IMR: DWC Get Out of the Way

Today's post was shared by WorkCompCentral and comes from daviddepaolo.blogspot.com

What is the purpose of California's Independent Medical Review? I have to ask myself this question in light of the most recent proposed changes to Utilization Review/IMR rules published by the Division of Workers' Compensation (a whopping 75 pages long, albeit inclusive of all changes since origin). What causes me to pause is that the new amendments would allow a medical reviewer to, “issue a determination as to whether the disputed medical treatment is medically necessary based on both a summary of medical records listed in the utilization review determination,” and additional documents submitted by the employee or requesting physician. In addition, the latest amendments reverse the order in which documentation is mandated - prior versions of the regulations said the claims administrator shall provide the documents. This version provides that the IMR entity shall RECEIVE documents. I don't know why this was done, but to me it seems bass-ackwards. Finally the pending amendments would allow the DWC administrative director to determine that an IMR decision is not valid because the case should not have been deemed eligible for review in the first place. The rules would say the director can vacate an IMR determination at any point unless an appeal has been filed with the Workers' Compensation Appeals Board or the time to file an appeal has expired. IMR was statutorily authorized by Labor Code section 4610.5, added via SB 863. LC 4610.5 provides a list of the documents...

[Click here to see the rest of this post]

Found on

Related articles

• Delay Or Deny At Your Risk (workers-compensation.blogspot.com)
• More Cost Shifting (workers-compensation.blogspot.com)
• Work Comp Lost Focus (workers-compensation.blogspot.com)
• Wah, Wah, Wah (workers-compensation.blogspot.com)
• Fee Schedules and Value (workers-compensation.blogspot.com)
• Oklahoma workers' compensation opt-out provisions spark judicial questions (workers-compensation.blogspot.com)
• Discovery Permitted Without Motion in Medical Provider Claims (workers-compensation.blogspot.com)

Keeping privacy in focus

Confidentiality has been the hallmark of Workers' Compensation since the inception of the program. Has been challenged federally through the portability act concerning the privacy of medical records. All that reach was bad enough, a data breach from and a governmental site is even worse. It is becoming more than obvious, but the weak financial infrastructure, of the patchwork of worker's Compensation systems for the country are creating serious challenges. Instead of attempting to run 50 different programs throughout the country, it is probably A good idea to start looking inward, and establishing a single solid system that can meet the needs required to run A multibillion-dollar benefit system the rep country and also maintain the confidentiality and privacy that the parties participating in it require. Today's post shared from therepublic.com Hackers gained access to the personal information of about 26,000 Pennsylvanians who use debit cards to receive jobless and workers' compensation benefits, the Pennsylvania Treasury Department said Thursday. The incident was part of a wider security breach affecting 465,000 holders of JPMorgan Chase & Co. prepaid cash cards nationwide. The breach affects only cardholders who used the JPMorgan Chase UCard Center website between mid-July and mid-September, the Treasury Department said. Michael Fusco, a spokesman for JPMorgan, said the bank found no evidence any information was used improperly. JPMorgan first contacted the Pennsylvania Treasury Department on Tuesday, agency spokesman Gary Tuma said. JPMorgan has referred the matter to law enforcement and would not explain details of how the breach occurred, the Treasury Department said. The Pennsylvania agency wants details from JPMorgan Chase about the bank's response to the breach, including an explanation for any delay in notifying it and the additional measures it will undertake to protect against a recurrence. The department said most of the personal information that might have been viewed includes card numbers, dates of birth, user IDs, email addresses. Information on external bank accounts might have been exposed, as well, if a cardholder completed a transaction to it, the department said. Cardholders are being contacted by letter with instructions and are being urged by JPMorgan Chase in the meantime to...

