The 2004 workers’ comp reforms made conservative changes to all aspects of workers compensation benefits. The mandated use of the American Medical Association Guides to the Evaluation of Permanent Impairment reduced permanent disability awards by more than 50%.

Attorneys for injured workers reacted by inventing what is now known as the "California Add-ons".This concept exploits chapters in the AMA Guides for seemingly non related impairment such as sleep disturbance, gastrointestinal distress, psychiatric injury and more.This presentation will cover how to deal with sleep disorder claims, one of the current California Add-On's.

• Introduction:Sleep disorder claims are also part of what is now called the “California Add-Ons” which applicant attorneys pursue to increase permanent impairment under the AMA Guides 5^th Edition.
  

• Industrial Causation and ApportionmentThe AMA Guides contemplates that a ratable sleep disorder be caused by problems with the nervous system, or mental and behavioral factors,or problems with the cardiovascular or hematopoietic system.Recent case law provides that causation of sleep disorders cannot be based solely on a consequence of pain which is often the theory of the claim. We will learn how to see the telltale signs of what is and is not industrial in origin.

• Dealing with Excessive Assessment Costs: Employers often are billed thousands of dollars for “sleep lab” studies that make assessment costs more serious than the potential cost of the permanent disability that is claimed. We will show how to minimize or avoid these costs by using recent assessment guidelines published by the AmericanAcademy of Sleep Medicine.
  

• Detection of Malingering:The sleep lab study known as polysomnography that is often obtained in a sleep disorder claim is not appropriate for forensic use.Instead, newer and cheaper tools known as actigraphy will help determine if a sleep disorder claim is authentic or exaggerated.We will discuss guidelines that can be used to obtain the correct forensic assessments at a much lower cost.

• Impairment:Assuming that a sleep disorder claim is not exaggerated and is industrially related, our final topic will discuss strategies that can minimize the level of permanent impairment that is claimed.

Introduction - History and Principles of Workers’ Compensation – Landmark Political Reform Measures and the Historical “Stress Claim Stigma”. The “Perfect Storm”, Unicover and Stock Market Losses. Organization and Stake Holders. Current political socio-economic climate.

Threshold Issues of Compensability – Basic Concepts of Injuries, Employment and AOE-COE

Benefit Scheme
a) Medical Care and Benefits - Treatment Issues. UR and ACOEM Guidelines
b) Temporary Disability Benefits
C) VR, Supplemental Job Displacement Benefits, Return to Work Incentives
d) Permanent Disability Benefits, AMA Guides and Apportionment
e) Death Benefits – Suicide

Penalties, Extraordinary Remedies. Audits and Enforcement. Penalties for Delay. Serious and Willful Misconduct. 132a

Physician Duties and Responsibilities – Specialist Reporting Requirements, Medical Legal Benefits. Substantial Evidence Rule

Introduction to Worker’s Compensation Informal Dispute Resolution and Litigation. The AME/QME process. WCAB Litigation Process and Statutes of Limitations.

The California workers compensation system is a no-fault system which means that the injured worker need not show fault such as negligence on the part of his employer in order to recover benefits. However, although fault is not required, the claimant must show that an "injury" occurred and that it "arose out of employment". The acronym for this is called AOE-COE or "Arising Out of Employment and Course of Employment. Thus, if an injury is found to be AOE-COE that means the threshold issues have been met and the claimant should recieve the scheme of benefits.

Once a claim has been made of an industrial injury by an employee, the employer or their carrier must conduct a thorough investigation to determine if the claim is authentic, and what benefits are payable. Investigation is therefore a required job skill for professional claims administrators and attorneys. The administrator may not restrict its investigation to preparing objections or defenses to a claim, but must fully and fairly gather the pertinent information, whether that information requires or excuses benefit payment. This course will discuss essential investigatory tools and methods used for basic AOE-COE investigations and more advanced topics including the SIU investigation of potentially fraudulent claims.

