CLRS – September 2004
CVVCI
California Workers’ Compensation Reform
Public Policy Research Implications
CLRS
September 14, 2004
California Workers’ Compensation Institute
www.cwci.org
Copyright 2004, CWCI All rights reserved
CLRS – September 2004
CWCI’s research:
• Focuses on the real costs in the system
• Helps establish consensus about problems
• Assists in establishing an agenda for improving the system
Specific areas of research:
•
•
•
•
•
•
•
•
System-wide cost drivers
Medical utilization
Claims adjudication
Fraud & abuse
Litigation
VR
PD
Reform Activities
Copyright 2004, CWCI All rights reserved
CVVCI
CLRS – September 2004
California Workers’ Compensation Reform
“Self-Executing” Changes
--AB 749 (2003) SB 227/228/899 (2004) -• Removal of PTP Presumption of Correctness
• OMFS & Medicare & 5% Reduction
• Outpatient Surgery Facility Fee Schedule
• ACOEM
• 2nd Opinion for Back Surgeries
• Utilization Review
• 1st Medical Pay
• Apportionment
• Expansion of ADR
• 2-yr Cap on TD
Copyright 2004, CWCI All rights reserved
CVVCI
CLRS – September 2004
California Workers’ Compensation Reform
Agenda
Part 1: Medical Utilization
Part 2: Benefit Delivery
Copyright 2004, CWCI All rights reserved
CVVCI
CLRS – September 2004
ACOEM & The California Workers’ Compensation System
Areas of Research – Part 1: Medical Utilization
1. Actual – to – ACOEM utilization comparisons
2. Incremental effects of medical services beyond
ACOEM recommended levels
Copyright 2004, CWCI All rights reserved
CVVCI
CLRS – September 2004
CVVCI
Estimated Ultimate Medical Per Indemnity Claim
(Reflecting the Impact of AB 227 & SB 228)
18%
Reduction
$40,000
$30,000
$20,000
$10,000
$0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Before 9,885 10,619 11,746 13,137 15,230 18,385 21,588 24,519 28,673 35,201
9,316 9,381 10,978 12,706 14,105 17,015 19,871 21,533 25,532 28,736 30,804
After
Results as of 12/02 & 12/03
Source: WCIRB
Copyright 2004, CWCI All rights reserved
CLRS – September 2004
Workers’ Comp Public Policy—Legislative History
California Labor Code, Section 4600
Provide all treatment “reasonably necessary to cure and relieve from the
effects of injury,”
Presumption of Correctness (1994)
Confers a presumption of correctness to the injured worker’s primary treating
physician; intended to neutralize the multiple and conflicting medicallegal evaluation reports
Minniear Decision (1996)
The injured worker’s primary treating physician’s presumption expands
beyond medical-legal evaluation to encompass “all issues” including
clinical treatment.
Copyright 2004, CWCI All rights reserved
CVVCI
CLRS – September 2004
CVC
C
V
V
V
ICI
The Effect of 1993 – 1996 Legislative Reform Activity
$200
Medical Treatment
Average Monthly Paid
(All Professional Fees)
76%
Increase
$175
$150
$125
$100
Source: CWCI 2003
Copyright 2004, CWCI All rights reserved
Ja
n99
Ju
n99
Ja
n98
Ju
n98
Ja
n97
Ju
n97
Ja
n96
Ju
n96
Ja
n95
Ju
n95
Ja
n94
Ju
n94
$75
CLRS – September 2004
CVVCI
Medical Utilization
The Effect of 1993 – 1996 Legislative Reform Activity
More Open
Claims
32.8%
Longer
Claim
Duration
49.0%
Residual
Effect
0.5%
Source: CWCI 2003
Copyright 2004, CWCI All rights reserved
Indemnity
0.5%
Case-mix
1.1%
Increased
Litigation
16.1%
CLRS – September 2004
CVVCI
How Safe Is Health Care?
