A TREATING PHYSICIAN’S GUIDE
to Patient Care in the Workers’ Compensation System
©State Compensation Insurance Fund
2007
This Guide is based upon selected highlights of recent workers' compensation legislation and is current through
November 15, 2007. This Guide is solely intended to assist physicians in navigating the workers’ compensation system.
This Guide is not intended to be a complete list of regulatory or statutory requirements and is not intended to be a
substitute for, or a legal interpretation of, any regulations or statutes. Because this is a general guide based on recent
changes in the law, it does not contain all requirements and may be subject to revision upon future changes in the law.
It is the responsibility of the reader to refer to all applicable regulations, statutes, and case law for detailed and exact
information, specifications, requirements, and exceptions Readers are cautioned to obtain legal advice for complete and
updated regulatory and statutory information.
State Compensation Insurance Fund
Table of Contents
CHAPTER 1: THE CALIFORNIA WORKERS’ COMPENSATION SYSTEM AT A GLANCE ............ 1
BENEFITS AVAILABLE TO THE INJURED EMPLOYEE ................................................................................................ 1
Medical Benefits..................................................................................................................................................... 1
Temporary Disability (TD) Benefits............................................................................................................ 1
Temporary Total Disability (TTD) Payments......................................................................................... 2
Temporary Partial Disability (TPD) Payments..................................................................................... 2
Permanent Disability (PD) Benefits ........................................................................................................... 2
Vocational Rehabilitation Benefits (Dates of Injury Prior to 1/1/04).................................. 2
Death Benefits ........................................................................................................................................................ 2
CHAPTER 2: THE ROLE OF THE PRIMARY TREATING PHYSICIAN................................................... 3
OVERVIEW ........................................................................................................................................................................ 3
DUTIES OF PRIMARY TREATING PHYSICIAN ............................................................................................................ 3
Initial Exam Report.............................................................................................................................................. 4
Primary Treating Physician Progress Reports ..................................................................................... 4
Primary Treating Physician’s Permanent and Stationary Report ............................................. 5
Causation and Apportionment....................................................................................................................... 5
ADDITIONAL DUTIES: MEDICAL PROVIDER NETWORK (MPN) DISPUTE RESOLUTION ............................... 6
Second-and Third-Opinion Process ............................................................................................................ 6
Independent Medical Review (IMR) Process........................................................................................ 7
REIMBURSEMENT OF REPORTS ........................................................................................................................................ 7
Reports Not Separately Reimbursable .......................................................................................................... 8
Reports Separately Reimbursable................................................................................................................... 8
CHAPTER 3: CLINICAL MANAGEMENT ............................................................................................................. 9
OVERVIEW ........................................................................................................................................................................ 9
TREATMENT GOALS ....................................................................................................................................................... 10
RETURN TO WORK ........................................................................................................................................................ 10
DELAYED RECOVERY ..................................................................................................................................................... 10
THE MOTIVATION FACTOR.......................................................................................................................................... 11
SECONDARY GAIN ......................................................................................................................................................... 11
COMMUNICATION IS THE KEY .................................................................................................................................... 12
Communicating With the Injured Employee ....................................................................................... 12
Communicating With the Employer.......................................................................................................... 13
Communicating With the Claims Administrator................................................................................ 13
THE PROBLEM OF LITIGATION ................................................................................................................................... 14
TOXIC EXPOSURE CASES ............................................................................................................................................. 14
CHAPTER 4: RETURN TO WORK......................................................................................................................... 15
OVERVIEW ...................................................................................................................................................................... 15
CORNERSTONES OF DISABILITY PREVENTION AND MANAGEMENT................................................................... 16
Consequences of Disability to the Individual ..................................................................................... 16
Functional Recovery and Return to Work ............................................................................................. 17
Employer’s Role.................................................................................................................................................... 17
Clinician’s Role...................................................................................................................................................... 18
FORMULATING AND COMMUNICATING A WORK PRESCRIPTION TO THE EMPLOYER/INSURER ................. 18
Employee’s/Patient’s Role ............................................................................................................................ 21
Payer’s Role............................................................................................................................................................ 21
CHAPTER 5: MEDICAL UTILIZATION REVIEW .......................................................................................... 22
OVERVIEW ...................................................................................................................................................................... 22
DEFINITIONS:................................................................................................................................................................ 23
UR PROCESS .................................................................................................................................................................. 24
The Treatment Plan ........................................................................................................................................... 25
Treatment Authorization Requests........................................................................................................... 25
UR Time Frames ................................................................................................................................................... 25
Expedited Review................................................................................................................................................ 26
Denial Decisions................................................................................................................................................... 27
UR Appeals .............................................................................................................................................................. 27
UR Reconsiderations ......................................................................................................................................... 28
UR Dispute Process ............................................................................................................................................ 28
Second-and Third-Opinion Process .......................................................................................................... 28
Tips for Faster Processing of Your UR Request................................................................................. 28
Hours of Availability .......................................................................................................................................... 28
Pharmacy Benefit Management Program ............................................................................................. 29
Spinal Surgery and the Spinal Surgery Second-Opinion Process ........................................... 29
State Fund MPN Treatment Authorization Program (TAP)......................................................... 29
CHAPTER 6: AMA GUIDES –THE EVALUATION OF PERMANENT IMPAIRMENT ...................... 30
OVERVIEW ...................................................................................................................................................................... 30
DEFINITIONS ................................................................................................................................................................. 31
GENERAL PRINCIPLES OF THE AMA GUIDES ......................................................................................................... 32
Whole Person Impairment (WPI) Rating.............................................................................................. 32
SUBJECTIVE FACTORS .................................................................................................................................................. 33
PHYSICIAN’S FINAL REPORT OF DISABILITY ........................................................................................................ 33
CALCULATING PERMANENT IMPAIRMENT................................................................................................................. 34
The Spine ................................................................................................................................................................. 34
The Upper Extremities...................................................................................................................................... 36
The Lower Extremities ..................................................................................................................................... 37
MULTIPLE IMPAIRMENTS ............................................................................................................................................ 40
CHAPTER 7: PREVENTING FRAUD .................................................................................................................... 41
OVERVIEW ...................................................................................................................................................................... 41
PROVIDER FRAUD ......................................................................................................................................................... 41
Billing Fraud ........................................................................................................................................................... 42
Treatment Fraud .................................................................................................................................................. 42
APPENDIX A: SAMPLE FORMS ............................................................................................................................ 45
APPENDIX B: RELEVANT LABOR CODE SECTIONS .................................................................................46
APPENDIX C: RESOURCES .....................................................................................................................................67
LIST OF STATE FUND OFFICES AND LOCATIONS ................................................................................................... 68
GLOSSARY.......................................................................................................................................................................73
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Chapter 1: The California
Workers’ Compensation System
at a Glance
Overview
Every year California’s assembly lines, farms, manufacturing facilities, offices, and other places of employment
produce some sobering results: Thousands of employees become ill, are injured, or are killed in the course of their
employment. Under California law, employers are liable for bearing the cost of any occupational illness or injury.
The California Workers’ Compensation System is a legislatively mandated expression of social policy. Under
California law, California’s employers must provide employees with, among other things, compensation for workrelated injury, illness, or death regardless of the fault of any party.
In California the law requires employers to provide workers’ compensation insurance that serves two functions:
1.
To ensure that injured employees receive prompt and complete medical treatment and wage-replacement
benefits for work-related injuries and illness; and
2. To enable the employer to assume a known and limited liability rather than risk the unknown--and possibly
disastrous--liability from civil lawsuits.
The majority of California workers’ compensation law is codified in the California Insurance Code, California
Labor Code (LC), and the Rules of Practice and Procedure of the Workers’ Compensation Appeals Board
(WCAB), which appear in Title 8 of the California Code of Regulations (CCR). Appropriate citations from these
sources appear throughout the text.
Benefits Available to the Injured Employee
The following types of financial benefits provided to an injured employee depend on the severity of the injury or
illness:
Medical Benefits
All injured employees are entitled to medical treatment for work-incurred injury or illness that includes professional
services, hospital charges, nursing care, medications, and medical and surgical supplies that are “reasonably
required to cure or relieve the injured worker from the effects of his or her injury” (LC §4600). The services of
a qualified interpreter may be authorized in some situations.
Temporary Disability (TD) Benefits
TD indemnity is a tax-free benefit paid to compensate an industrially injured or ill employee for the period in which
he or she is undergoing medical treatment and is unable to work. TD payments are based on a seven-day week.
Financial incentives or disincentives may influence motivation for return to work.
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Temporary Total Disability (TTD) Payments
Temporary total disability payments are calculated using a formula based on two-thirds of the injured employee’s
average weekly earnings at the time of the injury (LC §4653). TTD payments are subject to maximum and
minimum amounts. For 2007 the maximum is $881.66 a week; the minimum is $132.25 a week. Both rates are
scheduled to increase in 2008. The 2008 maximum will be $916.33 a week; the minimum will be $137.45 a week.
Temporary Partial Disability (TPD) Payments
When an injured employee has been released for modified duty that is available only at a reduced wage or reduced
hours the injured employee may be eligible for TPD benefits during the recovery period. The TPD payment is
based on two-thirds of the actual weekly wage loss and is subject to the statutory maximum and minimum amounts
(LC §4657).
Permanent Disability (PD) Benefits
Under the California workers’ compensation system, permanent disability is expressed in terms of a rating that is a
percentage of total disability, the latter being considered as 100 percent. In rating PD, consideration is given to the
nature of the injury or disfigurement, occupation of the injured employee, and his or her age at the time of injury,
with consideration given to an employee’s diminished future earning capacity. The “nature of the physical injury or
disfigurement” must incorporate the descriptions and measurements of physical impairments and the
corresponding percentages of impairments published in the American Medical Association (AMA) Guides to the
Evaluation of Permanent Impairment, 5th Edition (LC §4660).
The amount of PD compensation can be determined after the employee has reached maximum medical
improvement (permanent and stationary), meaning the employee’s condition is well stabilized and unlikely to
change substantially in the next year with or without medical treatment.
Vocational Rehabilitation Benefits (Dates of Injury Prior to 1/1/04)
When an injured employee is unable to return to his or her usual and customary occupational duties as a result of
permanent impairment, the injured employee may receive vocational rehabilitative services that are reasonably
necessary to restore the individual to suitable gainful employment
For an injured employee to receive vocational rehabilitation benefits, he or she must be found to be a “Qualified
Injured Worker” (QIW). Under California law, a qualified injured worker is defined as an employee who is both
medically eligible and vocationally feasible.
Death Benefits
When a work-related injury/illness causes the death of that injured employee, the employer is liable--in addition to
any other benefits--for the following death-related benefits (LC §§4700-4706.5):
1.
Reasonable burial expenses for the employee, not exceeding $5,000 for injuries occurring on or
after January 1, 1991;
2.
A statutory death benefit to be paid to the dependents of the deceased employee; and
3.
In the event the deceased leaves no surviving persons who were financially
dependent upon him or her at the time of death, the commuted value of the
death benefit is payable to the Department of Industrial Relations.
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Chapter 2: The Role of the
Primary Treating Physician
Overview
Labor Code §3209.3 of the workers’ compensation laws of California defines a physician as including physicians
and surgeons holding an M.D. or D.O. degree, psychologists, acupuncturists, optometrists, dentists, podiatrists, and
chiropractic practitioners licensed by California State law and within the scope of their practice as defined by
California state law. However, an acupuncturist cannot determine disability (LC §3209.3(e). In addition to the
definition in LC §3209.3, physicians located and licensed to practice in another state may provide treatment in
accordance with LC §4600. A primary treating physician is the physician who is primarily responsible for
managing the care of an injured employee, and who has examined the employee at least once for the purpose of
rendering or prescribing treatment and has monitored the effect of the treatment thereafter. The primary treating
physician can be an employer-designated physician or employee-selected physician as outlined in the Section 9785,
Title 8, of the California Code of Regulations. (See Appendix B)
Only one primary treating physician is allowed at a time. If the primary treating physician releases the injured
employee from care with no need for continuing or future medical treatment, and a dispute arises over the need for
further medical care, no other primary treating physician can be selected until the dispute is resolved. (Resolution
requires the procedures described in LC §§4061-4062.)
A secondary physician is any physician other than the primary treating physician, who examines or provides
treatment to the injured employee, but is not primarily responsible for continuing management of the employee’s
care. The secondary physician shall report to the primary treating physician in the manner required by the primary
treating physician.
A physician’s assistant or nurse practitioner may provide medical treatment for a work-related injury within the
scope of their respective license and under the supervision of the treating physician. The primary treating physician
shall make any determination of temporary disability and shall sign the report (LC §3209.10). All care given the
injured employee is ultimately the responsibility of the supervising physician.
Duties of Primary Treating Physician
REPORTING
Ÿ When to report
What to report
How to report
Whom to report
h Why to report
The primary treating physician should work closely with the claims adjuster to coordinate
the injured employee’s recovery. 8 CCR §9785 specifies the primary treating physician shall
make reports to the claims administrator rendering opinions on all medical issues
necessary to determine the injured employee’s eligibility for compensation. Issues include
diagnosis of the work injury or illness, a timetable for recovery, and determination of when
the injured employee is medically able to return to transitionally modified or alternate
work. These reports may be transmitted via fax, U.S. postal mail, or by any other means
satisfactory to the claims administrator.
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Duties of the primary treating physician include:
• Determine medical causation, specifically, the work relatedness of a condition.
• Provide diagnosis and treatment.
• Communicating the patient’s functional status to the claims administrator.
• Providing timely, accurate reports (DLSR 5021, PR-2, PR-3, PR-4).
• Determining work restrictions, and releasing the injured employee to return to work.
• Managing and coordinating the care of the injured employee.
• Obtaining all the reports of secondary physicians, and incorporating or commenting upon the findings and
opinions.
• Writing and/or consolidating reports.
• Determining when the condition of the injured employee is permanent and stationary.
• Providing copies of reports to the claims administrator.
Initial Exam Report
Within 5 working days of an initial exam, the primary treating physician shall submit a Doctor’s First Report (DFR) of
Occupation Injury or Illness (Form DLSR 5021; see Appendix A). On Line 24 of the DFR, or continuing onto the reverse
side if necessary, the primary treating physician shall establish a treatment plan listing all methods, frequencies, and
durations of the medical treatment. Additionally the type, frequency, and duration of planned physical medicine services
(for example: physical therapy, manipulation, acupuncture) must be specified.
When appropriate, the primary treating physician must specify recommendations for consultations and referrals to
specialists, as well as the need for surgery or hospitalization. The primary treating physician is responsible for
overseeing the medical care of the injured employee and ensuring that all reasonable and necessary medical
treatment is provided. Secondary physicians, physical therapists, and other health care providers to whom the
employee is referred shall report to the primary treating physician. The primary treating physician is responsible for
obtaining all of the reports of the secondary physicians and other health-care providers and shall incorporate or
comment upon the findings and opinions of the other physicians in the primary treating physician’s report, which is
due no later than 20 days after receipt of this information.
Primary Treating Physician Progress Reports
Additionally, the primary treating physician shall report to the claims adjuster within 20 days when any of the
following events occur:
1. The employee’s condition undergoes a previously unexpected significant change.
2. There is any significant change in the treatment plan reported, including, but not limited to, (A) an
extension of duration or frequency of treatment; (B) a new need for hospitalization or surgery; (C) a new
need for referral to or consultation by another physician; (D) a change in methods of treatment or in
required physical medicine services; or (E) a need for rental or purchase of durable medical equipment or
orthotic devices.
3. The employee's condition permits return to modified or regular work.
4. The employee's condition requires him or her to leave work, or requires changes in work restrictions or
modifications.
5. The employee is released from care. (“Released from care” means a determination by the primary treating physician
that the employee’s condition has reached a permanent and stationary status, with no need for continuing or future medical
treatment.)
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6. The primary treating physician concludes that the employee's permanent disability precludes, or is likely to
preclude, the employee from engaging in the employee's usual occupation or the occupation in which the
employee was engaged at the time of the injury, as required pursuant to LC §4636(b).
7. The claims administrator reasonably requests appropriate additional information that is necessary to
administer the claim. “Necessary” information is that which directly affects the provision of compensation
benefits as defined in LC §3207.
When continuing medical treatment is provided, a progress report shall be made no later than 45 days from the last
report of any type under this section, even if no event described in paragraphs (1) to (7) has occurred. If an
examination has occurred, the report shall be signed and transmitted within 20 days of the examination.
Except for a response to a request for information made in paragraph 7 above, reports shall be submitted on the
“Primary Treating Physician's Progress Report” form (DWC Form PR-2) contained in 8 CCR §9785.2 (as shown in
Appendix A), or in the form of a narrative report. If a narrative report is used, it must be entitled “Primary Treating
Physician's Progress Report” in boldfaced type, must indicate clearly the reason the report is being submitted, and must
contain the same information, using the same subject headings in the same order as DWC Form PR-2. A response
to a request for information made in paragraph 7 may be made in letter format. A narrative report and a letter
format response to a request for information must contain the same declaration under penalty of perjury that is set
forth in DWC Form PR-2: “I declare under penalty of perjury that this report is true and correct to the best of my knowledge and
that I have not violated Labor Code §139.3.”
Primary Treating Physician’s Permanent and Stationary Report
When the primary treating physician determines that the employee's condition has reached permanent and
stationary (P&S) status the physician shall submit a P&S report within 20 days from the date of examination. The
P&S report shall include any findings concerning the existence and extent of permanent impairment and limitations
(permanent disability) and, in addition, shall specify any need for continuing and/or future medical care resulting
from the injury.
The P&S report may be submitted on the “Primary Treating Physician's Permanent and Stationary Report” form
(DWC Form PR-3, for injuries with a finding of permanent and stationary status prior to 1-1-05, or DWC Form PR-4, for
injuries reaching a permanent and stationary status after 1-1-05) contained in section CCR §9785.3 or section 8 CCR
§9785.4 (as shown in Appendix A), or in such other manner which provides all the information required by CCR
§10606 (see Appendix B). Qualified Medical Evaluators and Agreed Medical Evaluators may not use DWC Form
PR-3 or DWC Form PR-4 to report medical-legal evaluations.
For permanent disability, evaluations performed according to the permanent disability evaluation schedule adopted
on or after January 1, 2005, the primary treating physician's reports concerning the existence and extent of
permanent impairment shall describe the impairment in accordance with the AMA Guides to the Evaluation of
Permanent Impairment, 5th Edition (DWC Form PR-4).
Causation and Apportionment
Any physician who prepares a report addressing the issue of permanent disability due to a claimed industrial injury
shall, in that report, address the issue of causation of the permanent disability. In order for a physician's report to
be considered complete on the issue of permanent disability, it must include an apportionment determination.
Apportionment of permanent disability shall be determined on the basis of causation. A physician shall make an
apportionment determination by finding the approximate percentage of permanent disability caused by the direct
result of:
1. The current industrial injury.
2. Other factors both before and after the industrial injury including, but not limited to, prior industrial
injuries.
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The physician’s opinion on apportionment must be based on “reasonable medical probability” and must include a
detailed discussion explaining “how and why” the physician came to his or her conclusion on apportionment. If
the physician is unable to include an apportionment determination in his or her report, the physician shall state the
specific reasons for not being able to determine the effect of that prior or subsequent condition on the permanent
disability arising from the injury. To make the final determination, the physician shall then consult with other
physicians, or refer the employee to another physician from whom the employee is authorized to seek treatment or
evaluation, in accordance with Division 4 of the Labor Code.
An employee who claims an industrial injury shall, upon request, disclose all previous permanent disabilities or
physical impairments. If the employee has received a prior award of permanent disability, it shall be conclusively
presumed that the prior permanent disability exists at the time of any subsequent industrial injury. This
presumption is a presumption affecting the burden of proof. The physician must explain how the disabilities
between the injuries overlap.
The accumulation of all permanent disability awards issued with respect to any one region of the body in favor of
one individual employee shall not exceed 100 percent over the employee's lifetime, unless the employee's injury or
illness is conclusively presumed to be total in character. For example, the loss of both eyes or sight, loss of both
hands or their use, an injury resulting in practically total paralysis, or an injury to the brain resulting in incurable
imbecility or insanity.
As used in this section, the regions of the body are the following:
(A) Hearing.
(B) Vision.
(C) Mental and behavioral disorders.
(D) The spine.
(E) The upper extremities, including the shoulders.
(F) The lower extremities, including the hip joints.
(G) The head, face, cardiovascular system, respiratory system, and all other systems or regions of the body not
listed in subparagraphs (A) to (F), inclusive.
Nothing in this section shall be construed to permit the permanent disability rating for each individual injury
sustained by an employee arising from the same industrial accident, when added together, from exceeding 100
percent. The employer shall be liable only for the percentage of permanent disability directly caused by the injury
arising out of and occurring in the course of employment.
Additional Duties: Medical Provider Network (MPN) Dispute
Resolution
Second-and Third-Opinion Process
If the injured employee is subject to the Medical Provider Network (MPN), and he or she disputes the diagnosis or
treatment of the primary treating physician, the dispute will be resolved in accordance with Labor Code §4616.3.
This resolution is also known as the second- and third-opinion process, where the employee may seek a second
opinion of another physician in the MPN.
If the injured employee disputes that diagnosis or treatment prescribed by the second-opinion physician, the
employee may seek an opinion of a third physician in the MPN. Additionally, selection of a subsequent physician
by the employee shall be based on the physician’s specialty or recognized expertise in treating the particular injury
or condition in question.
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Independent Medical Review (IMR) Process
If the injured employee is still disputing the treatment or diagnostic service after the third physician renders his or
her opinion, the injured employee may request an independent medical review (IMR) regarding the dispute. An
application for an IMR must be completed and signed by the injured employee or the person authorized by law to
act on behalf of the injured employee, and submitted to the Administrative Director (AD). Upon receipt of the
application, the AD or the IMR organization shall assign the independent medical reviewer. Following appointment
of the independent medical reviewer, the insurer or employer shall provide all relevant material or documentation
considered in relation to the disputed treatment or diagnostic service, including both of the following items:
1. A copy of all correspondence from, and received by, any treating physician who provided a treatment
or diagnostic service to the injured employee in connection with the injury.
2. A complete and legible copy of all medical records and other information used by the physicians in
making a decision regarding the disputed treatment or diagnostic service.
Upon receipt of information and documents related to the disputed treatment or diagnostic service, the independent medical
reviewer shall conduct a physical examination of the injured employee at the employee's discretion. The reviewer may order
any diagnostic tests necessary to make his or her determination regarding medical treatment.
To make the determination the reviewer shall use the medical treatment utilization schedule established pursuant to LC
§5307.27, or the American College of Occupational and Environmental Medicine's (ACOEM) Occupational Medicine
Practice Guidelines, as appropriate, and take into account any reports and information provided. The reviewer shall determine
whether the disputed health-care service was consistent with LC §5307.27 or ACOEM Occupational Medicine Practice
Guidelines based on the specific medical needs of the injured employee.
Within 30 days of the exam, or less as prescribed by the AD, the reviewer shall render a written report (in layperson’s terms as
much as practicable) to the AD containing his or her analysis and determination whether the disputed health-care services
were consistent with the medical-treatment utilization schedule established pursuant to LC §5307.27 or the ACOEM
guidelines. The AD shall immediately adopt the determination of the reviewer and shall promptly issue a written decision to
all parties. (LC §4616.4)
If the IMR finds that the disputed treatment or diagnostic services were consistent with the medical treatment utilization
schedule or the ACOEM guidelines, the injured employee may seek the services of a physician of his or her choice inside or
outside the MPN to provide those services. Such treatment shall be provided in accordance with ACOEM Occupational
Medicine Practice Guidelines. The employer shall be liable for the cost of any approved medical treatment in accordance with
LC §5307.1 or §5307.11
Reimbursement of Reports
OMFS
has been adopted by the
Administrative Director
as the basis for the
billing and payment of
medical services
provided injured
employees under the
workers’ compensation
laws of the state of
California.
Claims administrators shall reimburse primary treating physicians for their reports submitted in
accordance with 8 CCR §9785, as required by the Official Medical Fee Schedule (OMFS). The
same reimbursement levels apply to both the employee-selected and employer-selected primary
treating physicians unless there is a written contract. Some treatment reports are separately
reimbursable, others are not.
Always provide the supporting documentation to support the level or service or service code for
which you are billing, especially if using the higher Evaluation and Management codes.
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Reports Not Separately Reimbursable
The following reports are not separately reimbursable, but they are included in the appropriate Evaluation and Management
code:
•
Doctor’s First Report of Occupational Injury or Illness (DLSR Form 5021) or other report of the primary
care provider with similar information.
•
•
Initial treatment report and plan.
Treating Physician’s Report of Disability Status (DWC Form RU90) when the physician has not been able
to form an opinion regarding the employee’s ability to return to the pre-injury occupation.
•
Report by a secondary physician to the primary treating physician.
Reports Separately Reimbursable
When an office visit is included, the report charge is payable in addition to the underlying Evaluation and Management
service for an office visit. The following reports are separately reimbursable:
• Primary Treating Physician’s Progress Reports (DWC Form PR-2 or its equivalent). Progress reports are
separately reimbursable even if the change in the patient’s condition or treatment warranting a progress report
occurs during the surgical global follow-up period. Use CPT code 99081.
•
Final Treating Physician’s Report of Disability Status (DWC Form RU90). The physician uses this
report when rendering an opinion concluding that the employee is released to return to the pre-injury occupation, or
concluding that the employee’s injury is likely to permanently preclude the employee from returning to the pre-injury
occupation. Use CPT code 99080.
•
Primary treating physician’s final discharge report. The primary treating physician provides this report
when determining that no further medical treatment is needed for this injury, the patient has no permanent disability,
and the employee is able to return to work with no restriction or diminished capacity related to this injury. The final
discharge report must be submitted using DWC Form PR-2 or its equivalent. Use CPT code 99081.
•
Primary Treating Physician’s Permanent and Stationary Report (DWC form PR-3 or PR-4). When
the physician determines that the employee’s condition is permanent and stationary, the physician shall report any
findings concerning the existence and extent of permanent impairment and limitations and include an assessment of
causation and apportionment, and any need for continuing medical care resulting from the injury. These findings
must be reported using DWC PR-3 for injuries with a finding of permanent and stationary status prior to 1-1-05 or
DWC PR-4 for injuries reaching a permanent and stationary status after 1-1-05. Use CPT code 99080.
•
Consultation reports. These reports are used when consultation is requested on one or more medical issues by the
treating physician, including a second medical opinion on the necessity or appropriateness of previously recommended medical
treatment or a surgical procedure. The consulting physician may also charge a confirmatory consultation. Use code 99080.
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Chapter 3: Clinical
Management
Overview
The clinician needs understanding and sensitivity on a few key issues to achieve the best possible outcomes for
patients with workers’ compensation claims:
1. Treatment goals must focus on functional restoration and return to work.
2. Recovery is often dependent on patient trust of the doctor and motivation to participate in
the treatment plan.