One of the major benefits provided by the California workers compensation system is medical care to cure or relieve from the effects of an industrial injury. Safeguards have been implemented to contain costs. One safeguard is called utilization review (UR) which provides a method for the review of a request for treatment requests to determine if they are medically necessary. UR applies standards called "evidence based medicine" which are published in various treatment guidelines such as the ACOEM (American College of Occupational and Environmental Medicine) Guideline which is incorporated into the California Medical Treatment Utilization Schedule (MTUS). This course will cover the following topics.

Medical Care - General Concepts Provision of Care. Escalation of Costs. Cost Drivers and Solutions. Access to Care Issues.

Price Controls – Fee Schedules OMFS. Payment Calculations. Abuses

Quantity Controls - Evidence Based Medicine EBM General Concepts. Next Step -Pay for Performance. Functional Restoration. Measurement Concepts.

Quantity Controls – ACOM/MTUS Implementation Transition to MTUS. Rebuttal of MTUS. Chapter 12-Low Back. Acupuncture. Pain Guideline.

Implementation of ACOEM/MTUS with Utilization Review Mandatory Plan. UR Reviewers. Time Limits. Types of Review. Penalty Regulations. Hard Caps. Recent Cases.

Quantity Controls- Spinal Surgery Second Opinion Process (SSSOP) Cost Drivers. CPT Codes. Voicing Objections. SSSOP Evaluations. Agreement and Disagreements.

Price and Quantity Controls – The MPN. Voluntary Implementation. 2nd and 3rd Opinion Process and IMR.

AME–QME Dispute Resolution Historical Provisions. QME Process for Represented and Unrepresented Workers. Proposed New Regulations.

Most industrial cases involve complex medical evidence. Physicians provide such evidence by way of narrative medical reports. The California WCAB disfavors the presentation of medical evidence by way of live testimony. There are standards that are used to determine if medical evidence is admissible, and persuasive and if the report is substantial evidence to support an award. This course will discuss the following topics.

Evidence - General Concepts Role of Claims. Burden of Proof. Admissibility vs Weight.

Statutory and Common Law Rules of Evidence. Rules Precluding Admission. MSC Statements, LC 4061/62 Objections. LC 4628 Objections. DWC Protocols, Face to Face Time. Service of Reports.

Scientific Evidence Standards Daubert and Fry Federal Standards, Weak and Strong science. Measurement of Strength of Science Standards in Utilization Review Issues.

Rules that Effect Weight Given to Medical Reports Substantial Evidence Rule. Single Reports and Range of Evidence. Lay Testimony Alone. Use of a Factual Timeline. Making “Sense” and People v Bassett. Expertise and Methodology. Probability vs Possibility. AMA Guide Standards and Rule 10606

Case Studies General Strategy When Reviewing Medical Evidence.

One of the several benefits paid by California workers' compensation is a permanent disability benefit. The calculation of the value of the benefits requires the use of the AMA Guides 5th Edition and the Schedule for Rating Permanent Disability. An estimate of this calculation is also required for reserving and negotiation prices. Topics in this class include the following.

Rating Permanent Disability Versions of PDRS. Which version to use. Rating Formula. FEC, Occupation and Age Adjustments. Combining and Adding. 15% Step Up/Down Examples and Exercises. Presumptions.

Introduction to the AMA Guides Historical Issues. Basic Concepts. General Overview. Introduction to the Quick Reference Guide. Spine Injury Examples.

Apportionment of PD Apportionment Rules Before and After S.B. 899. Pathology and Speculation. Calculation Using Formula A. Benson Case

Life Pensions Formula and Calculators

Commutation of Permanent Disability Authority, Grounds and Examples.

Reserving Rules for Insurance Companies and Self Insured. Use of Quick Reference Chart. Review and Adjustments.

Claim Evaluation and Negotiations Claim Evaluation Tangible and Intangible Factors. Types of Settlement. Intended Resolution Point. Negotiation Psychology. Transcending Impasse.

California has now mandated the use of the AMA Guides, 5th Edition. Physicans, attorneys and other claim professionals must now learn how to apply the hundreds of tables and charts contained in the Guides. This course walks you through all of the chapters of the Guides, and simplifies the task of learning by finding just those sections that apply to common every day claims. In this way the task of learning is greatly simplified. This course has been given for four years to a variety of professional audiences, and has been praised for making learning the Guides straight forward and manageble.