(Leape 2002)
DANGEROUS
ULTRA-SAFE
(>1/1000)
Total lives lost per year
100,000
(<1/100K)
HealthCare
Driving
10,000
1,000
Scheduled
Airlines
100
Mountain
Climbing
10
Chemical
Manufacturing
Bungee
Jumping
European
Railroads
Chartered
Flights
Nuclear
Power
1
1
10
100
1,000
10,000
100,000
Number of encounters for each fatality
Copyright 2004, CWCI All rights reserved
1,000,000
10,000,000
CLRS – September 2004
Utilization Review as Part of System Reform:
--AB 749 (2003) SB 227/228/899 (2004) -• New emphasis on evidence-based medicine
• New definition of “reasonable care” to cure & relieve
• American College of Occupational & Environmental
Medicine (ACOEM )
• Presumption of Correctness
• DWC to review guidelines
Copyright 2004, CWCI All rights reserved
CVVCI
CLRS – September 2004
CVVCI
ACOEM Guidelines
• Provide medical providers:
– Information on “best practices”; i.e., what is
known to work
– Reflect the state of the science
– Need to assess applicability to workers’
compensation
Copyright 2004, CWCI All rights reserved
CLRS – September 2004
ACOEM: Impact on Workers’ Comp System
Claim Sample:
• Data compiled from ICIS database
• DOI Jan 1997 – Dec 2000; benefits valued at June 2002
• ACOEM treatment category assigned
• Actual utilization levels compared to ACOEM recommendations
Claim Type
Claims
Total Paid
Medical Paid
Indemnity
Paid
$4.514B
Indemnity
361,242
$8.132B
$3.619B
Med-Only
665,354
$.434B
$.434B
1,026,596
$8.567B
$4.053B
Total
Copyright 2004, CWCI All rights reserved
$4.514B
CVVCI
CLRS – September 2004
CVVCI
Actual-to-ACOEM-Recommended Utilization Comparison:
ACOEM Injury Categories
• Low Back – Soft Tissue Complaints (N=168,885 claims)
• Low Back – Nerve Involvement (N=10,416 claims)
Utilization Comparison
• Actual: Derived from ICIS claim and MBR data
• ACOEM: Recommended utilization, from ACOEM Guidelines,
2nd Edition
Six Medical Service Categories
1.
2.
3.
4.
5.
6.
X-Rays
CT/MRI
Physical medicine visits
Chiropractic visits
Back surgeries (Fusions & Laminectomies)
TD days
Copyright 2004, CWCI All rights reserved
CLRS – September 2004
CVVCI
Actual – to – ACOEM utilization comparisons
Percentage of Claims Covered by ACOEM Guidelines
100%
75%
50%
25%
0%
Claims
Medical
Indemnity
ACOEM
48.3%
54.6%
60.4%
Non-ACOEM
51.8%
45.4%
39.7%
Source: CWCI 2004
Copyright 2004, CWCI All rights reserved
Non-ACOEM
ACOEM
CLRS – September 2004
CVVCI
Injury Categories Not Included in ACOEM Guidelines
Non-ACOEM Categories
Pcnt
Claims
Trauma Diagnoses
21.6%
Non-Specific Diagnoses
30.2%
Copyright 2004, CWCI All rights reserved
CLRS – September 2004
CVVCI
Top 10 Non-Specific Diagnosis Codes
Claims
Total
Paid
Total
Medical
Total
Indemnity
1
95990 – Injury –Site NOS
15.2%
14.8%
14.1%
15.60%
2
95980 – Injury Multiple Site/Site
NEC
12.0%
18.1%
17.2%
19.0%
3
7998 - Ill-Defined Condition NEC
4.9%
6.9%
5.9%
7.9%
4
71946 – Joint Pain-Lower Leg
1.7%
2.9%
2.7%
3.1%
5
959 - Injury NEC/NOS*
1.6%
2.4%
2.4%
2.4%
6
95910 – Trunk Injury NOS
1.6%
3.8%
3.8%
3.8%
7
95970 – Lower Leg Injury NOS
1.2%
2.7%
2.5%
2.8%
8
7295 - Pain In Limb
1.0%
1.1%
1.0%
1.1%
9
8488 – Sprain NEC
1.0%
0.3%
0.3%
0.3%
7262 - Shoulder Region
Dislocation NEC
0.8%
3.2%
3.1%
3.3%
41.0%
56.2%
53.0%
59.3%
10
Top 10 Sub-total:
Copyright 2004, CWCI All rights reserved
CLRS – September 2004
Actual-to-ACOEM-Recommended Utilization Comparison:
Medical Service Categories
X-Rays
• Not recommended by ACOEM
• Strains and other causes of non-specific pain cannot be
visualized on plain x-ray films with enough detail to be
clinically useful
• Actual utilization: Pcnt of ICIS claims with x-rays
- Low back / soft tissue claims:
56.2%
- Low back / nerve involvement claims: 74.8%
Copyright 2004, CWCI All rights reserved
CVVCI
CLRS – September 2004
CVVCI
X-Rays
Comparison of Actual to ACOEM-Recommended Utilization
200,000
199,391
Films
150,000
100,000
50,000
22,581
N/A
0
Low Back - Soft Tissue
N/A
Low Back - Nerve Involvement
Actual
N/A: Test or service not recommended by ACOEM Guidelines
Source: CWCI
Copyright 2004, CWCI All rights reserved
ACOEM (est.)
