State News

In an effort to educate injured employees on the complexities of Texas workers’ compensation, the Division has produced seven brief instructional videos, viewable athttp://www.tdi.texas.gov/wc/employee/guide.html. The surprisingly not-terrible videos guide potential claimants through the labyrinthine Texas Work Comp system, providing instructions for how to file a claim, explaining differences in types of income benefits, and mapping out the stages of the dispute resolution process. 

In announcing the creation of the videos, then-Commissioner Brannan hoped that the videos would assist injured workers in better understanding the workers’ comp system, acknowledging that, “People are busy these days and are much more likely to watch a video to learn about something new.”  But there is value in the videos for even the most seasoned Texas Work Comp veteran: eagle-eyed system participants may spot San Antonio Benefit Review Officer Samuel Peralez as “Injured Worker at BRC.”  Spoiler alert: he’s only pretending to be injured.

Copyright 2018, Stone Loughlin & Swanson, LLP

Last month we reported on the Appeals Panel’s puzzling decision to distinguish “headaches” from “ongoing headaches” as separate conditions.  This month, a pair of Appeals Panel Decisions suggests an emerging trend that may itself become an ongoing headache for Carriers.

Appeals Panel Decision No. 180603, decided April 19, 2018, reversed the Administrative Law Judge by determining that headaches were indeed a part of the claimant’s injury, which already included a traumatic brain injury.  The case was remanded for an amended MMI/IR certification by the designated doctor with the newly compensable condition, even though a rating for headaches is (presumably) subsumed in a rating for a traumatic brain injury. 

Similarly, Appeals Panel Decision No. 180602, decided April 30, 2018, remanded the case for a new certification from the DD to incorporate the AP’s finding of headaches as part of the compensable injury.  Their reasoning: the claimant complained of head pain in “numerous medical records,” which is perhaps unsurprising given that the accepted injury was a scalp laceration that required repair with staples. 

And only on May 16, 2018, did the Appeals Panel issue Decision No. 180702.  Once again, the Administrative Law Judge excluded headaches from the compensable injury, only to suffer a reversal at the hands of the AP.  This time, “periodic headaches” resulted from a concussion.  As before, the judge was instructed to obtain a new certification from the designated doctor that includes a rating for “periodic headaches.”

With four of their most recent decisions focused on the addition of headaches to compensable injuries, each requiring case management and a new certification from the designated doctor, it would seem the Appeals Panel has a bit of a bee in its bonnet about this topic lately. (The Appeals Panel is respectfully cautioned that bonneted bees are also a known cause of headaches.)

Copyright 2018, Stone Loughlin & Swanson, LLP

Jammers Groundscapes, a landscaping company operating out of Pflugerville, Texas, just north of Austin, entered a plea of guilty in defrauding its workers’ compensation carrier by omitting the payroll from a non-covered ancillary business.  The omission was Jammers’ attempt to secure lower workers’ compensation premiums, which are calculated, in part, on an employer’s payroll.  The scam succeeded for six years until the carrier’s internal investigation uncovered it.  A Travis County District Court ordered Jammers to reimburse its carrier to the tune of $400,000.00. 

Copyright 2018, Stone Loughlin & Swanson, LLP

A healthcare provider who performed Functional Capacity Evaluations (F.C.E.’s), examinations designed to gauge employees’ abilities to perform their pre-injury job functions, has been sentenced to three years’ deferred adjudication and ordered to pay $10,000.00 in restitution by a Travis County District Court.  Marcus Ricoy of Rancho Viejo was found guilty of falsifying medical claims to an insurer for more time than the examinations required.  The Division of Workers’ Compensation’s unit in the Travis County District Attorney’s Office prosecuted the case. 

Copyright 2018, Stone Loughlin & Swanson, LLP

On 5/18/18, the Texas Department of Insurance, Division of Workers’ Compensation, informed system participants of its intent to amend the designated doctor rules.  The DWC identified three problem areas:  the DD assignment process, qualification standards, and certification requirements. 