CE Credit. Rene Thomas Folse, JD, Ph.D. is approved by the American Psychological Association to sponsor continuing education for psychologists (#1948), and the California Bar Association (#11240) to sponsor MCLE programs for attorneys and the firm of Floyd, Skeren & Kelly is approved to give Legal Specialization Credit (#13169) and they maintain sole responsibility for this program and its content. Attorneys may receive 6 hours of MCLE or Legal Specialization in Workers' Compensation credit, and psychologists may obtain 6 hours of CE for taking this course online.

The California legislature has created various penalties and sanctions to help insure that parties will comply with the provisions of the labor code. When violations are alleged, then if proven, penalties and sanctions may apply. This course covers the more common claims for penalties, sanctions and other extraordinary remedies as follows:

• Serious and Willful Misconduct
• Penalties for Delay
• Bad Faith Claims
• Costs and Attorney Fees
• 132a Discrimination
• SIF Benefits
• Concluding Remarks

Essentially workers compensation benefits have statutory restrictions on assignment of benefits to any third parties. In instances where a third party claims some right to claim an injured workers' benefits, the person making such claim is called a lien claimant, and they document their position by filing a "lien" claim in the litigation case. The most common lien claimant is a medical treatment provider who has not been paid the fees to which they feel they are entitled. The following topics are discussed.

Introduction, Lien Definition and Types Limits on Benefit Assignment

Liens Against Compensation Attorney Fees. Inadequate Withholding. Fees during Subrogation. Reasonable Living Expenses. Neglected Family. ADFC and County Welfare. Child Support. Group and EDD Disability. Baird Formula
Victims of Violent Crimes

Other (Conditional) Liens Medical Legal Liens. Non Medical Litigation Costs. Interpreter Fees. LC 5811 Costs.

Medical Treatment Liens. Non Medical Provider Liens (3d Party Payers). Gregory Formula. Direct Provider Liens. Threshold Issues. Failure to Object, Thomas Findings. Strategic Disadvantage of Liens. Medical Control. Qualifications of Provider. Corporate Status and FBN Statements. Kickbacks and Referral Fees. Medical Necessity. MTUS. Employer Dilemma. Reasonable Value. OMFS. Medical Transportation. Repackaged Pharmaceuticals. Interpreters. Housekeeping and Attendant Care.

Penalties and Sanctions Applicant. Treatment, Med-Legal, and Non Providers.

Lien Litigation Procedure. Time Limits. Filing and Service. Post Settlement Process.

The California system of Workers' Compensation has its own adjudication system known as the WCAB. Although most litigation is accomplished by attorneys, the labor code allows non attorneys to litigate claims as well. Non attorneys are known as hearing representatives, and they are commonly used by some insurance companies. This is a basic course about litigation before the WCAB. It is appropriate for hearing representative and new attorneys who desire to litigate cases before an Administrative Law Judge of the WCAB. This course will cover the following topics.

• Preparation Process and The IRAC Framework
• Rules of Law – Legal Precedents
• Timeline Preparation and Issue Spotting
• Discovery & Investigation Methods and Tools
• Negotiation and Negotiation Strategy
• Rules of Evidence
• Trial Planning and Procedure
• Examination of Witnesses
• Reconsideration and Appeals

The Self Insured Examination will be given in November, 2009. If you intend to take this examination, you may wish to take a review course to help you prepare. This is a twelve hour course that covers the following topics.

1. Introduction to the SIA Examination and Test Taking Strategies
2. Mandatory Training Requirement for Claims Professionals
3. The Administration of Self Insured Programs
4. The Claim Process Workflow and Time Limits
5. Claim File Reserving Requirements
6. Subrogation
7. Audits and Compliance
8. Industrial Medicine Fundamentals
9. Death Benefits
10. Jurisdiction and Injury AOE-COE
11. Course of Employment
12. Earnings
13. Temporary Disability Benefits
14. Rating Permanent Disability
15. Utilization Review
16. Medical Provider Networks
17. SSSOP - Spinal Surgery Second Opinion Process
18. QME Process

This is a fast paced, advanced level course. It assumes that you have a basic understanding of the fundamentals of workers' compensation, and professional experience handling claims. The course will discuss advanced issues in each one of the above topics.

