ALL QME'S AND ATTORNEYS SHOULD READ THIS (California)

This category is meant for discussion of technical legal issues in workers' compensation. If you are an injured worker, do not ask questions here. Go to the Injured Workers' forum.

ALL QME'S AND ATTORNEYS SHOULD READ THIS (California)

Postby appliedpsych on Wed Sep 02, 2009 11:46 am

ALL QME'S AND ATTORNEYS SHOULD GO TO THE CSIMS SITE AND READ THE RECENT POSTINGS OF MOVEMENTS AFOOT TO CHANGE THE RULES.
Heres a sample from the CSIMS WEBSITE

This proposal is much worse than the labor-management package I sent you last Friday. Here are a few highlights of the Republican proposal:

1. It abolishes all AME and panel QME exams and replaces them with evals done by the PTP or a single QME selected by the DWC. This would be a non-random assignment. The DWC Medical Director could hand-pick whomever he/she chooses to do the eval.

2. All impairment evaluations would be done strictly in compliance with the AMA Guides, 5th edition. It would specifically overturn Almaraz-Guzman. "The literal methodology of the calculation of impairment found in the Guides shall always be applied. The examples found within the guides shall be as the only source used to address ambiguities."

3. All current QMEs would have to take and pass a new examination to demonstrate their proficiency using the AMA Guides, the MTUS, and understanding of evidence-based medicine.

4. The QME assigned by the DWC Medical Director would have to begin the evaluation within 30 days of the assignment, unless the Medical Director permits it to be scheduled later.

5. The DWC Administrative Director would contract with individual physicians the AD feels are qualified in the application of the AMA Guides or in making determinations of medical necessity (UR) to review reports written by QMEs. If the reviewing doctor concludes that the QME's report is deficient, (A) the report will be inadmissible; (B) the QME will not be paid for the report and must refund any amounts previously paid; and (C) the reviewing physician (without examining the patient) can issue "a corrected evaluation of permanent impairment or a corrected determination of medical necessity" and the reviewing physician's determination will be "conclusively presumed to be correct."

6. Unless a treating physician was a predesignated personal physician or a member of the employer's MPN, that physician would not be paid for any treatment rendered to an injured worker unless, prior to providing treatment, the physician contacts the employer to determine if there is an MPN in place. If there is an MPN, the physician must obtain prior authorization for any one-time medical service necessary to stabilize the employee's medical condition. The physician, after rendering the one-time care, must provide the employee with information on how to select an MPN physician to continue the treatment.

7. All treatment (except emergency care) would have to be preauthorized.

8. All liens for services must be filed within one year of the date of service. All liens must include supporting documentation to establish a prima facie entitlement to payment. No accounts receivable liens can be assigned unless the provider is going out of business. All liens must include an affidavit, signed under penalty of perjury, that the provider actually rendered the services, and that the employer gave prior authorization for the services (except emergency care). If a lien is not filed timely, all right to reimbursement "shall be extinguished."

9. If there is a billing dispute, the matter will be referred to the DWC Medical Unit for a determination of the amount due. The determination of the Medical Unit will be binding on the parties unless it is appealed within 20 days. On appeal, the Medical Unit's determination shall be affirmed unless it was not supported by substantial evidence.
User avatar
appliedpsych
 
Posts: 390
Joined: Fri Mar 06, 2009 8:31 am

Re: ALL QME'S AND ATTORNEYS SHOULD READ THIS (California)

Postby rider001 on Wed Sep 02, 2009 2:47 pm

Talk about skewing numbers to promote an agenda.
rider001
 
Posts: 151
Joined: Tue Mar 10, 2009 10:20 am

Re: ALL QME'S AND ATTORNEYS SHOULD READ THIS (California)

Postby jonbrissman on Wed Sep 02, 2009 3:16 pm

Appliedpsyche said "Here are a few highlights of the Republican proposal:"

As much as he would like to demonize Republicans, they had nothing to do with it. The backroom negotiations took place between the Commission on Health and Safety and Workers' Compensation (CHSWC) and the AFL-CIO. The labor union is very much a pro-Democrat group, and CHSWC has no alignment with the GOP.

The community would have little to fear if it was a Republican proposal, because Republicans hold so few seats in the Assembly and Senate that they can get none of their agenda passed. The legitimate fear is that the AFL-CIO, who contributes heavily to Democratic Assemblymen and Senators, might coerce the Democrats to pass this addlepated proposal.

In California politics, both parties are pretty inept. But regarding this circumstance alone, someone owes Republicans an apology.

By the way, how in hell does a labor union have standing to negotiate proposals for workers' comp legislation?

JCB
User avatar
jonbrissman
 
Posts: 391
Joined: Mon Mar 02, 2009 5:43 pm

Re: ALL QME'S AND ATTORNEYS SHOULD READ THIS (California)

Postby davidd on Wed Sep 02, 2009 3:20 pm

addlepated


Cool word! I'm using it in the future!!
User avatar
davidd
Site Admin
 
Posts: 362
Joined: Thu Dec 04, 2008 4:09 pm

Re: ALL QME'S AND ATTORNEYS SHOULD READ THIS (California)

Postby appliedpsych on Wed Sep 02, 2009 4:34 pm

Sure did not mean cause any injury to the psyche to anyone - - -

the 'Republican' thing was not my word - I just copied that whole section straight from the CSIMS website.

If you read the other articles on that site, it reports that the wish list of changes generates from the California State Republican Caucus - I don't know if it's true or not.

For full disclosure, I am a registered Independent.

