Author: WorkCompAcademy

In 1993 the California legislature directed the Division of Workers’ Compensation to put together comprehensive information about workers’ compensation in California. The result is the Workers’ Compensation Information System (WCIS). The WCIS has 4 components: the First Reports of Injury (FROI) reporting guidelines were implemented March 1, 2000. The Subsequent Reports of Injury (SROI) reporting guidelines were implemented July 1, 2000. Reporting of annual summary of benefits began January 31, 2001. Medical bill payment reporting regulations were adopted on March 22, 2006.

Regulations require medical services with a date of service on or after September 22, 2006 and a date of injury on or after March 1, 2000 to be transmitted to the DWC. Medical services are required to be reported to the WCIS by all claims administrators handling 150 or more total claims per year.

Electronic data interchange (EDI) is the computer-to-computer exchange of data or information in a standardized format. In California workers’ compensation, medical EDI refers to the electronic transmission of detailed medical bill payment records information from senders to the DWC. Medical bill payment data are transmitted in a format standardized by the American National Standards Institute (ANSI). The International Association of Industrial Accident Boards and Commissions (IAIABC) adapted the ANSI file standard to workers’ compensation.

The Division of Workers’ Compensation (DWC) is planning to transfer the Workers’ Compensation Information System (WCIS) from International Association of Industrial Accident Boards and Commissions (IAIABC) Medical Release 1.1 to IAIABC Medical Release 2 in the fall of 2014. This migration has significant transaction improvements that address the industry’s needs. In general it is believed to be efficient and easier to implement. Moreover, it puts in synch the CA WCIS data collection with the Divisions electronic billing regulation that went into effect on October 2012. It will also bring the WCIS data collection to the current industry standard of doing business between providers and insurers.

The California Electronic Data Interchange (EDI) Implementation Guide for Medical Bill Payment Records for Release 2 and the programming logic for validating incoming data for the new release are posted to the online forum, so that members of the public may review and comment on the proposal. This Guide is adopted by the Administrative Director of the Division of Workers’ Compensation pursuant to the authority of Labor Code sections §138.6, and §138.7. The Guide contains the California – specific protocols and excerpts from the IAIABC EDI Implementation Guide for Medical Bill Payment Records Release 2, explains the technical design and functionality of th e WCIS system, testing options for the trading partners, instructions regarding the medical billing data elements, and reporting standards and requirements.

The forum has been posted online the DWC forums web page under “current forums.” Comments will be accepted on the forum until 5 p.m. on Aug. 5.

Horace Grant played professional basketball from 1987 through March 12, 2004, when he injured his hip and was unable to continue in that line of work. His last year of employment as a professional athlete was with the defendant Los Angeles Lakers . In 2011, applicant filed a claim of cumulative trauma industrial injury against the Lakers.

The WCJ relied upon the reporting of applicant’s two QMEs to find that applicant was 90% permanently disabled without apportionment to any non-industrial factors. The WCJ implicitly accepted the view expressed by Dr. Styner that the AMA Guides do not straightforwardly apply to the applicant because he is a professional athlete and not a “normal person,” and that the holding in the consolidated Almaraz/Guzman cases authorized the physician to construe the AMA Guides in a way that “allows for a higher rating.”

Dr. Styner justified his rating with the following comments. “Mr. Grant was a professional basketball player for a long period of time, Professional basketball is a profession that is very exclusive and requires the participants to be in superb condition. Professional basketball players are also required to deal with daily severe pain and to be able to perform with severe pain. Furthermore, as part of the conditioning process, the basketball player must stay in tip top shape in order to be able to keep his job. This involves repetitive lifting, running, jumping, squatting, etc while lifting weights far in excess of what the average person can lift. Based on the unique qualifications required to be a professional basketball player, it is simply unreasonable to use the usual charts in the AMA Guides to rate this patient. These charts were designed to measure impairment in the average worker, not a top tier professional athlete such as Mr. Grant. Fortunately for the patient, the recent Almaraz/Guzman ruling has allowed the physician to rate the patient using the any [sic] chart within the AMA Guides that he feels is appropriate and that is what I did in my report of 8/2011. I continue to stand by my rating of this patient.”

The WCAB reversed the award in the panel decision of Horace Grant v Los Angeles Lakers ruling that “Dr. Styner’s application of the AMA Guides and understanding of the Almaraz/Guzman holding are incorrect, and his reporting is not substantial evidence in support of the WCJ’s decision.”

