LFLM Workers’ Compensation Newsletter – June 2022
June 3, 2022
LFLM is proud to share our new LFLM June 2022 Workers’ Compensation Newsletter
Our Articles in this edition of the Newsletter:
Utilization Review Denials v. Utilization Review Deferrals
Ever since utilization review (UR) became a mandatory requirement for all medical treatment requests, there have been numerous attempts to challenge not only individual UR determinations and the timeframes in which they have to be made, but the entire UR framework itself. Usually, these challenges came in the context of UR denials; however, very few if any cases have explored the idea of utilization review deferral. Deferral of utilization review pursuant to Labor Code §4610(l) and California Code of Regulations (CCR) §9792.9.1.(b) is an often misunderstood procedural remedy where a requested treatment is disputed on grounds unrelated to medical necessity. Conflating the two separate procedures utilized for denials on medical necessity, and deferrals on legal grounds, can have potentially disastrous outcomes, and it is important to be aware of the difference.
The UR process is used by employers and claims administrators to determine whether a request for treatment is medically necessary. Labor Code § 4610 and California Code of Regulations § 9792.9.1 outline the procedural requirements for UR decisions.
New Workers Compensation Regulations and Guidelines: What’s it Worth?
There have been significant changes in workers’ compensation regulations and guidelines recently that have arguably increased the value of claims. In April 2021, The California Department of Industrial Relations, Division of Workers’ Compensation’s (DWC) new medical-legal fee schedule went into effect. The new fee schedule drastically increases medical-legal costs and may prompt defendants to consider whether early settlement may be more cost-effective.
Additionally, earlier this year, version 3.5 of CMS’ Workers’ Compensation Medicare Set Aside Reference Guide was published including a new regulation targeted at non-submit and evidence-based Medicare Set-Aside (MSA) allocations. This new regulation creates a risk for defendants who choose to forego the Centers for Medicare/Medicaid Services (CMS) review process.
UPCOMING CONFERENCES & EVENTS
June 8 – 10, 2022
Disneyland (Anaheim, CA)
Demetra Johal, Managing Partner of LFLM Los Angeles, will be presenting “It’s Your Turn: Ask the Legal Experts” on Thursday June 9 at 1:45pm.
August 21 – 24, 2022
Michelle Sebring, Partner in LFLM San Diego, will be presenting “Late Night!… with Workers’ Comp”. Date & Time TBD
September 13 – 16, 2022
Vicki Lindquist, Partner in LFLM Oakland, will be presenting “Blast Off into Discussions of Rebutting and Defending Against PTSD Claims”. Ms. Lindquist will be presenting with Dr. Tyrone Spears, Division Chief, City of Los Angeles and Dr. Ron Heredia, Director, Good Mood Legal. Date & Time TBD
Laughlin, Falbo, Levy & Moresi, LLP.