Tuesday, March 17, 2015

Bigger Than Enforcement

Don't step in it...
Now I really don't know who or what to believe.

After the last couple of posts raising cain about the number of Independent Medical Review cases missing records for significant amounts of time, assuming that it was the fault of carriers and TPAs, then finding out that there's a records management issue at Maximus that may have been the cause of all these numbers, we find out, according to the Division of Workers' Compensation, that most of those missing records files have actually been closed.

Peter Melton, a spokesman for the Division of Workers' Compensation said in an email to WorkCompCentral that the majority of those cases with records missing for at least 90 days have been closed.

"Maximus indicates that the majority of those cases are terminations (closed), either because the treatments in dispute were authorized, the underlying case was settled by compromise and release, the IMR was moot because circumstances changed, or the injured worker or their representative withdrew the request for IMR," he said.

WorkCompCentral inquired about the cases missing records on Thursday. Melton acknowledged at that time that there were 4,900 cases on which records were at least 90 days late.

He didn't answer the question at the time of why the administration had not started the process to assess penalties or offer the explanation from Maximus that most of the cases were closed.

Honestly, now I'm confused. You probably are too.

If all of those cases are in fact closed, then why would Melton say just a few days ago that there were so many with late records?

And why would Maximus' spreadsheet, dated March 9, 2015, reflect all of those missing records numbers?

(While the spreadsheet shows as of 3/9/15 6,743 files missing records, it does say "0701 Still Open" total of 984.)

And even if most of those cases were closed, the fact remains that there is still a records management issue because there were a lot of cases that at some point, regardless of current open versus closed status, that Maximus says records are late.

Now it appears that there's also a data management and reporting issue.

At least DWC now says it is in the process of serving Orders to Show Cause on violators.

"Because this is a new dispute resolution system, and the IMR filings of an unanticipated volume, DWC wanted to work with Maximus to clear the backlog and quicken response time," Melton said. "We believe that Maximus has done that, in part by making a good faith effort to reach out to claims administrators and try to obtain documents necessary to close the cases. At the same time, we understand that each case represents an injured worker and their treatment, and we are continuing to work diligently to improve the process."

There were many claims administrators who said they are compliant with the 15 day records rule; Maximus' data says that there are 128 entities handling California workers' compensation cases that have at least one IMR case for which they have not submitted medical records in 90 days.

And the overall percentage of late records is alarmingly high with 65 entities reflecting 100% failure to submit records by the 90 day period, at least based on the Maximus spreadsheet.

There are a whole host of potential violations for which a claims administrator could be fined under Title 8, Regulation section 9792.12(c), and there's nothing there that excuses a claims administrator from a penalty if the case is "closed."

So, now there are even more unanswered questions.

At least in my mind the credibility of the IMR process, DWC and Maximus is called into question. For one reason or another we don't have the whole story, and we don't know who's really late, who's really non-compliant, who's to blame.

And likewise, I don't think I can trust either DWC or Maximus to give us straight answers, in part because I don't think they really know the answers.

Unfortunately what this really tells me is that we have a regulatory process that is out of control.

I think this is a bigger issue than just one of enforcement...

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