March 15, 2010:  Division of Workers’
Compensation reminds facilities seeking
to be paid for high cost outlier cases to
submit by March 31, 2010 and posts
adjustments to outpatient hospital and
ambulatory surgical center services
section of the official medical fee
schedule.

March 09, 2010:  Division of Workers’
Compensation issues notice of rulemaking
and public hearing for adoption of
amendment to the ambulance fee
schedule contained within the official
medical fee schedule

March 04, 2010:  Division of Workers’
Compensation issues notice of rulemaking
and public hearing for adoption of
electronic medical treatment billing
standards and standardized paper billing
forms

March  04, 2010: Division of Workers’
Compensation posts proposed pharmacy
benefit network regulations on DWC
forum for pre-rulemaking public comment

March 03, 2010:  Division of Workers'
Compensation issues first 15-day notice
of revisions to proposed medical
provider network and employee
information regulations

March 02, 2010: Since these documents
were the   bills themselves and not
"statements concerning" them, it would
seem unnecessary not to admit them.
Furthermore, the undersigned has
searched for case law on the subject
and found no guidance on the subject

February 26, 2010:  A roofing contractor
was convicted today of failing to provide
workers' compensation insurance for an
injured employee who fell from a roof
and failing to pay insurance premiums
for unclaimed employees, who were
paid in cash

February 19, 2010: Insurance
Commissioner Poizner Announces Two
San Diego
Men Plead No Contest in Workers'
Compensation Fraud Cases
Duo Agree to Forgo $60 Million in
Medical Liens and Bills Pending at WCAB

February 17, 2010:  California Insurance
Commissioner Steve Poizner today
announced that Richard Lewis Johnson,
49, of City of Commerce pled no contest
Feb. 4 to one count of grand theft of
workers' compensation payments and
was placed on three years probation and
ordered to pay $20,714 in restitution to
Avizent Risk Management.

February 16, 2010:  The Division of
Workers’ Compensation has
successfully processed one million
document batches into the Electronic
Adjudication Management System
(EAMS), achieving this milestone in less
than a year and a half since the case
management system was activated.

February 11, 2010: ROOFING
CONTRACTOR CONVICTED IN
CALIFORNIA'S LARGEST PREMIUM
INSURANCE FRAUD SCAM

February 11, 2010:  SELF-PROCLAIMED
NATURAL DOCTOR SENTENCED FOR
TREATING CANCER PATIENTS WITHOUT
A LICENSE AND PRACTICING MEDICINE
WHILE RUNNING ILLEGAL HMO

February 08, 2010:  As part of its
strategy to increase access to the
Electronic Adjudication Management
System (EAMS), the Division of Workers’
Compensation today began work with
external partners on a plan that will
allow bulk filing of selected documents
by the end of the year.

February 05, 2010: February Collection
Newsletter

January 25, 2010: California Insurance
Commissioner Steve Poizner today
announced that Bellflower-based
Staffing Services Inc. has been ordered
by the Los Angeles County Superior
Court to pay $20 million in restitution
after a plea bargain was reached Jan.
15 in a workers' compensation
insurance fraud case.

January 11, 2010: Insurance
Commissioner Poizner Announces
Morgan Hill Couple Arrested
for Not Carrying Workers' Comp
Insurance at Local Cafe

January 11,2010: After the
administrative director adopted the Jan.
1, 2010 DMEPOS fee schedule update,
Medicare adopted a new fee schedule
file which revises two codes, E1405
and E1406. The update includes all
changes adopted in the Dec. 2, 2009
order and the two code revisions.  The
order is effective for services on or after
Jan. 1, 2010. The order can be found at
http://www.dir.ca.gov/dwc/OMFS9904.
htm#3 .