"The conclusion you jump to may be your own" --- James Thurber

"When you jump to conclusions you often skip over the truth"... - Unknown
User avatar
appliedpsych
 
Posts: 390
Joined: Fri Mar 06, 2009 8:31 am

Re: ALL QME'S AND ATTORNEYS SHOULD READ THIS (California)

Postby jobmdpsych on Wed Sep 02, 2009 7:06 pm

I think CSIMS overreacted. Read the source document. They are talking about taking AMEs out of the treatment decision process, not eliminating them for medical legal determinations. I don't believe for a minute that anyone seriously believes the system can function without AMEs or QMEs.

However, AFL-CIO is way over their heads here and do not understand how they are setting themselves up. Increased benefits wont mean anything if these lien procedures go through.

More importantly there won't be anyone left to provide unapproved treatment.
jobmdpsych
 
Posts: 377
Joined: Sun Jun 28, 2009 7:28 am

Re: ALL QME'S AND ATTORNEYS SHOULD READ THIS (California)

Postby jonbrissman on Wed Sep 02, 2009 9:07 pm

No prob, appliedpsych. I have fallen into the same trap, quoting others when I didn't check the source.

One scary thing about the proposal involves liens: Liens may be filed only if "the employer gave prior authorization for the services (except emergency care)." So how does an injured worker whose claim is denied obtain treatment? And if the employer did give prior authorization, why hasn't the employer paid for the services?

JCB

"Life is tough, but it's tougher if you're stupid." -- John Wayne, in the role of Sgt. Stryker, in "The Sands of Iwo Jima," 1949.
User avatar
jonbrissman
 
Posts: 391
Joined: Mon Mar 02, 2009 5:43 pm

Re: ALL QME'S AND ATTORNEYS SHOULD READ THIS (California)

Postby MHarrisLaw@verizon.net on Thu Sep 03, 2009 4:27 am

The document I read (see http://www.csims.net/pdf/Senate%20Repub ... nguage.pdf) would eliminate Agreed Medical Evaluators and Qualified Medical Evaluator panels. Instead, a Qualified Medical Evaluator would be assigned. Just one, whether represented or not. This is not just for treatment disputes but for all disputes.
Marjory Harris
Certified Specialist in Workers' Compensation Law
San Francisco Bay Area & Inland Empire
Editor, getMedLegal Magazine
(888) 858-9882
mharrislaw@verizon.net
User avatar
MHarrisLaw@verizon.net
 
Posts: 4
Joined: Mon Mar 02, 2009 10:31 am

Re: ALL QME'S AND ATTORNEYS SHOULD READ THIS (California)

Postby rbaird on Thu Sep 03, 2009 9:28 am

I previously described the evaluation and treatment issue process resulting from the reform legislation and the proliferating regulatory action as resembling Frankenstein's monster. The CHSWC proposal has something to please and displease all participants in the game, but I doubt even if there was AFL-CIO input, there is much chance of enactment in its present form. It attempts to drastically simplify the forensic evaluation procedure which may well serve the large number of unrepresented claimants. Liens are a major problem administratively, even without the dubious aid of EAMS.In a better world, medical providers would be promptly paid at an economically reasonable rate and there would be monetary consequences for wrongful denials of authorization. Even if it is impracticable to schedule payments by procedure (Is anyone happy with MediCare reimbursement levels?), the practice of over-billing in the hope of collecting partial payment is unwise. Left unmentioned in the initial post is that the CHSWC proposal significantly increases PD. The benefits of the reform are far from apparent over the long run; the data suggests a significant increase in medical costs and pretty conclusively demonstrates a large amount of uncompensated long term wage loss and the AMA guidelines have some intrinsic conceptual flaws...
rbaird
 
Posts: 83
Joined: Thu Mar 05, 2009 12:04 pm

Re: ALL QME'S AND ATTORNEYS SHOULD READ THIS (California)

Postby cmunday on Thu Sep 03, 2009 9:31 am

Just to clarify....CSIMS first report was based on the information from Workcompcentral. Subsequently two documents have shown up and they are somewhat different. The first was a "secret proposal" by CHSWC and some group from labor and that one ONLY took evaluation of medical treatment necessity from AME/QME evaluators and created IMRs (Independent Medical Review) which would be appointed panels to review medical treatment issues. The second document has been titled the Republican wish-list but as some have pointed out we're not sure precisely who put this together. This makes specific amendments to the Labor Code which as Ms. Harris points out would not only do away with AMEs and Panel QMEs but DWC would "appoint" on a NON-RANDOM basis a QME to evaluate permanent disability issues. My read on both of these is a desire to take out any independent review of treatment or disability issues and give the power to state appointed panels and bureaucrats.

I may be naive but I do think some semblance of reason will prevail (don't bother telling me I'm naive - I have been told that enough - I just continue to prefer to focus on the optimistic side). My suspicion is that it is too late to actually take any legislative action this session (the fear is that some of these proposals get added on to some existing legislation at the last moment and could potentially sneak through without a great deal of scrutiny by all interested parties). Virtually every patient I evaluate complains of delays or denials in terms of treatment and much of this is non-controversial, should-be-routine treatment (in my humble opinion). Making access to care even more difficult just might well result in such a backlash that the pendulum swings back again. As an observer of these things I tend to sit back and with some perverse sense wait to see the unintended consequences - there always are some.

My favorite curse applies here - "May you live in interesting times".

Claude Munday
cmunday
 
Posts: 200
Joined: Wed Mar 04, 2009 9:54 am

Next

Return to Legal

Who is online

Users browsing this forum: No registered users and 7 guests