Menu Close

Tag: 2016 News

DIR Report Shows Markedly Lower Rates of Injuries

According to estimates from the Survey of Occupational Injuries and Illnesses (SOII) conducted by the US Bureau of Labor Statistics (BLS) and the California Department of Industrial Relations (DIR), over 470,000 nonfatal workplace injuries and illnesses were reported by private-sector and public-sector employers in California in 2015.

However, California’s overall incidence rate of nonfatal occupational injuries and illnesses remains unchanged at 3.8 cases per 100 workers for full-time employees, the lowest rate in over a decade. There has been a steady decline in injury rates over the last decade. In 2002 the rate was 6 cases per 100 workers for full-time employees.

Of the nonfatal reportable job-related injuries and illnesses in 2015, 77 percent occurred in private industry and 23 percent in state and local government. Reported Days Away From Work incidence rates (injuries and illnesses per 10,000 workers) differ substantially between private-sector and government workers, whether state or local. In 2015, the reported rate of DAFW injury or illness among government workers was approximately twice that of private-sector employers. The Report does not speculate as to the reason for this discrepancy.

The Days Away From Work incidence rate for California private sector industries remained at 1.0 case per 100 workers, equaling the national rate. Nearly 83,000 DAFW injuries, or 76 percent of those in private industry, occurred in service-sector industries. The remaining 26,000 injuries, or 24 percent, occurred in goods-producing industries.

In 2015, employer reports for California show that occupational injuries are more prevalent and the rate of injuries per 100 higher among males than among females. Sixty percent of reported cases with days away from work (DAFW) were for male workers, with 40 percent for females. The incidence rate per 100 workers was also approximately 5 percent higher among males than females. Compared to 2014, the rates for both working men and women dropped in 2015 in private sector.

In 2015, 28 percent of reported Days Away From Work work injuries in private industry in California occurred among workers with less than a year of tenure. At goods-producing firms in the private sector, nearly 35 percent of DAFW injuries and illnesses occurred within a year of hire. In manufacturing, 25 percent of those injuries occurred within a year of hire; in construction and natural resources, however, 45 percent of those injuries occurred within a year of hire. Notably, in the natural resources and mining sector, nearly one-quarter of DAFW cases occurred during the first three months of work. The report does not speculate as to the reason why new hires have more injuries than long term workers.

The highest private-sector injury and illness rate in 2015 is among twenty- to twenty-four-year-olds, with the lowest injury or illness rates at the other end of the age spectrum, those above age sixty-five. Compared to 2014, the DAFW injury and illness incidence rate in 2015 for private-sector employers dropped among sixteen- to nineteen-year-olds, twenty-five- to thirty-four-year-olds and for those age forty-five to fifty-four, while it rose or stayed the same for other age groups.

Transportation and material-moving occupations, food service workers, building and ground maintenance, and office and administrative support work were the occupational groupings with the largest number of lost-time injuries and illnesses. Service occupations also showed high number of injuries and illnesses with reported days away from work in 2015.

Among private-sector workers, the highest number of lost-time injuries were caused by overexertion and bodily reaction, by contact with an object or piece of equipment, and by falls, trips, and slips. Other major causes of lost-time injuries and illness included exposure to harmful substances or environments, transportation incidents and workplace violence.

“Pharmacovigilance” is Emerging Claims Best Practice

As claims administrators seek out ways to minimize the risk of opioid abuse and addiction in workers’ compensation programs, they should be aware of the principles of pharmacovigilance.

The article in Property Casualty 360 reports that this is a practice that has long been used in the pharmaceutical industry to ensure safety around prescription drug use. It involves various stakeholders participating in the monitoring and reporting of adverse drug reactions that could be dangerous – as well as promoting their safe, prescribed usage.

As the term implies, comprehensive and ongoing surveillance of prescribing and usage patterns is the key to safety, and this spirit of vigilance is urgently needed in workers’ comp around opioid use.

Addiction to prescription painkillers is a growing problem in the United States. Physicians feel compelled to write a prescription at each patient visit, and patients equally desire a quick fix for health issues, particularly pain. As a result, opioid prescription sales have increased 300 percent since 1999. Another consequence is that drug overdoses, predominantly from opioid painkillers such as OxyContin and Percocet, now exceed car crashes as the leading cause of unintentional death.

