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Tide TRACKER

Helping to Navigate the Troubled Waters of Workers Compensation


Table of Contents
A False Debate on Safety Priorities
pg.
Resolving Medical Disputes
pg. 2
Are We There Yet?: A Guide to
Senate Bill 863 Lien Reform
pg. 4
Delayed Recovery- A Case Study
pg. 6
A False Debate on Safety
Priorities by Joe Stevens
There is a debate going on in
safety circles regarding the most
effective way to minimize
injuries. One school of thought
insists that training and
compliance are the keys, while
the other group believes that it is
more important to focus on
behavior. In reality, it isnt a
case of one way being more effective than the other.
The real key is the order in which they are
implemented.
A workplace free of unnecessary safety hazards and
in full compliance with OSHA regulations is the
starting point, the foundation, the platform. Hiring
the right people for the jobs, then providing them with
thorough, ongoing training in a safe and
compliant workplace comes first. These are the nuts
and bolts of a safety program. Only after these things
are in place is the company ready to move on to
behavior.
An analogy that may help is to think of safety in
football terms. The field must be in perfect condition,
and the players must be well coached and know all
the plays. Thats the equivalent of a safe workplace
and excellent training. Now, in order to achieve the
goal of winning, the players must perform to a high
level. Thats where behavior comes in. If the field is
in poor shape, and the players are not well coached,
the attitude of the players is affected and we can
expect the results and, most likely, the effort - to be
negative.
Summer 2014
If the basics arent provided, there is little chance
for success. When they are provided, the coaches
and the team can focus on performance. Safety in
the workplace has the same formula: first make
sure that basics are in place and then focus on
behavior. To affect behavior positively, provide
clear goals, encourage reporting of hazards and
near misses, recognize contributions and record of
excellence in both departments and individuals.
Make everyone accountable by discussing injuries
and posting results and show appreciation for a job
done well, and done safely. The better the job
a company does at convincing its workers that
safety is its highest priority, the greater the
likelihood that workers will perform safely.
Joe Stevens founded Bridge Safety Consultants in 2003
with a focus on safety culture. Having served on The
Governors Task Force for Workers Comp Reform in
2004, Mr. Stevens helps companies understand the cost
drivers in the workers comp system, and customizes
safety programs that strengthen the safety culture,
produce lower X-Mods and reduce premiums.
Website: www.bridgesafetyconsultants.com
Email: stevens@bridgeconsultants.net
Twitter: @safety_experts.
Resolving Medical Disputes
by James Carey
The medical dispute resolution
process has been evolving
substantially over the past
decade. We have become
accustomed to hearing the
acronyms of MPN and UR being
thrown about on a regular basis. But do we know
how to use these effectively to defend a case and
manage costs?
One might argue that the ongoing increases in
premium rates do not show a substantial cost
savings, whereas another might argue that it does
not adequately ensure that the injured workers are
getting the treatment they need. The truth lies
somewhere in between and the reality is that we must tailor
our use of these tools to each situation to ensure the best
possible outcome. A prior authorization plan as part of
the utilization review protocol will go far to ensure that
care is delivered efficiently, costs are kept under control
and ultimately, requests for independent medical review
(IMR) are kept to a minimum. A custom and
well-policed Medical Provider Network would go far to
ensure that a certain quality of care is maintained within
the network.
Following is a brief outline of the medical dispute
resolution process. Additional information concerning the
medical-legal process and other strategies can be seen with
the rest of this article on the RiskSolutions blog.
