Q2, 2015 – August 11, 2015
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Research IMR Outcomes in California Workers’ Compensation. Amid continuing debate over whether utilization review and independent medical review improve the California workers’ compensation medical dispute process, a new CWCI analysis of IMR decisions from 2014 finds that 91% of physician-level UR modifications or denials of treatment reviewed by an IMR physician were upheld, while 9% were overturned – suggesting that UR and IMR not only work to assure that the care rendered to injured workers is appropriate, but also provide a needed check against pharmaceuticals, diagnostic tests, surgeries and other procedures that fail to meet evidence-based medicine standards and that are could delay recovery or lead to further impairment or disability. CWCI Research Update (4/25/15) (members only) Bulletin (4/25/15) (members only) News Release (4/25/15) (public) PPO to MPN: Impact of Physician Networks in the California Workers’ Comp System. CWCI research examines changes in the use of physician networks in California workers’ comp from AY 2000 – June AY 2011, measures their impact on medical costs and compares the changing nature and characteristics of claims where treatment is managed inside and outside of networks. Results show network providers are the primary treating physicians in 80% of California work injury claims, and though savings associated with network management have diminished in recent years, results vary significantly by network and by region. Executive Briefing (5/13/15) (members only) CWCI Research Update (6/9/15) (members only) Bulletin (6/19/15) (members only) News Release (6/9/15) (public) 2014 Insured Experience Report. The WCIRB projects 2014 losses & ALAE will ultimately total $12.6 billion, up 4% from 2013, so the AY 2014 estimated ultimate loss & ALAE ratio is expected to be 77.9%, and the ultimate AY combined loss & expense ratio is pegged at 103%, down from 109% in 2013. Following the report and a hearing in late April, Commissioner Jones approved WCIRB’s recommended mid-year rate reduction and cut the advisory pure premium rate 10.2% to an avg of $2.46/$100 of payroll for policies incepting o/a 7/1/15. Executive Briefing (5/13/15) (members only) Breakdown of California Direct Written Premium and Rankings of Largest Insurers in 2014. For the fifth year in a row, California workers’ compensation total direct written premium (DWP) increased in 2014, climbing 10.7 percent to more than $11.4 billion — up $4.5 billion from the 10-year low noted in 2009, but still $4.7 billion below the record high of $16.1 billion noted in 2004. Bulletin (6/11/15) (members only) California Workers’ Compensation Profitability in 2013. The latest National Association of Insurance Commissioners (NAIC) profitability report shows California workers’ comp insurers’ return on net worth declined from 3.9 percent in 2012 to 3.0 percent in 2013 – the lowest level in a decade, ranking the state 45th out of 46 states that operate without a monopolistic state fund. Bulletin (6/16/15) (members only)
Legal Last Call: 2015 Case Law Update Seminar. The Supreme Court has retained the traditional causation standard for work-related deaths, rejecting the Court of Appeal’s determination that the QME’s opinion was not substantial evidence and that industrial injury must be a ‘material factor’ for a death to be compensable. Executive Briefing (5/13/15) (members only) South Coast Framing v. WCAB. The Supreme Court has retained the traditional causation standard for work-related deaths, rejecting the Court of Appeal’s determination that the QME’s opinion was not substantial evidence and that industrial injury must be a ‘material factor’ for a death to be compensable. Significant Decision Summary (6/3/15) (members only)
Statutory/Regulatory WC Adjuster Certification (WCAC) Data Call. The Dept. of Insurance announced it would issue this year’s WC Adjuster and Medical Bill Reviewer Certification Data Call on April 17, and that the deadline for insurers to submit the data would be July 6. Executive Memo (4/13/15) (members only) Benefit Notice, Posting Notice, Claim Form/NOPE. CWCI first 15-day comments on the proposed benefit notice regulation revisions. 