3. A “team approach” produces the most successful management of industrial disability. The
players include the patient’s employer, various ancillary providers, and the claims
administrator.
4. Timely and effective communication between all parties is essential.
5. The clinician should be involved with injury prevention.
When a clinician ignores these factors, rehabilitation of work-related injury/illness often becomes problematic. The
clinician, patient, and employer may all become frustrated when symptoms persist, delaying a return to work
despite state-of-the-art diagnostic and treatment methods. The goal of this chapter is to provide a clinical approach
and philosophy that will help minimize disability and optimize rehabilitation outcome.
As for any patient, the first order of business is to establish a diagnosis. This matter is often straightforward, clearcut, and completed at the first visit. In other cases it may involve observation over time and monitoring response
to therapy (for example, establishing a diagnosis of nonspecific mechanical low-back pain or upper-extremity
repetitive-strain injury).
After establishing a working diagnosis, the physician usually can make a reasoned judgment regarding workrelatedness. This judgment is essential, since it determines who will be the payer. The workers’ compensation
system demands a “Yes” or a “No” determination, even when there is medical uncertainty. This requirement can
be a source of frustration for the inexperienced clinician who is accustomed to the scientific basis for clinical
decision-making.
In the workers’ compensation system, a determination that a condition is probably (“more likely than not”) related to
the alleged mechanism of injury or illness is sufficient to establish causation. Statements indicating that a condition
is “possibly” related or that a condition “may be” related are inadequate to establish compensability and will
generally result in further inquiries by the claims administrator.
It should be noted that there is nothing wrong with the physician changing an opinion after more information
becomes available, (such as more complete history, results of diagnostic testing). If the physician determines workrelatedness immediately but eventually determines causation to be nonindustrial, the cost for the initial evaluation is
generally considered compensable under workers’ compensation. Further medical care, however, will not be the
employer’s responsibility.
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Treatment Goals
The management of work-related injuries must emphasize restoration of function and return
to the workplace as the primary objective rather than the alleviation of symptoms. If not, the
treatment of workers’ compensation patients will be fraught with problems. There are at
least three reasons for this outcome:
1. The longer an employee is away from the work site, the less likely the chance for a successful
return to work.
2. Brief periods of rest may be necessary to initiate healing, but prolonged rest will cause
deconditioning, which impedes further healing and may predispose the employee to chronic
symptoms.
3. When there is a delay in the return to work, psychological factors interfere with recovery.
Once functional restoration and return to work are the primary treatment objectives, the injured employee
can become an active participant in the rehabilitation process. For example, the clinician can de-emphasize passive
modalities that alleviate symptoms but do nothing to improve strength and flexibility, while introducing exercise
therapy and transitional work as essential elements of the treatment plan as early as possible. Discussion and
reinforcement of the treatment goals should occur at every visit to avoid misunderstanding and dependency, and to
establish the patient as a partner in the rehabilitation process. A clear understanding of the treatment goals
facilitates successful outcomes and minimizes the frustrations of delayed recovery.
Return to Work
(See Chapter 4: Return to Work for a complete discussion of a return to work.)
Returning the injured employee to gainful employment as expeditiously as possible is a major goal of the workers’
compensation system, and the reasoned opinion of the treating physician is essential in this regard. When
evaluating an injured employee’s functional capacity, the treating physician must understand the essential
functions of the job in order to assess the patient’s readiness to return.
During the period of recovery, the treating physician must work with the employer to identify possible transitional
work tasks that would facilitate the employee’s rehabilitation. The physician should consider work alternatives, job
accommodation, or reassignment to another job.
Delayed Recovery
Another essential component of successfully managing workers’ compensation cases is early identification of those
patients at risk for delayed recovery. A review of the literature relating to work-related disability reveals a number of
demographic and psycho-social variables that appear to be risk factors for prolonged disability. Although severity
of injury is obviously a determinant of duration of disability, it is not relevant to a discussion of delayed recovery.
Delayed recovery implies failure to regain functional capacity within the expected time period, given the nature of the
injury or illness. The type of injury is significant. For example, so-called “soft tissue” injuries are more likely to be
problematic than fractures, dislocations, burns, or lacerations. This aspect is particularly true of spine related
conditions (nonspecific mechanical back and neck pain) because subjective complaints often occur without
objective findings, there is no opportunity for a right-left comparison, and the source of pain is often obscure--even
after a comprehensive diagnostic work-up by experts in spine medicine.
Significant factors associated with delayed recovery include age, lack of education, and poor general health.
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Job-related variables of importance include low wages, low seniority, heavy work, low job satisfaction, and poor
relationship with supervisor. There has been significant research in this area, but there are no adequately-validated,
predictive tools available to date.
The Motivation Factor
Most risk factors for delayed recovery are associated with the level of motivation to return to work. Experienced
vocational rehabilitation professionals usually can recall at least one example of phenomenal recovery of function
following severe trauma. These individuals have the will to recover and refuse to accept disability, despite extensive
injury.
At the opposite end of the spectrum are those individuals who persistently complain of pain and other subjective
symptoms, with little or no objective findings (that is, they are functionally disabled without evidence of physiologic
impairment). The importance of motivation cannot be overstated. The physician must consciously assess patient
motivation and attempt specific psychotherapeutic interventions when appropriate. The earlier the physician can
identify patients at increased risk for delayed recovery and chronic disability, the greater the potential to arrest the
process and return the patient to a productive lifestyle.
Secondary Gain
The assumption has been that disability behavior is learned, because the same impairment produces very different
behavior in different individuals. There are a number of psychological influences that reinforce the disabled role
and counteract the desire to recover. The term “secondary gain” has been used to describe the factors that
contribute to the maintenance of symptoms and inhibition of work performance. In essence, they create an
advantage to persistent disability behavior. Secondary gain is distinct from malingering in that it involves
unconscious phenomena that go beyond monetary support. The three identified types of secondary gain are:
•
Sympathy, attention and support.
•
Being excused from responsibility, obligation or challenge.
•
Influence over important people by virtue of their acceptance that the individual is
sick.
Additionally, the feeling of “victimization” (that, of having suffered an injustice, of society owing something) is
often a factor in secondary gain for workers’ compensation patients.
The current workers’ compensation system may foster illness behavior in a number of ways:
•
Providing tax-free income, although usually less than full wages, may not constitute
a financial hardship on employees earning near the minimum wage.
•
Current laws provide compensation for being disabled, which may make a full effort
toward rehabilitation difficult.
•
Disputed cases typically last more than a year. During this time the individual avoids
work because he or she feels it would adversely affect the claim. In addition,
litigation can prolong symptoms by creating unrealistic expectations of a large
financial reward. Patients may recover quickly when their claim is settled.
•
Often multiple physicians evaluate individuals and subject them to extensive
diagnostic testing. This extensive treatment reinforces the perception that the
patient may have a serious medical condition.
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The treating physician can play a key role in the prevention of delayed recovery. When the disabled employee has
persistent symptoms, the temptation is for the physician to respond by providing additional rest and time off from
work. This common therapeutic approach actually creates a vicious cycle that prolongs recovery and perpetuates
the sick role. Transitional work is the most effective approach for the prevention of chronic disability. It
should be a consideration at the first visit and an integral part of the treatment plan. (See Chapter 4.)
Communication Is the Key
One of the unique features of occupational medicine is the need for the treating physician to function as part of a
team. The players on this team include the injured employee, the employer, the physician, and the claims
administrator. Depending on the specifics of the case, other parties may be involved, including an occupational
health nurse, a physical therapist, a vocational rehabilitation counselor, or the patient’s family physician.
Communicating With the Injured Employee
Experienced clinicians are aware of the importance of trust in the doctor-patient relationship. For the occupational
injury patient, the establishment of this trust may be particularly challenging and can require special attention. This
need is especially true if the employer has referred the patient. In this situation, the patient may view the treating
physician as the stereotypical “company doctor” whose allegiance is primarily to the employer.
This view should never be the case, either ethically or as a matter of law. It is important to remember that
professional ethical codes and civil court rulings require that the physician’s primary allegiance be to the patient.
Ethical and legal obligations notwithstanding, the injured employee often may assume that the employer-designated
physician is unable to make objective, unbiased decisions relating to such issues as return to work, and that cost
containment considerations are compromising the quality of medical care. For the physician, effective
communication and an appropriate “bedside manner” require an awareness of this potential mistrust. Open and
frank discussions concerning the patient’s attitude and feelings about work are essential. It is often appropriate to
discuss return-to-work goals before establishing the diagnosis and treatment plan.
It should be noted that making the decision regarding return to work status can be fraught with pitfalls, especially
for the “soft tissue” injuries that are so common in the industrial setting. These conditions often involve pain
syndromes with minimal or no objective findings. It is important to listen carefully to the patient and correlate the
subjective complaints with clinical findings and diagnostic studies. Decisions regarding functional status and work
restrictions, however, must be the physician’s. The physician must make the decision on sound medical judgment
and should not be inappropriately swayed by the employer, the claims administrator, the attorney, or the patient’s
wishes.
The challenge for the clinician managing work injuries is to maintain a focus on the patient’s problems and to
involve him or her as an active participant in the rehabilitation process. It is important to emphasize that the
physician, the patient, the employer, and the claims administrator all share a common goal: effective rehabilitation
and prevention of further injury. When communicating with the injured employee:
•
Listen.
•
Sit down.
•
Explain.
•
Perform a hands-on exam.
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Communicating With the Employer
Communication with the employer is essential in every case for a number of reasons, including:
1. The employer is either directly (self-insured) or indirectly (via a workers’ compensation
carrier) paying for the medical care and disability benefits.
2. The employer has information regarding the work process and physical demands of the job
that is essential in making decisions regarding the ability to accommodate functional
restrictions. Since the physician does not always have the opportunity to visit the work site,
obtaining information from the employer as well as the patient may alert the physician to
ongoing issues that need attention (such as personnel problems or lack of adequate health
and safety training) or the existence of specific hazards that could be eliminated through
workplace redesign.
3. The employer must be informed about the prognosis for recovery in order to plan
effectively for modified duty assignments, temporary coverage, or permanent replacement
for the injured employee.
Optimally, the employer should be consulted as soon as possible after an injury regarding the potential for
transitional work so that the injured employee can return to the work site without unnecessary delay.
Communicating With the Claims Administrator
As the variety of health insurance systems has expanded in recent years, communication between providers and
payers has become increasingly complex. It is not uncommon for a primary care physician to belong to dozens of
Preferred Provider Organizations (PPOs) and HMOs, each with unique authorization and reporting protocols. The
typical medical office has at least one staff person to keep abreast of the resultant paperwork.
There are fundamental differences, however, between group health plans and workers’ compensation in relation to
the provision of medical-care benefits. These differences affect the nature and frequency of the physician’s
communication with the payer.
Group health is a contractual arrangement that may include arbitrary limits on the extent of treatment covered.
Workers’ compensation medical care, on the other hand, is a statutory benefit with no arbitrary limits on the
frequency, duration, or extent of services. A group health claims administrator simply determines whether a given
bill for medical services falls within the contractual limits of the policy. Workers’ compensation personnel,
however, must determine that the medical services rendered are “reasonable and necessary” to “cure and relieve
from the effects of an occupational injury,” and whether they are likely to produce the efficient recovery of
function and return to work.
In the workers’ compensation arena, claims administrators need more frequent contact with physicians because
information regarding possible transitional work, job modification, return to work, and prognosis for permanent
impairment is critical to the fair and efficient provision of disability payments.
This contact with the claims administrator can have real advantages for the physician by providing direct access to
the person paying the bills and allowing authorization for the reimbursement of treatment without
misunderstanding and resultant delays. It is important to remember that claims administrators have an incentive to
assure prompt and effective medical treatment so that claims are resolved as quickly as possible, but there must be
clear documentation from the physician about treatment goals and progress toward those goals. When the
treatment plan involves unusual procedures or more extensive treatment than is expected for the “average” patient,
the treating physician should provide specific justification. (For a more complete discussion of this process, see
Chapter 5: Utilization Review.)
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The Problem of Litigation
A significant decline in the litigation rate can be expected when the physician is oriented to the workers’ compensation
system, maintains effective relationships with injured employees, and has learned how to manage common occupational
injuries.
If the treating physician fails to recognize and address the psycho-social aspects of the recovery process, the injured
employee is apt to feel neglected. The doctor then often becomes frustrated because the injured employee is not
responding as anticipated. In the workers’ compensation system, this cycle is what often leads to litigation, which,
in turn, tends to perpetuate disability behavior.
An injured employee will litigate his or her claim for many reasons. Regardless of the issues in dispute, the litigation
process may greatly reduce the chance of successful rehabilitation and the return of functional capacity. Litigation
provides incentives to stay away from work, since the system provides permanent disability awards that are related, in
part, to duration of disability. Since attorneys receive reimbursement based on the basis of a percentage of the
permanent disability award, the goals shift away from functional restoration and focus instead on the financial award or
settlement.
Toxic Exposure Cases
In situations where work disability has resulted from exposure to toxic chemicals, it is important to take care in
communicating with the patient. These individuals typically have many questions regarding the type of exposure
and potential health effects, but significant data gaps often exist in the exposure and effect information. Particular
care is necessary so that the patients receive reassurance when appropriate, without misleading them or withholding
information.
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Chapter 4: Return to Work
Overview
Working in conjunction with our Utilization Review (UR) Program, State Fund’s Return to Work (RTW) Program
promotes early intervention and injury/illness management to expedite the opportunity for injured employees to
return to work. The consequences of disability to the individual are profound and multidimensional in scope, yet
many injured employees and their families are unaware of the harm that may result from an unnecessary absence
from work. We believe these programs will improve the overall quality of care and reduce unnecessary costs.
Early events are key, and the primary treating physician’s (PTP’s) involvement early in a case can be some of the most
valuable work he or she does. During those critical first few days, the PTP sets the tone by providing extra support to
make sure anxious or reluctant employees return to full function as soon as possible. This type of care helps avoid
inadvertently rewarding evasion behavior or phobic-like reactions to return to work. It is important to stay attuned to the
issue of time away from work.
An absence of over four weeks should be considered in the danger zone. By one month, many patients begin to develop a
disability rather than an ability mindset.
The PTP who treats work-related injuries and illnesses plays a vital role in the appropriate management of the
return to work process by managing disability and time lost from work as well as medical care.
The PTP should be asking the following questions after the initial examination and all follow-up examinations:
1. Can the employee perform his or her regular work duties?
2. If not, what kinds of temporary restriction must the employer consider to determine if a
transitional modified or alternative job is available?
3. Is a reduction in daily work hours a practical solution?
The emphasis is on keeping life as normal as possible for ill and injured employees, keeping them at work, or safely
returning them to appropriate work as soon as possible. The PTPs must step beyond their usual medical treatment
approach and actively facilitate the patient’s return to work.
It is paramount that the clinician should understand the importance of communication with the injured employee
on a return to full function as early as possible in a participatory management approach. PTPs can assume patients
will work during the medical workup and treatment. Treatment plans can always include staying at or returning to
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work (with modifications as necessary to keep the patient safe and as comfortable as possible), unless bed or home confinement
is specifically medically indicated.
The following excerpts are reprinted with permission from ACOEM’s Occupational Medicine Practice Guidelines,
Second Edition, Chapter 5.
Cornerstones of Disability Prevention and Management
This chapter emphasizes the importance of keeping life as normal as possible for ill and injured workers, keeping them
at work, or safely returning them to appropriate work as soon as possible. In addition, the chapter examines tools and
techniques that have proven effective in assisting workers to remain engaged in society at all levels. It also examines the
role of each of the participants in the stay-at-work/return-to-work (SAW/RTW) process (the employee, provider,
insurer, and employer).
Most workers who report a work related health concern can return to regular, temporary, or modified duty
immediately or within a short time. Occupational physicians and other health professionals who treat work-related
injuries and illness can make an important contribution to the appropriate management of work-related symptoms,
illnesses, or injuries by managing disability and time lost from work as well as medical care.
Prompt return to work in a capacity suitable for the worker’s current capabilities and needs for rest, treatment, and
social support prevents de-conditioning and disabling inactivity, reinforces self-esteem, reduces disability, and
improves the therapeutic outcome in most individual cases and on an aggregate basis. Ill or injured workers can be
temporarily placed in different jobs from their usual jobs (temporary duty), or their usual jobs can be temporarily
modified to accommodate their limitations and remaining abilities (modified or temporary transitional work).
Accommodation, with progressively fewer restrictions as healing occurs, generally has a greater chance of success;
the highest success rates are achieved when workers return to a modification of their pre-injury job. Disability
management conveys respect for injured or ill employees and provides social support that hastens recovery.
Consequences of Disability to the Individual
The consequences of disability to the individual are profound and multidimensional in scope, yet many workers
and their families are unaware of the harm that may result from unnecessary absence from work.
Most adults derive a good deal of their self-image from their work role. The inability to do one’s job removes a
pillar of his or her self-esteem and sense of well-being, and leads to a profound change in identity. Inactivity leads
rather quickly to muscle and joint aches, pain, and stiffness that may become a vicious cycle of inactivity and
worsening musculoskeletal complaints.
Within a matter of days, muscle mass, tendon strength, and bone mass begin to decline. Reversing these changes
often takes much longer than the inactivity that caused them, particularly in older patients. Even limited activity,
which often is easier to accomplish at the worksite, can prevent or mitigate these changes. For this and other
reasons, patients with no absences from work have the best chance of recovery.
Preferential consideration should be given to plans that involve (in descending order) light or modified work,
flexible schedules, and reduced hours. Injured workers often experience a decrease in health due to the injury and
pain medications. In many cases, depression occurs due to a sharp decrease in an injured worker’s quality of life,
including a loss of independence.
The consequences of disability can affect an entire family, across generations, and often change and reverse
traditional societal roles. Individuals may be unable to fulfill their normal roles as spouse or parent, and other
members of the family may be forced to assume new duties. The new role may be a barrier to functional recovery.
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Functional Recovery and Return to Work
In order for an injured worker to stay at or return successfully to work, he or she must be physically able to
perform some necessary job duties. This does not necessarily mean that the worker has fully recovered from the
injury, or is pain free; it means that the worker has sufficient capacity to safely perform some job duties. Known as
functional recovery, this concept defines the point at which the worker has regained specific physical functions
necessary for re-employment.
While return to modified or temporary duty work is an important first step in the functional improvement of
workers with health concerns, it must be managed carefully. The factors contributing to absences from work are
complex. Some factors are medically related; others are personal or related to family, job, worksite, or the economy.
Certain factors have been shown to promote an ill or injured worker’s functional recovery, including:
•
Encouragement and support from the worker’s employer, coworkers, doctor, family, and friends.
•
Injured workers’ perceptions that their jobs (whether the usual job or the modified duty job) are
commensurate with their qualifications and that they can perform the job duties adequately.
•
Access to quality medical care after the injury. This includes a positive relationship between the worker and
his or her doctor, in which the doctor provides adequate information about proposed treatments and
recovery expectations and discusses the worker’s job duties and ways to avoid aggravation or re injury.
Additional components of quality care include resuming aerobic activity as soon as possible to avoid deconditioning, and exhausting reasonable care methods prior to electing surgery (unless surgery is clinically
indicated).
•
Injured workers’ positive expectations and experiences with medical care and work-related injuries. This
includes previous positive experiences the workers have had with quality medical care and/or managing
work-related injuries. These experiences may be their own or shared by coworkers, family, and friends.
These previous experiences often shape expectations about the success of proposed medical treatments or
modified-duty proposals.
Employer’s Role
A successful return-to-work program must have multiple levels of responsibility that include the employer, safety
professionals, supervisors, and the injured worker. To be most effective, the return-to-work process starts before
any injury has occurred.
This process includes educating management and workers and is best supported by a non-hostile work
environment in which a positive supervisor/management response follows an injury or onset of symptoms.
In situations involving unsophisticated, passive or actively hostile employers in which the worker may perceive
dangerous working conditions or a negative interpersonal climate, there is little incentive for a worker to return if
alternatives, such as extended workers' compensation benefits or sick leave are available.
The optimal system allows early return to modified work and communication with the employee, provider, and
insurance carrier. Ideally, the employer will have job descriptions readily available for provider review and be willing
to participate in job/schedule modification as necessary. A lost-time injury can often be avoided if the employer,
physician, and insurer communicate and collaborate to get the employee’s life back to normal.
Typically, the medical care associated with these model programs is conservative and guided by evidence-based
treatment guidelines.
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The employer’s (or insurer’s) willingness and ability to eliminate obstacles, and arrange an appropriate on-the-job
recovery, based on the provider’s work prescription, will determine the date when the employee actually gets back
to work. Additionally, employers consistently monitor and evaluate the progress of return-to-work programs in
order to identify opportunities for improvement.
Clinician’s Role
Under the optimal system, a clinician acts as the primary case manager. The clinician provides appropriate medical
evaluation and treatment and adheres to a conservative evidence-based treatment approach that limits excessive
physical medicine usage and referral. Ideally, the clinician has previously visited the job site and knows the
functional demands of the position. If this is not possible, a review of the job description is appropriate.
Clinicians must step beyond their usual medical treatment approach and actively communicate with other members
of the return-to-work program including employers and/or payers. It is paramount that the clinician understands
the importance of communication with the worker on return to full function as early as possible in a participatory
management approach. Several key points should be kept in mind when dealing with the ill or injured worker:
•
Early events are key. Occupational health practitioners’ involvement early in a case can be some of the
most valuable work they do. During those critical first few days, they set the tone.
•
Occupational health practitioners can ask about disruption of normal activities as well as work. They also
can check to see that patients released to work have actually returned to work.
•
Clinicians can assume patients will work during the medical work-up and treatment. Treatment plans can
always include staying at or returning to work (with modifications as necessary to keep the patient safe and
as comfortable as possible), unless bed or home confinement is specifically medically indicated.
•
Clinicians can provide extra support to make sure anxious or reluctant patients return to full function as
soon as possible in order to avoid inadvertently rewarding avoidance behavior or phobic-like reactions.
Even when the medical condition is not expected to change appreciably from week to week frequent
follow-up visits are often warranted for monitoring in order to provide structure and reassurance.
•
It is important to stay alert to the issue of elapsed time away from work: Over four weeks should be
considered in the danger zone. By one month, many patients begin to develop a disability mindset.
Ascertain whether specific obstacles are preventing the patient from returning to work and ask: What is the specific
reason the patient is not working? Non-medical or administrative details often delay return to work and cannot be
rectified unless first identified.
Non-medical issues, once identified, need to be referred or, if possible, managed by the provider. These issues can
be handled in the same way as a regular medical specialist referral. In other words, physicians need to find their
comfort point and refer the situations that are beyond it. This may require developing a network of resources to
call when non-medical issues prolong disability. The clinician should judiciously select and refer to specialists who
will support functional recovery as well as provide expert medical recommendations. Close communication is
necessary and should emphasize the occupational health clinician’s role as the primary case manager.
Formulating and Communicating a Work Prescription to the
Employer/Insurer
When treating work illness or injuries, providing guidance regarding the worker’s ability to stay at work or return to
work, estimating work capacities, and describing medical restrictions and limitations are among the most important
assessments occupational health practitioners can make. It is appropriate to view this activity as formulating a
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medical prescription for functional activity with a particular focus on work. Providers should strive to provide
unbiased, objective, and dispassionate advice. Their reasoning should follow a logical sequence such as that
described here:
Step 1. Determine if absence from work is medically required. If not, then the patient can be cleared to do
medically appropriate work during recovery. The next steps will determine the specifications for that appropriate
work. Typically, absence is medically required when:
•
Attendance is required at a place of care (hospital, doctor’s office, physical therapy).
•
Recovery (or quarantine) requires confinement to bed or home.
•
Being in the workplace or traveling to work is medically contraindicated (poses a specific hazard to the
public, coworkers, or to the worker personally, i.e., risks damage to tissues or delays healing).
Step 2. Look for any obvious mismatch between the patient’s medical condition and the demands of the
regular job (or any proposed modified-duty job). For example, what part of the patient’s body needs to be
protected? What kinds of activities or functions should the patient avoid? Are special protections, reduced demands
on capability or endurance, or a special accommodation needed? If so, for how long?
In order to assess the situation accurately, clinicians may need to augment their clinical judgment with further input
from the employer. Office staff can request this data, which might include job descriptions including tasks, data on
physical demands and chemical exposures of the job, and information regarding whether accommodations can be
made allowing an employee to function in his or her original job category despite physical limitations.
Step 3. Describe any medical restrictions (i.e., what the patient should not be allowed to do, or what the
employer should do). Distinct from work capacities and limitations, these are specific medical concerns or
protective circumstances that are required in order to protect and keep the patient safe while working. An example
is a prohibition against working at heights for a patient with a balance problem or seizure disorder. Determining
restrictions is a medical issue. The physician’s medical knowledge and some knowledge of potential hazards at work
and at home are required. These restrictions should not be modified by either the patient or the employer without
the physician’s consent, even if the patient is fully capable of performing the task.
Step 4. Describe the functional limitations (i.e., what the patient cannot or is unable to do). Limitations
represent the difference between the patient’s current physical stamina, agility, strength, and cognitive ability and
potential job requirements. If specific job demands are known, it will be possible to describe more precisely the fit
between the patient’s current capability and actual job requirements.
Determining limitations is not really a medical issue; clinicians are simply being asked to provide an independent
assessment of what the patient is currently able and unable to do. In many cases, physicians can listen to the
patient’s history, ask questions about activities, and then extrapolate, based on knowledge of the patient and
experience with other patients with similar conditions. It may be necessary to obtain a more precise delineation of
patient capabilities than is available from routine physical examination. Under some circumstances, this can best be
done by ordering a functional capacity evaluation of the patient.
Whatever the basis of work capacities or restrictions, it is necessary for physicians to state their sources of
information. In particular, avoid relying solely on the patient or the employer for input; instead, seek objective
information or third-party corroboration, especially when controversy exists.
This is particularly true when a patient may be asked to do work that may exceed his or her limitations and lead to
further injury or create a hazard. In addition to considering functional testing, these circumstances may necessitate
arranging for a conference with the patient, his or her supervisor, and/or the insurer to eliminate any possible
misunderstandings. If the employer is unable to abide by the physician’s work prescription, the physician should be
available to discuss and explain the basis of limitations and the implication of not following them. The physician is
not an arbitrator, but may help identify resources to resolve any disagreement.
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Medically discretionary disability is time away from work at the discretion of a patient or employer that is
• Associated with a diagnosable medical condition that may have created some functional impairment but
left other functional abilities still intact.
Most commonly due to a patient’s or employer’s decision not to make the extra effort required to find a
way for the patient to stay at work during illness or recovery.
Occupational health practitioners need to remember that while impairment is defined as an anatomic change or a
reduction in physiologic or psychological function (World Health Organization, 1979), impairment may or may not
result in disability.
•
Employers who provide accommodations based on essential job function matched to worker abilities can prevent
an impairment from causing disability. Unfortunately, employers often choose not to provide accommodations for
a worker who is medically able to do some productive work and increase the likelihood of disability.