1. Utilization Review:
a. Purpose: Assess medical necessity for proposed
medical treatment
b. When Used: For medical treatment requests on
uncontested/accepted body parts
c. Appeals: As of 7/1/13, all disputes concerning UR
denials are to go through Independent Medical
Review (IMR)
d. Limitations:
i. Does not address causation
ii. Certification does not guarantee payment
(authorization comes from adjuster)
iii. If time frame is not met, presumed authorized
and medical-legal exam cannot be undertaken for
the sole purpose of medical necessity (Sandhagen
v. SCIF)
e. Caveats:
i. Objection to extent & scope of medical treatment
under LC 4062 defers medical necessity decisions
to med-legal examiner No further referral to UR,
just send denials & copies of objection to provider
ii. Denied body parts can be reviewed
retroactively if found compensable.
iii. Approval/authorization can be rendered
directly by adjuster and thus bypass UR via
prior authorization protocol or at adjusters
discretion
2. Second Opinion Process:
a. Purpose: To address and resolve disputes
concerning diagnosis or treatment plan
b. When Used: For any dispute arising from the
diagnosis or treatment plan from the primary
treating physician (PTP) within a valid medical
provider network (MPN) or health care
organization (HCO)
c. Appeals: Proceed to second or third opinions
within MPN/HCO and then to medical-legal
examination if controversy remains
d . Limitations:
i. Does not address causation or disability
ii. Second & third opinion must come from
MPN physicians (no requirement for opinion to
come from specialist)
e. Caveats:
i. Not binding and does not automatically allow
change in PTP
ii. All opinions are admissible before WCAB
proceedings or med-legal exams
3. Medical Provider Network (MPN) / Health Care
Organization (HCO):
a. Purpose: To extend medical control for the
duration of a claim
i. MPN: Medical in place for duration of claim
if claimant properly notified
1. Notice requirements are more lenient
due to SB 863
2. Treatment can be transferred out of
network if failure to provide notice
results in denial of medical care
(solution: send claimant to industrial
clinic every time)
3. Medical provider listing must be
comprehensive within a reasonable
distance of claimants home (typically
30 mile radius) for the requested
specialty or specialties
ii. HCO: Absolute medical control for 90 or
180 days
1. 90 Day Control: If employer does not
offer or pay for more than 50% of
employees non-occupational health
care coverage
2. 180 Day Control: If employer offers
or pays for more than 50% of
non-occupational health care coverage
3. Medical provider listing need only list
five medical providers within a
reasonable distance of claimants home
for requested specialty
b. When Used: For medical treatment on
all accepted injuries and/or body parts.
c. Appeals: Second opinion process; UR &
IMR; medical-legal tract (4061/4062)
d. Limitations: Does not apply to disputed
body parts (e.g. psyche) or denied
claims, but medical control can be
retained where there are multiple
allegations to body parts covered by one
specialty (e.g. accepted finger, denied
lumbar spine)
e. Caveats:
i. Valdez decision: Allows for consultations
secured by injured workers to address
recommendations concerning medical treatment
or disability, but does not allow for ongoing
treatment outside of the MPN
ii. Failure to provide proper notice of MPN:
Allows for treatment outside of MPN, but only
applies if failure results in denial of medical
treatment
iii. UR denials: Claimant can go out of MPN
to secure if IMR overrules UR decision
iv. No providers within reasonable geographic
distance: If no MPN providers are present
within a 30 mile radius of claimants home,
claimant can treat outside of MPN network
v. Denied claim: Employee is free to treat
outside of MPN if claim is denied in its entirety
* To see the rest of this article, please go to the
Risksolutions blog at risksolutions-inc.blogspot.com
James Carey, CSIA, WCCP is a graduate of the University
of California, Irvine and a veteran claims adjuster with
more than a decade of experience. He has handled claims
at insurance companies, third party administrators and
government entities with strong experience handling highly
complicated cases across multiple states and jurisdictions.
He brings an aggressive, employer-oriented style to the
table along with practical knowledge to help employers
navigate the treacherous waters of the workers
compensation system.
Are We There Yet?: A Guide
to Senate Bill 863 Lien Reform
by Lisa Sanchez
Congratulations! That claim
you've been struggling with has
been settled by a Compromise and
Release. A judge has approved it
and the check has been issued.
This is great news - the claim
appears to have been finalized
and a closed claim should be right
around the corner. However, we cannot forget about
those pesky little guys that can hold up the closure of
a claim: LIENS.