By its nature, the workers’ comp industry experiences a disproportionately high incidence of opioid use due to the type of accidents and injuries that occur. For claimants with chronic pain issues, opioid abuse can occur in up to 41 percent of cases.

Claimants prescribed an opioid painkiller can develop a tolerance to the drug, require increased dosages and become highly reliant. These claimants may require extensive time away from work, lose the motivation to return and become negatively affected in a number of other ways.

At the macro level, regulators can strengthen pharmacovigilance. In California CURES 2.0 (Controlled Substance Utilization Review and Evaluation System) is a database of Schedule II, III and IV controlled substance prescriptions dispensed in California serving the public health, regulatory oversight agencies, and law enforcement. CURES 2.0 is committed to the reduction of prescription drug abuse and diversion without affecting legitimate medical practice or patient care.

Norwalk, Connecticut-based Shatterproof, an organization that strives to end addiction, supports legislation that would require physicians and pharmacies to engage with state-run prescription drug monitoring programs to help identify and address prescription drug abuse.

Mandating a closed formulary backed by evidence-based medical guidelines is another macro-level change that would promote alternative pain therapies and use of opioids only when medically necessary.

At the micro level, nurse case managers serve as the central architects for “pharmacovigilance.” Their monitoring helps detect situations that require further review and proactive intervention. For example, they may find prescription costs are rising faster than overall medical costs on a particular claim, without a subsequent improvement in the injured worker’s functional status. They may detect other signs of abuse, such as opioid prescriptions from three or more providers or a significant increase in dosage – all of which can be addressed to avoid the spiral into addiction.

CWCI Reports on Implications of New Marijuana Law

California employers have been dealing with the ramifications of legal medicinal marijuana for years. Now that voters have passed Proposition 64, legalizing so-called “recreational” marijuana use, the CWCI expects that employers face a new reality of potentially outdated workplace policies, employee accommodation, and the applicability of drug-free workplace guidelines. Workers’ compensation carriers and self-insured employers in particular must begin to consider the impact that Proposition 64 may have on claims processing.

According to the CWCI report “Working Through the Haze: Implications of Legalized Marijuana for California Workers’ Compensation System,” last August the National Conference of State Legislatures adopted a resolution asking the federal government to remove marijuana from Schedule I. But the following day, the Drug Enforcement Agency announced that it would not remove marijuana from its Schedule I classification, reaffirming its determination that the drug’s therapeutic value has not been scientifically proven. Thus it remains illegal under federal law. As a Schedule I drug under the Controlled Substances Act, marijuana may not be prescribed, administered, or dispensed, and it is illegal to possess, use, purchase, sell, or cultivate.

Thus, even in states where medical marijuana is legal, doctors can only write a “recommendation” for the remedy.

But the federal government has decided it has higher priorities than enforcement of its anti marijuana stance. The US Department of Justice has actually formalized a “hands-off’ policy, leaving enforcement of minor drug activity up to the states, while the federal government’s priorities have been restricted to eight significant issues, including the operation of drug cartels, narcotics activity leading to violence, and preventing drugs from being provided to minors. “For states … that have enacted laws to authorize the production, distribution, and possession of marijuana, the Department expects these states to establish strict regulatory schemes that protect the [priority] interests identified by the Department,” leaving the decision on whether to enforce restrictions on marijuana being sold to minors or trafficked to other states, federal authorities could step in with enforcement. Otherwise, states can decide to legalize, tax, and regulate marijuana.

Out of 25 states that allow medical marijuana, only five explicitly exempt workers’ compensation payers from liability for medical marijuana. And at least one state has no legislation or judicial case law either requiring or prohibiting workers’ compensation payers from reimbursing an injured worker for medical marijuana.

The remainder of the states that allow medical marijuana, including California, rely on analogous statutory language that precludes a private health insurer from being forced to pay for marijuana. In California, Health and Safety Code Section 11362.785(d) specifically provides that nothing in the state’s medical marijuana program shall require any other health insurance provider or health care service plan to be liable for reimbursement for the medical use of marijuana.

But there may be a developing trend toward compelled compensation, if other states follow the lead of New Mexico. Beginning with a New Mexico Supreme Court case in 2014, New Mexico has required reimbursement for medical marijuana pursuant to that state’s workers’ compensation statute requiring provision of “reasonable and necessary” medical treatment services to an injured worker.

