Source: http://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=LAB&division=1.&title=&part=&chapter=5.&article=
Timestamp: 2018-12-11 21:16:06
Document Index: 174926187

Matched Legal Cases: ['art 1', 'art 1', 'art 4', 'art 1', 'art 2', 'art 2', 'art 2']

(Amended by Stats. 2011, Ch. 559, Sec. 2. (AB 1426) Effective October 7, 2011.)
The Workers’ Compensation Appeals Board, consisting of seven members, shall exercise all judicial powers vested in it under this code. In all other respects, the Division of Workers’ Compensation is under the control of the administrative director and, except as to those duties, powers, jurisdiction, responsibilities, and purposes as are specifically vested in the appeals board, the administrative director shall exercise the powers of the head of a department within the meaning of Article 1 (commencing with Section 11150) of Chapter 2 of Part 1 of Division 3 of Title 2 of the Government Code with respect to the Division of Workers’ Compensation which shall include supervision of, and responsibility for, personnel, and the coordination of the work of the division, except personnel of the appeals board.
(Amended by Stats. 2012, Ch. 728, Sec. 117. (SB 71) Effective January 1, 2013.)
The members of the appeals board shall be appointed by the Governor with the advice and consent of the Senate. The term of office of the members appointed prior to January 1, 1990, shall be four years, and the term of office of members appointed on or after January 1, 1990, shall be six years and they shall hold office until the appointment and qualification of their successors.
Five of the members of the appeals board shall be experienced attorneys at law admitted to practice in the State of California. The other two members need not be attorneys at law. All members shall be selected with due consideration of their judicial temperament and abilities. Each member shall receive the salary provided for by Chapter 6 (commencing with Section 11550) of Part 1 of Division 3 of Title 2 of the Government Code.
(Amended by Stats. 1990, Ch. 1550, Sec. 8.5.)
(Repealed and added by Stats. 1965, Ch. 1513.)
The chairman shall assign pending cases in which reconsideration is sought to any three members thereof for hearing, consideration and decision. Assignments by the chairman of members to such cases shall be rotated on a case-by-case basis with the composition of the members so assigned being varied and changed to assure that there shall never be a fixed and continued composition of members. Any such case assigned to any three members in which the finding, order, decision or award is made and filed by any two or more of such members shall be the action of the appeals board unless reconsideration is had in accordance with the provisions of Article 1 (commencing with Section 5900), Chapter 7, Part 4, Division 4 of this code. Any case assigned to three members shall be heard and decided only by them, unless the matter has been reassigned by the chairman on a majority vote of the appeals board to the appeals board as a whole in order to achieve uniformity of decision, or in cases presenting novel issues.
The seal of the appeals board bearing the inscription “Workers’ Compensation Appeals Board, Seal” shall be affixed to all writs and authentications of copies of records and to such other instruments as the appeals board directs.
(Amended by Stats. 1981, Ch. 21, Sec. 4. Effective April 18, 1981.)
The administrative director may appoint an attorney licensed to practice law in the state as counsel to the division.
(Amended by Stats. 1989, Ch. 892, Sec. 13.)
(a) Represent and appear for the state and the Division of Workers’ Compensation and the appeals board in all actions and proceedings arising under any provision of this code administered by the division or under any order or act of the division or the appeals board and, if directed so to do, intervene, if possible, in any action or proceeding in which any such question is involved.
(b) Commence, prosecute, and expedite the final determination of all actions or proceedings, directed or authorized by the administrative director or the appeals board.
(c) Advise the administrative director and the appeals board and each member thereof, upon request, in regard to the jurisdiction, powers or duties of the administrative director, the appeals board and each member thereof.
(d) Generally perform the duties and services as attorney to the Division of Workers’ Compensation and the appeals board which are required of him or her.
(Amended by Stats. 1994, Ch. 1097, Sec. 6. Effective January 1, 1995.)
The administrative director and the chairman of the appeals board may each respectively appoint a secretary and assistant secretaries to perform such services as shall be prescribed.
The chairman of the appeals board may authorize its secretary and any two assistant secretaries to act as deputy appeals board members and may delegate authority and duties to these deputies. Not more than three deputies may act as appeals board members at any one time. No act of any deputy shall be valid unless it is concurred in by at least one member of the appeals board.
(Amended by Stats. 1981, Ch. 1150, Sec. 1.)