The Division acknowledges the dramatic decrease in the number of designated doctors in the system overall and, even more alarmingly, the steep decline in the number of M.D.’s and D.O.’s assigned to perform such examinations.  Much of the blame for this phenomenon lies in in the automated system that assigns a designated doctor to a case, which relegates the most qualified doctors into rarely-needed specialization categories and excludes them from the far more common musculoskeletal examinations.  The unintended result is that the best doctors receive the fewest appointments.

The DWC intends to rectify that problem by implementing two separate DD lists in each county. One list will consist of all available doctors and chiropractors qualified to perform the most common musculoskeletal examinations; the other will be limited to medical doctors qualified to perform the more complex examinations, including those requested to address conditions requiring board-certification. 

The twin list system is intended to remedy the inequity of board-certified M.D.’s or D.O.’s being selected for one specialized examination, then dropping to the bottom of the list and missing out on four or five of the far more common musculoskeletal examinations thereafter.  The new process is intended to raise the number of exams available to M.D.’s and D.O.’s each year, thereby incentivizing the most qualified physicians to become—and remain—designated doctors.

The DWC also seeks to elevate training, testing, and qualification standards by narrowing the timeframe between training and applying for certification/recertification in order to ensure that designated doctors are always apprised of the most current information.  Limiting the number of times a prospective DD can take the qualification examination in a given time period has also been suggested to address problems with test security.   

Finally, the DWC is contemplating adding obligatory reviews of a designated doctor’s work product to the recertification process.  Factors that may be considered include complaint history, excessive requests for deferral from the DD list, a pattern of overturned or substandard reports, a demonstrated inability to apply the AMA Guides, the timeliness of submitted reports, maintaining patient record confidentiality, or participant’s willingness to identify potential disqualifying associations.

Visit http://www.tdi.texas.gov/wc/rules/proposedrules/documents/pr127dd0518.pdf to view the proposed rule changes. 

 Copyright 2018, Stone Loughlin & Swanson, LLP

On April 18, 2018, the Disciplinary Panel of the Texas Medical Board suspended the medical license of John Tai Dang, M.D., of Cleburne, Texas.  The suspension will remain in effect until superseded by an Order of the Board. 

Among the myriad violations of the Medical Practice Act, Dr. Dang was found to have prescribed dangerous drugs (Diazapam, Alprazolam, Opana, and Xartemis) after becoming aware of a patient’s history of substance abuse and her admission into a treatment facility.  While treating that same patient, Dr. Dang borrowed money from her totaling $20,000.00 and used a Care Credit account in her name and without her knowledge to bill another $5,000.00 in fraudulent services.  Worst of all, the doctor was found to have assaulted two patients during examinations. 

The Disciplinary Panel determined that Dr. Dang failed to maintain adequate medical records, failed to adhere to guidelines for treatment of pain, became financially involved with a patient, and engaged in sexual contact with a patient, among other infractions.  In suspending his licencse, the Board deemed Dr. Dang’s medical practice a “continuing threat to the public welfare.”

Copyright 2018, Stone Loughlin & Swanson, LLP

By order of the Commissioner, beginning July 1, 2018, the Iowa Division of Workers’ Compensation will impose a monetary late settlement sanction on parties in cases where settlements are reported to the Division less than 24 hours before the scheduled start time of the hearing. Settlements must be reported to both the Division and the Deputy Commissioner assigned to hear the case 24 hours or more before the hearing is scheduled to start to avoid imposition of the sanction. This sanction is modeled on the late settlement sanction which is imposed by the Iowa District Courts. The Division has recently experienced an increase in late settlements which places further strains on diminishing resources. This action is necessary to allow the Division to better serve the people of the State of Iowa. The late settlement sanction order is effective for all cases with hearing dates of July 1, 2018, or later.

Claims that have been assessed a late settlement sanction will not have the settlement approved until the sanction has been paid. The late settlement sanctions shall be paid to the Division of Workers’ Compensation and all funds received will be paid over to the Iowa General Fund.

