Q1, 2017 – April 4, 2017
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Research Spinal Fusion Claims in California Workers’ Compensation. A Report to the Industry identifying spinal fusion claim characteristics (cause and nature of injury, part of the spine that was fused and the number of spinal segments involved); patient demographics; the presence of comorbidities; and the average amounts paid in indemnity and medical benefits. Based on data from more than 18,266 California work injury claims from AY 2000 – 2014 in which one or more spinal fusions were performed, the study also measures the timing of the initial fusion; the presence and timing of any subsequent fusions; independent medical review outcomes for spinal fusion requests; utilization trends for pre- and post-surgery physical therapy and MRIs; and the level of pre- and post-surgical opioid use. Executive Briefing (3/29/17) (members only) Report to the Industry (3/22/17) members only) Bulletin (3/22/17) (members only) News Release (3/22/17) (public) IMR Decisions: January 2014 – December 2016. A spotlight report updating independent medical review volume and outcomes and comparing the results from 2014, 2015, and 2016. The results show 2016 IMR volume increased more than 6 percent, but as in the two prior years, about 9 out of 10 IMR decisions upheld the utilization review physician’s modifications or denials of treatment Executive Briefing (3/29/17) (members only) CWCI Spotlight Report (3/17/17) (members only) Bulletin (3/17/17) (members only) News Release (3/17/17) (public) California Workers Comp Regional Score Card: Northern Counties. . The seventh installment of CWCI’s series of Regional Score Card series provides detailed data derived from nearly 63,000 AY 2005-2015 job injury claims filed by residents living in the nine northernmost counties of California. The Score Card notes that workers living in the northern counties represent just 1.1% of the California work force, but account for 3.3% of all claims in the state. Because their average claim costs are relatively low, however, they account for just 2.2% of workers’ comp paid losses. The scorecard examines factors that make claims in the northern counties different by providing data comparing key aspects of claims from this region to those from other parts of California. Regional Score Card (3/13/17) (members only) Bulletin (3/13/17) (members only) News Release (3/13/17) (public) California Workers Comp Regional Score Card: Central Coast. The sixth installment of CWCI’s series of Regional Score Card series provides detailed data derived from more than 127,000 AY 2005-2015 job injury claims filed by workers living in the five counties that comprise California’s Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey, and Santa Cruz). The Score Card shows that workers living in the region account for 6.7% of all claims in the state and 6.3% of paid losses. The scorecard examines factors that make claims in the Central Coast different by providing data comparing key aspects of claims from this largely agricultural region to those from other parts of California. Regional Score Card (2/15/17) (members only) Bulletin (2/15/17) (members only) News Release (2/15/17) (public) Executive Briefing (3/2/17) (members only) Update on Volume and Regional Distribution of Liens. A 2016 analysis of data in DWC’s EAMS Lien Filing System noted that 95% of all lien filings from 3Q 2015 originated in So. California, and that 2/3 of them originated in the L.A. Basin. An update on lien counts shows that there were 112,148 liens filed in the Q4 2016, and 70,425 (62.8%) of those came from the L.A. Basin, so as of the end of last year there had been little change in the regional distribution. Executive Briefing (1/26/16) (members only) New Public Self-Insured Data: 1st Reports on FY 15/16 Claims. OSIP 1st report data on FY 15/16 public self-insured claims shows there were 115,830 new claims reported to the state by public self-insured entities last year, 1,035 more than in the FY 14/15 initial report — the 1st time in a decade that the claim count in the public S-I initial report increased. That increase, however, was driven by a jump in public sector employment, as claim frequency declined from 5.8 claims per 100 ees in the prior year’s 1st report to 5.6 claims per 100 ees in the latest report. Meanwhile average incurred losses at 1st report on public Self-Insured claims rose for the 3rd consecutive year in FY 15/16 and hit a 10-year high. Executive Briefing (1/26/16) (members only) California Workers Comp Regional Score Card: San Diego. . The fifth installment of CWCI’s series of Regional Score Card series provides detailed data derived from nearly 154,000 AY 2005-2015 job injury claims filed by residents of San Diego County – the second most heavily populated county in California. The Score Card finds that