Menu Close

Author: WorkCompAcademy

WCJ Cris Gondak to Become WCAB Deputy Commissioner

Chairwoman Ronnie G. Caplane of the California Workers’ Compensation Appeals Board: announced that WCJ Cris Gondak has been appointed to the position of Deputy Commissioner at the Workers’ Compensation Appeals Board.

As a Deputy Commissioner, Judge Gondak will supervise the Appeals Board’s staff attorneys, train and mentor new attorneys and act as counsel to the Commissioners when necessary. She will also participate in drafting regulation, en banc and significant panel decisions as well as participate as a panelist on cases as necessary.

Judge Gondak has been a Workers’ Compensation Administrative Law Judge in Santa Rosa and Oakland since 1998. Prior to that, she was a partner at Hanna, Brophy, MacLean, McAleer and Jensen in Oakland where she began her career in workers’ compensation law in 1981. Judge Gondak received her JD from U.C. Hastings College of the Law in 1975 and her BA from Stanford University in 1971.

Chairwoman Caplan said that “Judge. Gondak is a highly respected Workers’ Compensation Administrative Law Judge for her legal acumen, knowledge, evenhandedness and well-reasoned decisions. She brings a wealth of experience and a good sense of humor to the Appeals Board. We look forward to having Judge Gondak join us on July 1, 2013.”

San Bernardino Claimant Faces Identity Theft and Perjury Charges

Roberto Carlos Mendoza-Lazo, 45, of San Bernardino, has been charged with Identity Theft and Attempted Perjury.

In Jan. 2013, the San Bernardino County District Attorney’s Office, Workers’ Compensation Fraud Unit began a criminal investigation into alleged workers’ compensation fraud committed by Mendoza-Lazo. During the course of the investigation, it was revealed that Mendoza-Lazo used the social security numbers of two individuals to obtain employment.

According to Senior Investigator Jose Guzman, who is assigned to the case, the defendant also attempted to obtain workers’ compensation benefits using the same social security numbers.

“After confirming with the Inspector General of the United States Social Security Administration that the numbers were valid and not issued to the defendant, we contacted the victims and they wanted prosecution,” Guzman said.

Investigators located Mendoza-Lazo at his place of employment in San Bernardino County where he was arrested and transported and booked into the San Bernardino County Sheriff’s Department, Central Detention Center jail.

Mendoza-Lazo was arraigned on May 31st, and pleaded not guilty to all counts. Deputy District Attorney Scott Byrd will prosecute this case. If convicted as charged, Mendoza-Lazo faces four years, two months in county prison.

DWC Says Most Injured Workers Satisfied With Medical Care

The California Division of Workers’ Compensation (DWC) released its 2013 study on access to medical care for injured workers, which finds that most workers have nearby access to providers and are satisfied with the medical care they receive.

The Labor Code requires that DWC complete annual studies to ensure workers have access to medical care. New to this year’s report are data from medical claims submitted to the Workers’ Compensation Information System (WCIS). The other source for the report, completed by the Berkeley Research Group, was a survey of workers injured in 2011 and 2012.

“We’re pleased to see that the majority of injured workers have access to needed care without barriers,” said DWC acting Administrative Director Destie Overpeck. “At the same time, this study does show that improvements are needed to increase rates of recovery and job modifications.”

This study marks DWC’s first effort to review medical claims data in order to gauge injured workers’ access issues. Previous studies conducted in 2006 and 2008 focused solely on survey data. All three studies included a survey of injured workers to measure their satisfaction with the care they received. Although survey methods differed, the findings for each survey were similar: 85 percent of the injured workers noted they were satisfied or very satisfied with their care.

WCIS uses electronic data to collect comprehensive information from claims administrators. The WCIS medical claims data indicated that the number of injured workers who obtain care from specialists rather than general practitioners is increasing, while the overall number of providers treating injured workers has not changed. Among the 500 randomly selected workers 84 percent expressed satisfaction with their main health care provider and 85 percent of those whose saw specialists were satisfied with the care they received. 7 percent of workers reported that they were denied care. 85 percent of injured workers saw a health care provider, most frequently a general practitioner, within three days of their injury. The distance traveled to the first provider visit was most frequently less than six miles (55 percent) and took less than 16 minutes (59 percent). Injured workers reported receiving care through a Medical Provider Network 85 percent of the time.

