[ Often Used | Right to Treat | Employers Duty to NOTIFY | Reporting Duties | MEDICAL BILLING | U&C Fees Apply | ACOEM BUSTERS | ER Duty to NOTIFY | MPN | UR on Future Medical Awards | Serious Medical Condition | Apportionment | The Cap | Other EBM Treatment Guidelines | Medical Billing | When NOT to Treat a WC Patient | Billing a WC patient | HCO | CASE LAW | Spiel | No Nos | Links | Sec 302 | Sample PR-4 | NEWS | Quotes of Interest ]

OFTEN USED:

Pfirrmann CS, Boos N, et al. "Magnetic resonance classification of lumbar intervertebral disc degeneration." Spine. 2001 Sep 1;26(17):1873-8.

Thirty Chiropractic Treatments per Year Support: [here]

Procured Chiro Treatment - Chapter 6 Style: [here]

Mercy Support of Chiro Treatment Frequency: [here]

Mercy Support of Chiro Tx Frequency for Acute Injuries and beyond: [here]

MPN Dispute: [here]

Cal. Code Regs., tit. 8, § 10111.1, subd. (d)(3) [penalty of up to $ 5,000 for claims administrator's failure to provide claim form on employee's request][Cal. Admin. Code, tit. 8, §§ 9781, 9783]

Lab. Code, § 4600, subd. (a)

American College of Occupational and Environmental Medicine’s Occupational Medicine Practice Guidelines – 5 th edition (“ACOEM”)

All further statutory references are to the Labor Code unless otherwise stated.

all further undesignated section references are to the Labor Code

Hamilton (32 CWCR 249); Herbinger (70 CCC 504 Writ Denied); and Macari (70 CCC 1733 Writ Denied).

Hamilton v. State Compensation Insurance Fund (2004) 32 CWCR 249 WCAB Panel Decision

Los Angeles Times v. WCAB (2005) (Herbinger) 70 CCC 504 Writ Denied

Regents of the University of California, Lawrence Livermore National Laboratory, PSI v. WCAB (Macari) (2005) 70 CCC 1733 Writ Denied

Per Title 8 CCR section 9792.9 (g)(1), the claims administrator has 5 working days to either object to the request for authorization, request additional information, or request an “expert reviewer.” YOUR CLAIMS ADMINISTRATOR HAS FAILED TO DO ANYTHING AND COMPLETELY BLOWN HER DUTY TO PROVIDE THIS INJURED WORKER WITH TIMELY MEDICAL CARE.

Labor Code section 4604.5(e): "For all injuries not covered by the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines or official utilization schedule after adoption pursuant to Section 5307.27, authorized treatment shall be in accordance with other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based."

Title 8 CCR section 9792.9: UTILIZATION REVIEW RULES

Since ACOEM is silent on treatment recommendations for patients who suffer chronic pain [Hamilton v. State Compensation Insurance Fund (2004) 32 CWCR 249 WCAB Panel Decision & Los Angeles Times v. WCAB (2005) (Herbinger) 70 CCC 504 WCAB Writ Denied Decision], I shall use “other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based” [Labor Code § 4604.5(e)] to support the treatment recommendations that I have made.

Labor Code section 4062 (a): Objections to Medical Determination - Call in the Panel QME.

Hamilton v. State Compensation Insurance Fund (2004) 32 CWCR 249 WCAB Panel Decision

Los Angeles Times v. WCAB (2005) (Herbinger) 70 CCC 504 Writ Denied

Regents of the University of California, Lawrence Livermore National Laboratory, PSI v. WCAB (Macari) (2005) 70 CCC 1733 Writ Denied (spiel)

Sandhagen v. Cox & Cox Construction; SCIF (2004) 69 CCC 1452 WCAB En Banc Decision

Smith vs. Churn Creek Construction Company and State Compensation Insurance Fund (2004) 69 CCC 1012

Metoyer v. Wilshire West Dental; Zenith Ins. Co. (2005) 34 CWCR 14 + MPN Busting Spiel (here)

Guidelines for Chiropractic Quality Assurance and Practice Parameters ("Mercy Guidelines") (here)

Colorado Medical Treatment Guidelines - Chronic Pain Disorder - Rule XVII, Exhibit F 2003; 2th edition: Section F(14)(d); Page 79-81 (here)

Casillas vs. the County of San Luis Obispo (2005) 33 CWCR 217 (Opinion and Order Granting Reconsideration and Decision after Reconsideration)

Willette vs. AU Electric Corporation; SCIF (2004) 69 CCC1298 WCAB en banc

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EMPLOYER BLOWN LC 3550 & CCR 9767.12 (EMPLOYEE NOTIFICATION REQUIRMENTS) (here)

EXACERBATIONS OF CHRONIC PAIN - CHIRO. SUPPORT : (here)

99358: Non face-to-face time (here)

Justify care for patient's who are 'Chronic' with Mercy & RCTs (here)

Justify care for patient's who have had "Acute Exacerbations" with Mercy. (here)

***********************************ACOEM***********************************************

Justify MD referral via ACOEM: (here)

Justify MRI via ACOEM: (here)

*********************************************************************************************

Justify Exacerbation Care for a Chronic pain patient FOR PR-2: (here)

Justify Past Care that UR did not comment upon: (here)

REQUEST PANEL-QME AFTER IC OBJECTION: (here)

Apportionment with discopathy; DDD & DJD (here)

Apportionment without discopathy; DDD & DJD. (here)

JUSTIFICATION OF PR-2 RECOMMENDED TREATMENT W/ ACOEM: (here)

MPN NOTIFICATION - INITIAL NOTIFICATION BLOWN: (here)

RIGHT TO TREAT A INDUSTRIAL INJURED PATIENT: [ Injured Worker's Duties | LC 4600 | Start the Claim | Investigation Period | Right to Change PTPs | Employer / Insurers Duties | Opinions | 24 hours & 10,000.00 | CCR 9781 | 90 Days | The Cap | IC Duty to Authorize TX | DWC-1 | | 4600 | Cure OR Relieve | ER must direct care | As is | Non-industrial care covered if | 4600 care presumed reasonable | Pre-Designation | Changing Doctors | Reasonable Geographic Area | Liberally Construed | ]

INJURED WORKER'S DUTIES FOLLOWING AN INJURY:

I) REPORT THE INJURY: The injured Worker only has 30 days to report the injury and file the "Claim Form" with the employer. The employer MUST provided a claim for to the injured worker within one day. More explicitly:

Labor Code section: 5400: "Except as provided by sections 5402 and 5403, no claim to recover compensation under this division shall be maintained unless within thirty days after the occurrence of the injury which is claimed to have caused the disability or death, there is served upon the employer notice in writing, signed by the person injured or someone in his behalf, or in case of the death of the person injured, by a dependent or someone in the dependent's behalf."

Labor Code section: 5401
Title: Claim form; limitations
History: Amended by stats 2002, Chap 6 (AB 749)

5401 (a): Within one working day of receiving notice or knowledge of injury under Section 5400 or 5402, which injury results in lost time beyond the employee's work shift at the time of injury or which results in medical treatment beyond first aid, the employer shall provide, personally or by first-class mail, a claim form and a notice of potential eligibility for benefits under this division to the injured employee, or in the case of death, to his or her dependents.

