Disclaimer: The statements and opinions contained in this publication are those of the contributors only and are not necessarily those of The California Lawyer’s Section, the Workers' Compensation Section, or any government body. This information is intended to be a reference tool only and is not meant to be relied upon as legal advice.
by David Skaggs
This edition of the E-News has announcements about the upcoming Spring Conference and annual workers’ compensation awards presentation in September. After a short hiatus, this year’s Spring Conference will return to the popular Cliffs Resort in Pismo Beach in California’s Central Coast. There will also be a northern California presentation in Burlingame. The conference often sells out so please plan to sign up early if you’re interested in joining us at either one of these great locations. The CLA’s annual workers’ compensation awards presentation is just six months away! The CLA relies on the workers’ compensation community to identify and nominate worthy award recipients. Often, it may be an opposing counsel or a judge who has first-hand knowledge of the work of an attorney, or an attorney of a judge, that merits recognition. The CLA encourages your nominations and considers each one when determining its award recipients. If you happen to have nominated someone in the past and they’ve not won, please don’t let that discourage a future nomination as some award recipients were not chosen the first time they were nominated, and they wouldn’t have later won had they not been nominated again.
Earn 6 Hours of participatory MCLE and Legal Specialization Credit
In TWO locations!
Satruday, March 24, 2018
San Francisco Airport Marriott Waterfront
1800 Old Bayshore Hwy.
Burlingame, CA 94010
Register Online Here!
Saturday, April 21, 2018
The Cliffs Resort
2757 Shell Beach Rd
Pismo Beach, CA 93449
Register Online Here!
Schedule | Essential Info | Printable Brochure | Mail/fax Registration Form
Click Here for more information!
By: Omar Behnawa, LFLM San Diego
Senate Bill 1160 was signed into law on 9/30/16. The Bill seeks to address concerns by both defendants and claimants/applicants. The Bill increases control of liens, a concern for defendants, in exchange for less restrictive Utilization Review (UR) at the start of the claim – a concern for claimants/ applicants.
For dates of injury on or after 1/1/18, there is no requirement for UR, subject to some exceptions. Treatment requests within the first 30 days following the initial date of injury must be authorized, unless the treatment request is for any of the following:
Surgery, psychological treatment, imaging/ radiology services other than X-rays, medical equipment costing more than $250.00, home health care, or medications not covered in the prescription formulary.
If the treatment requested within the first 30 days of the claim is for any of the foregoing treatment modality (not subject to the 30-day UR exemption), it is imperative that defendants submit the treatment request to UR for a determination as to reasonableness. Otherwise, claimants/applicants will be able to proceed to an Expedited Hearing on the issue, likely obtain the treatment and thereby subvert the UR and Independent Medical Review (IMR) process altogether.
The treatment rendered within the first 30 days of the claim must still be reported to the claims administrator and a provider may be forced to go through retroactive UR – to ensure the treatment rendered was within evidence based medical standards. Labor Code Section 4610(f) allows retroactive UR for the sole purpose of determining whether a provider is consistent with the Medical Treatment Utilization Schedule (MTUS). A provider may be removed from the Medical Provider Network (MPN) if there is a “pattern and practice” of treatment inconsistent with the MTUS. If providers are non-compliant with the reporting requirements, the providers’ 30-day exemption from UR may be removed.
UR decisions covered by the medication formulary must be made within 5 business days. The 14-calendar day timeframe to obtain additional information prior to issuing a UR decision is inapplicable to the medication formulary. Formulary disputes must be submitted to IMR within 10 days (still 30 days for all other disputes). IMR must decide medication formulary disputes within 5 days (all other disputes still to be decided within 30 days, though per case law no real remedy for untimely IMR decision).
As part of Senate Bill 1160’s lien/anti-fraud provisions, Labor Code Section 4615 requires an immediate stay on the liens of medical providers criminally charged with fraud against the workers’ compensation system, medical billing fraud, or fraud against the Medicare/Medi-Cal programs, until the criminal proceedings are resolved.
The Bill also requires lien claimants to file a Declaration stating that they are within the employer’s MPN, have searched and do not believe the employer has an MPN, or have proof of denial of care. The Declaration is required for any lien filed after 1/1/17. All liens filed prior to 1/1/17 were to file the foregoing Declaration by 7/1/17. Lien claimants that failed to file the Declaration by 7/1/17 are dismissed by operation of law.
© Copyright 2018 Laughlin, Falbo, Levy & Moresi. All rights reserved. Reprinted with permission
Every year, Awards are presented by the Workers’ Compensation Section for the following categories:
1.) Lifetime Achievement
2.) Judge of the Year
3.) Applicant’s Attorney of the Year
4.) Defense Attorney of the Year
5.) Young Lawyer of the Year
The Awards will be presented at a reception on Friday, 9/14/2018, in conjunction with the Sections Convention in San Diego.
Deadline for nominations is March 30, 2018.
For information regarding the Awards including past recipients, please go to: http://cla.legal/Sections/Workers-Compensation/Awards
The nomination form is currently being updated and should be available at the above link shortly.
Nominations can also be sent to Joan Succa at firstname.lastname@example.org
As a benefit of Section membership, the state bar is pleased to offer six hours of MCLE credit, offering credit in all of the MCLE subfields, Elimination of Bias in the Legal Profession, Detection and Prevention of Substance Abuse and Emotional Distress and Legal Ethics. Just watch these programs found at the link below, and keep a record of having done so, in the event you're audited for MCLE compliance.
State Bar Workers’ Comp Section members may also use this link to access a plethora of our most popular articles from our publications.