 | SB 403, Affecting Statutory Filing of Liens |
April 29, 2009
Richard J Boggan JD
After a public meeting on SB 403 it appears that it will not become law any time soon as written, unless the author makes some major changes, which is not
Cal Lab Code § 4903.5 (2008) state as follows
(a) No lien claim for expenses as provided in subdivision (b) of Section 4903 may be filed after six months from the date on which
the appeals board or a workers' compensation administrative law judge issues a final decision, findings, order, including an order
approving compromise and release, or award, on the merits of the claim, after five years from the date of the injury for which the services
were provided, or after one year from the date the services were provided, whichever is later. ................
| Collections Strategy |
April 22, 2009
Richard J Boggan JD
The summer months are coming and with that vacations and slow collection months for medical providers as defense attorneys and insurance adjusters
providers start filing Declaration of Readiness (DORs) so your liens can be resolved or cleared before the vacations begin.
| Denial of Authorization |
April 19, 2009
workcompliens.com
I recently fielded a question where someone asked what happens when the treatment was not authorized. When treatment is not authorized it is not the
dispute. Authorization means assurance that appropriate reimbursement for a specific treatment will be paid. (8 CCR §9792.6(b)) There
exists no law that states that if treatment is not authorized then the medical provider does not get paid. Lack of authorization is a denial
of treatment it does not mean that the treatment was not reasonable or necessary or that eventually the provider does not get paid it
just means a dispute as to whether the treatment was necessary now has surfaced. So do not be afraid of the word “Authorization”, and
become knowledgeable about utilization review and how it must be done as it is mandatory when the employer is denying medical
treatment.
| Psychiatric Injury and Pain Management |
April 10, 2009
by workcompliens.com
There exists several aspects of psychiatric injury and or psychiatric treatment. There is the claimed psychiatric injury from events that happened at work (i.
most widely used is the psychiatric treatment for the consequence of being injured (i.e., treating the consequence of the orthopedic
injury or pain management).
In the 1990s, a practice by some in the industry, caused a significant change in some of the laws addressing psychiatric injury. What
use to happen is that “cappers” (not sure if that’s the right word), use to take a van to the unemployment offices and ask people
standing in line if getting laid off or fired from work caused them emotional distress and when they affirmed the “capper” would explain to
them that filing a workers’ compensation claim would give them more benefits than filing an unemployment claim. So the van was loaded
up and the potential applicants were taken to medical providers who would pay for each patient and a workers compensation claim was
filed. In response to such practice, the post termination defense (Labor Code § 3208.3(e)) was created stating that if a claim was filed
after termination for psychiatric injury it was barred. However, the practice of the above caused a prejudice for the treatment of
psychiatric injury that has just recently turned around where the law now reflects the need for psychiatric treatment in most cases as
reflected in case law that the treatment of psychiatric consequence of an orthopedic injury is necessary, as being injured and going
through the workers compensation system does necessity the treatment of the emotional stress and related consequences.
What I see a lot of today, is that the psychiatric injury, and or treatments are being settled, where the case in chief will be resolved with
the stipulation that no psychiatric injury happened, or settlements negating the potential recovery for the Lien Claimant that provides
psychiatric treatment. Hopefully, the material contained herein will show that recovery for psychiatric treatment is obtainable in most
circumstances.
| Utilization Review and Authorization for Medical Treatment |
April 05, 2009
by Richard J Boggan JD
I have received numerous questions as to utilization review and denial of authorization from medical providers. Utilization review and
treatment. There exists more case law interpreting utilization review and authorization issues than I have seen in along time, and it
touches every aspect of every other law and regulation as to when a medical provider gets paid. Here are some valid and answerable
questions:
1. The treating physician in his or medical report recommended additional treatment for chiropractic treatment over the 24-visit-cap
and no objection to the additional treatment was made and or not made in 20 days, does the provider get paid for those additional
treatments?
2. The provider requested authorization for treatment and the insurance company responded that the provider was not part of an
MPN, no utilization review was done on the medical treatment requested , was that a proper notification to the medical provider of the
existence of an MPN, and is the treatment considered authorized?
3. What is a request for authorization from a secondary treating medical provider that triggers, the mandatory utilization review, is it
the referral from the primary treating physician that is considered a request for authorization for treatment by the secondary physician.