The administrative director shall appoint a medical director who shall possess a physician’s and surgeon’s certificate granted under Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code. The medical director shall employ medical assistants who shall also possess physicians’ and surgeons’ certificates and other staff necessary to the performance of his or her duties. The salaries for the medical director and his or her assistants shall be fixed by the Department of Human Resources, commensurate with the salaries paid by private industry to medical directors and assistant medical directors.
(Amended by Stats. 2012, Ch. 665, Sec. 176. (SB 1308) Effective January 1, 2013.)
The administrative director may employ necessary assistants, officers, experts, statisticians, actuaries, accountants, workers’ compensation administrative law judges, stenographic shorthand reporters, legal secretaries, disability evaluation raters, program technicians, and other employees to implement new, efficient court management systems. The salaries of the workers’ compensation administrative law judges shall be fixed by the Department of Human Resources for a class of positions which perform judicial functions.
(Amended by Stats. 2012, Ch. 665, Sec. 177. (SB 1308) Effective January 1, 2013.)
Any official reporter employed by the administrative director shall render stenographic or clerical assistance as directed by the presiding workers’ compensation administrative law judge of the office to which the reporter is assigned, when the presiding workers’ compensation administrative law judge determines that the reporter is not engaged in the performance of any other duty imposed by law.
(Amended by Stats. 2002, Ch. 6, Sec. 26. Effective January 1, 2003.)
(Amended by Stats. 2011, Ch. 559, Sec. 3. (AB 1426) Effective October 7, 2011.)
(Amended by Stats. 2011, Ch. 559, Sec. 4. (AB 1426) Effective October 7, 2011.)
The appeals board may, by rule or regulation, establish procedures whereby attorneys who are either certified specialists in workers’ compensation by the California State Bar, or are eligible for this certification, may be appointed by the presiding workers’ compensation judge of each board office to serve as a pro tempore workers’ compensation judge in a particular case, upon the stipulation of the employee or his or her representative, and the employer or the insurance carrier. Service in this capacity by an attorney shall be voluntary and without pay. It is the intent of the Legislature that the use of pro tempore workers’ compensation judges pursuant to this section shall not result in a reduction of the number of permanent civil service employees or the number of authorized full-time equivalent positions.
(Amended by Stats. 1985, Ch. 326, Sec. 6.)
(Amended by Stats. 2015, Ch. 515, Sec. 1. (AB 438) Effective January 1, 2016.)
The administrative director shall cause to be printed and furnished free of charge to any person blank forms that may facilitate or promote the efficient performance of the duties of the Division of Workers’ Compensation.
(Amended by Stats. 1994, Ch. 146, Sec. 139. Effective January 1, 1995.)
The Division of Workers’ Compensation, including the administrative director and the appeals board, shall keep minutes of all their proceedings and other books or records requisite for proper and efficient administration. All records shall be kept in their respective offices.
(Amended by Stats. 1994, Ch. 146, Sec. 140. Effective January 1, 1995.)
(Amended by Stats. 2011, Ch. 559, Sec. 5. (AB 1426) Effective October 7, 2011.)
The appeals board may accept appointment as deputy commissioner under, or any delegation of authority to enforce, the United States Longshoremen’s and Harbor Worker’s Compensation Act. The appeals board may enter into arrangements with the United States, subject to the approval of the Department of Finance, for the payment of any expenses incurred in the performance of services under said act. In the performance of any duties under said act, appointment, or authority, the appeals board may, subject to the provisions thereof, exercise any authority conferred upon the appeals board by the laws of this state.
The appeals board and each of its members, its secretary, assistant secretaries, and workers’ compensation judges, may administer oaths, certify to all official acts, and issue subpoenas for the attendance of witnesses and the production of papers, books, accounts, documents and testimony in any inquiry, investigation, hearing or proceeding in any part of the state.
(Amended by Stats. 1985, Ch. 326, Sec. 8.)
Each witness who appears by order of the appeals board or any of its members, or a workers’ compensation judge, shall receive, if demanded, for his or her attendance the same fees and mileage allowed by law to a witness in civil cases, paid by the party at whose request the witness is subpoenaed, unless otherwise ordered by the appeals board. When any witness who has not been required to attend at the request of any party is subpoenaed by the appeals board, his or her fees and mileage may be paid from the funds appropriated for the use of the appeals board in the same manner as other expenses of the appeals board are paid. Any witness subpoenaed, except one whose fees and mileage are paid from the funds of the appeals board, may, at the time of service, demand the fee to which he or she is entitled for travel to and from the place at which he or she is required to appear, and one day’s attendance. If a witness demands his or her fees at the time of service, and they are not at that time paid or tendered, he or she shall not be required to attend as directed in the subpoena. All fees and mileage to which any witness is entitled under this section may be collected by action therefor instituted by the person to whom the fees are payable.