Many employers feel ill-prepared to make accommodations even though they are willing to do so (e.g., they may
have a lack of knowledge about adaptive equipment or creative solutions). Occupational health professionals can
assist by suggesting practical and simple accommodations: including workstation adjustment (including task
alignment); load; seating; support; unbundling heavy collections of objects; and/or periodic assistance by coworkers
for infrequent but demanding tasks and rest breaks.
Step 5. Identify any non-medical obstacles that appear to be primary or secondary barriers to return to
work. Medically unnecessary disability occurs whenever a person stays away from work because of non-medical
issues such as:
•
The misperception that a diagnosis alone (without demonstrable functional impairment) justifies work
absence.
•
Other problems that masquerade as medical issues, e.g., job dissatisfaction, anger, fear, or other
psychosocial factors.
•
Poor information flow or inadequate communications.
• Administrative or procedural delay.
Ideally, the provider is aware of risk factors for needless disability or delayed recovery from the first visit.
Depending on the presentation, the clinician may address the risk factors early on or monitor them closely and
recruit other resources, as necessary, to address them.
Step 6. Provide three intervals as part of the “prognosis,” on an ongoing basis, so others can plan
accordingly.
• When the patient will next need to be seen?
• How long will it take for a next-step improvement in functional capacity?
• How much time should it take until the medical condition is fully resolved? To monitor progress, a
provider may use return to work guidelines. All members of the team should be aware of the pros and
cons of using such guidelines.
Step 7. Let others determine the actual return to work date (i.e., the extent and speed with which the clinician’s
recommendations regarding work capacities and restrictions are translated into actual employment decisions).
Remember while the provider’s role is to assess work capacities and restrictions, the employer’s responsibility is to
determine how and when they are accommodated.
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Employee’s/Patient’s Role
To achieve functional recovery, patients must assume certain responsibilities. It is important that patients stay
active or increase activity to minimize disuse, atrophy, aches, and musculoskeletal pain, and to raise endorphin
levels. They must adhere to exercise and medication regimens, keep appointments, and take responsibility for their
moods and emotional states. They must work within their medical restrictions, and refuse unreasonable requests by
coworkers and supervisors to function over their limitations in a way that could endanger their health or safety.
Payer’s Role
Payers must act expeditiously in evaluating responsibility for a claim. If the claim is accepted worker payments must
be timely in accordance with applicable statutes. Claims should be monitored for indicators of delayed recovery
and, if necessary, trigger early case management to support providers in their efforts. They should play a nonadversarial role and work with the employer to define their approach.
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Chapter 5: Medical
Utilization Review
Overview
Utilization Review (UR) is now mandatory per Labor Code §4610, which requires every employer to establish a UR
process for treatment recommendations by a physician. The UR process applies to ACCEPTED and DELAYED
cases only. As part of it’s program, State Fund has UR contractors who will perform UR services on claims that
State Fund administers. State Fund’s UR Program is founded on the principle that appropriate medical care for a
work-related injury or illness improves medical outcomes while containing costs. Quality medical care for injured
employees is enhanced through timely communication and education between State Fund and the medical
provider. State Fund’s UR Program ensures that medical care is consistent with evidence-based practice, and meets
current evidence-based medical standards and guidelines.
The presumption of correctness has shifted from the PTP to evidence-based medical (EBM) guidelines. The
Administrative Director (AD) has adopted the Medical Treatment Utilization Schedule (MTUS), including the
American College of Occupational and Environmental Medicine Practice Guidelines (ACOEM Practice
Guidelines), the Acupuncture Medical Treatment Guidelines, and other evidence-based guidelines. The MTUS is
presumptively correct on the issue of extent and scope of medical treatment. The presumption is rebuttable and
may be controverted by a preponderance of the scientific medical evidence establishing that a variance from the
guidelines is reasonably required to cure or relieve the injured employee from the effects of his or her injury.
There are now special provisions for spinal surgery.
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Definitions:
ACOEM Practice Guidelines - The American College of Occupational and Environmental Medicine’s
Occupational Medicine, Second Edition. This guideline is incorporated into the Medical Treatment Utilization
Schedule (MTUS).
Authorization - Assurance that appropriate reimbursement will be made for an approved specific course of
proposed medical treatment to cure or relieve the effects of the industrial injury, pursuant to LC §4600, subject to
the provisions of LC §5402.
Concurrent Review - Utilization review conducted during an inpatient stay.
Expedited Review - Utilization review conducted when the injured employee’s condition is such that the
injured employee faces an imminent and serious threat to his or her health. A serious threat to the injured
employee's health includes, but is not limited to: the potential loss of life, limb, or other major bodily function; or
when the normal time frame for the decision-making process would be detrimental to the injured employee’s life or
health or could jeopardize the injured employee’s permanent ability to regain maximum function.
Expert Reviewer - A medical doctor, doctor of osteopathy, psychologist, acupuncturist, optometrist, dentist,
podiatrist, or chiropractic practitioner licensed by any state or the District of Columbia, competent to evaluate the
specific clinical issues involved in the medical treatment services and where these services are within the individual’s
scope of practice, who has been consulted by the reviewer or the UR medical director to provide specialized review
of medical information.
Immediately - Within 24 hours after learning the circumstances that would require an extension of the
timeframe for decisions.
Medical Treatment Utilization Schedule (MTUS): Assists in the provision of medical treatment by
offering an analytical framework for the evaluation and treatment of injured workers and to help those who make
decisions regarding the medical treatment of injured workers understand what treatment has been proven effective
in providing the best medical outcomes to those workers, in accordance with section 4600 of the Labor Code. The
MTUS is presumptively correct on the issue of extent and scope of medical treatment and diagnostic services
addressed in the MTUS for the duration of the medical condition. (8 CCR §§9792.20 – 9792.23)
Normal Business Day - A business day as defined in LC §4600.4 and Civil Code section 9.
Prospective Review - Any utilization review conducted, except for during an inpatient stay, prior to the
delivery of the requested medical services.
Request for Authorization - A written confirmation of an oral request for a specific course of proposed
medical treatment pursuant to LC §4610(h), or a written request for a specific course of proposed medical
treatment. An oral request for authorization must be followed by a written confirmation of the request within 72
hours. Both the written confirmation of an oral request and the written request must appear on the “Doctor’s First
Report of Occupational Injury or Illness” (Form DLSR 5021, 8 CCR §14006) or on the Primary Treating Physician
Progress Reports, (DWC Form PR-2, as contained in CCR §9785.2) or in narrative format containing the same
information required in the PR-2 form. If in a narrative format, the document shall state clearly at the top that it is
a request for authorization.
Retrospective Review - Utilization review conducted after the provision of medical services, for which
approval has not yet been given.
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Reviewer - A medical doctor, doctor of osteopathy, psychologist, acupuncturist, optometrist, dentist, podiatrist,
or chiropractic practitioner licensed by any state or the District of Columbia, competent to evaluate the specific
clinical issues involved in medical treatment services, where these services are within the scope of the reviewer’s
practice.
Utilization Review Process - Utilization management functions that prospectively, retrospectively, or
concurrently review and approve, modify, delay, or deny, based in whole or in part on the medical necessity to cure
or relieve, treatment recommendations by physicians, as defined in LC §3209.3, prior to, retrospectively, or
concurrent with the provision of medical treatment services pursuant to LC §4600.
Written - Communications in paper form as well as a facsimile.
UR Process
UR
PROCESS
³ Treatment
plan
Ÿ Time Frames
K Expedited
Reviews
G Appeals
Process
In most cases, the UR process begins with a written request for authorization for treatment
from the medical provider. That is, the UR process is prospective, occurring before services are
rendered. Occasionally, the UR process is retrospective, being linked to the bill review process
after services have occurred.
Written requests are required and can be submitted by FAX, or regular mail. Medical services
must be specified in either the Doctor’s First Report (DSLR 5021), Primary Treating
Physician’s Progress Report (PR2) or narrative report containing the same information as a
PR2. The request for authorization must include specific identification of the patient and
provider, with a clear statement describing the proposed treatment. When cases involve
surgical or unusual treatment or high-cost diagnostics, a specific statement explaining the
medical necessity saves time and expedites the authorization process.
After receipt of a written request for authorization, the UR reviewer makes a determination. The UR
reviewer provides a written decision within the legally specified number of days from the date of receipt of the
information reasonably necessary to make the determination (See section on UR Time Frames below for the
specific applicable time frames).The UR reviewer may communicate the following types of UR decisions:
•
AUTHORIZATION for all or part of the requested services:
•
MODIFICATION of all or part of the requested services:
•
DELAY in decision pending receipt of additional information from the provider requesting the treatment.
Such a delay notification must specify what additional information is needed and when a decision can be
expected after receipt of that information.
•
DENIAL of all or part of the requested services.
A nonphysician reviewer may request additional information, or approve or negotiate requests for authorization for
medical services. Only a physician reviewer may delay, deny, or modify requests for authorization. If you disagree
with the UR reviewer’s decision, you can submit a written request for an appeal or a request for reconsideration of
the decision.
A nonphysician reviewer may discuss applicable criteria with the requesting physician if the treatment requested
appears to be inconsistent with criteria. In such cases, the requesting physician may decide to withdraw a portion
or all of the treatment in question and submit an amended request for treatment authorization. The nonphysician
reviewer may approve the amended request for treatment authorization.
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The Treatment Plan
Effective medical management begins with the injured employee’s first visit for treatment of an injury. An appropriate
initial evaluation, diagnosis, and the setting of treatment goals and treatment plan with the injured employee promote early
return to work and functional recovery.
Treatment Authorization Requests
As previously stated, requests for authorization must be in writing. All requests must specify the course of the proposed
medical treatment. Any oral request for authorization must be followed by a written confirmation of the request within 72
hours. The written request must appear in the Doctor’s First Report (Form DLSR 5021) or in the Primary Treating
Physician’s Progress Report (PR-2). The PR-2 may be in a narrative format. However, the narrative must contain the
same information as required in the PR-2 form, and the document shall state clearly marked at the top that it is a request for
authorization. These requests may be submitted via facsimile or U.S. mail.
All treatment requests shall be reviewed on the basis of criteria consistent with the MTUS or other evidence based
guidelines that are nationally recognized by the medical community and are scientifically based. The relevant portion of
the criteria or guidelines used as a basis of a decision to delay, deny, or modify, treatment shall be disclosed in written from
to the requesting physician, the injured employee, and if the employee is represented, his or her attorney.
UR Time Frames
For prospective or concurrent reviews, the reviewer must make a decision in a timely fashion that is appropriate
for the nature of the employee’s condition. The time frame shall not exceed 5 working days from the date of
receipt of the information reasonably necessary to make the determination; in no event shall it be more than 14
days from receipt of the initial medical treatment recommendation. When a provider sends a request that requires
additional information, the non-physician reviewer may telephone the provider to request the additional
information within 5 working days of the initial request for authorization. A written confirmation of the request
that clearly indicates what additional information is needed should follow the verbal request. If the provider fails to
submit the requested information, the request may be denied on a conditional basis within 14 days from the date of
the original request, and reconsideration may be given upon receipt of the requested information.
The reviewer shall communicate to the requesting physician within 24 hours of the decision, either by telephone or
facsimile, decisions to approve a physician's request for authorization prior to, or concurrent with, the provision of
medical services to the injured employee. Written notice to the requesting physician shall follow the telephone
communication within 24 hours of the decision for concurrent review, and within 2 business days for prospective
review.
Decisions communicated to the requesting physician to modify, delay, or deny a physician's request for
authorization prior to, or concurrent with the provision of medical services to the injured employee shall be initially
by telephone or facsimile. Written notice to the requesting physician, the injured employee, and if represented, the
injured employee’s attorney, shall follow the telephone communication within 24 hours of the decision for
concurrent review and within 2 business days of the decision for prospective review. In addition, the nonphysician
provider of goods or services (servicing provider) identified in the request for authorization, and for whom contact
information has been included, shall receive notification in writing of the decision modifying, delaying, or denying a
request for authorization. The notification shall not include the rationale, criteria, or guidelines used for the
decision.
¯
When review is retrospective, the reviewer shall communicate decisions to the requesting
physician who provided the medical services and to the individual who received the medical
services, and applicant’s attorney, if the injured worker is represented, within 30 days of receipt
of the medical information that is reasonably necessary to make this determination.
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In addition, the servicing provider identified in the request for authorization, and for whom contact information
has been included, shall receive notification in writing of the decision modifying, delaying, or denying a request for
authorization. The notification shall not include the rationale, criteria, or guidelines used for the decision.
The claims administrator may extend the time frame for decisions specified for authorizations, denials, delays, or
modifications only under the following circumstances:
•
The claims administrator is not in receipt of all of the necessary medical information reasonably
requested.
•
The reviewer has asked that an additional examination or test be performed upon the injured employee
that is reasonable and consistent with professionally recognized standards of medical practice.
•
The claims administrator needs a specialized consultation and review of medical information by an
expert reviewer.
If any of these circumstances apply, the claims administrator shall immediately provide written notification to the
following individuals: the requesting physician, the injured employee, and if represented, his or her attorney. The
notice shall inform them that the claims administrator cannot make a decision within the required time frame.
Additionally the claims administrator must specify the information requested but not received, the additional
examinations or tests required, or the specialty of the expert reviewer to be consulted. The claims administrator
shall also notify the requesting physician, the injured employee, and if represented, his or her attorney, of the
anticipated date when the claims administrator will be rendering a decision.
This notice shall include a statement that, if the injured employee believes that a bona fide dispute exists relating to
his or her entitlement to medical treatment, the injured employee or the injured employee's attorney may file an
Application for Adjudication of Claim and Request for Expedited Hearing (DWC Form 4) in accordance with CCR
§§ 10136(b)(1), 10400, and 10408.
In addition, the servicing provider identified in the request for authorization, and for whom contact information
has been included, shall receive notification in writing of the decision to extend the time frame and the anticipated
date when the decision will be rendered in accordance with this subdivision. The written notification shall not
include the rationale, criteria, or guidelines used for the decision.
Upon receipt of the “additional” information, the claims administrator shall make the decision to approve, and the
reviewer shall make a decision to modify or deny the request for authorization, within 5 working days of receipt of
the information for prospective or concurrent review. The claims administrator shall communicate the decision in
the manner previously specified for all prospective or concurrent reviews. For retrospective reviews, the claims
administrator shall render written communication of the decision to approve, modify, or deny within 30 days of
receipt of the information.
Expedited Review
For use when
there is imminent
and serious threat
to health, life, or
limb.
•
The reviewer shall make prospective or concurrent decisions related to an expedited review
time frame in a timely fashion appropriate to the injured employee's condition. The decision
shall not exceed 72 hours after the receipt of all necessary information to make the
determination. The requesting physician must indicate the need for an expedited review
upon submission of the request. Decisions related to expedited review involve the following
situations:
When the injured employee's condition is such that the injured employee faces an imminent and
serious threat to his or her health, including, but not limited to, the potential loss of life, limb, or other
major bodily function. OR
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•
The normal time frame of 5 working days for the decision-making process would be detrimental to the
injured employee's life or health or could jeopardize the injured employee's permanent ability to regain
maximum function.
A reviewer who is competent to evaluate the specific clinical issues involved in the medical-treatment services,
where these services are within the scope of the individual’s practice, must conduct the review and make the
decision to deny, delay or modify a request for medical treatment.
Denial Decisions
Denial decisions are based on the Medical Treatment Utilization Schedule (MTUS) adopted by the Administrative
Director in accordance with Labor Code §5307.27. (See also 8 CCR §§9792.20 – 9792.23.) The schedule currently
recommends standards based on the MTUS or other evidence-based medical-treatment guidelines that are
nationally recognized and scientifically based (per LC §9792.8), to determine whether the requested treatment is
reasonably required to cure or relieve the injured employee from the effects of his or her injury. The regulations
provide assurance that any denial decision is made by a licensed physician who is competent to evaluate the specific
clinical issues involved in the medical treatment services, where these services are within the scope of the
physician's practice. All denial decisions will be in writing.
All UR denials of physician requests for medical treatment authorization shall include the following details:
• Date the decision was made.
• Description of the specific course of proposed medical treatment requested.
• Description of the medical treatment service approved (if any).
• Clear, concise explanation of the reasons for the UR reviewer’s decision.
• Description of the medical criteria or guidelines used.
• Clinical reasons regarding medical necessity.
• Dispute-resolution process and additional mandatory language as outlined in Labor Code §9792.9 (j) and
(k).
If you disagree with the decision, you may send a written appeal. (See the section on Utilization Review Appeals
below.)
Note: A physician’s written objection to a denial may initiate a medical-legal dispute that requires resolution in accordance with Labor
Code §4062.
UR Appeals
Only the requesting physician may appeal a UR decision. The requesting physician’s appeal must be in writing, or
via fax, and must be received within 10 days of the date of the UR decision. The written request for appeal should
be prominently identified as a “UR Appeal” at the top of the page, and it must include a copy of the specific UR
Decision under appeal.. For an appeal to qualify for review, the requesting physician must outline his or her reason
for the appeal. The reason must cite sources from a nationally recognized, evidence-based medicine (EBM)
treatment guideline, and/or give the clinical reasons for this specific patient’s medical condition warranting care
that falls outside the MTUS or other EBM guidelines that the UR reviewer cites. Appeals received from parties
other than the requesting physician, or appeals without such substantial supporting information, will not qualify for
consideration. Participation in the appeals process is voluntary. The 10-day time frame for appeals does not extend
or alter the statutory 20-day time frame for dispute resolution outlined in Labor Code §4062.
If the treating physician appeals a UR decision from an on-site UR physician, the UR Coordinator will initiate
contact with a board-certified specialist from the Specialty Panel established for this purpose. If the treating
physician appeals a UR decision from an off-site UR contractor, the requesting physician must submit his or her
appeal to the off-site contractor.
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UR Reconsiderations
If the requesting physician provides additional information for review to substantiate a request for authorization,
the matter becomes a reconsideration. The same UR physician who reviewed the original request may handle the
reconsideration. Reviews of reconsiderations may occur upon receipt of additional information from the treating
physician.
UR Dispute Process
The injured employee or (the injured employee’s attorney, if the injured employee is
represented by counsel,) may object to the UR decision. He or she has 20 days to file an
objection to the UR decision, in accordance with Labor Code §4062. Additionally, the injured
employee or the injured employee’s attorney may file an Application for Adjudication of Claim,
and a Request for Expedited Hearing (DWC Form 4) in accordance with LC §§10136(b)(1), 10400, and 10408.
Upon filing, he or she can request an expedited hearing and decision on his or her entitlement to medical
treatment, if the request for medical treatment does not receive authorization within the time limitations set forth
in LC §9792.9, or if there exists a bona fide dispute as to entitlement to medical treatment.
Second-and Third-Opinion Process
If the employee is subject to the MPN, and he or she disputes the diagnosis or treatment of the primary treating
physician, the dispute resolution will occur in accordance with LC §4616.3. These disputes are not considered UR
disputes.
Tips for Faster Processing of Your UR Request
The following tips can help expedite processing of your treatment-authorization requests:
•
Fax your treatment request to the Adjusting Location’s UR Department by using the dedicated UR fax number.
•
Provide complete legible reports. State the requested treatment clearly.
•
Allow for open lines of communication with the UR reviewers. The UR physicians and nonphysician reviewers
will attempt to contact you in person if they have any questions, or if they need to modify, delay, or deny your
treatment request.
•
Provide supporting documentation with your treatment request. This step is especially important when your
treatment request falls outside the Medical Treatment Utilization Schedule—the ACOEM Guidelines, the
Acupuncture Guidelines, and other specific guidelines adopted by the AD.
Hours of Availability
State Fund provides 24 hour telephone and facsimile access for physicians to submit requests for treatment State
Fund will process requests for treatment from 9:00 a.m. to 5:30 p.m. Pacific Time, on Monday
through Friday, except state holidays. Each District Office for State Fund has a dedicated fax
number for the purpose of receiving treatment requests.
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Pharmacy Benefit Management Program
State Fund uses a Pharmacy Benefit Management (PBM) Program to provide pharmaceuticals for injured
employees.
Handling prescriptions electronically through network pharmacies helps expedite the authorization process. The
PBM program has a formulary that includes the authorization of medications for common workers’ compensation
injuries and illnesses. The claims adjuster also has the ability to preauthorize medications as indicated in the
approved treatment plan.
Spinal Surgery and the Spinal Surgery Second-Opinion Process
State Fund refers requests for spinal surgery to Blue Cross of California (BCC) for utilization review. BCC will conduct the
utilization review in accordance with all regulatory requirements. Disputes regarding any UR decision for spinal surgery are
subject to the “Spinal Surgery Second Opinion Procedure, pursuant to 8 CCR §9788.01-9788.91 and LC §4062(b).
State Fund MPN Treatment Authorization Program (TAP)
Physicians in State Fund’s MPN have limited authority to provide specific services without the need to submit requests for
preauthorization through utilization review.
All services performed under this program require reporting on a special form. The MPN physician must include the
form with either the Doctor’s First Report of Occupational Injury or Illness (Form DLSR 5021, as contained in CCR
§14006) or on the Primary Treating Physician Progress Reports (DWC Form PR-2, as contained in CCR §9785.2) or in
narrative form with the same information required in the PR-2 form. As outlined in the program, physician-notification
letters will not be provided for these covered services. This program is available to State Fund MPN Physicians only.
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Chapter 6: AMA Guides –
The Evaluation of
Permanent Impairment
Overview
When California first instituted a workers’ compensation insurance system in 1911, it also adopted a permanent
disability schedule for rating permanent residuals resulting from an industrial injury or illness. This rating schedule
was developed in accordance with the requirements spelled out in the California Labor Code. Before enactment
of reform legislation in April 2004, the Schedule for Rating Permanent Disabilities was considered the sole authority for
establishing disability and determining an injured worker’s permanent disability rating. The Schedule was meant to
serve as a mechanism to allow for equitable and predictable compensation for the residual effect(s) of industrial
injury. The Schedule was also developed in an effort to promote consistency, uniformity, and objectivity.
The Labor Code as most recently amended, however, requires the physician to describe ‘permanent impairment’
in accordance with the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition to describe the
nature of the physical injury or disfigurement resulting from the industrial injury. The amendment of LC §4660
changed the process for determining the percentage of permanent disability by replacing ratable factors of
“diminished ability to compete in the open labor market” with “diminished future earning capacity.” So now, LC
§4660(b)(2) mandates that the Schedule shall adjust for impairment due to diminished earning capacity by a formula
based on the empirical data of average long-term loss of earnings from each type of injury for similarly situated
employees, including age and occupation. And LC §4660(b)(1) requires that the “nature of the physical injury or
disfigurement” component of permanent disability shall incorporate the AMA Guides to the Evaluation of
Permanent Impairment, 5th Edition, for both descriptions and percentage impairments.
The AMA Guides have been in existence since 1958 and were first published in the form of 13 articles in the
Journal of the American Medical Association (JAMA) between 1958 and 1970. The first edition of the current book
format was published in 1971, with the 5th and most recent edition being published in July 2004. The Guides are a
“consensus-driven” reference manual created by physicians for physicians to evaluate and determine permanent
impairment, not disability. Several different physician groups of various specialties collaborated to produce this
guide for determining impairment values. A different specialty group developed each chapter of The Guides so it is
not unusual for the reader to notice differences between chapters. The Guides have become the most commonly
used reference for assessing and determining permanent impairment not only in the United States but also in other
countries. In the U.S, 40 states and the District of Columbia use The Guides for evaluating permanent impairment
in workers’ compensation cases.
The basis of impairment assessments, also known as impairment standards, is whole person impairment (WPI).
The assessments incorporate available scientific evidence and prevailing medical opinion. Physicians must now
determine impairment not disability.
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Definitions
AMA Guides – American Medical Association Guides to the Evaluation of Permanent Impairment – Fifth Edition. The
Guides are used to evaluate impairment and not disability.
Nature of the Physical Injury or Disfigurement – The descriptions and measurements of physical
impairment and the corresponding percentages of impairments published in the AMA Guides.
Employee’s Diminished Future Earning Capacity – A numeric formula established on the basis of empirical
data and findings from the Evaluation of California’s Permanent Disability Rating Schedule, Interim Report (12/03),
prepared by the Rand Institute for Civil Justice.
Impairment – Loss, loss of use, or derangement of any body part, organ system, or organ function.
• Measured against the Activities of Daily Living (ADL) performance.
• Impairment does not equal disability.
• The impairment rating does not factor social or recreational activities and work. These factors are not ADL.
Only the impairment that interferes with ADL qualifies for an impairment rating on the basis of the AMA
Guides.
ADL include:
• Self care
• Communication
• Physical Activity
• Sensory Function
• Nonspecialized hand activity
• Travel
• Sexual Function
• Sleep
Disability – In California it is an alteration of an individual’s capacity to meet personal, social or occupational demands
due to an impairment measured against the loss of earning capacity
Maximum Medical Improvement (MMI) – A condition or state that is well stabilized and is unlikely to change
substantially in the next year, with or without medical treatment. Over time there may be some changes, but further
recovery or deterioration is not anticipated. MMI is equivalent to permanent and stationary, but does not equal disability.
Impairment Standard – Whole person impairment (WPI) estimate, expressed in percentages on a scale from 0% –
100%) and listed in the AMA Guides. This standard reflects the severity of the medical condition and the degree to which
the impairment affects an individual’s ability to perform common activities of daily living, excluding social, recreational, or
occupational impact.
Anatomic loss – Measurable diminution of “normal” anatomic integrity, compared with either known populations or
the individual’s prior known history.
Normal – The range of healthy functioning that varies with age, gender and other factors, such as environmental
conditions, from either an individual or population perspective.
Functional Loss – Reduction in the ability of a body part or system to perform a task in a normal or usual way,
compared with either known populations or the individual’s known prior history.
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General Principles of the AMA Guides
PURPOSE &
APPLICATION
³ MMI
Ÿ
WPI Rating
K Activities of Daily
As a primary treating physician you should familiarize yourself with Chapters 1 and 2 of
the AMA Guides as well as the Glossary. The two chapters cover the Guides’ purpose,
applications, and methods for performing and reporting impairment evaluations. The
Glossary provides definitions of common terms that many specialties use in
impairment evaluations.
Living (ADL)
G Subjective Factors
Whole Person Impairment (WPI) Rating
California’s new “Schedule For Rating Permanent Disabilities” became effective January 1, 2005. It requires the
use of an impairment standard in combination with age, occupation and loss of future earning capacity in order to
determine the amount of permanent disability resulting from an industrial injury. Licensed physicians must
perform impairment evaluations using the AMA Guides for assessing and calculating the injured employee’s WPI
standards when the industrial injury or illness occurred on or after January 1, 2005. The new schedule also applies
to earlier dates of injury when the injured employee’s condition reaches MMI as of January 1, 2005 or thereafter.