And the trend toward finding compensability for marijuana treatment seems to be spreading. Beyond New Mexico, workers’ compensation payers have been required to reimburse payments for medical cannabis in Minnesota, Maine, Connecticut, and Massachusetts. In two cases from Maine, for example, the Appellate Division of the workers’ compensation system upheld rulings from an administrative law judge that marijuana could be a compensable form of medical treatment for injured workers.

Only two reported cases at the California WCAB have addressed a claims administrator’s liability for marijuana treatment. The first, in 2012, Cockrell v. Farmers, did not directly resolve the question of compensability for medical marijuana. Instead, the Appeals Board merely returned the matter to the trial level for consideration of the impact, if any, of the prohibition against payment for marijuana by health insurance providers under Health and Safety Code §11362.785(d). It appears the case was thereafter resolved by settlement. But in 2013, a second case, Pedro de Dios v. Carroll’s Tire Warehouse, specifically found that the workers’ compensation carrier was not liable for reimbursement of medical marijuana under the Health and Safety Code exemption.

Constitutional Challenge to Comp System Dies in US Top Court

The Insurance Journal reports that the United States Supreme Court has refused to review a Florida case challenging the state’s entire workers’ compensation system, which could be seen as the state’s only reprieve on workers’ comp this year.

The Court’s decision without comment was in response to the case of Daniel Stahl v. Hialeah Hospital, which made its way through the state courts until April when the Florida Supreme Court ruled it did not have jurisdiction in the case. The petitioners sought U.S. Supreme Court review in August.

The Stahl case questioned whether Florida’s workers’ comp system is an adequate alternative for injured workers since its major overhaul in 2003. More specifically, the case challenged whether the elimination of a type of partial disability benefits by lawmakers is legal.

The case stems from a back injury the petitioner, Stahl, suffered while working as a nurse for Hialeah Hospital in 2003, just a few months after the changes to the workers’ comp system went into effect. Stahl’s physician found in October 2005 that he had reached his maximum medical improvement (MMI) and his injury was later classified as career-ending because he could not return to work as a nurse. He was then entitled to impairment income benefits of 12 weeks and compensated $5,472 for his career-ending injury. It was later determined that Stahl did not meet the definition of permanent total disability (PTD) and his claim for PTD benefits was denied.

Stahl claimed that the benefits available since Oct. 1, 2003, when Florida’s workers’ comp reforms went into effect, are “inadequate and therefore cannot be the exclusive remedy for on the job injuries,” and that the Florida workers’ comp law violates the U.S. Constitution.

Florida attorneys who are familiar with the case are not surprised the U.S. Supreme Court declined to hear the case.

“The petition to the U.S. Supreme Court was a long shot at best by the Petitioner seeking to have the U.S. Supreme Court determine a challenge of the constitutionality of the Florida’s workers’ compensation system. The lack of action on the petition means that Mr. Stahl’s case is essentially over as to challenging the act as a whole,” said Allison Hartnett, senior partner for Florida firm Walton Lantaff Schroeder & Carson LLP.

“Essentially, Stahl was an indictment of the entire workers’ compensation law in Florida, and the 1st District Court of Appeal, the Florida Supreme Court, and the U.S. Supreme court have rejected that indictment,” said Justin Parafinczuk of insurance defense firm Koch Parafinczuk & Wolf P.A, in Florida.

Parafinczuk added that the effort to eliminate the entire workers’ compensation law could have done much more harm to workers than good.

There have been constitutional challenges to “reform” efforts in various jurisdictions including California.  None of them have had input from the U.S. Supreme Court. The failure of the Florida claimants in this instance may be seen by the employer community as a favorable outcome with repercussions nationwide.

More Employers Sue Berkshire Hathaway Company

David Miller is a stickler for safety at the Goodwill stores he runs in central California. So when Applied Underwriters offered his nonprofit a deal on insurance for workplace accidents if he could minimize injuries, he jumped at the opportunity. Even better, Applied was part of Berkshire Hathaway Inc., the firm controlled by Warren Buffett.

But according to the report in the Insurance Journal, these days, he wishes he hadn’t. The contracts Miller signed have turned into a burden for his organization. It paid $1.8 million to cover about 350 employees, many disabled or disadvantaged at 17 locations from Lodi to Visalia. When the nonprofit switched carriers last year, Applied demanded hundreds of thousands of dollars more to fund remaining claims.