There is a magnitude of information contained at the Department of Workers Compensation web page and cases that have come down regarding
utilization review and authorization which makes the task of reading all the material a major undertaking that has been put off by many providers forgoing
potential recoverable medical costs. In response, to this need I encourage medical providers and representatives to email actual cases where these issues
arise and they will be shown on this web page with case and regulator law interpretation to show how the process works. Every week something will be
published on these issues or for comprehensive information.
| The Present State Of Law And Its Exceptions, That SB 403 Is Trying To Change (making it one year to file a lien from date of EOB /EOR and or | |
| objection or lose your right to assert a lien) |
March 28, 2009
workcompliens.com
Cal Lab Code § 4903.5 (2008) state as follows
(a) No lien claim for expenses as provided in subdivision (b) of Section 4903 may be filed after six months from the date on which the appeals board or a
workers' compensation administrative law judge issues a final decision, findings, order, including an order approving compromise and release, or award, on
the merits of the claim, after five years from the date of the injury for which the services were provided, or after one year from the date the services were
provided, whichever is later. ...............................
| Lien Claimants Are Getting Issued “Notice of Intention To Dismiss Lien Claim” For Failure to Appear At Hearings Other Then Lien Hearings. |
March 25, 2009
by Richard J Boggan JD
I have been receiving at lest three to four requests a week in the last two months from different medical providers (Lien Claimants) who have received a
have requested a drafted response.
8 CCR 10240 ( set forth in full at end of this article) puts forth the requirements for necessary and unnecessary appearances by Lien
Claimants. The regulation was adopted to allow the necessary parties to appear at the proceedings, and to prevent unnecessary
appearances on the part of the Lien Claimants.....................................
| California Medical Providers Mystified By MPNs (Medical Provider Networks) |
by Richard J Boggan JD
March 24, 2009
I continually get questions from Lien Claimants who state that their medical bills are being denied because they treated outside an MPN, asking what
Carriers that all rules would be followed, however this is not the case, as cases continually come down where medical providers who treat
outside the MPNs are getting paid.
| MPNS (MEDICAL PROVIDER NETWORK) AND SAMPLE RESPONSES |
By Richard J Boggan JD
As a rule a medical provider will not treat in a non-emergency situation if they know they will not get paid so look at the facts of the case and determined
| GETTING PAID FOR NON-INDUSTRIALLY CAUSED INJURY |
There are several circumstances where a provider must treat a non-industrial injury in order to treat an admitted industrial injury. The law recognizes the
and knowing that it would be difficult if not impossible to divide or apportion the cost between industrially related and non-industrially
related treatment......................................................................
| DISCOVERY, THE NEED TO RESPOND |
By Richard J Boggan JD
Although, what is discoverable has its long radius of inclusion, it does not mean that all things that the defense requests are discoverable, and must be
responded to before the defense gets a motion to compel discovery from the Judge. . ..
| LACHES, DOCTRINE OF – |
Based on the maxim that equity aids the vigilant and not those who procrastinate regarding their rights; Neglect to assert a right or claim that, together with
claim or right for an unreasonable and unjustified time causing disadvantage to another...............................................
| REVISITING MPNS (MEDICAL PROVIDER NETWORK) AND SAMPLE RESPONSES |
By Richard J Boggan JD
As a rule a medical provider will not treat in a non-emergency situation if they know they will not get paid so look at the facts of the case and determined
| GETTING PAID FOR NON-INDUSTRIALLY CAUSED INJURY |
There are several circumstances where a provider must treat a non-industrial injury in order to treat an admitted industrial injury. The law recognizes the
and knowing that it would be difficult if not impossible to divide or apportion the cost between industrially related and non-industrially
related treatment. ..............
RESPONDING TO "NOTICE OF INTENTION TO DISALLOW LIEN"
By Richard J Boggan JD
I continually see and hear about medical providers getting a “Notice of Intention to Disallow Lien” and not responding, than wondering what to do next. You
have to show respect to the court when a Judge issues anything regardless of its content and to that which is requested, the medical provider must respond.
