This report assesses California workers' compensation–required reports — including the structure and content, level of effort, and allowances — and compares the elements and processes with other systems to inform potential improvements and further refinements to California's reporting requirements and policies. The report should be of general interest to stakeholders in California's workers' compensation (WC) system and in other WC programs.
Physician Reporting Requirements for Injured Workers in California
A Review of Reporting Processes and Payment Policies
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Research Questions
- What are the current processes — such as level of effort, timeline, and allowances — associated with filing WC-required reports in California?
- How does the reporting requirements and processes in California compare with those of other populous states? How can other state systems inform potential improvements to California's reporting requirements and payment policies?
- What are the attributes of high-quality reports, as perceived by physicians and users of WC-required reports?
- What are some of the current reporting and payment issues in California's WC system?
- What are the potential opportunities for improvement in policies related to WC-required reports?
California's workers' compensation (WC) program provides medical care and wage-replacement benefits to workers who suffer on-the-job injuries and illnesses. Individuals who are injured on the job are entitled to receive the medical care they need to relieve the effects of their injury with no deductibles or copayments. Physicians who treat and provide care to injured workers are required to file reports with the WC payer that address the worker's treatment, medical progress, and work-related issues. California's Division of Workers' Compensation (DWC) asked the RAND Corporation to review the reporting process and pricing structure of the WC-required reports to ensure that the policies are consistent with efficient program administration. This report provides a framework for understanding the current processes for filing WC-required reports in California and establishes a baseline for comparison with other state systems. The objective of this report is to provide an assessment of WC-required reports, including the structure and content, level of effort, and allowances, and to compare the elements and processes with other systems to inform potential improvements and further refinements to California's reporting requirements and policies. The report should be of general interest to stakeholders in California's WC system and in other WC programs.
Key Findings
There Are Several Opportunities to Streamline WC-Required Reports
- There is a general consensus that the report should be required from the first physician who examines the patient following a work-related incident.
- The elimination of the redundancies between the Primary Treating Physician's Progress Report (PR-2) and the Request for Authorization (RFA) represents another opportunity to reduce physicians' reporting burden.
- Program efficiency could be increased through electronic reporting of all WC-required reports and documentation.
- While electronic reporting has distinct advantages over the current system, it is important to recognize that physician practices providing services to WC patients have different levels of health information technology capabilities.
Intense Care Coordination Is Required Between the Primary Treating Physician and Any Secondary Physicians in Treating an Injured Worker and in Efficiently Gaining Needed Treatment
- Requiring the primary treating physician to submit the reports facilitates care coordination, but there are downsides to this.
- Primary treating physicians indicated that obtaining and compiling reports from secondary physicians was time consuming and can create delays in filing progress reports.
- Requiring a secondary treating physician to submit the RFA raises an issue of whether the secondary physician should also file a PR-2.
The Fee Schedule Should Account for Reporting Burden Not Otherwise Incorporated into the Allowance for the Related Medical Care
- Findings are mixed about the lack of an allowance for the Doctor's First Report of Occupational Injury or Illness (DFR).
- PR-2 is undervalued relative to other services for comparable activities.
Recommendations
- To reduce administrative burden, require a DFR only from the first primary treating physician and, if applicable, the first physician who examines the worker following a work-related incident who will not continue to treat the patient; combine the PR-2 and the RFA into a single form that clearly indicates when treatment authorization is being requested; eliminate the redundancies between the P&S report and the RTW and Voucher report; investigate whether to require electronic reporting for all WC-required reports and related documentation.
- To facilitate care coordination, clarify that secondary treating physicians should submit RFAs for proposed treatment related to their services but that the primary treating physician should be copied on the requests; develop an abbreviated, combined PR-2/RFA for secondary physicians to use when requesting or modifying treatment that would be filed directly with the claims administrator with a copy to the primary treating physician.
- To align fee schedule policies with reporting objectives, pay for a timely, fully completed DFR filed by the first primary treating physician at the same rate as the PR-2; increase the allowance for a fully completed PR-2 filed by a primary treating physician to be more in line with resource-based relative value system allowances for similar services (approximately $30); consider restructuring the allowance for a P&S report.
Table of Contents
Chapter One
Introduction
Chapter Two
Doctor's First Report of Occupational Injury or Illness
Chapter Three
Primary Treating Physician Progress Report and Request for Authorization
Chapter Four
Permanent and Stationary Report and Return-to-Work and Voucher Report
Chapter Five
Allowances for Workers' Compensation–Required Reports Within the Resource-Based Relative Value System Context
Chapter Six
Summary of Findings, Discussion, and Recommendations
Appendix A
Methods
Appendix B
Interview Protocol Guide for Stakeholder Interviews
Appendix C
Interview Questions for Division of Workers' Compensation Staff for Environmental Scan
Appendix D
Summary of Domains and Data Elements for California's Workers' Compensation–Required Reports
Appendix E
Reporting Characteristics for California and the 20 Most Populous States, by Report
The research described in this report was prepared for the Department of Industrial Relations and conducted by the Justice Policy Program within RAND Justice, Infrastructure, and Environment.
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