January 05, 2010:  Division of Workers’
Compensation administrative director
issues clarification of utilization review
audit measures due to Cervantes
decision

December 30, 2009:  Adjustments to the
pathology and clinical laboratory section
of the Official Medical Fee Schedule to
conform to the changes in the Medicare
payment system are posted on the DWC
Web site

December 15, 2009:  $193,000 In
Federal Stimulus Funds Awarded For
Training Health Professionals in
Community Clinics

December 14, 2009:  Mileage rate for
medical and medical-legal travel
expenses will decrease Jan. 1, 2010

December 13, 2009:  Collection
Newsletter for December 2009 published

December 09, 2009:  INSURANCE
COMMISSIONER POIZNER ANNOUNCES
ARREST OF PRUNEDALE WOMAN ON
WORKERS’ COMPENSATION FRAUD,
ELDER ABUSE CHARGES

December 09, 2009: INSURANCE
COMMISSIONER POIZNER ANNOUNCES
ANALYSIS REVEALS RELATIVELY-
STABLE WORKERS’ COMP RATES FOR
2010

December 07, 2009:  Adjustments to the
DMEPOS section of the Official Medical
Fee Schedule to conform to changes in
the Medicare payment system are
posted on the DWC Web site

December 02, 2009:  Commissioner
Poizner Calls for Complete Divestment,
Subpoenas 10 Insurance Companies
that Failed to Respond to Data Call

Insurance Commissioner Steve Poizner
today announced that insurance
companies licensed to do business in
California have admitted to holding $12
billion in investments in companies that
do business with the Iranian energy,
nuclear, banking and defense industries.

November 30, 2009:  Division of
Workers’ Compensations administrative
director announces 2010 profile audit
review and full compliance audit
performance standards

November 19, 2009: En Banc Decision

(1) when a treating physician
recommends spinal surgery, a defendant
must undertake utilization review (UR);
(2) if UR approves the requested spinal
surgery, or if the defendant fails to timely
complete UR, the defendant must
authorize the surgery; (3) if UR denies
the spinal surgery request, the defendant
may object under section 4062(b), but
any objection must comply with AD Rule
9788.1 and use the form required by AD
Rule 9788.11; (4) the defendant must
complete its UR process within 10 days
of its receipt of the treating physician’s
report, which must comply with AD Rule
9792.6(o), and, if UR denies the
requested surgery, any section 4062(b)
objection must be made within that
same 10-day period; and (5) if the
defendant fails to meet the 10-day
timelines or comply with AD Rules
9788.1 and 9788.11, the defendant loses
its right to a second opinion report and it
must authorize the spinal surgery.

November 14, 2009: Govt: Medicare
paid $47 billion in suspect claims

November 09, 2009: Insurers Continue
to Ignore Readily-Available Cost
Controls, Commissioner Poizner Says
Insurance Commissioner Steve Poizner
today declined a second consecutive
request by the Workers Compensation
Insurance Bureau (WCIRB) to increase
the Workers' Compensation Claims Cost
Benchmark.

October 29, 2009: Notice of rulemaking
and public hearing regarding proposed
changes to Workers’ Compensation
Information System rules /  rules part of
Division of Workers’ Compensation 12-
point plan to control medical costs

October 29, 2009: Insurance
Commissioner Poizner Announces Guilty
Pleas in Orange County Workers' Comp
Fraud Cases Totalling $6.7 Million

October 16 2009: The Legislative
Analyst's Office has just issued the
following report:
Workers’ Compensation: Recent
Decisions Likely to Increase Benefits
and Employer Costs

October 12, 2009:  Two Bills signed into
law that directly affect Medical
Providers  SB - 186 and AB - 361  
Authorization and pre designation read
BILL ANALYSIS  at the end of each bill.

October 11, 2009: Panel Decision Lack
of UR establishes medical necessity --
republished

October 01, 2009:  Division of Workers'
Compensation Sacramento district office
moves to new location effective Oct. 12

September 25, 2009: Panel Decision
Sanctions Against Lien Claimant for
Failure to Appear

September 25, 2009:  Dismissal Order of
Premier Medical Liens
1
CASE LAW SELF-PROCURED MEDICAL
TREATMENT AND MPNs (Medical Provider
Networks)

June 12, 2009 - Republished

Bruce Knight, United Parcel Service; and
Liberty Mutual Insurance Company
October 10, 2006  71 Cal. Comp. Cases
1423







Department of Industrial Relations - DIR
Frequently asked questions
http://www.dir.ca.gov/faqslist.html

Division of Workers' Compensation -
Electronic Adjudication Management
System (EAMS) - Filing Liens etc.,
http://www.dir.ca.gov/dwc/eams/eams.htm

Division of Workers' Compensation -
Official Medical Fee Schedule (OMFS)
http://www.dir.ca.gov/dwc/OMFS9904.htm
“Notice of Intention To Dismiss Lien Claim”
For Failure to Appear At Hearings Other
Then Lien Hearings.       

