Tag: Workers Comp

A California appellate court has overturned a longstanding practice of the state’s Workers’ Compensation Appeals Board involving cases where parties in comp claims petition for a reconsideration of decisions by either the board or a comp judge.

In a Tuesday ruling, the Court of Appeals of California, Second District sided with a handful of petitioners who argued that the comp board for years has engaged in a “grant-for-study” practice in which it grants reconsideration petitions for the purposes of further study without first deciding whether reconsideration is warranted.

The practice often leads to the board ruling on the merits of a reconsideration petition many months after a petition is filed, despite the fact that the board is required to act on these petitions within 60 days.

“The Board may not simply grant reconsideration for the purpose of further study,” the court wrote. “We therefore issue a writ of mandate requiring the Board to cease its grant-for-study procedure and to comply with the statute when granting reconsideration.”

The court said state statute requires the board to make a “reasoned decision” when granting petitions for reconsideration, and the grant-for-study practice has been an impermissible way of circumventing its duties.  

The court further held that the board is not required to issue a final ruling on the merits of a petition for reconsideration within 60 days, but that it simply must decide whether to grant reconsideration within that timeframe. 

 

 

The workers compensation industry is seeing a rise in the percentage of claims containing prescriptions for drugs used to manage opioid dependency or overdoses, even as claims with opioids continue to decline.

A July 19 report by Enlyte LLC showed that comp opioid prescriptions fell 1.3% in 2022, with associated costs declining 2.5%. Prescriptions for opioid dependency drugs and those used to reverse overdoses rose 11.6%.

Nikki Wilson, Omaha, Nebraska-based senior director of clinical pharmacy services at Enlyte, said the new data reflects improved education around opioid dangers.

“The shift has gone to alternative pain management,” she said, most notably a rise in drugs to treat opioid dependency.

Experts said the rise in such drugs could partly be the result of still-evolving prescribing regulations.

Reema Hammoud, Southfield, Michigan-based assistant vice president, clinical pharmacy, for Sedgwick Claims Management Services Inc., attributed the increase in opioid dependency drugs in part to there being “no exit plan” for those taking medication-assisted treatment. 

“We don’t have clear guidelines on how long to use those medications,” Ms. Hammoud said of opioid dependency drugs. “That’s why patients who are prescribed those medications often stay on those medications.”

Ms. Hammoud said dependency drugs don’t cure opioid use disorder but merely help with withdrawal symptoms.

“Patients are still getting that pain relief without going into addiction or dependency,” she said.

The problem is that there is no “cure” for opioid use disorder, so injured workers who are put on the dependency drugs as part of their comp benefits could potentially stay on them indefinitely.

Ms. Hammoud said the currently accepted recommendation is to include psychotherapy or cognitive behavioral therapy along with dependency-assisting medication.

Naloxone, a drug used to reverse an opioid overdose, is also on the rise in comp, and Ms. Hammoud said one reason could be new provider requirements to prescribe the drug alongside opioids anytime a high-dosage opioid prescription is filled.

“It doesn’t mean they’re actually using it; it’s for safety’s sake,” she said. “That’s why we’re seeing an increase in naloxone, because some states are requiring the prescription.”

Tina Brletich, Ponte Vedra Beach, Florida-based vice president of managed care and clinical in workers comp for AmTrust Financial Services Inc., said the network is seeing increases in medications to assist with overdose reversal and the management of withdrawal symptoms.

“It’s not surprising, really,” Ms. Brletich said of the Enlyte report’s findings concerning both opioids and dependency medications. “The industry trend is a decrease in opioids. Certainly, regulations have been rolled out by states. We’ve seen similar trends at AmTrust in terms of decrease in opioids as well.”

Del Doherty, owner of Houston-based pharmacy benefit manager ProdigyRX, said providers, in comp and in general health care, are striving to be more “proactive and preventative” when it comes to prescribing dependency drugs.

“Clinically, it is the right thing for the patient if a prescriber sees this as something that could be beneficial for the patient,” Mr. Doherty said.

And if an injured worker does overdose on opioids, a naloxone prescription is less costly than a trip to the emergency room, he said.

The U.S. Occupational Safety and Health Administration has cited a Miami-based excavation contractor after a worker drowned while removing debris from an eight-foot canal.

OSHA on Monday announced it cited Downrite Engineering Corp. for 18 serious violations and proposed $258,935 in penalties following the January workplace fatality.

Inspectors determined the company failed to properly train dive teams on equipment use, techniques and emergency procedures when performing underwater tasks.

The company was also cited for failing to assess water conditions before sending in divers, failing to require an experienced diver to supervise dredging operations in a canal with limited visibility, and failing to brief workers on basic diving procedures and environmental conditions, among other failures.

OSHA said it previously cited the company for other safety violations, including failing to provide an injured worker with prompt medical care and not having readily available first aid equipment.

The company has 15 business days to contest the latest citations and fines. 

 

 

After hitting an all-time low in 2022, the number letters from doctors regarding injured workers challenging the denial of treatment or medications in the workers compensation system in California increased 4.1% in the first half of 2023 compared with the same period last year, according to a report issued Monday by the California Workers’ Compensation Institute.

The number of letters and individual decisions remained below pre-pandemic levels, according to the report.

Total IMR volume trended down for four consecutive years, from 2019 through 2022, as the number of work injury claims fell during the pandemic and pharmaceutical disputes declined after the state adopted the evidence-based Medical Treatment Utilization Schedule Prescription Drug Formulary and Pain Management and Opioid Guidelines. 

After climbing to a record 184,735 letters in 2018, IMR letter volume declined 31.1% over the next four years, falling to 127,215 letters in 2022. While IMR decisions were down across all medical service categories, the addition of the treatment guidelines in late 2017 and the implementation of the formulary in January 2018 had “a huge effect” as prescription drug disputes fell from 47.3% of all IMRs in 2017 to 33.3% in 2022.