The late settlement sanction will apply in cases filed using the Form 100. It will also apply in full and partial commutation cases filed before July 1, 2017. It is not applicable to alternate medical care, vocational benefits or compliance proceedings.

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Peddicord Wharton Legislative Updates are intended to provide information on current developments in legislation impacting our clients. Readers should not rely solely upon this information as legal advice. Peddicord Wharton attorneys would be pleased to answer any questions you may have about this update. ©2018 Peddicord Wharton. All Rights Reserved.

The failure to report a claim in a timely manner generally leads to powerful defenses that help employers prevail in workers’ compensation court.  But lack of timely notice is seldom one of those defenses in New Jersey.  That sounds like a conundrum.  Shouldn’t lack of timely notice be the first defense that jumps to one’s mind when a claim is not reported within 30 or 60 days?  It should, but unfortunately the way the New Jersey notice statute is written, employers almost never win on that limited defense.  Employers do often win cases that are not timely reported for completely different reasons discussed below.

Think of lack of timely notice under N.J.S.A. 34:15-17 as an ironclad rule.   A worker could legitimately have a work injury on January 1, 2018, but if that employee for whatever reason fails to report the work injury within a certain period of time the employer automatically wins.  Here’s the rub:  the New Jersey statute allows so many extensions on reporting that the notice defense is generally toothless.

The statute begins by stating that an employee must report a work injury within 14 days, and no compensation is due until the employer becomes aware of the injury.  That sounds good until you read the rest of the provision.  If the employee reports the claim after 14 days but before 30 days, the employer only wins on notice if it can show it suffered prejudice due to the late reporting.  But wait – the statute next proceeds to water down the previous language even further.  If the employer becomes aware of the injury within 90 days and there is no prejudice to the employer caused by the late notice, the employer cannot win on the notice defense.

In effect this notice provision has two meaningless stages:  14 days and 30 days.  Proving prejudice to the employer is not easy, so employers are effectively left with a 90-day notice rule.  Further, the statute does not define what the word “prejudice” means, and there are really no cases on it.  Frankly, it is unfair to employers that the statute allows up to 90 days to report a claim.  How can an employer investigate any claim that is reported one month or even several months late?  Memories fade, and potential witnesses forget.  This practitioner recalls only one trial in decades where the employee actually testified to not reporting the injury to her employer or anyone in supervision for more than 90 days and therefore lost her case.

Yet failure to report a claim in a timely manner should raise red flags and almost always leads to powerful defenses.  The two main defenses that should leap to an employer’s mind when a claim is not reported timely are first, that there is no evidence that an accident happened, and second that even if an accident did take place, it was not significant enough to account for the present pathology.  Most employers train their employees over and over to report work injuries within 24 hours.  So when an employee reports a work injury 35 or 40 days after it happened, it seldom makes any sense.  An employer will deny such a claim on the basis that there was no accident.  If it did happen, why would the employee who has been trained to report claims within 24 hours wait so long to notify the supervisor or HR representative? Often that same employee has promptly reported other work injuries that have occurred over the years, so the employee clearly knows the reporting procedures.

Suppose an employee says that he bumped his knee at work on July 1, 2017 and felt pain in his knee right away but it quickly diminished. He never treats in July or August. He does not lose any time at all from work.  In mid-September, he reports for the first time to his employer that he bumped his knee at work 75 days ago and needs to see a doctor.  The employer asks why the employee waited so long. The employee says he thought it was nothing at all, so he never mentioned it to anyone.  The pain went away and was barely noticeable for months.  But in the past week the knee has become very painful.   An MRI shows a medial meniscal tear that needs surgery.  The employer probably will not win on the technical notice defense because the notification came within 90 days and the employee will argue that there was no prejudice to his employer by the delay.  Yet this claim should be denied, and the employer may very well prevail.  Here is the issue:  how could the bumping incident on July 1^st that caused no lost time and led to no treatment for months be responsible for a meniscal tear that manifests in mid September?