1st 15-Day Comments (5/15/15) ( public) $120 Million RTW Supplementary Fund. Calif workers injured after 1/1/13 who have received an SJDB voucher can now apply for a one-time $5K payment from the $120M “Return to Work Fund” created by SB 863 to provide additional money to injured workers whose PD awards result in a “disproportionate wage loss.” The regs governing the fund were adopted in April and the DIR, which oversees the fund, began accepting apps April 13, though the initial response was underwhelming. Executive Briefing (5/13/15) (members only) DWC’s Draft Benefit Notice Regs. In April the DWC released draft benefit notice regs for public comment. The regs have a 1/1/16 effective date, so even if approved by OAL and filed with the Secretary of State before September, claims operations will be given a grace period to update and distribute materials and reprogram their systems. CWCI will update our claim forms, posting notices and pamphlets once the changes are finalized and adopted. In the meantime, the draft regs and CWCI’s comments are in the Regulatory section of our website. Executive Briefing (5/13/15) (members only) Interpreter Fee Schedule. CWCI first forum comments on the proposed interpreter fee schedule. 1st Forum Comments (5/18/15) ( public) Qualified Medical Evaluator Regs. CWCI’s 45-day public hearing comments on proposed changes to the QME regs. 45-Day Public Comment (5/22/15) ( public) CWCI Web-Based Regulatory Training. CWCI’s online seminar on MTUS Revisions, the New Copy Service Fee Schedule and the regulations governing DIR’s $120 million per year Return to Work Supplement Program. News Release (6/5/15) (public) Executive Memo (6/5/15) (members only) Executive Briefing (6/18/15) (members only) California Workers’ Compensation Benefit Increases for 2016. California’s State Average Weekly Wage (SAWW) rose just under 2.3 percent from in the year ending March 31, 2015, which the California Workers’ Compensation Institute (CWCI) notes will boost temporary total disability (TTD) and permanent total disability (PTD) rates for 2016 work injury claims, and other workers’ comp benefits that are tied to changes in the SAWW. News Release (6/16/15) (public) Executive Briefing (6/18/15) (members only) Executive Memo (6/18/15) (members only) Bulletin (6/16/15) (members only) Hospital Outpatient Department and ASC Fee Schedule. CWCI comments to the DWC on proposed changes to the Hospital Outpatient and ASC Fee Schedule. 30-Day Public Testimony (6/17/15) ( public) Bill Requiring Physicians to Check CURES Advances. SB 482 (Lara) which would require California physicians to check the states prescription drug database before prescribing opioids and other addictive drugs, passed the Senate Appropriations Committee and has moved on to the Assembly. Executive Briefing (6/18/15) (members only) WC Prescription Drug Formulary Bill Advances. AB 1124 (Perea) was passed by the Assembly Appropriations Committee and moved on to the Senate for further consideration. The bill would require the DWC to adopt a workers’ comp prescription drug formulary. Estimates prepared for the committee show it would cost about $500K for DWC to develop a formulary, which given the estimated $708 million spent on Calif WC pharmacy benefits in 2013, could offer a great return on investment depending on how the formulary is structured. Executive Briefing (6/18/15) (members only) Three Other 2015 Workers’ Comp Bills That Are Still Alive. CAAA’s bill prohibiting apportionment of a WC disability from being based on pregnancy, menopause, or osteoporosis; a bill to allow a covered claim to be submitted to CIGA prior to a final determination of the claim in an insolvent insurer’s liquidation proceeding and allowing the person who submitted it a year to challenge if CIGA denies the claim; and a bill to require insurers to report claim info to the state prior to claim payment so the Dept of Child Support Services can determine if the payment should be withheld to pay back child support. Executive Briefing (6/18/15) (members only) Medicare Begins Crackdown on High-Fraud Risk Doctors. CMS began fingerprint-based background checks for Medicare providers last August, and starting this August, will require states to do background checks and fingerprint providers in their state Medicaid programs (Medi-Cal in Calif) if the physician is deemed a high-fraud risk. Executive Briefing (6/18/15) (members only) Qualified Medical Evaluator Regs. CWCI’s comments on proposed changes to the QME regs, 1st 15-day comment period. 1st 15-Day Comments (6/20/15) ( public)
Other Minutes of the Meeting of the Legal Committee. Minutes of the meeting held via conference call on May 28, 2015 Committee Meeting Minutes (5/29/15) ( members only) Minutes of the Meeting of the Claims & Medical Care Committees. Minutes of the meeting held Monday, June 8 at the 5-Star Conference Facility in Oakland. Committee Meeting Minutes (6/10/15) ( 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 Q1/15 (4/28/15) (members only) |