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Table of Contents

CHAPTER ONE       LIEN CLAIMS

I.       BACKGROUND

§1:01           Constitutional Prohibition Against Incumbrances

§1:02           Rationale for Creation of Lien Rights

II.     STATUTORY AUTHORITY

§1:10           Nature of Workers’ Compensation Liens

§1:11           Statutorily Authorized Liens

§1:12           Unauthorized Liens

§1:13           Liberal Construction

§1:14           Effects of 2004 Legislative Reforms on Liberal Construction

III.    LIEN RECOVERY

A.          Conditions For Payment

§1:20           Statutory Conditions

§1:21           Consent of the Parties Immaterial

§1:23           Lien Claimant’s Good Faith Not Controlling

B.          Burden of Proof

§1:30           Relationship to Applicant’s Claim

§1:31           Establishing a Prima Facie Case

CHAPTER TWO      MEDICAL TREATMENT LIENS

I.       MEDICAL TREATMENT LIENS IN GENERAL

§2:01           Scope of Benefit

§2:02           Necessity of Lien Rights

§2:03           Nature of Medical Treatment Liens

§2:04           Jurisdiction over Lien Disputes

§2:05           Basic Requirements for Recovery of Treatment Liens

II.     COMPENSABILITY OF APPLICANT’S CLAIM

A.          Prior to Resolution of the Case in Chief

§2:20           In General

§2:21           Cases of Disputed Liability

§2:22           Cases of Admitted Liability

B.          Findings and Awards

§2:30           Liens Should be Adjudicated Concurrently

§2:31           Orders That Jurisdiction Be Reserved

§2:32           Orders to Adjust Liens

§2:33           Conditional Stipulations for Payment

C.          Stipulations With Request for Award

§2:40           Stipulated Awards

§2:41           Stipulations to No Injury to Part of Body Treated

§2:42           Remedy After Issuance of Award

§2:43           Liens Filed Subsequent to Award

D.          Orders Approving Compromise and Release

§2:50           Lien Dispositions in Settlement Agreements

§2:51           Agreements to Adjust and/or Pay

§2:52           Agreements to Adjust, Pay and/or Litigate

§2:53           Treatment Authorized by Defendant

§2:54           Liens Filed Subsequent to Compromise and Release

§2:55           Lien “Statute of Limitations”

§2:56           The Doctrine of Laches

E.           Determination of Treatment Liens in Separate Proceedings

1.          Cases of Disputed Liability

§2:70           Unresolved Threshold Issues

§2:71           Thomas Finding

§2:72           Defendant’s Violation of Labor Code §5402

§2:73           Relevance of Amount of Settlement

2.          Whether Applicant’s Testimony Is Needed

§2:80           Nature of Dispute Over Liability

§2:81           Medical Disputes

§2:82           Legal Disputes

§2:83           Factual Disputes

3.          The Keifer Case

§2:90           Applicability of Keifer Holding

§2:91           Appeals Board Interpretations of Keifer

§2:92           The Hunt Case

F.           Alternative Approaches

§2:100         Expediting the Process

§2:101         Trial Without Applicant’s Testimony

§2:102         Reliance on the Medical Evidence

§2:103         Settlement Per Estimate of Probabilities

G.          The Gregory Formula

§2:110         Proportional Reduction of Health Provider’s Claim

H.          Hold Harmless Agreements

§2:120         Purpose

§2:121         Effect of a Hold Harmless Agreement

§2:122         The Lien Claimant’s Civil Action

I.           Dismissal of Case in Chief

§2:130         Dismissals for Lack of Prosecution

§2:131         Dismissals Pursuant to Applicant’s Request

§2:132         Orders Suspending Proceedings and Barring Benefits

J.           Other Threshold Issues Affecting Lien Recovery

§2:136         California Insurance Guarantee Association

§2:137         Federal Pre-Emption

III.    MEDICAL CONTROL

A.          The Right to Select the Treating Physician

1.          Initial Control by Defendant

§2:140         Medical Control Requirement

§2:141         Immediate Medical Treatment

§2:142         Traditional 30-Day Period of Control

2.          Managed Care

§2:150         Extension of Period of Control

§2:151         Initial Medical Control for 90 Days

§2:152         Initial Medical Control for 180 Days

§2:153         Initial Medical Control for 365 Days

§2:154         Disputes Over HCO Enrollment

3.          Exceptions

a.                 General Exceptions to Initial Employer Control

§2:160         Generally No Liability Without Control

§2:161         Emergency Situations

§2:162         Employer Neglect

§2:163         Requests for a Change of Physician

§2:164         Failure to Post Notice of Benefits

b.                 Employee’s Pre-Designation of Personal Physician

§2:165         General Requirements

§2:166         Additional Requirements Imposed by SB 899

§2:167         Effect of New Requirements for Predesignation

4.          Medical Provider Networks

a.                 Employer May Establish a Medical Provider Network

§2:170         Purpose of Networks

§2:171         Requirements for Establishing or Modifying a Network

§2:172         Approval of Medical Provider Network by the Administrative Director