An injured employee’s medical impairment is considered permanent when it has reached MMI (previously known
as permanent and stationary). In other words, the impairment is already well-stabilized and unlikely to change
substantially in the next year.
An impairment evaluation is a medical assessment, it is not medical treatment. Using the Guides, the physician must
provide an impairment rating that reflects the severity of the medical condition. When evaluating impairment, The
Guides allow consideration for both anatomic and functional loss. The impairment rating is expressed in WPI terms
and must also be substantiated by the impact of the impairment on the injured employee’s overall ability to perform
activities of daily living (ADL). The Guides give these comparisons:
•
A zero percent WPI is assigned if the impairment has no significant organ or body system functional
consequences and does not limit the performance of common ADL.
•
A 90-100 percent WPI indicates a very severe organ or body system impairment requiring the individual to
be fully dependent on others for self care, approaching death.
The physician must consider the ADL when establishing a permanent impairment rating. The physician can often
assess a person’s ability to perform ADL on the basis of his or her knowledge of the patient’s medical condition
and exercise of “clinical judgment.” Per the Guides, the physician should use clinical judgment based upon
experience, training, skill, and thoroughness in clinical examination. It combines the “art” and “science” of medicine
and “constitutes the essence of medical practice.”
Where the Guides cannot provide an impairment rating, the physician should use clinical judgment by comparing
the measurable impairment resulting from the unlisted condition to the measurable impairment resulting from
similar listed conditions with similar impairment of function in performing ADL. In deciding where to place an
individual’s impairment rating within a range, the physician needs to consider the ADL and estimate the degree to
which the medical impairment interferes with these activities. Keep in mind, total impairment cannot exceed 100
percent of the WPI.
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Subjective Factors
This impairment evaluation system has not eliminated consideration for subjective complaints. Instead, the system
already incorporates within the impairment rating a value for subjective complaints of pain that are customary or
expected. The impairment rating accounts for commonly associated pain, including pain an injured employee may
experience in areas distant to the specific site of pathology (i.e., pain radiating down the leg due to a lumbar spine
disorder). The physician must distinguish between pain that accompanies illness or injury from pain that has
become an autonomous process. Subjective complaints a physician substantiates with objective findings may
increase the impairment rating. If the physician is of the opinion that the injured employee is experiencing more
pain than what is factored into the rating, an additional 1 to 3 percent add-on may be appropriate. Difficulty in
concentrating, pain, and fatigue generally do not have separate impairment ratings when unaccompanied by
demonstrable clinical signs or other independent, measurable abnormalities. Chapter 18 of The Guides provides the
protocol for evaluating permanent impairment in such cases.
Physician’s Final Report of Disability
PTP’s Final Report
must
not
only
provide
the
impairment rating
but also address the
foundation for the
When the PTP determines that the employee's condition has reached MMI, the physician
shall report within 20 days from the date of examination any findings concerning the
existence and extent of permanent impairment and limitations. The physician will also
specify any need for continuing and/or future medical care resulting from the injury.
The final report may be submitted on the “Primary Treating Physician's Permanent and
Stationary Report” (DWC Form PR-3 for injuries becoming P&S prior to 1-1-05, or DWC Form
PR-4 for injuries reaching MMI after 1-1-05) contained in CCR §9785.3 or CCR §9785.4 (See Appendix B) In the report
the physician must describe the following areas in detail:
•
The chief complaint(s).
•
The symptoms.
•
The quality, severity, and anatomic location, frequency, and duration of the symptoms.
•
The initiating, exacerbating, and alleviating factors involved.
•
The way in which the condition interferes with ADL.
• Any change in function of the organ or body system.
In addition to providing the impairment rating, the physician must also address the basis for his or her conclusion(s),
including the tables and figures used, calculation(s), as well as any additional considerations.
For the report to be considered as evidence in a Workers’ Compensation Appeals Board hearing or trial, it must provide
all the following information required by CCR §10606 (see appendix B).
• Narrative history.
•
Current clinical status.
•
Diagnostic study results.
•
Whether or not the injured employee is at Maximum Medical Improvement (MMI).
•
Discussion of diagnoses and impairment.
•
Comparison of medical findings with impairment criteria.
• Discussion of impairment rating calculations.
Qualified Medical Evaluators and Agreed Medical Evaluators may not use DWC Form PR-3 or PR-4 to report medicallegal evaluations.
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Calculating permanent impairment
When conducting an impairment evaluation the physician should focus on taking a detailed
history of the patient, a description of the injury, reviewing prior medical reports, and integrating
this information with the related physical findings. The Guides outline the evaluation process for
the physician. They provide detailed clinical information and diagrams to evaluate specific
factors, and calculate an impairment rating of the injured employee. To be of clinical value,
clinical signs and symptoms must be consistent with the imaged findings. Each chapter in The
Guides provides instructions for the physician on how to rate WPI for that specific body region,
using the tables and text in that chapter.
The PTP explains
the basis for the
rating, listing all
charts and tables
used to calculate the
rating.
This section will review the impairment rating process for several of the more common body regions seen in industrial
injuries. It will also review how to use the combined values chart when an injured employee has multiple injuries.
The Spine
Instructions for assessment of spinal impairment are found at Chapter 15. The Guides assume the evaluator understands
basic spine anatomy. While there are five regions to the spine (cervical, thoracic, lumbar, sacral and coccygeal) the Guides
consider only the cervical, thoracic, lumbar and sacral spine of clinical importance for impairment purposes. A spinal
level refers to an area bounded by two vertebrae, a single spinal disc, and associated nerve roots and nerves.
When evaluating the spine for impairment rating, physicians use one of two methods:
•
The Diagnosis Related Estimates (DRE)
•
Range of Motion (ROM)
Unlike the prior rating system, the Guides do not include work restrictions.
DRE Method
This primary method of rating the spine is preferred because it provides diagnostic categories that account for common
neurological and muscular changes associated with a condition. Within the spine chapter, there is a separate table for each
of the three regions of the spine. In placing an individual into the correct category in the table, the physician must consider
clinical findings as well as the presence of fractures and dislocations.
When to Use the DRE method
A physician should use the DRE method when a distinct or specific trauma, not a cumulative trauma, has occurred.
Additionally the physician should use the DRE method even if the cause of impairment is not easily determined yet
the impairment can be well characterized under this method. Other situations in which the DRE method should be used
are:
•
Single-level involvement (that is, one disc or one vertebrae).
•
First injury (or repeat injury, but to a different region).
•
Fracture, dislocation, or both at one level in the same spinal region (with or without clinical symptoms).
ROM Method
The second and less commonly used approach for rating spinal impairment is the ROM method. Again, the DRE
method is the preferred procedure but it has been recognized that in some instances the DRE method is not adequate to
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evaluate impairment. One such instance is when the injured employee has sustained an injury over time rather than a
specific or distinct trauma.
The ROM method is comprised of three elements:
1. The range of motion of the impaired spine region.
2. Accompanying diagnosis. (See Table 15-7 of the Guides, page 404)
3. Any spinal nerve deficit.
The Guides recognize that mobility, diagnosis, and nerve root deficits all provide important clinical information about the
function of the individual’s spine. The WPI rating is determined by combining the percentage ratings from all three of
these components using the combined values chart on page 604 of The Guides.
First Element of ROM - Measurement
Measure the motion of the relevant planes of the spine using an inclinometer and the standard ROM measurement
principles set out in the Guides. Using the maximum motion for the reproducible set of measurements, the physician
determines the impairment rating from the appropriate tables, on the basis of the spinal region and type of movement.
These measurements can be recorded on summary sheets such as those found at Figures 15-10 (lumbar), 15-14 (thoracic)
and 15-18 (cervical) of the Guides.
Second Element of ROM - Diagnosis
Use Table 15-7 in the Guides to determine the percent of impairment. If there are two or more diagnoses within the spinal
region, use the one that is most significant.
Third Element of ROM – Neurological Deficit
Determine any impairment due to neurological deficits, such as radiculopathy or spinal nerve injuries as follows:
•
Use Table 15-15, page 424, for any sensory deficits.
•
Use Table 15-16, page 424 for estimating loss of strength.
•
Apply these tables to Table 15-17, page 424 (cervical and thoracic nerve roots); or Table 15-18 (lumbar and sacral
nerve roots), as needed.
•
Convert the neurological impairment, initially calculated as upper extremity (Table 16-3, page 349) or lower
extremity (Table 17-3, page 527), into WPI.
Once all three of these elements have been completed, combine all three impairment rating percentage results, using the
combined values chart on page 604 of the Guides.
When to use the ROM Method
The best scenario for using the ROM technique is when impairment is not caused by a specific injury but
rather accumulated over a period of time. The physician should also use this method when the cause of
the condition is uncertain and it is not easy to classify the injured employee into the DRE category.
Additionally, use the ROM method if the injured employee has multilevel involvement in the same spinal
region (for example, fractures at multiple levels) or fusions at multiple levels, with the exception of involvement of the
corticospinal tract. Likewise, if the injured employee has recurrent radiculopathy caused by a new disk herniation, use the
ROM method.
V
On those rare occasions when the injured employee’s condition allows for use of both the ROM and DRE methods , the
physician is instructed to evaluate the individual using both methods and to report the higher impairment rating.
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The Upper Extremities
In evaluating upper-extremity impairment, the Guides use an anatomic approach. While some conditions also call for
cosmetic and functional assessment, it is the evaluation of anatomic impairment that is most reproducible. This evaluation
provides a standardized means for determining a numeric impairment rating.
General Evaluation Principles for Upper Extremities
The Guides discuss upper extremity impairment at Chapter 16. Some general ground rules apply in the evaluation of upper
extremity impairment. Anatomic impairment is the only basis for upper-extremity assessment in the Guides. This basis
relies on the history and a detailed physical examination of the injured employee and the upper-extremity upon MMI. The
categories of anatomic impairment are listed below. The physician must note each category and rate each of them
separately:
•
Amputation
•
Digital Nerve Lesions
•
Restriction of Active Motion/Ankylosis
•
Peripheral Nerve Disorders
•
Peripheral Vascular Disease
•
Other Musculoskeletal Abnormalities
•
Strength Evaluation
‰
The Guides provide the physician with a standardized process for evaluating each of the categories listed
above as well as any other considerations that are appropriate to the assessment of upper extremity
impairment. The Guides provide an Upper Extremity Evaluation Record (Figures 16-1a and 16-1b) for
the physician to use so that all upper extremity changes are assessed and properly recorded during
examination. Record forms are available for both the hand and arm. The forms track the steps required by the Guides for
evaluating impairments of the upper extremity. The Guides also instruct physicians about when to add and when to
combine factors of upper extremity impairment.
When tests or measurements fall between two scheduled levels of impairment values, the physician can interpolate and
assign the more appropriate value. For example, if the physician’s opinion is that the ADLs are more severely affected than
expected, the physician can use his findings to adjust the impairment rating accordingly. Unlike the old permanent
disability rating system, the Guides do not call for the adjustment of impairment ratings for hand dominance. When
working with impairment ratings in the upper extremity keep in mind the upper limb is considered a “unit” of the WPI.
The upper extremity consists of four “units”:
•
Hand
•
Wrist
•
Elbow/Forearm
• Shoulder
Each “unit” is given a relative value to the entire upper limb. The “hand” unit is divided into “digits” which are given
relative value to the entire hand. The entire hand is part of the upper extremity and the upper extremity is part of the WPI.
When conducting an evaluation the Guides require that the physician first determine the impairment value for the level or
“unit” being evaluated before combining it with the next larger body unit until the correct WPI (digit>hand>upper
extremity>WPI) is determined.
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Chapter 16 of the Guides provides separate tables for the physician to make these conversions. For instance, in Table 16-1
(conversion chart for digits to hand impairment) each digit is given a separate value in the hand. So if an injured employee
had complete loss or loss of use of the thumb it is a 100 percent digit impairment but according to the conversion chart, it
is a 40 percent hand impairment.
A physician continues to use the conversion charts until a whole person impairment rating is determined. An upperextremity impairment rating can never exceed 100 percent of the value of the upper extremity or the maximum relative
value of 60 percent WPI.
The Lower Extremities
Chapter 17 of the Guides covers impairment of the feet, ankles, legs, knees, hips and pelvis. The Guides utilize a
multifaceted approach for lower-extremity disorders by dividing the assessment into three categories:
•
Anatomic (Ankylosis, Limb Length Discrepancy, Arthritis, Amputation, Muscle Atrophy, etc)
•
Function (Range-of-Motion, Muscle Strength, and Gait Derangement)
• Diagnosis based (Fractures, Deformities, and Various Surgical Procedures)
The assessment types, methods and the Guide section numbers where an explanation of the method may be found are
detailed in Table 17-1. The ability to choose among several evaluation methods allows the physician to customize the
assessment for each injured employee. The physician must select the method that is the most specific and is best at
describing the impairment rating. It is imperative that the physician explain why a particular evaluation method was
chosen over another in the body of their report.
At Figure 17-10 of the Guides there is evaluation record and worksheet for the lower extremities for the
physician to use to ensure a systematic examination and record of results. Most of the tables in the lower
extremity section show the impairment ratings of the whole person, the lower extremity, and the specific
lower extremity part. As a result, there is no need for conversion tables like those used with upper
extremity evaluations. Loss or loss of use of a lower extremity is 100 percent of the lower extremity impairment rating
equates to a 40 percent WPI.
†
General Evaluation Principles for Lower Extremities
Upon MMI, determine the diagnosis. Identify each lower extremity anatomic region (thigh, knee, calf, etc.) with
abnormalities that are related to the industrial injury or illness in question. List all the potential methods appropriate for
conducting an impairment rating of that region.
•
Anatomic method includes measurements to assess anatomic changes such as ankylosis, limb-length
discrepancy, arthritis, amputation and muscle atrophy.
•
Diagnosis-based estimates are for conditions with well-defined diagnostic criteria such as fractures,
deformities, and various surgical procedures.
•
Function assessment (ROM, muscle strength, gait derangement) is for those conditions where anatomic
changes are difficult to categorize. Functional impairment is assessed last.
The physician should calculate impairment according to the text and tables for each applicable method.
Identify and calculate impairment related to peripheral nervous system, vascular system or Complex Regional Pain
Syndromes (CCRPS-- for example, Reflex Sympathetic Dystrophy or Causalgia). If no other method is available, the
physician should determine impairment due to gait derangement, if clinically applicable.
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The physician should consult the lower-extremity cross-usage Table 17-2 to determine possible method groupings. Only
certain methods may be combined to avoid duplication for the same impairment. If both lower extremities are involved,
the physician must rate each one separately and convert these regional impairments to a WPI rating using the Combined
Values Chart (page 604 of the Guides).
Lower-Extremity Assessment Methods
Anatomic
Limb Length Discrepancy (LLD)
While x-rays may be the most accurate way to measure an LLD, the most common measurement method by way of
physical examination is as follows: Place the individual supine; measure the distance between the anterior superior iliac
spine and the medical malleolus on the involved side; compare that measurement with the opposite side. If the physician
believes a more precise measurement is necessary, he or she may do a teleroentgenography study to measure the length of
the bones.
Muscle Atrophy (Unilateral)
The physician can estimate diminished muscle function using four different methods:
•
Atrophy
•
Gait Derangement
•
Muscle Weakness
• Peripheral Nerve Injury
Atrophy ratings should not be combined with ratings from the other three methods. The physician is to use only that
method which most accurately and objectively describes the impairment. Leg circumference should be measured at the
maximum level bilaterally.
Joint Ankylosis
An immobile joint is an impairment even when the position of ankylosis is optimal. Any variation from the optimal
position of an ankylosed joint increases the baseline impairment percent. The physician should use baseline rating for
ankylosis in the neutral position only once per joint.
The physician should add multiple malposition deformities of the same joint (for example, angulations and mal rotation).
However, he or she should combine deformities of different joints, using the Combined Values chart on page 604 of the
Guides. Added or combined impairment ratings can never exceed 100 percent of the lower extremity value nor the
maximum relative value of 40 percent WPI.
Arthritis
Osteoarthritis is characterized by the deterioration of cartilage in the joints resulting in pain and loss of function. The
condition primarily affects weight-bearing joints, such as the knees, hips, feet, and back. Aging is a risk factor of
osteoarthritis. Other major risk factors are trauma (i.e. ligament damage and fracture) and repetitive over use from
occupational, recreational, and/or athletic activities. The standard method for diagnosing osteoarthritis is using
roentgenography.
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In x-rays the cartilage appears as a black space between the bones. In injured employees with osteoarthritis this space is
noticeably diminished. Bone spurs also identify the arthritic condition and these, too, are visible on x-rays. The prime
indicator of an arthritic disease stage and the impairment for a person due to the arthritis is the cartilage interval or joint
space.
Amputations
Refer to Table 17-32 of the Guides for the impairment estimates of amputations.
Skin Loss
Even when appropriate types of skin grafts successfully cover full-thickness skin loss within certain areas of the lower
extremities, there is still significant impairment according to the Guides. This method also evaluates chronic osteomyelitis .
The physician should consult Table 17-37 of the Guides to determine impairment for skin loss.
Peripheral Nerve Injury
Peripheral neuropathy describes damage to the peripheral nerves. The cause may be mechanical pressure due to
compression or entrapment, direct trauma, penetrating injuries, contusions, fracture, or dislocated bones. Although the
causes of peripheral neuropathy are diverse, they produce common symptoms that include weakness, numbness,
paresthesia, and pain. Recovery from peripheral neuropathy is usually slow. Depending on the type of peripheral
neuropathy, the injured employee may fully recover without residual effects or may partially recover and have sensory,
motor, and vasomotor deficits. If severely affected, the injured employee may develop chronic muscular atrophy. The
Guides divide peripheral nerve injuries into two components:
•
Motor Deficits
• Sensory Deficits
To determine impairment due to motor deficits, the physician should consult Section 17.21 and Table 17-37 of the Guides.
Sensory deficits are subjective in nature so the physician must evaluate them carefully.
The physician may combine estimates for peripheral nerve impairment with those for other types of lower-extremity
impairment, with the exception of muscle weakness, atrophy, and gait derangement.
Causalgia and Complex Regional Pain Syndrome (CRPS)
Complex Regional Pain Syndrome (CRPS) is a nerve disorder that occurs at the site of an injury (most often to the arms or
legs). It occurs especially after injuries from high velocity impacts, such as those from bullets or shrapnel. It may also occur
after a sprain, fracture, or nerve or vascular injury.
One visible sign of CRPS near the injury site is warm, shiny red skin that later becomes cool and blushed. The pain that
the injured employee may report is out of proportion to the severity of the injury and gets worse, rather than better, over
time. Eventually the joints become stiff from disuse and the skin, muscles, and bone atrophy. The symptoms of CRPS
vary in severity and duration. The actual cause of CRPS is unknown and the disorder is unique in that it simultaneously
affects the nerves, skin, muscles, blood vessels, and bones. When Causalgia or CRPS occurs in an extremity, the physician
should use the method described in Chapter 13, “The Central and Peripheral Nervous System” of the Guides to determine
impairment.
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Functional
Gait Derangement
Pathologic findings, such as x-rays, must support an impairment rating due to gait derangement. Gait derangement is
present in many lower extremity impairments and is always secondary to another condition. Whenever possible, the
physician should use a more specific method for evaluating lower extremity impairment.
Table 17-5 in the Guides is used to determine impairment due to gait derangement.
Except as otherwise noted, the impairment percentages in Table 17-5 are for full-time gait derangements of injured
employees who are dependent on assistive devices, such as canes, crutches, or ankle braces. (Note: An impairment rating
for an individual who is wheelchair-dependent is only 80 percent.)
Manual Muscle Testing
This method depends on patient cooperation and is subject to conscious and unconscious control. Even in a fully
cooperative individual, strength may vary from one examination to another but not by more than one grade. Observable
pathological signs and medical evidence should support results.
Range of Motion (ROM)
The physician can evaluate lower-extremity impairment by assessing the ROM of its joints. ROM restrictions in multiple
directions increases the impairment. The physician should add up the ROM impairment values for a single joint to
determine the total joint ROM impairments. Impairment values for each part of the lower extremity can be found in
Tables 17-9 through 17-14 of the Guides.
Diagnosis-Based Estimates (DBE)
In certain situations, impairment is better described on the basis of a diagnosis as opposed to findings from a physical
examination. A good example would be a successful hip replacement. The injured employee may function well but require
prophylactic ADL restrictions to prevent further impairment such as premature failure of the prosthesis. In those
instances, where both the diagnostic and examination approaches apply to a specific situation, the physician should
combine the impairment ratings from both approaches using the Combined Values Chart on page 604 of the Guides.
Multiple Impairments
Under the Guides, the physician is to calculate multiple impairments by using the prescribed combination method. The
Combined Values chart on page 604 of the Guides is designed to enable the physician to account for the effects of multiple
impairments through a combined value. The physician must determine the impairment of an individual extremity or body
part in a whole person impairment before combining it with the whole person impairment of other body parts. This
formula ensures that regardless of the number of impairments, the summary value does not exceed 100 percent of the
whole person. To combine any two values, the physician should locate the larger value on the left side of the chart and the
smaller value on the bottom of the chart. The intersection of that row and column contains the combined value of the
impairment.
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Chapter 7: Preventing
Fraud
Overview
Workers’ compensation fraud increases the cost of doing business and may result in the reduction of employee
salaries, lay off or the failure of a business. Fraud also increases healthcare costs which in turn effects the overall
cost of the workers’ compensation system for all Californians.
Pursuant to LC §3822, the Administrative Director of the Division of Workers’ Compensation (DWC) must send
an annual notice to every employer, claims adjuster, third- party administrator, physician, and attorney who
participates in the workers’ compensation system that warns against committing workers’ compensation fraud and
advises of the penalties for such fraud.
Workers compensation fraud can be committed by anyone in the system: injured employees, medical providers,
employers, claims adjusters, and attorneys. Punishment for workers’ compensation fraud may include
imprisonment in county jail for one year; or in a state prison for two, three, or five years; or by a fine not exceeding
$150,000 or double the value of the fraud, whichever is greater; or by both imprisonment and fine. In addition, if
someone is convicted of workers’ compensation fraud, the court is required to order payment or restitution,
including restitution for the costs of any medical evaluation or treatment services.
If any individual or organization approaches you and requests that you participate in any potentially fraudulent
activity; or if you would like to report an occurrence of workers’ compensation fraud, please call the Department of
Insurance Fraud Division hotline at (800) 927-4357. Alternatively, you may access the Fraud Division Web Site at:
www.insurance.ca.gov/FRD/Frd_main.htm.
For additional information, please refer to Insurance Code §§1871.4, 1871.5 and Penal Code §550.
Provider Fraud
The majority of medical care providers are honest and ethical professionals. Unfortunately, a small number of
providers try to cheat the system by committing fraud.
Medical provider fraud can include:
•
Billing for visits or services never received.
•
Employing runners, cappers, or steerers to solicit or obtain patients for the medical provider.
•
Billing the workers' compensation payer and the employee's group health insurance for the same services.
•
Performing medically unnecessary treatments, examinations, or diagnostic procedures in order to bill for
them.
•
Referring the injured employee for treatment to a separate facility in which the referring physician has an
undisclosed financial interest.
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•
Unbundling claims: billing separately for procedures normally covered by a single fee.
•
Double billing: charging more than once for the same service.
•
Upcoding: charging for a more complex service than the provider performed.
•
Miscoding: using a billing code that does not apply to the service or procedure.
•
Taking kickbacks: receiving payment or some other benefit for making a referral.
•
Dispensing generic drugs while billing for brand names.
•
Billing for durable medical equipment never dispensed, or selling used equipment as new.
Billing Fraud
Up-Coding
The treatment bill represents a procedure code for a more complicated procedure than actually performed.
Unbundling
The treatment bill reflects a breakdown of individual procedure codes that properly belong grouped into one code
at a lower price.
Prescription Drugs
Billing for expensive, brand name drugs when generic drugs were dispensed. Billing for a quantity or strength
greater than actually dispensed. Providing unnecessary x-rays, exams, and treatment to prolong the length of the
claim and attempt to make the injury appear to be more serious than it is.
Durable Medical Equipment
Billed as continued rental and subsequent purchase, or billed as a new purchase, when used equipment or no
equipment is actually prescribed.
Services Never Rendered
Patients sign in for more visits than actually occurred and/or the provider pads the bill with treatment modalities
not actually provided.
Treatment Fraud
Interviews and the review of suspected fraudulent behavior indicate that attorneys and service providers who were
previously involved in the operation of medical-legal mills have now diversified and specialized in treatment fraud.
While claims are low, reports indicate that treatment-claim frequency is up and the costs of medical treatment
continue to rise. Treatment fraud, on the basis of legitimate injuries, occurs in the offices of medical practitioners
or in medical-legal mills. Detecting and prosecuting medical providers who have no intention of helping their
patients is a very costly and is a serious crime that often requires many hours of undercover investigation to
discover and substantiate.
Although public opinion does not perceive workers’ compensation defrauders as dangerous criminals, the
awareness of treatment fraud might change the general public’s view. Unlike medical-legal fraud where most of the
patient’s claims are entirely fraudulent, the victim of treatment fraud is a legitimate patient truly in need of medical
care.
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Employing Individuals (Cappers or Steerers) to Solicit New Patients
Although a good number of the most flagrant medical-legal mills operating in California have been investigated and
prosecuted, there are still many mills operating. The nature of the workers’ compensation system combined with
minimal accountability demanded of service providers to allow documenting fraud and establishing potential
criminal responsibility make fraud exceptionally difficult to detect and prosecute. These mills repetitively defraud
insurers and policyholders by causing the filing of fraudulent claims. Corrupt medical or legal professionals usually
initiate these mills. The mills constitute a segment of insurance fraud known as "white collar crime". The scheme
involves the corrupt attorney employing people known as “cappers” to recruit both legitimate and fraudulent
accident victims who are the backbone of the mill operation. The attorney pays the cappers a flat fee up to several
thousands per client, depending on the referral. A capper might be a clinic employee, a legal administrator, an
emergency room attendant, or an emergency medical technician–anyone who has contact with injured or
potentially injured people.
Self-Interest Referrals
It is unlawful for a physician to refer a person to a facility where the physician or his or her immediate family has a
financial interest with the person or in the entity that receives the referral. Self interest can include referrals for
clinical laboratory, diagnostic nuclear medicine, radiation oncology, physical therapy, physical rehabilitation,
psychometric testing, home infusion therapy, outpatient surgery, or diagnostic imaging goods or services whether
for treatment or medical-legal purposes.
According to Labor Code 139.3 (4): financial interest includes, but is not limited to, any type of ownership, interest,
debt, loan, lease, compensation, remuneration, discount, rebate, refund, dividend, distribution, subsidy, or other
form of direct or indirect payment, whether in money or otherwise, between a licensee and a person or entity to
whom the physician refers a person for a good or service. A financial interest also exists if there is an indirect
relationship between a physician and the referral recipient, including, but not limited to, an arrangement whereby a
physician has an ownership interest in any entity that leases property to the referral recipient. Any financial interest
transferred by a physician to, or otherwise established in, any person or entity for the purpose of avoiding the
prohibition of LC§139.3 shall be deemed a financial interest of the physician.
