MICHAEL SULLIVAN & ASSOCIATES BLOG

As stated in Labor Code § 4610(a), utilization review is the process a defendant uses to "prospectively, retrospectively, or concurrently review and approve, modify, or deny, based in whole or in part on medical necessity to cure and relieve, treatment recommendations by physicians, ..." (emphasis added). UR is the process to determine only whether a request for treatment is medically necessary. It does not determine other issues.

LC 4610(l) states, "Utilization review of a treatment recommendation shall not be required while the employer is disputing liability for injury or treatment of the condition for which treatment is recommended pursuant to Section 4062." Accordingly, California Code of Regulations 9792.9.1(b) states that UR "may be deferred if the claims administrator disputes liability for either the occupational injury for which the treatment is recommended or the recommended treatment itself on grounds other than medical necessity." So a defendant is not required to submit a treatment recommendation to utilization review when a claim is denied or when it is disputing liability for reasons other than the reasonableness of the proposed care.

It’s the November Rhino Round-Up!

We attended inspiring industry conferences, hosted client education events, and strengthened our bonds during holiday parties and team-building activities. These moments remind us of the incredible people we work with every day—our team, clients, and community. Thank you for being part of our journey as we head into the holiday season!

If you'd like to join MS&A at one of our upcoming events, just follow us on one of our social media channels--we're on LinkedIn, Instagram, and Facebook. We'd love to have you attend one of our events!

It has long been recognized that an applicant's ability to participate in vocational retraining is a significant factor in assessing the worker's permanent disability. (LeBoeuf v. WCAB (1983) 48 CCC 587, 597.) In 2004, the Legislature enacted Senate Bill (SB) 899, and among the provisions was a requirement that permanent disability give consideration to an applicant's "diminished future earnings capacity," rather than the "ability to compete in the open labor market" (Labor Code § 4660(a).) The Labor Code was amended to require permanent disability to incorporate the "impairments published in the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment (5th Edition)" (LC 4660(b)). Prior to SB 899, permanent disability generally was rated based on work restrictions reported by doctors, but now, it is generally rated using impairments assigned by doctors under the AMA guides.

What an inspiring time at PIHRA's CELU 2024 Conference in Orange County!

Check out the highlights! MS&A’s Eric De Wames and PIHRA President Tara Fournier teamed up for the latest “Building Airplanes in Flight” session, where they explored the cutting-edge intersection of AI technology and employment law. MS&A and Lockton sponsored the post-conference happy hour, creating the perfect atmosphere to connect, unwind, and discuss the day's insights.

Thank you to everyone who attended, joined the discussion, and made this event so impactful. Here’s to more innovation and collaboration in the world of employment law!

Under former Labor Code § 5909, a petition for reconsideration was deemed denied by operation of law unless the Workers' Compensation Appeals Board (WCAB) acted on it within 60 days from the date of filing. Effective July 2, 2024, LC 5909 states:

• "(a) A petition for reconsideration is deemed to have been denied by the appeals board unless it is acted upon within 60 days from the date a trial judge transmits a case to the appeals board.
• "(b)(1) When a trial judge transmits a case to the appeals board, the trial judge shall provide notice to the parties of the case and the appeals board.
• "(2) For purposes of paragraph (1), service of the accompanying report, pursuant to subdivision (b) of Section 5900, shall constitute providing notice."

LC 5909(c) specifies that the statute will be repealed as of July 1, 2026. The Court of Appeal has explained that LC 5909 was amended as a short-term fix to the WCAB's need for resources, and gives it the additional time to act on petitions it needs to resolve normal human errors or administrative irregularities. (Mayor v. WCAB (2024) 104 Cal. App. 5th 1297.)^[1]

On Nov. 5, 2024, the WCAB issued a significant panel decision, Reed v. County of San Bernardino, applying the time limits to act on a petition for reconsideration and explaining when a petition for reconsideration is appropriate.

It’s the October Rhino Round-Up!

October was packed with team-building events, industry conferences, and giving back at the Olive Crest fundraiser! From strengthening bonds to supporting children and families, it was a rewarding month for MS&A.

If you'd like to join MS&A at one of our upcoming events, just follow us on one of our social media channels--we're on LinkedIn, Instagram, and Facebook. We'd love to have you attend one of our events!

MS&A had an amazing time at PIHRA's CELU 2024 Conference in Los Angeles last week! It was a fantastic opportunity to connect with so many industry professionals and exchange valuable insights.

Check out the highlights! 📸 Eric De Wames and Tara Fournier led the latest installment of their ongoing “Building Airplanes in Flight” session, where they explored the intersection of AI technology and employment law. The energy at the conference happy hour was incredible, and our MS&A booth was buzzing with engaging conversations.

Thanks to everyone who stopped by, attended our session, and joined us in celebrating this outstanding event!

If you'd like to join MS&A at one of our upcoming events, just follow us on one of our social media channels--we're on LinkedIn, Instagram, and Facebook. We'd love to have you attend one of our events!

Medicare is a secondary payor. That is, it does not have primary payment responsibility for its beneficiaries when another entity is responsible for paying for medical care before Medicare. Workers' compensation is a primary payor for work-related illnesses or injuries. Medicare will not pay for a beneficiary's medical expenses when payment has been made or can reasonably be expected to be made by a workers' compensation insurer.

Medicare, however, may pay for medical services when the primary payor has not made or cannot reasonably be expected to make payment for them promptly. Those Medicare payments are referred to as “conditional payments,” because Medicare pays under the condition that it is reimbursed when the beneficiary gets a workers' compensation settlement, judgment, award or other payment. Medicare is required by statute to seek reimbursement for conditional payments related to the settlement.