5401 (c): The completed claim form shall be filed with the employer by the injured employee, or, in the case of death, by a dependent of the injured employee, or by an agent of the employee or dependent. Except as provided in subdivision (d), a claim form is deemed filed when it is personally delivered to the employer or received by the employer by first-class or certified mail.

EXCEPTIONS TO 5400:

LC 5402:

5402 (a): "Knowledge of an injury, obtained from any source, on the part of an employer, his or her managing agent, superintendent, foreman, or other person in authority, or knowledge of the assertion of a claim of injury sufficient to afford opportunity to the employer to make an investigation into the facts, is equivalent to service under Section 5400."

(b) If liability is not rejected within 90 days after the date the claim form is filed under Section 5401, the injury shall be presumed compensable under this division. The presumption of this subdivision is rebuttable only by evidence discovered subsequent to the 90-day period.

90 DAYS TO INVESTIGATION: DWC-1 STARTS THE CLAIM:

The employee MUST file the DWC-1 ("claim form") in order to start the claim rolling forward. More explicitly, The California Supreme Court stated in Honeywell vs. WCAB (Wagner) (2005) 70 CCC 97; Supreme Court of California, "... absent circumstances creating an equitable estop-pel, the 90-day period for the employer to deny liability runs only from the date the worker files a claim form with the employer. (§ 5402, subd. (b).) Neither the WCAB nor this court can alter the clear statutory command.”

The Employer better not refuse the claim form: [see Janke] 90 period starts when ER refused to accept the claim form.

EMPLOYER INVESTIGATION PERIOD: [ LC 5402 |

The employer has 90 days to investigate the claim with regard to compensibility. The 90 days starts on the day the employee turns-in the DWC-1 to the employer. The Supreme Court of California stated in relevant part: "...section 5402's 90-day period for denial of liability runs only from the date the employee files a claim form, not from the date the employer receives notice or knowledge of the injury or claimed injury."

RIGHT TO CHANGE PTPS:

A.) NON-MPN EMPLOYERS / INSURERS: [CCR 9781]

1) WITHIN 30 DAYS: the Injured Worker (“IW”) can request a one time change of PTPs within the initial 30 days. After receiving a request for a change of PTP to a Chiropractor, the Insurance Company’s (“IC”) Claims Administrator (“CA”) then has “5 working days” to either authorize the requested chiropractor (“chiro”) or provide an alternative chiro. If the CA blows this code, the IC may well lose the right to control medical care.

More explicitly, CCR 9781 (b) states in relevant part: “Pursuant to section 4601 of the Labor Code, and notwithstanding the 30 day time period specified in subdivision (c), the employee may request a one time change of physician at any time.” And: “An employee's request for change of physician pursuant to this subdivision need not be in writing. The claims administrator shall respond to the employee in the manner best calculated to inform the employee, and in no event later than 5 working days from receipt of said request, the claims administrator shall provide the employee an alternative physician, or if the employee so requests, a chiropractor or acupuncturist.”

In the 1984 Court of Appeal opinion in Derrick v. W.C.A.B (1984) 49 Cal. Comp. Cas 621, the justices stated in pertinent part:

EMPLOYERS / INSURERS DUTIES AFTER THE CHANGE OF PTPS:

2) AFTER 30 DAYS: the IW can is free to treat wherever they please. More explicitly, CCR 9781 (c) states in relevant part: “Pursuant to section 4600, after 30 days from the date the injury is reported, the employee shall have the right to be treated by a physician or at a facility of his or her own choice within a reasonable geographic area.

The only requirement need to start the treatment is that the IW (or PTP) informs the CA of the name and address of the newly selected primary treating physician (“PTP”). More explicitly, CCR 9781 (c)(1) states: “The employee shall notify the claims administrator of the name and address of the physician or facility selected pursuant to this subdivision. However, this notice requirement will be deemed to be satisfied if the selected physician or facility gives notice to the claims administrator of the commencement of treatment or if the claims administrator receives this information promptly from any source.”

3) INSURER RESPONSE: After the CA is notified of the IW’s notification of the newly elected PTP, she must, among other things, “authorize such physician or facility or personal chiropractor or acupuncturist to provide all medical treatment reasonably required pursuant to section 4600 of the Labor Code,” and “arrange for the delivery to the selected physician or facility of all medical information relating to the claim, all X-rays and the results of all laboratory studies done in relation to the injured employee's treatment.” [CCR 9781 (d)(1) and (d)(2)]

B.) MPN Insurers: (CCR 9767.6 & LC 4616.3)

1) CCR 9767.6 (a) states: “When the injured covered employee notifies the employer or insured employer of the injury or files a claim for workers' compensation with the employer or insured employer, the employer or insurer shall arrange an initial medical evaluation with a MPN physician in compliance with the access standards set forth in section 9767.5 [which is 3 business days].

2) CCR 9767.5 (f) states: “For non-emergency services, the MPN applicant shall ensure that an appointment for initial treatment is available within 3 business days of the MPN applicant’s receipt of a request for treatment within the MPN.

3) LC 4616.3 (b) The employer shall notify the employee of his or her right to be treated by a physician of his or her choice after the first visit from the medical provider network established pursuant to this article, and the method by which the list of participating providers may be accessed by the employee.

CCR 9784 states in relevant part: [PROBLEM: This was Repealed 03-15-06.]

Labor Code 3600: Conditions of Compensation:

(a) Liability for the compensation provided by this division, in lieu of any other liability whatsoever to any person except as otherwise specifically provided in Sections 3602, 3706, and 4558, shall, without regard to negligence, exist against an employer for any injury sustained by his or her employees arising out of and in the course of the employment... [3600]

OPINIONS:

Pre-Authorization not given which effectively denied medical care to applicant:
......Penalty allowed, Paula Ins. (CAMACHO) 62 CCC 820

PTPs do not have to get authorization from claims administrator to treat: A.D.
......Dec., LOPEZ 31 CWCR 80

24 HOURS & $10,000.00 Labor Code section 5402 (c) states:

This means that once the employer receives a DWC-1 (I would fax serve it, verbally inform them and certified mail serve it) informing them of and industrial injury to the employee, it would seem that they are on the hook for ACOEM compliant medical treatment up to $10,000.00 until they (the employers insurer or employer) deny the claim after investigation. Although there is no WCAB decision on this yet, there is a case (Ruvalcaba vs. SCIF (2005) OXN 0129714) in which a WCJ agreed with the argument that the employer was on the hook for initial Chiropractic treatment until rejection; plus, Labor Code section 5402 was ruled to be retro-active! (SCIF is appealing this as of 01-15-06).

The Employer, if they want to use their MPN, also had better comply with Labor Code section 3550 and
Title 8 CCR 9767.12 or (as noted in Metoyer vs. Wilshire West Dental) they may well loss the right to control medical. (here)

Title 8 CCR 9781 [this is the main code for the right for an injured worker to receive medical treatment. This was just modified on 03-15-06.