§2:173         Utilization Issues

§2:174         Continuity of Care

§2:175         Medical Control by Applicant Within the Network

b.                 Resolution of Disputes Concerning the Diagnosis or the Treatment

§2:176         Second and Third Opinions

§2:177         Independent Medical Review

§2:178         Independent Medical Review Procedures

§2:179         The Administrative Director’s Decision

B.          Medical Control by the Applicant

§2:180         Employee’s Right to Choose Physician

§2:181         Duties of the Employee

§2:182         Duties of the Employer

§2:183         Duties of the Physician Before January 1, 1999

§2:184         Duties of the Physician After January 1, 1999

§2:185         Effect of Medical Provider Networks on Medical Control by the Appliant

§2:186         Required Notices

§2:187         Transfer of Ongoing Care

§2:188         Twenty-Four Hour Medical Care

C.          The Primary Treating Physician (PTP)

1.          Designation and Change

§2:190         Definition

§2:191         One Primary Treating Physician at a Time

§2:192         The Tenet/Centinela Case

§2:193         Exceptions to the Tenet/Centinela Rule

§2:194         Litigating Pre-June 19, 2003 Disputes Before the WCAB

§2:195         Post-Award Treatment

§2:196         Reporting Requirements for Primary Treating Physicians

2.          Secondary Physicians

§2:210         Other Treating Physicians

§2:211         Consulting Physicians

3.          Potential Difficulties

§2:220         Requirements for Reimbursement in the OMFS

§2:221         Primary Treating Physicians

§2:222         Secondary Physicians

§2:223         Consulting Physicians

D.          Petitions to the Administrative Director

1.          Jurisdiction

§2:230         Petition to Require Employee to Select Employer—Designated Physician

§2:231         Free-Choice Versus Self-Procured Treatment

§2:232         Limitations on Award of Future Medical Treatment

2.          Preparing and Filing the Petition

§2:240         Grounds

§2:241         Deletion of Appropriateness of Treatment

§2:242         Forms and Supporting Evidence

§2:243         Offer of a Panel of Five Physicians

§2:244         Chiropractors

§2:245         Opportunity to Cure Defects

3.          What Constitutes Good Cause to Grant or Deny Petition

a.                 Failure to Comply With Reporting Requirements

§2:260         Right to Notice

§2:261         Failure to Provide a Treatment Plan

§2:262         Primary Treating Physicians (PTPs)