“I’m trying to make money in my stores to help people,” said Miller, chief executive officer of Goodwill Industries of San Joaquin Valley. “Instead, I’m writing big checks to an insurance company that I probably don’t even owe.”

Miller’s nonprofit is one of dozens of employers – from a bike-courier service in Manhattan to a linen-supply company in Sacramento – that have sued Applied for deceptive practices. The businesses allege the insurer peddled products regulators hadn’t approved. They complain about being surprised by large bills based on formulas that stacked the deck in the insurer’s favor. California, Vermont and Wisconsin have banned some Applied plans.

The insurer says that its products save employers money and that customers were aware of the terms. Companies that are litigating account for only about one in 400 policies sold, said Jeffrey Silver, Applied’s lawyer. The plans didn’t work out in their favor because they had claims that caused costs to go up, he said. They’re now “taking advantage of a regulatory situation” to avoid paying what they owe. About 90 percent of employers renew, Silver said.

The Berkshire subsidiary agreed to orders by regulators in California, Vermont and Wisconsin to halt some of its sales. But the company continues to press its case in California, its largest market, where it has asked a state court judge to overturn the insurance commissioner’s decision that its plans were illegal.

“It’s an innovative product,” Silver said. “And sometimes when you have an innovative product, regulators take a while to catch up to it. And that’s exactly what we think is happening here.”

As courts weigh these quarrels, this much is clear: It’s a lot of hot water for one of Buffett’s companies. The billionaire, who didn’t respond to requests for comment, tells Berkshire managers that “there’s plenty of money to be made in the center of the court.” In other words, no need to get close to the line, legally or ethically, to make some extra bucks.

Yet Applied has done just that, according to court filings, public records and interviews with more than two dozen business owners, brokers, consultants, attorneys, regulators and former employees of the insurer. Together, they describe a company that profits by enticing employers to make a financial gamble, even though some say they didn’t fully understand the rules.

It’s hard to pinpoint Applied’s profit. The unit accounts for just a sliver of Berkshire’s insurance business, which also includes Geico and contributed about one-fifth of the $24 billion of net income at Buffett’s firm last year. But state regulatory filings show how lucrative Applied’s workers’ comp plans were. Net income at California Insurance, one of the company’s largest subsidiaries, rose to $65.5 million in 2014 from a loss of $4.4 million five years earlier.

Margins were fat, too. The same subsidiary made more than 35 cents on each dollar in premium revenue it collected every year from 2010 to 2014, while workers’ comp insurers in California posted, in aggregate, an underwriting loss, according to the state’s insurance regulator.

Santa Fe Springs Explosion Leads to Cal/OSHA Citation

Cal/OSHA has cited AAA Roofing by Gene, Inc. for serious safety violations following an asphalt tanker explosion in Santa Fe Springs that burned two workers and launched them 10 feet onto the ground. Both workers suffered third-degree burns. One worker’s burns covered up to 36 percent of his body.

AAA Roofing had been hired to repair the flat roof of a warehouse when the accident occurred on May 2, 2016.

Two employees standing on top of a tanker truck were attempting to turn the truck’s discharge pipe to face another direction. Cal/OSHA inspectors learned that the workers’ foreman instructed them to heat the pipe with a propane torch to loosen it.

The tanker was half-filled with hot liquid asphalt. Heated liquid asphalt releases flammable vapors.

“Flammable vapors accumulated in kettles and tankers, if ignited, can burn or explode,” said Cal/OSHA Chief Juliann Sum. “Employers must ensure that no source of ignition is permitted in any location, indoors or outdoors, where the concentration of flammable gases or vapors exceeds or may reasonably be expected to exceed 25 percent of the lower explosive limit.”

Cal/OSHA issued three workplace safety citations to AAA Roofing by Gene this week, with proposed penalties of $24,575. Two of the citations are serious, and one is regulatory in nature.

One of the serious citations involves AAA’s failure to ensure the tanker truck was equipped with a 42-inch guardrail. This could have helped ensure the workers did not fall 10 feet as they did.

The other serious citation was for allowing a source of ignition to be introduced where the flammable gases exceeded 25 percent of the lower explosive limit. A serious violation is cited when there is a realistic possibility that death or serious harm could result from the actual hazardous condition.