90 Days to Reject a Claim, or it's Covered: LC 5402 & SCIF v. WCAB (Welcher)

5402 (b) states: "If liability is not rejected within 90 days after the date the claim form is filed under Section 5401, the injury shall be presumed compensable under this division. The presumption of this subdivision is rebuttable only by evidence discovered subsequent to the 90-day period."

THE CAP: 24 Chiropractic - 24 physical therapy - 24 occupational therapy Cap:

Chiros are still safe from retroactivity of the 24 visit cap, for section 4604.5 (d) has language built in ["for injuries occurring on and after January 1, 2004"] which trigger the "unless otherwise specified" provision from uncodified section 47, which states: "The amendment to 4604.5 made by this act shall apply prospectively from the date of enactment of this act, regardless of the date of injury, unless otherwise specified..."

Therefore, we are safe from that land mine.

Uncodifed section 47 of SB899 mandated [see LC 4604.5 (d)] for dates of injury on or after 01-01-04, that only 24 "visits" of chiropractic, physical therapy, and occupational therapy are allowed; unless the CA authorizes more in writing. This code in NOT retroactive because it is "otherwise specified." More explicitly,SB 899 uncodified section 47 states: "2004 Note: The amendment to 4604.5 made by this act shall apply prospectively from the date of enactment of this act, regardless of the date of injury, unless otherwise specified, but shall not constitute good cause to reopen or rescind, alter, or amend any existing order, decision, or award of the Workers' Compensation Appeals Board. Stats. 2004 ch. 34 (SB 899) 47."

"S.B. 899 makes clear that retroactive application is what the Legislature intended. Section 47 states in part that "[t]he amendment, addition, or repeal of, any provision of law made by this act shall apply prospectively from the date of enactment of this act ... ." 35. S.B. 899 was enacted long after the injuries in question. If this is all we had, we very well might conclude uniform prospective application was the rule. However, the use of "prospectively" in Section 47 is not dispositive when other language is considered. The term is almost immediately followed by the phrase "unless otherwise specified". New section 5814(h) is precisely a provision that "otherwise specifies," and thus is an exception to the prospective application of the new law." See Green, 70 CCC 294, 304 (2005)

Therefore, LC 4604.5(d) makes it clear that the limitation on Chiro care ( as well as PT and OCC med treatment) is effective for injuries on or after 1/1/04 only and therefore the "unless otherwise specified" provision is triggered.

Employers Duty to Authorized TX: Title 8 CCR section 9784: Notify that employer!

NOTE: THIS WAS REPEALED 03-15-06. NOW OLD LAW. [SEE CCR 9781]

Braewood Convalescent Hospital v. WCAB(Bolton) (1983) 48 CCC 566, 193 Cal. Rptr. 157, 666 P.2d 14 Supreme court In Banc (good case)

I) Filing of the Employee Claim Form: This tolls the clock: LC 5400 - 5413

1) The injured work only has 30 days to inform the employer of his disabling injury. LC 5400

2) The employer has only 1 day to provide the injured worker with the Claim form (DWC-1). LC 5401(a)

3) The employer, after the claim form is completed by the injured worker, only has 1 working day to "authorized" medical treatment. LC 5402 (c).

II) Labor Code Section 4600:

III) Employer must pay for all medical treatment necessary to CURE OR RELIEVE.

Grom vs. Shasta Wood Products [(2004) 69 CCC 1567 (WCAB significant panel decision)]. In Grom, the commissioners stated in relevant part:

“Medical treatment which is intended only to relieve, but not cure, the effects of an industrial injury is appropriate under section 4600. (See Dept. of Corrections v. Workers' Comp. Appeals Bd. (Rowan) (1997) 62 Cal.Comp.Cases 353 [writ denied]; Kellogg Co. v. Workers' Comp. Appeals Bd. (Battle) (1996) 61 Cal.Comp.Cases 519 [writ denied].) This is true in cases of chronic conditions where a cure is not possible, but where relief of symptoms is essential for continued functioning.”

III) Employer Must Direct Medical Care or loss it: The Employer MUST "specifically instruct the employee what to do and whom to see" after a claim form is filed or else they lose medical control. More explicitly, here's what the California Supreme Court said in Braewood Convalescent Hospital v. WCAB(Bolton) (1983) 48 CCC 566, 193 Cal. Rptr. 157, 666 P.2d 14 Supreme court In Banc:

IV) AS IS, No Matter if Pre-exiting Condition was Present: The Employer, at the time of hire, accepts the employee as he finds them.

V) Non-Industrial Condition Covered if it Interferrs With Treatment of Industrial Injury:

VI) Medical Care Under 4600 is "Presumed Reasonable":

VII) Pre-Designation of a Chiropractor: Labor Code section 4601 (a):

VIII) Change of Treating Doctors:

CCR 9781: Change Doctors "at any time." The IW may request a change of PTPs "one time" at any time, notwithstanding the 30 control period. This request "need not be in writing." The CA must respond to said request within "5 working days."

Ralph's Grocery vs. WCAB (LARA) (1995) 38 Cal. App. 4th 820, 45 Cal. Rptr. 2nd 197, 60 CCC 840:

VIII) Transfer of Medical Care & Geographic Location: 8 CCR section 9780

IX Liberally Construed:

EMPLOYERS DUTY TO NOTIFY:

CCR 9782:
CCR 9880
CCR 9881

REPORTING DUTIES of the primary treating physician ("PTP"):
[ DRF | Report Contents Smith v. Churn Creek | PR-2 |Time Deadline | SERVICE METHOD | Report Requirements | Narrative Style PR-2 | Duty to Adapt and incorporate ]

CCR 9785: Reporting Duties of the PTP.
LC 4628: Physician's Reporting Duties.
CCR 9793(c): Get paid for Med-legal fees.
LC 4603.2

Spiel for Supporting Manipulation (Acute FU of Chronic pain)

Doctors First Report of Occupational Injury or Illness: [ CCR 9785(e) | CCR 14003(a) ]

You absolutely MUST fax in that DFR before 5:30PM within 5 WORKING DAYS (Saturday and Sunday don't count) in order to avoid the dreaded UR retrospective review, which carries the 30 day time-dead line as opposed to the 14 day time dead-line mandated by Sandhagen vs. SCIF I (2004) 69 CCC 1452 WCAB En Banc. More explicitly, LC 4603.2 (a) states:

CCR 9785 (e) (1) states, in relevent part:

Title 8 CCR section 14003 (a), in relevant part, states:

REPORT CONTENT: Smith & CCR 9785(d)

Smith vs. Churn Creek Construction (2004) 69 CCC 1012 WCAB Panel Decision [HERE]: Since the ACOEM guidelines became presumptively correct on March 22, 2004 on the issue of the extent and scope of medical treatment (pursuant to Labor Code section 4604.5(a) [Deering's]), the report writing duties of the PTP have greatly increased. Now the PTP has the "burdon of proof" to support his/her recommended treatment recommendations. In Smith vs. Churn Creek, the commisioners admonished the PTP for not supporting what medical treatment he requested and in fact denined said medical treatment. Here are some passages from the decision:

Therefore, I believe that if the PTP is required to put more non-patient face to face time into his reporting, the insurer should be required to pay for it. [see billing]

Title 8 CCR §9785(d) states the following:

CLOSING STATEMENT IN PR-2 REPORTS:

PRIMARY TREATING PHYSICIAN'S PROGRESS REPORT: ("PR-2") (Down load here)

TIME DEAD-LINES for the PTP:

DFR: Per Labor Code (aka: LC) 4603.2(a), the doctor has "5 working days" to get that Doctor's First Report of Occupational Injury (aka: DFR) to the Employer/Insurance Company. The fastest way is to Fax it to the Claims Department. Per CCR 9792.9(a)(1) as long as you get the DFR faxed by 5:30pm on "working day" five, you've complied with your reporting obligation. Facsimile is the ONLY way to prove you have served the insurance company in one day. There are some required things you need on the fax cover sheet, so please read CCR 9792.9(a)(1) carefully. If you send the DFR out "proof of service," per CCR 9792.9(a)(2) it's deemed to be received by the insurance company "5 days after the deposit in the mail." If you don't "proof of service" you report, per CCR 9792.9(a)(2) it's deemed to have been received by the Insurance Company (IC) the day it's "stamped as received" by the insurance company's mail room!

PR-2 or "Primary Treating Physician's Progress Report" must be filed every 45 day per CCR 9758(f)(8); if the patients condition changes, however, a PR-2 may be required sooner. Here's the code:

SERVIVCE METHOD: Service is EXTREMELY important. If you can't prove the insurer got your report, you may not get paid!

CCR 9792.9 (a) is the main code. In relevant part, it states:

REPORT REQUIREMENTS (CCR 10606): If you want your Report to Count:

If you want your report to count at the WCAB as sustancial evidence, then CCR 10606 lists what needs to be contained in your report: CCR 10606

REQUEST FOR AUTHORIZATION: Without a Request for Authorization ("RFA"), the insurance company doesn't own the injured worker (IW) medical treatment. Title 8 CCR 9792.6 [UR Definitions] defines RFA as follows:

NARRATIVE STYLE PR-2: A narrative style PR-2 is allowed; however, it must be formated in accordance with CCR 9785 (f) (8), which states in relevant part:

These Heading Are:

I) STATE THE REASON FOR THE REPORT: Periodic Report, Change in Work Status, Change in patient Condition, Need for Referral or Consultation, Need for Surgery or Consultation, Response for Request for Information, and/or Request for Authorization.

2) SUBJECTIVE COMPLAINTS:

3) OBJECTIVE FINDINGS:

4) DIAGNOSIS:

5) TREATMENT PLAN:

6) WORK STATUS:

7) PRIMARY TREATING PHYSICIAN: This must contain the PTP's signature under the statement: "I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I have not violated Labor Code § 139.3."

ADOPT AND INCORPORATE: Via CCR 9785 (e)(4), the PTP MUST review requested testing and medical opinions and incorporate them into his/her report. More explicity, 9785 (e)(4) states: "The primary treating physician shall be responsible for obtaining all of the reports of secondary physicians and shall, unless good cause is shown, within 20 days of receipt of each report incorporate, or comment upon, the findings and opinions of the other physicians in the primary treating physician's report and submit all of the reports to the claims administrator.

MEDICAL BILLING: [ Billing Rules | Ground Rules | CPT vs. Face-to-Face | Prolonged Service Codes&More | Penalties & Interest | Penalty & Interest Calculations | Filing Fee Reimbursement | Sanctions | Usual & Customary Fees - Valdez ]

DWC'S OMFS - Past and Current: [here]
DWC's Application of the OMFS: [here]
CCR 9797.1 Medical Fee Schedule
CCR 9792.5 Payment for Medical Treatment:
Labor Code 4603.2 Payment for Medical Treatment - Main one for Penalties & Lien Fee Recovery

Here's the DWC's Web Site, which contains a history of Fee Schedules (except for the Ground Rules which must be purchased) [ DWC FEE SCHDULES ]

The Ground Rules:

For Physician Services Rendered after or on 07-01-04, CCR 9789.11 is the law and the OMFS is governed by the Official Medical Fee Schedule book of 1999 and an update that occurred on 07-12-04 which you can get for free HERE in .PDF. [it's also included in the OMFS Book] The Ground Rules, which explain the intricacies of how insurance companies are to pay physician billing, can be ordered form the DIR at (916) 445-5357. The 1999 OMFS Book is what is used, despite what CCR 9789.11 states. I investigated this error in CCR 9789.11 - which claims that the OMFS of 2003 contains the ground rules - and received this reply from the DWC Medical Unit's Manager:

Notes about the "Ground Rules" for billing multiple Physician Services [ Here ]

CPT vs. FACE-TO-FACE TIME:

Average Time Spent: (per Beebe M, Dalton J, et al. “Current Procedural Terminology: CPT 2005” AMA Press 2005; Chicago, Illinois: p. 27

PROLONGED SERVICE CODES & More:

Doctor / Patient face-to-face time: if you spend between 30 and 60 minutes of face-to-face time with the patient, in addition to the time value already given to the EM code (for eg. 99214 has 25 minutes of doctor / patient face-to-face time build in) that you performed, then you may bill a 99354 (RV 21.2 (X) CF 8.5 = 182.75 less 5% = $171.19). If you go over 60 minutes of earned face-to-face time, then you may bill a 99355 for every 30 minutes more. 99355 is billed at RV 10.6 X CF 8.5 less 5% or $90.10. [Note: the RV and CF number are based upon Table A of the OMFS of May 2005.]

99358 & CCR 9789.11(a)

Team Management Conference & Phone Calls: 99361& 99372

These codes, which are the most commonly used in my office, may be billed for requested or necessitated phone calls to other doctors, claims administrators, or patients. (codes calculated using the OMFS of May 2005 - Table A.)

WORK CONDITIONING: CPT Code 97545:

DISCLAIMER: Always consult the OMFS Book to insure you are properly billing for services rendered. I am not responsible for your billing actions. If you have questions about billing, call our board of Chiropractic Examiners for help and clarification.

WHEN NOT TO ACCEPT A WORKERS' COMPENSATION PATIENT:

CCR 9785(b)(3) state the following:

Tenent vs. WCAB(Rushing) 65 CCC 477 was a published District Court of Appeals opinion that basically said that a PTP writes a report that states the patient is "discharged," than NO other treating doc can be obtained UNTIL an opinion is gotten from a QME.

Pinkerton vs. WCAB(Samuel) 66 CCC 1114 was a published District Court of Appeals opinion that stated, among other things, that if the discharge report was not "served" upon the injured worker (IW), then that PTP was not a PTP. This case might give a doc in this situation some bargaining power at a trial, but probably not too much.

Be careful not to accept a WC patient in whom the prior PTP released the patient with NO NEED FOR ANY FROM OF MEDICAL CARE and then that patient failed to obtain a QME to resolve the problem. (I learned the hard way at the WCAB on this one!)