Additionally, LC§§139.3(c) (1), (2), (d), (e), (f), (g) sited below further illustrate what is legally regarded as a selfinterest referral and disclose the consequences for violation of this section.
(c) (1) It is unlawful for a licensee to enter into an arrangement or scheme, such as a cross-referral
arrangement, that the licensee knows, or should know, has a principal purpose of ensuring referrals by the
licensee to a particular entity that, if the licensee directly made referrals to that entity, would be in violation
of this section.
(2) It shall be unlawful for a physician to offer, deliver, receive, or accept any rebate, refund, commission,
preference, patronage dividend, discount, or other consideration, whether in the form of money or otherwise, as
compensation or inducement for a referred evaluation or consultation.
(d) No claim for payment shall be presented by an entity to any individual, third-party payer, or other entity
for any goods or services furnished pursuant to a referral prohibited under this section.
(e) A physician who refers to or seeks consultation from an organization in which the physician has a financial
interest shall disclose this interest to the patient, or if the patient is a minor, to the patient's parents or legal
guardian in writing at the time of the referral.
(f) No insurer, self-insurer, or other payer shall pay a charge or lien for any goods or services resulting from a
referral in violation of this section.
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(g) A violation of labor code 139.9 (a) shall be a misdemeanor. The appropriate licensing board shall review
the facts and circumstances of any conviction pursuant to subdivision (a) and take appropriate disciplinary
action if the licensee has committed unprofessional conduct. Violations of this section may also be subject
to civil penalties of up to five thousand dollars ($5,000) for each offense, which may be enforced by the
Insurance Commissioner, Attorney General, or a district attorney. A violation of labor code 139.9
subdivision (c), (d), (e), or (f) is a public offense and is punishable upon conviction by a fine not exceeding
fifteen thousand dollars ($15,000) for each violation and appropriate disciplinary action, including
revocation of professional licensure, by the Medical Board of California or other appropriate governmental
agency.
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Appendix A: Sample Forms
Doctor’s First Report of Occupational Injury or
Illness (DLSR Form 5021)
http://www.dir.ca.gov/dlsr/dlsrform5021.pdf
Primary Treating Physician’s Progress Report
(DWC Form PR-2)
http://www.dir.ca.gov/dwc/PR-2.pdf
Primary Treating Physician’s Permanent and Stationary
Report (DWC Form PR-3)
http://www.dir.ca.gov/dwc/PR-3.pdf
Primary Treating Physician’s Permanent and Stationary Report
(DWC Form PR-4)
http://www.dir.ca.gov/dwc/PR-4.pdf
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Appendix B: Relevant
Labor Code Sections
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Workers’ Compensation Laws of California
A. Selected Sections of the California Labor Code
(Link to Labor Code)
§139.47. Program established to educate employers about early and sustained return to work after employee’s
industrial injury or illness.
The Director of Industrial Relations shall establish and maintain a program to encourage, facilitate, and educate
employers to provide early and sustained return to work after occupational injury or illness. The program shall do both of
the following:
(a) Develop educational materials and guides, in easily understandable language in both print and electronic form, for
employers, health care providers, employees, and labor unions. These materials shall address issues including, but not
limited to, early return to work, assessment of functional abilities and limitations, development of appropriate work
restrictions, job analysis, worksite modifications, assistive equipment and devices, and available resources.
(b) Conduct training for employee and employer organizations and health care providers concerning the accommodation
of injured employees and the prevention of reinjury.
§139.48. [Repealed January 1, 2009] Return-to-Work Program; reimbursement; restrictions on return to work of
injured employee; regulatory authority; fund.
(a)(1) The administrative director shall establish the Return-to-Work Program in order to promote the early and
sustained return to work of the employee following a work-related injury or illness.
(2) This section shall be implemented to the extent funds are available.
(b) Upon submission by eligible employers of documentation in accordance with regulations adopted pursuant to
subdivision (h), the administrative director shall pay the workplace modification expense reimbursement allowed under
this section.
(c) The administrative director shall reimburse an eligible employer for expenses incurred to make workplace
modifications to accommodate the employee's return to modified or alternative work, as follows:
(1) The maximum reimbursement to an eligible employer for expenses to accommodate each temporarily disabled
injured worker is one thousand two hundred fifty dollars ($1,250).
(2) The maximum reimbursement to an eligible employer for expenses to accommodate each permanently disabled
worker who is a qualified injured worker is two thousand five hundred dollars ($2,500). If the employer received
reimbursement under paragraph (1), the amount of the reimbursement under paragraph (1) and this paragraph shall not
exceed two thousand five hundred dollars ($2,500).
(3) The modification expenses shall be incurred in order to allow a temporarily disabled worker to perform modified or
alternative work within physician-imposed temporary work restrictions, or to allow a permanently disabled worker who is
an injured worker to return to sustained modified or alternative employment with the employer within physician-imposed
permanent work restrictions.
(4) Allowable expenses may include physical modifications to the worksite, equipment, devices, furniture, tools, or other
necessary costs for accommodation of the employee's restrictions.
(d) This section shall not create a preference in employment for injured employees over noninjured employees. It shall
be unlawful for an employer to discriminatorily terminate, lay off, demote, or otherwise displace an employee in order to
return an industrially injured employee to employment for the purpose of obtaining the reimbursement set forth in
subdivision (c).
(e) For purposes of this section, the following definitions apply:
(1) "Eligible employer" means any employer, except the state or an employer eligible to secure the payment of
compensation pursuant to subdivision (c) of Section 3700, who employs 50 or fewer full-time employees on the date of
injury.
(2) "Employee" means a worker who has suffered a work-related injury or illness on or after July 1, 2004.
(f) The administrative director shall adopt regulations to carry out this section. Regulations allocating budget funds that
are insufficient to implement the workplace modification expense reimbursement provided for in this section shall include
a prioritization schema.
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(g) The Workers' Compensation Return-to-Work Fund is hereby created as a special fund in the State Treasury. The
fund shall consist of all penalties collected pursuant to Section 5814.6 and transfers made by the administrative director
from the Workers’ Compensation Administration Revolving Fund established pursuant to Section 62.5. The fund shall be
administered by the administrative director. Moneys in the fund may be expended by the administrative director, upon
appropriation by the Legislature, only for purposes of implementing this section.
(h) This section shall be operative on July 1, 2004.
(i) This section shall remain in effect only until January 1,2009, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2009, deletes or extends that date.
§139.49. [Repealed January 1, 2009] Study of Return-to-Work Program; report.
(a) The administrative director shall contract with an independent research organization to conduct a study and issue a
report on the Return-to-Work Program established in Section 139.48.The study shall examine at least two years' operation
of the program and shall address all of the following:
(1) The effectiveness of the wage reimbursement, workplace modification expense reimbursement, and premium
reimbursement components of the program.
(2) The rate of participation by insured and self-insured employers, including information on the size and industry of
employers.
(3) Comparison of rates of utilization of modified and alternative work before and after establishment of the program
and evaluation of whether there is an increase in sustained return to work.
(4) The impact of the program on injured employees.
(5) The cost-effectiveness of the program.
(6) Identification of potential future funding mechanisms for the program.
(b) On or before January 1, 2008, the administrative director shall make the report available to the public and the
Legislature.
(c) This section shall remain in effect only until January 1,2009, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2009, deletes or extends that date.
§3209.3. “Physician”; ‘psychologist”; “acupuncturist”; request for medical collaboration; acupuncturist
unauthorized to determine disability.
(a) "Physician" includes physicians and surgeons holding an M.D. or D.O. degree, psychologists, acupuncturists,
optometrists, dentists, podiatrists, and chiropractic practitioners licensed by California state law and within the scope of
their practice as defined by California state law.
(b) "Psychologist" means a licensed psychologist with a doctoral degree in psychology, or a doctoral degree deemed
equivalent for licensure by the Board of Psychology pursuant to Section 2914 of the Business and Professions Code, and
who either has at least two years of clinical experience in a recognized health setting or has met the standards of the
National Register of the Health Service Providers in Psychology.
(c) When treatment or evaluation for an injury is provided by a psychologist, provision shall be made for appropriate
medical collaboration when requested by the employer or the insurer.
(d) "Acupuncturist" means a person who holds an acupuncturist's certificate issued pursuant to Chapter 12 (commencing
with Section 4925) of Division 2 of the Business and Professions Code.
(e) Nothing in this section shall be construed to authorize acupuncturists to determine disability for the purposes of
Article 3 (commencing with Section 4650) of Chapter 2 of Part 2, or under Section 2708 of the Unemployment Insurance
Code.
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§3209.10. Physician assistant or nurse practitioner may provide treatment for work-related injury under
supervision; supervising physician deemed treating physician.
(a) Medical treatment of a work-related injury required to cure or relieve the effects of the injury may be provided by a
state licensed physician assistant or nurse practitioner, acting under the review or supervision of a physician and surgeon
pursuant to standardized procedures or protocols within their lawfully authorized scope of practice. The reviewing or
supervising physician and surgeon of the physician assistant or nurse practitioner shall be deemed to be the treating
physician. For the purposes of this section, "medical treatment" includes the authority of the nurse practitioner or
physician assistant to authorize the patient to receive time off from work for a period not to exceed three calendar days if
that authority is included in a standardized procedure or protocol approved by the supervising physician. The nurse
practitioner or physician assistant may cosign the Doctor's First Report of Occupational Injury or Illness. The treating
physician shall make any determination of temporary disability and shall sign the report.
(b) The provision of subdivision (a) that requires the cosignature of the treating physician applies to this section only and
it is not the intent of the Legislature that the requirement apply to any other section of law or to any other statute or
regulation. Nothing in this section implies that a nurse practitioner or physician assistant is a physician as defined in
Section 3209.3.
§4061.5. Treating physician to render opinions on medical issues needed to determine eligibility for compensation.
The treating physician primarily responsible for managing the care of the injured worker or the physician designated by
that treating physician shall, in accordance with rules promulgated by the administrative director, render opinions on all
medical issues necessary to determine eligibility for compensation. In the event that there is more than one treating
physician, a single report shall be prepared by the physician primarily responsible for managing the injured worker's care
that incorporates the findings of the various treating physicians.
§4604.5. Medical treatment utilization schedule—Guidelines to reflect accepted practices and current standard of
care; rebuttable presumption on issue of extent and scope of medical treatment; inapplicability of section.
(a) Upon adoption by the administrative director of a medical treatment utilization schedule pursuant to Section 5307.27,
the recommended guidelines set forth in the schedule shall be presumptively correct on the issue of extent and scope of
medical treatment. The presumption is rebuttable and may be controverted by a preponderance of the scientific medical
evidence establishing that a variance from the guidelines is reasonably required to cure or relieve the injured worker from
the effects of his or her injury. The presumption created is one affecting the burden of proof.
(b) The recommended guidelines set forth in the schedule adopted pursuant to subdivision (a) shall reflect practices that
are evidence and scientifically based, nationally recognized, and peer-reviewed. The guidelines shall be designed to assist
providers by offering an analytical framework for the evaluation and treatment of injured workers, and shall constitute
care in accordance with Section 4600 for all injured workers diagnosed with industrial conditions.
(c) Three months after the publication date of the updated American College of Occupational and Environmental
Medicine's Occupational Medicine Practice Guidelines, and continuing until the effective date of a medical treatment
utilization schedule, pursuant to Section 5307.27, the recommended guidelines set forth in the American College of
Occupational and Environmental Medicine’s Occupational Medicine Practice Guidelines shall be presumptively correct on
the issue of extent and scope of medical treatment, regardless of date of injury. The presumption is rebuttable and may be
controverted by a preponderance of the evidence establishing that a variance from the guidelines is reasonably required to
cure and relieve the employee from the effects of his or her injury, in accordance with Section 4600. The presumption
created is one affecting the burden of proof.
(d)(1) Notwithstanding the medical treatment utilization schedule or the guidelines set forth in the American College of
Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines, for injuries occurring on and
after January 1, 2004, an employee shall be entitled to no more than 24 chiropractic, 24 occupational therapy, and 24
physical therapy visits per industrial injury.
(2) This subdivision shall not apply when an employer authorizes, in writing, additional visits to a health care
practitioner for physical medicine services.
(e) For all injuries not covered by the American College of Occupational and Environmental Medicine's Occupational
Medicine
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Practice Guidelines or official utilization schedule after adoption pursuant to Section 5307.27, authorized treatment shall
be in accordance with other evidence based medical treatment guidelines generally recognized by the national medical
community and that are scientifically based.
§4610. Utilization review process to be established; administrative penalties for failure to meet certain
requirements.
(a) For purposes of this section, "utilization review" means utilization review or utilization management functions that
prospectively, retrospectively, or concurrently review and approve, modify, delay, or deny, based in whole or in part on
medical necessity to cure and relieve, treatment recommendations by physicians, as defined in Section 3209.3, prior to,
retrospectively, or concurrent with the provision of medical treatment services pursuant to Section 4600.
(b) Every employer shall establish a utilization review process in compliance with this section, either directly or through
its insurer or an entity with which an employer or insurer contracts for these services.
(c) Each utilization review process shall be governed by written policies and procedures. These policies and procedures
shall ensure that decisions based on the medical necessity to cure and relieve of proposed medical treatment services are
consistent with the schedule for medical treatment utilization adopted pursuant to Section 5307.27. Prior to adoption of
the schedule, these policies and procedures shall be consistent with the recommended standards set forth in the American
College of Occupational and Environmental Medicine Occupational Medical Practice Guidelines. These policies and
procedures, and a description of the utilization process, shall be filed with the administrative director and shall be
disclosed by the employer to employees, physicians, and the public upon request.
(d) If an employer, insurer, or other entity subject to this section requests medical information from a physician in order
to determine whether to approve, modify, delay, or deny requests for authorization, the employer shall request only the
information reasonably necessary to make the determination. The employer, insurer, or other entity shall employ or
designate a medical director who holds an unrestricted license to practice medicine in this state issued pursuant to Section
2050 or Section 2450 of the Business and Professions Code. The medical director shall ensure that the process by which
the employer or other entity reviews and approves, modifies, delays, or denies requests by physicians prior to,
retrospectively, or concurrent with the provision of medical treatment services, complies with the requirements of this
section. Nothing in this section shall be construed as restricting the existing authority of the Medical Board of California.
(e) No person other than a licensed physician who is competent to evaluate the specific clinical issues involved in the
medical treatment services, and where these services are within the scope of the physician's practice, requested by the
physician may modify, delay, or deny requests for authorization of medical treatment for reasons of medical necessity to
cure and relieve.
(f) The criteria or guidelines used in the utilization review process to determine whether to approve, modify, delay, or
deny medical treatment services shall be all of the following:
(1) Developed with involvement from actively practicing physicians.
(2) Consistent with the schedule for medical treatment utilization adopted pursuant to Section 5307.27. Prior to adoption
of the schedule, these policies and procedures shall be consistent with the recommended standards set forth in the
American College of Occupational and Environmental Medicine Occupational Medical Practice Guidelines.
(3) Evaluated at least annually, and updated if necessary.
(4) Disclosed to the physician and the employee, if used as the basis of a decision to modify, delay, or deny services in a
specified case under review.
(5) Available to the public upon request. An employer shall only be required to disclose the criteria or guidelines for the
specific procedures or conditions requested. An employer may charge members of the public reasonable copying and
postage expenses related to disclosing criteria or guidelines pursuant to this paragraph. Criteria or guidelines may also be
made available through electronic means. No charge shall be required for an employee whose physician's request for
medical treatment services is under review.
(g) In determining whether to approve, modify, delay, or deny requests by physicians prior to, retrospectively, or
concurrent with the provisions of medical treatment services to employees all of the following requirements must be met:
(1) Prospective or concurrent decisions shall be made in a timely fashion that is appropriate for the nature of the
employee's condition, not to exceed five working days from the receipt of the information reasonably necessary to make
the determination, but in no event more than 14 days from the date of the medical treatment recommendation by the
physician. In cases where the review is retrospective, the decision shall be communicated to the individual who received
services, or to the individual's designee, within 30 days of receipt of information that is reasonably necessary to make this
determination.
(2) When the employee's condition is such that the employee faces an imminent and serious threat to his or her health,
including, but not limited to, the potential loss of life, limb, or other major bodily function, or the normal timeframe for the
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decision making process, as described in paragraph (1), would be detrimental to the employee's life or health or could
jeopardize the employee's ability to regain maximum function, decisions to approve, modify, delay, or deny requests by
physicians prior to, or concurrent with, the provision of medical treatment services to employees shall be made in a timely
fashion that is appropriate for the nature of the employee's condition, but not to exceed 72 hours after the receipt of the
information reasonably necessary to make the determination.
(3)(A) Decisions to approve, modify, delay, or deny requests by physicians for authorization prior to, or concurrent with,
the provision of medical treatment services to employees shall be communicated to the requesting physician within 24
hours of the decision. Decisions resulting in modification, delay, or denial of all or part of the requested health care
service shall be communicated to physicians initially by telephone or facsimile, and to the physician and employee in
writing within 24 hours for concurrent review, or within two business days of the decision for prospective review, as
prescribed by the administrative director. If the request is not approved in full, disputes shall be resolved in accordance
with Section 4062. If a request to perform spinal surgery is denied, disputes shall be resolved in accordance with
subdivision (b) of Section 4062.
(B) In the case of concurrent review, medical care shall not be discontinued until the employee's physician has been
notified of the decision and a care plan has been agreed upon by the physician that is appropriate for the medical needs of
the employee. Medical care provided during a concurrent review shall be care that is medically necessary to cure and
relieve, and an insurer or self-insured employer shall only be liable for those services determined medically necessary to
cure and relieve. If the insurer or self-insured employer disputes whether or not one or more services offered concurrently
with a utilization review were medically necessary to cure and relieve, the dispute shall be resolved pursuant to Section
4062, except in cases involving recommendations for the performance of spinal surgery, which shall be governed by the
provisions of subdivision (b) of Section 4062. Any compromise between the parties that an insurer or self-insured
employer believes may result in payment for services that were not medically necessary to cure and relieve shall be
reported by the insurer or the self-insured employer to the licensing board of the provider or providers who received the
payments, in a manner set forth by the respective board and in such a way as to minimize reporting costs both to the board
and to the insurer or self-insured employer, for evaluation as to possible violations of the statutes governing appropriate
professional practices. No fees shall be levied upon insurers or self-insured employers making reports required by this
section.
(4) Communications regarding decisions to approve requests by physicians shall specify the specific medical treatment
service approved. Responses regarding decisions to modify, delay, or deny medical treatment services requested by
physicians shall include a clear and concise explanation of the reasons for the employer's decision, a description of the
criteria or guidelines used, and the clinical reasons for the decisions regarding medical necessity.
(5) If the employer, insurer, or other entity cannot make a decision within the timeframes specified in paragraph (1) or
(2) because the employer or other entity is not in receipt of all of the information reasonably necessary and requested,
because the employer requires consultation by an expert reviewer, or because the employer has asked that an additional
examination or test be performed upon the employee that is reasonable and consistent with good medical practice, the
employer shall immediately notify the physician and the employee, in writing, that the employer cannot make a decision
within the required timeframe, and specify the information requested but not received, the expert reviewer to be consulted,
or the additional examinations or tests required. The employer shall also notify the physician and employee of the
anticipated date on which a decision may be rendered. Upon receipt of all information reasonably necessary and requested
by the employer, the employer shall approve, modify, or deny the request for authorization within the timeframes specified
in paragraph (1) or (2).
(h) Every employer, insurer, or other entity subject to this section shall maintain telephone access for physicians to
request authorization for health care services.
(i) If the administrative director determines that the employer, insurer, or other entity subject to this section has failed to
meet any of the timeframes in this section, or has failed to meet any other requirement of this section, the administrative
director may assess, by order, administrative penalties for each failure. A proceeding for the issuance of an order
assessing administrative penalties shall be subject to appropriate notice to, and an opportunity for a hearing with regard to,
the person affected. The administrative penalties shall not be deemed to be an exclusive remedy for the administrative
director. These penalties shall be deposited in the Workers' Compensation Administration Revolving Fund.
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§4616.3. Initial medical evaluation; notice of right to be treated by physician of employee’s choice; second and third
opinions; specialists.
(a) When the injured employee notifies the employer of the injury or files a claim for workers' compensation with the
employer, the employer shall arrange an initial medical evaluation and begin treatment as required by Section 4600.
(b) The employer shall notify the employee of his or her right to be treated by a physician of his or her choice after the
first visit from the medical provider network established pursuant to this article, and the method by which the list of
participating providers may be accessed by the employee.
(c) If an injured employee disputes either the diagnosis or the treatment prescribed by the treating physician, the
employee may seek the opinion of another physician in the medical provider network. If the injured employee disputes the
diagnosis or treatment prescribed by the second physician, the employee may seek the opinion of a third physician in the
medical provider network.
(d) (1) Selection by the injured employee of a treating physician and any subsequent physicians shall be based on the
physician's specialty or recognized expertise in treating the particular injury or condition in question.
(2) Treatment by a specialist who is not a member of the medical provider network may be permitted on a case-by-case
basis if the medical provider network does not contain a physician who can provide the approved treatment and the
treatment is approved by the employer or the insurer.
§4658.1. Meaning of “regular work”, ”modified work”, and “alternate work”; equivalent wages and compensation;
location.
As used in this article, the following definitions apply:
(a) "Regular work" means the employee's usual occupation or the position in which the employee was engaged at the
time of injury and that offers wages and compensation equivalent to those paid to the employee at the time of injury, and
located within a reasonable commuting distance of the employee's residence at the time of injury. (b) "Modified work"
means regular work modified so that the employee has the ability to perform all the functions of the job and that offers
wages and compensation that are at least 85 percent of those paid to the employee at the time of injury, and located within
a reasonable commuting distance of the employee's residence at the time of injury.
(c) "Alternative work" means work that the employee has the ability to perform, that offers wages and compensation that
are at least 85 percent of those paid to the employee at the time of injury, and that is located within reasonable commuting
distance of the employee's residence at the time of injury.
(d) For the purpose of determining whether wages and compensation are equivalent to those paid at the time of injury,
the wages and compensation for any increase in working hours over the average hours worked at the time of injury shall
not be considered.
(e) For the purpose of determining whether wages and compensation are equivalent to those paid at the time of injury,
actual wages and compensation shall be determined without regard to the minimums and maximums set forth in Chapter 1
(commencing with Section 4451).
(f) The condition that regular work, modified work, or alternative work be located within a reasonable distance of the
employee's residence at the time of injury may be waived by the employee. The condition shall be deemed to be waived if
the employee accepts the regular work, modified work, or alternative work and does not object to the location within 20
days of being informed of the right to object. The condition shall be conclusively deemed to be satisfied if the offered
work is at the same location and the same shift as the employment at the time of injury.
§4658.5. Supplemental job displacement benefits—Eligibility; voucher; notice of employee’s rights; applicability.
(a) Except as provided in Section 4658.6, if the injury causes permanent partial disability and the injured employee does
not return to work for the employer within 60 days of the termination of temporary disability, the injured employee shall
be eligible for a supplemental job displacement benefit in the form of a nontransferable voucher for education-related
retraining or skill enhancement, or both, at state-approved or accredited schools, as follows:
(1) Up to four thousand dollars ($4,000) for permanent partial disability awards of less than 15 percent.
(2) Up to six thousand dollars ($6,000) for permanent partial disability awards between 15 and 25 percent.
(3) Up to eight thousand dollars ($8,000) for permanent partial disability awards between 26 and 49 percent.
(4) Up to ten thousand dollars ($10,000) for permanent partial disability awards between 50 and 99 percent.
(b) The voucher may be used for payment of tuition, fees, books, and other expenses required by the school for
retraining or skill enhancement. No more than 10 percent of the voucher moneys may be used for vocational or return to
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work counseling. The administrative director shall adopt regulations governing the form of payment, direct reimbursement
to the injured employee upon presentation to the employer of appropriate documentation and receipts, and any other
matters necessary to the proper administration of the supplemental job displacement benefit.
(c) Within 10 days of the last payment of temporary disability, the employer shall provide to the employee, in the form
and manner prescribed by the administrative director, information that provides notice of rights under this section. This
notice shall be sent by certified mail.
(d) This section shall apply to injuries occurring on or after January 1, 2004.
§4663. Apportionment of permanent disability; causation as basis; physician’s report; apportionment
determination; disclosure by employee.
(a) Apportionment of permanent disability shall be based on causation.
(b) Any physician who prepares a report addressing the issue of permanent disability due to a claimed industrial injury
shall in that report address the issue of causation of the permanent disability.
(c) In order for a physician's report to be considered complete on the issue of permanent disability, the report must
include an apportionment determination. A physician shall make an apportionment determination by finding what
approximate percentage of the permanent disability was caused by the direct result of injury arising out of and occurring in
the course of employment and what approximate percentage of the permanent disability was caused by other factors both
before and subsequent to the industrial injury, including prior industrial injuries. If the physician is unable to include an
apportionment determination in his or her report, the physician shall state the specific reasons why the physician could not
make a determination of the effect of that prior condition on the permanent disability arising from the injury. The
physician shall then consult with other physicians or refer the employee to another physician from whom the employee is
authorized to seek treatment or evaluation in accordance with this division in order to make the final determination.
(d) An employee who claims an industrial injury shall, upon request, disclose all previous permanent disabilities or
physical impairments.
(e) Subdivisions (a), (b), and (c) shall not apply to injuries or illnesses covered under Sections 3212, 3212.1, 3212.2,
3212.3, 3212.4, 3212.5, 3212.6, 3212.7, 3212.8, 3212.85, 3212.9, 3212.10, 3212.11, 3212.12, 3213, and 3213.2.
§4664. Liability of employer for percentage of permanent disability directly caused by injury; conclusive
presumption from prior award of permanent disability; accumulation of permanent disability awards.
(a) The employer shall only be liable for the percentage of permanent disability directly caused by the injury arising out
of and occurring in the course of employment.
(b) If the applicant has received a prior award of permanent disability, it shall be conclusively presumed that the prior
permanent disability exists at the time of any subsequent industrial injury. This presumption is a presumption affecting the
burden of proof.
(c) (1) The accumulation of all permanent disability awards issued with respect to any one region of the body in favor of
one individual employee shall not exceed 100 percent over the employee's lifetime unless the employee's injury or illness
is conclusively presumed to be total in character pursuant to Section 4662. As used in this section, the regions of the body
are the following:
(A) Hearing.
(B) Vision.
(C) Mental and behavioral disorders.
(D) The spine.
(E) The upper extremities, including the shoulders.
(F) The lower extremities, including the hip joints.
(G) The head, face, cardiovascular system, respiratory system, and all other systems or regions of the body not listed in
subparagraphs (A) to (F), inclusive.
(2) Nothing in this section shall be construed to permit the permanent disability rating for each individual injury
sustained by an employee arising from the same industrial accident, when added together, from exceeding 100 percent.