As in previous reviews, the latest data show that a small number of physicians continue to drive much of the IMR activity, with the top 1% of requesting physicians — 80 doctors — accounting for 40.3% of the disputed service requests that underwent IMR in the 12 months ending on June 30.

 

 

 

Missouri Gov. Mike Parson on Thursday ceremonially signed into law Senate Bill 24, which, among other things, creates a post-traumatic stress disorder presumption in workers compensation for first responders.

Under the new law, first responders such as firefighters, police officers and EMTs would qualify for comp benefits if their PTSD stemmed from job activities.

The law would not be contingent upon the presence of a physical injury.

First responders seeking benefits under a PTSD presumption would have to meet certain criteria as far as qualifying events, including witnessing the death of a minor, seeing someone suffer a serious physical injury that “shocks the conscience,” directly witnessing any type of death while on the job, or be involved firsthand in a job-related incident that causes, or may cause, a serious physical injury.

A compensable PTSD claim would be measured from time of exposure or time of diagnosis and any such claim would have to be filed within 52 weeks after the event or diagnosis.

The expansive bill also includes a provision that now officially classifies 911 dispatchers as first responders. 

 

 

Divided over the issue, the Michigan Supreme Court on Friday tossed what it considered a “rigid” legal test when determining whether post-traumatic stress disorder and non-epileptic seizures were connected to a dietician’s electrocution and fall from a ladder, thus reviving the disability claim earlier rulings suggested were not proven to be connected to the workplace injury.

Doctors disagreed whether the worker’s 2012 fall while cleaning a light fixture at Transitional Health Services of Wayne, Michigan, which caused head and shoulder injuries, were connected to the woman’s mental injury diagnosis, which the defense in No. 163559 argued could have been related to abuse, a divorce and other family issues.

At issue was a four-factor legal test that stemmed from a 2001 case Martin v. Pontiac Sch Dist., which the ruling described as “initially designed to be used merely as a ‘guide’ when determining whether a plaintiff has demonstrated that their workplace injury significantly contributed to the claimed disability” that “has morphed into a straitjacket” legal requirement for disability, according to the ruling.

As outlined in Martin, the validity of a claim is weighed based on “(1) the number of occupational and nonoccupational contributors to the disability, (2) the relative amount of contribution of each contributor, (3) the duration of each contributor, and (4) the extent of permanent effect that resulted from each contributor.”

Applying the so-called “Martin test,” a magistrate, the Michigan Compensation Appellate Commission, and the state Court of Appeals ruled in favor of the employer, arguing there was no “objective” evidence connecting the woman’s mental injuries to her fall from a ladder and electrocution.  

Four state Supreme Court justices called the Martin test “rigid” and instead applied 1993 case law outlined in Farrington v Total Petroleum Inc. to reverse and remand the case. Under the so-called “Farrington test,” an injured worker “must show that their health injury was significantly caused or aggravated by employment considering the totality of all the occupational factors and the claimant’s health circumstances and nonoccupational factors.”

Two judges dissented because “there was a lack of evidence supporting (the) plaintiff’s claim of developing non-epileptic seizures as a result of her accident” and that “the case was a poor vehicle to consider altering the longstanding standards set forth” in the Martin test. 

 

A Georgia appellate court ruled the Atlanta Police Department wrongly suspended an injured officer’s workers compensation benefits on the basis that the officer received a return-to-work release from a provider who was not his treating comp physician.

The Georgia Court of Appeals on Thursday said the city erred in suspending comp benefits for Officer Justin Sebastian after the officer went out on workers comp due to injuries sustained in an on-duty vehicle accident in December 2017.

After treatment, Mr. Sebastian was released to return to work on light duty with restrictions. His treating physician recommended Mr. Sebastian see a spine specialist to address related back problems.

That specialist later found Mr. Sebastian was at maximum medical improvement, determining the officer could resume normal work activities. The treating physician released Mr. Sebastian to return to work based on the spine specialist’s recommendation.

The city subsequently suspended benefits.

Mr. Sebastian sought benefits reinstatement, arguing suspension was improper because it was based on a recommendation from the spine doctor, not his treating physician.

An administrative law judge found the suspension improper, a decision upheld by a review board.

On appeal, the city argued the suspension was proper since the spine specialist was “an authorized treating physician” in comp, even though he wasn’t Mr. Sebastian’s treating physician.

The appeals court found the city’s argument meritless, since benefits can only be suspended based on reports from treating physicians, not referred doctors. 

 

 

President Joe Biden on Thursday outlined steps his administration is taking to address the consequences of extreme heat, including targeted inspections of industries where workers are at increased risk of heat exposure and the adoption of federal heat-related protections.

Mr. Biden said he asked acting Labor Secretary Julie Su to issue a heat hazard alert clarifying that workers have federal heat-related protections and telling employers what they can or should be doing to protect workers.

“We should be protecting workers from hazardous conditions, and we will,” the president said. “And those states where they do not, I’m going to be calling them out, where they refuse to protect these workers in this awful heat.”

The president also said Ms. Su will work with her team to ramp up enforcement efforts and conduct more inspections of high-risk industries such as construction and agriculture.

Increased enforcement activities will take place while the federal Occupational Safety and Health Administration continues drafting national workplace heat-safety rules.

OSHA started the process of adopting federal workplace heat-safety standards in October 2021. According to the U.S. Government Accountability Office, the Labor Department takes anywhere from 15 months to 19 years to finish. On average, from 1981 to 2010, OSHA took seven years to develop and issue workplace health and safety standards, according to the GAO.

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