WIGGLE ROOM: IF the patient wasn't "served" a copy of the PTPs damming release report, then you may have been prejudiced.

CAN YOU CHARGE A PATIENT WHO'S BEEN INJURED ON THE JOB?

Labor Code section 3751 (b) states:

Thompson 61 CCC 1337 stated that Employees are not to be billed after claim form is filed and where the medical treater has received no rejection of claim.

USUAL AND CUSTOMARY FEES:

CCR 9791: You are only allowed to be paid at the OMFS rate. In pertinent part, section 9791 states, " the Official Medical Fee Schedule applies to all covered medical services provided, referred or prescribed by physicians." [see Valdez for a way around.] [also see Gould]

"to obtain a fee in excess of the reasonable maximum, the “medical service” provider must submit an itemization and (1) show that the requested fee is reasonable and is not in excess of the provider’s usual fee; and (2) explain the extraordinary circumstances, related to the unusual nature of the services rendered. (Lab. Code, §§5307.1(b), 5307.6(b); Cal. Code Regs., tit. 8, §§9792(c), 9792.5(c).)" [See Kunz for more]

Penalty & Interest on Medical Billing: 15% penalty, 10% interest. [Lopez case, 64 CCC 1350 (1999)(writ granted)]

Labor Code 4603.2 describes the rules for paying medical billing: After the insurance company receives your medical bill, they only have 60 calendar days to pay it. If they fail, LC4603.2(b)(1) lays down the ground rules, which are as follows: 1) the amount of the medical bill is now increased by 15%, and 2) 10% interest begins to accrue from the date the insurer received your bill. [See methods of service here: CCR 9792.9 ] IF, however, the insurance company "contests" the bill, the penalty may not be collected unless the WCAB rules in your favor. So, always request penalties, interest and reimbursement of the "filing fees" per LC 4603.2. There are specific rules for contesting a claims, so be sure to read LC 4603.2 in its entirety.

In Lopez, the Disctrict Court of Appeal, in relative part, opined: "(2) Section 4603.2, subdivision (b) provides, in part: "If an employer contests all or part of a billing, any amount determined payable by the appeals board shall carry interest from the date the amount was due until it is paid." The dispute in this case concerns when a bill is due under this subdivision. The simple answer is found in the first sentence of the subdivision: "Payment for medical treatment provided or authorized by the treating physi-cian shall be made by the employer within 60 days after receipt of each separate, itemized billing, together with any required reports." Accordingly, interest on the bill to be paid by the employer begins to accrue 60 days after a proper bill is received by the employer. If the employer contests liability and waits until the appeals board has determined the employer must pay the bill, the employer must then pay the bill plus interest accrued from 60 days after the employer received the bill."

REIMBURSEMENT OF LIEN FILING FEE: [Cardoso vs. SCIF (2006) 34 CWCR 77]

Labor Code Section 4603.2 (b) (1) (B), in relevant part, states, "If any contested itemization is determined payable by the appeals board, the defendant shall be ordered to reimburse the provider for any filing fees paid pursuant to Section 4903.05."

Medical Legal Filing Fee Reimbursement is no longer a gray area. I have changed that with Cardoso vs. SCIF (2006) 34 CWCR 77 where a WCAB Panel over ruled the WCJ and ordered the $100.00 filing fee reimbursed.

SANCTIONS & PENALTIES:

If a DA fails to show, you may ask for sanctions. In Runnion, a mere Claims Administrator received sanction money for wasted time secondary to the AA not showing up:

"Although the WCJ lacked the authority to hold Runnion [Applicant Attorney] in contempt under the circumstances of this case, the WCJ could properly sanction him under section 5813. Runnion contends, however, that he did not act unreasonably when he elected not to appear. We conclude the WCJ was well within her powers to decide otherwise." And : "Although Runnion cites section 4903, subdivision (a), in support of his claim that the WCJ erred in awarding fees to a nonattorney for attending an unproductive hearing, the authority he cites is not pertinent. Section 4903, subdivision (a), addresses liens filed by attorneys against their clients' awards, and it bars awarding fees for legal services to nonattorney representatives. That statute has no force here, where the fees were not assessed against the client's award, they are to be paid to an adversary as a sanction, and they are to compensate Evans for time wasted, not for legal services rendered." [Runnion v. Workers' Comp. Appeals Bd., 59 Cal. App. 4th 277]

"In Kunz vs. (2002) 67 Cal.Comp.Cases 1588 WCAB En banc, the following was opined: "[T]he only potential consequences of a defendant’s failure to timely state any given specific objection under section 4603.2 are: (1) the defendant may become liable for a ten-percent penalty and/or interest, accrued from the date the defendant received the lien claimant’s bill, on the unpaid balance of the lien allowed by the Board (Lab. Code, §4603.2(b); Boehm & Associates v. Workers’ Comp. Appeals Bd. (Lopez) (1999) 76 Cal.App.4th 513 [64 Cal.Comp.Cases 1350]); and (2) the defendant may become liable for a section 5814 penalty [fn: A defendant’s failure to properly object under section 4603.2 may also subject it to audit penalties. (Cal. Code Regs., tit. 8, §§10108(e), 10111(a)(9).)[old law]] to the applicant, if the defendant’s failure to object and pay is unreasonable. (Lab. Code, §4603.2(b)).... However, a defendant does not forever waive any specific objection(s) it does not make."

Per Labor Code 5813 and CCR 10561 a lien claimant is allowed, on occasion, to ask for additional penalties to be paid for by the insurer This one, however, should ONLY be requested if the insurer absolutely screwed up, for you may get sanctioned for frivolously filing the petition for sanctions. Here's the full Labor Code:

The ground rules that apply to LC 5813 are described in CCR 10561. Make sure you read them carefully and only ask, IF there is no question that the insurer was in violation. Here's some high-lights of the regulation:

BIGGER Penalty: Labor Code 5814, which yields a 25% penalty, goes to the applicant, not the doc; It states the following: [ see the WCAB en banc opinion of Abney v. Aera Energy and Liberty Mutual Ins. Co. (2004) 69 Cal.Comp.Cases 1552 (Abney) ]

LC 5814(e): "No unreasonable delay in the provision of medical treatment shall be found when the treatment has been authorized by the employer in a timely manner and the only dispute concerns payment of a billing submitted by a physician or medical provider as provided in Section 4603.2."