The WCAB reasoned that “Dr. Styner is correct in noting that there is a relationship between an injured worker’s occupation and the level of permanent disability that results from certain injuries. However, that occupational factor is already accounted for in the rating string. In this case, the DEU rater applied the occupational variant of 590J, which represents the most physically strenuous occupations. Thus, reference to applicant’s occupation as a professional athlete as reason to use other than the usual charts and tables in the AMA Guides to rate whole person impairment is unjustified. Moreover, Dr. Styner’s deviation from the usual method of measuring impairment under the AMA Guides just to obtain higher whole person impairment is contrary to the holding in Almaraz/Guzman.”

Because the WCJ’s relied upon medical reporting that is not substantial medical evidence, the December 5, 2012 decision was rescinded and the case was returned to the trial level for further proceedings.

Health insurance giant Anthem Blue Cross is spurning California’s new insurance market for small businesses, a potential setback in the state’s rollout of the federal healthcare law. Anthem, a unit of WellPoint Inc., is California’s largest insurer for small employers. The Los Angeles Times reports that the company’s surprising move raised concerns about the state’s ability to offer competitive rates and attract businesses to its new Covered California exchange that opens Jan. 1. Friday’s disclosure made Anthem the first big insurer in California to publicly pass on the small-business pool. Some other big names, such as UnitedHealth Group Inc. and Aetna Inc., have already opted out of California’s larger exchange for individual consumers. Anthem’s decision in California underscored that the small-business exchanges are the most susceptible to a lack of interest among insurers.

The state’s largest for-profit health insurer isn’t abandoning the small employer market, which is limited to firms with 50 or fewer workers. It said it would keep selling coverage to small companies outside the exchange, and it also remains one of 13 health insurers that will offer policies to individuals in Covered California.

Anthem led California with 31% of the small-employer market in 2011, according to the most recent Citigroup data. Kaiser Permanente was a close second with a 28% share, followed by Blue Shield of California with 18% of small firms. Both Kaiser and Blue Shield are expected to participate in the small-group exchange. Nonetheless, Anthem’s move caught many observers off guard. “That’s really surprising and not a good thing for the exchange,” said Micah Weinberg, a senior policy advisor at the Bay Area Council, an employer-backed San Francisco group. “Anthem is a very major player in the small-group market and you want a broad range of insurers, particularly the most compelling brand names.”

Covered California sought to downplay any potential fallout on rates and employer choice, likening Anthem’s departure to one airline pulling out of a highly competitive market. “We don’t think it will have a huge impact,” said exchange spokesman Dana Howard. “There are other companies that are just as big. This will be a competitive market.” Employers will learn more early next month when Covered California announces the health insurers and their proposed rates for the small-business exchange. In the first few years, the state estimates up to 200,000 small-business workers and family members may get coverage through the state’s market.

One concern for health insurers selling in exchanges is that too many customers with big medical bills pick a certain company and it absorbs a higher share of the medical costs among that population. “The reality is that risk is not spread equally in an exchange,” said Bruce Jugan, an insurance agent in Montebello and president of Benefitscafe.com, which sells health insurance to individuals and businesses. “If SHOP can offer comparable plans with lower rates then they will get a lot of business, even without Anthem Blue Cross participating,” Jugan added.

Anthem has come under fire from regulators recently over rate hikes for small businesses. Last month, California Insurance Commissioner Dave Jones asked the exchange to bar Anthem from its small-group market because of what he viewed as unreasonable premium increases. “I think Anthem withdrew because they felt they would be excluded or at a minimum they didn’t want to face additional debate” over their rate hikes, Jones said Friday. Covered California had said it would consider the commissioner’s request alongside other factors. Anthem said the recommendation by Jones had no bearing on its decision to drop out.

On July 9, 2013, the Workers’ Compensation Appeals Board announced its intent to modify the text of proposed amendments to its Rules of Practice and Procedure that had been the subject of a public hearing on April 16. The announcement stated that written comments regarding the proposed modifications would have to be received by the WCAB by 5 p.m. on July 25.

Following this announcement, some members of the workers’ compensation community requested the WCAB to extend the time for submitting written comments. The WCAB agreed that a limited extension of time was reasonable. Therefore, the WCAB extended the time for submitting written comments by an additional 15 days to Friday, August 9 by 5 p.m. The WCAB will consider only comments it has received by that time.

