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Posted on: Feb 11, 2019

Last week, the Workers Compensation Research Institute (WCRI) released a nationwide study examining treatment guidelines and utilization management called "State Policies on Treatment Guidelines and Utilization Management: A National Inventory."

While 23 states have adopted workers' compensation medical treatment guidelines, there are wide variations in the guidelines themselves, including how they're used.

The study also notes that while treatment guidelines provide more consistency in care, consistency in care does not necessarily mean more effective care at a more reasonable cost.  Consistency of inadequate care is not something California injured workers need!

One area where California could learn from other states and adopt more cost-effective guidelines might be with Utilization Review, which is mandatory in 25 states. In most states with Utilization Review and a prior authorization requirement if the services are not timely reviewed or the employer does not respond within a set time frame, the requested services are deemed authorized... right then.

In California, the penalty is monetary with assessments of $100 for late response and $1,000 for no response. However, even these weak penalties are rarely enforced.

Wouldn't it be nice for California's injured workers to receive the care they need in a timely manner? Perhaps California should consider automatic authorization seen in other states when Utilization Review is drawn out. We can certainly dream.

The full study is available for purchase here.

CAAA IN ACTION

On Monday, February 4th, CAAA's Amicus Committee submitted an amicus curiae letter to the California Supreme Court in support of the Petition for Review filed by Aaron Lindh on January 17 seeking review of the First District Court of Appeal's December 10, 2018, decision in City of Petaluma v WCAB (Lindh).

In the letter, CAAA emphasized the far-reaching impacts the decision could have on apportionment, should it stand, and urged the court to grant review: "The decision reverses the determinations of the Workers' Compensation Trial Judge and the Workers' Compensation Appeals Board, eviscerates the defendants' burden of proof on the affirmative defense of apportionment, neglects the meaning of the phrase 'direct cause' in apportionment analysis, and is inconsistent with prior decisions of the Court of Appeal and of this Court."

As a refresher, Mr. Lindh worked as a peace officer with the City of Petaluma and sustained an industrial injury consisting of several blows to his head. One month after the injurious event, he lost most of the vision in his left eye. The QME in the case noted that the injured worker had an underlying vasospastic personality that affected his left optic nerve vessels and apportioned 85 percent of the cause of his permanent disability to this previously quiescent underlying condition and 15 percent to the industrial injury.

Both the trial judge and the Appeals Board rejected the apportionment analysis and issued an un-apportioned award of 40 percent PD. Applying the law on apportionment post SB-899 to this case, the First District Court of Appeal reversed that decision and held that the QME's opinion should be followed.

To view CAAA's full amicus letter urging the Supreme Court's review, click here.

Special thanks to Mark Gearheart and CAAA's Amicus Committee for their work on this case.