[Click here to see the rest of this post]

Found on

Related articles

• Workers' Compensation Board hosts meetings to help improve services (workers-compensation.blogspot.com)
• The Road toward Fully Transparent Medical Records (workers-compensation.blogspot.com)
• Discovery Permitted Without Motion in Medical Provider Claims (workers-compensation.blogspot.com)
• California Workers' Compensation Rates Going Up in 2014 (workers-compensation.blogspot.com)
• NJ COLA Bill - Legislative Hearings Scheduled (workers-compensation.blogspot.com)
• John Burton Reports on Workers' Compensation Insurance Industry Underwriting Results (workers-compensation.blogspot.com)
• Coal industry pays lawyers, doctors to lie and let workers to die penniless (workers-compensation.blogspot.com)

The Road toward Fully Transparent Medical Records

Privacy of medical data in the workers' compensation system does not exist. Federal portability act excluded worker's Compensation claims. In some jurisdictions, claimants are able to seek declaratory relief to shield the records. The processes costly, onerous, and incompatible with the underlining summary and remedial legislative intent of a viable Worker's Compensation program. Today's post was shared by NEJM and comes from www.nejm.org

Perspective Jan Walker, R.N., M.B.A., Jonathan D. Darer, M.D., M.P.H., Joann G. Elmore, M.D., M.P.H., and Tom Delbanco, M.D. December 4, 2013DOI: 10.1056/NEJMp1310132 Article Forty years ago, Shenkin and Warner argued that giving patients their medical records “would lead to more appropriate utilization of physicians and a greater ability of patients to participate in their own care.”1 At that time, patients in most states could obtain their records only through litigation, but the rules gradually changed, and in 1996 the Health Insurance Portability and Accountability Act entitled virtually all patients to obtain their records on request. Today, we're on the verge of eliminating such requests by simply providing patients online access. Thanks in part to federal financial incentives,2 electronic medical records are becoming the rule, accompanied increasingly by password-protected portals that offer patients laboratory, radiology, and pathology results and secure communication with their clinicians by e-mail. One central component of the records, the notes composed by clinicians, has remained largely hidden from patients. But now OpenNotes, an initiative fueled primarily by the Robert Wood Johnson Foundation, is exploring the effects of providing access to these notes.3 Beginning in 2010, at Beth Israel Deaconess Medical Center (which serves urban and suburban Boston), Geisinger Health System (in rural Pennsylvania), and Harborview Medical Center (Seattle's...

[Click here to see the rest of this post]

Found on

Related articles

• Discovery Permitted Without Motion in Medical Provider Claims (workers-compensation.blogspot.com)
• California Workers' Compensation Rates Going Up in 2014 (workers-compensation.blogspot.com)
• Florida rejects workers' compensation rate hike (workers-compensation.blogspot.com)
• Work Comp Lost Focus (workers-compensation.blogspot.com)
• Workers' Compensation Board hosts meetings to help improve services (workers-compensation.blogspot.com)
• John Burton Reports on Workers' Compensation Insurance Industry Underwriting Results (workers-compensation.blogspot.com)
• California Tossed Out NFL Players Brain Injury Claim: Time To Change The System? (workers-compensation.blogspot.com)

THE TRUTH ABOUT CHEATIN’ AND LYIN’

Today's post comes from guest author Susan C. Andrews, from Causey Law Firm.

     You hear it all over the place these days: there are lots of people out there who lied and cheated to get Social Security Disability (SSD) benefits. I’m here to tell you that is a myth. You don’t have to drill down very far to find out differently. I should know, from where I sit, as an attorney who handles SSD cases. Where I sit most days is in front of a big pile of medical records—I mean HUNDREDS of pages of medical records, all belonging to the same person. You see, some of my clients have just one great big medical issue—like cancer, or Multiple Sclerosis, or Parkinson’s, and many of my clients have multiple medical problems. Either way, they have spent more time in doctors' offices and hospitals than any of us would ever choose to do.

 There is a mistaken notion floating around out there that a person can just waltz into Social Security, claim to be disabled, and voila—he’s granted benefits!