Not responding, negates any legal issues as to the merits of your case and now the issue is the failure to respond and in some Judges mind a lack of
respect for the Judge and Judicial System is the issue. This also applies to discovery , i.e., notices to produce served by the defense attorney, even if you
cannot or will not produce everything asked for you still must respond and or object to that which is requested...................................................................
| MPNS ( Medical Providers Networks) |
By Richard J Boggan JD
I often come across the question asking how one gets paid if the applicant was part of an MPN and the treating medical provider was not? In order to
adequate medical treatment, and they must be informed as to their rights and responsibilities..................................................
| Cal Lab Code § 4903.5 (2008) Should there be a "Tolling of The Statute of Limitations" |
§ 4903.5. Time period for filing lien for expenses; Applicability
(a) No lien claim for expenses as provided in subdivision (b) of Section 4903 may be filed after six months from the date on which the appeals board or a
release, or award, on the merits of the claim, after five years from the date of the injury for which the services were provided, or after one
year from the date the services were provided, whichever is later......................................................................
| GETTING PAID AFTER 24-VISIT CAP ON PHYSICAL MEDICINE |
In 2008 AB 1073 was adopted to exempt post-surgical patients from 24-visit caps on physical therapy and chiropractic care if the physical medicine and
are still not getting paid when their treatment exceeds 24 visits, prior to
2008...........................................................................................................................
| WHERE TO FILE AN APPLICATION |
A lien claimant, lien representative or lien service company cannot file an application based on where it does business. Labor Code section 5501.5
(1) In the county where the injured employee or dependent of a deceased employee resides on the date of filing.
(2) In the county where the injury allegedly occurred, or, in cumulative trauma and industrial disease claims, where the last alleged
injurious exposure occurred.
(3) In the county where the employee's attorney maintains his or her principal place of business, if the employee is represented by an
attorney.
If a lien claimant, lien representative or lien service company files an application in an inappropriate venue, the application will be
rejected.
| Boehm , &, Associates v. Workers' Comp. Appeals Bd., 108 Cal. App. 4th 137, 133 Cal. Rptr. 2d 396, 2003 Cal. App. LEXIS 616, 68 Cal. Comp. Cas. | |
| (MB) 548, 2003 Cal. Daily Op. Service 3562, 2003 D.A.R. 4515 ( Cal. App. 3d Dist. 2003) |
As indicated previously, section 14124.791, subdivision (a) specifically states that a provider that has rendered services to a beneficiary and that has received
payment under the Medi-Cal program is entitled to file a lien for all fees and services. That section goes on to say that a medical provider may "recover" only if
it has reimbursed any fees paid by Medi-Cal. Similarly, section 14019.3, subdivision (d) reads: "Notwithstanding subdivision (c), payment received from the
state in accordance with Medi-Cal fee structures shall constitute payment in full, except that a provider, after making a full refund to the department of any Medi-
Cal payments received for services, may recover all provider fees … ." (Italics added.)
As is clear from the language used by the Legislature, a medical provider may not recover until it has first reimbursed Medi-Cal. By express provision, a
provider need not reimburse Medi-Cal before asserting its lien claim. The providers, not yet having recovered on their lien claims, are not yet called upon to
reimburse Medi-Cal. The point at which there is a recovery within the meaning of the statutes is not before us in this appeal.
| CASE LAW MAY ALLOW MEDICAL PROVIDERS TO COLLECT ADDITIONAL REVENUE |
| DURABLE MEDICAL EQUIPMENT AND OUTPATIENT SURGERY BILLING |
| REVIEW COMPANIES |
| INSURER DID NOT COMPLY WITH 14-DAY STATUTORY DEADLINE......... |
| SILENT PPO CONTRACTS | |
- "Thus we have determined the restitution orders were unfair and must be annulled.”
June 22, 2009
Richard J Boggan JD
It appears that some defense attorneys had a meeting and some have found a new or reinvented an old strategy to deny medical providers just compensation
for medical treatment rendered to an injured worker. I have seen a lot of defense attorneys putting reimbursement as an issue for court or filing a petition for
reimbursement as retaliation for medical providers seeking to get paid their fees under the fee schedule and or usual and customary fees. In addition I have seen
this ploy work as some medical providers, get upset and just withdraw their lien. The law does not favor reimbursement unless it is a dupe payment.
