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 socioeconomic climate.
Threshold Issues of Compensability AOE-COE Basic Concepts of Injuries, Employment and AOE-COE
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 AOE-COE 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.
- Getting Started Part I - Getting a New Loss and Investigation (37 Minutes)
- Getting Started Part II - Where to Begin Part I (34 Minutes)
- Getting Started Part III - Where to Begin Part II (26 Minutes)
- The Three Point Contact Part I (36 Minutes)
- The Three Point Contact Part II - The Decision-Making Process (35 Minutes)
- Statutory Defenses Part I (28 Minutes)
- Statutory Defenses Part II - The Post Termination Defense (27 Minutes)
Overview of Liens" explains what a lien is and how to handle them as a
claims adjuster. Join Dennis Knotts, adjuster veteran, on a journey of
the lien process, learning from his experience and techniques in handing
lien claims. This 1.25 hour course covers the following topics:
Part 1 - What is a Lien, Types of Liens, and Conditions of Compensation (17 Minutes)
Part 2 - Medical Control and Medical Necessity (27 Minutes)
Part 3 - Case Law, Statute of Limitations, and the Lien Filing Fee (15 Minutes)
Part 4 - OMFS and IBR (19 Minutes)
This course goes over many of the changes to Liens and UR due to legislation taking effect in 2017 and 2018. Suzanne P. Honor-Vangerov, Managing Attorney of Floyd, Skeren & Kelly's Lien Unit leads the charge to 2017 with this informative presentation.
The course consists of:
1: Speech from California State Senator Tony Mendoza.
2: Utilization Review Update - John Riggs, Manager of Workers' Compensation in Disneyland, and Jay Garrard, CEO of GSG Associates, Inc.
3: Lien Provisions of SB 1160 - by Suzanne Honor-Vangerov, Managing Attorney Lien Unit, Floyd, Skeren & Kelly LLP.
- Preparation Process and The IRAC Framework
- Rules of Law and Legal Precedent
- 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
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 ACOEM/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 Ã¢â‚¬â€œ 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.
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.
Qualified medical evaluators (QMEs) are qualified physicians who are certified by the Division of Workers' Compensation - Medical Unit to examine injured workers to evaluate disability and write medical-legal reports. The reports are used to determine an injured worker's eligibility for workers' compensation benefits. QMEs include medical doctors, doctors of osteopathy, doctors of chiropractic, dentists, optometrists, podiatrists, psychologists and acupuncturists.
This 2 hour course is designed to help practitioners meet the regulatory requirements so that a QME panel can be obtained on the first try. The Labor Code and QME regulations have been amended in 2013 to comply with newly enacted S.B. 863. This course discusses these changes.
Prior to becoming an attorney, the instructor, Suzanne Honor-Vangerov, was the Manager of the DWC Medical Unit. As the Medical Unit Manager she oversaw the Qualified Medical Evaluator, Spinal Surgery Second Opinion, Medical Provider Network, and Utilization Review programs.
- Serious and Willful Misconduct
- Penalties for Delay
- Bad Faith Claims
- Costs and Attorney Fees
- 132a Discrimination
- SIF Benefits
- Concluding Remarks
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.
- Introduction to tort law.
- Spotting the case
- Investigation techniques
- Civil discovery rules
- Civil litigation basics
- Rules for obtaining credit at the WCAB
- Formulas for computing comparative negligence
In mid 2013 S.B. 863 passed the state legislature, and was soon signed by Governor brown. The new law brings wide-ranging changes to California's system for treating and compensating injured and ill workers.
Key elements of SB 863 would increase permanent disability benefits by $740 million - an average hike of about 30 percent - and would create a $120 million program for workers injured severely enough that they cannot go back to a job at their previous wage level. It would pay for the increased benefits by squeezing medical costs and administrative procedures.
This two hour seminar will guide you through this new law, and will focus on "what changed?" The 85 new or amended statutes are organized by topic. Topics include what changed in Jurisdiction, Insurance Coverage, Permanent Disability Benefits, Medical Care, Lien Claims, The AME/QME UR, IBR, IMR, and SSSOP Process, and to the Practice and Procedure before the WCAB.
Two hours of MCLE or Continuing Education credit for adjusters will be given for taking this class. To enroll please call 805 341-2296.
The Official Medical Fee Schedule (OMFS) is promulgated by the DWC administrative director under Labor Code section 5307.1 and can be found in sections 9789.10 et seq. of Title 8, California Code of Regulations. It is used for payment of medical services required to treat work related injuries and illnesses.
Medical coding is the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes. The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician's notes, laboratory and radiologic results, etc.
This course is an introduction to coding medical treatment bills and using the OMFS.