Chapter 5. Division Of Workers’ Compensation of California Labor Code >> Division 1. >> Chapter 5.
As used in this chapter:
(a) "Appeals board" means the Workers' Compensation Appeals Board.
The title of a member of the board is "commissioner."
(b) "Administrative director" means the Administrative Director of
the Division of Workers' Compensation.
(c) "Division" means the Division of Workers' Compensation.
(d) "Medical director" means the physician appointed by the
administrative director pursuant to Section 122.
(e) "Qualified medical evaluator" means physicians appointed by
the administrative director pursuant to Section 139.2.
The Workers' Compensation Appeals Board, consisting of seven
members, shall exercise all judicial powers vested in it under this
code. In all other respects, the Division of Workers' Compensation is
under the control of the administrative director and, except as to
those duties, powers, jurisdiction, responsibilities, and purposes as
are specifically vested in the appeals board, the administrative
director shall exercise the powers of the head of a department within
the meaning of Article 1 (commencing with Section 11150) of Chapter
2 of Part 1 of Division 3 of Title 2 of the Government Code with
respect to the Division of Workers' Compensation which shall include
supervision of, and responsibility for, personnel, and the
coordination of the work of the division, except personnel of the
appeals board.
The members of the appeals board shall be appointed by the
Governor with the advice and consent of the Senate. The term of
office of the members appointed prior to January 1, 1990, shall be
four years, and the term of office of members appointed on or after
January 1, 1990, shall be six years and they shall hold office until
the appointment and qualification of their successors.
Five of the members of the appeals board shall be experienced
attorneys at law admitted to practice in the State of California. The
other two members need not be attorneys at law. All members shall be
selected with due consideration of their judicial temperament and
abilities. Each member shall receive the salary provided for by
Chapter 6 (commencing with Section 11550) of Part 1 of Division 3 of
Title 2 of the Government Code.
The Governor shall designate the chairman of the appeals board
from the membership of the appeals board. The person so designated
shall hold the office of chairman at the pleasure of the Governor.
The chairman may designate in writing one of the other members of
the appeals board to act as chairman during such time as he may be
absent from the state on official business, on vacation, or absent
due to illness.
Actions of the appeals board shall be taken by decision of a
majority of the appeals board except as otherwise expressly provided.
The chairman shall assign pending cases in which reconsideration
is sought to any three members thereof for hearing, consideration and
decision. Assignments by the chairman of members to such cases shall
be rotated on a case-by-case basis with the composition of the
members so assigned being varied and changed to assure that there
shall never be a fixed and continued composition of members. Any such
case assigned to any three members in which the finding, order,
decision or award is made and filed by any two or more of such
members shall be the action of the appeals board unless
reconsideration is had in accordance with the provisions of Article 1
(commencing with Section 5900), Chapter 7, Part 4, Division 4 of
this code. Any case assigned to three members shall be heard and
decided only by them, unless the matter has been reassigned by the
chairman on a majority vote of the appeals board to the appeals board
as a whole in order to achieve uniformity of decision, or in cases
presenting novel issues.
The seal of the appeals board bearing the inscription "Workers'
Compensation Appeals Board, Seal" shall be affixed to all writs and
authentications of copies of records and to such other instruments as
the appeals board directs.
The administrative director may appoint an attorney licensed
to practice law in the state as counsel to the division.
The attorney shall:
(a) Represent and appear for the state and the Division of Workers'
Compensation and the appeals board in all actions and proceedings
arising under any provision of this code administered by the division
or under any order or act of the division or the appeals board and,
if directed so to do, intervene, if possible, in any action or
proceeding in which any such question is involved.
(b) Commence, prosecute, and expedite the final determination of
all actions or proceedings, directed or authorized by the
administrative director or the appeals board.
(c) Advise the administrative director and the appeals board and
each member thereof, upon request, in regard to the jurisdiction,
powers or duties of the administrative director, the appeals board
and each member thereof.
(d) Generally perform the duties and services as attorney to the
Division of Workers' Compensation and the appeals board which are
required of him or her.
The administrative director and the chairman of the appeals
board may each respectively appoint a secretary and assistant
secretaries to perform such services as shall be prescribed.
The chairman of the appeals board may authorize its secretary
and any two assistant secretaries to act as deputy appeals board
members and may delegate authority and duties to these deputies. Not
more than three deputies may act as appeals board members at any one
time. No act of any deputy shall be valid unless it is concurred in
by at least one member of the appeals board.
The administrative director shall appoint a medical director
who shall possess a physician's and surgeon's certificate granted
under Chapter 5 (commencing with Section 2000) of Division 2 of the
Business and Professions Code. The medical director shall employ
medical assistants who shall also possess physicians' and surgeons'
certificates and other staff necessary to the performance of his or
her duties. The salaries for the medical director and his or her
assistants shall be fixed by the Department of Human Resources,
commensurate with the salaries paid by private industry to medical
directors and assistant medical directors.
The administrative director may employ necessary assistants,
officers, experts, statisticians, actuaries, accountants, workers'
compensation administrative law judges, stenographic shorthand
reporters, legal secretaries, disability evaluation raters, program
technicians, and other employees to implement new, efficient court
management systems. The salaries of the workers' compensation
administrative law judges shall be fixed by the Department of Human
Resources for a class of positions which perform judicial functions.
Any official reporter employed by the administrative
director shall render stenographic or clerical assistance as directed
by the presiding workers' compensation administrative law judge of
the office to which the reporter is assigned, when the presiding
workers' compensation administrative law judge determines that the
reporter is not engaged in the performance of any other duty imposed
by law.
(a) Workers' compensation administrative law judges employed
by the administrative director shall be taken from an eligible list
of attorneys licensed to practice law in this state, who have the
qualifications prescribed by the State Personnel Board. In
establishing eligible lists for this purpose, state civil service
examinations shall be conducted in accordance with the State Civil
Service Act (Part 2 (commencing with Section 18500) of Division 5 of
Title 2 of the Government Code). Every workers' compensation judge
shall maintain membership in the State Bar of California during his
or her tenure.
A workers' compensation administrative law judge may not receive
his or her salary as a workers' compensation administrative law judge
while any cause before the workers' compensation administrative law
judge remains pending and undetermined for 90 days after it has been
submitted for decision.
(b) All workers' compensation administrative law judges appointed
on or after January 1, 2003, shall be attorneys licensed to practice
law in California for five or more years prior to their appointment
and shall have experience in workers' compensation law.
(a) All workers' compensation administrative law judges
employed by the administrative director shall subscribe to the Code
of Judicial Ethics adopted by the Supreme Court pursuant to
subdivision (m) of Section 18 of Article VI of the California
Constitution for the conduct of judges and shall not otherwise,
directly or indirectly, engage in conduct contrary to that code or to
the commentary to the Code of Judicial Ethics.
In consultation with the Commission on Judicial Performance, the
administrative director shall adopt regulations to enforce this
section. To the extent possible, the rules shall be consistent with
the procedures established by the Commission on Judicial Performance
for regulating the activities of state judges, and, to the extent
possible, with the gift, honoraria, and travel restrictions on
legislators contained in the Political Reform Act of 1974 (Title 9
(commencing with Section 81000) of the Government Code).
(b) Honoraria or travel allowed by the administrative director,
and not otherwise prohibited by this section in connection with any
public or private conference, convention, meeting, social event, or
like gathering, the cost of which is significantly paid for by
attorneys who practice before the board, may not be accepted unless
the administrative director has provided prior approval in writing to
the workers' compensation administrative law judge allowing him or
her to accept those payments.
The appeals board may, by rule or regulation, establish
procedures whereby attorneys who are either certified specialists in
workers' compensation by the California State Bar, or are eligible
for this certification, may be appointed by the presiding workers'
compensation judge of each board office to serve as a pro tempore
workers' compensation judge in a particular case, upon the
stipulation of the employee or his or her representative, and the
employer or the insurance carrier. Service in this capacity by an
attorney shall be voluntary and without pay. It is the intent of the
Legislature that the use of pro tempore workers' compensation judges
pursuant to this section shall not result in a reduction of the
number of permanent civil service employees or the number of
authorized full-time equivalent positions.
(a) In administering and enforcing this division and Division
4 (commencing with Section 3200), the division shall protect the
interests of injured workers who are entitled to the timely provision
of compensation.
(b) Forms and notices required to be given to employees by the
division shall be in English and Spanish.
(c) In addition to the requirement in subdivision (b), no later
than January 1, 2018, the department and the division shall make at
least the following forms, notices, and materials available in
Chinese, Korean, Tagalog, and Vietnamese:
(1) The workers' compensation claim form required pursuant to
Section 5401.
(2) The application for the Return-to-Work Supplement Program
authorized pursuant to Section 139.48.
(3) Supplemental Job Displacement Non-Transferable Voucher.
(4) Division of Workers' Compensation fact sheets distributed to
injured workers, including, but not limited to, those addressing the
following topics:
(A) Temporary disability.
(B) Permanent disability.
(C) Qualified medical evaluators.
(D) Uninsured Employers Benefits Trust Fund.
(E) Utilization review.
(F) Basic facts on workers' compensation.
(G) Glossary of terms in workers' compensation.
(d) (1) Commencing January 1, 2018, the Administrative Director
shall annually review the forms, notices, and materials that are
published and distributed by the division to injured workers and
recommend to the division any other documents that should be
translated into languages other than English pursuant to subdivisions
(b) and (c).
(2) Commencing January 1, 2018, and annually thereafter, the
department and the division shall submit the recommendations and any
translated documents to the Legislature.
The administrative director shall cause to be printed and
furnished free of charge to any person blank forms that may
facilitate or promote the efficient performance of the duties of the
Division of Workers' Compensation.
The Division of Workers' Compensation, including the
administrative director and the appeals board, shall keep minutes of
all their proceedings and other books or records requisite for proper
and efficient administration. All records shall be kept in their
respective offices.
The administrative director may do all of the following:
(a) Charge and collect fees for copies of papers and records, for
certified copies of official documents and orders or of the evidence
taken or proceedings had, for transcripts of testimony, and for
inspection of case files not stored in the place where the inspection
is requested. The administrative director shall fix those fees in an
amount sufficient to recover the actual costs of furnishing the
services. No fees for inspection of case files shall be charged to an
injured employee or his or her representative.
(b) Publish and distribute from time to time, in addition to the
reports to the Governor, further reports and pamphlets covering the
operations, proceedings, and matters relative to the work of the
division.
(c) Prepare, publish, and distribute an office manual, for which a
reasonable fee may be charged, and to which additions, deletions,
amendments, and other changes from time to time may be adopted,
published, and distributed, for which a reasonable fee may be charged
for the revision, or for which a reasonable fee may be fixed on an
annual subscription basis.
(d) Fix and collect reasonable charges for publications issued.
The appeals board may accept appointment as deputy
commissioner under, or any delegation of authority to enforce, the
United States Longshoremen's and Harbor Worker's Compensation Act.
The appeals board may enter into arrangements with the United States,
subject to the approval of the Department of Finance, for the
payment of any expenses incurred in the performance of services under
said act. In the performance of any duties under said act,
appointment, or authority, the appeals board may, subject to the
provisions thereof, exercise any authority conferred upon the appeals
board by the laws of this state.
(a) To make certain that injured workers, and their dependents
in the event of their death, receive promptly and accurately the
full measure of compensation to which they are entitled, the
administrative director shall audit insurers, self-insured employers,
and third-party administrators to determine if they have met their
obligations under this code. Each audit subject shall be audited at
least once every five years. The audit subjects shall be selected and
the audits conducted pursuant to subdivision (b). The results of
audits of insurers shall be provided to the Insurance Commissioner,
and the results of audits of self-insurers and third-party
administrators shall be provided to the Director of Industrial
Relations. Nothing in this section shall restrict the authority of
the Director of Industrial Relations or the Insurance Commissioner to
audit their licensees.