Opioids Provide Only “Limited Relief” for Back Pain

Research presented at the ANESTHESIOLOGY® 2016 annual meeting claimed that millions of people take opioids for chronic back pain, but many of them get limited relief while experiencing side effects and worrying about the stigma associated with taking them. The American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 52,000 members organized to raise and maintain the standards of the medical practice of anesthesiology.

The presentation noted that more than 100 million people in the United States suffer from chronic pain, and those with chronic low back pain are more likely than patients with other types of pain to be prescribed opioids. Unfortunately, these medications are addictive and can cause side effects, ranging from drowsiness to breathing problems.

“Patients are increasingly aware that opioids are problematic, but don’t know there are alternative treatment options,” said Asokumar Buvanendran, M.D., lead author of the study, director of orthopedic anesthesia and vice chair for research at Rush University, Chicago, and vice chair of the American Society of Anesthesiologists (ASA) Committee on Pain Medicine. “While some patients may benefit from opioids for severe pain for a few days after an injury, physicians need to wean their patients off them and use multi-modal therapies instead.”

In the study, 2,030 people with low back pain completed a survey about treatment. Nearly half (941) were currently taking opioids. When asked how successful the opioids were at relieving their pain, only 13 percent said “very successful.” The most common answer – given by 44 percent – was “somewhat successful” and 31 percent said “moderately successful.” Twelve percent said “not successful.”

Seventy-five percent said they experienced side effects including constipation (65 percent), sleepiness (37 percent), cognitive issues (32 percent) and dependence (29 percent).

Respondents also had concerns about the stigma associated with taking opioids. Forty-one percent said they felt judged by using opioids. While 68 percent of the patients had also been treated with antidepressants, only 19 percent felt a stigma from using those.

A major pharmaceutical company recently agreed to disclose in its promotional material that narcotic painkillers carry serious risk of addiction and not to promote opioids for unapproved, “off-label” uses such as long-term back pain. Researchers also note a lack of solid studies on the effectiveness of opioids in treating back pain beyond 12 weeks.

Patients with chronic low back pain, persistent pain lasting more than three months, should see a pain medicine specialist who uses an approach that combines a variety of treatments that may be more beneficial, said Dr. Buvanendran. These treatments include physical therapy, bracing, interventional procedures such as nerve blocks, nerve ablation techniques or implantable devices, other medications such as anti-inflammatories and alternative therapies such as biofeedback and massage, he said.

Device Maker Pays $36 Million in Misbranding Case

The Justice Department announced that medical device manufacturer Biocompatibles Inc., a subsidiary of BTG plc, pleaded guilty to misbranding its embolic device LC Bead and will pay more than $36 million to resolve criminal and civil liability arising out of its illegal conduct. LC Bead is used to treat liver cancer, among other diseases.

Under the terms of the plea agreement before the U.S. District Court for the District of Columbia, Biocompatibles pleaded guilty to a misdemeanor charge in connection with the company’s misbranding of LC Bead, in violation of the Food, Drug and Cosmetic Act. LC Bead was cleared by the U.S. Food and Drug Administration (FDA) as an embolization device that can be placed in blood vessels to block or reduce blood flow to certain types of tumors and arteriovenous malformations. LC Bead has never been cleared or approved by FDA as a drug-device combination product or for use as a drug-delivery device or “drug-eluting” bead.

As part of the criminal resolution, Biocompatibles will pay an $8.75 million criminal fine for the misbranding of LC Bead and a criminal forfeiture of $2.25 million. The FDA sought assurances in 2004 that Biocompatibles would not use FDA clearance for the device for embolization to market the device for drug delivery, according to a statement of offense to which the company agreed. Biocompatibles told the FDA that “under no circumstance” would the company use the embolization clearance to market the device for drug delivery.

However, two years later, Biocompatibles began marketing LC Bead for drug delivery through the company it hired to carry out its sales and distribution in the United States. According to the statement of offense, the distribution company told its sales representatives that LC Bead was “[a] drug-delivery device” and trained its sales representatives to “aggressively penetrate the chemoembolization market.”

Sales representatives subsequently told health care providers that the device increased the level of chemotherapy delivered to a liver tumor and resulted in “better tumor response rates,” despite the lack of FDA clearance or approval for that use and despite the absence at that time of statistically significant evidence to support such claims.