     There is a mistaken notion floating around out there that a person can just waltz into Social Security, claim to be disabled, and voila—he’s granted benefits! Nothing could be further from the truth. The burden of proof is on the claimant (the person claiming benefits) to show that he or she is disabled from engaging in substantial gainful activity (SGA) for a period of at least 12 continuous months. More about SGA in a bit. That proof starts with medical records, and diagnoses made by doctors. Self-diagnosing just doesn’t cut it, even if you’ve read up on your condition all over the internet, and you’re absolutely positive you know what’s wrong with you! Sometimes we get calls from people who do not have health insurance, and even though they have a serious medical condition, they have been unable to access much in the way of health care. Sadly, some of those folks who should be able to qualify for benefits do not, because they simply do not have the necessary treatment records to document the seriousness of their conditions.
     As mentioned above, Social Security’s definition of disability is the inability, due to one or more medical impairments, to engage in substantial gainful activity for a period of at least 12 continuous months. Social Security defines SGA in part by a dollar figure that usually goes up a little every year. In 2013 it is $1,040. Social Security looks at a person’s GROSS earnings, not net earnings or take-home pay. So if I’m able to gross $1,040 or more per month, I can engage in substantial gainful activity and I do not qualify for SSD. This concept is important especially for individuals with progressive conditions.
     Take, for example, a person diagnosed with Parkinson’s. One famous example is the actor Michael J. Fox. His Parkinson’s affects his functioning, but he is still working. Many people with progressive conditions continue to work for some time after receiving their diagnosis. At some point, progression of the disease may force some of them to go to part-time work. When the hours worked decrease, their earnings may no longer qualify as SGA. Or—and I see this a great deal in my practice—some people begin to have more bad days than good days, and work performance is impacted. There are days so bad that they really have no choice but to call in sick. Then this begins to happen more frequently than a couple of days a month. In my experience, at that point most employers become very unhappy campers. Not only are the employees taking sick leave faster than they are accruing it, they can’t tell their employers ahead of time which days they will wake up with an exacerbation of symptoms that keep them in bed, or at least in their bathrobe, all day.
     Which brings me to my final point: Many of my clients look okay to the casual passer-by. Take the guy with a serious heart problem. Well sure, if I followed him around for half a day, I’d see that he can barely exert himself without getting out of breath. But if I just passed by, he might look fine. And the day he spends at home in his bathrobe because he can hardly catch his breath—I’m not going to see him at all when he’s having one of those really lousy days. His condition may be largely invisible.
     To sum it up, I’d say there’s a bit of wisdom in being slow to judge. Thank goodness we take our good health for granted—it’d be a miserable existence if I spent too much time worrying about getting sick before it actually happened. But, of course, serious illness can strike any of us when we least expect it. And on the other side of that defining moment, the world can look a whole lot different.
 Photo credit: Gemma Grace / Foter / CC BY-NC

Found on

Related articles

• What is the Date Last Insured, and Why Does it Matter? (workers-compensation.blogspot.com)
• Media Portrays Social Security as an Avenue to Benefits for the Unemployed - WRONG! It's Not That Simple... (workers-compensation.blogspot.com)
• Listen to the GAO Podcast: Social Security Administration Improper Disability Insurance Payments (workers-compensation.blogspot.com)
• Are You Overexposing Yourself in Social Media? (workers-compensation.blogspot.com)
• What Does That Stand For? Commonly Used Acronyms in Workers' Compensation Cases (workers-compensation.blogspot.com)
• NJ Court Sets the Evidentiary Proof Standard for a Pulmonary - Cardiovascular Claim (workers-compensation.blogspot.com)

Major California Medical Record Privacy Breach Disclosed

The lack privacy of medical records in workers' compensation claims has perpetually been a huge concern for workers since Congress ignored requests to protect their dissemination. A recent disclosure in California that the medical records of 300,000 injured workers were available online to the public through a mere Google search further demonstrates that the system is failing workers.

"Identity Finder, LLC (www.identityfinder.com), a global leader in identity theft prevention and data loss protection (DLP), discovered that a website exposed documents containing hundreds of individuals health information and database files containing approximately 300,000 names and social security numbers of California residents who applied for workers' compensation benefits. Identity Finder notified the websites owners, Southern California Medical-Legal Consultants, Inc. (SCMLC), of the breach on May 11, 2011 and SCMLC restricted access to all files within minutes of notification."

Over the last two decades the erosion of the privacy of injured workers medical records has continued unabated. Workers who are injured on the job should not have their medical records published without restriction or limitation. Injured workers should not be subject to public humiliation and embarrassment through disclosure of their medical records. It is time for Congress to revisit the issue.

Related articles

• Patient Data Posted Online in Major Breach of Privacy (nytimes.com)
• State Acts to Restrict Medical Care (workers-compensation.blogspot.com)
• That Used to Be Comp (workers-compensation.blogspot.com)
• New data spill shows risk of online health records (seattlepi.com)
• New Data Spill Shows Risk of Online Health Records (nytimes.com)
• Whose Business is it Anyway: The Compelling Need for Privacy of Medical Records in the Workplace (gelmans.com)