Category: Daily News

SB 863 created several new requirements for medical service providers when seeking reimbursement. This included the provision of a copy of a prescription for pharmaceutical services. After the passage of SB 863, several stakeholders reached out to the Legislature regarding the challenges of this requirement. Specifically, proponents note that there is no electronic method to transmit a paper prescription, and that the use of paper prescriptions is becoming increasingly rare. Additionally, some stakeholders have noted that other states have used electronic prescriptions, rather than paper prescriptions, as a method for combating opioid abuse.

Proponents of this new law noted that the Division of Workers Compensation’s electronic billing standard for pharmacy bills does not currently support the inclusion of attachments, making pharmacy billers unable to comply. Proponents also argue that a list of billed components provides the same information as prescription for pharmaceutical drugs, and that the requirement of a prescription may impact a pharmacy’s ability to fill workers’ compensation prescriptions, limiting access to medically necessary medication.

The California legislature has passed, and Governor Brown has signed SB146 which amends labor code section 4602.3. to correct these problems. S.B.146 was enacted as an “urgency statute” and thus it is effective immediately.

This new law (1) provides that a copy of a prescription for pharmaceutical services is not necessary unless the provider of services has entered into a written agreement, as specified, that requires a copy of the prescription for a pharmacy service;(2) allows an employer, pharmacy benefits manager, insurer, or third-party claims administrator to request a copy of the prescription during a review of any records of prescription drugs dispensed by a pharmacy; and, (3) provides that any entity submitting a pharmacy bill for payment, on or after January 1, 2013, and denied payment for not including a copy of the prescription from the treating physician, shall have until March 31, 2014 to resubmit those bills for payment.

The public eye and caustic scrutiny moves quickly to claims of industrial injury made by workers who are perceived by the public or the press to be “politically incorrect.” Last week the press was hard on John Pike, a former U.S. Marine with 17 years of law enforcement experience, who gained worldwide notoriety after he pepper-sprayed seated, unarmed Occupy UC Davis protesters who blocked police on a Quad sidewalk on Nov. 18, 2011. Pike applied for worker’s compensation, claiming he suffered psychiatric injury from the 2011 confrontation. Protesters threatened to picket the WCAB district office where his August MSC was to be held. The parties took the MSC off calendar to circumvent the planned protest.

This week the focus is on the tale of Henry Alvarez’s departure from the imploding San Francisco Housing Authority. When Alvarez went on paid medical leave back in February, before being fired in April, he took heat for setting up a restaurant in Berkeley while presumably too ill to do his day job as the executive director for the city’s public housing agency.

Now it turns out that Alvarez has filed a workers’ compensation claim contending he was injured from stress on the job – his full-time one at the Housing Authority, according to new stories. He is seeking disability payments, health care and a voucher worth up to $10,000 for job training. Alvarez contends that he was injured on Jan. 29, records show. That’s four days after he requested his leave of absence for “personal reasons” and indicated he would not seek to renew his contract, which expired in June.

The story in the San Francisco Chronicle characterizes his claim as “laced with irony.”

Alvarez filed the claim April 26, about two weeks after he was fired amid mounting concern about his leadership of the public housing agency, which was about to run out of money, was rated one of the two worst in the state, and was the subject of a federal probe into its contracting practices. The Housing Authority was also defending itself against lawsuits from three former employees, including two who said they were discriminated against for taking paternity or disability leave.

In one case, Beverly Bernell Myres, a workers’ compensation analyst with the Housing Authority, said she was fired while out on disability leave with a knee injury. Her lawsuit alleges Alvarez asked in a meeting, “How can the workers’ comp person be out on workers’ comp?” He also allegedly “made derisive comments” about her disability, the suit says. “We find it the height of hypocrisy that after an extensive record of saying that anyone who takes workers’ comp is a malingerer and a fraud, Mr. Alvarez then files for it,” said Heidi Machen, Myres’ attorney.

San Jose-based EK Health Services Inc., a national workers’ compensation managed care company, has opened its locally based national medical bill review services office in a new, larger site.

Formerly operating at 2081 Arena Blvd. in Sacramento, the local office now comprises 10,000 square feet at 6970 Destiny Drive in Rocklin.

“We reached capacity in our previous location and lacked room for future expansion of staff and services,” said Kerri Lierman, EK Health’s operations vice president.

The Office of Administrative Law has approved the DWC final version of interpreter services regulations, one of the sections that implemented major reform provisions of Senate Bill 863. The interpreter services regulations went into effect on August 13. The final version of the interpreter services regulations differs from the emergency regulations as follows:

The regulations specify different standards for interpreters based on where services are provided. The first standard applies to interpreters providing services at a hearing, deposition or arbitration; while the second set applies for those interpreting for a medical appointment or medical legal exam.

Interpreting at a hearing, deposition or arbitration:
Interpreters must be certified or provisionally certified to qualify to be paid for interpreter services at a hearing, deposition or arbitration. Names of certified interpreters are listed on the State Personnel Board webpage or the California Courts webpage.