(b) The administrative director shall schedule and conduct audits
as follows:
(1) A profile audit review of every audit subject shall be
conducted once every five years and on additional occasions indicated
by target audit criteria. The administrative director shall annually
establish a profile audit review performance standard that will
identify the poorest performing audit subjects.
(2) A full compliance audit shall be conducted of each profile
audited subject failing to meet or exceed the profile audit review
performance standard. The full compliance audit shall be a
comprehensive and detailed evaluation of the audit subject's
performance. The administrative director shall annually establish a
full compliance audit performance standard that will identify the
audit subjects that are performing satisfactorily. Any full
compliance audit subject that fails to meet or exceed the full
compliance audit performance standard shall be audited again within
two years.
(3) A targeted profile audit review or a full compliance audit may
be conducted at any time in accordance with target audit criteria
adopted by the administrative director. The target audit criteria
shall be based on information obtained from benefit notices, from
information and assistance officers, and from other reliable sources
providing factual information that indicates an insurer, self-insured
employer, or third-party administrator is failing to meet its
obligations under this division or Division 4 (commencing with
Section 3200) or the regulations of the administrative director.
(c) If, as a result of a profile audit review or a full compliance
audit, the administrative director determines that any compensation,
interest, or penalty is due and unpaid to an employee or dependent,
the administrative director shall issue and cause to be served upon
the insurer, self-insured employer, or third-party administrator a
notice of assessment detailing the amounts due and unpaid in each
case, and shall order the amounts paid to the person entitled
thereto. The notice of assessment shall be served personally or by
registered mail in accordance with subdivision (c) of Section 11505
of the Government Code. A copy of the notice of assessment shall also
be sent to the affected employee or dependent.
If the amounts are not paid within 30 days after service of the
notice of assessment, the employer shall also be liable for
reasonable attorney's fees necessarily incurred by the employee or
dependent to obtain amounts due. The administrative director shall
advise each employee or dependent still owed compensation after this
30-day period of his or her rights with respect to the commencement
of proceedings to collect the compensation owed. Amounts unpaid
because the person entitled thereto cannot be located shall be paid
to the Workers' Compensation Administration Revolving Fund. The
Director of Industrial Relations shall promulgate rules and
regulations establishing standards and procedures for the payment of
compensation from moneys deposited in the Workers' Compensation
Administration Revolving Fund whenever the person entitled thereto
applies for compensation.
(d) A determination by the administrative director that an amount
is or is not due to an employee or dependent shall not in any manner
limit the jurisdiction or authority of the appeals board to determine
the issue.
(e) Annually, commencing on April 1, 1991, the administrative
director shall publish a report detailing the results of audits
conducted pursuant to this section during the preceding calendar
year. The report shall include the name of each insurer, self-insured
employer, and third-party administrator audited during that period.
For each insurer, self-insured employer, and third-party
administrator audited, the report shall specify the total number of
files audited, the number of violations found by type and amount of
compensation, interest and penalties payable, and the amount
collected for each violation. The administrative director shall also
publish and make available to the public on request a list ranking
all insurers, self-insured employers, and third-party administrators
audited during the period according to their performance measured by
the profile audit review and full compliance audit performance
standards.
These reports shall not identify the particular claim file that
resulted in a particular violation or penalty. Except as required by
this subdivision or other provisions of law, the contents of
individual claim files and auditor's working papers shall be
confidential. Disclosure of claim information to the administrative
director pursuant to an audit shall not waive the provisions of the
Evidence Code relating to privilege.
(f) A profile audit review of the adjustment of claims against the
Uninsured Employers Fund by the claims and collections unit of the
Division of Workers' Compensation shall be conducted at least every
five years. The results of this profile audit review shall be
included in the report required by subdivision (e).
(a) The administrative director may assess an administrative
penalty against an insurer, self-insured employer, or third-party
administrator for any of the following:
(1) Failure to comply with the notice of assessment issued
pursuant to subdivision (c) of Section 129 within 15 days of receipt.
(2) Failure to pay when due the undisputed portion of an indemnity
payment, the reasonable cost of medical treatment of an injured
worker, or a charge or cost implementing an approved vocational
rehabilitation plan.
(3) Failure to comply with any rule or regulation of the
administrative director.
(b) The administrative director shall promulgate regulations
establishing a schedule of violations and the amount of the
administrative penalty to be imposed for each type of violation. The
schedule shall provide for imposition of a penalty of up to one
hundred dollars ($100) for each violation of the less serious type
and for imposition of penalties in progressively higher amounts for
the most serious types of violations to be set at up to five thousand
dollars ($5,000) per violation. The administrative director is
authorized to impose penalties pursuant to rules and regulations
which give due consideration to the appropriateness of the penalty
with respect to the following factors:
(1) The gravity of the violation.
(2) The good faith of the insurer, self-insured employer, or
third-party administrator.
(3) The history of previous violations, if any.
(4) The frequency of the violations.
(5) Whether the audit subject has met or exceeded the profile
audit review performance standard.
(6) Whether a full compliance audit subject has met or exceeded
the full compliance audit performance standard.
(7) The size of the audit subject location.
(c) The administrative director shall assess penalties as follows:
(1) If, after a profile audit review, the administrative director
determines that the profile audit subject met or exceeded the profile
audit review performance standard, no penalties shall be assessed
under this section, but the audit subject shall be required to pay
any compensation due and penalties due under subdivision (d) of
Section 4650 as provided in subdivision (c) of Section 129.
(2) If, after a full compliance audit, the administrative director
determines that the audit subject met or exceeded the full
compliance audit performance standards, penalties for unpaid or late
paid compensation, but no other penalties under this section, shall
be assessed. The audit subject shall be required to pay any
compensation due and penalties due under subdivision (d) of Section
4650 as provided in subdivision (c) of Section 129.
(3) If, after a full compliance audit, the administrative director
determines that the audit subject failed to meet the full compliance
audit performance standards, penalties shall be assessed as provided
in a full compliance audit failure penalty schedule to be adopted by
the administrative director. The full compliance audit failure
penalty schedule shall adjust penalty levels relative to the size of
the audit location to mitigate inequality between total penalties
assessed against small and large audit subjects. The penalty amounts
provided in the full compliance audit failure penalty schedule for
the most serious type of violations shall not be limited by
subdivision (b), but in no event shall the penalty for a single
violation exceed forty thousand dollars ($40,000).
(d) The notice of penalty assessment shall be served personally or
by registered mail in accordance with subdivision (c) of Section
11505 of the Government Code. The notice shall be in writing and
shall describe the nature of the violation, including reference to
the statutory provision or rule or regulation alleged to have been
violated. The notice shall become final and the assessment shall be
paid unless contested within 15 days of receipt by the insurer,
self-insured employer, or third-party administrator.
(e) In addition to the penalty assessments permitted by
subdivisions (a), (b), and (c), the administrative director may
assess a civil penalty, not to exceed one hundred thousand dollars
($100,000), upon finding, after hearing, that an employer, insurer,
or third-party administrator for an employer has knowingly committed
or performed with sufficient frequency so as to indicate a general
business practice any of the following:
(1) Induced employees to accept less than compensation due, or
made it necessary for employees to resort to proceedings against the
employer to secure compensation.
(2) Refused to comply with known and legally indisputable
compensation obligations.
(3) Discharged or administered compensation obligations in a
dishonest manner.
(4) Discharged or administered compensation obligations in a
manner as to cause injury to the public or those dealing with the
employer or insurer.
Any employer, insurer, or third-party administrator that fails to
meet the full compliance audit performance standards in two
consecutive full compliance audits shall be rebuttably presumed to
have engaged in a general business practice of discharging and
administering its compensation obligations in a manner causing injury
to those dealing with it.
Upon a second or subsequent finding, the administrative director
shall refer the matter to the Insurance Commissioner or the Director
of Industrial Relations and request that a hearing be conducted to
determine whether the certificate of authority, certificate of
consent to self-insure, or certificate of consent to administer
claims of self-insured employers, as the case may be, shall be
revoked.
(f) An insurer, self-insured employer, or third-party
administrator may file a written request for a conference with the
administrative director within seven days after receipt of a notice
of penalty assessment issued pursuant to subdivision (a) or (c).
Within 15 days of the conference, the administrative director shall
issue a notice of findings and serve it upon the contesting party by
registered or certified mail. Any amount found due by the
administrative director shall become due and payable 30 days after
receipt of the notice of findings. The 30-day period shall be tolled
during any appeal. A writ of mandate may be taken from the findings
to the appropriate superior court upon the execution by the
contesting party of a bond to the state in the principal sum that is
double the amount found due and ordered by the administrative
director, on the condition that the contesting party shall pay any
judgment and costs rendered against it for the amount.
(g) An insurer, self-insured employer, or third-party
administrator may file a written request for a hearing before the
Workers' Compensation Appeals Board within seven days after receipt
of a notice of penalty assessment issued pursuant to subdivision (e).
Within 30 days of the hearing, the appeals board shall issue
findings and orders and serve them upon the contesting party in the
manner provided in its rules. Any amount found due by the appeals
board shall become due and payable 45 days after receipt of the
notice of findings. Judicial review of the findings and order shall
be had in the manner provided by Article 2 (commencing with Section
5950) of Chapter 7 of Part 4 of Division 4. The 45-day period shall
be tolled during appellate proceedings upon execution by the
contesting party of a bond to the state in a principal sum that is
double the amount found due and ordered by the appeals board on the
condition that the contesting party shall pay the amount ultimately
determined to be due and any costs awarded by an appellate court.
(h) Nothing in this section shall create nor eliminate a civil
cause of action for the employee and his or her dependents.
(i) All moneys collected under this section shall be deposited in
the State Treasury and credited to the Workers' Compensation
Administration Revolving Fund.
The appeals board and each of its members, its secretary,
assistant secretaries, and workers' compensation judges, may
administer oaths, certify to all official acts, and issue subpoenas
for the attendance of witnesses and the production of papers, books,
accounts, documents and testimony in any inquiry, investigation,
hearing or proceeding in any part of the state.
Each witness who appears by order of the appeals board or any
of its members, or a workers' compensation judge, shall receive, if
demanded, for his or her attendance the same fees and mileage allowed
by law to a witness in civil cases, paid by the party at whose
request the witness is subpoenaed, unless otherwise ordered by the
appeals board. When any witness who has not been required to attend
at the request of any party is subpoenaed by the appeals board, his
or her fees and mileage may be paid from the funds appropriated for
the use of the appeals board in the same manner as other expenses of
the appeals board are paid. Any witness subpoenaed, except one whose
fees and mileage are paid from the funds of the appeals board, may,
at the time of service, demand the fee to which he or she is entitled
for travel to and from the place at which he or she is required to
appear, and one day's attendance. If a witness demands his or her
fees at the time of service, and they are not at that time paid or
tendered, he or she shall not be required to attend as directed in
the subpoena. All fees and mileage to which any witness is entitled
under this section may be collected by action therefor instituted by
the person to whom the fees are payable.
The superior court in and for the county in which any
proceeding is held by the appeals board or a workers' compensation
judge may compel the attendance of witnesses, the giving of testimony
and the production of papers, including books, accounts, and
documents, as required by any subpoena regularly issued hereunder. In
case of the refusal of any witness to obey the subpoena the appeals
board or the workers' compensation judge, before whom the testimony
is to be given or produced, may report to the superior court in and
for the county in which the proceeding is pending, by petition,
setting forth that due notice has been given of the time and place of
attendance of the witness, or the production of the papers, that the
witness has been subpoenaed in the prescribed manner, and that the
witness has failed and refused to obey the subpoena, or has refused
to answer questions propounded to him or her in the course of the
proceeding, and ask an order of the court, compelling the witness to
attend and testify or produce the papers before the appeals board.
