Should a “carve out”
be in your future?
CAJPA 2012
Patti Williams, ARM, WCCP
Risk Manager
The passing of SB 899 in 2004 amended Labor Code section 3201.7 to
include Cities as having the ability to carve-out aspects of workers’
compensation claims.
Carve-out programs allow labor-management agreements for
alternative dispute resolution of workers’ compensation claim issues
defined by the agreement.
This is a voluntary program enabling public employers to “opt-out” of
the State of California workers’ compensation program when there is a
dispute in medical opinions.
This program utilizes physicians from an agreed upon IME list, rather
than Agreed Medical/Qualified Medical Examiners.
When a determination needs to be made regarding
compensability of the claim for AOE/COE.
The nature and extent of the injury and permanent
disability.
Workability – work restrictions and duration of TTD.
Utilization Review disputes.
Second opinions for spinal surgery.
Program is for active sworn employees and retirees who
claim a presumptive injury within 5 years of retirement.
An ADR program is used to help reduce the amount of time
required to resolve a medical dispute with respect to a
workers’ compensation claim.
This can decrease litigation and improve employee morale.
Ensures the employees will receive a prompt evaluation
when their claim involves a dispute.
This helps both the employer and the injured worker by
reducing costs and determining the ability or inability for
the claimant to return to work.
The Police Officers Association and the Firefighters
Association approached the City Management team and the
Human Resources Department/Risk Management
regarding the delays as well as other issues their members
were having regarding medical treatment and related
benefits.
Risk Management researched carve-out programs and
decided to proceed with the ADR process.
Meetings have been held with union representatives as well
as their attorney. The Risk Manager, representatives from
TPA and defense attorney present.
Discussions regarding the objectives of program as well as
everyone’s role and responsibilities took place.
Also had discussions regarding the selection process and
criteria for the IME physician panel.
Review MOU’s to amend or do a side letter to include the
ADR Carve-Out program and process.
Unions must provide evidence they are a bona-fide labor
organization, must submit Petition for Permission to
Negotiate a Section 3201.7 Labor-Management Agreement to
the State.
Provide contact information for Union groups and City
representatives/TPA representatives to the State.
DWC website has pamphlets available on how to create a
carve-out in California.
Develop IME panel list that is agreeable to Unions, City and/or their
representatives. Both parties will be bound by the decision of the IME.
Goal is to choose physicians based on their ability to be impartial and
maintain compliance with timelines for evaluations and reports. In
addition, they must have a good understanding of workers’
compensation process and importance of return to work issues.
Need to have enough specialists in each field to have the program
work properly.
Need to develop contracts for IME physicians to agree with.
We will have a special meeting for IME physicians and/or their
representative to attend to review their responsibilities.
Depending on your Organization’s processes, may need to go to
Council to approve any and/or all documents.
IME evaluations are utilized upon written request of dispute
resolution.
IME’s are rotated within specialties. For example, if there are five
orthopedic specialists, you would use them in order.
The IME fee schedule is somewhat higher than the OMFS.
IME must schedule appointments within 30 days of contact from the
Risk Manager, claims examiner or authorized delegate.
Reports must be received by claims examiner within 30 days from
appointment. If tests are required, they must be completed within 14
days of examination and report will be due 30 days from that date.
The IME must write reports that are compliant with AMA guidelines.
The IME can only do evaluations, cannot provide medical treatment.
Provide payment to IME physician with 45 days of receipt of
billings.
Inform concerned parties if an IME will be removed from
the panel for any reason, such as breach of contract or upon
mutual agreement of both parties.
Tracking must be done to ensure the physicians are meeting
the requirements of the timeline and are submitting
compliant reports.
Additional tracking needs to take place to determine the
length of TTD vs. RTW.
The employee must provide statement upon request.
The employee must provide fully executed medical,
employment, financial releases and any other documents
reasonably necessary for Agency to resolve employee’s
claim when requested.
The employee will agree to a deposition when requested.
The employee shall be responsible for providing the claims
staff with his/her work schedule prior to an appointment
being made so that appointments can be made during an
employee’s nonworking hours or the first or last hour of
his/her workday.
The amount of time allotted for hours spent at a physician’s
appointment during working hours will be subject to
verification and will be allowed accordingly.
Continuing and ongoing communication with all involved
parties is necessary for success.
Keep union representatives informed on progress of
implementation process on a regular basis.
Continuing communication with claims examiners is critical
to ensure the program is being administered properly.
I hope this has been of some benefit to you.
Questions?