CWCI Appoints New COO and CFO

Rena B. David has been named the Chief Operations and Chief Financial Officer of the California Workers’ Compensation Institute (CWCI), the Oakland-based nonprofit organization that serves as the research and educational arm of the California workers’ compensation industry.

Ms. David joins CWCI after having served as a consultant and manager with more than 25 years of experience in finance, data systems development, product development, workers’ compensation and group health pricing, health services research and hospital operations. The majority of her experience has been at Kaiser Permanente where she managed high-level consultants and programmers supporting a variety of data coordination/development, budgeting, pricing model development and medical risk assessment projects. In the mid-1990s, she was project lead for the implementation of Kaiser’s 24-hour care product combining group health and workers’ compensation medical care in Sacramento and San Diego. She also played a key role in developing and evaluating the performance of the Kaiser Permanente/State Fund Alliance Initiative. From 2006 to 2008, she managed the California Healthcare Foundation’s “In Search of Affordability Initiative,” which included consulting on the development of a 24-hour coverage carve-out model.

A graduate of Stanford University, where she earned a bachelor’s degree in human biology, Ms. David also holds master’s degrees in business administration and public health from U.C. Berkeley. In her new position, she will be responsible for CWCI’s accounting and budgeting functions, oversee the Institute’s general administration, human resources, facilities and systems, and provide support and expertise to the Research Department on designated research projects. Commenting on Ms. David’s appointment, CWCI president Alex Swedlow said “We’re very pleased to have Rena join the Institute staff. She is a great addition to our professional team, and her technical qualifications and familiarity with key industry issues will provide CWCI with thoughtful leadership and expertise.”

Researchers Review Medical Necessity for Air Ambulance Services

Air ambulance vendors have prevailed in workers’ compensation litigation allowing them to be exempt from state adopted maximum fee schedules. Courts have found that federal law regulating air carriers preempts state law. The cost of an air ambulance transport is therefore uncontrolled, and unfettered. However, their may remain legal challenges to these fees based upon medical necessity.

Researchers at the Stanford University School of Medicine have for the first time determined how often emergency medical helicopters need to help save the lives of seriously injured people to be considered cost-effective compared with ground ambulances. The researchers found that if an additional 1.6 percent of seriously injured patients survive after being transported by helicopter from the scene of injury to a level-1 or level-2 trauma center, then such transport should be considered cost-effective. In other words, if 90 percent of seriously injured trauma victims survive with the help of ground transport, 91.6 need to survive with the help of helicopter transport for it to be considered cost-effective. The study, published online in the Annals of Emergency Medicine, does not address whether most helicopter transport actually meets the additional 1.6 percent survivorship threshold.

The study summarized in an article in Science Daily, comes at a time when finding ways to cut medical costs has become a national priority, and the overuse of helicopter transport has come under scrutiny. Previous studies have shown that, on average, over half of patients transported by helicopter have only minor, non-life threatening injuries. For these patients, transport by helicopter instead of ground ambulance is not likely to make a difference in outcomes, and the additional risk and cost of helicopter transport outweighs the benefit, the study’s lead author, M. Kit Delgado, MD, MS,said.

In 2010, there were an estimated 44,700 U.S. helicopter transports from injury scenes to level-1 and level-2 trauma centers, with an average cost of about $6,500 per transport. The total annual cost is around $290 million. (Level-1 and -2 trauma centers are hospitals equipped and staffed to provide the highest levels of surgical care to trauma patients; level-1 centers offer a broader array of readily available specialty care, and also are committed to research and teaching efforts.)

Yet emergency helicopter transport sits in a cost-efficiency conundrum: It is most needed in remote, rural areas where transport by ground can take far longer than by air. These areas also tend to have sparser populations and therefore fewer calls for aid, making it difficult to recoup the overhead costs of maintaining helicopter services, Delgado said. In some areas of the country, however, helicopters are automatically launched based on the 911 call. “Once ground responders and the helicopter arrive, sometimes they may find patients who are awake, talking and have stable vital signs,” Delgado said. “The challenge is getting helicopters to patients who need them in a rapid fashion so the flight team can intervene and make a difference, but also know based on certain criteria who isn’t sick enough to require air transport.”

There is mixed evidence in the literature about the degree to which helicopter transport reduces mortality. It is therefore uncertain whether the routine use of helicopter transport is cost-effective for most patients in the United States when ground transport is also feasible. The study found that the cost-effectiveness also depends on regional variation in the costs of air and ground transport and the percentage of patients who are flown that have minor injuries.