The court shall thereupon enter an order directing the witness to
appear before the court at a time and place fixed in the order, the
time to be not more than 10 days from the date of the order, and then
and there show cause why he or she had not attended and testified or
produced the papers before the appeals board or the workers'
compensation judge. A copy of the order shall be served upon the
witness. If it appears to the court that the subpoena was regularly
issued hereunder and that the witness was legally bound to comply
therewith, the court shall thereupon enter an order that the witness
appear before the appeals board or the workers' compensation judge at
a time and place fixed in the order, and testify or produce the
required papers, and upon failure to obey the order, the witness
shall be dealt with as for contempt of court. The remedy provided in
this section is cumulative, and shall not impair or interfere with
the power of the appeals board or a member thereof to enforce the
attendance of witnesses and the production of papers, and to punish
for contempt in the same manner and to the same extent as courts of
record.
132a. It is the declared policy of this state that there should not
be discrimination against workers who are injured in the course and
scope of their employment.
(1) Any employer who discharges, or threatens to discharge, or in
any manner discriminates against any employee because he or she has
filed or made known his or her intention to file a claim for
compensation with his or her employer or an application for
adjudication, or because the employee has received a rating, award,
or settlement, is guilty of a misdemeanor and the employee's
compensation shall be increased by one-half, but in no event more
than ten thousand dollars ($10,000), together with costs and expenses
not in excess of two hundred fifty dollars ($250). Any such employee
shall also be entitled to reinstatement and reimbursement for lost
wages and work benefits caused by the acts of the employer.
(2) Any insurer that advises, directs, or threatens an insured
under penalty of cancellation or a raise in premium or for any other
reason, to discharge an employee because he or she has filed or made
known his or her intention to file a claim for compensation with his
or her employer or an application for adjudication, or because the
employee has received a rating, award, or settlement, is guilty of a
misdemeanor and subject to the increased compensation and costs
provided in paragraph (1).
(3) Any employer who discharges, or threatens to discharge, or in
any manner discriminates against any employee because the employee
testified or made known his or her intentions to testify in another
employee's case before the appeals board, is guilty of a misdemeanor,
and the employee shall be entitled to reinstatement and
reimbursement for lost wages and work benefits caused by the acts of
the employer.
(4) Any insurer that advises, directs, or threatens an insured
employer under penalty of cancellation or a raise in premium or for
any other reason, to discharge or in any manner discriminate against
an employee because the employee testified or made known his or her
intention to testify in another employee's case before the appeals
board, is guilty of a misdemeanor.
Proceedings for increased compensation as provided in paragraph
(1), or for reinstatement and reimbursement for lost wages and work
benefits, are to be instituted by filing an appropriate petition with
the appeals board, but these proceedings may not be commenced more
than one year from the discriminatory act or date of termination of
the employee. The appeals board is vested with full power, authority,
and jurisdiction to try and determine finally all matters specified
in this section subject only to judicial review, except that the
appeals board shall have no jurisdiction to try and determine a
misdemeanor charge. The appeals board may refer and any worker may
complain of suspected violations of the criminal misdemeanor
provisions of this section to the Division of Labor Standards
Enforcement, or directly to the office of the public prosecutor.
The Division of Workers' Compensation, including the
administrative director and the appeals board, shall have power and
jurisdiction to do all things necessary or convenient in the exercise
of any power or jurisdiction conferred upon it under this code.
The appeals board or any member thereof may issue writs or
summons, warrants of attachment, warrants of commitment and all
necessary process in proceedings for contempt, in like manner and to
the same extent as courts of record. The process issued by the
appeals board or any member thereof shall extend to all parts of the
state and may be served by any persons authorized to serve process of
courts of record or by any person designated for that purpose by the
appeals board or any member thereof. The person executing process
shall receive compensation allowed by the appeals board, not to
exceed the fees prescribed by law for similar services. Such fees
shall be paid in the same manner as provided herein for the fees of
witnesses.
In accordance with rules of practice and procedure that it may
adopt, the appeals board may, with the approval of the Secretary of
State, destroy or otherwise dispose of any file kept by it in
connection with any proceeding under Division 4 (commencing with
Section 3200) or Division 4.5 (commencing with Section 6100).
The administrative director may appoint a deputy to act when
he or she is absent from the state due to official business,
vacation, or illness.
The administrative director shall be appointed by the
Governor with the advice and consent of the Senate and shall hold
office at the pleasure of the Governor. He or she shall receive the
salary provided for by Chapter 6 (commencing with Section 11550) of
Part 1 of Division 3 of Title 2 of the Government Code.
(a) The headquarters of the Division of Workers'
Compensation shall be based at and operated from a centrally located
city.
The administrative director shall have an office in that city with
suitable rooms, necessary office furniture, stationery, and
supplies, and may rent quarters in other places for the purpose of
establishing branch or service offices, and for that purpose may
provide those offices with necessary furniture, stationery, and
supplies.
(b) The administrative director shall provide suitable rooms, with
necessary office furniture, stationery, and supplies, for the
appeals board at the centrally located city in which the board shall
be based and from which it shall operate, and may rent quarters in
other places for the purpose of establishing branch or service
offices for the appeals board, and for that purpose may provide those
offices with necessary furniture, stationery, and supplies.
(c) All meetings held by the administrative director shall be open
and public. Notice thereof shall be published in papers of general
circulation not more than 30 days and not less than 10 days prior to
each meeting in Sacramento, San Francisco, Fresno, Los Angeles, and
San Diego. Written notice of all meetings shall be given to all
persons who request, in writing directed to the administrative
director, that they be given notice.
The administrative director shall, with respect to all
injuries, prescribe, pursuant to Section 5402, reasonable rules and
regulations requiring the employer to serve notice on the injured
employee that he may be entitled to benefits under this division.
(a) For the purpose of this section, "claims administrator"
means a self-administered workers' compensation insurer; or a
self-administered self-insured employer; or a self-administered
legally uninsured employer; or a self-administered joint powers
authority; or a third-party claims administrator for an insurer, a
self-insured employer, a legally uninsured employer, or a joint
powers authority.
(b) With respect to injuries resulting in lost time beyond the
employee's work shift at the time of injury or medical treatment
beyond first aid:
(1) If the claims administrator obtains knowledge that the
employer has not provided a claim form or a notice of potential
eligibility for benefits to the employee, it shall provide the form
and notice to the employee within three working days of its knowledge
that the form or notice was not provided.
(2) If the claims administrator cannot determine if the employer
has provided a claim form and notice of potential eligibility for
benefits to the employee, the claims administrator shall provide the
form and notice to the employee within 30 days of the administrator's
date of knowledge of the claim.
(c) The administrative director, in consultation with the
Commission on Health and Safety and Workers' Compensation, shall
prescribe reasonable rules and regulations, including notice of the
right to consult with an attorney, where appropriate, for serving on
the employee (or employee's dependents, in the case of death), the
following:
(1) Notices dealing with the payment, nonpayment, or delay in
payment of temporary disability, permanent disability, supplemental
job displacement, and death benefits.
(2) Notices of any change in the amount or type of benefits being
provided, the termination of benefits, the rejection of any liability
for compensation, and an accounting of benefits paid.
(3) Notices of rights to select the primary treating physician,
written continuity of care policies, requests for a comprehensive
medical evaluation, and offers of regular, modified, or alternative
work.
(d) The administrative director, in consultation with the
Commission on Health and Safety and Workers' Compensation, shall
develop, make fully accessible on the department's Internet Web site,
and make available at district offices informational material
written in plain language that describes the overall workers'
compensation claims process, including the rights and obligations of
employees and employers at every stage of a claim when a notice is
required.
(e) Each notice prescribed by the administrative director shall be
written in plain language, shall reference the informational
material described in subdivision (d) to enable employees to
understand the context of the notices, and shall clearly state the
Internet Web site address and contact information that an employee
may use to access the informational material.
The Division of Workers' Compensation shall cooperate in the
enforcement of child support obligations. At the request of the
Department of Child Support Services, the administrative director
shall assist in providing to the State Department of Child Support
Services information concerning persons who are receiving permanent
disability benefits or who have filed an application for adjudication
of a claim which the Department of Child Support Services determines
is necessary to carry out its responsibilities pursuant to Section
17510 of the Family Code.
The process of sharing information with regard to applicants for
and recipients of permanent disability benefits required by this
section shall be known as the Workers' Compensation Notification
Project.
(a) The administrative director, in consultation with the
Insurance Commissioner and the Workers' Compensation Insurance Rating
Bureau, shall develop a cost-efficient workers' compensation
information system, which shall be administered by the division. The
administrative director shall adopt regulations specifying the data
elements to be collected by electronic data interchange.
(b) The information system shall do the following:
(1) Assist the department to manage the workers' compensation
system in an effective and efficient manner.
(2) Facilitate the evaluation of the efficiency and effectiveness
of the delivery system.
(3) Assist in measuring how adequately the system indemnifies
injured workers and their dependents.
(4) Provide statistical data for research into specific aspects of
the workers' compensation program.
(c) The data collected electronically shall be compatible with the
Electronic Data Interchange System of the International Association
of Industrial Accident Boards and Commissions. The administrative
director may adopt regulations authorizing the use of other
nationally recognized data transmission formats in addition to those
set forth in the Electronic Data Interchange System for the
transmission of data required pursuant to this section. The
administrative director shall accept data transmissions in any
authorized format. If the administrative director determines that any
authorized data transmission format is not in general use by claims
administrators, conflicts with the requirements of state or federal
law, or is obsolete, the administrative director may adopt
regulations eliminating that data transmission format from those
authorized pursuant to this subdivision.
(d) (1) The administrative director shall assess an administrative
penalty against a claims administrator for a violation of data
reporting requirements adopted pursuant to this section. The
administrative director shall promulgate a schedule of penalties
providing for an assessment of no more than five thousand dollars
($5,000) against a claims administrator in any single year,
calculated as follows:
(A) No more than one hundred dollars ($100) multiplied by the
number of violations in that year that resulted in a required data
report not being submitted or not being accepted.
(B) No more than fifty dollars ($50) multiplied by the number of
violations in that year that resulted in a required report being late
or accepted with an error.
(C) Multiple errors in a single report shall be counted as a
single violation.
(D) No penalty shall be assessed pursuant to Section 129.5 for any
violation of data reporting requirements for which a penalty has
been or may be assessed pursuant to this section.
(2) The schedule promulgated by the administrative director
pursuant to paragraph (1) shall establish threshold rates of
violations that shall be excluded from the calculation of the
assessment, as follows:
(A) The threshold rate for reports that are not submitted or are
submitted but not accepted shall not be less than 3 percent of the
number of reports that are required to be filed by or on behalf of
the claims administrator.
(B) The threshold rate for reports that are accepted with an error
shall not be less than 3 percent of the number of reports that are
accepted with an error.
(C) The administrative director shall set higher threshold rates
as appropriate in recognition of the fact that the data necessary for
timely and accurate reporting may not be always available to a
claims administrator or the claims administrator's agents.
(D) The administrative director may establish higher thresholds
for particular data elements that commonly are not reasonably
available.
(3) The administrative director may estimate the number of
required data reports that are not submitted by comparing a
statistically valid sample of data available to the administrative
director from other sources with the data reported pursuant to this
section.
(4) All penalties assessed pursuant to this section shall be
deposited in the Workers' Compensation Administration Revolving Fund.
(5) The administrative director shall publish an annual report
disclosing the compliance rates of claims administrators.
(a) Except as expressly permitted in subdivision (b), a
person or public or private entity not a party to a claim for workers'
compensation benefits may not obtain individually identifiable
information obtained or maintained by the division on that claim. For
purposes of this section, "individually identifiable information"
means any data concerning an injury or claim that is linked to a
uniquely identifiable employee, employer, claims administrator, or
any other person or entity.
(b) (1) (A) The administrative director, or a statistical agent
designated by the administrative director, may use individually
identifiable information for purposes of creating and maintaining the
workers' compensation information system as specified in Section
138.6.
(B) The administrative director may publish the identity of claims
administrators in the annual report disclosing the compliance rates
of claims administrators pursuant to subdivision (d) of Section
138.6.