(Amended by Stats. 1985, Ch. 326, Sec. 9.)
The superior court in and for the county in which any proceeding is held by the appeals board or a workers’ compensation judge may compel the attendance of witnesses, the giving of testimony and the production of papers, including books, accounts, and documents, as required by any subpoena regularly issued hereunder. In case of the refusal of any witness to obey the subpoena the appeals board or the workers’ compensation judge, before whom the testimony is to be given or produced, may report to the superior court in and for the county in which the proceeding is pending, by petition, setting forth that due notice has been given of the time and place of attendance of the witness, or the production of the papers, that the witness has been subpoenaed in the prescribed manner, and that the witness has failed and refused to obey the subpoena, or has refused to answer questions propounded to him or her in the course of the proceeding, and ask an order of the court, compelling the witness to attend and testify or produce the papers before the appeals board. The court shall thereupon enter an order directing the witness to appear before the court at a time and place fixed in the order, the time to be not more than 10 days from the date of the order, and then and there show cause why he or she had not attended and testified or produced the papers before the appeals board or the workers’ compensation judge. A copy of the order shall be served upon the witness. If it appears to the court that the subpoena was regularly issued hereunder and that the witness was legally bound to comply therewith, the court shall thereupon enter an order that the witness appear before the appeals board or the workers’ compensation judge at a time and place fixed in the order, and testify or produce the required papers, and upon failure to obey the order, the witness shall be dealt with as for contempt of court. The remedy provided in this section is cumulative, and shall not impair or interfere with the power of the appeals board or a member thereof to enforce the attendance of witnesses and the production of papers, and to punish for contempt in the same manner and to the same extent as courts of record.
(Amended by Stats. 1985, Ch. 326, Sec. 10.)
(Amended by Stats. 2011, Ch. 559, Sec. 7. (AB 1426) Effective October 7, 2011.)
The appeals board or any member thereof may issue writs or summons, warrants of attachment, warrants of commitment and all necessary process in proceedings for contempt, in like manner and to the same extent as courts of record. The process issued by the appeals board or any member thereof shall extend to all parts of the state and may be served by any persons authorized to serve process of courts of record or by any person designated for that purpose by the appeals board or any member thereof. The person executing process shall receive compensation allowed by the appeals board, not to exceed the fees prescribed by law for similar services. Such fees shall be paid in the same manner as provided herein for the fees of witnesses.
In accordance with rules of practice and procedure that it may adopt, the appeals board may, with the approval of the Secretary of State, destroy or otherwise dispose of any file kept by it in connection with any proceeding under Division 4 (commencing with Section 3200) or Division 4.5 (commencing with Section 6100).
(Amended by Stats. 2014, Ch. 28, Sec. 61. (SB 854) Effective June 20, 2014.)
(Amended by Stats. 2011, Ch. 559, Sec. 8. (AB 1426) Effective October 7, 2011.)
(Amended by Stats. 2011, Ch. 559, Sec. 9. (AB 1426) Effective October 7, 2011.)
(Amended by Stats. 2011, Ch. 559, Sec. 10. (AB 1426) Effective October 7, 2011.)
The administrative director shall, with respect to all injuries, prescribe, pursuant to Section 5402, reasonable rules and regulations requiring the employer to serve notice on the injured employee that he may be entitled to benefits under this division.
(Added by Stats. 1975, Ch. 1099.)
(Amended by Stats. 2016, Ch. 868, Sec. 1. (SB 1160) Effective January 1, 2017.)
The Division of Workers’ Compensation shall cooperate in the enforcement of child support obligations. At the request of the Department of Child Support Services, the administrative director shall assist in providing to the State Department of Child Support Services information concerning persons who are receiving permanent disability benefits or who have filed an application for adjudication of a claim which the Department of Child Support Services determines is necessary to carry out its responsibilities pursuant to Section 17510 of the Family Code.
The process of sharing information with regard to applicants for and recipients of permanent disability benefits required by this section shall be known as the Workers’ Compensation Notification Project.
(Amended by Stats. 2000, Ch. 808, Sec. 110. Effective September 28, 2000.)
(Amended by Stats. 2016, Ch. 868, Sec. 2. (SB 1160) Effective January 1, 2017.)