GET PAID AT YOUR USUAL AND CUSTOMARY FEES? Maybe yes: Valdez

MPN ENTRY CRITERIA: Possible Ways to Jerk Away Employer Medical Control from within an MPN: [ 3 Day Rule | 24 Hour Rule | Initial Notification Rule | Continuity of Care Policy | The Employee Notice | (Metoyer-old) | Knight- WCAB en banc! | "Serious Condition" --buy some extra time ]

If--and that is a big if--the employer has complied with all patient MPN Notification requirments, then there is no way (as of 10-13-09) to stop them from taking a non-MPN doctor's patient away from them. (see the en banc decision of Babbitt vs. WCAB. (real case) Although via LC 4616.2 (d), you can probably get an extra year to treatment (by then all 24 visits may be gone anyway). If the employer/insurer have screwed up the rigorous MPN notification rules, then there is a chance you can treat (see Knight vs. Liberty Mutual - [real case])

KNIGHT V. LIBERTY MUTUAL: 2006 wcab en banc:

The En Banc decision of Knight v. Liberty Mutual has mandated that the employer comply with all the notification requirments of CCR 9767.12 etc. by allowing an injured worker to treat outside of an MPN because of such failure. In fact, here's what they said:

#1) 3 Working Days to see an MPN doctor after IW request:

Title 8 CCR section 9767.5 (f) states, in relevant part:

In my lay opinion, it would seem that if a freshly injured worker presented to a non-MPN doctor and a request for medical treatment was made of the employer, then that an appointment can be set for no later than 3 business days. If the employer blows it, then that would be grounds to treat outside of the MPN.

#2) 24 Hour Rule (LC 5402) : Within 1 Working Day, the employer must act.

Labor section 5402 (c) state:

#3) Initial Notification Required: (CCR 9767.12 (a))

It would appear that the employer must initially notify the employee prior to injury that they are bound for medical treatment within an employer MPN. In pertinant part, Title 8 CCR 9767.12 (a) states:

#4) Metoyer v. Wilshire West Dental; (old- see Knight) Zenith Ins. Co. (2005) 34 CWCR 14

In this recent panel decision, the WCAB commissioners upheld the WCJ’s decision to award medical care provided by a medical facility that was NOT within the insurer’s MPN because of failure to comply with Labor Code § 3550. The commissioners further reasoned that a violation of Title 8 CCR 9767.12 would also constitute loss of control. More explicitly, the commissioner’s stated:

[ CCR 9767.12(1) | LC 4616.2(c) | LC 3550 | *LC 3551 | Spiel for Blown LC 3551 + ]

In a recent Findings & Award involving one of my patients, a WCJ found that the IC failed to comply with Title 8 CCR §9765.12(a)(1) [effective 09-15-05] that states the following:

I'm wondering if this omittion shall be enough to over-throw the employer right to control medical care?

LETTER FIGHTING MPN TAKE-OVER ATTEMPT: [HERE]

Here are some other requirements: Every employer (not federal) MUST comply with posting the rights of an injured worker. If they don't, they may well lose medical control and the MPN-strapped injured worker may be free to treat with a non-MPN provider. We are still waiting for this one to get tested at the WCAB level. LC 3551 is especially interesting for it states that every new employee must be given "written notification" of the information contained in LC3550 which is a very long list of stuff.

LC 4616.2(c): Continuity of Care Policy for Employer's with a MPN.
Here's the full Labor Code: LC 4616.2(c)

You just get a new patient that has been injured at work and the injury has been reported more than 30 days ago. Here's a very important question: Mr. New patient, has your employer "provided notice" of the company "Written Continuity of Care Policy" and the "Process for an Employee to request a Review" with in the Employers MPN? Probably not. Many applicant attorneys believe that this is grounds the loss of Employer Medical Control and a means you're free to treat the patient even if you're not a member of the MPN. You might have to file a lien (remember to bill your regular fees and not work Comp Fees) but you've got a good chance of winning.

LC 4616.2(c): The insurer or employer shall provide to all employees entering the workers' compensation system notice of its written continuity of care policy and information regarding the process for an employee to request a review under the policy and shall provide, upon request, a copy of the written policy to an employee.

LC 3550: The Employee Notice. (Here's the full LC 3550 (CCR 9881) & CCR 9782)

Again, Employers MUST post this notice (In Spanish & English if Spanish speaking workers are employed) of risk loosing medical control. All of the forthcoming mandated place-of-employment posting "shall" be given to each new employ "in writing" per LC 3551 [no employer ever does this! Do you??]

LC 3550(a): "Every employer subject to the compensation provisions of this division shall post (the Employee Notice) and keep (it) posted in a conspicuous location frequented by employees, and where the notice may be easily read by employees during the hours of the workday, a notice that states the name of the current compensation insurance carrier of the employer, or when such is the fact, that the employer is self-insured, and who is responsible for claims adjustment."

LC 3550(d): "The notice shall be easily understandable. It shall be posted in both English and Spanish where there are Spanish-speaking employees. The notice shall include the following information:

(1) How to get emergency medical treatment, if needed.
(2) The kinds of events, injuries, and illnesses covered by workers' compensation.
(3) The injured employee's right to receive medical care.
(4) The rights of the employee to select and change the treating physician pursuant to the provisions of Section 4600.
(5) The rights of the employee to receive temporary disability indemnity, permanent disability indemnity, vocational rehabilitation services, and death benefits, as appropriate.
(6) To whom injuries should be reported.
(7) The existence of time limits for the employer to be notified of an occupational injury.
(8) The protections against discrimination provided pursuant to Section 132.a.
(9) The location and telephone number of the nearest information and assistance officer."

LC 3550(e): "Failure of an employer to provide the notice required by this section shall automatically permit the employee to be treated by his or her personal physician with respect to an injury occurring during that failure." [see the Metoyer case]

LC 3551: Written Notice to New Employees. (full LC 3551)

This is a very strong labor code and speaks for itself:

LC 3551(a): "Every employer... shall give every new employee, either at the time the employee is hired or by the end of the first pay period, written notice of the information contained in Section 3550."

LC 3551(b): "The notice required by this section shall be easily understandable and available in both English and Spanish. In addition to the information contained in Section 3550 the content of the notice required by this section shall include:

(1) Generally, how to obtain appropriate medical care for a job injury.
(2) The role and function of the primary treating physician.
(3) A form that the employee may use as an optional method for notifying the employer of the name of the employee's "personal physician," as defined by Section 4600, or "personal chiropractor," as defined by Section 4601.

Spiel for Blown LC 3351 & LC 4612.2(c)

Knight v. Liberty Mutual (2006) 71 Cal. Comp. Cases 1423; WCAB En Banc

On 10/10/06, in an En Banc decision (this type of decision is the “law of the land” until the District Court of Appeals or Supreme Court of California change it), the seven commissioners of the WCAB handed down a unanimous ruling that allowed an injured worker to receive medical treatment outside of the employers Medical Provider Network (“MPN”).  In Knight v. Liberty Mutual [(2006) WCAB En Banc; 71 Cal. Comp. Cases 1423]  an injured worker, who was not satisfied with treatment from the company clinic, opted to change primary treating physicians to a doctor who was not a member of the employers MPN.  Needless to say, the insurer refused to authorized any treatment outside of their MPN and left the patient without any treating doctor.  The case went to trial and the administrative Law Judge ordered the insurer to pay for the treatment procured outside of the MPN.  Aggrieved by the decision, the Insurer appealed and, in a surprise decision, the entire 7-member WCAB voted to take on this case.  In their ruling—which has sent a sobering shockwave throughout the insurance industry—the WCAB agreed with the initial ruling and ordered that all medical treatment  be paid.  More explicitly, the commissioners stated:

“In sum, the record in this case compels the conclusion that defendant neglected and refused to provide reasonable medical treatment by failing to provide applicant with required notice of his rights under the MPN.  Because reasonable medical treatment was neglected or refused, applicant is entitled to self-procure reasonable treatment and defendant is liable under section 4600(a) for that treatment.” (Emphasis added.)