In addition, Biocompatibles will pay $25 million to resolve civil allegations under the False Claims Act that the company caused false claims to be submitted to government healthcare programs for procedures in which LC Bead was loaded with chemotherapy drugs and used as a drug-delivery device. When LC Bead was combined with prescription drugs for use as a drug-eluting bead, it constituted a new combination drug-device product that was not approved or cleared by the FDA and not covered by Medicare and other federal health care programs. The federal share of the civil settlement is approximately $23.6 million, and the state Medicaid share of the civil settlement is approximately $1.4 million.

The civil settlement with Biocompatibles resolves a lawsuit filed under the whistleblower provision of the False Claims Act, which permits private parties to file suit on behalf of the United States for false claims and share in a portion of the government’s recovery. The civil lawsuit was filed in the Western District of Texas and is captioned United States ex rel. Ryan Bliss v. Biocompatibles, Inc., et al. As part of this resolution, Bliss will receive approximately $5.1 million from the civil settlement.

WCAB Has Jurisdiction Over UR Penalties and Sanctions

Kathleen McKinney injured her neck and other body parts in 2014 while working as a driver for Enterprise Rent a Car. She filed four separate Petitions for Penalties and Sanctions under Labor Code sections 5813 and 5814. The gravamen of applicant’s theory is that when the RFAs were submitted, defendant had in its possession and control medical reports and records germane to each of the four RFAs and failed to provide the same to WellComp, its UR organization for consideration, causing the RFAs to be denied.

The defendant filed an Answer to each of the four Petitions for Penalties and Sanctions. In answer to Petition for Penalties and Sanctions # 1, defendant asserts that the RFA for Diclofenac ER 100 mg #60 was timely denied by Utilization Review (UR). In answer to Petition #2, defendant asserts that the RFA for two boxes of Salonpas was timely denied by UR;  and in answer to Petition #3, defendant contends that the RFA for trigger point injections was timely denied by UR;  and in answer to Petition #4, defendant also asserts that the RFA for Soma 350 mg. #60 was timely denied by UR. With respect to all four Petitions, it claimed that the WCAB lacks jurisdiction over applicant’s claim for penalties and sanctions.

Each of the four UR determinations identify the documentation reviewed by the physician. In each instance, the documentation reviewed was limited to the actual RFA and the treating physician’s contemporaneous progress report. There is no indication that additional records or documents, including the January 8, 2015 MRI results, were provided to the evaluating doctor.

The MRI findings that were not reviewed by UR note “chronic discogenic endplate changes at several levels,” and go on to describe central and neural forarninal narrowing at several levels, as well as “concentric uncovertebral hypertrophy (3 mm) with a superimposed left paracentral disc protrusion” at C4-C5.

The reason given for the non-certification was “[r]equest does not adequately document myofascial pain syndrome.” However the PTP progress reports dated June 4, 2015; June 25, 2015; and July 23, 2015 state that applicant has myofascial pain syndrome.

The WCJ found that defendant acted with bad faith in its handling of four separate Requests for Authorization of Treatment’ (RFA), making it liable for the imposition of sanctions under the provisions of Labor Code2 section 5813. The WCAB disagreed and reversed the sanctions in the panel decision of McKinney v Enterprise Rent a Car.

The significant issues in this case is jurisdiction of the WCAB to award penalties and sanctions despite the fact that UR was timely. In this regard the defendant argued that any dispute over the medical necessity of a particular treatment modality is within the exclusive purview of Independent Medical Review (IMR).

On the issue of jurisdiction, the WCAB disagreed with the defendant and ruled that Labor Code 5813 specifically authorizes the Appeals Board or a WCJ to order a party, a party’s attorney, or both, to pay any reasonable expenses incurred by another party as a result of bad faith actions or tactics that are frivolous or solely intended to cause unnecessary delay. Similarly, if the employer or its insurance carrier unreasonably delay or refuse to pay compensation and/or provide reasonable and necessary medical treatment to the industrially injured worker, section 5814 authorizes an increase in the delayed compensation payment up to prescribed monetary amounts.

The WCJ determined that defendant’s conduct in handling the four RFAs resulted from its willful failure to comply with its obligations under Administrative Director Rule 10109 because it had access to all of applicant’s medical records and diagnostic testing results but did not take the initiative to insure that complete records were provided to the UR doctor.

On this issue the WCAB panel disagreed with the WCJ. It noted that Administrative Director Rules 9785(g) and 9792.6.1(1)(2) require the RFA to include documentation substantiating the need for the requested treatment. The primary treating physician, and not a claims adjustor, is the one who knows what medical records substantiate the requested treatment. The four RFAs submitted by the PTP did include documentation, and presumably, the records and reports the PTP included with each RFA were those, in her expert medical opinion, that supported the recommended treatment.