American Psychometric Consultants Inc. v. Workers' Compensation Appeals Bd., 36 Cal. App. 4th 1626, 43 Cal. Rptr. 2d 254, 60 Cal. Comp. Cas. (MB) 559, (Cal.
App. 2d Dist. 1995)
“Approving restitution in these cases would set a precedent which would have unfortunate consequences for the workers' compensation system. It would
introduce the possibility of continued transactional instability so negative it would impact the number of medical providers willing any longer to participate in the
system by evaluating workers with industrial injuries. No one can operate a business on receipts only conditionally possessed, and medical providers are no
exception. Thus we have determined the restitution orders were unfair and must be annulled.”
- Lien Claimants Are Getting Issued “Notice of Intention To Dismiss Lien Claim” For Failure to Appear At Hearings Other Than Lien Hearings.
June 29, 2009 -Republished
by Richard J Boggan JD
I have been receiving at lest three to four requests a week in the last two months from different medical providers (Lien Claimants) who have received a
“Notice of Intention To Dismiss Lien Claim” for failure to appear at various hearings, other then Lien Conferences and or Lien Trials who have requested a
drafted response.
8 CCR 10240 ( set forth in full at end of this article) puts forth the requirements for necessary and unnecessary appearances by Lien Claimants. The
regulation was adopted to allow the necessary parties to appear at the proceedings, and to prevent unnecessary appearances on the part of the Lien
Claimants......................................................................
July 19, 2009
workcompliens.com
"To the extent that the WCJ finds that the notice described in Labor Code § 4904(a) was given to the defendant, we find that the defendant was required to
comply with WCAB Rules 10886, 10888, and 10890. Pursuant to Labor Code § 4904(a), When a defendant has been given written notice ''setting forth the
nature and extent of any claim that is allowable as a lien,'' a lien is created in favor of the claimant. WCAB Rule 10886 explicitly requires a defendant to
serve a lien claimant with a compromise and release when a lien has been served on the defendant regardless of whether the lien claim has been filed with
the WCAB. We also note that Rules 10888 and 10890 are not limited in their application to lien claimants who have filed their liens with the
WCAB.".................
July 19, 2009
workcompliens.com
The goal is to ensure that injured employees who have to undergo surgery to repair their injuries are never left in a situation where appropriate physical
medicine services such as physical therapy are unavailable due to the 24-visit cap. ..........................
DENIED CLAIMS AND SELF-PROCURED MEDICAL TREATMENT(CORRECTED)
By Richard J Boggan JD
Initially cases are denied and than the medical legal dance takes place. The case in chief is than resolved in the majority of cases with a “Thomas Finding”, which
states in the settlement documents legally sufficient grounds that if the case was be tried on the merits that the applicant would take nothing.
CASE LAW SELF-PROCURED MEDICAL TREATMENT AND MPNs (Medical Provider Networks)
June 12, 2009 - Republished
by Workcompliens.com
“The Board held that an employer or insurer's failure to provide required notice to an employee of rights under the MPN (medical provider network) that results in a
June 12, 2009 - Republished
by Workcompliens.com
 | Bruce Knight, United Parcel Service; and Liberty Mutual Insurance Company October 10, 2006 71 Cal. Comp. Cases 1423 |
“The Board held that an employer or insurer's failure to provide required notice to an employee of rights under the MPN (medical provider network) that results in a
employee.”
| Jennifer Balkowitsch, Applicant v. Home Depot, PSI, adjusted by Sedgwick Claims Management Services, Defendants, 2008 Cal. Wrk. Comp. P.D. LEXIS | |
| 567, Opinion Filed August 11, 2008 |
| Authority to Award Above Fee Schedule |
May 06, 2009
by workcomppliens.com
8 CCR 9792.5
Ҥ 9792.5. Payment for Medical Treatment
(c) To be properly documented, a bill for medical treatment which exceeds the amount presumed reasonable in the Official Medical Fee Schedule adopted
Gould v. Workers' Comp. Appeals Bd. (1992) 4 Cal. App. 4th 1059, 1068-1069 [6 Cal. Rptr. 2d 228]. The court held;
“In deciding whether fees in excess of the schedule are reasonable, the WCAB may consider evidence regarding the medical provider's training, qualifications,
and length of time in practice; the nature of the services provided; the fees usually charged by the medical provider; the fees usually charged in the general
geographical area in which the services were rendered; other aspects of the economics of the medical provider's practice that are relevant; and any unusual
circumstances in the case. We emphasize, however, that, although unusual circumstances are a factor that may be considered, a fee in excess of the
schedule may be reasonable even if no unusual circumstances are present.”