§5307.1. Official medical fee schedule.
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(a) The administrative director, after public hearings, shall adopt and revise periodically an official medical fee schedule
that shall establish reasonable maximum fees paid for medical services other than physician services, drugs and pharmacy
services, health care facility fees, home health care, and all other treatment, care, services, and goods described in Section
4600 and provided pursuant to this section. Except for physician services, all fees shall be in accordance with the feerelated structure and rules of the relevant Medicare and Medi-Cal payment systems, provided that employer liability for
medical treatment, including issues of reasonableness, necessity, frequency, and duration, shall be determined in
accordance with Section 4600. Commencing January 1, 2004, and continuing until the time the administrative director has
adopted an official medical fee schedule in accordance with the fee-related structure and rules of the relevant Medicare
payment systems, except for the components listed in subdivision (j), maximum reasonable fees shall be 120 percent of the
estimated aggregate fees prescribed in the relevant Medicare payment system for the same class of services before
application of the inflation factors provided in subdivision (g), except that for pharmacy services and drugs that are not
otherwise covered by a Medicare fee schedule payment for facility services, the maximum reasonable fees shall be 100
percent of fees prescribed in the relevant Medi-Cal payment system. Upon adoption by the administrative director of an
official medical fee schedule pursuant to this section, the maximum reasonable fees paid shall not exceed 120 percent of
estimated aggregate fees prescribed in the Medicare payment system for the same class of services before application of
the inflation factors provided in subdivision (g). Pharmacy services and drugs shall be subject to the requirements of this
section, whether furnished through a pharmacy or dispensed directly by the practitioner pursuant to subdivision (b) of
Section 4024 of the Business and Professions Code.
(b) In order to comply with the standards specified in subdivision(f), the administrative director may adopt different
conversion factors, diagnostic related group weights, and other factors affecting payment amounts from those used in the
Medicare payment system, provided estimated aggregate fees do not exceed 120 percent of the estimated aggregate fees
paid for the same class of services in the relevant Medicare payment system.
(c) Notwithstanding subdivisions (a) and (d), the maximum facility fee for services performed in an ambulatory surgical
center, or in a hospital outpatient department, may not exceed 120 percent of the fee paid by Medicare for the same
services performed in a hospital outpatient department.
(d) If the administrative director determines that a medical treatment, facility use, product, or service is not covered by a
Medicare payment system, the administrative director shall establish maximum fees for that item, provided that the
maximum fee paid shall not exceed 120 percent of the fees paid by Medicare for services that require comparable
resources. If the administrative director determines that a pharmacy service or drug is not covered by a Medi-Cal payment
system, the administrative director shall establish maximum fees for that item. However, the maximum fee paid shall not
exceed 100 percent of the fees paid by Medi-Cal for pharmacy services or drugs that require comparable resources.
(e) Prior to the adoption by the administrative director of a medical fee schedule pursuant to this section, for any
treatment, facility use, product, or service not covered by a Medicare payment system, including acupuncture services, or,
with regard to pharmacy services and drugs, for a pharmacy service or drug that is not covered by a Medi-Cal payment
system, the maximum reasonable fee paid shall not exceed the fee specified in the official medical fee schedule in effect
on December 31, 2003.
(f) Within the limits provided by this section, the rates or fees established shall be adequate to ensure a reasonable
standard of services and care for injured employees.
(g) (1) (A) Notwithstanding any other provision of law, the official medical fee schedule shall be adjusted to conform to
any relevant changes in the Medicare and Medi-Cal payment systems no later than 60 days after the effective date of those
changes, provided that both of the following conditions are met:
(i) The annual inflation adjustment for facility fees for inpatient hospital services provided by acute care hospitals and
for hospital outpatient services shall be determined solely by the estimated increase in the hospital market basket for the 12
months beginning October 1 of the preceding calendar year.
(ii) The annual update in the operating standardized amount and capital standard rate for inpatient hospital services
provided by hospitals excluded from the Medicare prospective payment system for acute care hospitals and the conversion
factor for hospital outpatient services shall be determined solely by the estimated increase in the hospital market basket for
excluded hospitals for the 12 months beginning October 1 of the preceding calendar year.
(B) The update factors contained in clauses (i) and (ii) of subparagraph (A) shall be applied beginning with the first
update in the Medicare fee schedule payment amounts after December 31, 2003.
(2) The administrative director shall determine the effective date of the changes, and shall issue an order, exempt from
Sections5307.3 and 5307.4 and the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing
with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), informing the public of the changes and
their effective date. All orders issued pursuant to this paragraph shall be published on the Internet Web site of the Division
of Workers' Compensation.
(3) For the purposes of this subdivision, the following definitions apply:
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(A) "Medicare Economic Index" means the input price index used by the federal Centers for Medicare and Medicaid
Services to measure changes in the costs of a providing physician and other services paid under the resource-based relative
value scale.
(B) "Hospital market basket" means the input price index used by the federal Centers for Medicare and Medicaid
Services to measure changes in the costs of providing inpatient hospital services provided by acute care hospitals that are
included in the Medicare prospective payment system.
(C) "Hospital market basket for excluded hospitals" means the input price index used by the federal Centers for
Medicare and Medicaid Services to measure changes in the costs of providing inpatient services by hospitals that are
excluded from the Medicare prospective payment system.
(h) Nothing in this section shall prohibit an employer or insurer from contracting with a medical provider for
reimbursement rates different from those prescribed in the official medical fee schedule. (i) Except as provided in Section
4626, the official medical fee schedule shall not apply to medical-legal expenses, as that term is defined by Section 4620.
(j) The following Medicare payment system components may not become part of the official medical fee schedule until
January 1,2005:
(1) Inpatient skilled nursing facility care.
(2) Home health agency services.
(3) Inpatient services furnished by hospitals that are exempt from the prospective payment system for general acute care
hospitals.
(4) Outpatient renal dialysis services.
(k) Notwithstanding subdivision (a), for the calendar years 2004 and 2005, the existing official medical fee schedule
rates for physician services shall remain in effect, but these rates shall be reduced by 5 percent. The administrative director
may reduce fees of individual procedures by different amounts, but in no event shall the administrative director reduce the
fee for a procedure that is currently reimbursed at a rate at or below the Medicare rate for the same procedure.
(l) Notwithstanding subdivision (a), the administrative director, commencing January 1, 2006, shall have the authority,
after public hearings, to adopt and revise, no less frequently than biennially, an official medical fee schedule for physician
services. If the administrative director fails to adopt an official medical fee schedule for physician services by January 1,
2006, the existing official medical fee schedule rates for physician services shall remain in effect until a new schedule is
adopted or the existing schedule is revised.
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B. Selected Sections of the California Code of Regulations
(Link to Regulations)
§9785. Reporting Duties of the Primary Treating Physician.
(a) For the purposes of this section, the following definitions apply:
(1) The “primary treating physician” is the physician who is primarily responsible for managing the care of an employee,
and who has examined the employee at least once for the purpose of rendering or prescribing treatment and has monitored
the effect of the treatment thereafter. The primary treating physician is the physician selected by the employer, the
employee pursuant to Article 2 (commencing with section 4600) of Chapter 2 of Part 2 of Division 4 of the Labor Code, or
under the contract or procedures applicable to a Health Care Organization certified under section 4600.5 of the Labor
Code, or in accordance with the physician selection procedures contained in the medical provider network pursuant to
Labor Code section 4616.
(2) A “secondary physician” is any physician other than the primary treating physician who examines or provides
treatment to the employee, but is not primarily responsible for continuing management of the care of the employee.
(3) “Claims administrator” is a self-administered insurer providing security for the payment of compensation required by
Divisions 4 and 4.5 of the Labor Code, a self-administered self-insured employer, or a third-party administrator for a selfinsured employer, insurer, legally uninsured employer, or joint powers authority.
(4) “Medical determination” means, for the purpose of this section, a decision made by the primary treating physician
regarding any and all medical issues necessary to determine the employee's eligibility for compensation. Such issues
include but are not limited to the scope and extent of an employee's continuing medical treatment, the decision whether to
release the employee from care, the point in time at which the employee has reached permanent and stationary status, and
the necessity for future medical treatment.
(5) “Released from care” means a determination by the primary treating physician that the employee's condition has
reached a permanent and stationary status with no need for continuing or future medical treatment.
(6) “Continuing medical treatment” is occurring or presently planned treatment that is reasonably required to cure or
relieve the employee from the effects of the injury.
(7) “Future medical treatment” is treatment which is anticipated at some time in the future and is reasonably required to
cure or relieve the employee from the effects of the injury.
(8) “Permanent and stationary status” is the point when the employee has reached maximal medical improvement,
meaning his or her condition is well stabilized, and unlikely to change substantially in the next year with or without
medical treatment.
(b)(1) An employee shall have no more than one primary treating physician at a time.
(2) An employee may designate a new primary treating physician of his or her choice pursuant to Labor Code §§4600 or
4600.3 provided the primary treating physician has determined that there is a need for:
(A) continuing medical treatment; or
(B) future medical treatment. The employee may designate a new primary treating physician to render future medical
treatment either prior to or at the time such treatment becomes necessary.
(3) If the employee disputes a medical determination made by the primary treating physician, including a determination
that the employee should be released from care, or if the employee objects to a decision made pursuant to Labor Code
section 4610 to modify, delay, or deny a treatment recommendation, the dispute shall be resolved under the applicable
procedures set forth at Labor Code sections4061 and 4062. No other primary treating physician shall be designated by the
employee unless and until the dispute is resolved.
(4) If the claims administrator disputes a medical determination made by the primary treating physician, the dispute shall
be resolved under the applicable procedures set forth at Labor Code sections 4610, 4061 and 4062.
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(c) The primary treating physician, or a physician designated by the primary treating physician, shall make reports to the
claims administrator as required in this section. A primary treating physician has fulfilled his or her reporting duties under
this section by sending one copy of a required report to the claims administrator. A claims administrator may designate
any person or entity to be the recipient of its copy of the required report.
(d) The primary treating physician shall render opinions on all medical issues necessary to determine the employee's
eligibility for compensation in the manner prescribed in subdivisions (e), (f) and (g) of this section. The primary treating
physician may transmit reports to the claims administrator by mail or FAX or by any other means satisfactory to the
claims administrator, including electronic transmission.
(e)(1) Within 5 working days following initial examination, a primary treating physician shall submit a written report to
the claims administrator on the form entitled “Doctor's First Report of Occupational Injury or Illness,” Form DLSR 5021.
Emergency and urgent care physicians shall also submit a Form DLSR 5021 to the claims administrator following the
initial visit to the treatment facility. On line 24 of the Doctor's First Report, or on the reverse side of the form, the
physician shall (A) list methods, frequency, and duration of planned treatment(s), (B) specify planned consultations or
referrals, surgery or hospitalization and (C) specify the type, frequency and duration of planned physical medicine services
(e.g., physical therapy, manipulation, acupuncture).
(2) Each new primary treating physician shall submit a Form DLSR 5021 following the initial examination in accordance
with subdivision (e)(1).
(3) Secondary physicians, physical therapists, and other health care providers to whom the employee is referred shall
report to the primary treating physician in the manner required by the primary treating physician.
(4) The primary treating physician shall be responsible for obtaining all of the reports of secondary physicians and shall,
unless good cause is shown, within 20 days of receipt of each report incorporate, or comment upon, the findings and
opinions of the other physicians in the primary treating physician's report and submit all of the reports to the claims
administrator.
(f) A primary treating physician shall, unless good cause is shown, within 20 days report to the claims administrator when
any one or more of the following occurs:
(1) The employee's condition undergoes a previously unexpected significant change;
(2) There is any significant change in the treatment plan reported, including, but not limited to, (A) an extension of
duration or frequency of treatment, (B) a new need for hospitalization or surgery, (C) a new need for referral to or
consultation by another physician, (D) a change in methods of treatment or in required physical medicine services, or (E) a
need for rental or purchase of durable medical equipment or orthotic devices;
(3) The employee's condition permits return to modified or regular work;
(4) The employee's condition requires him or her to leave work, or requires changes in work restrictions or modifications;
(5) The employee is released from care;
(6) The primary treating physician concludes that the employee's permanent disability precludes, or is likely to preclude,
the employee from engaging in the employee's usual occupation or the occupation in which the employee was engaged at
the time of the injury, as required pursuant to Labor Code Section 4636(b);
(7) The claims administrator reasonably requests appropriate additional information that is necessary to administer the
claim. “Necessary” information is that which directly affects the provision of compensation benefits as defined in Labor
Code Section 3207.
(8) When continuing medical treatment is provided, a progress report shall be made no later than forty-five days from the
last report of any type under this section even if no event described in paragraphs (1) to (7) has occurred. If an examination
has occurred, the report shall be signed and transmitted within 20 days of the examination.
Except for a response to a request for information made pursuant to subdivision (f)(7), reports required under this
subdivision shall be submitted on the “Primary Treating Physician's Progress Report” form (Form PR-2) contained in
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Section 9785.2, or in the form of a narrative report. If a narrative report is used, it must be entitled “Primary Treating
Physician's Progress Report” in bold-faced type, must indicate clearly the reason the report is being submitted, and must
contain the same information using the same subject headings in the same order as Form PR-2. A response to a request for
information made pursuant to subdivision (f)(7) may be made in letter format. A narrative report and a letter format
response to a request for information must contain the same declaration under penalty of perjury that is set forth in the
Form PR-2: “I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I
have not violated Labor Code §139.3.”
By mutual agreement between the physician and the claims administrator, the physician may make reports in any manner
and form.
(g) When the primary treating physician determines that the employee's condition is permanent and stationary, the
physician shall, unless good cause is shown, report within 20 days from the date of examination any findings concerning
the existence and extent of permanent impairment and limitations and any need for continuing and/or future medical care
resulting from the injury. The information may be submitted on the “Primary Treating Physician's Permanent and
Stationary Report” form (DWC Form PR-3 or DWC Form PR-4) contained in section 9785.3 or section 9785.4, or in such
other manner which provides all the information required by Title 8, California Code of Regulations, section 10606. For
permanent disability evaluation performed pursuant to the permanent disability evaluation schedule adopted on or after
January 1, 2005, the primary treating physician's reports concerning the existence and extent of permanent impairment
shall describe the impairment in accordance with the AMA Guides to the Evaluation on Permanent Impairment, 5th
Edition (DWC Form PR-4). Qualified Medical Evaluators and Agreed Medical Evaluators may not use DWC Form PR-3
or DWC Form PR-4 to report medical-legal evaluations.
(h) Any controversies concerning this section shall be resolved pursuant to Labor Code Section 4603 or 4604, whichever
is appropriate.
(i) Claims administrators shall reimburse primary treating physicians for their reports submitted pursuant to this section as
required by the Official Medical Fee Schedule.
§9792.6. Utilization Review Standards.
As used in this Article:
(a) “ACOEM Practice Guidelines” means the American College of Occupational and Environmental Medicine's
Occupational Medicine Practice Guidelines, Second Edition.
(b) “Authorization” means assurance that appropriate reimbursement will be made for an approved specific course of
proposed medical treatment to cure or relieve the effects of the industrial injury pursuant to section 4600 of the Labor
Code, subject to the provisions of section 5402 of the Labor Code, based on the Doctor's First Report of Occupational
Injury or Illness,” Form DLSR 5021, or on the “Primary Treating Physician's Progress Report,” DWC Form PR-2, as
contained in section 9785.2, or in narrative form containing the same information required in the DWC Form PR-2.
(c) “Claims Administrator” is a self-administered workers' compensation insurer, an insured employer, a self-administered
self-insured employer, a self-administered legally uninsured employer, a self-administered joint powers authority, a thirdparty claims administrator or other entity subject to Labor Code section 4610. The claims administrator may utilize an
entity contracted to conduct its utilization review responsibilities.
(d) “Concurrent review” means utilization review conducted during an inpatient stay.
(e) “Course of treatment” means the course of medical treatment set forth in the treatment plan contained on the “Doctor's
First Report of Occupational Injury or Illness,” Form DLSR 5021, or on the “Primary Treating Physician's Progress
Report,” DWC Form PR-2, as contained in section 9785.2 or in narrative form containing the same information required in
the DWC Form PR-2.
(f) “Emergency health care services” means health care services for a medical condition manifesting itself by acute
symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to
place the patient's health in serious jeopardy.
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(g) “Expedited review” means utilization review conducted when the injured worker's condition is such that the injured
worker faces an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life,
limb, or other major bodily function, or the normal timeframe for the decision-making process would be detrimental to the
injured worker's life or health or could jeopardize the injured worker's permanent ability to regain maximum function.
(h) “Expert reviewer” means a medical doctor, doctor of osteopathy, psychologist, acupuncturist, optometrist, dentist,
podiatrist, or chiropractic practitioner licensed by any state or the District of Columbia, competent to evaluate the specific
clinical issues involved in the medical treatment services and where these services are within the individual's scope of
practice, who has been consulted by the reviewer or the utilization review medical director to provide specialized review
of medical information.
(i) “Health care provider” means a provider of medical services, as well as related services or goods, including but not
limited to an individual provider or facility, a health care service plan, a health care organization, a member of a preferred
provider organization or medical provider network as provided in Labor Code section 4616.
(j) “Immediately” means within 24 hours after learning the circumstances that would require an extension of the timeframe
for decisions specified in subdivisions (b)(1), (b)(2) or (c) and (g)(1) of section 9792.9.
(k) “Material modification” is when the claims administrator changes utilization review vendor or makes a change to the
utilization review standards as specified in section 9792.7.
(l) “Medical Director” is the physician and surgeon licensed by the Medical Board of California or the Osteopathic Board
of California who holds an unrestricted license to practice medicine in the State of California. The Medical Director is
responsible for all decisions made in the utilization review process.
(m) “Medical services” means those goods and services provided pursuant to Article 2 (commencing with Labor Code
section 4600) of Chapter 2 of Part 2 of Division 4 of the Labor Code.
(n) “Prospective review” means any utilization review conducted, except for utilization review conducted during an
inpatient stay, prior to the delivery of the requested medical services.
(o) “Request for authorization” means a written confirmation of an oral request for a specific course of proposed medical
treatment pursuant to Labor Code section 4610(h) or a written request for a specific course of proposed medical treatment.
An oral request for authorization must be followed by a written confirmation of the request within seventy-two (72) hours.
Both the written confirmation of an oral request and the written request must be set forth on the “Doctor's First Report of
Occupational Injury or Illness,” Form DLSR 5021, section 14006, or on the Primary Treating Physician Progress Report,
DWC Form PR-2, as contained in section 9785.2, or in narrative form containing the same information required in the PR2 form. If a narrative format is used, the document shall be clearly marked at the top that it is a request for authorization.
(p) “Retrospective review” means utilization review conducted after medical services have been provided and for which
approval has not already been given.
(q) “Reviewer” means a medical doctor, doctor of osteopathy, psychologist, acupuncturist, optometrist, dentist, podiatrist,
or chiropractic practitioner licensed by any state or the District of Columbia, competent to evaluate the specific clinical
issues involved in medical treatment services, where these services are within the scope of the reviewer's practice.
(r) “Utilization review plan” means the written plan filed with the Administrative Director pursuant to Labor Code section
4610, setting forth the policies and procedures, and a description of the utilization review process.
(s) “Utilization review process” means utilization management functions that prospectively, retrospectively, or
concurrently review and approve, modify, delay, or deny, based in whole or in part on medical necessity to cure or relieve,
treatment recommendations by physicians, as defined in Labor Code section 3209.3, prior to, retrospectively, or
concurrent with the provision of medical treatment services pursuant to Labor Code section 4600. Utilization review does
not include determinations of the work-relatedness of injury or disease, or bill review for the purpose of determining
whether the medical services were accurately billed.
(t) “Written” includes a facsimile as well as communications in paper form.
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§9792.7. Utilization Review Standards--Applicability
(a) Effective January 1, 2004, every claims administrator shall establish and maintain a utilization review process for
treatment rendered on or after January 1, 2004, regardless of date of injury, in compliance with Labor Code section 4610.
Each utilization review process shall be set forth in a utilization review plan which shall contain:
(1) The name, address, phone number, and medical license number of the employed or designated medical director, who
holds an unrestricted license to practice medicine in the state of California issued pursuant to section 2050 or section 2450
of the Business and Professions Code.
(2) A description of the process whereby requests for authorization are reviewed, and decisions on such requests are made,
and a description of the process for handling expedited reviews.
(3) A description of the specific criteria utilized routinely in the review and throughout the decision-making process,
including treatment protocols or standards used in the process. A description of the personnel and other sources used in the
development and review of the criteria, and methods for updating the criteria. Prior to and until the Administrative
Director adopts a medical treatment utilization schedule pursuant to Labor Code section 5307.27, the written policies and
procedures governing the utilization review process shall be consistent with the recommended standards set forth in the
American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines, Second
Edition. The Administrative Director incorporates by reference the American College of Occupational and Environmental
Medicine's Occupational Medicine Practice Guidelines (ACOEM), Second Edition (2004), published by OEM Press. A
copy may be obtained from OEM Press, 8 West Street, Beverly Farms, Massachusetts 01915 (www.oempress.com). After
the Administrative Director adopts a medical treatment utilization schedule pursuant to Labor Code section 5307.27, the
written policies and procedures governing the utilization review process shall be consistent with the recommended
standards set forth in that schedule.
(4) A description of the qualifications and functions of the personnel involved in decision-making and implementation of
the utilization review plan.
(5) A description of the claims administrator's practice, if applicable, of any prior authorization process, including but not
limited to, where authorization is provided without the submission of the request for authorization.
(b)(1) The medical director shall ensure that the process by which the claims administrator reviews and approves,
modifies, delays, or denies requests by physicians prior to, retrospectively, or concurrent with the provision of medical
services, complies with Labor Code section 4610 and these implementing regulations.
(2) A reviewer who is competent to evaluate the specific clinical issues involved in the medical treatment services, and
where these services are within the reviewer's scope of practice, may, except as indicated below, delay, modify or deny,
requests for authorization of medical treatment for reasons of medical necessity to cure or relieve the effects of the
industrial injury.
(3) A non-physician reviewer may be used to initially apply specified criteria to requests for authorization for medical
services. A non-physician reviewer may approve requests for authorization of medical services. A non-physician reviewer
may discuss applicable criteria with the requesting physician, should the treatment for which authorization is sought
appear to be inconsistent with the criteria. In such instances, the requesting physician may voluntarily withdraw a portion
or all of the treatment in question and submit an amended request for treatment authorization, and the non-physician
reviewer may approve the amended request for treatment authorization. Additionally, a non-physician reviewer may
reasonably request appropriate additional information that is necessary to render a decision but in no event shall this
exceed the time limitations imposed in section 9792.9 subdivisions (b)(1), (b)(2) or (c). Any time beyond the time
specified in these paragraphs is subject to the provisions of subdivision (g)(1)(A) through (g)(1)(C) of section 9792.9.
(c) The complete utilization review plan, consisting of the policies and procedures, and a description of the utilization
review process, shall be filed by the claims administrator, or by the external utilization review organization contracted by
the claims administrator to perform the utilization review, with the Administrative Director. In lieu of filing the utilization
review plan, the claims administrator may submit a letter identifying the external utilization review organization which has
been contracted to perform the utilization review functions, provided that the utilization review organization has filed a
complete utilization review plan with the Administrative Director. A modified utilization review plan shall be filed with
the Administrative Director within 30 calendar days after the claims administrator makes a material modification to the
plan.
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(d) Upon request by the public, the claims administrator shall make available the complete utilization review plan,
consisting of the policies and procedures, and a description of the utilization review process.
(1) The claims administrator may make available the complete utilization review plan, consisting of the policies and
procedures and a description of the utilization review process, through electronic means. If a member of the public
requests a hard copy of the utilization review plan, the claims administrator may charge reasonable copying and postage
expenses related to disclosing the complete utilization review plan. Such charge shall not exceed $0.25 per page plus
actual postage costs.
§9792.8. Utilization Review Standards--Medically-Based Criteria.
(a)(1) The criteria shall be consistent with the schedule for medical treatment utilization adopted pursuant to Labor Code
section 5307.27. Prior to adoption of the schedule, the criteria or guidelines used in the utilization review process shall be
consistent with the American College of Occupational and Environmental Medicine's (ACOEM) Practice Guidelines,
Second Edition. The guidelines set forth in the ACOEM Practice Guidelines shall be presumptively correct on the issue of
extent and scope of medical treatment until the effective date of the utilization schedule adopted pursuant to Labor Code
section 5307.27. The presumption is rebuttable and may be controverted by a preponderance of the scientific medical
evidence establishing that a variance from the guidelines is reasonably required to cure or relieve the injured worker from
the effects of his or her injury.
(2) For all conditions or injuries not addressed by the ACOEM Practice Guidelines or by the official utilization schedule
after adoption pursuant to Labor Code section 5307.27, authorized treatment shall be in accordance with other evidencebased medical treatment guidelines that are generally recognized by the national medical community and are scientifically
based. Treatment may not be denied on the sole basis that the treatment is not addressed by the ACOEM Practice
Guidelines until adoption of the medical treatment utilization schedule pursuant to Labor Code section 5307.27. After the
Administrative Director adopts a medical treatment utilization schedule pursuant to Labor Code section 5307.27, treatment
may not be denied on the sole basis that the treatment is not addressed by that schedule.
(3) The relevant portion of the criteria or guidelines used shall be disclosed in written form to the requesting physician, the
injured worker, and if the injured worker is represented by counsel, the injured worker's attorney, if used as the basis of a
decision to modify, delay, or deny services in a specific case under review. The claims administrator may not charge an
injured worker, the injured worker's attorney or the requesting physician for a copy of the relevant portion of the criteria or
guidelines used to modify, delay or deny the treatment request.
(4) Nothing in this section precludes authorization of medical treatment not included in the specific criteria under section
9792.8(a)(3).
§9792.9. Utilization Review Standards--Timeframe, Procedures and Notice Content
(a) The request for authorization for a course of treatment as defined in section 9792.6(e) must be in written form.
(1) For purposes of this section, the written request for authorization shall be deemed to have been received by the claims
administrator by facsimile on the date the request was received if the receiving facsimile electronically date stamps the
transmission. If there is no electronically stamped date recorded, then the date the request was transmitted. A request for
authorization transmitted by facsimile after 5:30 PM Pacific Time shall be deemed to have been received by the claims
administrator on the following business day as defined in Labor Code section 4600.4 and in section 9 of the Civil Code.
The copy of the request for authorization received by a facsimile transmission shall bear a notation of the date, time and
place of transmission and the facsimile telephone number to which the request was transmitted or be accompanied by an
unsigned copy of the affidavit or certificate of transmission which shall contain the facsimile telephone number to which
the request was transmitted. The requesting physician must indicate the need for an expedited review upon submission of
the request.