DWC Posts Proposed Changes to QME Regulations

The Division of Workers’ Compensation (DWC) has modified the proposed Qualified Medical Evaluator (QME) regulations. DWC has electronically distributed the 15-day notice of modification to interested parties and has posted the modified regulation text and forms on the DWC website. Members of the public may comment on the modifications until 5 p.m., June 18. The proposed modifications include:

  • Section 13 is revised to require all QME applicant requests to add or remove a specialty to be in writing and include documentation that establishes the physician is board certified in the specialty
  • Section 26 is revised to clarify that QMEs may continue to request additional office locations up to the 10 office location limit
  • Section 30 is revised to state that an issued panel may be revoked by the medical unit if the panel was issued by mistake, misrepresentation of facts, or the parties have agreed to resolve their dispute by using an AME
  • Section 35 is revised to allow the claims administrator or injured worker to provide a letter to the QME or AME outlining the medical determination of the primary treating physician or the compensability issue that the evaluator is requested to address
  • Section 35.5 is revised to state that if the evaluator declares the injured worker permanent and stationary for the body part evaluated and the evaluator finds injury has caused permanent partial disability, the evaluator shall completer the Physician’s Report of Permanent and Stationary Status and Work Capacity and serve it on the claims administrator and the employee, together with the medical report
  • The application for appointment as QME (QME form 100) requires the applicant to indicate whether he or she is certified by a specialty board recognized by the Medical Board of California or the Osteopathic Medical Board of California or have qualifications deemed to be equivalent to board certification in a specialty by the Medical Board or Osteopathic Medical Board, and requires a copy of the board certificate and certificates completion of residency and fellowship training programs
  • The panel request form instructions are stricken. Instructions that explain how to fill out the form field by field will be posted with the final form.

The notice, text of the regulations, and forms can be found on the DWC website.

TTD Rates to Increase Slightly in 2014

California’s State Average Weekly Wage (SAWW) rose less than 1 percent from $1,059.38 to $1,067.25 in the 12 months ending March 31, 2013, which the California Workers’ Compensation Institute (CWCI) reports will boost temporary total disability (TTD) rates for 2014 work injury claims, as well as other workers’ compensation benefits that are tied to changes in the SAWW.

California’s TTD maximum rate for 2013 job injuries is $1066.72 per week, but with the marginal increase in the SAWW, CWCI calculates that the maximum TTD rate will rise to $1,074.64 per week for claims with injury dates on or after January 1, 2014. State law also links the minimum weekly TTD rate to SAWW increases, so the CWCI calculates that the minimum rate will edge up a fraction from the current $160 per week to $161.19 for claims with 2014 dates of injury. The Institute has confirmed both the minimum and maximum TTD rates for 2014 injury claims with the California Division of Workers’ Compensation.

Beginning next January, other workers’ compensation benefits also will be bumped up by the recent increase in the SAWW, including TTD paid 2 years or more after injury, life pension and Permanent Total Disability payments for injuries on or after January 1, 2003, and installment payments on death claims.

Underpayment of benefits results in penalties, so CWCI encourages claims administrators to review changes in benefit rates with legal counsel to assure that adjustments are appropriate and accurate.

OxyContin – Good News and Bad News

A new OxyContin formulation is providing relief for workers compensation payers strapped with paying for the illegal diversion of the prescription pain reliever. But unfortunately for society overall, heroin and other narcotics are replacing OxyContin as a drug of choice among addicts because the new formulation contains polymers that make it harder to crush for snorting or melt for injecting.

According to the story in Business Insurance, the abuse-deterrent OxyContin formulation was introduced in 2010. Then in 2012, a study in the New England Journal of Medicine found that abusers preferred to shift from the reformulated OxyContin to heroin and other high-potency opioids. The study relied on surveys completed by 2,566 people entering treatment programs because of opioid dependency. It revealed that before the release of the abuse-deterrent formula, 35.6% favored OxyContin as their primary drug. That dropped to 12.8% just 21 months later, after introduction of the new OxyContin formulation.

The survey also found that of all opioids used to get high at least once during the past 30 days, OxyContin fell from 47% to 30%. Heroin use nearly doubled during that time and was the most-used alternative, according to the survey relying on data collected from July 2009 through March 2012.

Meanwhile, pharmacy benefit managers said in their workers compensation drug-trend reports released in April that opioid prescribing dropped during 2012.Westerville, Ohio-based Progressive Medical Inc., for instance, said a drop in opioid prescriptions resulted from changing government prescribing guidelines, urine drug testing and the introduction of abuse-deterrent formulations.