(2) (A) The State Department of Public Health may use individually
identifiable information for purposes of establishing and
maintaining a program on occupational health and occupational disease
prevention as specified in Section 105175 of the Health and Safety
Code.
(B) (i) The State Department of Health Care Services may use
individually identifiable information for purposes of seeking
recovery of Medi-Cal costs incurred by the state for treatment
provided to injured workers that should have been incurred by
employers and insurance carriers pursuant to Article 3.5 (commencing
with Section 14124.70) of Chapter 7 of Part 3 of Division 9 of the
Welfare and Institutions Code.
(ii) The Department of Industrial Relations shall furnish
individually identifiable information to the State Department of
Health Care Services, and the State Department of Health Care
Services may furnish the information to its designated agent,
provided that the individually identifiable information shall not be
disclosed for use other than the purposes described in clause (i).
The administrative director may adopt regulations solely for the
purpose of governing access by the State Department of Health Care
Services or its designated agents to the individually identifiable
information as defined in subdivision (a).
(3) (A) Individually identifiable information may be used by the
Division of Workers' Compensation and the Division of Occupational
Safety and Health as necessary to carry out their duties. The
administrative director shall adopt regulations governing the access
to the information described in this subdivision by these divisions.
Any regulations adopted pursuant to this subdivision shall set forth
the specific uses for which this information may be obtained.
(B) Individually identifiable information maintained in the
workers' compensation information system and the Division of Workers'
Compensation may be used by researchers employed by or under
contract to the Commission on Health and Safety and Workers'
Compensation as necessary to carry out the commission's research. The
administrative director shall adopt regulations governing the access
to the information described in this subdivision by commission
researchers. These regulations shall set forth the specific uses for
which this information may be obtained and include provisions
guaranteeing the confidentiality of individually identifiable
information. Individually identifiable information obtained under
this subdivision shall not be disclosed to commission members. No
individually identifiable information obtained by researchers under
contract to the commission pursuant to this subparagraph may be
disclosed to any other person or entity, public or private, for a use
other than that research project for which the information was
obtained. Within a reasonable period of time after the research for
which the information was obtained has been completed, the data
collected shall be modified in a manner so that the subjects cannot
be identified, directly or through identifiers linked to the
subjects.
(4) The administrative director shall adopt regulations allowing
reasonable access to individually identifiable information by other
persons or public or private entities for the purpose of bona fide
statistical research. This research shall not divulge individually
identifiable information concerning a particular employee, employer,
claims administrator, or any other person or entity. The regulations
adopted pursuant to this paragraph shall include provisions
guaranteeing the confidentiality of individually identifiable
information. Within a reasonable period of time after the research
for which the information was obtained has been completed, the data
collected shall be modified in a manner so that the subjects cannot
be identified, directly or through identifiers linked to the
subjects.
(5) (A) This section shall not operate to exempt from disclosure
any information that is considered to be a public record pursuant to
the California Public Records Act (Chapter 3.5 (commencing with
Section 6250) of Division 7 of Title 1 of the Government Code)
contained in an individual's file once an application for
adjudication has been filed pursuant to Section 5501.5.
(B) However, individually identifiable information shall not be
provided to any person or public or private entity who is not a party
to the claim unless that person identifies himself or herself or
that public or private entity identifies itself and states the reason
for making the request. The administrative director may require the
person or public or private entity making the request to produce
information to verify that the name and address of the requester is
valid and correct. If the purpose of the request is related to
preemployment screening, the administrative director shall notify the
person about whom the information is requested that the information
was provided and shall include the following in 12-point type:
"IT MAY BE A VIOLATION OF FEDERAL AND STATE LAW TO DISCRIMINATE
AGAINST A JOB APPLICANT BECAUSE THE APPLICANT HAS FILED A CLAIM FOR
WORKERS' COMPENSATION BENEFITS."
(C) Any residence address is confidential and shall not be
disclosed to any person or public or private entity except to a party
to the claim, a law enforcement agency, an office of a district
attorney, any person for a journalistic purpose, or other
governmental agency.
(D) Nothing in this paragraph shall be construed to prohibit the
use of individually identifiable information for purposes of
identifying bona fide lien claimants.
(c) Except as provided in subdivision (b), individually
identifiable information obtained by the division is privileged and
is not subject to subpoena in a civil proceeding unless, after
reasonable notice to the division and a hearing, a court determines
that the public interest and the intent of this section will not be
jeopardized by disclosure of the information. This section shall not
operate to restrict access to information by any law enforcement
agency or district attorney's office or to limit admissibility of
that information in a criminal proceeding.
(d) It shall be unlawful for any person who has received
individually identifiable information from the division pursuant to
this section to provide that information to any person who is not
entitled to it under this section.
(e) This section shall remain in effect only until January 1,
2017, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2017, deletes or extends
that date.
(a) Except as expressly permitted in subdivision (b), a
person or public or private entity not a party to a claim for workers'
compensation benefits may not obtain individually identifiable
information obtained or maintained by the division on that claim. For
purposes of this section, "individually identifiable information"
means any data concerning an injury or claim that is linked to a
uniquely identifiable employee, employer, claims administrator, or
any other person or entity.
(b) (1) (A) The administrative director, or a statistical agent
designated by the administrative director, may use individually
identifiable information for purposes of creating and maintaining the
workers' compensation information system as specified in Section
138.6.
(B) The administrative director may publish the identity of claims
administrators in the annual report disclosing the compliance rates
of claims administrators pursuant to subdivision (d) of Section
138.6.
(2) The State Department of Public Health may use individually
identifiable information for purposes of establishing and maintaining
a program on occupational health and occupational disease prevention
as specified in Section 105175 of the Health and Safety Code.
(3) (A) Individually identifiable information may be used by the
Division of Workers' Compensation and the Division of Occupational
Safety and Health as necessary to carry out their duties. The
administrative director shall adopt regulations governing the access
to the information described in this subdivision by these divisions.
Any regulations adopted pursuant to this subdivision shall set forth
the specific uses for which this information may be obtained.
(B) Individually identifiable information maintained in the
workers' compensation information system and the Division of Workers'
Compensation may be used by researchers employed by or under
contract to the Commission on Health and Safety and Workers'
Compensation as necessary to carry out the commission's research. The
administrative director shall adopt regulations governing the access
to the information described in this subdivision by commission
researchers. These regulations shall set forth the specific uses for
which this information may be obtained and include provisions
guaranteeing the confidentiality of individually identifiable
information. Individually identifiable information obtained under
this subdivision shall not be disclosed to commission members. No
individually identifiable information obtained by researchers under
contract to the commission pursuant to this subparagraph may be
disclosed to any other person or entity, public or private, for a use
other than that research project for which the information was
obtained. Within a reasonable period of time after the research for
which the information was obtained has been completed, the data
collected shall be modified in a manner so that the subjects cannot
be identified, directly or through identifiers linked to the
subjects.
(4) The administrative director shall adopt regulations allowing
reasonable access to individually identifiable information by other
persons or public or private entities for the purpose of bona fide
statistical research. This research shall not divulge individually
identifiable information concerning a particular employee, employer,
claims administrator, or any other person or entity. The regulations
adopted pursuant to this paragraph shall include provisions
guaranteeing the confidentiality of individually identifiable
information. Within a reasonable period of time after the research
for which the information was obtained has been completed, the data
collected shall be modified in a manner so that the subjects cannot
be identified, directly or through identifiers linked to the
subjects.
(5) (A) This section shall not operate to exempt from disclosure
any information that is considered to be a public record pursuant to
the California Public Records Act (Chapter 3.5 (commencing with
Section 6250) of Division 7 of Title 1 of the Government Code)
contained in an individual's file once an application for
adjudication has been filed pursuant to Section 5501.5.
(B) However, individually identifiable information shall not be
provided to any person or public or private entity who is not a party
to the claim unless that person identifies himself or herself or
that public or private entity identifies itself and states the reason
for making the request. The administrative director may require the
person or public or private entity making the request to produce
information to verify that the name and address of the requester is
valid and correct. If the purpose of the request is related to
preemployment screening, the administrative director shall notify the
person about whom the information is requested that the information
was provided and shall include the following in 12-point type:
"IT MAY BE A VIOLATION OF FEDERAL AND STATE LAW TO DISCRIMINATE
AGAINST A JOB APPLICANT BECAUSE THE APPLICANT HAS FILED A CLAIM FOR
WORKERS' COMPENSATION BENEFITS."
(C) Any residence address is confidential and shall not be
disclosed to any person or public or private entity except to a party
to the claim, a law enforcement agency, an office of a district
attorney, any person for a journalistic purpose, or other
governmental agency.
(D) Nothing in this paragraph shall be construed to prohibit the
use of individually identifiable information for purposes of
identifying bona fide lien claimants.
(c) Except as provided in subdivision (b), individually
identifiable information obtained by the division is privileged and
is not subject to subpoena in a civil proceeding unless, after
reasonable notice to the division and a hearing, a court determines
that the public interest and the intent of this section will not be
jeopardized by disclosure of the information. This section shall not
operate to restrict access to information by any law enforcement
agency or district attorney's office or to limit admissibility of
that information in a criminal proceeding.
(d) It shall be unlawful for any person who has received
individually identifiable information from the division pursuant to
this section to provide that information to any person who is not
entitled to it under this section.
(e) This section shall become operative on January 1, 2017.
(a) The administrative director shall appoint qualified
medical evaluators in each of the respective specialties as required
for the evaluation of medical-legal issues. The appointments shall be
for two-year terms.
(b) The administrative director shall appoint or reappoint as a
qualified medical evaluator a physician, as defined in Section
3209.3, who is licensed to practice in this state and who
demonstrates that he or she meets the requirements in paragraphs (1),
(2), (6), and (7), and, if the physician is a medical doctor, doctor
of osteopathy, doctor of chiropractic, or a psychologist, that he or
she also meets the applicable requirements in paragraph (3), (4), or
(5).
(1) Prior to his or her appointment as a qualified medical
evaluator, passes an examination written and administered by the
administrative director for the purpose of demonstrating competence
in evaluating medical-legal issues in the workers' compensation
system. Physicians shall not be required to pass an additional
examination as a condition of reappointment. A physician seeking
appointment as a qualified medical evaluator on or after January 1,
2001, shall also complete prior to appointment, a course on
disability evaluation report writing approved by the administrative
director. The administrative director shall specify the curriculum to
be covered by disability evaluation report writing courses, which
shall include, but is not limited to, 12 or more hours of
instruction.
(2) Devotes at least one-third of total practice time to providing
direct medical treatment, or has served as an agreed medical
evaluator on eight or more occasions in the 12 months prior to
applying to be appointed as a qualified medical evaluator.
(3) Is a medical doctor or doctor of osteopathy and meets one of
the following requirements:
(A) Is board certified in a specialty by a board recognized by the
administrative director and either the Medical Board of California
or the Osteopathic Medical Board of California.
(B) Has successfully completed a residency training program
accredited by the Accreditation Council for Graduate Medical
Education or the osteopathic equivalent.
(C) Was an active qualified medical evaluator on June 30, 2000.
(D) Has qualifications that the administrative director and either
the Medical Board of California or the Osteopathic Medical Board of
California, as appropriate, both deem to be equivalent to board
certification in a specialty.
(4) Is a doctor of chiropractic and has been certified in
California workers' compensation evaluation by a provider recognized
by the administrative director. The certification program shall
include instruction on disability evaluation report writing that
meets the standards set forth in paragraph (1).
(5) Is a psychologist and meets one of the following requirements:
(A) Is board certified in clinical psychology by a board
recognized by the administrative director.
(B) Holds a doctoral degree in psychology, or a doctoral degree
deemed equivalent for licensure by the Board of Psychology pursuant
to Section 2914 of the Business and Professions Code, from a
university or professional school recognized by the administrative
director and has not less than five years' postdoctoral experience in
the diagnosis and treatment of emotional and mental disorders.