Provisional certification indicates that the individual has been deemed qualified to perform interpreter services when a certified interpreter cannot be present. Provisional certification is made by agreement of the parties, based on a finding by the workers’ compensation administrative law judge conducting a hearing that the individual is qualified to interpret at the hearing, or by an arbitrator conducting an arbitration that the interpreter is qualified to interpret at the arbitration.

Interpreting for a medical appointment or medical legal exam:
Interpreters must be certified, certified for medical treatment appointments or medical legal exams, or provisionally certified in order to be paid for interpreter services at a medical treatment appointment or medical legal exam.

Certified interpreters’ names are listed on the State Personnel Board webpage or the California Courts webpage.

Interpreters certified for medical treatment appointments or medical legal exams qualify through successfully passing the Certification Commission for Healthcare Interpreters (CCHI) exam or by passing the National Board of Certification for Medical Interpreters (National Board). A CCHI certification or credential indicates the name of the interpreter and the language for which he or she is certified to provide interpreter services. The certification procedure is detailed on the CCHI website. CCHI credentials are valid for four years and specify the language the interpreter for which the interpreter is certified. The National Board certification is valid for five years.

Interpreters can also be provisionally certified as an interpreter in this category is the claims administrator has given prior written consent to the interpreter providing services or if the injured worker requires interpreter services in a language other than Spanish, Tagalog, Arabic, Cantonese, Japanese, Korean, Portuguese, and Vietnamese. In this case, the physician may use a provisionally certified interpreter if the record of the medical evaluation documents the need and the language required

Interpreter directories are maintained as follows:
–  Certified interpreters are listed at on the State Personnel Board webpage or the California Courts webpage;
–  Certified interpreters for the purposes of medical treatment appointments and medical legal exams are listed in the registry for Certification Commission for Healthcare Interpreters (CCHI) or National Board of Certification for Medical Interpreters (National Board).

Proof of certification may be requested by the claims administrator and shall be provided by the certified interpreter for the purposes of medical treatment appointments and medical legal exams if the interpreter is not listed on the CCHI or National Board website directory.

Interpreter services FAQs with additional information on the new regulations are posted here.

Doctors who are the most worried about malpractice suits are more likely than less fearful colleagues to order extra diagnostic tests and refer patients to emergency rooms, even if the real threat of a lawsuit is low, according to a new U.S. study reported in Reuters Health.

The practice of so-called defensive medicine “is one of those things that everyone knows goes on, but doesn’t know how to control,” said Michelle Mello, senior author of the new analysis and a professor of law and public health at the Harvard School of Public Health in Boston. The problem is a driver of excessive healthcare costs, but tackling it effectively requires a better understanding of what drives defensive medicine, Mello and her colleagues write in the journal Health Affairs.

In earlier research, Mello found that medical liability and defensive medicine accounted for approximately $55.6 billion or 2.4 percent of U.S. healthcare spending in 2008. “It’s an area where we can chip away at healthcare costs without causing pain to the patient, since these are services ordered not primarily because doctors think they’re medically necessary,” Mello told Reuters Health.

Past research has surveyed doctors about their behavior or their level of concern about malpractice, according to Emily Carrier, a senior researcher at the Center for Studying Health System Change in Washington D.C. and lead author of the new study. Other researchers have gauged the amount of defensive medicine in everyday practice by looking at insurance claims, she said.

To get a better sense of the reasons doctors may engage in defensive medicine, Carrier, Mello and their coauthors combined both approaches. The researchers started with a database of 1.9 million Medicare claims for 2008 as well as responses to a survey that same year that asked some 3,400 doctors about their malpractice concerns. Among the Medicare patients in the database, there were 29,000 who had visited an office-based physician that year for one of three complaints: chest pain, lower back pain or headache, but who were not later diagnosed with a serious illness related to that complaint. “The three complaints were chosen, in part, because each could indicate relatively minor problems, but could also suggest more severe and even life-threatening issues that would be likely to trigger testing in a risk-averse provider,” Carrier told Reuters Health in an email.

Based on the survey results, the researchers designated doctors as having a low, medium or high level of concern about malpractice, and then linked those doctors using the claims data to the tests they had ordered for patients. The team found that patients with a headache who saw a physician with a high level of malpractice concern were more likely to receive advanced imaging like a CT scan, than patients who saw a doctor less worried about malpractice. More than 11 percent of the headache patients seen by a physician with a high level of concern got additional services and testing, versus 6 percent of patients seen by a physician with a low level of concern.

Almost 30 percent of patients with lower back pain seen by a physician with high malpractice concern were given additional imaging services, compared with 18 percent of patients who saw a physician with low concern.

For chest pains, however, the less worried physicians were about malpractice, the more likely they were to order a stress test. Stress tests can involve running on a treadmill, or taking medication to make the heart work harder. Carrier said physicians who are already nervous about medical liability might avoid this test and instead choose to admit the patient to a hospital for more evaluation.

The study also found that physicians’ level of malpractice concern didn’t change, even if they were practicing in a state with medical liability reforms like caps on how much money patients can claim in damages. “Even with caps or other reform measures, it’ doesn’t make physicians feel safer,” Mello said. “We are finding that the focus should be on how physicians are feeling – that has real implications for future policies.”