California Medical Providers Mystified By
MPNs (Medical Provider Networks)      

MPNS (MEDICAL PROVIDER NETWORK)
AND SAMPLE RESPONSES    

GETTING PAID FOR NON-INDUSTRIALLY
CAUSED INJURY   

DENIED CLAIMS AND SELF-PROCURED
MEDICAL TREATMENT
(CORRECTED)        

DISCOVERY, THE NEED TO RESPOND   

LACHES, DOCTRINE OF –    

GETTING PAID FOR NON-INDUSTRIALLY
CAUSED INJURY   

RESPONDING TO "NOTICE OF
INTENTION TO DISALLOW LIEN"    

MPNS ( Medical Providers Networks)    

Cal Lab Code § 4903.5 (2008) Should
there be a "Tolling of The Statute of
Limitations"    

GETTING PAID AFTER  24-VISIT CAP ON
PHYSICAL MEDICINE    

DURABLE MEDICAL EQUIPMENT AND
OUTPATIENT SURGERY BILLING   

SUCCESS OF SELF-PROCURED
TREATMENT   

FICTITIOUS-NAME PERMIT    

Psychiatric Treatment - Getting Paid    

DISCOVERY, THE NEED TO RESPOND

California Labor Code Section 4609 PPO
Contracts in Workers Comp
WE RECOMMEND
Decided May 11, 2009    COAST PLAZA
DOCTORS HOSPITAL, v .BLUE CROSS OF
CALIFORNIA et al.,   No. B205892, Cal. App.,
2nd Dist, May 11, 2009  
"Third, section 1371.4 alters the scope of
permissible bargains between the insurer and
insured by telling them what bargains are
acceptable and what bargains are
unacceptable.  (Miller, supra, 538 U.S. at p. 338;
Benefit Recovery Inc. v. Donelon (5th Cir. 2008)
521 F.3d 326, 331 [state law that tells parties
what bargains are acceptable in an insurance
contract substantially affects risk pooling
arrangement].)  Section 1371.4 tells the insurer
and insured that they cannot enter into a bargain
whereby the insurer only pays for emergency
services rendered by providers inside the insured’s
network. "
Decided July 16, 2009
Cantrell v. WCAB (Wal-Mart Stores)      

PDF /   WORD DOC
Unpublished Decision. FIFTH APPELLATE
DISTRICT F057606 Filed 7/16/09

Whether Wal-Mart’s drug testing policy
discriminated against Cantrell as an industrially
injured worker and if so, whether its conduct in
implementing and applying the policy was
necessary and directly linked to the realities of
doing business.                 
Durable Medical Equipment, Prosthetics, Orthotics,
and Supplies When billing for Out-Patient Surgery-

July 28, 2009

Section 9789.38 adopts the federal regulation (42
C.F.R. § 419.2) which addresses the practices of
outpatient facilities. It does not address the
providers of durable medical equipment or restrict
the number of mechanisms for billing for durable
medical equipment that is implantable.

Ocean View School Dist. v. Workers' Comp.
Appeals Bd., 72 Cal. Comp. Cas. (MB) 1683 (Cal.
App. 2d Dist. 2007

A provider of Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies who bills for
the equipment can  file a lien and get paid
regardless of claim that it should be included in
"Outpatient Billing".