(C) Has not less than five years' postdoctoral experience in the
diagnosis and treatment of emotional and mental disorders, and has
served as an agreed medical evaluator on eight or more occasions
prior to January 1, 1990.
(6) Does not have a conflict of interest as determined under the
regulations adopted by the administrative director pursuant to
subdivision (o).
(7) Meets any additional medical or professional standards adopted
pursuant to paragraph (6) of subdivision (j).
(c) The administrative director shall adopt standards for
appointment of physicians who are retired or who hold teaching
positions who are exceptionally well qualified to serve as a
qualified medical evaluator even though they do not otherwise qualify
under paragraph (2) of subdivision (b). A physician whose full-time
practice is limited to the forensic evaluation of disability shall
not be appointed as a qualified medical evaluator under this
subdivision.
(d) The qualified medical evaluator, upon request, shall be
reappointed if he or she meets the qualifications of subdivision (b)
and meets all of the following criteria:
(1) Is in compliance with all applicable regulations and
evaluation guidelines adopted by the administrative director.
(2) Has not had more than five of his or her evaluations that were
considered by a workers' compensation administrative law judge at a
contested hearing rejected by the workers' compensation
administrative law judge or the appeals board pursuant to this
section during the most recent two-year period during which the
physician served as a qualified medical evaluator. If the workers'
compensation administrative law judge or the appeals board rejects
the qualified medical evaluator's report on the basis that it fails
to meet the minimum standards for those reports established by the
administrative director or the appeals board, the workers'
compensation administrative law judge or the appeals board, as the
case may be, shall make a specific finding to that effect, and shall
give notice to the medical evaluator and to the administrative
director. Any rejection shall not be counted as one of the five
qualifying rejections until the specific finding has become final and
time for appeal has expired.
(3) Has completed within the previous 24 months at least 12 hours
of continuing education in impairment evaluation or workers'
compensation-related medical dispute evaluation approved by the
administrative director.
(4) Has not been terminated, suspended, placed on probation, or
otherwise disciplined by the administrative director during his or
her most recent term as a qualified medical evaluator.
If the evaluator does not meet any one of these criteria, the
administrative director may in his or her discretion reappoint or
deny reappointment according to regulations adopted by the
administrative director. A physician who does not currently meet the
requirements for initial appointment or who has been terminated under
subdivision (e) because his or her license has been revoked or
terminated by the licensing authority shall not be reappointed.
(e) The administrative director may, in his or her discretion,
suspend or terminate a qualified medical evaluator during his or her
term of appointment without a hearing as provided under subdivision
(k) or (l) whenever either of the following conditions occurs:
(1) The evaluator's license to practice in California has been
suspended by the relevant licensing authority so as to preclude
practice, or has been revoked or terminated by the licensing
authority.
(2) The evaluator has failed to timely pay the fee required by the
administrative director pursuant to subdivision (n).
(f) The administrative director shall furnish a physician, upon
request, with a written statement of its reasons for termination of,
or for denying appointment or reappointment as, a qualified medical
evaluator. Upon receipt of a specific response to the statement of
reasons, the administrative director shall review his or her decision
not to appoint or reappoint the physician or to terminate the
physician and shall notify the physician of its final decision within
60 days after receipt of the physician's response.
(g) The administrative director shall establish agreements with
qualified medical evaluators to ensure the expeditious evaluation of
cases assigned to them for comprehensive medical evaluations.
(h) (1) When requested by an employee or employer pursuant to
Section 4062.1, the medical director appointed pursuant to Section
122 shall assign three-member panels of qualified medical evaluators
within five working days after receiving a request for a panel.
Preference in assigning panels shall be given to cases in which the
employee is not represented. If a panel is not assigned within 20
working days, the employee shall have the right to obtain a medical
evaluation from any qualified medical evaluator of his or her choice
within a reasonable geographic area. The medical director shall use a
random selection method for assigning panels of qualified medical
evaluators. The medical director shall select evaluators who are
specialists of the type requested by the employee. The medical
director shall advise the employee that he or she should consult with
his or her treating physician prior to deciding which type of
specialist to request.
(2) The administrative director shall promulgate a form that shall
notify the employee of the physicians selected for his or her panel
after a request has been made pursuant to Section 4062.1 or 4062.2.
The form shall include, for each physician on the panel, the
physician's name, address, telephone number, specialty, number of
years in practice, and a brief description of his or her education
and training, and shall advise the employee that he or she is
entitled to receive transportation expenses and temporary disability
for each day necessary for the examination. The form shall also state
in a clear and conspicuous location and type: "You have the right to
consult with an information and assistance officer at no cost to you
prior to selecting the doctor to prepare your evaluation, or you may
consult with an attorney. If your claim eventually goes to court,
the workers' compensation administrative law judge will consider the
evaluation prepared by the doctor you select to decide your claim."
(3) When compiling the list of evaluators from which to select
randomly, the medical director shall include all qualified medical
evaluators who meet all of the following criteria:
(A) He or she does not have a conflict of interest in the case, as
defined by regulations adopted pursuant to subdivision (o).
(B) He or she is certified by the administrative director to
evaluate in an appropriate specialty and at locations within the
general geographic area of the employee's residence. An evaluator
shall not conduct qualified medical evaluations at more than 10
locations.
(C) He or she has not been suspended or terminated as a qualified
medical evaluator for failure to pay the fee required by the
administrative director pursuant to subdivision (n) or for any other
reason.
(4) When the medical director determines that an employee has
requested an evaluation by a type of specialist that is appropriate
for the employee's injury, but there are not enough qualified medical
evaluators of that type within the general geographic area of the
employee's residence to establish a three-member panel, the medical
director shall include sufficient qualified medical evaluators from
other geographic areas and the employer shall pay all necessary
travel costs incurred in the event the employee selects an evaluator
from another geographic area.
(i) The medical director appointed pursuant to Section 122 shall
continuously review the quality of comprehensive medical evaluations
and reports prepared by agreed and qualified medical evaluators and
the timeliness with which evaluation reports are prepared and
submitted. The review shall include, but not be limited to, a review
of a random sample of reports submitted to the division, and a review
of all reports alleged to be inaccurate or incomplete by a party to
a case for which the evaluation was prepared. The medical director
shall submit to the administrative director an annual report
summarizing the results of the continuous review of medical
evaluations and reports prepared by agreed and qualified medical
evaluators and make recommendations for the improvement of the system
of medical evaluations and determinations.
(j) After public hearing pursuant to Section 5307.3, the
administrative director shall adopt regulations concerning the
following issues:
(1) (A) Standards governing the timeframes within which medical
evaluations shall be prepared and submitted by agreed and qualified
medical evaluators. Except as provided in this subdivision, the
timeframe for initial medical evaluations to be prepared and
submitted shall be no more than 30 days after the evaluator has seen
the employee or otherwise commenced the medical evaluation procedure.
The administrative director shall develop regulations governing the
provision of extensions of the 30-day period in both of the following
cases:
(i) When the evaluator has not received test results or consulting
physician's evaluations in time to meet the 30-day deadline.
(ii) To extend the 30-day period by not more than 15 days when the
failure to meet the 30-day deadline was for good cause.
(B) For purposes of subparagraph (A), "good cause" means any of
the following:
(i) Medical emergencies of the evaluator or evaluator's family.
(ii) Death in the evaluator's family.
(iii) Natural disasters or other community catastrophes that
interrupt the operation of the evaluator's business.
(C) The administrative director shall develop timeframes governing
availability of qualified medical evaluators for unrepresented
employees under Section 4062.1. These timeframes shall give the
employee the right to the addition of a new evaluator to his or her
panel, selected at random, for each evaluator not available to see
the employee within a specified period of time, but shall also permit
the employee to waive this right for a specified period of time
thereafter.
(2) Procedures to be followed by all physicians in evaluating the
existence and extent of permanent impairment and limitations
resulting from an injury in a manner consistent with Sections 4660
and 4660.1.
(3) Procedures governing the determination of any disputed medical
treatment issues in a manner consistent with Section 5307.27.
(4) Procedures to be used in determining the compensability of
psychiatric injury. The procedures shall be in accordance with
Section 3208.3 and shall require that the diagnosis of a mental
disorder be expressed using the terminology and criteria of the
American Psychiatric Association's Diagnostic and Statistical Manual
of Mental Disorders, Third Edition-Revised, or the terminology and
diagnostic criteria of other psychiatric diagnostic manuals generally
approved and accepted nationally by practitioners in the field of
psychiatric medicine.
(5) Guidelines for the range of time normally required to perform
the following:
(A) A medical-legal evaluation that has not been defined and
valued pursuant to Section 5307.6. The guidelines shall establish
minimum times for patient contact in the conduct of the evaluations,
and shall be consistent with regulations adopted pursuant to Section
5307.6.
(B) Any treatment procedures that have not been defined and valued
pursuant to Section 5307.1.
(C) Any other evaluation procedure requested by the Insurance
Commissioner, or deemed appropriate by the administrative director.
(6) Any additional medical or professional standards that a
medical evaluator shall meet as a condition of appointment,
reappointment, or maintenance in the status of a medical evaluator.
(k) Except as provided in this subdivision, the administrative
director may, in his or her discretion, suspend or terminate the
privilege of a physician to serve as a qualified medical evaluator if
the administrative director, after hearing pursuant to subdivision
(l), determines, based on substantial evidence, that a qualified
medical evaluator:
(1) Has violated any material statutory or administrative duty.
(2) Has failed to follow the medical procedures or qualifications
established pursuant to paragraph (2), (3), (4), or (5) of
subdivision (j).
(3) Has failed to comply with the timeframe standards established
pursuant to subdivision (j).
(4) Has failed to meet the requirements of subdivision (b) or (c).
(5) Has prepared medical-legal evaluations that fail to meet the
minimum standards for those reports established by the administrative
director or the appeals board.
(6) Has made material misrepresentations or false statements in an
application for appointment or reappointment as a qualified medical
evaluator.
A hearing shall not be required prior to the suspension or
termination of a physician's privilege to serve as a qualified
medical evaluator when the physician has done either of the
following:
(A) Failed to timely pay the fee required pursuant to subdivision
(n).
(B) Had his or her license to practice in California suspended by
the relevant licensing authority so as to preclude practice, or had
the license revoked or terminated by the licensing authority.
(l) The administrative director shall cite the qualified medical
evaluator for a violation listed in subdivision (k) and shall set a
hearing on the alleged violation within 30 days of service of the
citation on the qualified medical evaluator. In addition to the
authority to terminate or suspend the qualified medical evaluator
upon finding a violation listed in subdivision (k), the
administrative director may, in his or her discretion, place a
qualified medical evaluator on probation subject to appropriate
conditions, including ordering continuing education or training. The
administrative director shall report to the appropriate licensing
board the name of any qualified medical evaluator who is disciplined
pursuant to this subdivision.
(m) The administrative director shall terminate from the list of
medical evaluators any physician where licensure has been terminated
by the relevant licensing board, or who has been convicted of a
misdemeanor or felony related to the conduct of his or her medical
practice, or of a crime of moral turpitude. The administrative
director shall suspend or terminate as a medical evaluator any
physician who has been suspended or placed on probation by the
relevant licensing board. If a physician is suspended or terminated
as a qualified medical evaluator under this subdivision, a report
prepared by the physician that is not complete, signed, and furnished
to one or more of the parties prior to the date of conviction or
action of the licensing board, whichever is earlier, shall not be
admissible in any proceeding before the appeals board nor shall there
be any liability for payment for the report and any expense incurred
by the physician in connection with the report.
(n) A qualified medical evaluator shall pay a fee, as determined
by the administrative director, for appointment or reappointment.
These fees shall be based on a sliding scale as established by the
administrative director. All revenues from fees paid under this
subdivision shall be deposited into the Workers' Compensation
Administration Revolving Fund and are available for expenditure upon
appropriation by the Legislature, and shall not be used by any other
department or agency or for any purpose other than administration of
the programs of the Division of Workers' Compensation related to the
provision of medical treatment to injured employees.