CLRS – September 2004
Actual-to-ACOEM-Recommended Utilization Comparison:
Medical Service Categories
Computer Axial Tomography (CT) Scans &
Magnetic Resonance Imaging (MRI)
• Recommended only to confirm clinical findings and clarify the
anatomy prior to surgery1
• If surgery is not contemplated, imaging will not affect the course of
treatment or recovery
• Actual utilization: Pcnt of claims with CTs/MRIs
- Low Back / Soft Tissue:
15.9%
- Low Back / Nerve Involvement:
45.7%
1 ACOEM
Occupational Medicine Practice Guidelines, ed.2, p. 303
Copyright 2004, CWCI All rights reserved
CVVCI
CLRS – September 2004
CVVCI
CTs & MRIs
Comparison of Actual to ACOEM-Recommended Utilization
60,000
42,862
Scans
40,000
20,000
11,424
2,399
0
N/A
Low Back - Soft Tissue
Actual
Low Back - Nerve Involvement
ACOEM (est.)
N/A: Test or service not recommended by ACOEM Guidelines
Source: CWCI
Copyright 2004, CWCI All rights reserved
CLRS – September 2004
Actual-to-ACOEM-Recommended Utilization Comparison:
Medical Service Categories
Physical Medicine
• Comprises one-third of all outpatient medical costs
• ACOEM-recommended number of visits is two or fewer, for teaching a
home exercise program
• There is insufficient evidence of effectiveness for traction, ultrasound,
massage, diathermy, biofeedback, TENS, magnet therapy, acupuncture,
neuroreflexotherapy or lumbar supports
• Actual utilization: Pcnt of claims with Physical Medicine visits:
- Low Back / Soft Tissue:
60.2%
- Low Back / Nerve Involvement:
78.3%
ACOEM Occupational Medicine Practice Guidelines, ed.2, p. 299.
Copyright 2004, CWCI All rights reserved
CVVCI
CLRS – September 2004
CVVCI
Physical Medicine
Comparison of Actual to ACOEM-Recommended Utilization
2,000,000
1,486,830
Visits
1,500,000
1,000,000
500,000
117,536
250,052
12,876
0
Low Back - Soft Tissue
Actual
Source: CWCI
Copyright 2004, CWCI All rights reserved
Low Back - Nerve
Involvement
ACOEM (est.)
CLRS – September 2004
Actual-to-ACOEM-Recommended Utilization Comparison:
Medical Service Categories
Chiropractic Manipulation
• ACOEM-recommended number of visits equals a maximum of 12
visits in first 30 days for Low Back / Soft Tissue claims
• Not recommended for Low Back / Nerve Involvement claims
• Actual utilization: Pcnt of claims with chiropractic visits:
- Low Back / Soft Tissue:
10.7%
- Low Back / Nerve Involvement:
32.5%
ACOEM Occupational Medicine Practice Guidelines, ed.2, p. 299.
Copyright 2004, CWCI All rights reserved
CVVCI
CLRS – September 2004
CVVCI
Chiropractic Manipulation
Comparison of Actual to ACOEM-Recommended Utilization
500,000
448,235
Visits
400,000
300,000
200,000
121,255
100,000
23,772
0
N/A
Low Back - Soft Tissue
Low Back - Nerve Involvement
Actual
N/A: Test or service not recommended by ACOEM Guidelines
Source: CWCI
Copyright 2004, CWCI All rights reserved
ACOEM (est.)
