specialties are going to respond to the "80% of Medicare" proposal? Imagine having to tell an injured son or daughter, "I'm sorry, but you got hurt on the job so you are simply not going to be able to get the quality care you need!"

Any way you cut it, that simply is not right! Injured workers in California deserve better than that!

I suspect people who favor "The Fix" have a mind-set like the owner/manager of a small business who had an employee who he said falsely claimed to have fallen and hurt himself at work.

Depositions of both were taken and the ER remained adamant, repeatedly saying, "He never fell!"

At trial the ER testified he worked around the EE all day and, "He never fell."

The EE a shy, quiet, meek fellow asked, "But Mr. ??, don't you remember? I slipped and fell right at your feet. You bent over and offered your hand to help me up?"

At this the ER said, "Well, maybe he did fall . . . . but he didn't get hurt!"

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Re: The Fix is in (California) (California) (California) (Califo

Postby ozzie on Mon Aug 13, 2012 2:39 pm

Hold on a minute, posters! All that was posted re: Medicare fees was "41) Require the AD to adopt a fee schedule methodology based on medicare's RBRVS system." NOTHING was said in the post about a limitation to 80% of Medicare, so thumping on me for applauding that is pretty unfair.

The 24 visit limit on D.C. tx has been around for years. If you were to try a subrogation case - as I have - judges, juries, civil defense attorneys - look with scorn, derision, disbelief, contempt - on the treatment bills for worker's comp cases. No one in an auto accident, even hit by a Rolls Royce or Bentley, gets - would get - anywhere near the astronomical, insane bills from comp cases. They laugh at us, and rightfully so. Our present system is a disgrace.

Frankly, so is the cost of medicine in this country, compared to other societies where medical care is far better. We are way the hell down on the list of access to care, quality of care, etc.

I fail to see all - or much of anything - horrible, drastic, or making huge, radical changes, much less anything really "bad" in the proposed changes, as described by the list.

At some point, all those hollering so loudly need to look at how our closer neighbors - Oregon and Washington - handle comp claims and what the worker gets out of it. We've been riding a workers' and provider's gravy train here, and I've been wondering for years and years when it was all going to collapse.

And IMHO, most of the long-overdue collapse is due to the extent to which every reasonable change of any kind is litigated to the death, over and over, in every possible way, by those who stand to benefit, or lose, depending. As witness the outcry over the death of the ancient monster of LC 5814 when SB 899 passed.

I am not immune to the desparate needs of injured workers, nor to replacement of their lost ability to earn a living. I am, however, repeatedly outraged by the constant and extensive abuses to which the system has fallen prey: the outpatient surgery center scam; the unlicensed, un-certified, next-door-neighbor interpreter abuse, and D.C. treatments going into 168 treatments or more, all "justified," despite the 24 visit limit; self-referrals to functional restoration programs which conveniently fall outside the fee schedule; the Ogilvie case, which effectively used the DFEC modifier to eliminate the PDRS: how many times do you think this can be done before you all end up with a big, fat, ZERO?
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Re: The Fix is in (California) (California)

Postby appliedpsych on Mon Aug 13, 2012 4:41 pm

I wanted to make sure that QME's and treating doctors are fully aware of this effort to ram through a terrible reform of workers comp law in the last few weeks of the legislative session, while many of you are out on vacation.

The legislative committe is reportedly having a hearing this Wednesday Aug 15th on a proposal to reform the system put together by a union lawyer and one or two parties in basically secret meetings.

See the below links for reference, and you may want to forward to your email list so they can start calling Sacramento and urging them not to pass this. ... r-now.aspx

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Re: The Fix is in (California) (California) (California) (Califo

Postby crrondeau on Mon Aug 13, 2012 6:33 pm

Shame on the individuals whose evil minds thought up this abomination, this total injustice to California's injured working men and women and the few physicians still deluded enough to keep treating them. Shame equally on anyone who tries to defend this so-called "reform bill" as in any way, shape or form "a good thing", especially if you haven't actually read the entire bill (which I did today). I do agree that this is "clean up" legislation: the employers and carriers would definitely "clean up". This is a wholesale gutting of the workers' compensation system and a denial of due process to injured workers and treating physicians.

The single most important question that I have for anyone who would defend SB 863 is this: "Where is the crisis?" The answer is obvious; there isn't any. This is not 2004. The business pages are not filled with stories of employers being forced out of business or out of state because of the cost of workers' compensation insurance. This bill is nothing more than a "bait and switch". The PD increases for the most severely disabled will be meaningless because they will never be able to get ratings that entitle them to what they are entitled to under current law. That is the plain and honest truth. I could go on and on, but I am going to spend my time fighting to see (hopefully) that SB 863 dies. I pray for the sake of those who get injured at work after 1/1/13 that it does.

It's been YEARS since I posted anything on these WCC forums, but I was moved to do so today.
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Re: The Fix is in (California) (California) (California) (Califo

Postby bknight on Mon Aug 13, 2012 6:48 pm

THe DFEC modifier increase impairment 10-40% depending which rank the body part was in. The age modifier is a neutral modifier with the break even point at age 39. With the aging of the work force this was probably a slight increase overall, so taking it away is a slight decrease.

The orthopedic chapters do not produce relatively high ratings in the AMA Guides (although Almaraz/Guzman rectifies some of that). Therefore parties are seeking higher ratings through use of secndary impairments such as psyche with its relatively genrous GAF, sleep arousal and reproductive impairments. Taking these impairments away will also lower ratings overall.

So you lower the heck out of ratings and then proclaim a generous increase in PD levels. That does not sound like such a good deal, especially when there was talk of an overdue revised PDRS and that revision might have taken the form of higher DFEC modifiers.

Well this labor negotiator appears to have been asleep at the wheel. It will be interesting to see the reaction the California Applicants Attorney Association.
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