That means the new formulations affecting pharmaceutical payer efforts to eliminate the diversion of addictive narcotic opioids also are helping. Diversion refers to using drugs outside their intended purpose, such as helping people with legitimate pain-management needs, to selling them on the street illegally.Payers have stepped up efforts to discourage diversion with measures such as urine testing to assure claimants are consuming prescribed opioids rather than diverting them.

This is good news for the workers comp industry. But the authors of the New England Journal of Medicine study, titled “Effect of Abuse-Deterrent Formulation of OxyContin,” wrote, the new formula reduced the abuse of one drug, but replaced it with a “drug that may pose a much greater overall risk to public health.”

And Barry Lipton, practice leader and senior actuary for Boca Raton, Fla.-based NCCI Holdings Inc. said during the rating and research organization’s recent 2013 Annual Issues Symposium, “It’s not good news for society, but it is a big pressure release for workers comp.”

Common Firbromyaligia Medication Does As Much Harm as Good

Among fibromyalgia patients taking either of two commonly prescribed drugs to reduce pain, 22 percent report substantial improvement while 21 percent had to quit the regimen due to unpleasant side effects, according to a new review in The Cochrane Library summarized by Science Daily. People with fibromyalgia suffer from chronic widespread pain, sleep problems and fatigue. The illness affects more than 5 million Americans, 80 percent of whom are women. The cause of fibromyalgia is unknown and currently there is no cure. Using a Quality of Life (QOL) scale for fibromyalgia, the studies reviewed reported QOL ratings lower than 15 on a scale of 0 to 100 even among patients on medications. The two medications often prescribed to treat fibromalgia are duloxetine, known by the brand name Cymbalta or milnacipran, commonly known as Savella.

“A frank discussion between the physician and patient about the potential benefits and harms of both drugs should occur,” noted the reviewers, led by Winfried Häuser, M.D. of Technische Universität München.

The authors reviewed 10 high-quality studies comprising more than 6,000 adults who received either duloxetine, milnacipran, or a placebo for up to six months. A substantial majority of study participants were middle-aged, white women.

“This is a very important study,” says Fred Wolfe, M.D. of the National Data Bank for Rheumatic Diseases. “There’s an enormous amount of advertising suggesting that these drugs really help, whereas the research data show that the improvement is really minimal.”

Treatment with drugs alone “should be discouraged,” the reviewers added. Instead, the review authors recommend a multi-faceted treatment approach including medications for those who find them helpful, exercises to improve mobility and psychological counseling to improve coping skills. “The medical field does poorly with the treatment of fibromyalgia in general,” says Brian Walitt, M.D., M.P.H., a co-author of the review and an expert in pain syndromes at Washington Hospital Center in Washington, D.C. “Chasing [a cure] with medicine doesn’t seem to work.The people who seem to me to do best sort of figure it out on their own by thinking about things, getting to know themselves, and making changes in their lives to accommodate who they’ve become,” concludes Walitt.

The only other medication approved for fibromyalgia treatment in the U.S. is the anti-convulsant pregabalin, known by the brand name Lyrica. The Cochrane Library plans to publish a review of its effectiveness later this year.

Intensive neuroscientific research is needed to reveal the underlying causes of fibromyalgia and other pain syndromes, say the researchers. In the meantime, combinations of various medications as well as combinations of drug and non-drug treatments may offer better symptom control for sufferers.

DWC Posts Revised Proposed Interpreter Services Regulations

The Division of Workers’ Compensation has again modified the proposed Interpreter Services regulations. DWC posted the modified regulation text and forms on the DWC website and electronically distributed the second 15 – day notice of modification to interested parties. Members of the public may comment on the modifications until 5 p.m. on June 14.

The proposed modifications include:

  • A new subdivision to allow certification by passing the National Board of Certification for Medical Interpreters (National Board) exam.
  • Requiring recertification as set forth by Certification Commission for Healthcare Interpreters (CCHI) or the National Board.
  • Revising section 9795.5 to state that certified interpreters for the purposes of medical treatment appointments and medical legal exams are listed in the CCHI and National Board website directories.
  • A new subdivision that requires a certified interpreter for the purposes of medical treatment appointments and medical legal exams who is not listed on the CCHI or National Board registry to provide proof of certification to the claims administrator upon request.

The notice, text of the regulations, and forms can be found here .