"In this case it is the equipment provider's billing
and lien that is in issue. A restriction on the surgery
center cannot automatically be applied to bar
recovery from a medical provider that is not subject
to that regulation."
Failure to Perform  Utilization Review Makes
Medical Necessity Issues Moot

July 29, 2009

State Comp. Ins. Fund v. Workers' Comp. Appeals
Bd., S149257, SUPREME COURT OF
CALIFORNIA, July 3, 2008, Filed

Download in Work Doc        ///     Download in PDF

“The insurer referred the matter for utilization
review but did not communicate its decision within
the 14-day statutory deadline set forth in § 4610,
subd. (g)(1). A workers' compensation judge found
that the insurer's failure to comply with the
statutory deadlines precluded it from relying on the
utilization review process or on its doctor's report to
deny the requested treatment”

“Thus, employers and their insurers could not use §
4062 as an alternative method for disputing
employees' treatment requests. Only an employee
could use the provisions of § 4062 to resolve a
dispute over a treatment request; an employer
could not do so.”
Lien Claimant requested authorization and
utilization review a response was not given within
the time frame allowable which precluded defense
from relaying on any medical reports to deny
treatment.         
About UR and causation decisions:

A denial issued directly from the reviewing
physician or URO to the primary treating physician
on causation grounds alone  could be found in
violation of 8 CCR § 9792.6(s), §  9792.9(j) and
probably §  9792.9(l), as well as the express wording
of Simmons, which states the UR reviewing
physician does not have the authority to determine
causation.
WORK COMP NEWS  
August 24, 2009:     // UR By DWC Education

UR and denied injury

The Lien Claimant, made a request for
authorization and the defendants did not perform
utilization review. The defendants are required to
perform a utilization review when a request for
authorization is made, even if the claim or body
part is denied. Simmons v. California, 70 Cal.
Comp. Cas. (MB) 866 (W.C.A.B. 2005)
WORK COMP CASES
Published August 21, 2009

CERTIFIED FOR PUBLICATION

LANCE BAUR,  Petitioner,   v.WORKERS’
COMPENSATION APPEALS BOARD and CITY
OF STOCKTON, Respondents.   THIRD
APPELLATE DISTRICT C061042(Super. Ct. Nos.
STK0191710, ADJ2866919)

In this case, petitioner Lance Baur, a police
officer employed by respondent City of Stockton
(the city), was injured on the job during an
altercation with suspect Richard Thomas Beck.  
The city provided Baur workers’ compensation
benefits.  Baur then filed a lawsuit against Beck,
but Beck’s insurance company was insolvent.  As
a result, Baur settled his lawsuit with the
California Insurance Guarantee Association
(CIGA).   The city then claimed a credit pursuant
to Labor Code section 3861, up to the amount of
the net settlement, against its liability for future
workers’ compensation benefits.  A workers’
compensation administrative law judge granted
the credit.
Published August 17, 2009

Lawrence Weiner  v.Ralphs Company,
Permissibly Self-Insured; and Sedgwick Claims
Management Services, Inc. (Adjusting Agent)
August 17, 2009 Case No. ADJ347040 (MON
0305426) 74 Cal. Comp. Cases

The Appeals Board denied applicant’s petition
for reconsideration of its en banc opinion of June
11, 2009
October 11, 2009

8 CCR 10240 (2009)
§ 10240.  Appearances Required

(a) All parties and lien claimants shall appear at all
hearings, except as provided below:
COLLECTION
PUBLICATIONS  
Discovery at Deposition

November 07, 2009

California Workers' Compensation Appeals Board in  
Maria Sandoval vs. Dollar Cleaners / State
Compensation Insurance Fund ADJ3447741 (OAK
02828060) denied defendants petition for removal,
for medical provider refusing to answer a discovery
question during a deposition. The Court held the
provider did not have to answer the question, as it
was irrelevant and not likely to lead to discoverable
evidence on  the denial for petition for removal  
dated August 13, 2009.

Read More...........
November 22, 2009:  NOT PERFORMING
UTILIZATION REVIEW WHEN TREATMENT IS
REQUESTED MEANS TREATMENT IS AUTHORIZED.

By www.workcompliens .com
November 22, 2009

Through SB 228 many changes in the Workers
Compensation Procedures were enacted, from fee schedule
for outpatient surgery to Utilization Review.