Hundreds of thousands of liens are filed each year
costing the California workers compensation system
hundreds of millions of dollars, according to the
Workers Compensation Insurance Rating Bureau. We
usually see liens filed on litigated claims, especially
when medical treatment has been denied by the insurance
carrier. Claims can remain open for months and even
years after the case in chief has been settled due to liens.
The lien reform under Senate Bill 863 creates new
statutes of limitation for filing liens and, also, provisions
for dismissing liens. The intention of the lien reform is to
help clear the workers compensation system of
lingering and inadmissible liens, while freeing up the
Workers Compensation Appeals Board (WCAB)
hearing calendar for more important matters.
According to the Department of Industrial Relations,
Division of Workers Compensation, lien claimants who
wish to file a lien after January 1, 2013 now have to pay
a filing fee of $150. A $100 activation fee is required for
liens filed before January 1, 2013, but activated for a
conference or trial after that date. Liens can be dismissed
if no filing or activation fee has been filed. Additionally,
there is an 18-month statute of limitations for filing liens
for services rendered after July 1, 2013 and a three year
statute of limitations for services provided before then. If
a lien is not properly submitted with proof that the filing
fee has been paid, it will be deemed invalid. Under the
statute, claims of two or more providers cannot be
merged into a single lien, thus requiring each provider to
file a separate lien and pay separate filing fees.
Unfortunately, we have already hit a major impediment
with the new system. The case of Angelloti et al. v.
Baker et al. challenged the provisions of the senate bill
requiring activation fees and allowing for dismissal of all
liens filed prior to 2013 if the $100 activation fee was not
filed by January 1, 2014. The case resulted in a federal
injunction against any further dismissal of liens due to a
failure to pay activation fees. This negates the
improvement we had already begun to see in the system.
Some lien claimants with smaller claims had been
choosing to abandon their claims rather than paying the
fee. Now, the courts have seen a glut of lien conferences
with lien claimants aggressively pursuing their claims,
eager to get what they can before a final decision is
issued regarding the constitutionality of the activation
fees. Obviously, we may have a long road ahead before
we see any lasting relief for lien resolution.
Lisa Sanchez, CSIA, WCCP is a graduate of the University
of California, Riverside and has a Bachelors degree in
Business Administration. She is a seasoned bilingual claims
adjuster with more than eight years experience, having
handled claims at a self-insured, self-administered employer
before being drafted to the RiskSolutions team. She brings a
unique, employer-driven perspective with her and hands-on
experience working one-on-one with management and
injured workers alike helps employers to fathom the endless
depths of Californias Workers Compensation system.
Delayed Recovery A Case
Study by James Carey
Early intervention in delayed
recovery cases is not a new concept,
however, applying it to workers
compensation is just starting to take
hold in our industry. Most payors
take this concept and apply various
means of identifying potential delayed recovery cases,
such as predictive modeling using pure statistical data
or having adjusters or nurses identify red flags. Seldom
is the next step taken- decisive action toward
intervention.
We have been developing and testing our own
program, DREI (Delayed Recover / Early
Intervention), which consists of an algorithm applied to
a behavioral interview at the three-point contact
coupled with predictive modeling elements and human
interpretation. The results is a report with
recommendations for early intervention. With these
recommendations, we have seen where intervention
has been successful and where a lack of action,
bureaucracy, or poor understanding caused
unnecessary time off work.
A sample case study: We start with a young worker at
a convenience store, who was robbed at gunpoint. She
exhibited immediate signs of post-traumatic stress
disorder as well as anxiety when talking about work.
She was sent to the occupational medicine clinic right
away and the doctors first report referred the patient
immediately to a psychologist or psychiatrist. In
conducting the initial three-point contact and running
this through our program, we found a few indicators
that the patient may not want to return to work right
away.
The first indicator is the most obvious: The patient was
a victim of a violent crime, which clearly meets all of
the criteria for this case to be considered AOE/COE.
