Presented exclusively by Sienna Staffing
inside:
- Editor's 2 cents: Regulation Is Here Again
- Beware of the Multi-Disciplinary Practice Scam
- The Rules of the California Game: An Orthopaedic Surgeon looks at Workers' Compensation
- Issues Under Consideration at the California Applicant’s Attorneys Association Conference
- Ask the Doctor: How the ACOEM Guidelines Suggest the Use of Testing
- Legal Update: Buzz from the Street: Questions and Issues from the New Legislation
- Events Calendar
- Poll: Does Rate Regulation Need to be Enacted?
- June Poll Results
- The Last Laugh
 |
Regulation Is Here AgainWilliam Nathans Just when you think that the legislature is through screwing up the workers compensation system, some of them decide it is time to try and close the barn door after the animals have escaped. There is a bill currently before the Legislature to regulate the rates that insurers charge employers. If they hadn’t deregulated the industry by moving to open rating under Pete Wilson, we would not be facing a crisis in the workers compensation community. CIGA would not be facing the financial crisis it currently is, and SCIF would not be embroiled in a power grab by the insurance commissioner and the attendant litigation that is wasting the taxpayer’s money. Money that could well be spent elsewhere. Like I don’t know….. maybe for education. Deregulation has not worked in any industry. Look at the bankruptcy of PGE and the airlines. We are seeing the same thing in workers compensation. The carriers deluded themselves by thinking they could keep business with deregulation, when common sense would have suggested that business will always go to the lowest bidder creating unrealistic pricing in the marketplace. The net result was a myriad of carriers going down the tubes and placing an undeserved strain on the remaining carriers and businesses that have to fund CIGA. Regulation is a good idea, but a little late in coming. Please e-mail at bill@siennastaffing.com with your comments. |
 |
 |
By Lori Webb, D.C., Q.M.E. SB 228 and SB 899 affect every health care professional in some way or another. Now special tests, referrals, consultations, and even treatment rendered by the PTP can go through the Utilization Review process. It seems that no one provider is immune to the far reaching effects of these new laws. Providers are becoming more creative in how they are dealing with the new laws. Providers are turning to multi-disciplinary practices, building relationships with other providers so that they can cross-refer, and trying to use the TTD as a bargaining chip. Be on the lookout for multi-disciplinary practices. Usually there is a chiropractor, an acupuncturist, and a medical doctor all in the same office. The medical doctor most likely only works 1-2 days in the office. If the PTP is a chiropractor and he feels that his treatment will get denied due to the UR process, he quickly switches care to the medical doctor in the group. This medical doctor then refers the claimant out for “work conditioning” or “therapy”. The work conditioning or therapy is done in the office by the chiropractor, thus allowing the chiropractor to continue treating the claimant. Another likely scenario is that of the chiropractor and physical therapist referring patients to each other. When the limit of 24 chiropractic visits is getting close, the chiropractor will refer the claimant out to physical therapy. This referral will go through UR and will likely get approved. The physical therapist can also scratch the chiropractor’s back. When the 24 limit of physical therapy is up, the physical therapist will recommend that the claimant see the chiropractor for additional therapy and manipulation. This scenario can also be used in almost any provider-provider relationship. The orthopedist will refer patients to the chiropractor because he knows that the chiropractor is sending him all his patients that need second opinions. The possibilities are endless. Also, providers are now using TTD as leverage to obtain more visits. Providers feel that they can keep the claimant out on TTD as long as necessary and there is no incentive to return the claimant back to work. For example, I recently had a provider who had returned the claimant back to modified duty. He then submitted a treatment plan that would go over the 24 visit cap. His treatment plan went through Utilization Review and was denied as not medically necessary. The provider then put the injured worker back on TTD, stating that she couldn’t work if he could not provide treatment. The only way he would return the claimant to work again would be if more visits were authorized. These are just 3 examples of different ways I’ve seen providers deal with the new laws. I’m sure that this is just the beginning. These laws were meant to contain costs and to control the treatment of PTP’s that are providing excessive or unnecessary treatment. These laws now put checks and balances into the California Worker’s Compensation system. Unfortunately, these laws are adversely affecting the majority of providers who are ethical and looking out for the best interests of their patients. About the author: Dr. Webb is the Supervisor for Chiropractic Field Case Management for Professional Dynamics, Inc. She also is an Examiner for the National Board of Chiropractic Examiners and a Qualified Medical Evaluator. Professional Dynamics is a California based company that provides chiropractic case management, nurse case management, and utilization review services. You can reach Dr. Webb at Drwebb@adjustingworld.com. |
|
Jerome H. Davis, M.D
Muir Orthopaedic Specialists
www.muir-orthopedic.com
drdavis@adjustingworld.com
As we all know, the system in California is considered to be in great disarray. Costs to the insurers are supposedly amongst the highest in the nation, while benefits to the claimants are among the lowest in the nation.
