Today’s post comes from guest author Kit Case, from Causey Wright, Seattle, Washington..
There is always discussion, in every state, about the expense of workers’ compensation insurance to employers. It is common to hear stories of corruption and fraud when employer costs run high. This discussion can lead to cries of fraud, usually with fingers pointed towards claimants and often tied into efforts to reduce benefits to injured workers. As a recent example, take a look at the article published on July 23rd in the Fresno Bee, written by Dan Walters of CALmatters, titled “California workers’ compensation system plagued by high costs and fraud.” In the article, Mr. Walters points to Southern California as an area particularly afflicted by fraud, inserting the hot-button phrase “immigrant workers,” as follows:
Showing posts sorted by date for query medical fees. Sort by relevance Show all posts
Showing posts sorted by date for query medical fees. Sort by relevance Show all posts
Thursday, December 21, 2017
Tuesday, November 7, 2017
Changes Urged for NJ Workers' Compensation System
The NJ 2017 Gubernatorial election results have not even been reported and major changes to the NJ Workers' Compensation system are already being urged. A leading practitioner in the workers' compensation arena is urging the adoption of a pure wage-loss system to replace the scheduled and time-limited disability benefits now embodied in the Act, and an employee choice of physician statute to replace the present employer directed system.
Saturday, October 21, 2017
Guidelines for Medical Provider Claims - A Valuable Approach
While the vast majority of jurisdictions in the US have the guidance of mandatory workers' compensation medical fee schedules, New Jersey remains one of the very few with no such structure. As I reported earlier, this generates multiple issues in the claims process and creates costly delays in the adjudication of disputes.
The Inherent Judicial Power of Judges of Compensation
A Judge of Compensation has the discretion to call and question witnesses in pending cases. A NJ Appellate Court affirmed the trial court award of additional weeks of temporary disability, the imposition of a 25% penalty for unreasonable and negligent delay in defending the case and 20% counsel fees.
Wednesday, September 6, 2017
Technology - Efficiency - Uniform Procedure
For decades the NJ Workers' Compensation administrative law system has had to adapt to meet the social, political, economic and technological changes of a changing world. The well thought-out proposals by the NJ State Bar Association (NJSBA) are a starting point to the beginning of a new wave of discussion and change.
Tuesday, August 29, 2017
Looking for Order in the Land of Chaos
The NJ Appellate Division was again faced with a dispute over medical fees. This issue has engulfed the NJ Division of Workers' Compensation over the decades. New Jersey remains a member of a diminishing minority of seven jurisdictions that lack a medical fee schedule for workers' compensation claims.
Thursday, April 21, 2016
Florida Appeallate Court Rules Attorney Fee Statute Unconstitutional
The Florida First District Court of Appeals has held counsel fee provisions in the Workers' Compensation Act to be unconstitutional, ,"We hold that the challenged provisions violate Claimant’s First Amendment
guarantees of free speech, freedom of association, and right to petition for redress." Miles v City of Edgewater, Decided April 20, 2016, setting the stage for review by the Florida Supreme Court.
Today's guest post is authored by the Hon. David Langham, Deputy Chief Judge of Compensation Claims for the Florida Office of Judges of Compensation Claims and Division of Administrative Hearings and is shared from http://flojcc.blogspot.com.
Today's guest post is authored by the Hon. David Langham, Deputy Chief Judge of Compensation Claims for the Florida Office of Judges of Compensation Claims and Division of Administrative Hearings and is shared from http://flojcc.blogspot.com.
Friday, July 3, 2015
NJ Senate Passes Workers' Compensation Collective Bargaining Legislation
The NJ Senate passed an historic legislative proposal that will change the way benefits are delivered in work related injuries in NJ. S2447 provides for a collective bargaining arrangement that allows for delivery of benefits without the necessity of formal intervention before the NJ Division of Workers' Compensation, that will however remain an option in the process.
Saturday, December 20, 2014
TRIA Non-Renewal: No Loss to Workers
Todays guest post is shared from workcompwire.com and is authored by Peter Rousmaniere.
The failure to renew the Terrorism Risk Insurance Act (TRIA) – first enacted in 2002, renewed in 2005 and 2007 – raises two questions: Who would have benefited from renewal, and who is harmed by non-renewal, with regards to workers’ compensation?