“Gould Two” Gould v. Workers' Compensation Appeals Bd. (Barry), 60 Cal. Comp. Cas. (MB) 1109 (Cal. App. 2d Dist. 1995)
“The Board noted that payment in excess of the fee schedule is discretionary with the Board and not mandatory [citing Gould v. Workers' Comp. Appeals Bd.
(1992) 4 Cal. App. 4th 1059, 6 Cal. Rptr. 2d 228, 57 Cal. Comp. Cases 157]. Since the Gould case was decided prior to the 1994 revision of the medical fee
schedule and because the fee schedule had not been revised biennially as required by statute, the introduction of evidence regarding the medical provider's
training and qualifications may be considered in the determination of whether a fee in excess of the schedule is reasonable. Under the circumstances of that
case, it was appropriate to look to factors outside the fee schedule”
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies When billing for Out-Patient Surgery-
July 28, 2009
Section 9789.38 adopts the federal regulation (42 C.F.R. § 419.2) which addresses the practices of outpatient facilities. It does not address the providers of
durable medical equipment or restrict the number of mechanisms for billing for durable medical equipment that is implantable.
Ocean View School Dist. v. Workers' Comp. Appeals Bd., 72 Cal. Comp. Cas. (MB) 1683 (Cal. App. 2d Dist. 2007
A provider of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies who bills for the equipment can file a lien and get paid regardless of claim that it
should be included in "Outpatient Billing".
"In this case it is the equipment provider's billing and lien that is in issue. A restriction on the surgery center cannot automatically be applied to bar recovery from a
medical provider that is not subject to that regulation."
July 28, 2009
Section 9789.38 adopts the federal regulation (42 C.F.R. § 419.2) which addresses the practices of outpatient facilities. It does not address the providers of
durable medical equipment or restrict the number of mechanisms for billing for durable medical equipment that is implantable.
Ocean View School Dist. v. Workers' Comp. Appeals Bd., 72 Cal. Comp. Cas. (MB) 1683 (Cal. App. 2d Dist. 2007
A provider of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies who bills for the equipment can file a lien and get paid regardless of claim that it
should be included in "Outpatient Billing".
"In this case it is the equipment provider's billing and lien that is in issue. A restriction on the surgery center cannot automatically be applied to bar recovery from a
medical provider that is not subject to that regulation."
Failure to Perform Utilization Review Makes Medical Necessity Issues Moot
July 29, 2009
State Comp. Ins. Fund v. Workers' Comp. Appeals Bd., S149257, SUPREME COURT OF CALIFORNIA, July 3, 2008, Filed
Download in Work Doc /// Download in PDF
“The insurer referred the matter for utilization review but did not communicate its decision within the 14-day statutory deadline set forth in § 4610, subd. (g)(1). A
workers' compensation judge found that the insurer's failure to comply with the statutory deadlines precluded it from relying on the utilization review process or on
its doctor's report to deny the requested treatment”
July 29, 2009
State Comp. Ins. Fund v. Workers' Comp. Appeals Bd., S149257, SUPREME COURT OF CALIFORNIA, July 3, 2008, Filed
Download in Work Doc /// Download in PDF
“The insurer referred the matter for utilization review but did not communicate its decision within the 14-day statutory deadline set forth in § 4610, subd. (g)(1). A
workers' compensation judge found that the insurer's failure to comply with the statutory deadlines precluded it from relying on the utilization review process or on
its doctor's report to deny the requested treatment”
About UR and causation decisions:
A denial issued directly from the reviewing physician or URO to the primary treating physician on causation grounds alone could be found in violation of 8 CCR §
9792.6(s), § 9792.9(j) and probably § 9792.9(l), as well as the express wording of Simmons, which states the UR reviewing physician does not have the authority
to determine causation.