When we read, look or listen to the mass media, all we hear is finger pointing from special interest groups, each accusing the other of being the problem.
Our legislators and applicants’ attorneys (often the same) accuse the medical profession of gouging and accuse the insurance companies of withholding appropriate treatment and gouging the public on premiums. The doctors accuse the attorneys of contributing to the high cost of premiums. The insurers blame the doctors and the attorneys and the sometimes doubtfully motivated patients.
It is strange to me that the media and the public haven’t caught onto the fact that our legislative representatives are about 80% to blame for the high cost.
They originally made the rules of the California game. The game rules are defined by legislative language. This legislative language mandates that if the workers’ injury on the job or cumulative stress on the job contributes only to a “scintilla” or 1% to the claimants’ residuals, then those residuals are considered to have arisen out of and in the course of employment.
Along the same lines, California code states that apportionments can only relate to previous disability in the workers’ compensation system and not to a pre-existing condition. These words alone account for millions of wasted dollars in our system.
This language ensures that countless patients with pre-existing conditions, such as osteoarthritis of the knees, degenerative disc disease of the cervical or lumbar spine, obesity and diabetes, become lifelong wards of the workers’ compensation system, even though 90 to 95% of their residuals can be related to a pre-existing condition and not to “cumulative stresses”, etc...
It is laudable and appropriate in every way to render excellent care to injured workers and provide disability protection for those legitimate injured workers who require it.
We are not talking about the roofer who falls off a roof and sustains serious head injuries or long bone fractures.
Because of legislative language, two conditions that occur commonly in the general population have been categorized as industrial. In many cases their categorization as industrial is just medically untrue.
One example of such a condition might be carpal tunnel syndrome.
In the last ten to fifteen years, carpal tunnel syndrome has been identified with computer use.
Although carpal tunnel syndrome is associated with some specific industrial activities, such as using jackhammers, working as a meta cutter or grocery store checker, current studies indicate that there is no relationship to the use of computers.
Except for a few well documented industrial activities, the most important factor in carpal tunnel syndrome is probably a genetically small carpal tunnel volume. The occasional confounding medical condition such as diabetes, thyroid disease, undeclared collagen disease or pregnancy, can both cause and exacerbate carpal tunnel syndrome.
Let’s look a moment at Australia. They have just categorically stated that carpal tunnel syndrome in NOT an industrial condition. The result of this statement is an immediate drop-off, not only of claims, but of carpal tunnel surgery.
In his next article Dr. Davis will address how the conditions of degenerative disc disease and disc herniation can also be related to genetic factors.
Dr. Davis currently practices general orthopedic surgery with a special interest in sports medicine at Muir Orthopaedic Specialists. He also serves on the demanding trauma service at John Muir Hospital, and is a Qualified Medical Examiner for California.
Luis Pérez-Cordero, MA, AAPMR
Permanent Disability Rating Specialist
pdrating@pacbell.net
WWW.PDRATINGS.COM
July 4th: The 77th day since SB 899 was signed.
Attending multiple seminars can help complete and balance our understanding of the legislative changes and possible outcomes in our day-to-day claims handling. Of course, bearing in mind the inclination of the presenting ‘expert’ panelists, since our manageable caseloads have to be administered under old/new or in-between laws.
Stephen Kline, Esq., said in his March Article: “…as the experts disagree, the courts will decide.” In a system of laws, that is the decisive guide in legislative interpretation.
In Dispute?
850+ attendees were present at the California Applicant’s Attorneys Association Conference. Multiple panelists in10 Sections addressed such topics as:
Handling Psychiatric Claims under the New Law
Questions to Consider: (Q:) What is the correlation of the AMA Guide’s 5 levels of impairment to the 8 work functions?
Delivery of Medical Care in 2004(ACOEM)
1st case dealing with ACOEM: Leon Smith vs. Churn Creek Construction & SCIF.
Q: Could this case be a guide on how to appeal or rebut ACOEM? Was UR Doctor’s denial of treatment based on ACOEM or other ‘scientific evidence’? Will this decision lead to more depositions of UR Doctors?
The Ethics of Settlement
Q: Is SB 899 creating Uncertainties, Added Responsibilities, and a demand for Higher Standards due to the need to process greater amounts of information?
Apportionment Under The New Law [new LC § 4663(a)]
A highly disputed area, for which we will likely see well-coordinated efforts in the development of ‘new’ case law and/or the preservation of existing law.
Q: Is Fuentes Abolished because of the deletion of LC §4750 and LC § 4663? Does the new code speak to legal or medical causation of Permanent Disability?
Q: Is the IMC's Physicians Guide definition of Apportionment/Causation still applicable? Are Danielle/Wilkinson/Neulle valid legal arguments?
The Most Important Cases
PEBWORTH vs. WCAB (March 2004) – This case has taken on new meaning after the implementation of SB 899. Although not the initial intent of this case, guidance (using old procedures) for what to do when there are gaps in the law can be found in this decision.