§2:263         Additional Appropriate Information

§2:264         Service of Report

§2:265         Doctor-Patient Relationship No Defense

§2:266         Conditioning Reports on Payment of Bill

§2:267         Failure to Submit Progress Reports

§2:268         Failure to Report on Official Forms

b.                 Other Bases

§2:280         Treatment Inconsistent With the Treatment Plan

§2:281         Reasonable Geographic Area

§2:282         Physician Conflicts of Interest and Bias

§2:283         Inappropriate or Ineffective Treatment

§2:284         Evidence of Ineffective Treatment

§2:285         Treatment by Other Than Medical Doctors

§2:286         Self-Referrals

§2:287         Inappropriate Grounds for Petition

4.          Pitfalls for Petitioners

§2:300         Technical Defects

§2:301         Petition Rendered Moot

5.          Post Petition Issues

§2:309         Response to Petition

§2:310         Liability Pending Issuance of Decision

§2:311         Time Limitations on Administrative Director to Act

§2:312         Appeal of Decisions of the Administrative Director

E.           Petitions to the WCAB

§2:320         Petition to Terminate Award

IV.     QUALIFICATIONS OF THE MEDICAL PROVIDER

§2:330         Qualified Practitioners

§2:331         MFCCs and LCSWs

§2:332         Registered Psychological Assistants

V.      NECESSITY

A.          General Considerations

§2:340         Medical Necessity Defined

§2:341         Further Treatment Not Needed

§2:342         No Causal Connection Between Injury and Treatment

§2:343         Psychiatric Treatment

B.          Determining the Issue

§2:350         Relevance of Applicant’s Testimony

§2:351         Relevance of a Successful Outcome

§2:352         Relevance of Permanent and Stationary Status

§2:353         Burden of Proof

§2:354         Primary Treating Physician’s Presumption

C.          Utilization Review

1.          Definition and Discovery

§2:355         Definition

§2:356         The 1993 Reforms: Model Utilization Protocols

§2:357         IMC Treatment Guidelines

2.          The 2003 and 2004 Reforms

a.                 General Points

§2:358         Need for Reform

§2:359         The Medical Treatment Utilization Schedule

§2:360         Bridging the Gap With the ACOEM Guidelines

§2:361         Timeframes for Application of ACOEM

b.                 Medical Treatment Utilization Schedule (Labor Code §4604.5)

§2:365         Presumption of Correctness

§2:366         Injuries Not Covered by the Utilization Schedule or the ACOEM Guidelines

§2:367         Limitations on Physical Medicine Services

c.                 Utilization Review Requirements (Labor Code §4610)

§2:370         Responsibilities of the Employer or Insurer

§2:371         Criteria for the Utilization Review Process

§2:372         Time Frames for Employer or Insurer Action

§2:373         Civil Penalties

3.          Practical Application of the ACOEM Guidelines

§2:375         Guidelines Are Recommendations Not Mandates

§2:376         Acute and Subacute Conditions Versus Chronic Conditions

§2:377         Medical Conditions Not Covered by the ACOEM Guidelines

§2:378         Consequences for Employer Violation of §4610

§2:379         Dispute Resolution

§2:380         Evidentiary Considerations

4.          Spinal Surgery

§2:385         Employer Entitled to Second Opinion

§2:386         Qualifications of Physicians Rendering Second Opinions

§2:387         Conflict of Interest Exclusions

VI.     REASONABLE VALUE

A.          The Official Medical Fee Schedule

1.          In General

§2:390         Use of Schedule

§2:391         Application of OFMS to Date of Injury and Date of Service

2.          Pre-1994 Injuries

§2:400         OMFS Is Prima Facie Evidence

§2:401         The Gould Decision

§2:402         Failure to Update Fee Schedule

§2:403         Explanation of Charges in Excess of the OMFS

§2:404         Effect of Late Explanation

§2:405         Right to Proceedings Before the WCAB

3.          Post-1993 Injuries

§2:420         Extraordinary Circumstances Required

§2:421         Explanation of Charges in Excess of the OMFS

§2:422         Jurisdiction Over OMFS Disputes

§2:423         Maximum Fees

4.          The 2003 Reforms

§2:425         The New Medicare-Based OMFS

§2:426         The Physician Service Fee Schedule

§2:427         No Basis for Payment in Excess of OMFS

§2:428         Annual Study of Access to Medical Treatment

B.          Calculation of the Fee

§2:430         Conversion Factors

§2:431         Evaluation and Management Services

C.          Selected Types of Medical Services

§2:440         Reports as a Treatment Cost

§2:441         Before January 1, 1996

§2:442         After January 1, 1996

§2:443         1999 Revision of the OMFS

§2:444         Primary Treating Physicians

§2:445         Secondary Physicians

§2:446         Consulting Physicians

§2:447         Pharmaceuticals

§2:448         Pharmaceuticals Capped at 100 Percent of Medi-Cal

§2:449         Drugs Dispensed From a Physician’s Office

§2:450         Generic Prescriptions and Supplies

§2:451         Implantable Medical Devices

§2:452         Durable Medical Goods

§2:453         Inpatient Services

§2:454         Outpatient Surgery Facility Fee Schedule

§2:455         Chart Notes and Duplicate Reports

§2:456         Interpreters in Connection With Medical Treatment

§2:457         Medical Transportation Services

D.          Application of the OMFS to Self-Procured Treatment

§2:460         Statute Authorizes Payment

§2:461         The Valdez and Federal Mogul Cases

§2:462         Treatment Rendered Prior to Notice of the Claim

E.           Disputes Over Application of the OMFS

1.          Prerequisites for Validity of Audit

§2:470         Audit Disputes

§2:471         All Relevant Documents

§2:472         Highest of Multiple Appropriate Values

2.          Alternatives to WCAB Involvement

§2:480         Resolution by Parties Preferable

§2:481         Informal Conferences

§2:482         Agreed Reviewers

§2:483         Splitting the Difference

§2:484         Reconstructing the Bill

§2:485         Litigating the Issue Before the WCAB

VII.   PENALTIES

A.          Penalties Imposed on Defendant