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Thread Title: There otta be a law...
Created On Thursday April 20, 2006 10:20 AM


theAxe
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Thursday April 20, 2006 10:20 AM

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My friend is the manager of the grounds maintenance dept of a large school district and called me with this scenario:

IW hurt on district grounds, performing usual & customary work, with a witness, reported injury immediately, treated with company MD, was TTD 3 weeks, and RTW w/out restrictions. This is a valued long time EE. All forms were completed and sent immediately. Seems like a no-brainer... take care of the employee and move on.

But no!
IW was paid for TTD out of his "sick-time" on the basis that IC "needed to complete a 90 day investigation" before they'll let him know about any benefits! The EE is back to work today, he just got this notice, and feels he's taken a hit for the ER when he got hurt and was then taken advantage of - by this "betrayal" of confidence.

ER (self insured) has recently outsourced it's WC handling. What would be their benefit in delaying this? Interest on the measly TTD $$? Additional billing hours to the ER?

Is this the new standard MO? Delay and Deny even at the most basic level? I see this all the time as a medical treater, but was appalled to hear it has trickled down to this. As a former claims adj. and employee supervisor I can't see any value in handling cases/employees in this manner.

-------------------------
theAxe

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scrapindee
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Thursday April 20, 2006 4:44 PM

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This has been the "game" of self-insurer for a very long. Deny, at the most basic level.


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bclinkenbeard
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Tuesday May 30, 2006 11:56 AM

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hmm, anyone ever hear of the Education Code?

If your friend works for a school district, his WC claim is subject to Ed. Code... can be substantially different from our regular Labor Code.. most school districts will pay salary continuation regardless of pending aoe/coe, deducting TTD days as "sick" or "vacation" days- then crediting them back after a voucher is rec'd from the claims adjuster.

It can be a good thing for workers claiming injury on the job, who continue to receive income, uninterrupted, even if the claims adjuster is lagging the aoe/coe decision for [seemingly] no reason, however it works against EEs who haven't accrued much paid time off.

just a thought


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steve appell
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Tuesday May 30, 2006 12:53 PM

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As with firemen, policemen, and (all/most) city and state EE's, public school teachers are entitled to 1 year salary wage continuation at full salary per Education Code 89529.03. After one year, teachers are entitled to 2/3 salary wage continuation. After the 90 day IV period, any non industrial benefits assessed will be credited back the the EE account if the injury is determined to be AOE COE.

Trust me. The aforementioned EE's have the best work comp benefits available!

-------------------------
Steve

A government which robs Peter to pay Paul can always depend on the support of Paul.
- George Bernard Shaw

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50lake4
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Tuesday May 30, 2006 8:39 PM

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This is SOP for allot of school districts they will credit the sick pay if this is found industrial.

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employernurse
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Wednesday May 31, 2006 2:53 PM

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How do we know the IW is a "teacher"? Perhaps it was a custodian or other classified personnel

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theAxe
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Wednesday May 31, 2006 5:15 PM

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As noted in my initial post, the IW is a grounds maintenance worker. And yes, his case has now been accepted and his sick time benefits reinstated.

What irks me and the IW is that there was never any question whatsoever that the injury occurred as described and the treatment and TTD were reasonable and warranted - he was treating with the co. industrial clinic the whole time

- the "investigation" was not initiated until 6 weeks post injury, was done face to face with all involved including the IW, witnesses, and supervisor; in a demeaning and bombastic manner - basically poking into any and all past life experiences - generating bad feelings all arround and a very definate distaste for having anything to do with anything workers' comp related in the future - no matter how obvious - all for a probable no permanent disability injury.

This is supposed to be a benefit to take care of persons injured on the job - this industry is one where injuries will occur - they're trimming trees and working with heavy equipment.

This type of claims handling appears caculated to intimidate workers from making legitimate claims - then they'll raise fraud questions when the badly injured IW finally gets an AA and says he was afraid to report the injury.
ERRRRRR!@!

-------------------------
theAxe

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stewshe@comcast.net
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Thursday June 01, 2006 6:04 AM

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theAxe,

What we have here is a classic example of defense paranoia. The personnel dept and adjusters have a tort mentality. The feeling is that ALL claims should be investigated to the hilt. The temperment is, "Admit nothing, deny everything and accuse all," as I once heard it put.

