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Answers to frequently asked questions about SB 899

GENERAL QUESTIONS

Q. What is the effective date of Senate Bill 899?

A: Most sections of SB 899 became effective on April 19, 2004, the date it was signed into law by Governor Schwarzenneger. Some sections will become effective later on dates specified in the bill, and some sections are retroactive. Many provisions require that the Division of Workers' Compensation adopt implementing regulations.

Q. How do we find out about the status of new regulations as they are developed?

A: Information on new or revised regulations will be posted on the DWC web site at http://www.dir.ca.gov/dwc throughout the rulemaking process That page has a link to an online discussion forum on proposed new rules (the "DWC/WCAB Forum") as well as a link to a "proposed rulemaking" page, which provides the latest information about the status of proposed regulations needed to implement this bill. Also check the "announcements" page, where developments will be announced as they occur. DWC will continue to update these FAQs as more questions arise and more information is available.

Q: What does this bill mean to me?

A: This bill makes major changes to the state's workers' compensation system. It affects injured workers with an ongoing workers' compensation claim or case before the Workers' Compensation Appeals Board (WCAB), as well as all employees in general. It also affects employers, insurance carriers and medical providers. Some of the more common questions we have received to date from these groups are addressed below.

MEDICAL QUESTIONS

Q: Can I still predesignate my personal physician?

A: Predesignation is still possible but only for employees whose employers provide non-occupational health insurance coverage through a group health plan, group health insurance policy, health care organization, or other specified entity. The physician must agree to be predesignated. DWC intends to adopt regulations relating to predesignation of personal physicians.

Q: Can I still change treating physicians after 30 days from the injury?

A: You can change your treating physician after 30 days unless your employer has established a medical provider network. On or after Jan. 1, 2005, an insurer or employer may establish a medical provider network.

Q: What form do I use to request a Qualified Medical Examiner (QME) panel?

A: Use the existing "IMC Form 6 (revised 4/14/00)" until new QME panel request forms are developed. The current form can be found on the DWC Medical Unit's site at www.dir.ca.gov/imc. In the future there will be two forms for requesting a QME panel, one for employees not represented by an attorney and one for represented employees.

Q: What are these new "medical provider networks," and when do they go into effect?

A: Labor Code section 4600 provides that medical provider networks may be established by employers or insurers on or after Jan. 1, 2005. The network must meet certain standards. These include accessibility of care for common occupational injuries and illness, types of providers, continuity of care, medical decision making, and following treatment guidelines. The standards must also include a process for allowing employees a choice of provider in the network (after the first visit) and for getting second and third opinions. If an employer or insurer uses an approved medical provider network, covered employees would receive their medical care in this network, unless a predesignated physician is chosen prior to an injury. Medical provider networks must be approved by DWC before they can be used.

Q: How do we become approved as a medical provider network?

A: DWC will be developing regulations and conducting a rulemaking action over the next several months to govern the process for review and approval of medical provider networks following the provisions of Labor Code section 4616. Labor Code Section 4616.7 specifies that some organizations -- certified health care organizations, health care service plans, group disability insurers, and Taft-Hartley Health and Welfare funds -- may be deemed to be medical provider networks after the DWC administrative director determines that they meet certain additional capabilities.

Q: How do I become approved as an Independent Medical Review physician?

A: DWC will implement a process by which physicians who meet the requirements for IMR can apply and become approved to conduct independent medical review for certain disputed cases of employees receiving medical care in an approved medical provider network. DWC will adopt regulations to govern the application process over the next few months.

EMPLOYER QUESTIONS

Q: We paid $5,211 in medical expenses on a claim that was subsequently denied. Can we seek reimbursement from the employee's health insurance carrier to recover our costs?

A: Section 5402 of the new statute requires the employer to authorize medical care within one day of receipt of a claim form and to reimburse for all medical treatment in accordance with the American College of Occupational and Environmental Medicine's (ACOEM) guidelines or utilization schedules adopted by the DWC administrative director. Until the claim is accepted or denied, liability for medical treatment is limited to $10,000. The legislation does not address an employer's recovery rights on denied claims.

Q: When can I expect my premiums to drop as the result of SB 899?

A: Insurance rates are set by the individual insurance carriers, although the State Insurance Commissioner recommends advisory rates. The Insurance Commissioner's future rate recommendations are expected to reflect cost savings contained in this bill, and in fact, on May 28, 2004 the commissioner announced his decision to lower the advisory rates by 20.9 percent for policies that begin on July 1, 2004, based on the impact of the 2003 reform bills as well as SB 899. In addition, SB 899 requires the DWC administrative director, in consultation with the Insurance Commissioner, to study the cost savings from the 2003 and 2004 reforms and issue a final report to report to the Governor, and others, by Jan. 1, 2006.

Q: How do I request reimbursement for my out-of-pocket expenses in returning an employee back to work under the new return-to work-program?