Causation is often the dominant issue in delayed reporting cases. The employer will want to look into past medical treatment to see if the employee has a history of knee problems.  Perhaps this is a recurring issue with the employee.  The employer will look into activities between July 1^st and September which the employee engaged in as possible causes for the tear.  What sports or activities did the employee engage in during that bridging period?  Does the employee jog or work out at a gym?  A medical expert will be asked to give an opinion whether bumping the knee in July which led to no treatment for months was the likely cause of a meniscal tear that shows up in mid-September.  Was the mechanism of injury (bumping the knee) consistent with a torn medial meniscus?  Is it likely that a tear occurred on July 1^st with no need for initial treatment and caused minimal pain for months only to become very painful in mid-September?  These are valid questions for the expert.

This sort of fact pattern happens quite frequently.  Employers should not be dismayed when they learn that New Jersey allows notice sometimes up to 90 days. That does not mean delayed reporting cases are compensable.  It just means that the employer will not win on the defense of notice.  The stronger defense is not lack of timely notice but whether there is any causal relationship between the alleged injury and the present knee pathology.  Good discovery and investigation may also lead the judge to conclude that there is insufficient evidence of any work accident at all.

In short, employers should continue to stress the need to report injuries within 24 hours.  It doesn’t matter that the New Jersey notice statute is exceptionally weak.   A timely reporting policy is very important and helpful to both employers and defense counsel.  Such a policy helps win cases because when an employee waits 15, 30, or even 60 days to provide notice in the face of a prompt reporting policy, it often suggests that the incident may never have happened or that the incident was simply inconsequential.

Thanks to our friend, Scott Tennant, of Arthur J. Gallagher for bringing this topic to our attention.

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John H. Geaney, Esq., is an Executive Committee Member and a Shareholder in Capehart Scatchard's Workers’ Compensation Group.  Mr. Geaney concentrates his practice in the representation of employers, self-insured companies, third-party administrators, and insurance carriers in workers’ compensation, the Americans with Disabilities Act and Family and Medical Leave Act. Should you have any questions or would like more information, please contact Mr. Geaney at 856.914.2063 or by e‑mail at jgeaney@capehart.com. 

In a rather unique unreported case, the Appellate Division recently held that a drive to the normal work site can be considered compensable on the facts in Minter v. Mattson,A-1916-15T4 (App. Div. May 10, 2018).  The case involved a kitchen worker, Antoine Minter, who called out of work due to a heavy snow storm that started the night before.  Minter advised his supervisor, Dan Beggs, the executive chef, that he had to miss his morning shift since the morning bus to work was not running on account of the snow storm.

The food service in the dining hall was essential, so the dining director, John Lear, came up with an alternative plan to get Minter to work.  Lear contacted Beggs, who advised the dining supervisor, William Mattson, to pick up Minter on the way to work since both Minter and Mattson lived in the same town.  According to Minter’s testimony, Mattson told him that Beggs made clear that Minter had to come in during the snowstorm.   Minter testified that he thought he would be fired if he refused.  The two men had ridden together to work before.  Mattson picked up Minter while the storm was still heavy and roads were ice-packed.  Mattson lost control of the car he was driving, entering the path of an oncoming pick-up truck.  In the collision, Minter suffered two broken legs, fractured ribs, and a deep laceration to his left arm.

The case was heard in Superior Court because Minter tried to bring a civil suit against Mattson and his employers.  The outcome of the civil suit depended largely on whether the two men were in the course of their employment. The employers argued that Minter’s only remedy was workers’ compensation and moved to dismiss the civil law suit.  Later the workers’ compensation carrier for the employer, Manufacturers Alliance Insurance Company, was joined in the suit, and the compensation carrier argued that Minter was not in the course of his employment because he was just on his way to work.  The compensation carrier argued that travel to and from work is excluded under N.J.S.A. 34:15-36.  The special mission exception only applies to trips away from the employer’s place of business.

Minter argued that he was compelled to perform an activity that he would not have otherwise engaged in, since he had called out that morning.  He relied on the case of Lozano v. Frank Deluca Constr., 178 N.J. 513 (2004), which held that an otherwise excluded activity may be deemed compensable if the employer compels the activity and if the employee has a reasonable basis to believe that participation in the activity is compelled.