Only after ruling out all other possibililties are any claims reluctantly accepted. Yes, they may find a hand full of claims to deny out of 100, but I think they inflate their own costs in the process.

It is supposed to be a benefit delivery system.

Often times the claims people huff and puff, stir up the mud and then point out all the issues they have actually created, which are for the most part eventually ruled out. The activity is more to impress the paranoid employer representatives/stockholders than to really accomplish something.

These are the same people who in effect shoot themselves in one foot and then threaten to shoot themselves in the other! They are often simply clueless, focused only on a slim to non-existent possibility to deny a claim.

They should be focusing instead on paying what they owe, no more, but no less and as promptly as possible. They should save their resources for a more intensive investigation where there are genuine indications the claim is not legitimate.

-------------------------
Stew (James T. Stewart) e-mail: stewshe@comcast.net
Author: Work Comp Index & Tables & Schedules in "The Labor Code Book," by LexisNexis/Matthew Bender.

7th ed. Work Comp Index (912 pgs), $119.00 ea; next ed. summer, 2010 {Discounts for orders of 12 or more}
Send check or money order & shipping info. (I cannot take credit cards.)

Prices INCLUDE sales tax, and shipping.

James T. Stewart; 1937 Santa Ana; Clovis, CA 93611

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straightshooter1965
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Monday September 04, 2006 7:16 PM

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"They should be focusing instead on paying what they owe, no more, but no less and as promptly as possible. They should save their resources for a more intensive investigation where there are genuine indications the claim is not legitimate".

I have argued this basic common sense, well since, "they" started spending more time and money on my demise, despite their own doctors and preliminary investigation up-holding my account of how I became injured, than my medical care, which is still in limbo! : (

I even cited that (above) in a recent letter complaining about some issues that required complaining about. One example complaint, just for the heck of it; the MPN network grows anytime I question certain providers and their behavior?! My attorney says this is simply S.O.P. This is "Alice in Wonderland" folks!!!

They are spending dollars to save nickels, but still report record profits???!!! The RICO Act comes to mind here. Anyone ever read the Federal RICO Act? With a few exceptions, a "MPN" is almost exactly what the Act was supposed to curtail!!!

Good night all...

JD13


-------------------------
"If you tell a lie big enough and keep repeating it, people will eventually come to believe it. The lie can be maintained only for such time as the State can shield the people from the political, economic and/or military consequences of the lie. It thus becomes vitally important for the State to use all of its powers to repress dissent, for the truth is the mortal enemy of the lie, and thus by extension, the truth is the greatest enemy of the State."
-Joseph Goebbels-

Edited: Monday September 04, 2006 at 7:25 PM by straightshooter1965

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claim_monkey
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Wednesday September 13, 2006 5:46 PM

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Hi All,

Please don't shoot at me... Just a resident adjuster stepping in with $0.02 and stepping out before you all start shooting.

I really hate hearing about scenarios where there are these overzealous adjusters who act like the bloody money is coming out of their pockets. I also hate seeing just how bloody conservative the WCAB has gotten recently. It's almost as if they've forgotten about LC 3202 & 3202.5. The insurance industry and the employers received a wonderful boon through SB899. The intent was to help control costs and curtail abuse in the system. Of course, it has been largely abused by the defense side of the fence. Honestly, it really bugs me when I hear some doofus say that a claim can be delayed for "any" reason. The scenario described by theAxe is a perfect scenario of defendants abusing the system. Defendants hide behind the remedies built in to SB899 as a means by which they can do whatever they want with impunity! If there is a witness, immediate report, and medical opinion indicative of a compensable case, where is the question? I see it as thus: If it walks like a duck...

Here's what your friend needs to do: File an Application for Adjudication and a Declaration of Readiness to Proceed for either a Status Conference for AOE/COE or, if represented, a Priority Conference with a Petition for Penalties & Interest under LC5814.