(2) Where the request for authorization is made by mail, and a proof of service by mail exists, the request shall be deemed
to have been received by the claims administrator five (5) days after the deposit in the mail at a facility regularly
maintained by the United States Postal Service. Where the request for authorization is delivered via certified mail, return
receipt mail, the request shall be deemed to have been received by the claims administrator on the receipt date entered on
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the return receipt. In the absence of a proof of service by mail or a dated return receipt, the request shall be deemed to have
been received by the claims administrator on the date stamped as received on the document.
(b) The utilization review process shall meet the following timeframe requirements:
(1) Prospective or concurrent decisions shall be made in a timely fashion that is appropriate for the nature of the injured
worker's condition, not to exceed five (5) working days from the date of receipt of the written request for authorization.
(2) If appropriate information which is necessary to render a decision is not provided with the original request for
authorization, such information may be requested by a reviewer or non-physician reviewer within five (5) working days
from the date of receipt of the written request for authorization to make the proper determination. In no event shall the
determination be made more than 14 days from the date of receipt of the original request for authorization by the health
care provider.
(A) If the reasonable information requested by the claims administrator is not received within 14 days of the date of the
original written request by the requesting physician, a reviewer may deny the request with the stated condition that the
request will be reconsidered upon receipt of the information requested.
(3) Decisions to approve a physician's request for authorization prior to, or concurrent with, the provision of medical
services to the injured worker shall be communicated to the requesting physician within 24 hours of the decision. Any
decision to approve a request shall be communicated to the requesting physician initially by telephone or facsimile. The
communication by telephone shall be followed by written notice to the requesting physician within 24 hours of the
decision for concurrent review and within two business days for prospective review.
(4) Decisions to modify, delay or deny a physician's request for authorization prior to, or concurrent with the provision of
medical services to the injured worker shall be communicated to the requesting physician initially by telephone or
facsimile. The communication by telephone shall be followed by written notice to the requesting physician, the injured
worker, and if the injured worker is represented by counsel, the injured worker's attorney within 24 hours of the decision
for concurrent review and within two business days of the decision for prospective review. In addition, the non-physician
provider of goods or services identified in the request for authorization, and for whom contact information has been
included, shall be notified in writing of the decision modifying, delaying, or denying a request for authorization that shall
not include the rationale, criteria or guidelines used for the decision.
(5) For purposes of this section “normal business day” means a business day as defined in Labor Code section 4600.4 and
Civil Code section 9.
(c) When review is retrospective, decisions shall be communicated to the requesting physician who provided the medical
services and to the individual who received the medical services, and his or her attorney/designee, if applicable, within 30
days of receipt of the medical information that is reasonably necessary to make this determination. In addition, the nonphysician provider of goods or services identified in the request for authorization, and for whom contact information has
been included, shall be notified in writing of the decision modifying, delaying, or denying a request for authorization that
shall not include the rationale, criteria or guidelines used for the decision.
(d) Failure to obtain prior authorization for emergency health care services shall not be an acceptable basis for refusal to
cover medical services provided to treat and stabilize an injured worker presenting for emergency health care services.
Emergency health care services, however, may be subjected to retrospective review. Documentation for emergency health
care services shall be made available to the claims administrator upon request.
(e) Prospective or concurrent decisions related to an expedited review shall be made in a timely fashion appropriate to the
injured worker's condition, not to exceed 72 hours after the receipt of the written information reasonably necessary to
make the determination. The requesting physician must indicate the need for an expedited review upon submission of the
request. Decisions related to expedited review refer to the following situations:
(1) When the injured worker's condition is such that the injured worker faces an imminent and serious threat to his or her
health, including, but not limited to, the potential loss of life, limb, or other major bodily function, or
(2) The normal timeframe for the decision-making process, as described in subdivision (b), would be detrimental to the
injured worker's life or health or could jeopardize the injured worker's permanent ability to regain maximum function.
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(f) The review and decision to deny, delay or modify a request for medical treatment must be conducted by a reviewer,
who is competent to evaluate the specific clinical issues involved in the medical treatment services, and where these
services are within the scope of the individual's practice.
(g)(1) The timeframe for decisions specified in subdivisions (b)(1), (b)(2) or (c) may only be extended by the claims
administrator under the following circumstances:
(A) The claims administrator is not in receipt of all of the necessary medical information reasonably requested.
(B) The reviewer has asked that an additional examination or test be performed upon the injured worker that is reasonable
and consistent with professionally recognized standards of medical practice.
(C) The claims administrator needs a specialized consultation and review of medical information by an expert reviewer.
(2) If subdivisions (A), (B) or (C) above apply, the claims administrator shall immediately notify the requesting physician,
the injured worker, and if the injured worker is represented by counsel, the injured worker's attorney in writing, that the
claims administrator cannot make a decision within the required timeframe, and specify the information requested but not
received, the additional examinations or tests required, or the specialty of the expert reviewer to be consulted. The claims
administrator shall also notify the requesting physician, the injured worker, and if the injured worker is represented by
counsel, the injured worker's attorney of the anticipated date on which a decision will be rendered. This notice shall
include a statement that if the injured worker believes that a bona fide dispute exists relating to his or her entitlement to
medical treatment, the injured worker or the injured worker's attorney may file an Application for Adjudication of Claim
and Request for Expedited Hearing, DWC Form 4, in accordance with sections 10136(b)(1), 10400, and 10408. In
addition, the non-physician provider of goods or services identified in the request for authorization, and for whom contact
information has been included, shall be notified in writing of the decision to extend the timeframe and the anticipated date
on which the decision will be rendered in accordance with this subdivision. The written notification shall not include the
rationale, criteria or guidelines used for the decision.
(3) Upon receipt of information pursuant to subdivisions (A), (B), or (C) above, and (b)(2)(A), the claims administrator
shall make the decision to approve, and the reviewer shall make a decision to modify or deny the request for authorization
within five (5) working days of receipt of the information for prospective or concurrent review. The decision shall be
communicated pursuant to subdivisions (b)(3) or (b)(4).
(4) Upon receipt of information pursuant to subdivisions (A), (B), or (C) above, the claims administrator shall make the
decision to approve, and the reviewer shall make a decision to modify or deny the request for authorization within thirty
(30) days of receipt of the information for retrospective review.
(h) Every claims administrator shall maintain telephone access from 9:00 AM to 5:30 PM Pacific Time, on normal
business days, for health care providers to request authorization for medical services. Every claims administrator shall
have a facsimile number available for physicians to request authorization for medical services. Every claims administrator
shall maintain a process to receive communications from health care providers requesting authorization for medical
services after business hours. For purposes of this section “normal business day” means a business day as defined in Labor
Code section 4600.4 and Civil Code section 9. In addition, for purposes of this section the requirement that the claims
administrator maintain a process to receive communications from requesting physicians after business hours shall be
satisfied by maintaining a voice mail system or a facsimile number for after business hours requests.
(i) A written decision approving a request for treatment authorization under this section shall specify the specific medical
treatment service approved.
(j) A written decision modifying, delaying or denying treatment authorization under this section shall be provided to the
requesting physician, the injured worker, and if the injured worker is represented by counsel, the injured worker's attorney
and shall contain the following information:
(1) The date on which the decision is made.
(2) A description of the specific course of proposed medical treatment for which authorization was requested.
(3) A specific description of the medical treatment service approved, if any.
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(4) A clear and concise explanation of the reasons for the claims administrator's decision.
(5) A description of the medical criteria or guidelines used pursuant to section 9792.8, subdivision (a)(3).
(6) The clinical reasons regarding medical necessity.
(7) A clear statement that any dispute shall be resolved in accordance with the provisions of Labor Code section 4062, and
that an objection to the utilization review decision must be communicated by the injured worker or the injured worker's
attorney on behalf of the injured worker to the claims administrator in writing within 20 days of receipt of the decision. It
shall further state that the 20-day time limit may be extended for good cause or by mutual agreement of the parties. The
letter shall further state that the injured worker may file an Application for Adjudication of Claim and Request for
Expedited Hearing, DWC Form 4, showing a bona fide dispute as to entitlement to medical treatment in accordance with
sections 10136(b)(1), 10400, and 10408.
(8) Include the following mandatory language:
Either
“If you want further information, you may contact the local state Information and Assistance office by calling [enter
district I & A office telephone number closest to the injured worker] or you may receive recorded information by calling
1-800-736-7401.
or
“If you want further information, you may contact the local state Information and Assistance office closest to you. Please
see attached listing (attach a listing of I&A offices and telephone numbers) or you may receive recorded information by
calling 1-800-736-7401.”
and
“You may also consult an attorney of your choice. Should you decide to be represented by an attorney, you may or may
not receive a larger award, but, unless you are determined to be ineligible for an award, the attorney's fee will be deducted
from any award you might receive for disability benefits. The decision to be represented by an attorney is yours to make,
but it is voluntary and may not be necessary for you to receive your benefits.”
In addition, the non-physician provider of goods or services identified in the request for authorization, and for whom
contact information has been included, shall be notified in writing of the decision modifying, delaying, or denying a
request for authorization that shall not include the rationale, criteria or guidelines used for the decision.
(9) Details about the claims administrator's internal utilization review appeals process, if any, and a clear statement that the
appeals process is on a voluntary basis, including the following mandatory statement:
“If you disagree with the utilization review decision and wish to dispute it, you must send written notice of your objection
to the claims administrator within 20 days of receipt of the utilization review decision in accordance with Labor Code
section 4062. You must meet this deadline even if you are participating in the claims administrator's internal utilization
review appeals process.”
(k) The written decision modifying, delaying or denying treatment authorization provided to the requesting physician shall
also contain the name and specialty of the reviewer or expert reviewer, and the telephone number in the United States of
the reviewer or expert reviewer. The written decision shall also disclose the hours of availability of either the review, the
expert reviewer or the medical director for the treating physician to discuss the decision which shall be, at a minimum,
four (4) hours per week during normal business hours, 9:00 AM to 5:30 PM., Pacific Time or an agreed upon scheduled
time to discuss the decision with the requesting physician. In the vent the reviewer is unavailable, the requesting physician
may discuss the written decision with another reviewer who is competent to evaluate the specific clinical issues involved
in the medical treatment services.
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(l) Authorization may not be denied on the basis of lack of information without documentation reflecting an attempt to
obtain the necessary information from the physician or from the provider of goods or services identified in the request for
authorization either by facsimile or mail.
§9792.10. Utilization Review Standards--Dispute Resolution
(a)(1) If the request for authorization of medical treatment is not approved, or if the request for authorization for medical
treatment is approved in part, any dispute shall be resolved in accordance with Labor Code section 4062.
(2) An objection to a decision disapproving in whole or in part a request for authorization of medical treatment, must be
communicated to the claims administrator by the injured worker or the injured worker's attorney in writing within 20 days
of receipt of the utilization review decision. The 20-day time limit may be extended for good cause or by mutual
agreement of the parties.
(3) Nothing in this paragraph precludes the parties from participating in an internal utilization review appeal process on a
voluntary basis provided the injured worker and if the injured worker is represented by counsel, the injured worker's
attorney have been notified of the 20-day time limit to file an objection to the utilization review decision in accordance
with Labor Code section 4062.
(4) Additionally, the injured worker or the injured worker's attorney may file an Application for Adjudication of Claim,
and a Request for Expedited Hearing, DWC Form 4, in accordance with sections 10136(b)(1), 10400, and 10408, and
request an expedited hearing and decision on his or her entitlement to medical treatment if the request for medical
treatment is not authorized within the time limitations set forth in section 9792.9, or when there exists a bona fide dispute
as to entitlement to medical treatment.
(b) The following requirements shall be met prior to a concurrent review decision to deny authorization for medical
treatment and to resolve disputes:
(1) In the case of concurrent review, medical care shall not be discontinued until the requesting physician has been notified
of the decision and a care plan has been agreed upon by the requesting physician that is appropriate for the medical needs
of the injured worker. In addition, the non-physician provider of goods or services identified in the request for
authorization, and for whom contact information has been included, shall be notified in writing of the decision modifying,
delaying, or denying a request for authorization that shall not include the rationale, criteria or guidelines used for the
decision.
(2) Medical care provided during a concurrent review shall be medical treatment that is reasonably required to cure or
relieve from the effects of the industrial injury.
§10606. Physicians' Reports as Evidence.
The Workers' Compensation Appeals Board favors the production of medical evidence in the form of written reports.
Direct examination of a medical witness will not be received at a trial except upon a showing of good cause. A
continuance may be granted for rebuttal testimony subject to Labor Code Section 5502.5.
These reports should include where applicable:
(a) the date of the examination;
(b) the history of the injury;
(c) the patient's complaints;
(d) a listing of all information received from the parties reviewed in preparation of the report or relied upon for the
formulation of the physician's opinion;
(e) the patient's medical history, including injuries and conditions, and residuals thereof, if any;
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(f) findings on examination;
(g) a diagnosis;
(h) opinion as to the nature, extent, and duration of disability and work limitations, if any;
(i) cause of the disability;
(j) treatment indicated;
(k) opinion as to whether or not permanent disability has resulted from the injury and whether or not it is stationary. If
stationary, a description of the disability with a complete evaluation;
(l) apportionment of disability, if any;
(m) a determination of the percent of the total causation resulting from actual events of employment, if the injury is
alleged to be a psychiatric injury;
(n) the reasons for the opinion; and,
(o) the signature of the physician.
Failure to comply with (a) through (o) will be considered in weighing the evidence.
In death cases, the reports of non-examining physicians may be admitted into evidence in lieu of oral testimony.
All medical-legal reports shall comply with the provisions of Labor Code Section 4628. Except as otherwise provided by
the Labor Code, including Labor Code Sections 4628 and 5703, and the rules of practice and procedure of the Appeals
Board, failure to comply with the requirements of this section will not make the report inadmissible but will be considered
in weighing the evidence.
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Appendix C: Resources
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This appendix lists government agencies, professional organization and printed materials, which may be helpful for primary treating
physicians.
State Compensation Insurance Fund
District Offices
Each District Office is organized into claims, field services, and legal departments. The claims department is
responsible for all matters related to delivery of medical and disability benefits. Each claims department has an
advanced claims administrator whose sole function is acting as the Medical Community Liaison (MCL). The MCL
facilitates communication between State Fund and the treating physicians. The individual claims administrator has
primary responsibility for treatment authorization and oversight on individual claims.
Most district offices have at least one full-time on-site registered nurse consultant to help the claims adjusters
interpret medical information and make appropriate decisions of authorization requests. All districts also have a
part or full-time on-site medical doctor to assist the nursing staff and/or claims adjusters. Some offices also use
part-time physical therapy and chiropractic consultants. These licensed medical professionals involved for the
purpose of rendering utilization review in accordance with Labor 4610. Additionally, each claims department has a
UR Coordinator (URC) who is responsible for overseeing the Utilization Review process in their location. The UR
Coordinator will ensure timely authorization and act as a resource for district office staff regarding the UR process.
Each District office also has a dedicated UR fax line for submission of treatment requests. The dedicated fax line
for each individual adjusting location may be obtained by calling district office phone number provided in the chart
below.
Click for a list of State Fund Locations
Claims Processing Centers
The Claims Processing Centers (CPC) of State Fund was created to centralize certain claims support functions of the
district offices in support of the Electronic Claims File. The purpose of this consolidation is to take advantage of the
economies of scale and technological innovation to reduce costs and save time. There are Claims Processing Centers
located in Fresno, Fairfield, and Burbank. The CPC provides service and support to adjusting locations throughout State
Fund. These services include bill review and payment. The Fresno and Fairfield Claims Processing Center locations are
responsible for the printing and mailing of the majority of State Fund’s medical and compensation checks. Checks
requiring special handling continue to be produced in the individual district offices. If you have general questions regarding
billing reimbursements or claims processing, please contact the appropriate CPC. The CPC address and telephone number
for each adjusting location is provided in the chart below.
State Fund Office
Bakersfield
Claims Processing Center
Mailing Address and
Telephone Number
P.O. Box 3171
Suisun City, CA 94585-6171
(707) 863-5601
Bay Area Claims – Pleasanton P.O. Box 3171
Suisun City, CA 94585
(707) 863-5601
Bay Area Satellite - Fairfield
P.O. Box 3171
Suisun City, CA 94585
(707) 863-5601
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State Fund Office
Claims Processing Center
Mailing Address and
Telephone Number
Claims Management Services
Santa Ana Location
(Self Insured Employers-TPA)
P.O. Box 65005
Pinedale, CA 93650-5005
(559) 440-5603
Claims Management Services
Sacramento Location
(Self Insured Employers-TPA)
P.O. Box 65005
Pinedale, CA 93650-5005
(559) 440-5603
Claims Management Services
San Bernardino Location
(Self Insured Employers-TPA)
P.O. Box 65005
Pinedale, CA 93650-5005
(559) 440-5603
Eureka
P.O. Box 3171
Suisun City, CA 94585-6171
(707) 863-5601
Fresno
P.O. Box 65005
Pinedale, CA 93650-5005
(559) 440-5603
Glendale
P.O. Box 65005
Pinedale, CA 93650-5005
(559) 440-5603
Orange County Claims
P.O. Box 65005
Pinedale, CA 93650-5005
(559) 440-5603
Orange County SatelliteCerritos
P.O. Box 65005
Pinedale, CA 93650-5005
(559) 440-5603
Oxnard
P.O. Box 65005
Pinedale, CA 93650-5005
(559) 440-5603
Redding
P.O. Box 3171
Suisun City, CA 94585-6171
(707) 863-5601
Riverside
P.O. Box 92622
Los Angeles, CA 90009-2622
(818)291-7240
Sacramento
P.O. Box 3171
Suisun City, CA 94585-6171
(707) 863-5601
San Bernardino
P.O. Box 92622
Los Angeles, CA 90009-2622
(818) 291-7240
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State Fund Office
Claims Processing Center
Mailing Address and
Telephone Number
San Diego
P.O. Box 65005
Pinedale, CA 93650-5005
(559) 440-5603
San Jose
P.O. Box 3171
Suisun City, CA 94585-6171
(707) 863-5601
Santa Rosa
P.O. Box 65005
Pinedale, CA 93650-5005
(559)440-5603
Stockton
P.O. Box 3171
Suisun City, CA 94585-6171
(707) 863-5601
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Government Resources
California State Department of Industrial Relations
Department of Industrial Relations
Office of the Director
455 Golden Gate Avenue
San Francisco CA 94102
www.dir.ca.gov
Public information office
(415) 703-5070
Workers' compensation:
Division of Workers Compensation
Public assistance
(800) 736-7401
Local Offices
Anaheim
(714) 738-4000
Long Beach
(562) 590-5001
Riverside
(951) 782-4269
San Jose
(408) 277-1246
Bakersfield
(661) 395-2723
Los Angeles
(213) 576-7335
Sacramento
(916) 263-2735
Santa Ana
(714) 558-4121
Eureka
(707) 445-6518
Oxnard
(805) 485-2533
Salinas
(831) 443-3060
Santa Monica
(310) 452-9114
Fresno
(559) 445-5051
Oakland
(510) 622-2866
San Bernardino
(909) 383-4341
Santa Rosa
(707) 576-2391
Goleta
(805) 968-0258
Pomona
(909) 623-4301
San Diego
(619) 767-2083
Stockton
(209) 948-7759
Grover Beach
(805) 481-4912
Redding
(530) 225-2845
San Francisco
(415) 703-5011
Van Nuys
(818) 901-5367 ext. 3501
For ongoing information on regulations affecting California Workers’ Compensation, ask to be added to the Administrative
Director’s (AD) mailing list. Write to:
Administrative Director’s Office
455 Golden Gate Avenue, Room 5182
San Francisco CA 94102
Division of Workers' Compensation Medical Unit
(800) 794-6900
The DWC Medical Unit examines and appoints physicians to be qualified medical evaluators (QMEs). QMEs perform the
examinations of injured workers that help determine the level of benefits to be received by a worker. The DWC Medical
Unit has enacted evaluation guidelines for some types of injuries to be used for these examinations. In addition, the
medical unit assists the DWC administrative director with issues affecting physicians and other providers in the workers'
compensation system and undertakes studies in current medical care issues.
Division of Workers' Compensation Medical Unit complaint line
(800) 999-1041
California Division of Occupational Safety and Health (Cal/OSHA)
(415) 703-5050
The Cal/OSHA enforcement unit has jurisdiction over every employment and place of employment in California, which is
necessary to adequately enforce and administer all occupational safety and health standards and regulations.
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The Cal/OSHA enforcement unit conducts inspections of California workplaces in response to a report of an industrial
accident, a complaint about an occupational safety and health hazard, or as part of an inspection program targeting
industries that have a high rate of occupational hazards, fatalities, injuries or illnesses.
Cal/OSHA also has a Consultation service, which provides free assistance to employers and employee groups to protect
workers from accidents and illness on the job.
Phone: (916) 263-5765
InfoCons@dir.ca.gov
Professional Organizations
American College of Occupational and Environmental Medicine (ACOEM)
25 Northwest Point Blvd., Suite 700
Elk Grove Village, IL 60007-1030
(847-818-1800
American Public Health Association (APHA)
800 “I” Street,
NW Washington DC, 20001-3710
California Chiropractic Association
1600 Sacramento Inn Way, Suite 106
Sacramento, CA 95815
(916) 648-2727
California Society of Industrial Medicine and Surgery (CSIMS)
1000 “Q” Street, Suite 201
Sacramento, CA 95814-6518
(916) 446-4199
Western Occupational Environmental Medicine Association (WOEMA)
575 Market Street, Suite 2125
San Francisco, CA 94105
(415) 927-5736
Printed Material
Utilization Review and Permanent Impairment Schedules
Guides to the Evaluation of Permanent Impairment, 5th Edition,; American Medical Association; AMA Press, 800621-8335; www.ama-assn.org
nd
Occupational Medicine Practice Guidelines, 2 Edition, American College of Occupational and Environmental
Medicine; OEM Press, 8 West Street, Beverly Farms, MS 01915;
800-533-8046
978-921-7300
Labor Code and Regulations
Workers’ Compensation Laws of California, yearly Edition; Mathew Bender & Co., Inc., 201 Mission Street, San
Francisco, CA 94105-1831
(415) 908-3200
Official Medial Fee Schedule
State of California – State and Consumer Services Agency
The Legislative Bill Room, State Capitol, RM B-32
Sacramento, CA 95814
(916) 445-5357State of California - State and Consumer Services Agency
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Glossary
Note: This glossary provides brief definitions of terms commonly used in the California workers’ compensation
system. Please consult the index to find more detailed information and examples in the text.
A
Accepted claim: Also called admitted claim. A claim in which the insurance company agrees your injury or illness
is covered by workers' compensation benefits. Even if the claim is accepted there may be delays or other problems.
ACOEM: American College of Occupational and Environmental Medicine. The Medical Treatment Utilization Schedule
(MTUS) incorporates ACOEM’s, Occupational Medicine Practice Guidelines, 2nd Edition (2004).
Aggravation: A change in a pre-existing condition that causes a temporary or permanent increase in disability or
creates a need for additional or different medical treatment. A new injury or work activity may cause the
aggravation.
Agreed Medical Evaluator (AME): A medical examiner selected by agreement between the employer (or the employer’s
insurance company) and a represented employee to resolve disputed medical issues referred by the parties in a workers’
compensation proceeding. The report of an AME is considered the evidence of both parties.
Alternative Work Assignment: Placement of an injured employee in another position with the same employer.
Intended to be a temporary or sustained accommodation to the employee’s work restrictions or disability.
Americans With Disabilities Act (ADA): A federal law providing disabled employees equal treatment regarding
the “terms, conditions and privileges” of employment, including the right to a harassment-free work environment.
AOE: “Arising out of employment.” AOE refers to how the activities of work led to the injury in question. It is
one of the legal tests required for a medical condition to be covered by workers’ compensation insurance.
Appeals Board: Also called the Reconsideration Unit. A group of seven commissioners appointed by the
governor, who review and reconsider decisions made by workers’ compensation administrative law judges.
Applicant: The party, usually the patient, who opens a case at the local Workers' Compensation Appeals Board
(WCAB) office by filing an application for adjudication of a claim.
Applicants' Attorney: A lawyer who represents a claimant in his or her workers' compensation case. Applicant
refers to the injured employee.
Apportionment: The process of determining if some portion of an injured employee’s permanent disability is due
to previous disabilities or some other cause, rather than the current injury. Apportionment applies only to
permanent disability.
Audit Unit: A unit within the DWC that receives complaints against claims administrators. These complaints may
lead to investigations of the way the company handles claims.
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C
Cal/OSHA: A unit within the state Division of Occupational Safety and Health (DOSH). Cal/OSHA inspects
workplaces and enforces laws to protect the health and safety of workers in California.
Claims Adjuster: See claims administrator.
Claims Administrator: Also called claims examiner or claims adjuster. Employee of an insurance company, selfinsured employer, third-party administrator, or other organization, who oversees the processing of individual
workers’ compensation claims.
Claims Examiner: See claims administrator.
Claim Form: The form used to report a work injury or illness to an employer.
COE: Occurring in the “course of employment.” An injury must occur in the course of employment to be
compensable in workers’ compensation insurance. Thus, the activity of the employee at the time of injury must
grow out of, or be incidental to, the employment.
Commission on Health and Safety and Worker’s Compensation (CHSWC): A state-appointed body that
conducts studies and makes recommendations to improve the California workers' compensation and workplace
health and safety systems.
Compensable Injury: Any injury sustained by an employee arising out of (AOE) and occurring in the course of
(COE) employment. This injury includes any aggravation or acceleration, due to employment, of a pre-existing
physical or mental condition or pathology.
Comprehensive Medical-Legal Evaluation: An evaluation of an employee that results in the preparation of a
narrative medical report by a QME, an AME, or the primary treating physician, to prove or disprove a contested
claim.
Compromise and Release (C&R): A type of settlement approved by a workers' compensation judge in which the
applicant receives a lump-sum payment and becomes responsible for paying for his or her future medical care.
Constant Symptoms: Symptoms that occur approximately 90–100 percent of the time.
Cumulative Injury: Also know as cumulative trauma or (CT): Occurring as repetitive mentally or physically
traumatic activities extending over a period of time, the combined effect of which causes any disability of need for
medical treatment. The date of a cumulative injury shall be the date determined in accordance with labor code
section 5412 (LC §3208.1).
D
Date of Injury (DOI): In a specific injury, the date of injury is the date that the incident or exposure occurred. In
a cumulative injury or occupational illness, the DOI (for statute of limitation purposes) is the date when the
employee first suffered disability from the exposure, and either knew, or “in the exercise of reasonable diligence”
should have known, that the disability resulted from present or previous employment.
Delayed Claim: A claim in which the insurance company, self-insured employer, or third-party administrator
gathers and investigates facts to determine if the claim meets AOE/COE compensability prior to acceptance or
denial of liability for the injury or illness claimed.
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Denied Claim: A claim determined as noncompensable by workers' compensation standards.
Description of Employee’s Job Duties (RU-91): A form the injured employee and the insurance company fill
out jointly. The form helps the treating physician decide whether the injured employee will be able to return to
his/her normal job and working conditions.