(Amended (as amended by Stats. 2012, Ch. 46, Sec. 80) by Stats. 2016, Ch. 30, Sec. 18. (SB 833) Effective June 27, 2016.)
(b) The administrative director shall appoint or reappoint as a qualified medical evaluator a physician, as defined in Section 3209.3, who is licensed to practice in this state and who demonstrates that he or she meets the requirements in paragraphs (1), (2), (6), and (7), and, if the physician is a medical doctor, doctor of osteopathy, doctor of chiropractic, or a psychologist, that he or she also meets the applicable requirements in paragraph (3), (4), or (5).
(B) Has successfully completed a residency training program accredited by the Accreditation Council for Graduate Medical Education or the osteopathic equivalent.
A hearing shall not be required prior to the suspension or termination of a physician’s privilege to serve as a qualified medical evaluator when the physician has done either of the following:
(Amended by Stats. 2016, Ch. 86, Sec. 214. (SB 1171) Effective January 1, 2017.)
(Amended by Stats. 2011, Ch. 545, Sec. 2. (AB 378) Effective January 1, 2012.)
(Amended by Stats. 2011, Ch. 545, Sec. 3. (AB 378) Effective January 1, 2012.)
(1) “Financial interest in another entity” means, subject to subdivision (h), either of the following:
(A) Any type of ownership, interest, debt, loan, lease, compensation, remuneration, discount, rebate, refund, dividend, distribution, subsidy, or other form of direct or indirect payment, whether in money or otherwise, between the interested party and the other entity to which the employee is referred for services.
(B) An agreement, debt instrument, or lease or rental agreement between the interested party and the other entity that provides compensation based upon, in whole or in part, the volume or value of the services provided as a result of referrals.
(2) “Interested party” means any of the following:
(A) An injured employee.
(B) The employer of an injured employee, and, if the employer is insured, its insurer.
(C) A claims administrator, which includes, but is not limited to, a self-administered workers’ compensation insurer, a self-administered self-insured employer, a self-administered joint powers authority, a self-administered legally uninsured employer, a third-party claims administrator for an insurer, a self-insured employer, a joint powers authority, or a legally uninsured employer or a subsidiary of a claims administrator.
(D) An attorney-at-law or law firm that is representing or advising an employee regarding a claim for compensation under Division 4 (commencing with Section 3200).
(E) A representative or agent of an interested party, including either of the following:
(i) An employee of an interested party.
(ii) Any individual acting on behalf of an interested party, including the immediate family of the interested party or of an employee of the interested party. For purposes of this clause, immediate family includes spouses, children, parents, and spouses of children.
(F) A provider of any medical services or products.
(3) “Services” means, but is not limited to, any of the following:
(A) A determination regarding an employee’s eligibility for compensation under Division 4 (commencing with Section 3200), that includes both of the following:
(i) A determination of a permanent disability rating under Section 4660.
(ii) An evaluation of an employee’s future earnings capacity resulting from an occupational injury or illness.
(B) Services to review the itemization of medical services set forth on a medical bill submitted under Section 4603.2.
(C) Copy and document reproduction services.
(D) Interpreter services.
(E) Medical services, including the provision of any medical products such as surgical hardware or durable medical equipment.
(G) Services in connection with utilization review pursuant to Section 4610.
(b) All interested parties shall disclose any financial interest in any entity providing services.
(c) Except as otherwise permitted by law, it is unlawful for an interested party other than a claims administrator or a network service provider to refer a person for services provided by another entity, or to use services provided by another entity, if the other entity will be paid for those services pursuant to Division 4 (commencing with Section 3200) and the interested party has a financial interest in the other entity.
(d) (1) It is unlawful for an interested party to enter into an arrangement or scheme, such as a cross-referral arrangement, that the interested party knows, or should know, has a purpose of ensuring referrals by the interested party to a particular entity that, if the interested party directly made referrals to that other entity, would be in violation of this section.
(2) It is unlawful for an interested party to offer, deliver, receive, or accept any rebate, refund, commission, preference, patronage, dividend, discount, or other consideration, whether in the form of money or otherwise, as compensation or inducement to refer a person for services.
(e) A claim for payment shall not be presented by an entity to any interested party, individual, third-party payer, or other entity for any services furnished pursuant to a referral prohibited under this section.
(f) An insurer, self-insurer, or other payer shall not knowingly pay a charge or lien for any services resulting from a referral for services or use of services in violation of this section.
