Medical reports to employer? (California) (California)

[compquest]

QUESTION:

Is there a law / regulation where the claims examiner is NOT allowed to send the medical reports to the Employer?

If yes, please cite if known.

[stevepsca]

The ER is entitled to the periodic PTP evaluation reports...the second or third copy that certifies continuing TTD, or MMI, and any restrictions. That does not include the narrative reports indicating diagnosis, treatment plan, or medical history. ER has no need for those reports/information.

HIPAA is generally exempt in WC... but there is still a need to know issue. Even with a ER is legally self insured, there is usually one person acting as CA, or a TPA handing provision of benefits.

HIPAA info is here http://www.hhs.gov/ocr/privacy/hipaa/un ... scomp.html

There is reference to a Minimum Necessary rule though, whereby only the persons directly associated with the claim would be entitled to the health protected information of the IW.

Minimum Necessary. Covered entities are required reasonably to limit the amount of protected health information disclosed under 45 CFR 164.512(l) to the minimum necessary to accomplish the workers’ compensation purpose. Under this requirement, protected health information may be shared for such purposes to the full extent authorized by State or other law. In addition, covered entities are required reasonably to limit the amount of protected health information disclosed for payment purposes to the minimum necessary.

Covered entities are permitted to disclose the amount and types of protected health information that are necessary to obtain payment for health care provided to an injured or ill worker. Where a covered entity routinely makes disclosures for workers’ compensation purposes under 45 CFR 164.512(l) or for payment purposes, the covered entity may develop standard protocols as part of its minimum necessary policies and procedures that address the type and amount of protected health information to be disclosed for such purposes.

Where protected health information is requested by a State workers’ compensation or other public official, covered entities are permitted to reasonably rely on the official’s representations that the information requested is the minimum necessary for the intended purpose. See 45 CFR 164.514(d)(3)(iii)(A). Covered entities are not required to make a minimum necessary determination when disclosing protected health information as required by State or other law, or pursuant to the individual’s authorization. See 45 CFR 164.502(b). The Department will actively monitor the effects of the Privacy Rule, and in particular, the minimum necessary standard, on the workers’ compensation systems and consider proposing modifications, where appropriate, to ensure that the Rule does not have any unintended negative effects that disturb these systems.

Once the ER files the claim with their carrier, and it's accepted, the IC steps in as the "ER" for the duration of the claim. There is no reason for the medical reports to be sent to the actual ER.

[jakelast@aol.com]

LC 3762 covers the information that an employer is entitled to receive from the claims administrator:

3762. (a) Except as provided in subdivisions (b) and (c), the insurer shall discuss all elements of the claim file that affect the employer's premium with the employer, and shall supply copies of the documents that affect the premium at the employer's expense during reasonable business hours.
(b) The right provided by this section shall not extend to any document that the insurer is prohibited from disclosing to the employer under the attorney-client privilege, any other applicable privilege, or statutory prohibition upon disclosure, or under Section 1877.4 of the Insurance Code.
(c) An insurer, third-party administrator retained by a self-insured employer pursuant to Section 3702.1 to administer the employer's workers' compensation claims, and those employees and agents specified by a self-insured employer to administer the employer's workers' compensation claims, are prohibited from disclosing or causing to be disclosed to an employer, any medical information, as defined in subdivision (b) of Section 56.05 of the Civil Code, about an employee who has filed a workers' compensation claim, except as follows:
(1) Medical information limited to the diagnosis of the mental or physical condition for which workers' compensation is claimed and the treatment provided for this condition.
(2) Medical information regarding the injury for which workers' compensation is claimed that is necessary for the employer to have in order for the employer to modify the employee's work duties.

As HIPPA does not cover WC, this section is more applicable to what can be disclosed that the HIPPA provisions. Subsections c (1) & (2) indicate what can be provided.

[compquest]

Jake:

Wow!

Thank you very much .