Workers did not benefit from TRIA. They may benefit from its non-renewal. For them, TRIA was useless.
For workers’ compensation insurers, TRIA simplified their management of risk and now they have to work harder. TRIA was, when you peel away the onion, about insurers taking care of their markets. Every other consideration appears to be secondary.
The impact of non-renewal on employers is ambiguous. Their risk management is now trickier, but they may come to see how poor a deal the federal backstop was for their employees.
TRIA mandated no expansion, clarification or revision of state workers’ compensation statutes, in coverage and process. After claim payers incurred a specified threshold of losses, the Federal Government was to begin to help fund further losses. (This is a very simplified but I think fair summary.)
Throughout the history of statute, including the legislative debates and published studies, few, if any, took the time to ask some fundamental questions:
What nature of conditions could arise from a terrorist attack?
Do workers’ compensation statutes cover these conditions?
For conditions that are covered, is there a reasonable chance that affected workers will obtain adequate benefits?
[Click here to see the rest of this post]
The failure to renew the Terrorism Risk Insurance Act (TRIA) – first enacted in 2002, renewed in 2005 and 2007 – raises two questions: Who would have benefited from renewal, and who is harmed by non-renewal, with regards to workers’ compensation?
Workers did not benefit from TRIA. They may benefit from its non-renewal. For them, TRIA was useless.
For workers’ compensation insurers, TRIA simplified their management of risk and now they have to work harder. TRIA was, when you peel away the onion, about insurers taking care of their markets. Every other consideration appears to be secondary.
The impact of non-renewal on employers is ambiguous. Their risk management is now trickier, but they may come to see how poor a deal the federal backstop was for their employees.
TRIA mandated no expansion, clarification or revision of state workers’ compensation statutes, in coverage and process. After claim payers incurred a specified threshold of losses, the Federal Government was to begin to help fund further losses. (This is a very simplified but I think fair summary.)
Throughout the history of statute, including the legislative debates and published studies, few, if any, took the time to ask some fundamental questions:
What nature of conditions could arise from a terrorist attack?
Do workers’ compensation statutes cover these conditions?
For conditions that are covered, is there a reasonable chance that affected workers will obtain adequate benefits?
| ... |
Wednesday, December 3, 2014
Florida Supreme Court Weighs Workers’ Comp Attorney Fee Schedule
| Today's post is shared from insurancejournal.com/ The Florida Supreme Court is considering whether to declare the state’s workers’ compensation attorney fee schedule unconstitutional. The court recently heard oral arguments in a case (Castellanos v. Next Door Company, SC13-2082) addressing the attorney fee schedule passed in 2003 as part of a comprehensive rewrite of the state’s workers’ compensation law. The attorney fee schedule was designed in part to end the practice of attorneys filing multiple benefit claims on a single case in order drive up their hourly fees. Proponents of the fee reform argued that a high rate of attorney involvement was one of the main reasons Florida’s workers’ compensation rates then were among the highest of the nation. Since then, rates have dropped by more than 50 percent including a statewide average 5.2 percent decrease scheduled to take effect January 1, 2015. The case before the court involves Marvin Castellanos who was injured in an altercation with another employee in 2009. At the time, Castellanos’ employer and its insurer, Amerisure Insurance, paid for Castellanos to see a doctor. However, the employer/carrier subsequently denied his claim for additional medical treatment that included three physical therapy visits for two weeks. Castellanos then hired an attorney who prevailed in the case and won him additional benefits in the amount of $822.70. Based on the state’s statutory fee schedule, Castellanos’ attorney was awarded... |
Wednesday, October 1, 2014
Detailing Financial Links of Doctors and Drug Makers
| Yoday's post is shared from nytimes.com Pharmaceutical and device makers paid doctors roughly $380 million in speaking and consulting fees, with some doctors reaping over half a million dollars each, during a five-month period last year, according to an analysis of federal data released Tuesday. Other doctors made millions of dollars in royalties from products they helped develop. The data sheds new light on the often murky financial ties between physicians and the health care industry. From August to December 2013, drug and device companies made 4.4 million payments to more than half a million health care professionals and teaching hospitals — adding up to about $3.5 billion. The lucrative arrangements are just some of the findings of the online database, which provides one of the most detailed looks at the payments health care professionals receive from drug and medical device companies. The website also allows consumers to find information about their own doctors to determine whether they might have conflicts of interest. The site, required by the recent health care law, is part of a broader push for transparency. Proponents say such disclosures are an important tool to help limit drug and device makers’ influence on doctors. But the website is being questioned by the industry, which says that technical problems and data inaccuracies limit its value. For example, about 40 percent of the records do not tie back to a specific professional or teaching hospital, accounting for 64 percent of the overall... |
Tuesday, September 23, 2014
Friday, September 19, 2014
Subcommittee to Examines Legislation to Provide Greater EEOC Transparency and Accountability
On Wednesday, September 17 at 10:00 a.m., the Subcommittee on Workforce Protections, chaired by Rep. Tim Walberg (R-MI), held a legislative hearing on the EEOC Transparency and Accountability Act (H.R. 4959), the Litigation Oversight Act of 2014 (H.R 5422), and the Certainty in Enforcement Act of 2014 (H.R. 5423).