The Courts continually are giving attention to Utilization
Review Process and have been persistent in their quest to
ensure that employers / insures perform utilization review to
achieve the ultimate goal of more efficient and expedite
medical treatment for the injured worker. Accordingly, the
implicit legislative purpose in establishing UR was to create
an expeditious and inexpensive method to assess treating
physician’s medical treatment recommendations.. Read More
Satisfaction Guaranteed, if not
satisfied return within 30 days
for a full  refund.  
SITE SEARCH
CALIFORNIA WORKERS COMPENSATION COLLECTIONS FOR LIEN CLAIMANT
REPRESENTATION AND MEDICAL PROVIDERS
TO RECEIVE MONTHLY COLLECTION NEWSLETTER EMAIL REQUEST: E-MAIL LINK
MARCH 2010 COLLECTION NEWSLETTER:  DOWN LOAD LAST COLLECTION NEWSLETTER
For Complete List Of Lien Claimant
Issue Booklets Follow Link
"Collection Issue Booklets Complete
List"
Richard J Boggan J.D. / email link
February  22, 2010: : CIGA on Assigned Claims

Black Diamond Asphalt, Inc. v. Superior Court, 114
Cal. App. 4th 109, 7 Cal. Rptr. 3d 466, 2003 Cal.
App. LEXIS 1827, 2003 Cal. Daily Op. Service
10641, 2003 D.A.R. 13420 (Cal. App. 3d Dist. 2003

“Under the unambiguous language of the statutory
scheme, an original claimant can be any person
(other than an insurer) instituting a liability claim
within the coverage of the policy, provided that he
or she does so in his or her own name and not
through assignment or by right of subrogation. (§
1063.1, subds. (c)(1), (c)(9), (g).) Because Black
Diamond wishes to make a liability claim in its own
name and for its own benefit, section 1063.1,
subdivision (c)(9), does not exclude the claim from
coverage and does not preclude Black Diamond
from pursuing a claim against Adames for
indemnity.”
COLLECTION ISSUES TO BE AWARE
OF for Lien Claimants / Medical
Providers  -- over 50 pages --

Overview on how the system works and
how to get paid

  • Helpful hints for collectors
  • How to maximize collections
  • What tools are you have to
    collect more revenue
  • Issues Regarding Collections
  • Case Law
  • Statutory Law
  • and more
MPNs (Medical Provider Networks)
Collections Booklet for
Lien Claimants / Medical Providers    
  • Contains, helpful hints on how to
    collect when treating outside the
    MPN.
  • Several cases that show when
    providers get paid when treating
    outside an MPN
  • Statutory Regulations and how
    they apply
  • Several sample appeal letters
  • Trial Brief on the issue
  • Article on the issue
  • and more
SELF-PROCURED MEDICAL TREATMENT
Collections Booklet  for Lien Claimants /
Medical Providers    -- 26 pages -- plus
attached flow chart

  • Contains helpful hints on self-
    procured medical treatment
  • How lack of Utilization Review
    establishes medical necessity
  • How a "Thomas Finding" effects
    medical payments
  • Usual and Customary Fees for
    denied cases
  • Flowchart
  • Sample trial briefs
  • Case Law
  • Statutory Law
  • and more
RESPONDING TO NOTICE OF
INTENTION TO DISALLOW LIEN CLAIM
Collections Booklet for Lien Claimants /
Medical Providers    --  15 pages --

  • Contains helpful hints for
    responding to Notice of
    Intention to Disallow
  • Three sample responses with
    detail instructions
  • Case Law
  • Statutory Law
  • Article
  • and more
HOW TO PREPARE A TRIAL BRIEF
Collections Booklet for Lien Claimants /
Medical Providers    -- 19 pages --

  • Contains helpful hints on how to
    prepare a Trial Brief
  • Three sample Trial Briefs on
    Lien Claimant issues
  • Detail instructions as to each
    element of a Trial Brief
  • and more
PREPARING A PETITION FOR
RECONSIDERATION Collections Booklet
for Lien Claimants / Medical Providers
--17 pages --