Therefore, the WCAB cannot say that under these circumstances, defendant’s failure to take the initiative and submit applicant’s complete medical record to the UR doctor was a willful failure to comply with its regulatory and statutory obligations, or an indication of a bad faith tactic that is frivolous or solely intended to cause delay.

BUT the WCAB did not reach the issue of a defendant’s duty in ensuring that there is a complete record review by the UR doctor since, in this case, it was not shown that defendant abrogated its duty in bad faith or by frivolous action solely intended to cause unnecessary delay.

PA High Court to Rule on AMA Guides “Constitutionality”

At oral argument over the constitutionality of a Pennsylvania Workers’ Compensation Act provision that requires the incorporation of “the most recent edition” of the American Medical Association guidelines for evaluating claimants’ impairment ratings, several justices questioned the legislature’s decision to give a private group such wide latitude to shape state law.

In the case that may inspire constitutional attacks in other jurisdictions, Protz v. Workers’ Compensation Appeal Board (Derry Area School District) centers on the issue of whether Section 306(a.2) of the Pennsylvania act violates Article II, Section 1 of the Pennsylvania Constitution by delegating the legislature’s lawmaking authority to the AMA and allowing it to set the criteria for workers’ compensation adjudications.

In a deeply divided en banc ruling in Protz, the Commonwealth Court found that the requirement that impairment ratings be determined under the most recent edition of the AMA Guides to the Evaluation of Permanent Impairment left “unchecked discretion completely in the hands of a private entity.”

“The General Assembly has failed to prescribe any intelligible standards to guide the AMA’s determination regarding the methodology to be used in grading impairments,” Judge Dan Pellegrini wrote for the 4-3 majority. “Section 306(a.2) of the act is wholly devoid of any articulations of public policy governing the AMA in this regard and of adequate standards to guide and restrain the AMA’s exercise of this delegated determination by which physicians and [workers’ compensation judges] are bound.”

But the Commonwealth Court did remand the case to apply the fourth edition of the AMA Guides. Pellegrini said in his opinion that the fourth edition was the most recent version of the guides available when the Workers’ Compensation Act was enacted in 1996 – there have been two revisions since – and therefore the legislature adopted the methodology in that edition as its own.

During a Nov. 1 oral argument session before the state Supreme Court in Pittsburgh, counsel for both sides were peppered with questions from the justices about whether the legislature imbued the AMA with too much unchecked power.

“Doesn’t the legislature of Pennsylvania have the obligation to look each year at the AMA guidelines and decide whether to use that by reference or not, rather than to just defer to the AMA for the most recent explication on the issues?” Justice Debra Todd asked Thomas C. Baumann, counsel for plaintiff Mary Ann Protz.

Baumann agreed, but noted that revisions to the guidelines come out roughly every five to 10 years, so the burden on the state to review them would be relatively light.

Justice Christine L. Donohue asked Baumann whether his position was that the legislature could rely on a private group to develop standards as long as there was an “intermediate step” in which a governmental agency reviewed those standards and recommended whether to adopt them.

“The position is that the basic policy choices have to be made by the legislature and there have to be some guidelines for the exercise of the delegation,” Baumann said.

Baumann’s opposing counsel, David Dille, representing the Derry Area School District and its workers’ compensation carrier, argued that the legislature correctly left it to a group of medical experts to set the guidelines for medical evaluations in Pennsylvania.

Donohue, however, said the Workers’ Compensation Act “ties the hands” of medical experts who may disagree with the AMA guidelines.

“It does not, for example, allow for a physician to say, ‘I don’t like the AMA standards and you want to know why? Because it doesn’t take into account certain factors that go to the essence of determining an impairment or a disability,'” Donohue said. “It’s not as though it’s not possible to do this without delegating all these policy decisions to a private entity.”

Justice Max Baer, however, said that if a party disagrees with a doctor’s conclusion following an impairment rating examination, the party could hire an expert to offer a differing opinion and it would be up to a workers’ compensation judge to make the ultimate determination.

Dille said that’s what happened in Protz. “There were different opinions … and the judge made determinations with respect to the interpretation of the AMA impairment guides,” Dille said.