As previously announced, the proposed modifications to the initially proposed Rules and related documents are posted on the WCAB’s website. The originally proposed new and amended Rules and related documents may also be found at this site.

Additionally, to facilitate further public comments, the WCAB is presently in the process of adding to its website all public comments it has received regarding the proposed Rules amendments. The documents to be posted will include the written comments the WCAB received on or before April 16, a transcript of the April 16, public hearing, and the written comments the WCAB has received in conjunction with the July 9 announcement. The posting of these written comments will be periodically updated until the August 9 closure of the written comment period.

The address for submission of comments by e-mail is WCABRules@dir.ca.gov. The address for submission of comments by mail is: Neil P. Sullivan, Assistant Secretary and Deputy Commissioner, Workers’ Compensation Appeals Board, P.O. Box 429459, San Francisco, CA 94142-9459. The address for submission of comments by delivery service or personal delivery is: Neil P. Sullivan, Assistant Secretary and Deputy Commissioner, Workers’ Compensation Appeals Board, 455 Golden Gate Avenue, Ninth Floor, San Francisco, CA 94102.

The WCAB will consider all written comments regarding the proposed Rules modifications it receives by Friday, August 9 at 5 p.m. It encourages all interested members of the workers’ compensation community to participate in this important process.

Ronald Gerton incurred cumulative industrial injury to his low back while working as a firefighter for the City of Pleasanton. The parties’ AME Dr. Post used the range of motion method to rate applicant’s back impairment under the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition (AMA Guides) in accordance with the 2005 PDRS, and the physician opined that applicant has a 21% whole person impairment using that rating. With regard to apportionment, Dr. Post noted that applicant obtained a prior award of 3% permanent disability for a January 11, 2004 specific injury to the back, which was rated using subjective factors under the earlier 1997 PDRS.

However, the WCJ rejected this rating, and explained that the Diminished Future Earning Capacity (DFEC) adjustment factor contained in the 2005 Permanent Disability Rating Schedule (2005 PDRS) was rebutted at trial by the testimony and reporting of applicant’s vocational expert Eugene Van de Bittner, Ph.D., who opined that applicant’s work preclusions resulted in a 65% DFEC, and the WCJ used that 65% figure to find applicant’s 62% permanent disability after applying apportionment pursuant to the opinion of the parties’ Agreed Medical Examiner (AME) Michael Post, M.D.

Defendant petitioned for reconsideration contending that Dr. Van de Bittner’s reporting was not substantial evidence in support of the WCJ’s finding of 62% permanent disability. The WCAB granted reconsideration, rescinded the aware and remanded the case of Ronald Gerton v City of Pleasanton for further proceedings.

One of the problems with the award was that the vocational expert excluded the Applicant’s actual post-injury earnings in his calculations of diminished future earning capacity. Starting in 6/10, applicant performed some work as a type of construction supervisor for his older brother and younger brothers. His first assignment was to live at a multimillion dollar home in Carmel, California during a remodel project conducted by his older brother. Mr. Gerton supervised the work of construction workers at this home. He worked for about 6 weeks at the rate of about 40 hours per week. Since then he has assisted his younger brothers in apartment remodeling projects. Apartments are gutted and remodeled when tenants vacate the premises. In exchange for his services, his brothers will perform construction work at his home in Livermore and at his cabin. Since his retirement, he has continued to work 20 to 40 hours per week as a jobsite supervisor for his brother’s construction company. He works as much as he wants to work. He is paid $45 per hour for his time

The WCJ found that those earnings were artificially high because the work was being done for a close relative, applicant’s brother. Dr. Van de Bittner found that this work lies outside what applicant could expect to compete for in the open labor market and said it was essentially sheltered employment. “The charity of Applicant’s family should not be used to create a false impression of Applicant’s true capacity for earnings.”

The WCAB disagreed. It concluded “We find no evidence in the record that supports the WCJ’s conclusion that applicant was performing “sheltered work” or that his post-injury earnings are “charity” provided by his family as stated in the Report. Instead, the expected duties of a construction supervisor, the continuing availability of that work to applicant and the $45 per hour pay he receives for it indicates otherwise, as does applicant’s expressed interest in performing that same kind of work as a volunteer overseeing the remodeling of homes. Upon return to the trial level the record should be further developed on the issue of applicant’s post-injury earnings and whether his actual earning history should be utilized to evaluate his DFEC and permanent disability.”