  • Contains helpful hints on how to
    prepare a Petition For
    Reconsideration
  • Several  samples, of actual  
    petitions
  • Detail instructions as to each
    element
  • Petitions for Removal
  • and more
Cal Lab Code § 4903.5 (2008)
"Tolling of The Statute of Limitations"
for Lien Claimants / Medical Providers

  • Contains helpful hints on
    "Tolling The Statutory Time
    Limit for Filing Liens"
  • Case Law
  • Statutory Law
  • Trial Briefs
  • Sample appeal letters
  • Laches arguments
  • and more
Psychiatric Injury and Pain
Management for Lien Claimants /
Medical Providers
-- 20 pages --

  • Contains, helpful hints on how
    to collect when treating for
    psychiatric injury.
  • How Utilization Review effects
    medical necessity
  • Exception for 6 month
    employment rule
  • Statutory Regulations and how
    they apply
  • Trial Brief on the issue
  • Article on the issue
  • and more
OVERVIEW OF COURT PROCESS for
Lien Claimants / Medical Providers
  • Helpful Hints
  • Where to get information
  • Court Rules and procedures
GETTING PAID AFTER 24-VISIT CAP
ON PHYSICAL MEDICINE
for Lien Claimants / Medical Provider
  • Contains, helpful hints on
    how to collect when treating
    over 24 cap
  • Case Law
  • Statutory Regulations and
    how they apply
  • Trial Brief on the issue
  • Article on the issue
  • and more
UTILIZATION REVIEW AND
AUTHORIZATION WHAT MUST BE
DONE
GETTING PAID USUAL AND
CUSTOMARY FEES
For Complete List Of Lien Claimant
Issue Booklets Follow Link
"Collection Issue Booklets Complete
List"
Orange v. FST Sand & Gravel, Inc., 63 Cal. App.
4th 353, 73 Cal. Rptr. 2d 633, 1998 Cal. App.
LEXIS 353, 98 Cal. Daily Op. Service 2983, 98 D.
A.R. 4037 (Cal. App. 4th Dist. 1998)

“The acid test of statutory interpretation based on
principles of statutory construction is always
whether the interpretation yields an absurd result.”

American Nat. Ins. Co. v. Low, 84 Cal. App. 4th
914, 101 Cal. Rptr. 2d 288, 2000 Cal. App. LEXIS
859, 2000 Cal. Daily Op. Service 9023, 2000 D.A.
R. 11961 (Cal. App. 2d Dist. 2000

“The meaning of a statute may not be determined
from a single word or sentence; the words must be
construed in  context, and provisions relating to
the same subject matter must be harmonized to
the extent possible. . . . An interpretation that
renders related provisions nugatory must be
avoided."


St. Joseph’s Hospital v. Workers’ Compensation
Appeals Bd., 70 Cal. Comp. Cas. (MB) 1612 (Cal.
App. 1st Dist. 2005) the Court held as follows:

“With regard to the lien of St. Joseph’s Hospital,
the WCAB stated that reasonable charges for
treatment that relate to Applicant’s injury would
constitute a ‘’covered claim’’ within the meaning
of Insurance Code § 1063.1.”
Lighting up or aggravation of a preexisting
condition by an industrial injury

New or aggravated injury which results from
medical or surgical treatment of industrial injury
is compensable, whether doctor was furnished by
employer, his insurance carrier, or was selected
by employee. Fitzpatrick v. Fidelity & Casualty
Co. (1936) 7 Cal 2d 230, 60 P2d 276, 1936 Cal
LEXIS 622.

Compensation is recoverable for disability which
results from the aggravation of a pre-existing
disease if the aggravation is reasonably
attributable to an industrial accident; but
compensation is not recoverable for disability
which results, irrespective of such accident, from
the normal progress or development of a
pre-existing disease. Industrial Indem. Co. v.
Industrial Acci. Com. (1949, Cal App) 95 Cal App
2d 443, 213 P2d 11, 1949 Cal App LEXIS 1132;
De La Tova v. Industrial Acci. Com. (1955, Cal
App 2d Dist) 137 Cal App 2d 516, 290 P2d 377,
1955 Cal App LEXIS 1218.