(o) An evaluator shall not request or accept any compensation or
other thing of value from any source that does or could create a
conflict with his or her duties as an evaluator under this code. The
administrative director, after consultation with the Commission on
Health and Safety and Workers' Compensation, shall adopt regulations
to implement this subdivision.
(a) Notwithstanding any other law, to the extent those
services are paid pursuant to Division 4 (commencing with Section
3200), it is unlawful for a physician to refer a person for clinical
laboratory, diagnostic nuclear medicine, radiation oncology, physical
therapy, physical rehabilitation, psychometric testing, home
infusion therapy, outpatient surgery, diagnostic imaging goods or
services, or pharmacy goods, whether for treatment or medical-legal
purposes, if the physician or his or her immediate family has a
financial interest with the person or in the entity that receives the
referral.
(b) For purposes of this section and Section 139.31, the following
shall apply:
(1) "Diagnostic imaging" includes, but is not limited to, all
X-ray, computed axial tomography magnetic resonance imaging, nuclear
medicine, positron emission tomography, mammography, and ultrasound
goods and services.
(2) "Immediate family" includes the spouse and children of the
physician, the parents of the physician, and the spouses of the
children of the physician.
(3) "Physician" means a physician as defined in Section 3209.3.
(4) A "financial interest" includes, but is not limited to, any
type of ownership, interest, debt, loan, lease, compensation,
remuneration, discount, rebate, refund, dividend, distribution,
subsidy, or other form of direct or indirect payment, whether in
money or otherwise, between a licensee and a person or entity to whom
the physician refers a person for a good or service specified in
subdivision (a). A financial interest also exists if there is an
indirect relationship between a physician and the referral recipient,
including, but not limited to, an arrangement whereby a physician
has an ownership interest in any entity that leases property to the
referral recipient. Any financial interest transferred by a physician
to, or otherwise established in, any person or entity for the
purpose of avoiding the prohibition of this section shall be deemed a
financial interest of the physician.
(5) A "physician's office" is either of the following:
(A) An office of a physician in solo practice.
(B) An office in which the services or goods are personally
provided by the physician or by employees in that office, or
personally by independent contractors in that office, in accordance
with other provisions of law. Employees and independent contractors
shall be licensed or certified when that licensure or certification
is required by law.
(6) The "office of a group practice" is an office or offices in
which two or more physicians are legally organized as a partnership,
professional corporation, or not-for-profit corporation licensed
according to subdivision (a) of Section 1204 of the Health and Safety
Code for which all of the following are applicable:
(A) Each physician who is a member of the group provides
substantially the full range of services that the physician routinely
provides, including medical care, consultation, diagnosis, or
treatment, through the joint use of shared office space, facilities,
equipment, and personnel.
(B) Substantially all of the services of the physicians who are
members of the group are provided through the group and are billed in
the name of the group and amounts so received are treated as
receipts of the group, and except that in the case of multispecialty
clinics, as defined in subdivision (l) of Section 1206 of the Health
and Safety Code, physician services are billed in the name of the
multispecialty clinic and amounts so received are treated as receipts
of the multispecialty clinic.
(C) The overhead expenses of, and the income from, the practice
are distributed in accordance with methods previously determined by
members of the group.
(7) Outpatient surgery includes both of the following:
(A) Any procedure performed on an outpatient basis in the
operating rooms, ambulatory surgery rooms, endoscopy units, cardiac
catheterization laboratories, or other sections of a freestanding
ambulatory surgery clinic, whether or not licensed under paragraph
(1) of subdivision (b) of Section 1204 of the Health and Safety Code.
(B) The ambulatory surgery itself.
(8) "Pharmacy goods" means any dangerous drug or dangerous device
as defined by Section 4022 of the Business and Professions Code, any
medical food as defined by Section 109971 of the Health and Safety
Code, and any over-the-counter drug as classified by the federal Food
and Drug Administration, except over-the-counter drugs sold at
commercially reasonable rates in physical retail outlets commonly
accessed by the public.
(c) (1) It is unlawful for a licensee to enter into an arrangement
or scheme, such as a cross-referral arrangement, that the licensee
knows, or should know, has a principal purpose of ensuring referrals
by the licensee to a particular entity that, if the licensee directly
made referrals to that entity, would be in violation of this
section.
(2) It shall be unlawful for a physician to offer, deliver,
receive, or accept any rebate, refund, commission, preference,
patronage dividend, discount, or other consideration, whether in the
form of money or otherwise, as compensation or inducement for a
referred evaluation or consultation.
(d) No claim for payment shall be presented by an entity to any
individual, third-party payor, or other entity for any goods or
services furnished pursuant to a referral prohibited under this
section.
(e) A physician who refers to or seeks consultation from an
organization in which the physician has a financial interest shall
disclose this interest to the patient or if the patient is a minor,
to the patient's parents or legal guardian in writing at the time of
the referral.
(f) No insurer, self-insurer, or other payor shall pay a charge or
lien for any goods or services resulting from a referral in
violation of this section.
(g) A violation of subdivision (a) shall be a misdemeanor. The
appropriate licensing board shall review the facts and circumstances
of any conviction pursuant to subdivision (a) and take appropriate
disciplinary action if the licensee has committed unprofessional
conduct. Violations of this section may also be subject to civil
penalties of up to five thousand dollars ($5,000) for each offense,
which may be enforced by the Insurance Commissioner, Attorney
General, or a district attorney. A violation of subdivision (c), (d),
(e), or (f) is a public offense and is punishable upon conviction by
a fine not exceeding fifteen thousand dollars ($15,000) for each
violation and appropriate disciplinary action, including revocation
of professional licensure, by the Medical Board of California or
other appropriate governmental agency.
The prohibition of Section 139.3 shall not apply to or
restrict any of the following:
(a) A physician may refer a patient for a good or service
otherwise prohibited by subdivision (a) of Section 139.3 if the
physician's regular practice is where there is no alternative
provider of the service within either 25 miles or 40 minutes
traveling time, via the shortest route on a paved road. A physician
who refers to, or seeks consultation from, an organization in which
the physician has a financial interest under this subdivision shall
disclose this interest to the patient or the patient's parents or
legal guardian in writing at the time of referral.
(b) A physician who has one or more of the following arrangements
with another physician, a person, or an entity, is not prohibited
from referring a patient to the physician, person, or entity because
of the arrangement:
(1) A loan between a physician and the recipient of the referral,
if the loan has commercially reasonable terms, bears interest at the
prime rate or a higher rate that does not constitute usury, is
adequately secured, and the loan terms are not affected by either
party's referral of any person or the volume of services provided by
either party.
(2) A lease of space or equipment between a physician and the
recipient of the referral, if the lease is written, has commercially
reasonable terms, has a fixed periodic rent payment, has a term of
one year or more, and the lease payments are not affected by either
party's referral of any person or the volume of services provided by
either party.
(3) A physician's ownership of corporate investment securities,
including shares, bonds, or other debt instruments that were
purchased on terms that are available to the general public through a
licensed securities exchange or NASDAQ, do not base profit
distributions or other transfers of value on the physician's referral
of persons to the corporation, do not have a separate class or
accounting for any persons or for any physicians who may refer
persons to the corporation, and are in a corporation that had, at the
end of the corporation's most recent fiscal year, total gross assets
exceeding one hundred million dollars ($100,000,000).
(4) A personal services arrangement between a physician or an
immediate family member of the physician and the recipient of the
referral if the arrangement meets all of the following requirements:
(A) It is set out in writing and is signed by the parties.
(B) It specifies all of the services to be provided by the
physician or an immediate family member of the physician.
(C) The aggregate services contracted for do not exceed those that
are reasonable and necessary for the legitimate business purposes of
the arrangement.
(D) A written notice disclosing the existence of the personal
services arrangement and including information on where a person may
go to file a complaint against the licensee or the immediate family
member of the licensee, is provided to the following persons at the
time any services pursuant to the arrangement are first provided:
(i) An injured worker who is referred by a licensee or an
immediate family member of the licensee.
(ii) The injured worker's employer, if self-insured.
(iii) The injured worker's employer's insurer, if insured.
(iv) If the injured worker is known by the licensee or the
recipient of the referral to be represented, the injured worker's
attorney.
(E) The term of the arrangement is for at least one year.
(F) The compensation to be paid over the term of the arrangement
is set in advance, does not exceed fair market value, and is not
determined in a manner that takes into account the volume or value of
any referrals or other business generated between the parties,
except that if the services provided pursuant to the arrangement
include medical services provided under Division 4, compensation paid
for the services shall be subject to the official medical fee
schedule promulgated pursuant to Section 5307.1 or subject to any
contract authorized by Section 5307.11.
(G) The services to be performed under the arrangement do not
involve the counseling or promotion of a business arrangement or
other activity that violates any state or federal law.
(c) (1) A physician may refer a person to a health facility as
defined in Section 1250 of the Health and Safety Code, to any
facility owned or leased by a health facility, or to an outpatient
surgical center, if the recipient of the referral does not compensate
the physician for the patient referral, and any equipment lease
arrangement between the physician and the referral recipient complies
with the requirements of paragraph (2) of subdivision (b).
(2) Nothing shall preclude this subdivision from applying to a
physician solely because the physician has an ownership or leasehold
interest in an entire health facility or an entity that owns or
leases an entire health facility.
(3) A physician may refer a person to a health facility for any
service classified as an emergency under subdivision (a) or (b) of
Section 1317.1 of the Health and Safety Code. For nonemergency
outpatient diagnostic imaging services performed with equipment for
which, when new, has a commercial retail price of four hundred
thousand dollars ($400,000) or more, the referring physician shall
obtain a service preauthorization from the insurer, or self-insured
employer. Any oral authorization shall be memorialized in writing
within five business days.
(d) A physician compensated or employed by a university may refer
a person to any facility owned or operated by the university, or for
a physician service, to another physician employed by the university,
provided that the facility or university does not compensate the
referring physician for the patient referral. For nonemergency
diagnostic imaging services performed with equipment that, when new,
has a commercial retail price of four hundred thousand dollars
($400,000) or more, the referring physician shall obtain a service
preauthorization from the insurer or self-insured employer. An oral
authorization shall be memorialized in writing within five business
days. In the case of a facility which is totally or partially owned
by an entity other than the university, but which is staffed by
university physicians, those physicians may not refer patients to the
facility if the facility compensates the referring physician for
those referrals.
(e) The prohibition of Section 139.3 shall not apply to any
service for a specific patient that is performed within, or goods
that are supplied by, a physician's office, or the office of a group
practice. Further, the provisions of Section 139.3 shall not alter,
limit, or expand a physician's ability to deliver, or to direct or
supervise the delivery of, in-office goods or services according to
the laws, rules, and regulations governing his or her scope of
practice. With respect to diagnostic imaging services performed with
equipment that, when new, had a commercial retail price of four
hundred thousand dollars ($400,000) or more, or for physical therapy
services, or for psychometric testing that exceeds the routine
screening battery protocols, with a time limit of two to five hours,
established by the administrative director, the referring physician
obtains a service preauthorization from the insurer or self-insured
employer. Any oral authorization shall be memorialized in writing
within five business days.
(f) The prohibition of Section 139.3 shall not apply where the
physician is in a group practice as defined in Section 139.3 and
refers a person for services specified in Section 139.3 to a
multispecialty clinic, as defined in subdivision (l) of Section 1206
of the Health and Safety Code. For diagnostic imaging services
performed with equipment that, when new, had a commercial retail
price of four hundred thousand dollars ($400,000) or more, or
physical therapy services, or psychometric testing that exceeds the
routine screening battery protocols, with a time limit of two to five
hours, established by the administrative director, performed at the
multispecialty facility, the referring physician shall obtain a
service preauthorization from the insurer or self-insured employer.