This two hour course is about the defense of Workers' Compensation psychiatric claims under California Law. It begins by discussing the latest cases defining injury, predominant cause, and apportionment using the causation standards of labor code section 3208.3 and the S.B. 899 apportionment rules, and concludes with a discussion of the Clinical Detection of Deception and Malingering using tools mandated by the DWC Psychiatric Protocols and the AMA Guides. It was recorded live on February 19, 2009 in Long Beach California during a presentation to claim professionals.

CE Credit. Rene Thomas Folse, JD, Ph.D. is approved by the American Psychological Association to sponsor continuing education for psychologists (#1948), and the California Bar Association (#11240) to sponsor MCLE programs for attorneys and the firm of Floyd, Skeren & Kelly is approved to give Legal Specialization Credit (#13169) and they maintain sole responsibility for this program and its content. Attorneys may receive 2 hours of MCLE or Legal Specialization in Workers' Compensation credit, and psychologists may obtain 2 hours of CE for taking this course online.

Claims of psychiatric injury are perhaps the most difficult and complex claim in California workers compensation. This is an advancded course that covers the topics in our basic two hour course in greater detail. The topics in this advanced course are as follows:

• Rating Psychiatric Claims
• Causation and Apportionment.
• Basics of Psychological Testing.
• Detection of Malingering
• Psychiatric Claim Investigation
• Evaluation & Cross-Ex of Experts.
• Case examples

This course is designed to keep the busy professional up-to-date with the latest developments in Workers' Compensation in California. Enrollment in this course includes unlimited searchable access to the online, up-to-the-minute version of Judge David O'Brien's text California Worker's Compensation Claims and Benefits. This treatise is edited daily, and always up to the minute.

Additionally the full text of recent decisions, and new statutes will be available. There is no better way to stay current than enrolling in this annual course.

A practicum is a course, often in a specialized field of study, that is designed to give students supervised practical application of a previously studied theory. A symposium is any academic conference, or a style of class characterized by an openly discursive rather than lecture and question–answer format. This course will serve as both a Practicum and a Symposium for the Defense.

This will be an ongoing opportunity to learn from colleagues, about topics raised by the students and then embellished by other students. There will be an open ended format with opportunities to use forums, chat areas and other resources all of which are confidential, and readable only by other members of this class. Enrollment is strictly limited to defense professionals who will be screened and vetted by WorkCompAcademy before the are admitted. The topics of conversation will be limited strictly to topics of interest to the defense community. This will include discussions about new cases or statutes, approached to problems encountered in your everyday practice, concerns about attorneys, judges, or physicians you meet along the way, and any other subject that might be appropriate from the defense point of view.

This course was recorded during the live training in Los Angeles on July 31, 2009. Admission is restricted to claims professionals who are members of the CIGA defense teams. The topics and list of presenters are as follows:

1. Pharmacy Trends and Clinical Management: Jim Andrews, R.Ph. Senior VP, Operations Cypress Care
2. Using Clinical Pharmacy Reviews to Mitigate Costs in Workers Compensation: Angie Hefner, Senior Account Executive – Cypress Care: Frank E. Carbonara, Esq., Guilford, Steiner, Sarvas and Carbonara LLP
3. Case Law Development and Statutory Defenses: Richard Guilford, Esq., Guilford, Steiner, Sarvas and Carbonara LLP
4. Medicare Secondary Payer Claims: Frank E. Carbonara, Esq., Guilford, Steiner, Sarvas and Carbonara LLP
5. Medical Provider Network Update - General Litigation Guidelines, Common Legal Issues and Adverse Awards: Barbara Hester, CIGA MPN and UR Manager, Frank E. Carbonara, Esq., Guilford, Steiner, Sarvas and Carbonara LLP

CE Credit

Attorneys may receive 6 hours of MCLE or Legal Specialization in Workers' Compensation credit, and Claims Professionals may obtain 6 hours of continuing education credit for taking this course online.

To enroll in this course please call Rene Thomas Folse, 805 907 6467.