A denial issued directly from the reviewing physician or URO to the primary treating physician on causation grounds alone could be found in violation of 8 CCR §
9792.6(s), § 9792.9(j) and probably § 9792.9(l), as well as the express wording of Simmons, which states the UR reviewing physician does not have the authority
to determine causation.
About UR and causation decisions:
A denial issued directly from the reviewing physician or URO to the primary treating physician on causation grounds alone could be found in violation of 8 CCR §
9792.6(s), § 9792.9(j) and probably § 9792.9(l), as well as the express wording of Simmons, which states the UR reviewing physician does not have the
authority to determine causation.
A denial issued directly from the reviewing physician or URO to the primary treating physician on causation grounds alone could be found in violation of 8 CCR §
9792.6(s), § 9792.9(j) and probably § 9792.9(l), as well as the express wording of Simmons, which states the UR reviewing physician does not have the
authority to determine causation.
| CALIFORNIA WORKERS COMPENSATION COLLECTIONS FOR LIEN CLAIMANT REPRESENTATION AND MEDICAL PROVIDERS |
workcompliens .com |
 |  |  |  |  |
July 26, 2010: Article:
Compensable Consequence Injuries
- The California law of workers' compensation has long followed a principal commonly known as the ''compensable consequences'' doctrine.
July 06, 2010: Article
Cal Lab Code § 4903.5
- The Workers Compensation Appeals Board agreed with this assertion that a medical provider would not know when the case had been resolved if
the settlement documents had not been served on the medical provider, therefore stopping the running of the six month to file a lien when the case
is resolved until the medical provider was served with those documents.
June 25, 2010 Article:
PPO Discounts / Hartford
- The reason for the inconsistencies by the Courts with the purchases and selling of contract discounts is that the defendants put on an admirable
magic show at trial and in their recons so that the Courts cannot see through the mazes of smoke and mirrors. The selling and purchasing of
contract discounts is just plan wrong, nothing more, and nothing less
June 05, 2010: Article:
Transfer of Care into the MPN
- "Medical, surgical, chiropractic, acupuncture, and hospital treatment, including nursing, medicines, medical and surgical supplies, crutches, and
apparatus, including orthotic and prosthetic devices and services, that is reasonably required to cure or relieve the injured worker from the effects
of his or her injury shall be provided by the employer. In the case of his or her neglect or refusal reasonably to do so, the employer is liable for the
reasonable expense incurred by or on behalf of the employee in providing treatment."
Director Rule 30(d)(3)
- California Code of Regulations, title 8, section 30(d)(3) (Administrative Director Rule 30(d)(3)), which states that when a claim has been entirely
denied by the defendant only the employee may request a panel of Qualified Medical Evaluators, is invalid because it conflicts with Labor Code
sections 4060(c) and 4062.2 and exceeds the scope of section 5402(b
Medical Provider Alert: May 25, 2010
- Recently I saw an EOB from Comp IQ that not only reduced the Hospital Bill under a questionable PPO contract but also took an additional 25%
(approximately $7,000.00) reduction without explanation. Unsure if this is a one-time error or a questionable policy of Comp IQ, but providers
should examine these EOBs carefully and make sure all the numbers are accurate
May 22, 2010: Article:
Article On: Assembly Bill 1177 (AB 1177) chaptering California Labor Code §5307.11
By Lloyd Godin
Lien Dept Mgr
ARM Solutions, Inc
LGodin@armsolutions.net
- "The Defendant’s assert, that the one word in Insurance Code § 1063.1 that being the word “assignment” and the one word in the relationship
between the medical provider and its Collection Company, “Assigns for Collection”, allows CIGA to be the recipient of unjust enrichment in not
paying the obligations of an insolvent insurance carrier, which was and is the sole purpose for the creation of CIGA. "
Phrase of the Week - Discovery
- “Attached to the Notice is a notice for production of documents that is a veritable laundry list of documents, most of which appear utterly unrelated
to the issues currently pending in applicant's case.”
May 11, 2010: Article:
- Carrier Seeking Reimbursement for Medical Benefits Paid
"No one can operate a business on receipts only conditionally possessed, and medical providers are no exception. Thus we have determined the
restitution orders were unfair and must be annulled.”