The compensation carrier argued that the principle of compulsion could not be applied to drives to and from work because attendance at work is compelled for all employees.  All employees are subject to termination if they fail to report to work. But the Appellate Division disagreed:  “In one sense, travel to and from work is always compelled.  Employers set work schedules and employees are generally expected to comply.  Those who do not comply usually risk losing their jobs.  But, the compulsion in Minter’s case was specific and exceptional.  Minter had already called out for the day. Thus, if he could establish that his employer compelled his non-work-related activity – the journey to work in a co-worker’s vehicle on a day he had already announced he would not work – the accident would be covered.”

The Appellate Division also noted that Minter could have argued that he was involved in a ride-sharing arrangement under N.J.S.A. 34:15-36.  That would have rendered his commute compensable.  However, his attorney never made that argument.  The Court emphasized that Minter’s belief that he might have been fired had he refused to come to work was objectively reasonable.  “In sum, Minter was injured in the course of his employment, despite the fact that he was not yet at his employer’s premises, because his employer had compelled his travel to work with a co-worker on a day he had already informed his employer he was not going to come in.”

This is the first Appellate Division level decision since the 1979 Amendments to the workers’ compensation law which has embraced the concept of compensability of a drive to a normal work site based on compulsion.  There is no reported case standing for this proposition.  The normal rule is that one is not at work until one arrives at premises owned or controlled by the employer.   Even though it is an unreported decision, this case is important because it charts new territory on compensability. The factual situation addressed in this case is one that does occur for employers with some frequency given severe weather conditions in the winter months.  It remains to be seen whether this logic is eventually embraced in a reported decision.

Our thanks to Ron Siegel, Esq. for bringing this case to our attention.

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John H. Geaney, Esq., is an Executive Committee Member and a Shareholder in Capehart Scatchard's Workers’ Compensation Group.  Mr. Geaney concentrates his practice in the representation of employers, self-insured companies, third-party administrators, and insurance carriers in workers’ compensation, the Americans with Disabilities Act and Family and Medical Leave Act. Should you have any questions or would like more information, please contact Mr. Geaney at 856.914.2063 or by e‑mail at jgeaney@capehart.com. 

SEDGWICK CMS, INC. v. BUREAU OF WORKERS’ COMPENSATION,

FEE REVIEW HEARING OFFICE (PISZEL AND BUCKS COUNTY PAIN CENTER)

1033 C.D. 2017 – Filed April 11, 2018

By Jeffrey D. Snyder, Esquire

The Commonwealth Court, referring to the matter as an issue of first impression, framed the issue here as “… what constitutes ‘a significant and separately identifiable service performed in addition to the other procedure’ under Workers’ Compensation Medical Costs Containment Regulation 34 Pa. Code §127.105(e), for which a chiropractor is entitled to payment for an office visit in addition to his charges for the treatment provided at the same visit”.  The Commonwealth Court remanded the case to the Bureau of Fee Review Hearing Office on this mixed question of fact and law to determine whether the office visit charges in question were for routine examinations involving a known medical condition, change in medical condition, or other circumstances that required an examination and assessment above and beyond the usual examination and evaluation for the treatment performed on that date.

The Claimant sustained a work injury on February 28, 2005 and thereafter entered into a Compromise and Release Agreement that left medical expense open with the Employer thus obligated to pay reasonable and necessary medical expenses for the work injury, described as right shoulder partial thickness tear and superior labrum tear with post-operative scarring, rotator cuff inflammation and left shoulder overuse rotator cuff inflammation.

The Claimant received chiropractic treatment for shoulder and neck pain approximately three times a week.  The chiropractic billed Sedgwick $78.00 per visit for office visits on dates in which the Claimant was the recipient of chiropractic treatment that was billed.  Sedgwick denied payment for the offices visit charges, but paid Provider for other treatments that were provided on the subject dates.  The Provider filed a Fee Review.