A: For employers with 50 or more employees, the DWC administrative director is required to adopt regulations to establish a return-to-work program to promote the early and sustained return to work of employees following a work related injury. These regulations will include procedures for requesting reimbursement for workplace modifications. To the extent funds are avaialable, employers with 50 or fewer full-time employees may be eligible for the reimbursements for workplace modifications to help an employee return to work if that employee is injured on or after July 1, 2004. Announcements regarding this new program will be posted to the DWC web site when further information is available.

Q: I am an insured employer. What do I need to do if I want to use a medical provider network for my employees?

A: As an insured employer, you should talk to your workers' compensation carrier about a Medical Provider Network. It is voluntary for insurers and self-insured employers to set up such a network. If your insurer is approved by the Division of Workers' Compensation for a Medical Provider Network, your injured employees would receive medical care through the insurer's network. Insured employers do not set up their own network.

INJURED WORKER QUESTIONS

Q: I was injured on July 28, 2002, prior to the enactment of SB 899. Does the 104-week limit on temporary disability payments apply to my claim?

A: No. The 104 week cap on temporary disability payments applies to injuries that occur on or after April 19, 2004.

Q: After 30 days do I have the right to change treating doctors to another chiropractor when my first chiropractor has exceeded 24 treatments and the carrier will not authorize more?

A: The statutory provision relating to the right to change treating doctors after 30 days is separate from the provision capping chiropractic treatment at 24 visits. There is nothing in the statute that says an injured worker can receive more than 24 chiropractic visits merely because he or she wishes to change physicians.

Q: My date of injury is Jan. 2, 2004, and I've seen my chiropractor 11 times already. Do these visits count toward the 24 visit cap?

A: Yes. The limitation on chiropractic visits applies to dates of injury on or after Jan. 1, 2004.

Q. My date of injury is Dec. 15, 2003. Do the limitations on chiropractic and physical therapy visits apply to my claim?

A: No. The limitation on chiropractic and physical therapy visits apply to dates of injury on or after Jan. 1, 2004. However, the American College of Occupational and Environmental Medicine's (ACOEM) guidelines for medical treatment apply, regardless of the date of injury.

Q: When is the new permanent disability rating schedule (PDRS) going to be adopted and what cases will be affected?

A: Labor Code Section 4660 requires the DWC administrative director to adopt a new PDRS on or before Jan. 1, 2005. The statute states that the new schedule will apply to any case, regardless of date of injury, so long as none of the following events have occurred before the adoption date of the schedule: issuance of a comprehensive medical-legal report, issuance of a treating doctor's report indicating permanent disability, or the employer has been required to issue the Section 4061 notice at the time of last payment of temporary disability. Labor Code section 4660 contains the specific statutory language.

Q: How else was my permanent disability affected by this bill?

A: Apportionment -- how an injured worker's permanent disability can be reduced due to a prior award or condition -- was modified by SB 899. The bill requires that disability shall be based on causation and that all permanent disability reports consider what portion is attributable to the work injury. The bill also establishes a presumption that any prior award of permanent disability exists at the time of any later injury. Finally the bill allows no more than 100 percent in permanent disability for seven specified body parts over the employee's lifetime.

Q: Does my treating doctor still have the presumption of correctness?

A: The presumption of correctness of the treating doctor's opinion has been repealed for all cases regardless of the date of injury.

Q: Does SB 899 change the medical evaluation process for employees not represented by an attorney?

A: Yes. Unrepresented injured workers seeking workers' compensation benefits must now select a Qualified Medical Evaluator (QME) from a panel of three evaluators provided by the DWC Medical Unit to resolve claims disputes on both accepted and denied cases. When requested by the insurance company, there is a ten-day time frame for the injured worker to submit the "Request for QME" form to the DWC Medical Unit. The "Request for QME" must indicate the QME specialty requested. If the unrepresented worker does not submit the "Request for QME" form to the DWC Medical Unit within the ten day time frame, the insurance company may submit the form and choose the specialty of the physician for the unrepresented worker. Within ten days after the DWC Medical Unit issues a panel of three QMEs, the employee has ten days to select a QME, make the appointment and communicate the information to the insurance company. If the employee fails to meet these time deadlines, the insurance company may choose the QME and the date and time for the appointment for the injured worker.

Q: Does SB 899 change the medical evaluation process for employees represented by an attorney?

A: Yes. However, the QME panel process for represented injured workers applies to injuries occurring on or after Jan. 1, 2005. In these cases, the parties must try to select an agreed medical examiner (AME). If no agreement is reached within ten days, either party may file a "Request for QME" form with the DWC Medical Unit. The "Request for QME" must indicate the QME specialty requested and the specialty of the treating physician if known. Within ten days after the DWC Medical Unit issues the panel of three QMEs, the parties have ten days to agree upon a QME selected from the panel to serve as an agreed medical evaluator (AME). If the parties do not agree on an AME by the tenth day, each party may then strike one name from the panel of QMEs. The remaining QME shall serve as the medical evaluator. A party loses the right to strike a QME from the list if the party fails to exercise its right to strike a QME within three working days of gaining the right to exclude an examiner.

Last Updated June 22, 2004