(g) (1) A violation of this section shall be misdemeanor. If an interested party is a corporation, any director or officer of the corporation who knowingly concurs in a violation of this section shall be guilty of a misdemeanor. The appropriate licensing authority for any person subject to this section shall review the facts and circumstances of any conviction pursuant to this section and take appropriate disciplinary action if the licensee has committed unprofessional conduct, provided that the appropriate licensing authority may act on its own discretion independent of the initiation or completion of a criminal prosecution. Violations of this section are also subject to civil penalties of up to fifteen thousand dollars ($15,000) for each offense, which may be enforced by the Insurance Commissioner, Attorney General, or a district attorney.
(2) For an interested party, a practice of violating this section shall constitute a general business practice that discharges or administers compensation obligations in a dishonest manner, which shall be subject to a civil penalty under subdivision (e) of Section 129.5.
(3) For an interested party who is an attorney, a violation of subdivision (b) or (c) shall be referred to the Board of Governors of the State Bar of California, which shall review the facts and circumstances of any violation pursuant to subdivision (b) or (c) and take appropriate disciplinary action if the licensee has committed unprofessional conduct.
(4) Any determination regarding an employee’s eligibility for compensation shall be void if that service was provided in violation of this section.
(h) The following arrangements between an interested party and another entity do not constitute a “financial interest in another entity” for purposes of this section:
(1) A loan between an interested party and another entity, if the loan has commercially reasonable terms, bears interest at the prime rate or a higher rate that does not constitute usury, and is adequately secured, and the loan terms are not affected by either the interested party’s referral of any employee or the volume of services provided by the entity that receives the referral.
(2) A lease of space or equipment between an interested party and another entity, if the lease is written, has commercially reasonable terms, has a fixed periodic rent payment, has a term of one year or more, and the lease payments are not affected by either the interested party’s referral of any person or the volume of services provided by the entity that receives the referral.
(3) An interested party’s ownership of the corporate investment securities of another entity, including shares, bonds, or other debt instruments that were purchased on terms that are available to the general public through a licensed securities exchange or NASDAQ.
(i) The prohibitions described in this section do not apply to any of the following:
(1) Services performed by, or determinations of compensation issues made by, employees of an interested party in the course of that employment.
(2) A referral for legal services if that referral is not prohibited by the Rules of Professional Conduct of the State Bar.
(3) A physician’s referral that is exempted by Section 139.31 from the prohibitions prescribed by Section 139.3.
(Added by Stats. 2012, Ch. 363, Sec. 6. (SB 863) Effective January 1, 2013.)
(a) The administrative director may review advertising copy to ensure compliance with Section 651 of the Business and Professions Code and may require qualified medical evaluators to maintain a file of all advertising copy for a period of 90 days from the date of its use. Any file so required to be maintained shall be available to the administrative director upon the administrative director’s request for review.
(b) No advertising copy shall be used after its use has been disapproved by the administrative director and the qualified medical evaluator has been notified in writing of the disapproval.
(c) A qualified medical evaluator who is found by the administrative director to have violated any provision of this section may be terminated, suspended, or placed on probation.
(d) Proceedings to determine whether a violation of this section has occurred shall be conducted pursuant to Chapter 4 (commencing with Section 11370) of Part 1 of Division 3 of Title 2 of the Government Code.
(e) The administrative director shall adopt regulations governing advertising by physicians with respect to industrial injuries or illnesses.
(f) Subdivision (a) shall not be construed to alter the application of Section 651 of the Business and Professions Code.
(Amended by Stats. 2003, Ch. 639, Sec. 13. Effective January 1, 2004.)
(a) No person or entity shall advertise, print, display, publish, distribute, or broadcast, or cause or permit to be advertised, printed, displayed, published, distributed, or broadcast in any manner, any statement concerning services or benefits to be provided to an injured worker, that is paid for directly or indirectly by that person or entity and is false, misleading, or deceptive, or that omits material information necessary to make the statement therein not false, misleading, or deceptive.
(b) As soon as reasonably possible, but not later than January 1, 1994, the administrative director shall adopt regulations governing advertising by persons or entities other than physicians and attorneys with respect to services or benefits for injured workers. In promulgating regulations pursuant to this subdivision, the administrative director shall review existing regulations, including those adopted by the State Bar, to identify those regulatory approaches that may serve as a model for regulations required by this subdivision.
(c) A violation of subdivision (a) is a misdemeanor, punishable by incarceration in the county jail for not more than one year, or by a fine not exceeding ten thousand dollars ($10,000), or both.