Disability: The inability or reduced ability to compete in the open labor market due to the effects of a physical or
mental injury.
Disability Evaluation Unit (DEU): A unit within the DWC that calculates the percent of permanent disability on
the basis of medical reports. See disability rater.
Disability Management: A process to prevent disability from occurring; or to intervene early, after the start of a
disability, to encourage and support continued employment. This is done early in the recovery process in severe
injury cases such as spinal injuries. Usually a rehabilitation nurse is involved with the injured employee and his or
her treating doctor, and the progress of the medical treatment is reported to the insurance company.
Disability Rater: An employee of the DWC Disability Evaluation Unit who rates an injured employee’s
permanent disability after reviewing a medical report or a medical-legal report describing the injured employee’s
condition.
Disability Rating: See permanent disability rating.
Dispute: A disagreement about payments or medical-treatment services.
Division of Workers’ Compensation (DWC): A division within the state Department of Industrial Relations
(DIR). The DWC administers workers' compensation laws, resolves disputes over workers' compensation benefits
and provides information and assistance to injured employees and others about the workers' compensation system.
E
Emergency Treatment: Medical treatment reasonably required by an injured employee immediately following an
industrial injury or illness, which, if delayed, could decrease the likelihood of maximum recovery.
Employee: Every person who performs a service for someone else under any employment or contract of hire or
apprenticeship, expressed or implied, oral or written, whether lawfully or unlawfully employed.
Employee-Selected Physician: Includes the personal physician and physician or facility the employee selects
more than 30 days from the date the injury is reported.
Employer: Any person or entity who engages the services of a person. It includes an individual employer,
partnership, the legal representative of a deceased employer, or a corporation. It also includes the state and every
state agency, every county, every city, and all public and quasi-public corporations and agencies (LC §3300).
Employer's Bill of Rights: An employer's statutory right to be advised of all aspects of a claim that affect an
employer's premium which includes a premium reimbursement provision.
Ergonomics: The study of how to improve the fit between the physical demands of the workplace and the
employees who perform the work. This is accomplished by considering the variability in human capabilities when
selecting, designing or modifying equipment, tools, work tasks and the work environment.
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Essential Functions: Job duties considered crucial to the employment position which the employee holds or
desires. Functions may be considered essential for the following reasons: the position exists to perform the
function, the function requires specialized expertise, serious results may occur if the function is not performed, the
other employees are not available to perform the function, or the function occurs at peak periods and the employer
cannot reorganize the work flow.
ExParte Communication: Communication by, or on behalf of, one party, without the knowledge of the opposing
party. In a workers’ compensation setting, ex parte means that neither party may have communication with a judge,
arbitrator, AME, or QME without knowledge of the other party.
F
Facility: A hospital, clinic, or other institution capable of providing the medical, surgical, chiropractic, or hospital
treatment reasonably required to cure or relieve the employee from the effects of the injury.
Filing: Sending or delivering a document to an employer or a government agency as part of a legal process. The
date of filing is the date the document is received.
Final Order: Any order, decision, or award made by a workers’ compensation judge that no one has appealed in a
timely way.
Findings & Award (F&A): A written decision by a workers’ compensation administrative law judge about the
injured employee’s case, including payments and future care that must be provided to the injured employee. The
F&A becomes a final order unless appealed.
First Aid: Any one-time treatment, and any follow-up visit for the purpose of observation of minor scratches, cuts,
burns, splinters, and so forth, which do not ordinarily require medical care. Such one-time treatment, and follow-up
visit for the purpose of observation, is considered first aid even though provided by a physician or registered
professional personnel (8 CCR §14311).
Flare-up: The “flare-up” of a previous industrial injury or illness (sometimes referred to as a recurrence or
recurrent injury). Refers to symptoms considered to be related to the natural course of the previous injury or
illness, rather than related to a new injury growing out of current employment.
Follow-up Medical-Legal Evaluation: An evaluation which includes an examination of an employee which (A)
results in the preparation of a narrative medical report prepared and attested to in accordance with LC §4628, any
applicable procedures promulgated under LC §139.2, and the 8 CCR §10606; (B) is performed by a qualified
medical evaluator, agreed medical evaluator, or primary treating physician within one year following the evaluator's
examination of the employee in a comprehensive medical-legal evaluation of the same injury or injuries evaluated in
the comprehensive medical-legal evaluation (8 CCR §9793).
Fraud: Any knowingly false or fraudulent statement for the purpose of obtaining or denying workers'
compensation benefits. The penalties for committing fraud are fines up to $150,000 and/or imprisonment for up
to 5 years.
Frequent Symptoms: Symptoms that occur approximately 75 percent of the time.
Functional Limitation: An individual's inability to perform certain actions due to impairment. (See impairment.)
Future Medical Treatment: Medical care that may be required in the future to relieve from the effects of an
injury, maintain an injured employee’s optimum condition, or deal with anticipated deterioration of an injury over
time. Awards for future medical treatment occur when a condition is permanent and stationary.
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G
Ghostwriting: As it relates to medical-legal reports, ghost writing occurs when the submitted medical report is
prepared in whole or in part by an individual or entity other than the physician who performed the actual
examination. Ghostwriting is prohibited by law.
H
Health Care Organization (HCO): An organization certified by the Department of Workers’ Compensation to
provide managed medical care within the workers’ compensation system.
Hearings: Legal proceedings in which a workers' compensation judge discusses the issues in a case or receives
information to make a decision about a dispute or a proposed settlement.
I
Impairment: The reduction or loss of function of an organ or body part compared to the prior level of function.
Impairment rating: A percentage estimate of how much normal use of the injured body parts the injured
employee has lost. Impairment ratings are determined on the basis of guidelines published by the American
Medical Association (AMA). An impairment rating helps calculate the permanent disability rating but is different
from a permanent disability rating.
Independent Medical Examiner (IME): A physician whom the Department of Industrial Relations, Division of
Workers’ Compensation appoints, when a judge believes additional medical evidence is necessary to provide a basis
for a decision on an issue the parties have presented, and the parties cannot agree on a medical evaluator. IMEs
become involved only for injuries occurring before January 1, 1991. Their assignment occurs at the request of the
Administrative Director, WCAB, or a workers’ compensation judge.
Industrial Medical Council (IMC): No longer in existence. (See Medical Unit.)
Information & Assistance (I&A) Officer: A DWC employee who answers questions, assists injured employees,
provides written materials, conducts informational workshops, and holds meetings for informal resolution of
problems with claims.
Information and Assistance (I&A) Unit: A unit within the DWC that provides information to all parties in
workers' compensation claims and informally resolves disputes.
Injury: Includes any injury or disease arising out of the employment, including injuries to artificial members,
dentures, hearing aids, eyeglasses and medical braces of all types; provided, however, that eyeglasses and hearing
aids will not be replaced, repaired, or otherwise compensated for, unless injury to them is incident to an injury
causing disability (LC §3208).
Injury and Illness Prevention Program (IIPP): A health and safety program which Cal/OSHA requires
employers are required to develop and implement. Cal/OSHA enforces this program.
In Pro Per: An injured employee not represented by an attorney.
Intermittent Symptoms: Symptoms that occur approximately 50 percent of the time.
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J
Judge: See workers' compensation administrative law judge.
L
Lien: A charge or obligation imposed upon a specific compensation claim as security for the performance of
services related to that claim.
Light Duty: Duties that are less physically or mentally stressful than those previously performed. This term is
inexact, and should not be used in workers’ compensation reporting.
Lighting Up: An aggravation of a pre-existing or underlying condition. An occurrence or change that causes a
temporary or permanent increase in disability, creating a new need for medical treatment or requiring a change in
the existing course of treatment.
Loss of Pre-Injury Capacity: The change in an individual’s capacity to perform physical or other activities,
comparing the individual’s capability before the injury with the capability after the injury has stabilized.
M
Maintenance Allowance: Monies paid on a weekly basis to the injured employee while that employee is engaged
in vocational rehabilitation, once temporary disability payments have ended. For injuries that occurred on or after
January 1, 1994, these payments are usually limited to 52 weeks; and are deducted from the $16,000 maximum
allocation for all vocational rehabilitation services.
Mandatory Settlement Conference (MSC): A required conference to discuss settlement prior to a trial.
Maximal Medical Improvement (MMI): The injured employee’s condition is well stabilized and unlikely to
change substantially in the next year, with or without medical treatment. Once the patient reaches MMI, a doctor
can assess how much, if any, permanent disability resulted from the work injury.
Mediation Conference: A voluntary conference held before an I&A officer to resolve a dispute, if an attorney is
not representing the injured employee.
Medical Care: See medical treatment.
Medical Director: The physician whom the Industrial Medical Council appoints pursuant to Section 122 (LC
§110).
Medical-legal Expense: Costs incurred by a party, the AD, or the WCAB for tests, reports, records, testimony,
and so forth. for the purpose of approving or disapproving a contested claim.
Medical-Legal Report: A doctor’s report that describes a medical condition. These written reports help
clarify disputed medical issues.
Medical-Legal Testimony: Expert testimony that a physician provides in a report at a deposition or WCAB
hearing. The report contains the physician’s medical opinion.
Medical Provider Network (MPN): An entity or group of health care providers set up by an insurer or selfinsured employer and approved by the DWC's Administrative Director to treat employees injured on the job.
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Medical Treatment: Also called medical care. Treatment reasonably required to cure or relieve the effects of a
work-related injury or illness.
Medical Treatment Utilization Schedule (MTUS): Assists in the provision of medical treatment by offering an
analytical framework for the evaluation and treatment of injured workers and to help those who make decisions
regarding the medical treatment of injured workers understand what treatment has been proven effective in
providing the best medical outcomes to those workers, in accordance with section 4600 of the Labor Code. The
MTUS is presumptively correct on the issue of extent and scope of medical treatment and diagnostic services
addressed in the MTUS for the duration of the medical condition.
Medical Unit: Formerly called the Industrial Medical Council (IMC). A unit within the DWC that oversees
MPNs, IMR physicians, HCOs, QMEs, panel QMEs, UR plans, and spinal surgery second-opinion physicians.
Medically Driven Issues that require medical opinion, in order to make decisions in accordance with the labor
code for the provision of workers’ compensations benefits to the injured employee.
Minimal Pain: A pain that would constitute an annoyance, but would cause no handicap in the performance of
the particular activity and would be considered a nonratable permanent disability (8CCR §9727).
Moderate Pain: A pain that could be tolerated, but would cause marked handicap in the performance of the
activity precipitating the pain (8 CCR §9727).
Modified Work Assignment: A work assignment changed to enable the injured employee to perform in that
position. Examples include: modifying the work station so the employee can perform the job seated, instead of
standing, or modifying the content of the work to exclude tasks that the employee can no longer perform.
O
Objective Factors: Factors of disability that the physician can directly measure, observe, or that the injured
employee can demonstrated. Objective factors include physical findings, such as range of motion, strength,
findings on x-ray, and the results of laboratory or other diagnostic tests.
Occasional Symptoms: Symptoms that occur approximately 25 percent of the time.
Occupational Illness: Any abnormal condition or disorder caused by exposure to environmental factors
associated with employment, including acute and chronic illnesses or diseases which may be caused by inhalation,
absorption, ingestion, or direct contact (LC §6409).
Off Calendar (OTOC): A WCAB case in which there is no pending action.
Offer of Modified or Alternative Work Form (RU-94): A form the injured employee receives from the insurance
company if he or she was injured before 2004, and the treating physician says he or she probably will never return
to the same job or one like it, and the employer is offering modified or alternative work instead of vocational
rehabilitation benefits.
Offer of Modified or Alternate Work Form (DWC form #AD 10133.53): A form the injured employee receives
from the insurance company if: he or she was injured in 2004: or later and your treating physician reports he or she
has a permanent disability; and the employer is offering modified or alternative work. This form also explains how
the permanent disability payments may be reduced by 15 percent because the employer is returning the injured
employee to work.
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P
Panel QME: A list of three independent QMEs the DWC Medical Unit issues. The patient selects any one of the
three doctors to conduct the evaluation.
Party: May include the insurance company, the employer, attorneys, and any other person with an interest in the
claim.
Permanent and Stationary (P & S): An injured employee’s medical condition after it has medically stabilized (this
is sometimes called MMI, although some slight medical improvement might be anticipated in the future), or when
the condition has been stationary for a “reasonable period of time.” If the physician uses the 2005 schedule to rate
the disability the term MMI is used instead of P&S.
Permanent and Stationary (P&S) Report: A medical report that a treating physician writes to describe the
injured employee’s medical condition when it has stabilized.
Permanent Disability (PD): Residual mental or physical impairment remaining after a injured employee’s
condition has reached MMI or has been stationary for a reasonable period of time and results in a reduced earning
capacity.
Permanent Disability Rating (PDR): A determination of the percentage of total disability for the individual
injured employee.. The law requires consideration of the nature of the injury, the occupation and the age of the
injured employee at the time of injury, as well as the extent to which the injured employee has diminished ability to
compete in the open labor market. In determining permanent disability, the physician rates the disability, not the
existence of a pathological condition. Thus, the physician does not rate an industrial disease, but rather its
permanent effect on the employee’s working ability. The DWC uses the Schedule for Rating Permanent Disabilities
to determine applicable permanent disability percentages on the basis of information that physicians provide.
Permanent Partial Disability (PPD): Disability that interferes with the injured employee’s future earning
capacity.
Permanent Total Disability (PTD): Disability considered to render an injured employee totally unable to have a
future earning capacity.
Personal Physician: A doctor of medicine or a doctor of osteopathy who prior to the injury, has directed the
medical treatment of the employee and who retains the employee's medical records and medical history. "Personal
physician" includes a corporation, partnership, or association of such doctors of medicine or osteopathy (LC
§4600).
Physician: Under the provisions of the Labor Code, the term physician includes medical doctors (physicians and
surgeons holding an M.D. or D.O. degree), psychologists, optometrists, dentists, podiatrists, chiropractors, and
acupuncturists licensed by California law. The definition of personal physician is more limited. (See personal
physician.)
Place of Employment: Any place, and the premises appurtenant thereto, where employment is carried out.
Predesignated Physician or Chiropractor: The physician who meets certain conditions and whom the employee
has selected as his or her physician of choice by notifying the employer in writing prior to the date of a work injury.
(See predesignation.)
Predesignation: The process of informing an employer that an employee wants to use his or her personal
physician to treat for a work injury. The injured employee can predesignate his or her personal doctor of medicine
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(M.D.) or doctor of osteopathy (D.O.) if the employer offers group health coverage, the doctor has treated the
employee in the past and has medical records, prior to the injury the doctor agrees to treat the employee for work
injuries or illnesses and, prior to the injury the employee provides the employer the following details in writing:
(1) Notice that the employee wants his or her personal doctor to treat him or her for a work-related injury or illness
AND
(2) The personal doctor's name and business address.
Preinjury Capacity: A worker's ability to perform work prior to his or her work-related injury or illness.
Preponderance of Evidence: Evidence that, when weighed with that opposed to it, has more convincing force
and the greater probability of truth. When weighing the evidence, the test is not the relative number of witnesses,
but rather the relative convincing force of the evidence (LC §3202.5).
Presumption: An inference in favor of a particular fact. A presumption is a rule of law, statutory or judicial, by
which finding of a basic fact gives rise to existence of presumed fact, until presumption is rebutted (Black's Law
Dictionary; 6th Edition, 1990).
Primary Treating Physician (PTP): The doctor who holds overall responsibility for treatment and/or managing
the treatment of the work injury or illness. This physician writes medical reports that may affect the provision of
benefits. Also called treating physician or treating doctor.
Proof of Service: A form used to show that documents have been sent to specific parties.
Prophylactic Restriction: A preventative measure or action taken against the possibility of disease or injury. In
the context of workers' compensation, this term may refer to the need to guard against the potential for aggravation
of impairment. In other words, if the restrictions were exceeded, the injured employee might be at risk for further
injury.
Proximate Consequence or Result: One which succeeds naturally in the ordinary course of things. A
consequence which, in addition to being in the train of physical causation, its not entirely outside the range of
expectation or probability, as viewed by ordinary men (Black's Law Dictionary; 6th Edition, 1990).
Q
Qualified Injured employee (QIW): An injured employee who is entitled to receive vocational rehabilitation
services because: 1) the injury prevents return to the usual and customary occupation or the job performed at the
time of the injury; and 2) the worker is reasonably expected to return to suitable, gainful employment through
vocational rehabilitation services.(This term applies to dates of injuries prior to 1/1/04.)
Qualified Medical Evaluator (QME): A physician appointed and certified by the IMC to conduct medical-legal
evaluations of injured employees.
Qualified Rehabilitation Representative (QRR): A person capable of developing and implementing a
vocational rehabilitation plan. This person’s experience and regular duties involve the evaluation, counseling, or
placement of disabled persons.
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R
Rating: See permanent disability rating.
Reasonable Accommodation: Any modification or adjustment to a job or the work environment that will enable
a qualified applicant or employee with a disability to participate in the application process or to perform essential
job functions.
Reasonable Medical Probability: The standard by which you must abide when rendering a medical opinion . It
means that you believe, from superior evidence, that something is probable or more likely than not, that there is at
least a 51% likelihood of certainty attached to your opinion.
Rebuttable Presumption: An assumption that can carry the burden of proof for the party entitled to benefits.
Evidence presented by the opposing party may overcome the presumption. In the workers’ compensation industry,
a rebuttable presumption means that certain conditions are assumed to be employment related for designated
groups of employees. In effect, the presumption shifts the burden of proof to the employer, who must then show
that work did not cause the condition otherwise the injury must be found compensable.
Reconsideration of a Summary Rating: Unrepresented injured employees use this process when they believe
mistakes were made in their permanent disability rating.
Reconsideration Unit: See Appeals Board.
Recurrence: “Recurrence” of a previous industrial injury or illness (also referred to as a “flare-up”). Refers to
symptoms that occur, or may have been expected to occur, without relationship to the current employment of the
injured employee, or the activities performed when the recurrence occurred. Used this way, a recurrence would not
constitute a new injury.
Regular Work: The employee’s usual and customary occupation or the position in which the employee was engaged at
the time of injury; offers wages and compensation equivalent to those paid to the employee at the time of injury; and
located within a reasonable commuting distance of the employee’s residence.
Rehabilitation (Rehab) Consultant: A DWC employee who oversees vocational rehabilitation procedures, makes
decisions about vocational rehabilitation benefits, and helps resolve disputes.
Rehabilitation (Rehab) Counselor: See qualified rehabilitation representative (QRR).
Rehabilitation Unit: A unit within the DWC that resolves vocational rehabilitation disputes, approves potential
settlements of vocational rehabilitation services, and reviews and approves vocational rehabilitation plans for
injuries that happened before January 1, 2004.
Represented Employee: An injured employee who is represented by an attorney.
Restrictions: See work restrictions.
S
Schedule for Rating Permanent Disabilities: See permanent disability rating schedule.
Self-Procured Care: Medical care obtained by an injured employee either prior to the determination of eligibility
or after rejection or delay of benefits by the insurer or employer.
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Serious and Willful (S&W): A petition alleging the employee’s injury is caused by the serious and willful
misconduct of the employer.
Serious Injury or Illness: Any injury or illness occurring in a place of employment or in connection with any
employment which requires inpatient hospitalization for a period in excess of 24 hours for other than medical
observation or in which an employee suffers a loss of any member of the body or suffers any serious degree of
permanent disfigurement (LC §6302).
Settlement: An agreement between the injured employee, his or her attorney, and the insurance company relating
to workers' compensation payments and future medical care. A workers' compensation judge must review the
settlement and determine it is legally adequate.
Severe Pain: A pain that precludes the activity precipitating the pain (8 CCR 9727).
Slight Pain: A pain that is tolerable but causes some handicap in the performance of the activity precipitating the
pain (8 CCR 9727).
SOAP: Acronym for Subjective symptoms, Objective signs, Assessment and Plan (Guidelines for Chiropractic
Quality Assurance & Practice Parameters, 1993).
Social Security Disability Benefits: Long-term financial assistance for totally disabled persons. These benefits
come from the U.S. Social Security Administration. They are reduced by workers' compensation payments received.
Specific Injury: An injury occurring as the result of one incident or exposure which causes disability or need for
medical treatment (LC §3208.1).
State Average Weekly Wage (SAWW): The average weekly wage paid in the previous year to employees in
California covered by unemployment insurance, as reported by the U.S. Department of Labor. Effective 2006,
temporary disability benefit increases are tied to this index.
State Disability Insurance (SDI): A partial wage-replacement insurance plan that the state Employment
Development Department (EDD) pays out to California employees. SDI provides short-term benefits to eligible
employees who suffer a loss of wages when they are unable to work due to a non-work-related illness or injury, or a
medically disabling condition from pregnancy or childbirth. Workers with job injuries may apply for SDI when
there is a delay in or denial of workers' compensation payments. Call (800-480-3287) for more information on SDI.
Stipulated Rating: Formal agreement on permanent disability rating that may require approval by a workers'
compensation judge.
Stipulation (Stip) with Award: A settlement of a case in which the parties agree on the terms of an award. The judge
signs this document to make the award final.
Stipulations(Stip) with Request for Award: A settlement in which the parties agree on the terms of an award.
The stip may include future medical treatment. Payment takes place over time. The judge receives this document
for final review.
Subjective Factors: The amount of pain and other symptoms described by an injured employee that a doctor
reports as contributing to a worker's permanent disability. Subjective factors are of nominal value since under the
2005 rating schedule impairment is to be based upon objective measurement.
Subjective Factors of Disability: Symptoms described by the employee that interfere with the injured employee’s
ability to work. These symptoms cannot be objectively measured, and include pain and emotional symptoms,
especially those that the patient describes as limiting particular activities (8 CCR 9727).
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Summary Rating: The percentage of permanent disability, according to calculations by the DWC Disability Evaluation
Unit.
Summary Rating Reconsideration: The procedure allowing objection to the summary rating determination of
the DWC Disability Evaluation Unit.
Supplemental Job Displacement Benefit (SJDB): A workers' compensation benefit with the following
requirements: The injury occurred in 2004 or later; the employee has a permanent partial disability that prevents a
return to the job the employee was doing on the date of injury; and the employer does not offer other work. The
benefit is in the form of a “voucher” that promises to help pay for educational retraining or skill enhancement, or
both, at state-approved or state-accredited schools.
Supplemental Medical-Legal Evaluation: An evaluation which (A) does not involve an examination of the
patient; (B) is based on the physician's review of records, test results or other medically relevant information which
was not available to the physician at the time of the initial examination; (C) results in the preparation of a narrative
medical report prepared and attested to in accordance with LC §4628, any applicable procedures promulgated
under LC §139.2, and 8 CCR §10606; and (D) is performed by a qualified medical evaluator, agreed medical
evaluator, or primary treating physician following the evaluator's completion of a comprehensive medical-legal
evaluation (8 CCR 9793).
T
Temporary Disability (TD): Entitles an injured employee to payment of benefits when a work related condition
has not yet reached a permanent and stationary status yet the condition prevents the employee from performing all
or part of the usual job duties.
Temporary Partial Disability (TPD): A disability that prevents an injured employee (whose condition is not yet
permanent and stationary) from performing all or part of his or her work duties, but does not completely prevent
the employee from working and earning some money. The basis of partial temporary disability payments is a
calculation of a percentage of the portion of earnings lost.
Temporary Total Disability (TTD): A disability that prevents a employee (whose condition is not yet permanent
and stationary) from performing the usual work, partial work, or modified work assignments.
Transportation Expenses: A benefit to reimburse the injured employee’s out-of-pocket expenses for mileage,
parking, and toll fees related to a claim.
Treating Doctor: See primary treating physician.
Treating Physician: See primary treating physician.
U
Uninsured Employers Fund (UEF): A fund that the DWC uses to pay an injured employee’s benefits if his or
her employer is illegally uninsured for workers' compensation.
Unrepresented Employee: An injured employee who is not represented by an attorney (LC §4062.1).
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Utilization Review (UR): The process, supported by evidence-based medicine guidelines, used by insurance
companies, self-insured employers and third-party administrators to determine whether to authorize, modify, delay,
or deny treatment recommended by the treating physician or another doctor (LC §4610).
V
Vocational Rehabilitation Maintenance Allowance (VRMA): Payments to help the injured employee with
living expenses while participating in vocational rehabilitation. See vocational rehabilitation plan.
Vocational Rehabilitation Plan: A written document describing the program intended and designed to provide
assistance in returning the injured employee to the labor market. A vocational rehabilitation plan may include direct
job placement, on-the-job training, formal training, academic instruction, job-placement assistance, or selfemployment, and income maintenance while an employee completes an academic course of study or pursues an
independent employment or vocational rehabilitation plan.
Vocational & Return to Work Counselor (VRTWC): If the employee has a permanent disability, the VRTWC is
the person or entity who helps the employee develop a return to work strategy. The VRTWC evaluates the injured
employee, provides counseling, and helps the employee get ready to work. The VRTWC may do an evaluation,
provide counseling, and help the employee during placement to return to work. A VRTWC must have at least an
undergraduate degree in any field and three or more years of full-time experience.
Voucher: See supplemental job displacement benefit and nontransferable voucher.
W
Wage Loss (temporary partial disability): See temporary partial disability.
Work Hardening: Programs using conditioning tasks (in conjunction with real or simulated work activities) graded
to progressively improve the biomechanical, neuromuscular, cardiovascular/metabolic, and psychosocial
functioning of the injured employee, to maximize the ability to return to work. In vocational rehabilitation, work
hardening can provide a valid test of the employee’s ability to return to work.
Work Restrictions: Temporary or permanent restrictions of specific activities, body positions, motions, exposure,
and time limitations that the treating or consulting physician places temporarily (to facilitate recovery from the
injury), or permanently (due to the effects of the injury). Restrictions can be actual (due to an inability to perform
the activity) or prophylactic (designed to prevent further injury). Permanent work restrictions are ratable disabilities.
Workers' Compensation Administrative Law Judge: A DWC employee who makes decisions about workers'
compensation disputes and approves settlements. Judges hold hearings at local WC AB offices, and the Reconsideration
Unit of the WCAB may review and reconsider their decisions. Also called a Workers' Compensation Judge.
Workers’ Compensation Appeals Board (WCAB): Consists of 24 district offices throughout the state where
workers' compensation judges initially decide issues regarding workers' compensation benefits. Also consists of the
WCAB in San Francisco which is a seven-member judicial body appointed by the governor and confirmed by the
Senate that holds jurisdiction over Petitions for Reconsideration and other matters stemming from the decisions of
workers' compensation administrative law judges.
Workers’ Compensation Insurance Rating Bureau (WCIRB): An agent of the state Department of Insurance;
and funded by the insurance industry. This private entity provides statistical and rating information for workers'
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compensation insurance and employers’ liability insurance, and collects and tabulates information to develop pure
premium rates.
Workers' Compensation Judge: See Workers' Compensation Administrative Law Judge.
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