The Equal Employment Opportunity Commission (EEOC) enforces federal laws prohibiting employment discrimination. At a recent oversight hearing, witnesses shared growing concerns with various EEOC regulatory and enforcement actions. For example, “guidance” finalized in 2012 limits employers’ use of criminal background checks during the hiring process. The subcommittee also examined EEOC’s increasing reliance on systemic discrimination cases and the commission’s delegation of its litigation authority to the Office of General Counsel. In response to these concerns, a number of legislative proposals have been introduced:
- H.R. 4959, introduced by Rep. Richard Hudson (R-NC), would increase EEOC transparency by, among other provisions, requiring the commission to post on its website and in its annual report any case in which the commission was required to pay court sanctioned fees or costs.
- H.R. 5422, introduced by Rep. Walberg, would require EEOC commissioners to approve by majority vote all EEOC-initiated litigation involving multiple plaintiffs or allegations of systemic discrimination.
- H.R. 5423, also introduced by Rep. Walberg, would provide a safe harbor to employers complying with federal or state mandates, such as a law requiring criminal background checks.
"Chairman Walberg, Ranking Member Courtney and members of the Subcommittee, I thank you for the opportunity to express my views on the proposed legislation. Unfortunately, however well intended, these proposed changes to the federal employment discrimination statutes are unnecessary, premature and in practical effect, would thwart the effective law enforcement function of the EEOC."
To learn more about the hearing, visit http://edworkforce.house.gov/hearings.
Wednesday, September 3, 2014
CMS To Publish Financial Interactions Between Industry and Physician and Teaching Hospitals
On September 30, 2014, the Centers for Medicare & Medicaid Services (CMS) will for the first time publish Open Payments (“the Sunshine Act”) data. This is a national program that promotes transparency by making public information about financial interactions between industry and individual physicians and teaching hospitals.
The Open Payments program allows physicians and teaching hospitals to register and review the financial data submitted by applicable manufacturers and group purchasing organizations to initiate disputes if necessary before the data is made public. Physicians and teaching hospitals have until September 10, 2014, to review and dispute payments reported about them.
Sunday, August 31, 2014
Coverage for End-of-Life Talks Gaining Ground
Today's post is shared from nytimes.com
[Click here to see the rest of this post]
Five years after it exploded into a political conflagration over “death panels,” the issue of paying doctors to talk to patients about end-of-life care is making a comeback, and such sessions may be covered for the 50 million Americans on Medicare as early as next year. Bypassing the political process, private insurers have begun reimbursing doctors for these “advance care planning” conversations as interest in them rises along with the number of aging Americans. People are living longer with illnesses, and many want more input into how they will spend their final days, including whether they want to die at home or in the hospital, and whether they want full-fledged life-sustaining treatment, just pain relief or something in between. Some states, including Colorado and Oregon, recently began covering the sessions for Medicaid patients. But far more significant, Medicare may begin covering end-of-life discussions next year if it approves a recent request from the American Medical Association, the country’s largest association of physicians and medical students. One of the A.M.A.’s roles is to create billing codes for medical services, codes used by doctors, hospitals and insurers. It recently created codes for end-of-life conversations and submitted them to Medicare. The Centers for Medicare and Medicaid Services, which runs Medicare, would not discuss whether it will agree to cover end-of-life discussions; its... |
Wednesday, August 27, 2014
The Word Didn't Get There
| Problems with the national workers' compensation system are addressed in today guest post authored by David DePaola and shared from http://daviddepaolo.blogspot.com/ Then I get an email from a former claims professional turned auditor that completely deflates my enthusiasm and makes me angry. The emailer has been in the process of auditing some cases on behalf of an insurance carrier whose cases are administered by a Third Party Administrator. This is a pretty typical arrangement. Carriers are very good at "writing the paper" and all the processes involved from brokerage administration to determining the risk (underwriting) and marketing. Then the job of actually handling the claims gets outsourced to specialized companies: TPAs. The auditor writes she's appalled; outraged at the lack of any sense of urgency, the lack of responsiveness to defense attorneys, not to mention applicant's attorneys. She's astounded at the failure to pay temporary total disability, the failure to advance permanent disability a year after the Agreed Medical Examiner's findings are undisputed to a person who's getting $500.00 a month from Social Security. She's offended that the TPA lets the defense attorneys handle the files, lets cases linger until a pinky finger from 2008 ends up turning into hand, arm, neck, back, internal, sleep, psyche, etc., etc. - on a case that was really ready to settle no less than 4 years ago. She asks, "Why would these cases still be open (excluding those with obvious complex if not catastrophic issues) when the file reflects many opportunities for settlement that slipped away?" Of... |