Since (in my experience) 95% of all injured workers are not informed of their MPN rights, it would seem that most can treat outside of the dreaded MPNs without worry.

Empirically, however, much like 3rd Party Personally Injury Cases, you’re going to have to wait to get paid on such cases and will need a decent Hearing Rep (or you can do it yourself if you’ve got the time), as the insurer will most likely fight tooth and nail.

Here's a link to the full ruling: Knight vs. Liberty Mutual

BUY SOME EXTRA TREATMENT TIME: LC 4616.2 (d)(1) (up-dated 10-13-09)

You may be able to avoid the inevitable insurer--taking of your patient into an MPN by using LC 4616.2 (d), which allow an extra year of treatment for patients of whom suffer a "serious medical condition," which is defined as:

LC 4616.2 (d)(3)(B) A serious chronic condition.  A serious chronic condition is a

medical condition due to a disease, illness, or other medical

problem or medical disorder that is serious in nature and that

persists without full cure or worsens over an extended period of time

or requires ongoing treatment to maintain remission or prevent

deterioration.  Completion of treatment shall be provided for a

period of time necessary to complete a course of treatment and to

arrange for a safe transfer to another provider, as determined by the

insurer or employer in consultation with the injured employee and

the terminated provider and consistent with good professional

practice.  Completion of treatment under this paragraph shall not

exceed 12 months from the contract termination date.

Usually a patient with chronic back /neck pain will fall under this category since they often get worse without the care.

LC4616.2 (d) states:

(d) (1) An insurer or employer that offers a medical provider

network shall, at the request of an injured employee, provide the

completion of treatment as set forth in this section by a terminated

provider.

The only potential snag here is the word "terminated provider." Does that mean the doctor had to be in the MPN to begin with? I think not, but the defense could certainly argue this.

GIVE ME BACK MY FUTURE MEDICAL AWARD: LC 5804

The ICs and UR teams are out of control and now trying to pull chiropractic care away from patient that have been awarded life time Chiropractic care. Here's some ammunition:

LC 5804 says: “No award of compensation shall be rescinded, altered, or amended after five years from the date of injury except upon a petition by a party in interest filed within such five years . . .” Since the date of injury at issue was 03/27/72, the time period in which defendant could contest the award elapsed in 1977.

FLASH: WCAB PANEL DECISION ALLOW CHIROPRACTIC OVER ACOEM DENIAL:

Casillas vs. The County of San Luis Obispo 33 CWCR 217 [GRO 24818 (Opinion and Order Granting Reconsideration and Decision after Reconsideration, 08-12-2005).] Persuasive Authority

On 08/12/05 a panel decision by the San Francisco WCAB overturned a ruling by a Workers’ Compensation Administrative Law Judge (WCJ) that barred further chiropractic care per ACOEM despite a stipulated future medical care award for such care that was awarded in 2002. This landmark WCAB panel decision entered a new order “allowing chiropractic care when reasonably necessary to address acute exacerbations of the applicant’s conditions.” More explicitly, Commissioner William K. O’Brien et al. opined as follows:

“In short, we do not find the ACOEM Guidelines to specifically preclude continuing chiropractic care for acute exacerbations of the applicant’s [the injured worker] symptoms. As such, no presumption is clearly established pursuant to [labor code] section 4604.5(c). But even if a presumption is said to exist, arguendo [argumentatively], we find in this case that the presumption would be rebutted by the reasoned opinion of the examining QME, the Mercy Guidelines, and the applicants experience in obtaining pain relief from acute exacerbations of her symptoms through the use of chiropractic care,” and “we will specify that future chiropractic care is to be provided when reasonably necessary to treat acute exacerbations of the applicant’s [the injured worker] symptoms.”

A future medical care award was stipulated on 06/24/02; this award was “for medical treatment to cure or relieve the effects of said injury.” In November 2004, the future care was cut-off by an insurance UR doctor based on the chiropractic treatment not being in accord with ACOEM. More explicitly, the UR doctor opined as follows: “On going treatment with spinal manipulation and physical modalities is not supported by ACOEM at this stage post injury…” and “continued chiropractic treatment with spinal manipulation and physical modalities is not effective in treating this type of injury at this stage after the date of injury…”

The WCAB stated that because the IC paid for the chiropractic treatment for nearly 5 years (even though the future medical award did not specifically state chiropractic care was included), they “acknowledged that occasional chiropractic care was part of the future medical treatment….”

The Commissioners based their needed “substantial evidence” on the following case law:

“The relevant and considered opinion of one physician, though inconsistent with other medical opinions, may constitute substantial evidence. (LeVesque; Smith v. Workers’ Comp. Appeals Bd. (1969) 71 Cal.2d 588 [34 Cal.Comp.Cases 424].) The Appeals Board is empowered to choose among conflicting medical reports and rely on that which is deems most persuasive. (Jones v. Workers’ Comp. Appeals Bd. (1986) 68 Cal.2d 476 [33 Cal.Comp.Cases 221].)”

"For the reasons discussed below, we [three commissioners of the WCAB] will grant the Petition for Reconsideration, rescind the Findings of Fact of June 9, 2005, and enter a new finding allowing chiropractic care when reasonably necessary to address acute exacerbations of applicants condition."

HCO [ CCR 9779.3 | CCR 9777 | CCR 9773 |LC 4600.3 | LC 4600.6 | LC 4600.5 ]

Wawona Packing (Valencia) 32 CWCR 213, 69 CCC 890: Treatment outside an HCO was allowed when Spanish Speaking Employee was not properly enrolled because the pamphlet was in English.

CCR 9779.3 (a)(3): an employer must provide information concerning the choice of HCOs available to its employees no later than 30 days prior to the final date for enrollment. Information shall be provided in written form, in no less than twelve (12) point typeface, and in a language understandable to employees. The information provided must include, at a minimum, the following:
(i) the names of each HCO offered;
(ii) the corporate or business name of all entities which own or control each HCO offered; and indication of relationship, if any, of HCO to workers' compensation carrier or self-insured employer;
(iii) the services offered by each HCO;
(iv) a complete listing of all primary treating physicians, specialist physicians, and clinics participating in each HCO who would be reasonably accessible to the employee for the provision of occupational health services. Primary treating physicians who are not accepting new patients must be clearly identified;
(v) If the HCO is also the provider of group health coverage for non-occupational health services, the HCO policy regarding enrollees' ability to use their personal physician (for non-occupational health services) for treatment of work injuries.
(vi) any provider risk-sharing arrangements related to utilization of services.

CCR 9779.3 (b): Employees shall designate their enrollment option on form DWC 1194. This form must be maintained in the employee's personnel file for a minimum of three (3) years, and be made available to the employee or employee's representative on request.