workers living San Diego County account for 8.1% of all claims in the state but only 6.2% of paid losses. The scorecard examines factors that make San Diego County claims different by providing data comparing key aspects of claims from this region to those from other parts of California. Regional Score Card (1/23/17) (members only) Bulletin (1/23/17) (members only) News Release (1/23/17) (public) Executive Briefing (1/26/17) (members only) California Workers Comp Regional Score Card: San Francisco Bay Area The fourth installment of CWCI’s series of Regional Score Card series provides detailed data compiled from 330,000 AY 2005-2015 job injury claims filed by residents of the 9-county San Francisco Bay Area – one of the wealthiest regions of the state, dominated by a largely urban and suburban worker force. The Score Card shows that Bay Area residents filed 17.5% of all California workers’ comp claims, but accounted for only 15.4% of paid losses, and highlights factors that make Bay Area claims different by providing data comparing key aspects of claims from this region to those from other parts of California. Regional Score Card (1/9/17) (members only) Bulletin (1/9/17) (members only) News Release (1/9/17) (public)
Legal Daniel Ramirez v. WCAB (SCIF). In a published decision that closely follows Stevens, another Court of Appeal has upheld the constitutionality of the UR/IMR process for resolving disputes over workers’ compensation medical treatment requests. The court emphasized that medical necessity decisions have been legislatively placed into the hands of medical professionals, instead of WCAB judges. Significant Decision (3/29/17) (members only) CWCI’s 19th Annual Case Law Seminar. The Institute has scheduled its annual California Workers’ Compensation Case Law Update Seminar for May 17 in Long Beach and May 15 in San Francisco. Executive Briefing (3/29/17) (members only) Executive Memo (3/17/17) (members only) News Release (3/17/17) (public) Seminar Flyer (3/17/17) (public) DCA Quickly Denies Suit Seeking to Declare DWCs New Anti-Fraud Authority Unconstitutional. The First District Court of Appeal rejected a convicted chiropractor’s request to stop the DWC from suspending providers from the workers’ comp system and staying the medical liens of providers linked to fraudulent activities. Executive Memo (2/21/17) (members only) Bradley Maxham v. Calif. Dept. of Corrections. An en banc decision in which the Appeals Board clarified the distinction between “communication” to an AME and “information” provided to an AME, as those terms are used in Labor Code Section 4062.3. Significant Decision (1/24/17) (members only)
Statutory/Regulatory DWC Releases Formulary Regs for Public Comment. 2014 legislation (AB 1124, Perea) required the DWC to adopt a formulary by July 1, 2017. DWC has been working for more than a year to develop regs in order to meet that deadline. In mid-March the Division released the proposed regs and associated documents, and announced that a public hearing will be held on May 1, 2017 in Oakland. Executive Briefing (3/29/17) (members only) RTW Fund Filing Deadline Extended…SB 863 set up a $120M/yr Return to Work Supplement Program (RTWSP) which allows workers who receive an SJDB voucher to apply for a $5K benefit, paid for by user funding fees from employers. The RTWSP regs, however, req’d the application to be submitted w/in 1 year of the date on the voucher. Response to the program was tepid, so the state amended CCR §17304 to extend (until 3/20/18) the deadline for injured workers who received an SJDB voucher from 4/13/15 to 12/1/15, and who may not have received notice of their eligibility, to apply for the $5K benefit. Executive Briefing (3/29/17) (members only) Proposed Revisions to the Medical Treatment Utilization Schedule. CWCI’s forum comments to draft revisions to the MTUS. Forum Comment (3/10/17) (public) DWC Claim Audit Results. Results of DWC’s CY 2015 audits of WC claims administrators, which summarizes the overall results from PAR and full compliance audits conducted during that year, and notes the number of files audited, the number and types of specific infractions found at each audited office, and the amount of undisputed compensation found to be due and unpaid to the injured worker. Executive Briefing (3/2/17) (members only) DWC Utilization Review Audit Results. 