MICHAEL SULLIVAN & ASSOCIATES BLOG

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CMS Warns Against Using 'Non-Submit' and 'Evidence-Based' Medicare Set-Asides

CMS Warns Against Using 'Non-Submit' and 'Evidence-Based' Medicare Set-Asides

The Centers for Medicare & Medicaid Services (CMS) has updated its Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide (Reference Guide). The latest version, Version 3.5, was published Jan. 10, 2022. The Reference Guide was updated to clarify the use of non-CMS-approved products to address future medical care.

Establishing Permanent Total Disability with Medical & Vocational Evidence

Establishing Permanent Total Disability with Medical & Vocational Evidence

It has long been recognized that an employee's ability to participate vocational retraining is a significant factor that must be considered in assessing the worker's permanent disability. (LeBoeuf v. WCAB (1983) 48 CCC 587, 597.) An employee's inability to compete in the open labor market could support an award of permanent total disability. Even though vocational rehabilitation was repealed and replaced with the supplemental job displacement benefit, in Ogilvie v. WCAB (2011) 76 CCC 624, the Court of Appeal held that an employee could still rebut a scheduled rating by establishing that he or she was not amenable to rehabilitation.

Special Report: Applied Materials v. WCAB

Special Report: Applied Materials v. WCAB

On June 1, 2021, the 6th Appellate District Court of Appeal certified for publication its decision in Applied Materials et al. v. WCAB.

In that case, the 6th District Court of Appeal issued a lengthy 73-page decision addressing multiple issues raised by the parties. However, the decision is most significant for two issues:

  1. Whether a worker's post-traumatic stress disorder (PTSD) arising from a treating physician's sexual misconduct is compensable under workers' compensation. It was.
  2. Whether the Fitzpatrick case[1] was wrongly decided. Fitzpatrick was important as it had held that the WCJ may not use LC 4662 on its own to make a finding of total permanent disability. This case and its finding were affirmed.

QME Evaluations via Telehealth

QME Evaluations via Telehealth

Because of the backlog of medical-legal evaluations caused by the COVID-19 pandemic, the Division of Workers' Compensation (DWC) adopted emergency regulations for medical-legal evaluations and reporting. The regulations became effective May 14, 2020, and originally were set to expire March 12, 2021. But they have been extended until Oct. 12, 2021.[1]

Special Report: Supplemental Sick Leave & Temporary Disability Overlap

Special Report: Supplemental Sick Leave & Temporary Disability Overlap

On March 19, 2021, Gov. Gavin Newsom signed Senate Bill 95 into law requiring most California employers to provide up to 80 hours of COVID-19 supplemental paid sick leave. The law went into effect on March 29, 2021, but the requirements applied retroactively to Jan. 1, 2021. So, if an employee was eligible, an employer retroactively must pay the COVID-19 supplemental leave when the employee requests it, either orally or in writing. We published a detailed exposition of this new law last week.

California Tort Claim Act

California Tort Claim Act

Under the California Torts Claim Act (CTCA), if an incident occurs with a defendant who is a governmental entity, state government, city, or other public entity, a proper notice of the claim must be filed within 6 months of the injury or accident. California Government Code section 905. This is known as an “administrative claim.” This claim form must be filed first before you can file a Complaint in court.