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FLASH REPORT!

CT Claims, Medical Disputes In The Spotlight At Second DWC Public Forum

Continuing their statewide listening tour, Department of Industrial Relations (DIR) director Christine Baker and Division of Workers’ Compensation (DWC) administrative director Rosa Moran received an earful at their first stop in Southern California. Injured workers, employers and carrier representatives all lamented the fact that too many disputes are developing around treatment decisions which are delaying care and increasing costs.

Employers also raised concerns about the rapid increase in the number of cumulative trauma claims that are coming into the system, particularly in post-termination situations (see tomorrow's edition of Workers' Comp Executive for additional information on this development). Some also lamented the lack of control exhibited by some workers' comp judges that may be causing cases to drag on unnecessarily, but others applauded the administration's move to improve the performance of WCJs going forward through a reintroduction of statewide training programs for the judges.

Baker and Moran traveled to Southern California for a pair of public meetings before turning back north for a forum in Fresno on Wednesday. Additional meetings will be held this month in the Inland Empire, San Diego County and Oakland.

The Los Angeles meeting drew well over 100 attendees and several dozen offered oral testimony for the official record. The department is also collecting testimony electronically through its dir@dir.ca.gov e-mail account. As of the end of last week more than 80 comments had been submitted electronically and officials say they will accept comments and suggestions for reforms via e-mail at least through the end of the month.

The Department is looking for suggestions on how to restore the balance between benefits and costs. DIR director Baker noted that the last round of reforms in 2003/2004 came about because California's workers' comp system had deteriorated to the point that it was the highest cost system in the nation. The Golden State has made progress but is still the fifth most expensive system, Baker says. "We've had time to evaluate and perhaps we need to make some changes again to create a better balance in the system," she told the attendees.

Noting the rapid increase in claims involving cumulative trauma -- especially claims filed post-termination -- attorney Stu Baron urged the department to consider reforms that would bring these claims more in line with the evidence standards for psych or stress claims. As it stands, he maintains that disgruntled employees are abusing the process for CT claims and are attempting to circumvent legitimate personnel decisions by filing the actions. "When an employee who is hired to do a job that produces no discernible injuries and who has been laid off for legitimate non-discriminatory reasons is able to work around the system by claiming a cumulative injury, then it is time to reassess the value of this section of the labor code," he testified.

Others on both sides of the claim also raised concerns about the current process for resolving medical disputes, which often involves lengthy delays until a workers' comp judge with no medical training can ultimately rule on the issue.

Candice Rushing, an injured worker, testified that she will likely burn through her 104 weeks of temporary disability benefits before she even has surgery on her injured knee let alone is well enough to return to work. She maintains that unnecessary delays in authorization are exacerbating the severity of her injury and endangering her ability to recover. 

PacificComp's Joyce Schulman's testimony echoed the sentiment that medical decisions should be made by medical personnel without undue delay. She questioned why workers' comp judges are making medical decisions at all.

She suggested a system mirroring what is common in the group health arena. "I believe that rather than a dispute process where we have to go to an AME/QME that all medical disputes should be resolved by independent medical review," she says, maintaining that the AME/QME process is broken. "I think the doctors are trying to please payors and if we go to an IME process where one doctor is generated from the state and makes all the determinations on disability we would all be in a better place."

The road show continues this morning with a public forum in Garden Grove. Stay tuned for additional coverage.

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(Filed by Brad Cain in Los Angeles)

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