(d) This section shall not apply to physicians or attorneys. It is the intent of the Legislature to exempt physicians and attorneys from this section because the conduct regulated by this section, with respect to physicians and attorneys, is governed by other provisions of law.
(Amended by Stats. 2004, Ch. 193, Sec. 138. Effective January 1, 2005.)
139.45.
(a) In promulgating regulations pursuant to Sections 139.4 and 139.43, the administrative director shall take particular care to preclude any advertisements with respect to industrial injuries or illnesses that are false or mislead the public with respect to workers’ compensation. In promulgating rules with respect to advertising, the State Bar and physician licensing boards shall also take particular care to achieve the same goal.
(b) For purposes of subdivision (a), false or misleading advertisements shall include advertisements that do any of the following:
(1) Contain an untrue statement.
(2) Contain any matter, or present or arrange any matter in a manner or format that is false, deceptive, or that tends to confuse, deceive, or mislead.
(3) Omit any fact necessary to make the statement made, in the light of the circumstances under which the statement is made, not misleading.
(4) Are transmitted in any manner that involves coercion, duress, compulsion, intimidation, threats, or vexatious or harassing conduct.
(5) Entice a person to respond by the offering of any consideration, including a good or service but excluding free medical evaluations or treatment, that would be provided either at no charge or for less than market value. No free medical evaluation or treatment shall be offered for the purpose of defrauding any entity.
(Amended by Stats. 2003, Ch. 639, Sec. 14. Effective January 1, 2004.)
139.47.
The Director of Industrial Relations shall establish and maintain a program to encourage, facilitate, and educate employers to provide early and sustained return to work after occupational injury or illness. The program shall do both of the following:
(a) Develop educational materials and guides, in easily understandable language in both print and electronic form, for employers, health care providers, employees, and labor unions. These materials shall address issues including, but not limited to, early return to work, assessment of functional abilities and limitations, development of appropriate work restrictions, job analysis, worksite modifications, assistive equipment and devices, and available resources.
(b) Conduct training for employee and employer organizations and health care providers concerning the accommodation of injured employees and the prevention of reinjury.
(Added by Stats. 2002, Ch. 6, Sec. 40. Effective January 1, 2003.)
(Amended by Stats. 2013, Ch. 28, Sec. 37. (SB 71) Effective June 27, 2013.)
(a) (1) The administrative director shall contract with one or more independent medical review organizations and one or more independent bill review organizations to conduct reviews pursuant to Article 2 (commencing with Section 4600) of Chapter 2 of Part 2 of Division 4. The independent review organizations shall be independent of any workers’ compensation insurer or workers’ compensation claims administrator doing business in this state. The administrative director may establish additional requirements, including conflict-of-interest standards, consistent with the purposes of Article 2 (commencing with Section 4600) of Chapter 2 of Part 2 of Division 4, that an organization shall be required to meet in order to qualify as an independent review organization and to assist the division in carrying out its responsibilities.
(2) To enable the independent review program to go into effect for injuries occurring on or after January 1, 2013, and until the administrative director establishes contracts as otherwise specified by this section, independent review organizations under contract with the Department of Managed Health Care pursuant to Section 1374.32 of the Health and Safety Code may be designated by the administrative director to conduct reviews pursuant to Article 2 (commencing with Section 4600) of Chapter 2 of Part 2 of Division 4. The administrative director may use an interagency agreement to implement the independent review process beginning January 1, 2013. The administrative director may initially contract directly with the same organizations that are under contract with the Department of Managed Health Care on substantially the same terms without competitive bidding until January 1, 2015.
(b) (1) The independent medical review organizations and the medical professionals retained to conduct reviews shall be deemed to be consultants for purposes of this section.
(2) There shall be no monetary liability on the part of, and no cause of action shall arise against, any consultant on account of any communication by that consultant to the administrative director or any other officer, employee, agent, contractor, or consultant of the Division of Workers’ Compensation, or on account of any communication by that consultant to any person when that communication is required by the terms of a contract with the administrative director pursuant to this section and the consultant does all of the following:
(A) Acts without malice.
(B) Makes a reasonable effort to determine the facts of the matter communicated.
(C) Acts with a reasonable belief that the communication is warranted by the facts actually known to the consultant after a reasonable effort to determine the facts.
(3) The immunities afforded by this section shall not affect the availability of any other privilege or immunity which may be afforded by law. This section shall not be construed to alter the laws regarding the confidentiality of medical records.
