Q2, 2016 &#8211; August 4, 2016

Regional Scorecard Preview: The L.A. Effect. An initial look at data from CWCI’s new regional scorecards, a research series that will examine variations in Calif WC claims experience by geographic region (based on the injured workers’ place of residence). The 8 regional scorecards contain AY 2005 through 2015 claims data compiled from the IRIS database, and the first one will focus on claims from L.A. County residents.

Bulletin (6/6/16) (members only)

California Workers’ Comp 2015 DWP. Total DWP rose for the sixth consecutive year in 2015, climbing nearly 8% to more than $12.3 billion according to data compiled by the NAIC released by the California Department of Insurance. The new market share data show total California DWP for 2015 was up $909 million from the 2014 level as both average premium rates and covered payroll increased as the state’s economy continued its post-recession rebound. CWCI looks at the changes in the rankings among the largest writers in the state.

1st Quarter 2016 IMR Results. An analysis of California workers’ compensation Independent Medical Review decisions from the first quarter of 2016 shows little change in the number of determinations, the percentage of utilization review modifications and denials upheld, the types of medical services reviewed and the high concentration of disputed medical service requests linked to a small number of physicians.

Spotlight Report (6/2/16) (public)

Bulletin (6/2/16) (members only)

News Release (6/2/16) (public)

IAIABC White Paper on the Use of Formularies in Workers’ Comp. The Medical Issues Committee of the International Association of Industrial Accident Boards and Commissions (IAIABC) recently published a comprehensive report on the use of formularies in workers’ compensation. CWCI Senior Research Associate Stacy Jones and CWCI President Alex Swedlow both contributed to the report, which is intended to provide public policymakers, regulators and workers’ compensation stakeholders with background information on what a formulary is and how it can be structured in workers’ compensation.

Executive Memo (5/16/16) (members only)

Trends in the Use of Opioids in California Workers’ Compensation. CWCI research based on 10.8 million California workers’ compensation prescriptions filled between 205 and 2014 identifies trends in the volume, cost, potency and types of opioids used to treat injured workers over the past decade.

Research Note (5/5/16) (public)

Bulletin (5/5/16) (members only)

News Release (5/5/16) (public)

Interactive Analytical Tool (5/6/16) (members only)

National Safety Council Physician Survey on Opioids. A survey of 201 board-certified family medicine or internal medicine physicians who treat patients for pain and spend at least 70% of their time seeing patients in the office found that 99% of the doctors prescribe opioids for longer than the 3 days recommended by the CDC, and 23% said they prescribe at least a month’s worth of opioids.

AY 2015 Insured Claims Experience. WCIRB’s report on insured claims experience through 4Q 2015 shows Calif WC insurers’ total DWP gross of deductible credits rose 7% last year to $17.6 billion, as covered payroll continued to increase, though notably the average charged rate per $100 of payroll fell to $2.86 in the 2^nd half of the year, down about 5% from the average for policies written in the first six months of the year — the first decline since 2009.

Spotlight Report (4/11/16) (public)

California Workers’ Compensation Claims Monitoring: Medical and Indemnity Development, AY 2005-2014. CWCI research that tracks average California workers’ comp medical loss, indemnity benefits, and medical cost containment payments on AY 2005-2014 indemnity claims finds mixed results, with more developed data on older claims showing paid medical losses and indemnity payments leveling out or declining, and less developed data on newer claims indicating that average amounts paid in the early stages of a claim are on the rise.

Bulletin (4/11/16) (members only)

News Release (4/11/16) (public)

Legal

Baker v. WCAB, Sierra Fleet Services. The contention that a late IMR decision by the Administrative Director vests the WCAB with independent jurisdiction to adjudicate the medical necessity issue is in direct contravention of Labor Code Section 4610.5(e) which prohibits utilization review decisions from being reviewed or appealed except via independent medical review.

CWCI Amicus Brief (6/4/16) (members only)

Zuniga v. Interactive Trucking, SCIF and the WCAB. The procedural safeguards and appellate opportunities provided by the Independent Medical Review statutes satisfy Due Process.

CWCI Amicus Brief (dated 6/1/16) (members only)

California Highway Patrol and SCIF v. WCAB and Dorothy Margaris. An untimely IMR determination is valid and binding on the parties. The time frame for the Administrative Director’s IMR decision is directory (not mandatory), and though the WCAB is authorized by Labor Code 4610.6(h) to invalidate an IMR decision on statutory grounds in, it is prohibited by Labor Code §4610.6(i) from making a determination of medical necessity contrary to an IMR determination

Reply to Repondent’s Answer to WCAB Response Brief (5/17/16) (members only)

Significant Decision Summary (6/23/16) (members only)

Significant Decision Summary (4/25/16) (members only)

Guerra v. WCAB (Rodas). The Court of Appeal ruled that an employee’s death was determined to be industrial based on the evaluating physician’s reasonable inferences from the record, confirming that circumstantial evidence is sufficient to support an award of benefits.