CLRS – September 2004
Actual-to-ACOEM-Recommended Utilization Comparison:
Medical Service Categories
Back Surgery (Spinal Fusions & Laminectomies)
• ACOEM recommends only patients with severe disc disease,
spinal stenosis or thoracic/lumbar disc displacement
• Fusions have a very low success rate in the absence of serious
conditions
• Surprisingly high surgical rate for backache NOS (5.2%) and sprain
of sacrum (4.0%)
• Actual utilization: Pcnt of claims with specified surgery:
• - Low Back / Soft Tissue:
1.4% (n=2,374)
• - Low Back / Nerve Involvement: 9.3% (n=968)
Copyright 2004, CWCI All rights reserved
CVVCI
CLRS – September 2004
Back Surgeries (Fusions & Laminectomies)
Comparison of Actual to ACOEM-Recommended Utilization
3,000
2,374
2,000
989
1,000
403
0
N/A
Low Back - Soft Tissue
Actual
N/A: Test or service not recommended by ACOEM Guidelines
Source: CWCI
Copyright 2004, CWCI All rights reserved
Low Back - Nerve Involvement
ACOEM (est.)
CVVCI
CLRS – September 2004
CVVCI
Actual-to-ACOEM-Recommended Utilization Comparison:
Medical Service Categories
Paid Temporary Disability Days
• Average Length of Paid TD :
Low Back / Soft Tissue:
Low Back / Nerve Involvement:
63.9 days
113.0 days
• NHIS study showed averages of 6 to 10 days for comparable
injuries
Copyright 2004, CWCI All rights reserved
CLRS – September 2004
CVVCI
Paid Temporary Disability Days
Comparison of Actual to ACOEM-Recommended Utilization
Paid TD Days
5,000,000
4,000,000
3,000,000
2,000,000
1,000,000
0
Low Back - Soft Tissue
Low Back - Nerve
Involvement
4,750,518
858,913
ACOEM (Low est.)
446,058
45,606
ACOEM (High est.)
743,430
76,010
Actual
Source: CWCI
Copyright 2004, CWCI All rights reserved
CLRS – September 2004
Summary of ACOEM-Recommended Utilization:
CVVCI
Percentage of Tests & Services Recommended
by ACOEM, Based on the Evidence, for Two Low Back Conditions
60%
40%
20%
12.0%
0%
N/A
N/A
X-Rays
7.9%
5.2%
9.6%
4.1%
N/A
N/A
CT/MRI
Phys Med
Low Back - Soft Tissue
Chiro
Copyright 2004, CWCI All rights reserved
N/A
Surgury
TD (Days)
Low Back - Nerve Involvement
N/A: Test or service not recommended by ACOEM Guidelines
Source: CWCI
15.6%
8.8%
CLRS – September 2004
Actual-to-ACOEM-Recommended Utilization
Comparisons
A common response to conservative nature of ACOEM:
“The absence of high-grade evidence is not conclusive
proof of lack of value to the injured worker.”
So, what and where is the value to the injured worker?
Copyright 2004, CWCI All rights reserved
CVVCI
CLRS – September 2004
ACOEM: Impact on Workers’ Comp System
Issues:
1.
Actual–to–ACOEM-Recommended Utilization Comparisons
2. Incremental Effects of Medical Services Beyond
ACOEM-Recommended Levels
Copyright 2004, CWCI All rights reserved
CVVCI
CLRS – September 2004
CVVCI
Incremental Effects Beyond ACOEM-Recommended Levels
Low Back – Soft Tissue Complaints
Incremental Effects on Claim Development for Treatment
Beyond ACOEM: Preliminary Results on:
•
•
•
•
Total Claim Costs
Medical Costs
Overall Length of Treatment
Length of Disability (TD days)
5 Medical Service Categories
1.
2.
3.
4.
5.
