Getting Ready for 2014

A brief review of permanent disability, SJDB, utilization review, independent medical review, liens, medical fee schedule (OMFS), consulting reports and Valdez, and COLAS going into 2014.

GettingReadyfor2014Title

PERMANENT DISABILITY: Lab C 4453(b)(9)

• For injuries on and after 1/1/2014, remember minimum AWW is $240=$160.00 per week

• For injuries on and after 1/1/2014, maximum AWW is $435 = $290.00 per week

• This applies for all PD rates from 1-99%

SJDB

• New Regulations for offers: to be made within 60 days of receipt of the Physician’s Return-to-Work & Voucher Report [DWC-AD 10133.36] but adds “that indicates the work capacities and activity restrictions that are relevant to regular, modified, or alternative work.” This also requires a new
form to be sent to the PTP to address work capacities and restrictions

• New Form for Offers: all offers on one form

• New Voucher Form: Includes new page for purchase of computer equipment and gives employee option to obtain computer equipment directly from the employer

• Employee may object to the offer based upon the job location

UTILIZATION REVIEW

• New Form RFA mandated as of 3/1/2014

• May use old forms until then

• Requires an actual attachment documenting the treating physician’s request and must be signed

• Content of UR decisions is expanded

• Time frames for internal UR changed

INDEPENDENT MEDICAL REVIEW

• New version of DWC Form IMR-1 must be used on or after 3/1/2014

• Request for IMR must be submitted with copy of written decision

• Notice of representation required with filing

• Response to Request for Information: time frame changes from 15 days to 5 business days

• Failure to provide PTP treatment records to Maximus: New regulations permit Maximus reviewer to issue determination, if possible, based on summary of records

• Maximus permitted to consolidate 2 or more IMR applications

• Administrative penalties modified

LIENS

• The Lien Activation Fee under Lab C 4903.06, is no longer being collected by the DWC, pending further litigation

• A preliminary injunction issued against the Lien Activation Fee on 11/19/2013, by a Federal Judge, in Angelotti Chiropractic v. Baker

• Remember: The new statute of limitations for liens arising from services provided on or after 7/1/2013 is 18 months

MEDICAL FEE SCHEDULE [OMFS]

• New regulations pending with AD

• AD to adopt new OMFS based upon the resource-based relative value scale, or “RBRVS”

• New fee schedule to be in accord with Medicare payment system, including a statewide adjustment factor of 1.078

• New conversion factors to take place

CONSULTING REPORTS AND VALDEZ

• California Supreme Court: Valdez: Out-of-network reports from non-network physicians are admissible for compensability (TD/PD)

• An out-of-network report cannot be the sole basis for a WCAB finding unless it is addressed and adopted by an in-network PTP, PQME or AME

COLAS

• 2014: SAWW is: $1,067.25

• 2014: SAWW increase is: 0.742887%

• 2013: SAWW is: $1,059.38

• 2013: SAWW increase is: 5.56325%

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