- UR for Admitted and Denied Case
Article on Utilization Review for Admitted and Denied Cases Made Simple
Excluding Defense QME Report
Pursuant to 8 CCR 30 (d)(3), once a claim has been denied in its entirety, only the employee may request a Panel QME. Therefore, the Courts must
look to the reports of the self-procured treating physician.
HCO has 90 days of medical control
HCO has 90 days of medical control, then injured worker may treat with his / her own provider.
Initiate the AME/QME
(2) A utilization review physician finds that a treatment is medically necessary but questions whether the need for that treatment is causally related
to the industrial injury, the defendant must either: (a) authorize the treatment;
or
(b) timely deny authorization based on causation within the deadlines set forth in section 4610(g)(1); timely communicate the denial based on
causation to both the treating physician and the applicant within the deadlines set forth in section 4610(g)(3)(A); and timely initiate the AME/QME
process within 20 days of the receipt of the utilization of physician's report, if the employee is represented by an attorney, or 30 days, if the
employee is unrepresented, in accordance with section 4062(a)*; and
 | Post “Kunz” pre “Tapia” -- "Valdez" |
The WCAB also concluded that the Official Medical Fee Schedule does not apply when an employer denies liability for a claim.
 | Flowchart "Thomas Finding" |
April 21, 2010 Article
The ACOEM Guidelines indicate (page 391) that the initial assessment of patents by the primary treating physician (“PTP”) “…should screen for potentially
April 20, 2010 Download
Sample Points and Authorities on Issue of CIGA and Assigned Claims
April 16, 2010 Article:
24-VISIT CAP ON PHYSICAL MEDICINE
It is appropriate under liberal construction per Labor Code 3202, to review and determine the appropriateness of allowing more than 24 visits especially in
this case where only limited visits were prescribed (six sessions) and where the purposes of the treatment falls outside the definition of physical therapy
April 14, 2010:
DISCOVERY
Although, what is discoverable has its long radius of inclusion, it does not mean that all things that the defense requests are discoverable, and must be
objected to. The point being is that when a Lien Claimant is served with a notice to produce from a defense attorney it must be responded to before the
defense gets a motion to compel discovery from the Judge. Supply what you think relates to the claim and what is reasonable and object to those you think
is burdensome, unrelated, privileged, etc.,. But you have to respond absolutely, failure to respond will certainly have negative consequences.
April 13, 2010:
LACHES –
Based on the maxim that equity aids the vigilant and not those who procrastinate regarding their rights; Neglect to assert a right or claim that, together with
lapse of time and other circumstances, prejudices an adverse party. Neglecting to do what should or could, have been done to assert a claim or right for an
unreasonable and unjustified time causing disadvantage to another.
April 07, 2010: Issue:
Usual ands Customary Charges
Lien Claimant is entitled to payment of its reasonable, usual and customary charges (not exceeding what is charged non-industrial patients) (Valdez)
Post / View Comments
April 02, 2010: Article:
SELF-PROCURED MEDICAL TREATMENT AND GETTING PAID USUAL AND CUSTOMARY FEES.
March 31, 2010 Article
California Insurers Seeking Second Round of Reductions of Medical Bills.
March 30, 2010: Article
CIGA on Assigned Claims
When a medical provider assigns its rights and title to a collection account, is CIGA responsible for payment of that “assigned claim”?
Post / View Comments
March 2010 Article
the employer cannot, as an alternative to utilization review, dispute the treatment request under the general dispute resolution framework set forth in section
4062, subdivision (a) (section 4062(a))
Article On Utilization Review
failure to conduct a timely Utilization review “renders its arguments that the treatment is not medically necessary moot”.
About UR and causation decisions:
A denial issued directly from the reviewing physician
Tolling of The Statutory Filing of Liens
"To the extent that the WCJ finds that the notice described in Labor Code § 4904(a) was given to the defendant, we find that the defendant was required to
comply with WCAB Rules 10886, 10888, and 10890. Pursuant to Labor Code § 4904(a),
Lien Claimants Are Getting Issued “Notice of Intention To Dismiss Lien Claim” For Failure to Appear At Hearings Other Than Lien Hearings.
8 CCR 10240 ( set forth in full at end of this article) puts forth the requirements for necessary and unnecessary appearances.......................................