X-Ray Films
CT/MRI
Physical Medicine
Chiropractic
Back Surgeries (Fusions & Laminectomies)
Copyright 2004, CWCI All rights reserved
CLRS – September 2004
CVVCI
Incremental Effects Beyond ACOEM: Preliminary Results
Low Back - Soft Tissue Complaints
Average Cost per Service Visit
Avg Cost/Visit
$3,000
$2,668
$2,250
$1,500
$602
$750
$197
$68
$63
PHYS MED
CHIRO
$0
X-RAY
CT/MRI
Note: average surgery fees are for professional component only
Copyright 2004, CWCI All rights reserved
SURG
CLRS – September 2004
CVVCI
Incremental Effects Beyond ACOEM : Preliminary Results
Low Back - Soft Tissue Complaints
Additional Payments Per Indemnity Claim Per Service
Beyond ACOEM
$100,000
$81,422
$75,000
$50,000
$25,000
$18,162
$2,738
$0
X-RAY
CT/MRI
Medical
Copyright 2004, CWCI All rights reserved
SURG
Indemnity
CLRS – September 2004
CVVCI
Incremental Effects Beyond ACOEM : Preliminary Results
Additional Treatment & Temporary Disability Days Per
Indemnity Claim Per Service Beyond ACOEM
Addtl Days/Srvc
800
600
400
200
0
X-RAY
CT/MRI
SURG
Addtl Tx Length
62.9
230.5
716.8
Addtl TD Days
6.1
43.9
229.1
Copyright 2004, CWCI All rights reserved
CLRS – September 2004
CVVCI
Incremental Effects Beyond ACOEM : Preliminary Results
Physical Medicine & Chiropractic Manipulation:
Percent of Claims Above & Below ACOEM Levels
100%
PHYS MED
CHIRO
Above ACOEM
87.7%
68.2%
Below ACOEM
12.3%
31.8%
Pcnt of Clms
>2
Visits
>12
Visits
In 1st
30 days
75%
50%
25%
0%
Copyright 2004, CWCI All rights reserved
CLRS – September 2004
CVVCI
Incremental Effects Beyond ACOEM : Preliminary Results
Low Back - Soft Tissue Complaints
Incremental Cost Per Indemnity Claim By Services Visits
Beyond ACOEM
$40,000
Addtl Paid/Clm
$30,000
$20,000
ACOEM
Phy
ACOEM
Med
Chiro
$10,000
$0
1
13
35
60
($10,000)
Visits
Physical Medicine
Copyright 2004, CWCI All rights reserved
Chiropractic
85
CLRS – September 2004
CVVCI
Incremental Effects Beyond ACOEM : Preliminary Results
Summary of Incremental Effects on Claim Development
- Phys Med & Chiro Services Low Back - Soft Tissue Complaints
Physical Medicine
Above
ACOEM
Total Claim Cost
Within
ACOEM
Chiropractic
Pcnt
Diff
Above
ACOEM
Within
ACOEM
Pcnt
Diff
$32,586
$28,991
12.4%
$49,192
$31,408
56.6%
Medical
$12,844
$11,482
11.9%
$20,815
$13,559
53.5%
Indemnity
$19,742
$17,509
12.8%
$28,377
$17,849
59.0%
Treatment Length
447.1
391.2
14.3%
749.3
427.4
75.3%
TD Days
100.1
92.1
8.7%
155.6
119.9
29.8%
Copyright 2004, CWCI All rights reserved
CLRS – September 2004
ACOEM: Impact on Workers’ Comp System
Summary:
1.
Significant differences between current and ACOEM-recommended
utilization patterns
2.
Significant variation in treatment selection, intensity and duration
3.
Excess utilization beyond ACOEM is not associated with:
•
•
•
4.
Overall lower medical costs
Shorter treatment
Faster return-to-work
Physical medicine & chiropractic utilization at or below ACOEM is
associated with positive claim outcomes
Copyright 2004, CWCI All rights reserved
CVVCI
CLRS – September 2004
Issues in Estimating ACOEM’s Impact
• Implications for:
1.
2.
3.
4.
Injured Worker
Providers & MCOs
Payors & Claims Administrators
Labor Code, Rules & Regs & Legal Interpretation
• Difficultly in Estimating Savings
1.
2.
