Note The IMR provisions borrow extensively from the statutes creating IMR in the Health & Safety Code [even to the point where the cut and paste uses the word “plan” in Labor Code § 4610.5(i)]. Note New Labor Code § 4610.6(m) gives the DWC the discretion to publish IMR decisions. This can be as simple as doing what is currently done in the Department of Managed Health Care and providing access to the complete list of IMR decisions or the Division may want to consider a more significant linkage between utilization review (UR) regulations, the UR penalty regulations, and the medical treatment utilization schedule (MTUS). Note Current IMR regulations, 8 CCR §§ 9768.1 apply only to IMR under the MPN statutes. Note timeframes and documentation requirements for processing IMR Note As mentioned in other comments, there needs to be a clarification of which IMR process (“UR” IMR or “MPN” IMR is to be used under what circumstances.) Note: Consideration should be given to adopting the regulations of the DMHC regarding post-IMR filing additional information: “Any medical records or other relevant matters not available at the time of the Department's initial notification, or
processes in Labor Code §§ 4616.3 and 4616.4) third opinion processes apply to diagnosis, IMR applies only to treatment or diagnostic service. [Sec. 4616.4(b)] Also, current DWC regulations define a “health care provider” to include an MPN for purposes of UR standards under Sec. 4610. [8 CCR § 9792.6(i)] Clarification is needed to make certain the employer and the injured work know which IMR process can be utilized for what treatment. QME Panel Requests Code § 4062.2 DWC/WCAB 01/01/13 Amends statute to create new timeframes in to request QME panels and prohibits an AME on requests subject to IMR under Labor Code § 4610.5 The instructions on various QME request will have to be changed to reflect the new timeframes and limitations. Note New Labor Code § 4062.2(f) would allow an AME when there is a
request for IMR under an MPN Chiropractor as treating physicians Labor Code § 4600 DWC/WCAB Prohibits a chiropractor from being a “treating physician” after the maximum number of visits allowed under Labor Code § 4604.5(d). (Note incorrect statutory reference) But isn’t the issue whether after 24 visits (or however many more authorized by the claims administrator) the chiropractor is the primary treating physician (PTP) and not simply a treating physician? It would seem that the PTP as defined in Labor Code § 4061.5 and 8 CCR § 9785 does not lose that status once his or her ability to treat is ended by operation of Sec. 4604.5. Indeed, 8 CCR § 9785(a)(1) only requires the PTP to examine the injured worker “at least This does not precisely track the definition of “primary treating physician” under Labor Code § 4061.5. The DWC will need to revise the definition of PTP in 8 CCR § 9785(a)(1). The statutory language raises the question of whether a chiropractor can continue to be the treating physician if the payer authorizes additional visits. The statutory language also raises the issue of whether a chiropractor can continue to be the PTP and “primarily responsible” for the care of the injured worker after the visit cap has been reached.
over whether an injured worker is properly treating outside the network. Note that the provisions of Sec. 4603.2(a)(2) would appear to preclude transition of care back into the MPN if the injured worker is authorized to treat outside the MPN. The reference to the continuity of care provisions in Labor Code § 4616.2 is misplaced as this is not a continuity of care issue. Amendments to the MPN statutes state that a failure to provide notice is insufficient grounds to obtain treatment outside the MPN unless the failure to provide notice resulted in a denial of care. The network treatment issue is eligible for an expedited hearing. contents of the petition to adjudicate this issue as well as the timeframes for service and other procedural issues created by this change. 8 CCR § 9767.9 (transfer of care regulations) will need to be revised to reflect the new procedures in Sec. 4603.2(a)(2) Note There is a disconnect between the provisions of Sec. 4603.2(a)(2) and new lien provisions in Sec. 4903.1(b). The latter suggests that the employer has no liability for payment (except for narrow circumstances) even if the physician properly submits a first report and it is adjudicated that the treatment outside the MPN is proper.
Supplemental Job Displacement Benefit Labor Code §§ 4658.5, 4658.6, 4658.7 DWC 01/01/13 There are changes both to vouchers issued on claims with dates of injury prior to 01/01/13 issued after 01/01/13 and a new structure for dates of injury after 01/01/13. Note that vouchers issued for dates of injury after 01/01/13 cannot be settled. The amount of the voucher is $6000 regardless of the level of PD. Existing notices will have to be revised to reflect the new statutory limitations on the SJDB. Consideration should be given to clarifying what to do when there is a P&S report but the injured worker is disputing his or her status. If there is a new P&S report that has different restrictions will a new offer have to be made? Permanent Disability Rating Schedule (PDRS) Labor Code § 4660.1 DWC 01/01/13 Allows the current age and occupational modifiers to be used until a new PDRS is promulgated No timeframe in which revisions have to be made. Note: Wage loss required in subdivision (i). Contrast this with the study also required of the Commission for the new supplemental payments authorized in Labor Code § 138.48
Code § 5813 and 8 CCR §§ 10450 and 10561, then there should be an express statement of that policy. Fee Schedules Labor Code §§ 5307.1, 5307.8, 5307.9, 5811 DWC 01/01/13 01/01/14 01/01/15 01/01/16 01/01/17 provisions either modify or enact a wide range of fee schedules, including moving to an RBRVS system for medical services, deleting the pass through for implantable hardware, and equalizing payments to ambulatory surgery centers. In addition, fee schedules will be established for home health care and interpreter services. The OMFS revisions are somewhat self-executing with the exception of the ground rule changes outlined in Sec. 5307.1(a)(2)(B) relating to new codes and evaluation and management services provided during a “global period of surgery”. As for the remaining schedules, it is up to the DWC to decide whether need to be done on an emergency basis under its authority in Secs. 5307.3 and 5307.4. Given that IBR applies at time of service, the adoption of these schedules will greatly aid the ability to realize the potential of the