2016 UR audit results show the overall performance rating for the 58 adjusting locations audited last year averaged 98.3%, well above the 85% threshold that DWC considers a passing grade. Since 2009, overall UR compliance rates have never fallen below 96.8%. Claims administrators can be fined $100 for each untimely decision, but those fines can be waived if the audited adjusting location scores 85% or higher on the overall audit, and in 2016, all 58 audited locations hit that benchmark. DWC is drafting regs to implement last year’s UR reform bill (SB 1160), which requires the AD to develop a system for mandatory electronic reporting of documents related to every UR performed. Executive Briefing (3/2/17) (members only) DWC Posts List of Suspended WC Medical Providers. The DWC has begun issuing notices of suspension to convicted WC providers and has placed stays on more than 200,000 liens worth more than $1 billion associated w/75 medical providers who have been charged with WC fraud. The list of suspended providers is posted at www.dir.ca.gov/fraud_prevention. Executive Briefing (1/26/17) (members only) Executive Memo (1/24/17) (members only) Employer Reminder: Feb. 1 Deadline for Posting OSHA 300s. The deadline for employers to post an OSHA 300A form (Summary of Work Related Injuries & Illnesses) is Feb. 1. Some employers (ie those w/10 or fewer employees and those in low-hazard industries such as retail and finance) may be exempt, but most must summarize their OSHA 300 Log info on a 300A form and post it by the deadline. While fed OSHA regulatory efforts may eventually be relaxed under the Trump Administration, injury & illness reporting and recordkeeping compliance requirements are still in effect, so WC insurers may want to remind policyholders about the OSHA regs. Executive Briefing (1/26/17) (members only) Member Advisory: Separate Medical Record Review Payments Reinstated. Executive Briefing (1/26/17) (members only) CWCI Members May Now Download the Institute’s Webinar on 2016 WC Legislation. CWCI scheduled a free, 90-minute, webinar to bring our members up to speed on the pending changes, review the technical aspects and practical implications of SB 1160 and other 2016 worker comp bills, and to confirm the implementation timeframes. Executive Memo (1/13/17) (members only) Other CWCI Elects 2017 Board of Directors The Institute elected its 2017 Board of Directors at the 53rd Annual Meeting in Oakland. Susan Gordon of Zurich North America was reelected as chair of the Board. News Release (3/24/17) (public) Minutes from the Claims and Medical Care Committee Meeting. The meeting was held March 22 at the 5 Star Conference Center in Oakland. The agenda included reviews of CWCI research including tha discussion of the interplay between the Rx drug formulary and the pass-through provisions of SB 1160; and provided updates on recent case law, pending and proposed regs, and upcoming research projects. Meeting Minutes (3/22/17) (members only) Denise Niber to Succeed Brenda Ramirez as CWCI Claims and Medical Director. Denise Niber was named to succeed Brenda Ramirez as Claims and Medical Director of the California Workers’ Compensation Institute and will begin transitioning into the position in March 2017. News Release (3/1/17) (public) Executive Briefing (3/2/17) (members only) Impact of New Marijuana Law in the Northern Counties. With approval of Prop 64 last fall, the Northern Counties’ $1 billion/year pot industry is expected to emerge from the unregulated shadows of the underground economy as it becomes subject to the same rules as other agricultural employers, including payroll taxes and employee benefit requirements, labor standards (i.e., worker housing, disabled parking and bathrooms, safety stations, shading and rest breaks, and hand-washing stations) and WC. Legitimate growers also will need to provide training on pesticide and hazardous materials handling, will become subject to the state’s water-quality standards, and beginning in 2019, will need to pay overtime. The cost of compliance will likely reduce what growers will pay workers (which the state pegs at $1K/week under the table) and it is unknown how many current operators will be willing to change how they do business and take on the financial burden of “going legit.” Executive Briefing (3/2/17) (members only) Minutes from the Legal Committee Meeting. This meeting was held by conference call on February 9, 2017. The agenda included status updates on amicus work, a regulatory update, a legislative review, and a review of the litigation environment. Meeting Minutes (2/9/17) (members only) CWCI 53rd Annual Meeting Announcement. The Institute’s 2017 meeting is set for Thurs, March 23, at the Oakland Marriott. The program will begin at 9:30 a.m., and the theme this year will be “Rethinking Disability Management: Lessons Learned from Research and the Field.” Executive Briefing (3/2/17) (members only) CWCI Hotlinks Update. Quarterly listings of all CWCI publications, including publication dates, brief summaries of each topic and the various formats in which the information is available (e.g., research report, Bulletin, Executive Briefing, news release), so users can choose the level of detail they want to view. Listings include live links so users can click into the CWCI website to access specific documents quickly and easily. Hotlinks Q4/16 (3/17/17) (members only) |