RECENT FIRST APPELLATE DISTRICT: ON
MANDATORY UTILIZATION REVIEW

•        In State Comp. Ins. Fund v. Workers’ Comp.
Appeals Bd. (2008) 44 Cal.4th 230, 233-234
(State Comp.), our Supreme Court clarified that
when an employer is faced with deciding whether
to approve or deny the treatment
recommendation of an injured worker’s physician,
it must conduct utilization review pursuant to
Labor Code section 4610.  By the same token the
employer cannot, as an alternative to utilization
review, dispute the treatment request under the
general dispute resolution framework set forth in
section 4062, subdivision (a) (section 4062(a))

•        Section 4062(a) specifically provides that
employer objections to a treating physician’s
recommendation for spinal surgery, after denial of
the physician’s recommendation pursuant to the
utilization review procedures detailed in section
4610,  shall be subject to section 4062(b).  In line
with this provision, section 4610(g)(3)(A) also
states:  “If a request to perform spinal surgery is
denied, disputes shall be resolved in accordance
with subdivision (b) of Section 4062.”  (Italics
added.)

•        Section 4062(b) in turn states that “[t]he
employer may object to a report of the treating
physician recommending that spinal surgery be
performed within 10 days of the receipt of the
report.”  (Italics added.)  Where, as here, the
employee is unrepresented at that time, the
statute calls for the administrative directorto
randomly select a surgeon “to prepare a second
opinion report resolving the disputed surgical
recommendation.”  (Ibid.) The evaluation occurs
on an accelerated basis, with the second opinion
report to be served within 45 days of the original
surgical request.  (Ibid.)  Moreover, the second
opinion physician must be a “licensed board-
certified or board-eligible orthopedic surgeon or
neurosurgeon . . . .”  (Ibid.)


•        Finally, Cervantes clarifies that the
employer must both complete its own utilization
review and make its section 4062(b) objection
within 10 days of receiving the treating physician’
s report recommending spinal surgery.  
(Cervantes, supra, 74 Cal.Comp.Cases at pp. 1351-
1352.)  First, section 4062(b) requires the
employer to object to the spinal surgery
recommendation within 10 days of receiving the
report.  Second, section 4062(a) states that these
employer objections are “subject to subdivision
(b), and after denial of the physician’s
recommendation, in accordance with Section
4610.”  (Italics added.)  In sync, section 4610(g)(3)
(A) provides that if utilization review denies the
spinal surgery request, disputes shall be resolved
in accord with section 4062(b). These three
statutory provisions, taken together, make it clear
that the spinal surgery second opinion process
commences after utilization review has denied
the requested spinal surgery. The utilization
review scheme does not mandate a 10-day
turnaround time, but 10 days is consistent with the
requirement that “[p]rospective or concurrent
decisions shall be made in a timely fashion that is
appropriate for the nature of the employee’s
condition, not to exceed five working days from
the receipt of the information reasonably
necessary to make the determination, but in no
event more than 14 days from the date of the
medical treatment recommendation by the
physician.”  (§ 4610, subd. (g)(1).)
Daily WC Issues March 02, 2010: Since these
documents were the   bills themselves and not
"statements concerning" them, it would seem
unnecessary not to admit them. Furthermore, the
undersigned has searched for case law on the
subject and found no guidance on the subject
Daily WC Issues March 03, 2010: psychiatric injury
was caused by psycho-social difficulties that
stemmed from applicant's unemployment/financial
difficulties stemming from his industrial injuries
Daily WC Issue March 16, 2010
Durable Medical Equipment

Section 9789.38 adopts the federal regulation (42
C.F.R. § 419.2) which addresses the practices of
outpatient facilities. It does not address the
providers of durable medical equipment or restrict
the number of mechanisms for billing for durable
medical equipment that is implantable.

Daily WC Issues March 15, 2010:  
Secondary Evidence

"The rule . . . for the admission of secondary
evidence of a lost paper, requires 'that a bona fide
and diligent search has been unsuccessfully made
for it in the place where it was most likely to be
found;' and further, 'the party is expected to show
that he has in good faith exhausted in a
reasonable degree all the sources of information
and means of discovery which the nature of the
case would naturally suggest, and which were
accessible to him.[']”

Daily WC Issues March 11, 2010:
Admissibility QME Report after denial

Once a defendant denies a case, defendant may
not obtain a panel QME report regarding the
compensability of an alleged industrial injury,
(only the injured worker may request a panel QME
exam), QME Regulation § 30(d)(3), effective
2/17/09.   --- treatment reports are always
admissible (LC 4060(b).

