On Spinal Surgery Requests

California Workers’ Compensation Defense practice offers few victories – but when they appear, they are sweet and make the whole effort worthwhile.

A recent decision from the Workers’ Compensation Appeals Board, Tomei v. Bay Alarm Company, addressed the application of California Code of Regulations section 9792.6(o).  As some readers might recall, earlier this month your humble author did a post on what constitutes a procedurally proper request for medical treatment.

The skinny:  A request for spinal surgery made in a narrative report must have the words “request for spinal surgery” clearly written by the surgeon across the top of the first page.

Applicant’s treating physician recommended spinal surgery, but the report in which the recommendation was made was in narrative form.  Although CCR 8 § 9792.6(o) allows requests for treatments to be made this way, it also requires “the document [to be] clearly marked at the top that it is a request for authorization.”

This treating physician didn’t mark the narrative report as required by § 9792.6(o), so applicant’s attorney did this for him in blue ink!  The report was sent to defendant with the words “request for treatment” hand-written across the top of the first page by the applicant’s attorney.

The WCAB held that the failure of the surgeon to clearly mark that the narrative report is a request for spinal surgery prejudices the defendant.  Therefore, the letter of the law applies.

In California Workers’ Compensation practice, defendants are given relatively little time to deal with spinal surgery requests.  The lesson here is that, when the physician requesting the treatment does not follow proper procedures, the defendant is shielded by the law.

As a habitual cynic, I can tell you that it is easy to become a perpetual cynic if you don’t keep your pessimism in check.  Cases like this one serve as an example of why it is important to fight for every inch of the relatively limited territory the law affords defendants.

Medical Records of 300k Californians Posted Online

The San Francisco Chronicle has an interesting article on the state of medical records in California.  Apparently, “medical files belonging to nearly 300,000 Californians sat unsecured on the Internet for the entire world to see.”

It appears that a consulting firm working to collect unpaid workers’ compensation bills for doctors and hospitals, mercifully to remain nameless, put the files online.  The firm mistakenly believed that only its own employees could see the files.

I’m a big fan of modern technology in general and the paper-less world especially.  That being said, even though fire was a wonderful invention, it came with its own dangers and to this day it must be handled with care.

Defendants and defense attorneys can benefit greatly from paperless environments – no more coffee-stained original documents; access for the entire office at the same time to any file; service of all medical records by CD or e-mail.

At the same time, records get accidentally attached and sent; e-mails are dispatched that should have been filtered (read: censored) by cooler heads; and, as here, the medical records of unsuspecting individuals are made available for the world to see.

Given the facts of this story, the defendants in the victims’ respective workers’ compensation cases are blameless (and probably safe from liability).  However, such a slip-up could have easily happened to a private investigator firm hired by a third-party administrator or a careless Agreed Medical Evaluator’s office.

In other words, the modern professional need not fear technology or the paperless environment any more than he or she fears a camp fire; but the same attention and care that goes into keeping a camp fire safe and contained should go into keeping that precious information neatly under a tight lid.

As your caveman author chisels this blog post into a stone tablet, he wishes you the safe and successful use of modern technology to increase your efficiency and reduce your costs, hopefully without the price of a privacy and security breach.

On The Inclusion of Medicare C&R Language

Centers for Medicare and Medicaid Services’ (CMS) regulations regarding Medicare Set-Asides have had a devastating effect upon California Workers’ Compensation practice.  Even when the parties want to settle a claim for a legitimate, good-faith amount, the nature of CMS’ approval system makes this nearly impossible.

Presently, CMS will not review set-asides for settlement amounts under $25,000, citing a shortage of man-power.  This means that the parties can settle a claim by compromise and release for under $25,000, only to have CMS later recoup costs from the self-insured employer or the insurer.  Naturally, this proves a strain to settlement negotiations.