(c) (1) An organization contracted to perform independent medical review or independent bill review shall be required to employ a medical director who shall be responsible for advising the contractor on clinical issues. The medical director shall be a physician and surgeon licensed by the Medical Board of California or the Osteopathic Medical Board of California.
(2) The independent review organization, any experts it designates to conduct a review, or any officer, director, or employee of the independent review organization shall not have any material professional, familial, or financial affiliation, as determined by the administrative director, with any of the following:
(A) The employer, insurer or claims administrator, or utilization review organization.
(B) Any officer, director, employee of the employer, or insurer or claims administrator.
(C) A physician, the physician’s medical group, the physician’s independent practice association, or other provider involved in the medical treatment in dispute.
(D) The facility or institution at which either the proposed health care service, or the alternative service, if any, recommended by the employer, would be provided.
(E) The development or manufacture of the principal drug, device, procedure, or other therapy proposed by the employee whose treatment is under review, or the alternative therapy, if any, recommended by the employer.
(F) The employee or the employee’s immediate family, or the employee’s attorney.
(d) The independent review organizations shall meet all of the following requirements:
(1) The organization shall not be an affiliate or a subsidiary of, nor in any way be owned or controlled by, a workers’ compensation insurer, claims administrator, or a trade association of workers’ compensation insurers or claims administrators. A board member, director, officer, or employee of the independent review organization shall not serve as a board member, director, or employee of a workers’ compensation insurer or claims administrator. A board member, director, or officer of a workers’ compensation insurer or claims administrator or a trade association of workers’ compensation insurers or claims administrators shall not serve as a board member, director, officer, or employee of an independent review organization.
(2) The organization shall submit to the division the following information upon initial application to contract under this section and, except as otherwise provided, annually thereafter upon any change to any of the following information:
(C) The names of all corporations and organizations that the independent review organization controls or is affiliated with, and the nature and extent of any ownership or control, including the affiliated organization’s type of business.
(D) The names and biographical sketches of all directors, officers, and executives of the independent review organization, as well as a statement regarding any past or present relationships the directors, officers, and executives may have with any employer, workers’ compensation insurer, claims administrator, medical provider network, managed care organization, provider group, or board or committee of an employer, workers’ compensation insurer, claims administrator, medical provider network, managed care organization, or provider group.
(E) (i) The percentage of revenue the independent review organization receives from expert reviews, including, but not limited to, external medical reviews, quality assurance reviews, utilization reviews, and bill reviews.
(ii) The names of any workers’ compensation insurer, claims administrator, or provider group for which the independent review organization provides review services, including, but not limited to, utilization review, bill review, quality assurance review, and external medical review. Any change in this information shall be reported to the department within five business days of the change.
(H) A description of how the independent review organization ensures compliance with the conflict-of-interest requirements of this section.
(3) The organization shall demonstrate that it has a quality assurance mechanism in place that does all of the following:
(A) Ensures that any medical professionals retained are appropriately credentialed and privileged.
(B) Ensures that the reviews provided by the medical professionals or bill reviewers are timely, clear, and credible, and that reviews are monitored for quality on an ongoing basis.
(E) Ensures the independence of the medical professionals or bill reviewers retained to perform the reviews through conflict-of-interest policies and prohibitions, and ensures adequate screening for conflicts of interest, pursuant to paragraph (5).
(4) Medical professionals selected by independent medical review organizations to review medical treatment decisions shall be licensed physicians, as defined by Section 3209.3, in good standing, who meet the following minimum requirements:
(A) The physician shall be a clinician knowledgeable in the treatment of the employee’s medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of treatment under review.
(B) Notwithstanding any other law, the physician shall hold a nonrestricted license in any state of the United States, and for physicians and surgeons holding an M.D. or D.O. degree, a current certification by a recognized American medical specialty board in the area or areas appropriate to the condition or treatment under review. The independent medical review organization shall give preference to the use of a physician licensed in California as the reviewer.
(C) The physician shall have no history of disciplinary action or sanctions, including, but not limited to, loss of staff privileges or participation restrictions, taken or pending by any hospital, government, or regulatory body.
(D) Commencing January 1, 2014, the physician shall not hold an appointment as a qualified medical evaluator pursuant to Section 139.2.
(5) Neither the expert reviewer, nor the independent review organization, shall have any material professional, material familial, or material financial affiliation with any of the following:
(A) The employer, workers’ compensation insurer or claims administrator, or a medical provider network of the insurer or claims administrator, except that an academic medical center under contract to the insurer or claims administrator to provide services to employees may qualify as an independent medical review organization provided it will not provide the service and provided the center is not the developer or manufacturer of the proposed treatment.