Q: Which changes can be retroactive – procedural or substantive? Are procedural changes for the enforcement of existing rights retroactive?
James Mason v. Lake Delores Group (April 2004)
Q: What is and what is not employment?
The Coming of The AMA Guides
We must all familiarize ourselves on the 5th Edition of the AMA Guides - it is our responsibility to make certain that the evaluating physicians (PTP or QME preparing the comprehensive P&S Report) properly address all issues.
Q: Aren’t measurable-clinical objective factors the core of the AMA Impairment Rating? (Before adjustment for age and occupation)
Q: Can the P&S evaluator perform an MDT calculation before first modifying the impairment percentages by the schedule’s variances for age and occupation?
Q: Will segmental limitations of spinal motion be rated separately and/or in the same manner that we now combine objective factors in a single extremity?
A draft of what a new comprehensive schedule might look like based on the new/old labor codes, as well as the ACOEM and AMA Guides is in the works. But first further training on Evaluating Impairment – Using the AMA Guides, and the ABIME’s Report Writing Seminar.
How the ACOEM Guidelines Suggest the Use of Testing
Alan C. Roth, MD JD
drroth@adjustingworld.com
As you recall my practice includes the treatment and evaluation of Neck, Spine, and Extremity pain with Neurological or Musculoskeletal origin. The ACOEM (American College of Occupational and Environmental Medicine) guidelines for the moment have been accepted as the recommended guidelines for reasonableness of both treatment and testing. They are only guidelines however. References stated here are from the 2nd edition, 2004. Statements contained here are not necessarily those agreed upon by the author of this column, but are from the guidelines themselves.
Musculoskeletal pain that develops with minimal exposure to actual work, related to positioning of equipment involving several areas of the back or extremities may be unrelated to work.
For conditions discussed in the guidelines, few useful or cost effective tests exist for the average patient or problems in the first few weeks.
For Independent Medical Examiners: If clarification of situations are necessary, the examiner may order special tests depending on what work up has been completed and the quality of the past tests.
Neck Pain: In the absence of red flags which include Fracture, tumor, infection and cord compromise, no tests are indicated including x-rays in the first month. After the first month, for only strain or neck pain alone, no tests are required. In case of radiculopathy after 6 weeks, MRI and EMG can be completed. EMG can clarify nerve root problems in the case of pre-op or pre epidural injections. In the cervical region only, preoperatively, discograms may be helpful, they don't believe Lumbar discograms are useful.
Shoulder pain: MRI only in the case that the patient is going to surgery anyway. Arthrograms are helpful if no MRI is available and preop. In the case of adhesive capsulitis and unknown etiology, and MRI is allowed.
Hand/wrist/forearm: No tests for the first 6 weeks, unless ruling out scaphoid fracture in which case, bone scan and x-rays are ok.
Low back: No tests for 6 weeks including x ray, unless red flag, see above (neck) in addition to cauda aquina. No x-ray even after 6 weeks unless aides in patient management. EMG and nerve conduction studies can be completed in the case of subtle focal neurological dysfunction after 4 weeks. Discography not reasonable for low back problems. If requested, however, it can be performed only after 3 months after onset, with failure of conservative care, satisfactory results from detailed psychosocial assessment, is a candidate for surgery. They site studies on discography which do not support its use as a preoperative indication for IDET or fusion. They are felt to be unreliable and produce symptoms for more than a year. There may not be a correlation anatomically with tears.
Knee: MRI only if surgery is seriously contemplated. "Repeated trauma with walking or crouching under a load is thought to contribute to tendonitis and nonspecific knee pain although the strength of association is not great."
X-ray of the knee only if there is blood in the joint or a history of trauma or suggestion of degeneration.
Alan Roth, MD JD
 |
Stephen L. Kline, Esq.
|
|
POLL
Results of the June PollIs the New Permanent Disability Rating System Going to Save Money?
|
||||
|
| Events
Calendar |
|||
|---|---|---|---|
| July |
|||
| DATE/TIME | EVENT/CONTACT | LOCATION | SPEAKER/TOPIC |
Tuesday
|
VICA Luncheon$35 for VICA members,
|
Marriott Hotel
|
Speaker:
|
Thursday
|
DVICA LuncheonContact: dvica@dvica.org |
Scott’s Seafood
Restaurant |
Speaker:
|
Thursday
|
SFICA July
|
TBA |
Speaker:
|
Friday
|
SBICA LuncheonAdjusters can Attend Luncheons for $5 during “Summer Sizzle”call or email for detailsContact: |
Eight Forty North First Restaurant840 N. 1st Street (near Hedding St.) |
Speaker:
|
Wednesday
|
SFICA LuncheonContact: |
Oakland Marriott City Center1001 Broadway |
Speaker:
|
Have an insurance related event coming up?
Email us the relevant information and we can place it in our Events Calendar. Send us a note with the relevant facts and sponsoring organization to eventform@adjustingworld.com
Join our email list