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SB 899 - The Claims Examiner Perspective Eileen Gould Assistant Vice President

SB 899 - The Claims Examiner Perspective Eileen Gould Assistant Vice President Workers’ Compensation Client Services Roseville, CA. Medical Treatment. Pre-designation of Treating Physician (change effective 4/19/04) Must be in writing and filed prior to date of injury

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SB 899 - The Claims Examiner Perspective Eileen Gould Assistant Vice President

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  1. SB 899 - The Claims Examiner Perspective Eileen Gould Assistant Vice President Workers’ Compensation Client Services Roseville, CA

  2. Medical Treatment • Pre-designation of Treating Physician (change effective 4/19/04) • Must be in writing and filed prior to date of injury • Must be with an employer who provides non-industrial health insurance • Must be employee’s regular “physician and surgeon” and must be licensed MD or DO • Must be employee’s primary care MD or DO • Physician must agree to pre-designation • Medical Treatment during 90 Day Delay Period (change effective 4/19/04) • “Shall authorize medical treatment” consistent with ACOEM Guidelines (American College of Occupational and Environmental Medicine) up until the date of accept/deny • Triggered by filing of DWC-1 • Must be provided within 1 day of filing of DWC-1 • $10,000 limit

  3. Medical Treatment Continued • Medical/Legal Process (Effective 4/19/04) • Unrepresented employees must follow LC 4062.1 • Panel Qualified Medical Evaluation Process • Medical Networks (Effective January 1, 2005) • Administrative Director shall approval all plans • Employee must treat inside of Medical Network unless pre-designated • Employer has exclusive right to decide which providers are in network

  4. Temporary Disability • Temporary Disability • Time Limitations (effective for dates of injury on or after 4/19/04) • Limited to 2 years from date of 1st provision of temporary disability • TD may extend to 5 years for certain injuries • Example; Hepatitis B, Amputations, HIV • 4850 Benefits are considered temporary disability benefits and fall under this provision

  5. Permanent Disability • Permanent Disability • New Rating Schedule (Effective January 1, 2005) • Addresses employee’s lost future earning capacity vs. diminished ability to compete in open labor market • Level of permanent disability to incorporate AMA guidelines • Decrease in number of weeks for permanent disability ratings less than 15% • Increase in number of weeks for cases greater than 70% • Apportionment • Based on Causation (effective April 19, 2004) • Pathology (arthritis or degenerative conditions not symptomatic) • Smoking in pulmonary cases • Permanent disability directly caused by injury • Prior award “conclusively presumed” to exist • Can not accumulate more than 100% in permanent disability

  6. Permanent Disability Continued • Return to Work Adjustment (Effective DOI: 4/30/04 & for all dates of injury that did not have permanent & stationary reports completed) • Permanent disability payments decreased by 15% from time of offer • Offered within 60 days of permanent & stationary status • Position must last 12 months • Regular/modified or alternative work can be offered • Does not apply to employers with less than 50 employees • Wages are not less than 85% of pre-injury earnings • Permanent disability payments increased by 15% • No offer is made within 60 days of permanent & stationary status • Position does not last 12 months • Less than 85% of pre-injury earnings

  7. Utilization Review • Purpose • Changed presumption of correctness for treating physician to ACOEM Guidelines • Provide treatment protocols in accordance with ACOEM Guidelines • Expedite treatment plans • Deter unnecessary testing & equipment • Medical Treatment Reviewed • Prospective treatment • Retrospective treatment • Concurrent treatment • Utilization Review Decisions • Approve • Modify • Delay • Deny

  8. A Day in the Life of a Delayed Claim • Employee reports injury • Employer provides DWC-1 within 24 hours of notice • Employer/Administrator authorizes medical treatment within 24 hours of DWC-1 receipt • Employer & Administrator determine if claim is disputed due to FACTUAL or MEDICAL reasons • Administrator will provide Qualified Medical Evaluation Panel Request to Injured Worker within 15 days of report of claim to meet the 90-day time-frame • Injured Worker has 10 days to complete the form & send to the Administrative Director to obtain a panel (injured worker picks specialty) • If no panel has been requested Administrator can send in request and pick specialty • Administrative Director to send 3 physician panel to injured worker within 20 days

  9. A Day in the Life of a Delayed Claim continued • Administrative Director issues panel • Injured worker has 10 days to select physician • Failure to make selection allows Administrator to select physician from obtained panel and schedule appointment • Administrator must complete thorough investigation quickly and efficiently to provide information to Qualified Medical Evaluator who will determine AOE/COE issues • All medical & non-medical information must be served on injured worker 20 days prior to scheduled examination • Injured Worker can object to all non-medical information • There can be no outside communication Qualified Medical Evaluator • Report issued within 30 days of examination

  10. Questions? Thank you

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