The California Workers’ Compensation Appeals Board issued its first en banc decision in almost a year, addressing the parameters of acceptable communications with agreed medical evaluators.
Labor Code Section 4062.3 requires that the parties to a comp case must both consent to any “information” being provided to an AME.
The California Code of Regulations further imposes an obligation on any party who wishes to provide information to an AME to furnish a copy of the information to opposing counsel at least 20 days before the information is provided to the AME. If the opposing party objects within 10 days, the party cannot provide the information to the AME without an order by a workers’ compensation judge.
In the En banc decision of MAXHAM vs. CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION; STATE COMPENSATION INSURANCE FUND ADJ3540065 (SAC 0361552) the WCAB held that:
1. “Information,” as that term is used in section 4062.3, constitutes (1) records prepared or maintained by the employee’s treating physician or physicians, and/or (2) medical and nonmedical records relevant to determination of the medical issues. 2. A “communication,” as that term is used in section 4062.3, can constitute “information” if it contains, references, or encloses (1) records prepared or maintained by the employee’s treating physician or physicians, and/or (2) medical and nonmedical records relevant to determination of the medical issues.
DIR Combats Workers’ Compensation Fraud, Stays 200,000 Liens with Claim Value of Over $1 Billion Issues report on efforts to reduce medical provider and premium fraud Oakland—The Department of Industrial Relations (DIR) today filed a report on its antifraud efforts in the California workers’ compensation system, and announced it has stayed more than 200,000 liens worth a combined claim value of more than $1 billion. The liens are associated with 75 medical providers facing criminal fraud charges. DIR’s efforts to eliminate medical provider fraud and illegitimate liens were bolstered by two new laws effective January 1: • SB 1160 (Mendoza) requires DIR to automatically stay liens owned by providers who have been indicted or charged with crimes until the disposition of criminal proceedings. • AB 1244 requires the Division of Workers’ Compensation (DWC) Administrative Director to suspend any medical provider, physician or practitioner from participating in the workers’ compensation system when convicted of fraud. DWC has adopted provider suspension regulations and is now issuing notices of suspension to convicted providers. “Over the past year, we have worked to prohibit criminal and indicted providers from lining their pockets through liens,” said DIR Director Christine Baker. “Removing fraudulent providers and their lien claims from the workers’ compensation system will further improve services to injured workers and ultimately reduce costs in the system.” DIR has posted information on its fraud prevention efforts online, including information on indicted medical providers. DIR is leading an effort to identify and address strategies for improved anti-fraud efforts in the workers’ compensation system. DIR and the Department of Insurance convened working groups last June to gather stakeholder input and evidence of fraudulent activity. At the direction of the Secretary of the California Labor and Workforce Development Agency, DIR prepared a report on further recommendations to the Governor and the Legislature. The report identifies premium fraud – through which unscrupulous employers seek to lower costs by underreporting payroll, misclassifying employees, or misreporting workers in high-risk occupations as engaged in low-risk occupation – as warranting the next series of significant anti-fraud policies.