Some parties have been adding language as an addendum, shifting the responsibility of all future medical costs to the applicant as part of the Compromise and Release.  A vendor is usually hired (Gould and Lamb is one example, Carr Allison is another) to perform a Medicare Set-Aside Analysis report, providing an estimate of how much future medical treatment will cost.  This figure is ear-marked for that purpose.

In one recent case before the Workers’ Compensation Appeals Board, Isaac v. Paramount Pictures, the validity of this addendum language was tested.  The Workers’ Compensation Judge rejected the addendum language, yet still held the rest of the compromise and release binding upon the parties.

Defendant filed a petition to set aside the order approving the compromise and release.

The skinny:  an addendum to a compromise and release agreement addressing the interests of Medicare may not be rejected by a WCJ without rejecting the entire agreement.

The WCAB ordered the approval of the compromise and release with the CMS addendum included.  The extent to which the addendum language will be binding on CMS down the road is questioned by the WCJ, WCAB, and most likely the parties as well.

But, if nothing else, the efforts on the part of the defense in this case firmly establish that the interests of the Federal Government have been fairly considered, and efforts have been made not to shift any of the burden of applicant’s treatment to Medicare.

If the applicant is on Medicare or is soon to be on Medicare, it’s probably a good idea to include some language in a compromise and release agreement addressing future medical costs.

Liability to Contractor’s Employees

The California Supreme Court recently issued an opinion addressing the extent of liability parties have to the employees of hired contractors.

Jack hires Jill Inc. to have his lawns mowed.  When Jill’s employee hurts himself on Jack’s lawn, is Jack liable?  What if Jack had violated Occupational Safety and Health Administration (OSHA) guidelines on how razor-sharp he can keep his blades of grass?  What if Jack’s own employee, Albert, hurt himself in the same way as Jill’s employee and received workers’ compensation benefits?

The skinny:  a party owes no duty to the employees of its contractors.  Even if two workers get hurt in the same event, the big boss is on the hook only for his own worker, not the employee of the contractor.

US Airways hired a contractor to maintain and operate a conveyor at San Francisco International Airport.  One of the contractor’s employees injured his arm inspecting the conveyor.  As it turns out, the conveyor “lacked certain safety guards required by applicable regulations.”  Fortunately, it wasn’t a back sprain while gently removing luggage from the conveyor.

The Court of Appeals held that the violation of an OSHA safety regulation imposes liability upon US Airways.  According to the Court of Appeals, observing OSHA safety regulations is a non-delegable duty.

The Supreme Court reversed, relying on its opinion in Privette v. Superior Court.  The Court re-affirmed the rule that a hirer owes no duty to the employees of the contractor.

Will this apply to the Workers’ Comp world?  Time will tell how Workers’ Compensation Judges respond to this ruling.  But I have a feeling that the world of Serious and Willful defense will never be the same.

AB 947 Progresses Further

SB-899 and the reforms of 2004 were a triumph for the State of California.  By no means did these reforms fix all the problems in California Workers’ Compensation, but at least some efforts were made to make California semi-profitable (read: survivable) for employers.

One of the regular targets for the chipping-away efforts of applicants, their attorneys, and their treating physicians, is Labor Code § 4656.  § 4656 limits applicants to 104 weeks of temporary disability within a 5 year period.

Temporary disability is meant to provide some semblance of income, 2/3rd of the injured workers’ average yearly wages, while the worker is recovering – treatment, improvement, etc.

That means that someone is paying the employee 2/3rd of his or her income and receiving no labor or benefits in return.

Assembly Bill 947, being pushed by Assemblyman Jose Solorio, would increase the cap on temporary disability to 240 weeks.  You can read the amended text here.  That means the self-insured employer or insurance company would be paying the worker three years worth of salary over the course of five years without seeing any productive labor in return.

Today, the Senate Appropriations Committee will have a hearing on the bill.  Having already worked its way through the Assembly your humble author can only hope that this bills finds a sudden and tragic demise somewhere in the Senate.