Tuesday, July 22, 2014
CA DWC Issues Notice of Public Hearing on September 3 for Proposed Workers’ Comp Benefit Notice Regulations Amendments
| San Francisco, CA (WorkersCompensation.com) - The Division of Workers' Compensation (DWC) has issued a notice of public hearing on proposed amendments to the Workers’ Compensation Benefit Notice regulations found in California Code of Regulations, title 8, sections 9810, 9811, 9812, 9813, 9814, 9815, 9881.1 and 10139. Formal notice of this rulemaking proceeding will be published in today’s California Regulatory Notice Register. A public hearing on the proposed regulations has been scheduled at 10 a.m., September 3 in the auditorium of the Elihu Harris State Office Building at 1515 Clay Street, Oakland, CA 94612. If public comment concludes before the noon recess, no afternoon session will be held. Members of the public may submit written comments on the proposed regulations until 5 p.m. that day. The rulemaking proposes to amend and update existing regulations requiring employers to serve notice on injured employees that they may be entitled to workers' compensation benefits. These notices deal with: the payment, nonpayment, or delay in payment of temporary disability, permanent disability, and death benefits; any change in the amount or type of benefits being provided; the termination of benefits; the rejection of any liability for compensation; and the requirement to provide an accounting of benefits paid. In addition, changes are also being proposed to the Notice to Employees Poster and the Notice of Potential Eligibility for Benefits and Claim Form. The... |
Sunday, July 20, 2014
CCWC at Disneyland
 Today's post is authored by Julius Young and shared from workcompzone.com I’ve been attending the 2014 California Coalition on Workers’ Compensation annual conference at Disneyland, which wrapped up yesterday. On Wednesday the conference kicked off with a blogger’s panel featuring myself, insurance consultant and blogger Peter Rousmaniere, Workcompcentral.com publisher David DePaolo, and WorkersCompensation.com publisher Bob Wilson. Mark Walls of Safety National Insurance moderated a lively discussion that got into some “out of the box” discussions about the direction of workers’ comp; in a coming post I’ll reprise some of the thoughts from the panel and offer some further insights. CCWC is a major player on the California workers’ comp scene. Many of California’s big employers are members. I’m talking companies like Safeway, Walt Disney and UPS. CCWC is one of several prominent employer advocates in Sacramento along with the Cal Chamber and groups like WCAN (Workers Compensation Action Network). Members of CCWC were pivotal in drafting and pushing through the 2012 SB 863 California comp reforms. Key board members clearly have the ear of Brown Administration policymakers. And the Sacramento lobbyists used by CCWC, Paul Yoder and Jason Schmelzer, are a talented bunch. In short, the conference attracts many of the key employer and insurer players in California workers’ comp. Here are some of the more interesting things I heard and some of my random impressions from the... |
Thursday, July 10, 2014
Patient Access To Physicians Notes: An Experiment of Psychological Importance
| Today's post is shared from the NYTimes.com What would happen if all workers' compensation patients had access to all their treating physician's records including pschiatric care? Would such access assist in limiting and increasing litigation for continued medical care and the need for medical treatment? David Baldwin wasn’t sure how he had come across the other day in group therapy at the hospital, near the co-op apartment where he lives with his rescue cat, Zoey. He struggles with bipolar disorder, severe anxiety and depression. Like so many patients, he secretly wondered what his therapist thought of him. But unlike those patients, Mr. Baldwin, 64, was able to find out, swiftly and privately. Pulling his black leather swivel chair to his desk, he logged onto a hospital website and eagerly perused his therapist’s session notes. The clinical social worker, Stephen O’Neill, wrote that Mr. Baldwin’s self-consciousness about his disorder kept him isolated. Because he longed to connect with others, this was particularly self-defeating, Mr. O’Neill observed. But during the session, he had also discussed how he had helped out neighbors in his co-op. “This seems greatly appreciated, and he noted his clear enjoyment in helping others,” Mr. O’Neill wrote. “This greatly assists his self-esteem.” A smile animated Mr. Baldwin’s broad, amiable features. “I have a tough time recognizing that... |
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Thursday, June 12, 2014
Compensation denied for false imprisonment type situation
The NJ Court of Appeals affirmed the dismissal of an employee's claim for mental disability based upon confinement by the employer against her will. The reviewing tribunal accepted the rationale of the the compensation court judge that the event was not a material contributing cause of the disability.