Any oral authorization shall be memorialized in writing within five
business days.
(g) The requirement for preauthorization in Sections (c), (e), and
(f) shall not apply to a patient for whom the physician or group
accepts payment on a capitated risk basis.
(h) The prohibition of Section 139.3 shall not apply to any
facility when used to provide health care services to an enrollee of
a health care service plan licensed pursuant to the Knox-Keene Health
Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section
1340) of Division 2 of the Health and Safety Code).
(i) The prohibition of Section 139.3 shall not apply to an
outpatient surgical center, as defined in paragraph (7) of
subdivision (b) of Section 139.3, where the referring physician
obtains a service preauthorization from the insurer or self-insured
employer after disclosure of the financial relationship.
(j) The prohibition of Section 139.3 shall not apply to a
physician's financial interest in a retailer of prescription drugs
sold by a physical retail outlet commonly accessed by the public or a
mail-order pharmacy serving a broad national or regional market,
provided that the majority of the physician's practice, with regard
to income, time, and number of patients, does not relate to
occupational medicine and the physician receives no remuneration from
the retailer of prescription drugs to market or otherwise solicit
occupational injury or occupational disease patients.
(a) For the purpose of this section, the following
definitions apply:
(1) "Financial interest in another entity" means, subject to
subdivision (h), either of the following:
(A) Any type of ownership, interest, debt, loan, lease,
compensation, remuneration, discount, rebate, refund, dividend,
distribution, subsidy, or other form of direct or indirect payment,
whether in money or otherwise, between the interested party and the
other entity to which the employee is referred for services.
(B) An agreement, debt instrument, or lease or rental agreement
between the interested party and the other entity that provides
compensation based upon, in whole or in part, the volume or value of
the services provided as a result of referrals.
(2) "Interested party" means any of the following:
(A) An injured employee.
(B) The employer of an injured employee, and, if the employer is
insured, its insurer.
(C) A claims administrator, which includes, but is not limited to,
a self-administered workers' compensation insurer, a
self-administered self-insured employer, a self-administered joint
powers authority, a self-administered legally uninsured employer, a
third-party claims administrator for an insurer, a self-insured
employer, a joint powers authority, or a legally uninsured employer
or a subsidiary of a claims administrator.
(D) An attorney-at-law or law firm that is representing or
advising an employee regarding a claim for compensation under
Division 4 (commencing with Section 3200).
(E) A representative or agent of an interested party, including
either of the following:
(i) An employee of an interested party.
(ii) Any individual acting on behalf of an interested party,
including the immediate family of the interested party or of an
employee of the interested party. For purposes of this clause,
immediate family includes spouses, children, parents, and spouses of
children.
(F) A provider of any medical services or products.
(3) "Services" means, but is not limited to, any of the following:
(A) A determination regarding an employee's eligibility for
compensation under Division 4 (commencing with Section 3200), that
includes both of the following:
(i) A determination of a permanent disability rating under Section
4660.
(ii) An evaluation of an employee's future earnings capacity
resulting from an occupational injury or illness.
(B) Services to review the itemization of medical services set
forth on a medical bill submitted under Section 4603.2.
(C) Copy and document reproduction services.
(D) Interpreter services.
(E) Medical services, including the provision of any medical
products such as surgical hardware or durable medical equipment.
(F) Transportation services.
(G) Services in connection with utilization review pursuant to
Section 4610.
(b) All interested parties shall disclose any financial interest
in any entity providing services.
(c) Except as otherwise permitted by law, it is unlawful for an
interested party other than a claims administrator or a network
service provider to refer a person for services provided by another
entity, or to use services provided by another entity, if the other
entity will be paid for those services pursuant to Division 4
(commencing with Section 3200) and the interested party has a
financial interest in the other entity.
(d) (1) It is unlawful for an interested party to enter into an
arrangement or scheme, such as a cross-referral arrangement, that the
interested party knows, or should know, has a purpose of ensuring
referrals by the interested party to a particular entity that, if the
interested party directly made referrals to that other entity, would
be in violation of this section.
(2) It is unlawful for an interested party to offer, deliver,
receive, or accept any rebate, refund, commission, preference,
patronage, dividend, discount, or other consideration, whether in the
form of money or otherwise, as compensation or inducement to refer a
person for services.
(e) A claim for payment shall not be presented by an entity to any
interested party, individual, third-party payer, or other entity for
any services furnished pursuant to a referral prohibited under this
section.
(f) An insurer, self-insurer, or other payer shall not knowingly
pay a charge or lien for any services resulting from a referral for
services or use of services in violation of this section.
(g) (1) A violation of this section shall be misdemeanor. If an
interested party is a corporation, any director or officer of the
corporation who knowingly concurs in a violation of this section
shall be guilty of a misdemeanor. The appropriate licensing authority
for any person subject to this section shall review the facts and
circumstances of any conviction pursuant to this section and take
appropriate disciplinary action if the licensee has committed
unprofessional conduct, provided that the appropriate licensing
authority may act on its own discretion independent of the initiation
or completion of a criminal prosecution. Violations of this section
are also subject to civil penalties of up to fifteen thousand dollars
($15,000) for each offense, which may be enforced by the Insurance
Commissioner, Attorney General, or a district attorney.
(2) For an interested party, a practice of violating this section
shall constitute a general business practice that discharges or
administers compensation obligations in a dishonest manner, which
shall be subject to a civil penalty under subdivision (e) of Section
129.5.
(3) For an interested party who is an attorney, a violation of
subdivision (b) or (c) shall be referred to the Board of Governors of
the State Bar of California, which shall review the facts and
circumstances of any violation pursuant to subdivision (b) or (c) and
take appropriate disciplinary action if the licensee has committed
unprofessional conduct.
(4) Any determination regarding an employee's eligibility for
compensation shall be void if that service was provided in violation
of this section.
(h) The following arrangements between an interested party and
another entity do not constitute a "financial interest in another
entity" for purposes of this section:
(1) A loan between an interested party and another entity, if the
loan has commercially reasonable terms, bears interest at the prime
rate or a higher rate that does not constitute usury, and is
adequately secured, and the loan terms are not affected by either the
interested party's referral of any employee or the volume of
services provided by the entity that receives the referral.
(2) A lease of space or equipment between an interested party and
another entity, if the lease is written, has commercially reasonable
terms, has a fixed periodic rent payment, has a term of one year or
more, and the lease payments are not affected by either the
interested party's referral of any person or the volume of services
provided by the entity that receives the referral.
(3) An interested party's ownership of the corporate investment
securities of another entity, including shares, bonds, or other debt
instruments that were purchased on terms that are available to the
general public through a licensed securities exchange or NASDAQ.
(i) The prohibitions described in this section do not apply to any
of the following:
(1) Services performed by, or determinations of compensation
issues made by, employees of an interested party in the course of
that employment.
(2) A referral for legal services if that referral is not
prohibited by the Rules of Professional Conduct of the State Bar.
(3) A physician's referral that is exempted by Section 139.31 from
the prohibitions prescribed by Section 139.3.
(a) The administrative director may review advertising copy
to ensure compliance with Section 651 of the Business and Professions
Code and may require qualified medical evaluators to maintain a file
of all advertising copy for a period of 90 days from the date of its
use. Any file so required to be maintained shall be available to the
administrative director upon the administrative director's request
for review.
(b) No advertising copy shall be used after its use has been
disapproved by the administrative director and the qualified medical
evaluator has been notified in writing of the disapproval.
(c) A qualified medical evaluator who is found by the
administrative director to have violated any provision of this
section may be terminated, suspended, or placed on probation.
(d) Proceedings to determine whether a violation of this section
has occurred shall be conducted pursuant to Chapter 4 (commencing
with Section 11370) of Part 1 of Division 3 of Title 2 of the
Government Code.
(e) The administrative director shall adopt regulations governing
advertising by physicians with respect to industrial injuries or
illnesses.
(f) Subdivision (a) shall not be construed to alter the
application of Section 651 of the Business and Professions Code.
(a) No person or entity shall advertise, print, display,
publish, distribute, or broadcast, or cause or permit to be
advertised, printed, displayed, published, distributed, or broadcast
in any manner, any statement concerning services or benefits to be
provided to an injured worker, that is paid for directly or
indirectly by that person or entity and is false, misleading, or
deceptive, or that omits material information necessary to make the
statement therein not false, misleading, or deceptive.
(b) As soon as reasonably possible, but not later than January 1,
1994, the administrative director shall adopt regulations governing
advertising by persons or entities other than physicians and
attorneys with respect to services or benefits for injured workers.
In promulgating regulations pursuant to this subdivision, the
administrative director shall review existing regulations, including
those adopted by the State Bar, to identify those regulatory
approaches that may serve as a model for regulations required by this
subdivision.
(c) A violation of subdivision (a) is a misdemeanor, punishable by
incarceration in the county jail for not more than one year, or by a
fine not exceeding ten thousand dollars ($10,000), or both.
(d) This section shall not apply to physicians or attorneys. It is
the intent of the Legislature to exempt physicians and attorneys
from this section because the conduct regulated by this section, with
respect to physicians and attorneys, is governed by other provisions
of law.
(a) In promulgating regulations pursuant to Sections 139.4
and 139.43, the administrative director shall take particular care to
preclude any advertisements with respect to industrial injuries or
illnesses that are false or mislead the public with respect to
workers' compensation. In promulgating rules with respect to
advertising, the State Bar and physician licensing boards shall also
take particular care to achieve the same goal.
(b) For purposes of subdivision (a), false or misleading
advertisements shall include advertisements that do any of the
following:
(1) Contain an untrue statement.
(2) Contain any matter, or present or arrange any matter in a
manner or format that is false, deceptive, or that tends to confuse,
deceive, or mislead.
(3) Omit any fact necessary to make the statement made, in the
light of the circumstances under which the statement is made, not
misleading.
(4) Are transmitted in any manner that involves coercion, duress,
compulsion, intimidation, threats, or vexatious or harassing conduct.
(5) Entice a person to respond by the offering of any
consideration, including a good or service but excluding free medical
evaluations or treatment, that would be provided either at no charge
or for less than market value. No free medical evaluation or
treatment shall be offered for the purpose of defrauding any entity.
The Director of Industrial Relations shall establish and
maintain a program to encourage, facilitate, and educate employers to
provide early and sustained return to work after occupational injury
or illness. The program shall do both of the following:
(a) Develop educational materials and guides, in easily
understandable language in both print and electronic form, for
employers, health care providers, employees, and labor unions. These
materials shall address issues including, but not limited to, early
return to work, assessment of functional abilities and limitations,
development of appropriate work restrictions, job analysis, worksite
modifications, assistive equipment and devices, and available
resources.
(b) Conduct training for employee and employer organizations and
health care providers concerning the accommodation of injured
employees and the prevention of reinjury.
(a) There is in the department a return-to-work program
administered by the director, funded by one hundred twenty million
dollars ($120,000,000) annually derived from non-General Funds of the
Workers' Compensation Administration Revolving Fund, for the purpose
of making supplemental payments to workers whose permanent
disability benefits are disproportionately low in comparison to their
earnings loss. Moneys shall remain available for use by the
return-to-work program without respect to the fiscal year.
(b) Eligibility for payments and the amount of payments shall be
determined by regulations adopted by the director, based on findings
from studies conducted by the director in consultation with the
Commission on Health and Safety and Workers' Compensation.
Determinations of the director shall be subject to review at the
trial level of the appeals board upon the same grounds as prescribed
for petitions for reconsideration.
(c) This section shall apply only to injuries sustained on or
after January 1, 2013.
(a) (1) The administrative director shall contract with one
or more independent medical review organizations and one or more
independent bill review organizations to conduct reviews pursuant to
Article 2 (commencing with Section 4600) of Chapter 2 of Part 2 of
Division 4. The independent review organizations shall be independent
of any workers' compensation insurer or workers' compensation claims
administrator doing business in this state. The administrative
director may establish additional requirements, including
conflict-of-interest standards, consistent with the purposes of
Article 2 (commencing with Section 4600) of Chapter 2 of Part 2 of
Division 4, that an organization shall be required to meet in order
to qualify as an independent review organization and to assist the
division in carrying out its responsibilities.