Anyway, this method is BS. I hate seeing employers getting away with this kind of shenanigans and hiding behind SB899 as if it were some sort of indelible shield against penalties & sanctions. I do not like to deny or delay claims when there is no reason to. However, lacking information, I have to delay claims in order to get to the bottom of things. Generally, I find the cause of the miscommunication and can wrap things up pretty quickly by talking to the injured worker, any witnesses, and the employer.

Oftentimes, if I delay a claim for lack of information, there is something the employer is trying to hide and they're insisting on a delay/denial. Also, a carrier or TPA handling these claims might delay the case because the employer is not providing the information. I would also recommend following up with the carrier/TPA on this matter and see what's going on... This is not Best Claims Practices.

Nonetheless, get in contact with the examiner and see what information they need. Remember, if you have information and documentation that can prove compensability by a preponderance of the evidence (LC 3202.5), the examiner has to act on that within 14 days! 90 days is the limit for delays, but 14 days is how long we examiners have to act on anything (issue benefits, make compensability determination, change benefits, deny benefits, rate and issue PD indemnity, etc.).

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stewshe@comcast.net
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Wednesday September 13, 2006 8:43 PM

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claim_monkey,

You posted:

<<
90 days is the limit for delays, but 14 days is how long we examiners have to act on anything
>>

Agreed. That is the theory. I can also cite you the requirement for medical reports to be served within 6 days of receipt. If I could get them served within 4 weeks I would be happy!

Admit/operative/discharge reports are becomming harder and harder to obtain. They go to "UR" who keep them for later reference, not returning them to claims who never get a chance to see them or send them to their attorneys to file and serve!

I have subpoenaed claims files in the past year to get them, only to find they are missing! Why? Because, as noted above, "UR has them!"

Talk about the tail wagging the dog! (Scary movie, if you've ever seen it. The satire would do Swift proud!)

There ought to be a separate "Penalty" vs U.R. providers who screw up! Make them responsible for their mistakes and perhaps they'd be a bit more cautious and less willing to refuse a crutch to someone recovering from a total hip surgery because it isn't mentioned in ACOEM as being needed! (Same for a total knee replacement, though I believe it is for an os calsis fracture or ankle problem.)

A Fresno ortho has pointed out evidence for the use of a crutch for a lower extremity injury pre-dates not only ACOEM but human speech as well! That is, over 30,000 years of evidence of use!

Bottom line? You just can't legislate or write down, nice and neat, all that "common sense" entails. A treating physician needs to be given some reasonable leeway to decide day to day treatment needs of their patients.

To have to go to an AME for a supplemental report over a $20 cane is simply stupid! Micro-management by AMEs is a waste of their time, the defendant's money and the needless pain and suffering of EEs.

Adjusters should be able to step back from a claim, decide to authorize something without the automatic referral to UR, or to override UR if the decision is obviously "stupid."

-------------------------
Stew (James T. Stewart) e-mail: stewshe@comcast.net
Author: Work Comp Index & Tables & Schedules in "The Labor Code Book," by LexisNexis/Matthew Bender.

7th ed. Work Comp Index (912 pgs), $119.00 ea; next ed. summer, 2010 {Discounts for orders of 12 or more}
Send check or money order & shipping info. (I cannot take credit cards.)

Prices INCLUDE sales tax, and shipping.

James T. Stewart; 1937 Santa Ana; Clovis, CA 93611

Edited: Wednesday September 13, 2006 at 8:44 PM by stewshe@comcast.net

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claim_monkey
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Monday November 20, 2006 8:48 AM

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Hey Stew,

Gotta love that common sense angle. If we actually used that in this industry on a widespread basis, I think I might just fall out of my chair and end up needing a DWC-1... :-)

Most of my medical providers and nurse case managers love dealing with me for one simple reason: If it sounds logical, I authorize it. A doctor tells me he's going to operate on someone's shoulder but forgets to mention that a specific immobilizer sling is going to be needed. UR approves the surgery and the doctor comes back saying, "Oh, by the way, she needs this very specific sling" and my response has always been, "Go through this vendor and get it. If they give you any grief, speak to Xxxxxx and just mention my name." I cannot even begin to tell you how many braindead adjusters will send the file *BACK* to UR... Remember, UR costs money people. Why spend $90 on one review when the item in question is $10? Jeez...

