1. California Workers’ Compensation
Make California WC Great Again
Jerry Ferris, ARM
Ferris Risk Solutions, LLC
(940)
Lesley Feldman, ESQ
Lesley Feldman Law
(818)
Paige Newbold, CWCP
LivHOME, Inc.
(800)

2. Agenda California WC - Fun Facts Pre-Claim Steps
Claims Management & Legal Environment
Questions

3. California WC - Fun Facts
More than 220 insurance companies provide workers compensation insurance coverage to nearly 700,000 employers and deliver medical and wage replacement benefits to almost 800,000 injured workers.
CA continues to average the highest workers compensation insurance rates in the country
CA rates are largely driven by the greatest frequency of permanent disability claims in the country, high medical costs per claim and higher than average costs of handling claims and delivering benefits

4. The Tangled Web

5. Cost Distributions
Distribution of Total Insured System Costs 2014 & 2015
WCIRB of California – Cost Distributions publication 2016

6. Cost Distributions Distribution of Medical Benefits Paid 2014 & 2015
WCIRB of California – Cost Distributions publication 2016

7. Statistics Body Part most injured: Back 23% Shoulders/arms 13%
Knees 9%
Fingers 7%
Percentage of Claims by date of hire:
0 – 90 days = 10%
91 – 180 days = 17%
181 + days = 73%

8. Pre-Claim Steps Establish a protocol for claims reporting internally
Set-up Clinic protocols
Return-to-Work Program
Establish Claims Management Guidelines with Carrier/TPA
Medical Provider Network (MPN) Participation
Identify WC Defense Counsel by Territory
Annual training for all staff
Communicate with adjuster, counsel & injured worker

9. After an Injury - Forms Workers Compensation checklist (optional)
Accident Investigation Report (AIR) – (optional)
Employee Claim form (DWC1) - (required)
Report of Illness or Injury (Form 5020) - (required)
Authorization for medical treatment & clinic locations (required)
Modified Duty Offer letter – template (required, only if offered)
Facts about Workers Compensation – Division of WC (required)
Medical Provider Network (MPN) handbook (required)

10. After an Injury - Investigation
The supervisor should visit the employee & accident location/site as soon as possible, no later than 24 hours, to review the site of the injury
The Accident Investigation Report (AIR) should be used to collect pertinent details about the claim
Photos should be taken of site and injured worker to ensure accident matches environment & injury matches investigation
The Safety/HR department and the supervisor will work together to determine the cause of the injury and how to prevent future occurrences
The employee/injured worker and any other witnesses should be interviewed
Potential hazards should be removed and retraining provided wherever & whenever possible
Document re-training on AIR

11. Return-to-Work – Transitional Work Program
Objective
Return injured employees (who might otherwise be out on disability) to productive employment as soon as possible
Benefits
Reduces the high cost of Temporary Disability (Indemnity) payments
Reduces potential for litigation of claim
Litigation adds to the overall cost of a claim
Disability periods are typically extended as a result of litigation
Speeds the recovery of the injured worker
Allows for flexible work schedule to accommodate physician appointments, therapy, etc.
Assist the injured worker and their families by staying active and providing them with meaningful work during their recovery.
Studies confirm that the longer an injured worker is restricted from work, the harder it is to get him or her back to regular employment

12. Return-to-Work – Transitional Work Program
How to get started:
Referral sent to Transitional Work Program provider.
Current work status/restrictions provided to assist provider in locating appropriate position.
Current Job Descriptions / duties, rate of pay, etc.
Date & time of next physician appointment, update after each appt.
If litigated, the petitioner’s attorney & defense information.
Provider will canvas area within 5-10 mile radius of employee’s residence to minimize transportation issues.
Once position is found, then employer will send out Offer of Modified Duty letter to employee.
If they accept, schedule & pay employee as you would if working normal duties.

13. Return-to-Work – Transitional Work Program
WCIRB of California – Cost Distributions publication 2016

14. Return-to-Work – Transitional Work Program

15. Why Have Claim Reviews?
Monitor the claims process – keeps claim active
Provide a forum to exchange information and ideas
Generate collaborative solutions
Reduce claims costs

16. Components of a Claims Review
Working as a Team
Employer
Carrier/Adjuster
Defense Counsel
Broker
Other Experts

17. Track Progress After a Claim Review Review Plans of Actions
Document progress and challenges
Discuss challenges with carrier/adjuster
Revise Plans of Actions as needed

18. Claims Management & Legal Environment
Whether to ACCEPT OR DENY a claim?
Case by case basis
Take the full 90-days to evaluate and determine validity and compensability of claim
Take deposition of applicant
Get witness statement
Subpoena medical records
Have to pay up to $10,000 in medical treatment
Deny claim you lose your MPN management and lose the UR process
A denial based on NO medical evidence is NOT a strong denial
If you went to trial on the issue of AOE/COE tomorrow would you prevail

19. Claims Management & Legal Environment
A Company’s best defense is PREPARATION
Additional body parts
Was the added body part pled as part of original injury
Did the applicant testify to these complaints at time of deposition
Does the applicant have non industrial treatment in regards to additional body parts?
Has the applicant in fact sought treatment for additional body parts or did AA just add them in hopes of getting more money?
Did Panel QME or AME comment on additional body parts
Cut off discovery before they receive treatment for additional body parts
Know the difference between underlying condition and additional body parts

20. Liens – Preparation for Lien Trial
How to be prepared for a Lien Trial at a Lien Conference:
When the case resolves via C&R or Stip serving all medicals onto physician lien claimants
Send a letter to all non-physician lien claimants and request they file a petition for medicals
Serving exhibits 30-days prior to the Lien Conference date

21. Liens – Preparing Exhibits “Accepted Claim”
When preparing exhibits on a an accepted claim, list the following:
Medical Provider Network (MPN) Notices
Delay Notices
Acceptance Notices
Benefit Notices
Benefit Printouts
Explanation of Reviews
Utilization Reviews (UR)
Bill Review Expert

22. Liens – Preparing Exhibits “Denied Claim”
When preparing exhibits on a an denied claim, list the following:
Delay Notice (if one was sent)
Denial Notice
Objection Letters
Witnesses
It becomes the lien claimant’s burden to prove AOE/COE for denied claims

23. Liens – Statue of Limitations
An entity has 3 years to file a lien with the WCAB if their last DOS is prior to July 1, 2013
An entity has 18 months to file a lien with the WCAB if their last DOS is after July 1, 2013
All entities that file a lien are subject to pay a lien filing fee of $150.00

24. 2 Year and Older Analysis

25. Questions?

26. Thank You! Jerry Ferris, ARM Ferris Risk Solutions, LLC (940) 489-2040
Lesley Feldman, ESQ
Lesley Feldman Law
(818)
Paige Newbold, CWCP
LivHOME, Inc.
(800)