(2) To enable the independent review program to go into effect for
injuries occurring on or after January 1, 2013, and until the
administrative director establishes contracts as otherwise specified
by this section, independent review organizations under contract with
the Department of Managed Health Care pursuant to Section 1374.32 of
the Health and Safety Code may be designated by the administrative
director to conduct reviews pursuant to Article 2 (commencing with
Section 4600) of Chapter 2 of Part 2 of Division 4. The
administrative director may use an interagency agreement to implement
the independent review process beginning January 1, 2013. The
administrative director may initially contract directly with the same
organizations that are under contract with the Department of Managed
Health Care on substantially the same terms without competitive
bidding until January 1, 2015.
(b) (1) The independent medical review organizations and the
medical professionals retained to conduct reviews shall be deemed to
be consultants for purposes of this section.
(2) There shall be no monetary liability on the part of, and no
cause of action shall arise against, any consultant on account of any
communication by that consultant to the administrative director or
any other officer, employee, agent, contractor, or consultant of the
Division of Workers' Compensation, or on account of any communication
by that consultant to any person when that communication is required
by the terms of a contract with the administrative director pursuant
to this section and the consultant does all of the following:
(A) Acts without malice.
(B) Makes a reasonable effort to determine the facts of the matter
communicated.
(C) Acts with a reasonable belief that the communication is
warranted by the facts actually known to the consultant after a
reasonable effort to determine the facts.
(3) The immunities afforded by this section shall not affect the
availability of any other privilege or immunity which may be afforded
by law. This section shall not be construed to alter the laws
regarding the confidentiality of medical records.
(c) (1) An organization contracted to perform independent medical
review or independent bill review shall be required to employ a
medical director who shall be responsible for advising the contractor
on clinical issues. The medical director shall be a physician and
surgeon licensed by the Medical Board of California or the
Osteopathic Medical Board of California.
(2) The independent review organization, any experts it designates
to conduct a review, or any officer, director, or employee of the
independent review organization shall not have any material
professional, familial, or financial affiliation, as determined by
the administrative director, with any of the following:
(A) The employer, insurer or claims administrator, or utilization
review organization.
(B) Any officer, director, employee of the employer, or insurer or
claims administrator.
(C) A physician, the physician's medical group, the physician's
independent practice association, or other provider involved in the
medical treatment in dispute.
(D) The facility or institution at which either the proposed
health care service, or the alternative service, if any, recommended
by the employer, would be provided.
(E) The development or manufacture of the principal drug, device,
procedure, or other therapy proposed by the employee whose treatment
is under review, or the alternative therapy, if any, recommended by
the employer.
(F) The employee or the employee's immediate family, or the
employee's attorney.
(d) The independent review organizations shall meet all of the
following requirements:
(1) The organization shall not be an affiliate or a subsidiary of,
nor in any way be owned or controlled by, a workers' compensation
insurer, claims administrator, or a trade association of workers'
compensation insurers or claims administrators. A board member,
director, officer, or employee of the independent review organization
shall not serve as a board member, director, or employee of a
workers' compensation insurer or claims administrator. A board
member, director, or officer of a workers' compensation insurer or
claims administrator or a trade association of workers' compensation
insurers or claims administrators shall not serve as a board member,
director, officer, or employee of an independent review organization.
(2) The organization shall submit to the division the following
information upon initial application to contract under this section
and, except as otherwise provided, annually thereafter upon any
change to any of the following information:
(A) The names of all stockholders and owners of more than 5
percent of any stock or options, if a publicly held organization.
(B) The names of all holders of bonds or notes in excess of one
hundred thousand dollars ($100,000), if any.
(C) The names of all corporations and organizations that the
independent review organization controls or is affiliated with, and
the nature and extent of any ownership or control, including the
affiliated organization's type of business.
(D) The names and biographical sketches of all directors,
officers, and executives of the independent review organization, as
well as a statement regarding any past or present relationships the
directors, officers, and executives may have with any employer,
workers' compensation insurer, claims administrator, medical provider
network, managed care organization, provider group, or board or
committee of an employer, workers' compensation insurer, claims
administrator, medical provider network, managed care organization,
or provider group.
(E) (i) The percentage of revenue the independent review
organization receives from expert reviews, including, but not limited
to, external medical reviews, quality assurance reviews, utilization
reviews, and bill reviews.
(ii) The names of any workers' compensation insurer, claims
administrator, or provider group for which the independent review
organization provides review services, including, but not limited to,
utilization review, bill review, quality assurance review, and
external medical review. Any change in this information shall be
reported to the department within five business days of the change.
(F) A description of the review process, including, but not
limited to, the method of selecting expert reviewers and matching the
expert reviewers to specific cases.
(G) A description of the system the independent medical review
organization uses to identify and recruit medical professionals to
review treatment and treatment recommendation decisions, the number
of medical professionals credentialed, and the types of cases and
areas of expertise that the medical professionals are credentialed to
review.
(H) A description of how the independent review organization
ensures compliance with the conflict-of-interest requirements of this
section.
(3) The organization shall demonstrate that it has a quality
assurance mechanism in place that does all of the following:
(A) Ensures that any medical professionals retained are
appropriately credentialed and privileged.
(B) Ensures that the reviews provided by the medical professionals
or bill reviewers are timely, clear, and credible, and that reviews
are monitored for quality on an ongoing basis.
(C) Ensures that the method of selecting medical professionals for
individual cases achieves a fair and impartial panel of medical
professionals who are qualified to render recommendations regarding
the clinical conditions and the medical necessity of treatments or
therapies in question.
(D) Ensures the confidentiality of medical records and the review
materials, consistent with the requirements of this section and
applicable state and federal law.
(E) Ensures the independence of the medical professionals or bill
reviewers retained to perform the reviews through
conflict-of-interest policies and prohibitions, and ensures adequate
screening for conflicts of interest, pursuant to paragraph (5).
(4) Medical professionals selected by independent medical review
organizations to review medical treatment decisions shall be licensed
physicians, as defined by Section 3209.3, in good standing, who meet
the following minimum requirements:
(A) The physician shall be a clinician knowledgeable in the
treatment of the employee's medical condition, knowledgeable about
the proposed treatment, and familiar with guidelines and protocols in
the area of treatment under review.
(B) Notwithstanding any other law, the physician shall hold a
nonrestricted license in any state of the United States, and for
physicians and surgeons holding an M.D. or D.O. degree, a current
certification by a recognized American medical specialty board in the
area or areas appropriate to the condition or treatment under
review. The independent medical review organization shall give
preference to the use of a physician licensed in California as the
reviewer.
(C) The physician shall have no history of disciplinary action or
sanctions, including, but not limited to, loss of staff privileges or
participation restrictions, taken or pending by any hospital,
government, or regulatory body.
(D) Commencing January 1, 2014, the physician shall not hold an
appointment as a qualified medical evaluator pursuant to Section
139.2.
(5) Neither the expert reviewer, nor the independent review
organization, shall have any material professional, material
familial, or material financial affiliation with any of the
following:
(A) The employer, workers' compensation insurer or claims
administrator, or a medical provider network of the insurer or claims
administrator, except that an academic medical center under contract
to the insurer or claims administrator to provide services to
employees may qualify as an independent medical review organization
provided it will not provide the service and provided the center is
not the developer or manufacturer of the proposed treatment.
(B) Any officer, director, or management employee of the employer
or workers' compensation insurer or claims administrator.
(C) The physician, the physician's medical group, or the
independent practice association proposing the treatment.
(D) The institution at which the treatment would be provided.
(E) The development or manufacture of the treatment proposed for
the employee whose condition is under review.
(F) The employee or the employee's immediate family.
(6) For purposes of this subdivision, the following terms shall
have the following meanings:
(A) "Material familial affiliation" means any relationship as a
spouse, child, parent, sibling, spouse's parent, or child's spouse.
(B) "Material financial affiliation" means any financial interest
of more than 5 percent of total annual revenue or total annual income
of an independent review organization or individual to which this
subdivision applies. "Material financial affiliation" does not
include payment by the employer to the independent review
organization for the services required by the administrative director'
s contract with the independent review organization, nor does
"material financial affiliation" include an expert's participation as
a contracting medical provider where the expert is affiliated with
an academic medical center or a National Cancer Institute-designated
clinical cancer research center.
(C) "Material professional affiliation" means any
physician-patient relationship, any partnership or employment
relationship, a shareholder or similar ownership interest in a
professional corporation, or any independent contractor arrangement
that constitutes a material financial affiliation with any expert or
any officer or director of the independent review organization.
"Material professional affiliation" does not include affiliations
that are limited to staff privileges at a health facility.
(e) The division shall provide, upon the request of any interested
person, a copy of all nonproprietary information, as determined by
the administrative director, filed with it by an independent review
organization under contract pursuant to this section. The division
may charge a fee to the interested person for copying the requested
information.
(f) The Legislature finds and declares that the services described
in this section are of such a special and unique nature that they
must be contracted out pursuant to paragraph (3) of subdivision (b)
of Section 19130 of the Government Code. The Legislature further
finds and declares that the services described in this section are a
new state function pursuant to paragraph (2) of subdivision (b) of
Section 19130 of the Government Code.
(a) The administrative director shall establish and effect
within the Division of Workers' Compensation a continuing program to
provide information and assistance concerning the rights, benefits,
and obligations of the workers' compensation law to employees and
employers subject thereto. The program shall include, but not be
limited to, the following:
(1) The preparation, publishing, and as necessary, updating, of
guides to the California workers' compensation system for employees
and employers. The guides shall detail, in easily understandable
language, the rights and obligations of employees and employers, the
procedures for obtaining benefits, and the means provided for
resolving disputes. Separate guides may be prepared for employees and
employers. The appropriate guide shall be provided to all labor and
employer organizations known to the administrative director, and to
any other person upon request.
(2) The preparation, publishing, and as necessary, updating, of a
pamphlet advising injured workers of their basic rights under workers'
compensation law, and informing them of rights under the Americans
with Disabilities Act, and the provisions of the Fair Employment and
Housing Act relating to individuals with a disability. The pamphlet
shall be written in easily understandable language. The pamphlet
shall be available in both English and Spanish, and shall include
basic information concerning the circumstances under which injured
employees are entitled to the various types of workers' compensation
benefits, the protections against discrimination because of an
injury, the procedures for resolving any disputes which arise, and
the right to seek information and advice from an information and
assistance officer or an attorney.
(b) In each district office of the division, the administrative
director shall appoint an information and assistance officer, and any
other deputy information and assistance officers as the work of the
district office may require. The administrative director shall
provide office facilities and clerical support appropriate to the
functions of these information and assistance officers.
(c) Each information and assistance officer shall be responsible
for the performance of the following duties:
(1) Providing continuing information concerning rights, benefits,
and obligations under workers' compensation laws to injured workers,
employers, lien claimants, and other interested parties.
(2) Upon request by the injured worker, assisting in the prompt
resolution of misunderstanding, disputes, and controversies arising
out of claims for compensation, without formal proceedings, in order
that full and timely compensation benefits shall be furnished. In
performing this duty, information and assistance officers shall not
be responsible for reviewing applications for adjudication or
declarations of readiness to proceed. This function shall be
performed by workers' compensation judges. This function may also be
performed by settlement conference referees upon delegation by the
appeals board.
(3) Distributing any information pamphlets in English and Spanish
as are prepared and approved by the administrative director to all
inquiring injured workers and any other parties that may request
copies of these pamphlets.
(4) Establishing and maintaining liaison with the persons located
in the geographic area served by the district office, with other
affected state agencies, and with organizations representing
employees, employers, insurers, and the medical community.