Workers Comp is not Group Health
Double-Counting Util Mgt. Savings
- ER vs. EE PTP
- Network Effects
- PT/Chiro Visit Caps
Copyright 2004, CWCI All rights reserved
CVVCI
CLRS – September 2004
CVVCI
Areas of Research – Part 2: Benefit Delivery
1. Alternative Dispute Resolution
2. 2-Year Temporary Disability Cap
3. 1st Medical Pay
Copyright 2004, CWCI All rights reserved
CLRS – September 2004
CVVCI
Alternative Dispute Resolution
• Significant expansion to new industries
• Little outcomes data
Data
Sample
Claims
Total Benefits
Medical
Indemnity
ADR
2,230
$
33,547,649
$ 12,835,963
$
Statutory
9,591
$ 175,123,851
$ 67,555,187
$ 107,568,665
11,821
$ 208,671,500
$ 80,391,150
$ 128,280,351
Total
Copyright 2004, CWCI All rights reserved
20,711,686
CLRS – September 2004
CVVCI
Alternative Dispute Resolution:
Rate of Attorney Involvement
Rate of Attorney Involvement
40%
32.2%
30%
20%
10%
9.0%
0%
ADR
Copyright 2004, CWCI All rights reserved
Statetory
CLRS – September 2004
CVVCI
Alternative Dispute Resolution:
Average Benefit Costs
Medical
Attorney
Involvement
Indemnity
ADR
Statutory
ADR
NO
$ 5,330
$ 1,788
$ 8,191
YES
$14,600
$ 16,270
Total
$ 6,161
$ 6,444
Total Benefits
Statutory
ADR
Statutory
$ 1,745
$13,520
$ 3,533
$36,710
$31,586
$51,309
$ 47,856
$10,928
$10,698
$17,089
$ 17,142
No Significant Difference
Copyright 2004, CWCI All rights reserved
CLRS – September 2004
CVVCI
Alternative Dispute Resolution:
Employer-level Outcome Variation
Top 3 Governing Classes
ADR ER
#1
ADR ER
#2
ADR ER
#3
Statutory
System
Electrical
$19,321
$20,865
$15,976
$16,283
Wallboard Application
$14,967
$17,452
$20,021
$20,413
Carpentry--Private
Residence
$14,286
$10,518
$18,231
$17,370
Copyright 2004, CWCI All rights reserved
CLRS – September 2004
CVVCI
2-Year Temporary Disability Cap (LC §4656)
• Injuries o/a 4/19/04
• TD cap -- max. of 104 weeks
60%
Pcnt of Claims & Benefits
>2Yrs of TD by Timeframe
40%
20%
0%
Pcnt All Claims
Pcnt All TD Payments (All TD
Claims)
Pmts >2Y Post DOI
12.6%
26.0%
Pmts >2Y 1st TD Date
8.5%
18.6%
Est. Paid TD Days
1.0%
5.4%
Pmts >2Y 1st TD Pymt
7.7%
16.1%
Copyright 2004, CWCI All rights reserved
CLRS – September 2004
CVVCI
2-Year TD Cap: Exempt Injuries
Acute & Chronic Hepatitis B & C
0.0%
Amputations
1.3%
Severe Burns
0.9%
HIV
0.0%
High-Velocity Eye Injuries
0.3%
Chemical Burns to Eyes
0.1%
Pulmonary Fibrosis
0.0%
Chronic Lung Disease
0.4%
Copyright 2004, CWCI All rights reserved
Exempt Injuries:
• 2.9% of TD Claims
• 5.3% of TD Pmts
• 88.7% Higher Benefits
CLRS – September 2004
CVVCI
Measuring First Medical Pay (LC §5402)
• Payors cover medical benefits prior to accept/reject decision
• $10K Cap on Initial Medical Payments
• Timeframe not defined
5%
Pcnt of Claims >$10k
by Timeframe
4%
3%
2%
1.3%
1.5%
45 Days
60 Days
1.9%
1%
0%
Copyright 2004, CWCI All rights reserved
90 Days
CLRS – September 2004
CVVCI
Measuring First Medical Pay
Initial medical payout patterns:
Estimated 1st Pay
$60,000
$40,000
$20,000
$0
All Claims
<= $10,000 Paid
> $10,000 Paid
45 Days
60 Days
90 Days
$1,440
$796
$49,682
$1,576
$883
$47,433
$1,836
$1,025
$42,744
Copyright 2004, CWCI All rights reserved
Future Issues:
• Denial Rates
• Claim Utilization
• Utilization
• Recovery
CLRS – September 2004
California Workers’ Compensation Reform
CVVCI
“Self-Executing” Changes
--AB 749 (2003) SB 227/228/899 (2004) -• Removal of PTP Presumption of Correctness
• OMFS & Medicare & 5% Reduction
• Outpatient Surgery Facility Fee Schedule
• ACOEM
• 2nd Opinion for Back Surgeries
• Utilization Review
• 1st Medical Pay
Coming Attractions…
• Apportionment
• Expansion of ADR
• New PD Schedule
• 2-yr Cap on TD
• New UR Protocols
• Medical Networks
Copyright 2004, CWCI All rights reserved
CLRS – September 2004
Strategies for Payors
1. Operations: Get up to speed on new rules
• Medical
• Indemnity
• Rules & Regs
2. Data & analysis & benchmarking
• Tracking internal operations & external vendors
- Networks
- Fee Schedules
- Utilization
- Claim Operations
Copyright 2004, CWCI All rights reserved
CVVCI
CLRS – September 2004
CVVCI
Public Policy Research Implications &
California Workers’ Compensation System
Reform
September 14, 2004
California Workers’ Compensation Institute
www.cwci.org
Copyright 2004, CWCI All rights reserved