Since the amendment to the NJ workers' compensation act in 1979, an employer is not responsible for a condition that is not materially contributing by the employment. Prior to 1979 the standard was that the employer took the employee as they found him or her. If the work related event was the "straw that broke the camel's back," the employer was then responsible for the end result.
In this instance, the trial judge had found that the employee had a pre-existing mental disability following from childhood sexual abuse and that condition was the sole material contributing cause of the injured workers' mental disability. The employment episode was deemed unrelated.
The Court held: "Here, the judge found appellant's history of childhood sexual abuse was in fact the true source of her disability; this finding is similar to Goyden, where the court found the appellant's compulsive personality and childhood problems caused his unfortunate reactions to his work environment. Id. at 458–59. Here, the testimony of Dr. Pipchick yields a similar analysis; she clearly stated that without the childhood sexual abuse, appellant would not have had the disabling response to the incident. Even though the incident may have “triggered” the appellant's PTSD, it did not cause the disability, and thus there is no basis for compensation."
Since the amendment to the NJ workers' compensation act in 1979, an employer is not responsible for a condition that is not materially contributing by the employment. Prior to 1979 the standard was that the employer took the employee as they found him or her. If the work related event was the "straw that broke the camel's back," the employer was then responsible for the end result.
In this instance, the trial judge had found that the employee had a pre-existing mental disability following from childhood sexual abuse and that condition was the sole material contributing cause of the injured workers' mental disability. The employment episode was deemed unrelated.
The Court held: "Here, the judge found appellant's history of childhood sexual abuse was in fact the true source of her disability; this finding is similar to Goyden, where the court found the appellant's compulsive personality and childhood problems caused his unfortunate reactions to his work environment. Id. at 458–59. Here, the testimony of Dr. Pipchick yields a similar analysis; she clearly stated that without the childhood sexual abuse, appellant would not have had the disabling response to the incident. Even though the incident may have “triggered” the appellant's PTSD, it did not cause the disability, and thus there is no basis for compensation."
For additional analysis of workers' compensation psychiatric disability claims see Gelman, Workers' Compensation Law, 38 NJ Practice 9.12 Psychological Disability--Harassment: "In Goyden the NJ Supreme Court rendered a split decision regarding the standard for awarding permanent disability for psychological illness arising out of stressful work conditions. The Court affirmed the opinion of the Appellate Division which stated that stress must stem from objectively proven stressful work conditions rather than from conditions the petitioner found stressful. The Court required the establishment of conditions “peculiar” to the workplace, conditions which justified the medical opinion that they were the “material” causes of the petitioner's disability.....“That Goyden's particular characteristics as a person may have made him more sensitive or susceptible to the influences of stress or even predisposed to develop a psychological illness does not impugn the Court's conclusion that his disability arose out of and in the course of employment,” the minority wrote. Goyden v. State, Judiciary, 128 N.J. 54, 607 A.2d 622 (1992)."
Rizzo v. Kean University, Not Reported in A.3d, 2014 WL 2590281 (N.J.Super.A.D.) June 12, 2014
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