(B) Any officer, director, or management employee of the employer or workers’ compensation insurer or claims administrator.
(C) The physician, the physician’s medical group, or the independent practice association proposing the treatment.
(E) The development or manufacture of the treatment proposed for the employee whose condition is under review.
(F) The employee or the employee’s immediate family.
(6) For purposes of this subdivision, the following terms shall have the following meanings:
(B) “Material financial affiliation” means any financial interest of more than 5 percent of total annual revenue or total annual income of an independent review organization or individual to which this subdivision applies. “Material financial affiliation” does not include payment by the employer to the independent review organization for the services required by the administrative director’s contract with the independent review organization, nor does “material financial affiliation” include an expert’s participation as a contracting medical provider where the expert is affiliated with an academic medical center or a National Cancer Institute-designated clinical cancer research center.
(C) “Material professional affiliation” means any physician-patient relationship, any partnership or employment relationship, a shareholder or similar ownership interest in a professional corporation, or any independent contractor arrangement that constitutes a material financial affiliation with any expert or any officer or director of the independent review organization. “Material professional affiliation” does not include affiliations that are limited to staff privileges at a health facility.
(e) The division shall provide, upon the request of any interested person, a copy of all nonproprietary information, as determined by the administrative director, filed with it by an independent review organization under contract pursuant to this section. The division may charge a fee to the interested person for copying the requested information.
(f) The Legislature finds and declares that the services described in this section are of such a special and unique nature that they must be contracted out pursuant to paragraph (3) of subdivision (b) of Section 19130 of the Government Code. The Legislature further finds and declares that the services described in this section are a new state function pursuant to paragraph (2) of subdivision (b) of Section 19130 of the Government Code.
(Amended by Stats. 2014, Ch. 71, Sec. 107. (SB 1304) Effective January 1, 2015.)
(a) The administrative director shall establish and effect within the Division of Workers’ Compensation a continuing program to provide information and assistance concerning the rights, benefits, and obligations of the workers’ compensation law to employees and employers subject thereto. The program shall include, but not be limited to, the following:
(1) The preparation, publishing, and as necessary, updating, of guides to the California workers’ compensation system for employees and employers. The guides shall detail, in easily understandable language, the rights and obligations of employees and employers, the procedures for obtaining benefits, and the means provided for resolving disputes. Separate guides may be prepared for employees and employers. The appropriate guide shall be provided to all labor and employer organizations known to the administrative director, and to any other person upon request.
(2) The preparation, publishing, and as necessary, updating, of a pamphlet advising injured workers of their basic rights under workers’ compensation law, and informing them of rights under the Americans with Disabilities Act, and the provisions of the Fair Employment and Housing Act relating to individuals with a disability. The pamphlet shall be written in easily understandable language. The pamphlet shall be available in both English and Spanish, and shall include basic information concerning the circumstances under which injured employees are entitled to the various types of workers’ compensation benefits, the protections against discrimination because of an injury, the procedures for resolving any disputes which arise, and the right to seek information and advice from an information and assistance officer or an attorney.
(b) In each district office of the division, the administrative director shall appoint an information and assistance officer, and any other deputy information and assistance officers as the work of the district office may require. The administrative director shall provide office facilities and clerical support appropriate to the functions of these information and assistance officers.
(c) Each information and assistance officer shall be responsible for the performance of the following duties:
(1) Providing continuing information concerning rights, benefits, and obligations under workers’ compensation laws to injured workers, employers, lien claimants, and other interested parties.
(2) Upon request by the injured worker, assisting in the prompt resolution of misunderstanding, disputes, and controversies arising out of claims for compensation, without formal proceedings, in order that full and timely compensation benefits shall be furnished. In performing this duty, information and assistance officers shall not be responsible for reviewing applications for adjudication or declarations of readiness to proceed. This function shall be performed by workers’ compensation judges. This function may also be performed by settlement conference referees upon delegation by the appeals board.
(3) Distributing any information pamphlets in English and Spanish as are prepared and approved by the administrative director to all inquiring injured workers and any other parties that may request copies of these pamphlets.
(4) Establishing and maintaining liaison with the persons located in the geographic area served by the district office, with other affected state agencies, and with organizations representing employees, employers, insurers, and the medical community.
(Amended by Stats. 1993, Ch. 121, Sec. 23. Effective July 16, 1993.)