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Gaylord & Nantais

Worker's Compensation Attorney

California State Report Touts Success of Worker's Compensation Reforms - Applicant Attorney's Disagree

Worker’s compensation reforms are bringing savings to California employers while increasing payments to workers, state officials have announced. The news comes from a report issued by the California Department of Industrial Relations on July 23, 2015.

The report explains how Senate Bill 863, which was signed by Governor Brown on September 2012 and went into effect on January 1, 2013, has improved the state's workers comp system.

Key Changes to Worker's Comp

  • Medical rather than legal professionals have more say in worker's comp cases
  • Acceleration in medical decision-making process
  • Emphasis on evidence-based medicine for treatment decisions
  • Increased role of independent medical reviewers to resolve disputes
  • Better access to network physicians for employees
  • Immediate Major Effects

One of the most noticeable effects of the new policies has been decreased medical costs, which fell by 3.3 percent in 2014. Additionally, workers with permanent disabilities (PD) saw benefits rise by about 30 percent.

Depending on PD ratings, weekly PD benefits that formerly ranged from $130 to $270 now range from $230 to $290. Meanwhile, workers with injuries since January 1, 2013, now receive a minimum weekly PD benefit of $160 and injuries since January 1, 2014, yield a maximum weekly payment of $290.

The implementation of the new law has been overseen by the Department of Industrial Relations (DIR) and the Division of Worker's Compensation (DWC). Over twelve sets of new regulations are now in effect. Following the enactment of SB 863, lien filings have been reduced by 60 percent. Medical cost savings, according to the WCIRB, have been revised from the initial projection of $480 million to an estimated $690 million.

A more recent effect has been that premiums fell by 10 percent in July 2015_ The overall system has been improved, as doctors can now provide treatment more quickly to patients.

Applicant Attorneys Disagree

While permanent disability payments have increased, access to medical treatment has become more difficult, and treating doctors are being micromanaged and precluded from giving adequate care.

Under the current reforms, medical treatment must be accessed via the insurance carrier's Medical Provider Network. (Doctors chosen and added and removed at the behest of the Insurance carrier.) In addition, the injured worker or "applicant' must obtain pre-authorization in order to get an appointment. Once under the care of a treating physician, utilization reviewers (UR) hired by the Insurance carrier can "non-certify and refuse any treatment they feel is not supported by "evidence based medicine.'

If the applicant challenges the UR decision, the applicant's only recourse Is another blank faced individual employed by Maximus, the company contracted by the state to perform Independent Medical Review or IMR. The IMR doctor never actually sees the applicant, and may not even get all of the medical records before rendering an opinion on the necessity of the treatment. This is because the insurance carrier is responsible for sending the records to the IMR physician. (The fox guarding the hen¬house)

To make matters worse, the IMR decision is final, notwithstanding a challenge based on fraud and other very limited basis. Attorneys are denied the right to cross-exam the IMR doctor. And, not even a judge can overrule an IMR decision. The IMR process is currently being challenged and will likely be reviewed by the California Supreme Court, due to what most attorneys representing applicants feel is a blatant lack of due process. The state's own statistics show that 85% of all treatment requests that are denied by UR are also denied by Maximus.

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