The Bureau administratively determined that the Provider’s claim for the office visit charges were to be denied.  The Provider filed a Request for Hearing before a Hearing Officer.  The chiropractor argued that: “Each time I treat Claimant, I perform a physical exam, I take a history of his subjective complaints, identified the objective findings on my exam, assess his conditions and treatment recommendations, and give a plan”.  The chiropractor further asserted that these examinations were not included in the value of another procedure.

On July 5, 2017, the Hearing Officer issued a Decision ordering Sedgwick to pay all of the presented office visit charges.  The Hearing Officer recognized that payment for office visits on the same day that another procedure is performed is permitted only when the office visit represents a significant and separately identifiable service performed in addition to the other procedures.  The Commonwealth Court noted, however, that the Hearing Officer made no factual findings as to the nature of any of the examinations and evaluations for which an office visit charge was billed, and made no findings as to whether any of them were non-routine or involved new medical conditions, or evaluations for new or different treatments.  Sedgwick argued that §127.105 of the Medical Cost Containment Regulations prohibit payment of office visit charges for routine physical examinations and evaluations on the same day as other treatment is performed where there is no new medical condition and that all of Provider’s office visit charges were for routine examinations for the same medical conditions.  The Commonwealth Court cited to the Workers’ Compensation Act, as well as to Medicare procedure codes.  The Court noted that the burden was on Sedgwick to prove by a preponderance of the evidence that it fully paid Provider the amounts to which Provider was entitled, citing the 34 Pa. Code §127.259(f).  The Commonwealth Court observed that the meaning of the phrase “significant and separately identifiable service” performed in addition to the other procedures in §127.105(e) is a question of law, not an issue of fact, citing Commonwealth v. Kerstetter, 62 A.3d 1065, 1068, note 4 (Pa. Cmwlth. Ct., 2013),affirmed, 94 A.3d 991 (Pa. 2014).  The Court noted that the Medical Cost Containment Regulations do not define any of the terms at issue and that no Court in the Commonwealth has interpreted §127.105(e) as to the phrase “significant and separately identifiable service”. 

Interpreting the regulations, the Court noted that the rules of statutory construction apply to administrative regulations and that no words of a regulation are to be treated as mere surplusage.  Federal decisions and regulatory interpretations addressing the same issue may be considered as well.  Federal Medicare case law suggests that an examination or evaluation on the same date as another procedure does not constitute a “significant and separately identifiable service” unless it is above and beyond the usual evaluation performed in conjunction with that procedure, or is unrelated to the procedure that was performed on the same day, citing toUnited States v. Chen (USD Nevada No. 2:04 C.V. 00859, PMPPAL, filed May 30, 2006).

The Center for Medicare and Medicaid Services has stated with respect to chiropractors that chiropractors should not bill for an examination every time they treat a patient. MLN Matters No. SE0514, a CMS Publication.  The Commonwealth Court observed that Federal law shows a clear intent to make payment for same day examination the exception, not the rule. 

The take away here is that physical examinations billed separately for dates of treatment where other treatment/procedures are billed for the same day should be carefully reviewed in context to analyze whether payment for those examinations should be made or refused.

ConnorsO’Dell LLP

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We defend Employers, Self-Insureds, Insurance Carriers, and Third Party Administrators in Workers’ Compensation matters throughout  Pennsylvania.  We have over 100 years of cumulative experience defending our clients against compensation-related liabilities, with no attorney in our firm having less than ten (10) years of specialized experience, empowering our Workers’ Compensation practice group attorneys to be more than mere claim denials, enabling us to create the factual and legal leverage to expeditiously resolve claims, in the course of limiting/reducing/extinguishing our clients’ liabilities under the Pennsylvania Workers’ Compensation Act.

Every member of our Workers’ Compensation practice group is AV rated.  Our partnership with the NWCDN magnifies the lens for which our professional expertise imperiously demands that we always be dynamic and exacting advocates for our clients, navigating the frustrating and form-intensive minefield pervasive throughout Pennsylvania Workers’ Compensation practice and procedure.