CCR 9777 (d): Informational materials must be in a form understandable to all [HCO]enrollees and available in Spanish. HCOs must provide in their application a description of how the information specified in subdivisions (a) through (c) will be provided to HCO enrollees.

CCR 9773 (c) (6): Enrollees [into the HCO] shall be entitled to at least one change of physician for an injury. The HCO shall provide the employee, within five days of a request by an HCO enrollee, with a choice of any other available participating provider in the appropriate specialty.

LC 4600.5 (l) (4): The health care organization shall inform employees of the procedures for processing and resolving grievances, including those related to chiropractic care, including the location and telephone number where grievances may be submitted.

LC 4600.5 (l) (1): When an injured employee requests chiropractic treatment for work-related injuries, the health care organization shall provide the injured worker with access to the services of a chiropractor pursuant to guidelines for chiropractic care established by paragraph (2). Within five working days of the employee's request to see a chiropractor, the health care organization and any person or entity who directs the kind or manner of health care services for the plan shall refer an injured employee to an affiliated chiropractor for work-related injuries that are within the guidelines for chiropractic care established by paragraph (2). Chiropractic care rendered in accordance with guidelines for chiropractic care established pursuant to paragraph (2) shall be provided by duly licensed chiropractors affiliated with the plan.

LC 4600.5 (l) (3) Whenever a dispute concerning the appropriateness or necessity of chiropractic care for work-related injuries arises, the dispute shall be resolved by the health care organization's utilization review process for chiropractic care in accordance with the health care organization's guidelines for chiropractic care established by paragraph (2).

LC 4600.3 (e) An employee enrolled in a health care organization shall have the right to no less than one change of physician on request, and shall be given a choice of physicians affiliated with the health care organization. The health care organization shall provide the employee a choice of participating physicians within five days of receiving a request. In addition, the employee shall have the right to a second opinion from a participating physician on a matter pertaining to diagnosis or treatment from a participating physician.

LC 4600.3 (a) (1): Notwithstanding Section 4600, when a self-insured employer, group of self-insured employers, or the insurer of an employer contracts with a health care organization certified pursuant to Section 4600.5 for health care services required by this article to be provided to injured employees, those employees who are subject to the contract shall receive medical services in the manner prescribed in the contract, providing that the employee may choose to be treated by a personal physician, personal chiropractor, or personal acupuncturist that he or she has designated prior to the injury, in which case the employee shall not be treated by the health care organization. Every employee shall be given an affirmative choice at the time of employment and at least annually thereafter to designate or change the designation of a health care organization or a personal physician, personal chiropractor, or personal acupuncturist. The choice shall be memorialized in writing and maintained in the employee's personnel records.

LC 4600.3 (a)(3) Insured employers, a group of self-insured employers, or self-insured employers who contract with a health care organization for medical services shall give notice to employees of eligible medical service providers and any other information regarding the contract and manner of receiving medical services as the administrative director may prescribe. Employees shall be duly notified that if they choose to receive care from the health care organization they must receive treatment for all occupational injuries and illnesses as prescribed by this section.

LC 4600.6 (j)(2) Every [HCO] organization shall inform employees upon enrollment and annually thereafter of the procedures for processing and resolving grievances. The information shall include the location and telephone number where grievances may be submitted.

NO NOS:

Labor Code section 3751 (a): "No employer shall exact or receive from any employee any contribution, or make or take any deduction from the earnings of any employee, either directly or indirectly, to cover the whole or any part of the cost of compensation under this division. Violation of this subdivision is a misdemeanor. (b) If an employee has filed a claim form pursuant to Section 5401, a provider of medical services shall not, with actual knowledge that a claim is pending, collect money directly from the employee for services to cure or relieve the effects of the injury for which the claim form was filed, unless the medical provider has received written notice that liability for the injury has been rejected by the employer and the medical provider has provided a copy of this notice to the employee. Any medical provider who violates this subdivision shall be liable for three times the amount unlawfully collected, plus reasonable attorney's fees and costs."

QUOTES OF INTEREST:

Quotes for the Supreme Court in Brodie:

"California’s workers’ compensation system was established to provide for the health, safety, and welfare of workers in the event of industrial injury by “ ‘relieving [them] from the consequences of any injury incurred by employees in the course of their employment.’ ”  (Mathews v. Workmen’s Comp. Appeals Bd. (1972) 6 Cal.3d 719, 731, fn. 8, quoting Stats. 1917, ch. 586, § 1, p. 832; see also Claxton v. Waters (2004) 34 Cal.4th 367, 372.)"

"If the Legislature had intended a departure from formula A, one would expect to find some trace of this intent in the legislative history, just as the legislative history explicitly identifies more than two dozen other intended reforms enacted by Senate Bill No. 899 (2003-2004 Reg. Sess.), including numerous intended changes to the apportionment scheme.  As the facts of these five consolidated cases demonstrate, a change from formula A to formula B or either version of formula C would have dramatic fiscal consequences for employers and insurers (as well as, of course, for employees). Such a change, if intended, would likely have been remarked upon.

Instead, one hears only silence."

CALIFORNIA CONSTITUTION ARTICLE 14 LABOR RELATIONS SEC. 4:

"The Legislature is hereby expressly vested with plenary power, unlimited by any provision of this Constitution, to create, and enforce a complete system of workers' compensation, by appropriate legislation, and in that behalf to create and enforce a liability on the part of any or all persons to compensate any or all of their workers for injury or disability, and their dependents for death incurred or sustained by the said workers in the course of their employment, irrespective of the fault of any party. A complete system of workers' compensation includes adequate provisions for the comfort, health and safety and general welfare of any and all workers and those dependent upon them for support to the extent of relieving from the consequences of any injury or death incurred or sustained by workers in the course of their employment, irrespective of the fault of any party; also full provision for securing safety in places of employment; full provision for such medical, surgical, hospital and other remedial treatment as is requisite to cure and relieve from the effects of such injury..."

Ins. Code 1871.4(a) and (a)(1): "It is unlawful to do any of the following: Make or cause to be made a knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying any compensation, as defined in Section 3207 of the Labor Code."

LINKS:

Labor Code:

California Code of Regulations (CCR): California Code of Regulation, Title 8, Division 1, Chapter 4.5 [Click on Title 8, Division #1 for the appropriate regs.]

http://www.cwcrwitt.com/: Look up those citation number here; it has CCC and CWCR citations.

Dictrict Court of Appeal Cases: you can not use CCC or CWCR numbers to look up things.

Senate & Legislature Bill Look-up:

Important WCAB decisions (the WCAB website):

Office of Administrative Law:

California Code of Civil Procedure: CCP

WorkCompForums.com:

DWC MEDICAL UNIT:

Writ Granted Cases:

Court of Appeals + Opinions:

WCAB Locations & Numbers :

OMFS: Past & Present: [here]

FORMS:

Pre-Trial Conference Statement (aka: Five Pager or Stips & Issues): (here) (here)

Work Comp Forms: From the DWC

http://www.workcompforums.com/ca/pro/index.cfm?token= (this is the old forum)

http://forums.workcompcentral.com/ new for 2009

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