If the DRG average length of stay is greatly exceeded is the provider entitled to paid for those additional days.
The per diem rate is determined by dividing the maximum reimbursement as determined under Title 8, California Code of Regulations ยง9789.22(a) by the average length of stay for that specific DRG.
Simmons v. California, (en banc) (2005)
Thus, by section 4610(a)’s express terms, utilization review is directed solely at determining the ”medical necessity” of treatment recommendations. Therefore, section 4610 does not authorize a utilization review physician to determine whether the employee’s industrial injury caused or contributed to a need for treatment.
The OMFS is not applicable in a case such as this when the compensability of a claimed injury is disputed and the injury was later found to be compensable. The Lien Claimant is entitled to payment of its reasonable, usual and customary charges (not exceeding what is charged non-industrial patients CNA Ins. Cos. v. Workers’ Compensation Appeals Bd. (Valdez)
Robert Klittich, Applicant v. Green Thumb International, State Compensation Insurance Fund, Defendants, 2008 Cal. Wrk. Comp. P.D. LEXIS 866, Opinion Filed August 11, 2008
Dr. Bresler appeared and testified on his own behalf. His services were found to involve extraordinary circumstances justifying fees above the Official Medical Fee Schedule as follows:
Daily WC Issue March 30, 2010:
CIGA on Assigned Claims
When a medical provider assigns its rights and title to a collection account, is CIGA responsible for payment of that ;assigned claim?
Daily WC Issues March 29, 2010:
Outpatient Fee Schedule
9789.38.Appendix X.42 C.F.R. ; 419.44(a) Multiple surgical procedures. When more than one surgical procedure for which payment is made under the hospital outpatient prospective payment system is performed during a single surgical encounter.
Maria Isabel Ramirez, Applicant v. Quiznos, State Farm 21567 Bakersfield, Defendants, 2009 Cal. Wrk. Comp. P.D. LEXIS 466, Opinion Filed September 8, 2009
We agree with the WCJ that for an injured worker who does not speak English, the use of an interpreter ;is reasonably required to cure or relieve the injured worker from the effects of his or her injury, ( Labor Code, ; 4600, subd. (a)) and that requiring an injured worker to be treated only by a physician proficient in the injured worker’s mother tongue would deprive [*6] the injured worker of the right to "be treated by a physician of his or her own choice…." ( Labor Code, 4600, subd. (c).) We also note that the provisions of Administrative Rule 9795.1 et seq. appear to relate only to interpreting services at legal and medical-legal appointments and hearings, and not to medical treatment appointments, such as the ones at issue here. ( Cal. Code Regs., tit. 8, ; 9795.3.) Accordingly, the fact that the interpreters sent by Ditto were not ;certified" or ;provisionally certified" does not create a defense to liability.
24 visit cap of Labor Code; 4604.5(d)(1).
The WCJ stated:
“In denying the chiropractic treatment, it appears that the defendant may have been under the mistaken presumption that the 24 visit cap of Labor Code ; 4604.5(d)(1). The limitation on chiropractic visits is not applicable to this 2001 case, as the provisions of Labor Code 4604.5(d)(1) apply only to injuries on or after January 1, 2004. The undersigned WCJ arrives at that conclusion because that was the main argument raised against Haynes Chiropractic by the defendant at trial.”
Daily WC Issues March 24, 2010:
AME Report
Rather, he merely stated that it was his
“impression” that chiropractic treatment was “not
require[d]” and was “contraindicated.” Dr.
Strassberg did not provide any facts or reasoning to
support and explain his “impression.” Moreover, the
WCJ did not interpret the AME’s mere “impressions”
to constitute statements of reasonable medical
probability.
—— unclear about whether Dr. Strassberg was
aware that chiropractic treatment may be
reasonable even if it did not cure Applicant’s
condition, but merely relieves the condition.
A few questions have been asked as to what is permissible referrals