Daily WC Issues March 10, 2010:
Division of Workers' Compensation educational
conference 2010 --- handout materials
http://www.dir.ca.
gov/dwc/educonf17/DWC_EducationalConference.
html

Daily WC Issue March 09, 2010:
Six Month Employment for Psyche Claims

The purpose of the six month employment
requirement for claims of injury to the psyche is to
weed out frivolous or fraudulent claims (Wal-Mart
Stores v. Workers' Comp. Appeals Board (Garcia)
(2003) 112 Cal.App.4th 1435 [68 Cal.Comp.Cases
1575]). By creating the exception for injuries
arising from sudden and extraordinary employment
conditions, the Legislature provided a means to
compensate authentic claims arising from
"uncommon, unusual and totally unexpected
events."

Daily WC Issues March 08, 2010:
Until the date the claim is accepted or rejected,
liability for medical treatment shall be limited to
ten thousand dollars ($10,000).

Cal Lab Code § 5402 (c) Within one working day
after an employee files a claim form under Section
5401, the employer shall authorize the provision of
all treatment, consistent with Section 5307.27 or
the American College of Occupational and
Environmental Medicine's Occupational Medicine
Practice Guidelines, for the alleged injury and
shall continue to provide the treatment until the
date that liability for the claim is accepted or
rejected. Until the date the claim is accepted or
rejected, liability for medical treatment shall be
limited to ten thousand dollars ($10,000).

Daily WC Issues March 07, 2010:
Post Termination
Labor Code § 3600(a)(10)(B) exception requires
only that medical records contain evidence of
injury, not evidence of industrial causation, and
that neither medical evidence that was
"incomplete" because doctor's report was a
progress note instead of a medical-legal report, nor
fact that causation had not yet been determined
were sufficient grounds to bar compensation based
on post-termination defense

Daily WC Issues March 04, 2010:
Restitution
"Approving restitution in these cases would set a
precedent which would have unfortunate
consequences for the workers' compensation
system. It would introduce the possibility of
continued transactional instability so negative it
would impact the number of medical providers
willing any longer to participate in the system by
evaluating workers with industrial injuries. No one
can operate a business on receipts only
conditionally possessed, and medical providers are
no exception. Thus we have determined the
restitution orders were unfair and must be
annulled."
March 03, 2010:
Recent SECOND APPELLATE DISTRICT
DECISION

CIGA must pay “covered claims.”

(§ 1063.2, subd. (a).)  A covered claim is an
obligation of an insolvent insurer.  (§ 1063.1, subd.
(b).)  However, “‘[c]overed claims’ does not include
. . . any claim to the extent it is covered by any
other insurance.”  (§ 1063.1, subd. (c)(9).)  In 2005,
section 1063.1, subdivision (c)(13) was added by
Assembly Bill No. 817 to  provide that covered
claims “include obligations arising under an
insurance policy written to indemnify a permissibly
self-insured employer . . . for its liability to pay
workers’ compensation benefits in excess of a
specific or aggregate retention.”   Subdivision (c)
(13) does not cross-reference subdivision (c)(9) or
purport to eliminate statutory exceptions to CIGA’s
liability.
workcompliens.com
MEDICAL COLLECTIONS
SERVICES
Collections Booklet for
Lien Claimants /
Medical Providers
Prepared by
RICHARD JOSEPH BOGGAN, B.S.L., JD
WORKERS’ COMPENSATION LIEN
CLAIMANT  CONSULTANT
  1. Issues to Be aware of                 6.  Petition for Recon
  2. MPNs                                         7.  Lien filing after deadline
  3. Utilization Review                      8.  Court Process
  4. Self-Procured Treatment             9.  Pain Management      
  5. Trial Briefs                                10.  And more