Oh yeah, let me incur $100+ for a supplemental AME report just to see if someone needs a crutch or a sling. Those things are obvious. It's not like the doctor is asking for a motorized wheelchair on an ankle sprain (yes, I've received such a request with such a diagnosis).

Finally, let's not forget one of the *MAJOR* provisions of the Sandhagen case law (and another example of how SCIF makes bad case law a daily reality): Utilization Review is ***OPTIONAL***!!! You miss the time frame for UR and your only back-up is a 4062 objection. Uh, are you really going to waste a Med-Legal eval. on something as simple as a cervical MRI or a pair of crutches?

Employers should take a close look at what their insurance companies are doing. And if the employer is directly to blame for this nonsense, then I really don't want to hear them bitching about their spiralling X-Mods or losses. Since when did filing a workers' comp injury equate to trying to defraud and abuse the system??

Since you mentioned Swift, I just can't bear to keep this under my hat any longer. This is Claim Monkey reform, henceforth to be known as AB(c)123.
1. Utilization review shall be conducted on three levels: common sense, logic, and necessity.
2. If anything requested by a medical provider does not exceed the cost of the review, then the adjuster or employer shall authorize or deny based on the common sense principles previously indicated. For instance: wounds require bandages, sprains require immobilization or splinting, broken bones require casts, and lower extremity injuries often require crutches.
3. Should an adjuster or employer deny any one of these common sense items or submit said request to utilization review, then the requesting physician may issue an automatic subpoena for personal appearance at his/her offices. When the adjuster or employer arrives under said subpoena, the physician is then authorized to conduct a "cerebral excess particle removal," defined herein as a slap across the back of one's head intended to clear the "excess particles" or "dust" from the top of one's brain (or lack therein).
4. Should an adjuster or employer receive three or more brain dusters, then the physician may issue an immediate request for a posterial kinetic application of tarsal structures (or PKATS) procedure to be conducted against said adjuster or employer. This may be carried out by the physician himself or his patient's counsel or otherwise designated agent, as this is a common and easy to carry out lay procedure. Of note, this is literally only a kick in the ass.
5. Should an adjuster or employer be injured in this Utilization Retribution process, they shall be barred from receiving compensation, as this is a natural consequence of their ignorance.

Nonetheless, I know this probably comes nowhere near the biting wit of Swift, but still, something really needs to be done about this obnoxious use of UR and medical-legal examinations. Are people already forgetting about that huge supreme court case a few years ago? Schaeffer Ambulance v. SCIF? If UR were to start coming out of insurers' "Loss Expense" lines, then they'll probably be a bit more judicious in the usage of UR and actually start authorizing stuff because the costs of UR could be considered the "cost of doing business" for the insurance company, much like sub rosa, medical-legal evaluations, and legal/expert expenses. But for now, it's being billed as medical costs and the employers are going to get hit one way or another with increased loss ratios, inflated X-Mods, and excessive expenses. Much like the 4061/4062 AME/QME tracks of old, UR is the same beast, but with different spots. UR companies can hire infamous doctors who will find *any* way possible to deny treatment, deny AOE/COE, deny everything. Wait a sec. It's a right-wing administration! I knew it. Anyone working at one of these UR brothels will tell the adjuster what they want to hear because the adjuster is paying for the review...

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majones
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Monday November 20, 2006 11:30 AM

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I second that motion Claim Monkey!!

My employment history involves 15 years of working for orthopedic surgeons. Some of the duties involved bill and collections as well as reading thousands of medical reports over that period of time. I believe this experience provided me a tremendous amount of insight into what is reasonable medical treatment. No, I am no doctor. But I know well enough that an excision of a ganglion cyst in the hand does not need physical therapy, but an IW, after a subacromial decompression, will gain greater mobility post surgically with the use of a CPM machine making it worth every penny of the $500-900 rental fee. I hate the fact that the mandate by the carriers/tpa's to utilize UR, ties my hands regarding the authorization of treatment. To deny treatment because a "T" is not crossed is a waste of my time, the IW's time, the doctor's time and my client's time as well as a waste of money!






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