The next involved performance issues at work, which
could demonstrate a lack of motivation for return to
work (RTW). Also, the patient had some non-industrial
pathology that could contribute to her overall
emotional state. It was our assessment that this case
needed an immediate approval for the psyche consult
and could quickly become litigated if not handled
expediently. Our other recommendations were to
maintain frequent contact with the patient to provide
additional support and to offer alternative work in an
area that would not be public-facing, so as to keep the
patient working and feeling productive.
Unfortunately, the case did not progress as smoothly
as we hoped. The adjuster submitted the request to
Utilization Review (UR) but the request was rejected
for being submitted on the wrong form and the new
Request for Authorization form was needed to
proceed. This caused an additional delay when the
medical provider had to go back and duplicate their
original efforts to get the patient to see a mental health
provider. Contact with the adjuster further
exacerbated the situation as they refused to allow any
consultation without it first being approved by UR.
First, this underscores an absolute need to have a
pre-authorization component to a UR plan, particularly
given the gravity of the situation and the urgent need
for the patient to be seen by a mental health
professional. Second, this also demonstrates how
quickly a cost-saving measure can be misused
simply for the sake of preserving rights under
Sandhagen. Finally, for a carrier to have their claims
department so incredibly hamstrung is beyond
comprehension because it mires patient care in an
impenetrable web of red tape.
While the request for consultation was waylaid by an
insistence to have the request processed through UR,
the patient remained off work receiving temporary
total disability (TTD) benefits. Had a pre-authorization
program been in place, the patient could have been
treating with a doctor of an appropriate specialty. For
instance, if one were to sustain multiple fractures to the
hand, it would only make sense to authorize an
immediate referral to a hand surgeon. In this case,
authorizing a referral to a psychologist would have
been the common sense choice, but for some reason, it
seems many adjusters these days want to avoid
anything to do with psychology. Every week that went
by added another payment that will ultimately go to
affect the employers loss ratio and experience
modification (X-Mod). Even worse, this was done
under a loss-sensitive policy and not a guaranteed cost
program.
Finding an appropriate provider is a task in and of itself.
Often, adjusters find themselves dealing with claims in
remote areas where in-network medical providers are
few and far between, sometimes leaving only one
provider available. Generally, this provider will have a
standard fee arrangement they want signed in advance
before theyll treat the injured worker. In my adjusting
days, I signed these right away because patient care,
recovery and RTW were my top priorities. Bickering
about bills was always secondary. In our case study, the
adjuster had this agreement sitting on their desk for a
significant period of time, thus causing another delay in
treatment. When another provider who did not require
a fee agreement up front was found, the patient felt
driving there would be burdensome and expensive with
gas prices in excess of $4 per gallon. While we all know
about mileage reimbursements, its always amazed me
how few injured workers know about it until I mention
it to them (despite being mentioned in the cover pages
on the DWC-1 claim form).
That said, the nurse case manager handled this case by
following the recommendations made by our program
and taking regular opportunities to reach out to the
patient and talk to her. One of the easiest ways to avoid
costly and drawn-out litigation is to simply talk to the
injured worker. Workers Compensation is downright
adversarial these days and no amount of legislation is
going to fix that. However, the simple act of reaching
out and demonstrating care goes a whole lot further than
treating each patient like a number.
Treating each patient as a whole person instead of a
subset of symptoms is the factor that drives our Delayed
Recover / Early Intervention initiative. When we
identify a patient at risk for a delayed recovery, we
address both the person as a whole and a common sense
case management. Though this trend may be in its
infancy with Workers Compensation, it is our mission
to change the status quo and aim for lower severity
injuries, less litigation and a more productive work
force. With medical reimbursements and permanent
disability maximums on the rise, insurance is just going
to get more expensive until something is done to
address these cost drivers from a holistic perspective.
(951) 943-6775 ext 151
Fax: (951) 943-5221
etaylor@risksolutions-Inc.com
reducing the costs of
doing business
P .O. Box 180
17602 17th St.
T ustin, CA 92780

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