Statutory/Regulatory

Regulatory Update: An summary of WC regs that are in the works, including the status of the MTUS Guidelines on Chronic Pain & Opioid Treatment; the Home Health Care Fee Schedule; The Workers’ Compensation Information System regs and Electronic Data Interchange guides for medical bill payment reporting and FROI/SROI; the Outpatient Facility Fee Schedule; the Interpreter Fee Schedule: the Return to Work Supplement Program and the prescription drug formulary.

Bulletin (6/9/16) (members only)

2017 Benefits Will Rise Following Increase in the State Average Weekly Wage: A 3.912% jump in the SAWW last year means TTD & PTD rates for injuries o/a 1/1/17 will increase, with the maximum weekly TTD & PTD rate rising to $1,172.57 for 2017 injuries, while the minimum will rise to $175.88.

Executive Memo (6/9/16) (members only)

News Release (6/9/16) (public)

CURES Bill Moving Forward… SB 482, a bill that would require physicians to consult the state’s prescription drug monitoring program (CURES database) to check a patient’s prescription history at least 24 hours before prescribing opioids and other controlled substances for the 1st time, and to check it at least annually if the patient continues to use these substances, is heading to the Assembly Appropriations Committee.

Employer Alert: New Anti-Retaliation Rule for Injury Reporting Takes Effect in August…After more than 2-1/2 years of development, the Obama Administration has signed off on controversial new regs that expand employers’ electronic recordkeeping requirements for work injuries & illnesses and make the records publicly available – a provision that met strong push back from employers concerned about the potential liabilities and consequences for employers and for employees.

1st 15-Day Comment (6/9/16) (public)

WCIS Standards and Medical FROI/SROI Guides: CWCI’s 45-day public comments on proposed regulations governing the Workers’ Compensation Information System Standards and the Medical First Report of Injury and Subsequent Report of Injury Guides.

Proposed Home Health Care Fee Schedule: SB 863 mandated adoption of a workers’ compensation Home Health Care Services Fee Schedule that sets forth fees and requirements for service providers, as well as maximum service hours and fees. CWCI comments on DWC’s proposed Home Health Care Services Fee Schedule which sets forth a methodology for payment and maximum allowable rates for payment for the full range of home health care services that may be required by injured workers.

1st 15-Day Comment (6/8/16) (public)

UR Bill Sent to Suspense File. The Senate Appropriations Committee sent the latest version of SB 1160, authored by Labor and Industrial Relations Cmte Chair Tony Mendoza, to the suspense file. The proposed legislation would require self-insured employers, insurers and TPAs to receive accreditation for their UR programs by July 2018 and have their programs reaccredited every 5 years thereafter; increase penalties for failing to report data to WCIS; declare that when a section of the MTUS has not been updated in 5 or more years treatment decisions shall be authorized in accordance with more recent evidence-based guidelines; and require DWC to adopt new physical medicine and rehab treatment guidelines.

Executive Memo (4/22/16) (members only)

Dept of Insurance Set to Release 2016 WC Adjuster Certification (WCAC) Data Call. The Department of Insurance (CDI) expects to issue the Workers’ Comp Adjuster Certification (2016 WCAC) Data Call for claims adjuster and medical bill reviewer data pursuant to California Insurance Code §11761 and CCR, Title 10, §§2592 – 2592.08 Friday, April 22. After the Data Call is received, the WCAC “Acknowledgement of Receipt Form” will be due by Friday, May 13. Insurance companies admitted to transact workers’ comp insurance in California must submit a completed Data Workbook to certify their adjusters and/or medical bill reviewers by July 8.

Other

Minutes from the Claims and Medical Care Committee Meeting. The meeting was held June 14 at the 5 Star Conference Center in Oakland. The agenda included reviews of CWCI research on prescription drug trends, the impact of the RBRVS Fee Schedule and Updated IMR results; and provided updates on pending and proposed regs, an update on 2016 legislation, and a discussion with DWC Medical Director Dr. Raymond Meister.

Meeting Minutes (6/14/16) (members only)

Minutes from the Legal Committee Conference Call. The conference call was held on May 26. The agenda included reports on 6 current and 3 proposed amicus cases, a regulatory update on the prescription drug formulary and the MTUS, a legislative update on 3 bills, a Chamber of Commerce report by Saul Allweiss, and a discussion of the current litigation environment.

Meeting Minutes (5/26/16) (members only)

Member Alert: Free CWCI Webinar on Opioid Study and Companion Analytic Tool. Announcement of a free webinar in May for Institute members on recent research tracking opioid trends in California workers’ comp using data from more than 10.8 million prescriptions filled between 2005 and 2014, resulting in $1.1 billion in pharmacy payments. CWCI members also can access a special interactive application to drill down into the prescription drug data to gain additional insights and to identify industry norms for comparison to their own results.

Executive Memo (5/5/16) (members only)

CWCI’s 18th Annual Case Law Seminar. The Institute has scheduled its annual California Workers’ Compensation Case Law Update Seminar for May 23 in Long Beach and May 25 in San Francisco.