BILL NUMBER: SB 522	AMENDED
	BILL TEXT

	AMENDED IN SENATE  APRIL 6, 2015

INTRODUCED BY   Senator Mendoza

                        FEBRUARY 26, 2015

   An act to amend Section  139.45   4616.4
 of the Labor Code, relating to workers' compensation.


	LEGISLATIVE COUNSEL'S DIGEST


   SB 522, as amended, Mendoza. Workers' compensation:
advertisements. 
   Existing law establishes a worker's compensation system,
administered by the Administrative Director of the Division of
Workers' Compensation, to compensate an employee for injuries
sustained in the course of his or her employment. Existing law
authorizes an insurer, employer, or entity that provides physician
network services to establish or modify a medical provider network
for the provision of medical treatment to injured employees, and
requires the administrative director to contract with individual
physicians or an independent medical review organization to perform
independent medical reviews.  
   This bill would clarify that those independent medical reviews are
medical provider network independent medical reviews. The bill would
make conforming changes.  
   Existing law establishes a workers' compensation system,
administered by the Administrative Director of the Division of
Workers' Compensation, to compensate an employee for injuries
sustained in the course of his or her employment. Existing law
requires the administrative director to promulgate regulations
regarding advertisements relating to workers' compensation, and
requires the administrative director to take particular care to
preclude any advertisements with respect to industrial injuries or
illnesses that are false or that mislead the public with respect to
workers' compensation.  
   This bill would make technical, nonsubstantive changes to these
provisions. 
   Vote: majority. Appropriation: no. Fiscal committee: no.
State-mandated local program: no.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

   SECTION 1.    Section 4616.4 of the   Labor
Code   is amended to read: 
   4616.4.  (a) (1) The administrative director shall contract with
individual physicians, as described in paragraph (2), or an
independent medical review organization to perform  medical
provider network (MPN)  independent medical reviews pursuant to
this section.
   (2) Only physicians licensed pursuant to Chapter 5 (commencing
with Section 2000) of the Business and Professions Code may be
independent medical reviewers.
   (3) The administrative director shall ensure that the independent
medical reviewers or those within the review organization shall do
all of the following:
   (A) Be appropriately credentialed and privileged.
   (B) Ensure that the reviews provided by the medical professionals
are timely, clear, and credible, and that reviews are monitored for
quality on an ongoing basis.
   (C) Ensure 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 consistent with the medical utilization
schedule established pursuant to Section 5307.27, or the American
College of Occupational and Environmental Medicine's Occupational
Medicine Practice Guidelines.
   (D) Ensure that confidentiality of medical records and the review
materials, consistent with the requirements of this section and
applicable state and federal law.
   (E) Ensure the independence of the medical professionals retained
to perform the reviews through conflict-of-interest policies and
prohibitions, and ensure adequate screening for conflicts of
interest.
   (4) Medical professionals selected by the administrative director
or the independent medical review organizations to review medical
treatment decisions shall be physicians, as specified in paragraph
(2) of subdivision (a), who meet the following minimum requirements:
   (A) The medical professional 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 provision of law, the medical
professional shall hold a nonrestricted license in any state of the
United States, and for physicians, a current certification by a
recognized American medical specialty board in the area or areas
appropriate to the condition or treatment under review.
   (C) The medical professional 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.
   (b) If, after the third physician's opinion, the treatment or
diagnostic service remains disputed, the injured employee may request
 MPN  independent medical review regarding the disputed
treatment or diagnostic service still in dispute after the third
physician's opinion in accordance with Section 4616.3. The standard
to be utilized for  MPN  independent medical review is
identical to that contained in the medical treatment utilization
schedule established in Section 5307.27, or the American College of
Occupational and Environmental Medicine's Occupational Medicine
Practice Guidelines, as appropriate.
   (c) Applications for  MPN  independent medical review
shall be submitted to the administrative director on a one-page form
provided by the administrative director entitled 
"Independent   "MPN Independent  Medical Review
Application." The form shall contain a signed release from the
injured employee, or a person authorized pursuant to law to act on
behalf of the injured employee, authorizing the release of medical
and treatment information. The injured employee may provide any
relevant material or documentation with the application. The
administrative director or the independent medical review
organization shall assign the independent medical reviewer.
   (d) Following receipt of the application for  MPN 
independent medical review, the employer or insurer shall provide the
independent medical reviewer, assigned pursuant to subdivision (c),
with all information that was considered in relation to the disputed
treatment or diagnostic service, including both of the following:
   (1) A copy of all correspondence from, and received by, any
treating physician who provided a treatment or diagnostic service to
the injured employee in connection with the injury.
   (2) A complete and legible copy of all medical records and other
information used by the physicians in making a decision regarding the
disputed treatment or diagnostic service.
   (e) Upon receipt of information and documents related to the
application for  MPN  independent medical review, the
independent medical reviewer shall conduct a physical examination of
the injured employee at the employee's discretion. The reviewer may
order any diagnostic tests necessary to make his or her determination
regarding medical treatment. Utilizing the medical treatment
utilization schedule established pursuant to Section 5307.27, or the
American College of Occupational and Environmental Medicine's
Occupational Medicine Practice Guidelines, as appropriate, and taking
into account any reports and information provided, the reviewer
shall determine whether the disputed health care service was
consistent with Section 5307.27 or the American College of
Occupational and Environmental Medicine's Occupational Medicine
Practice Guidelines based on the specific medical needs of the
injured employee.
   (f) The independent medical reviewer shall issue a report to the
administrative director, in writing, and in layperson's terms to the
maximum extent practicable, containing his or her analysis and
determination whether the disputed health care service was consistent
with the medical treatment utilization schedule established pursuant
to Section 5307.27, or the American College of Occupational and
Environmental Medicine's Occupational Medicine Practice Guidelines,
as appropriate, within 30 days of the examination of the injured
employee, or within less time as prescribed by the administrative
director. If the disputed health care service has not been provided
and the independent medical reviewer certifies in writing that an
imminent and serious threat to the health of the injured employee may
exist, including, but not limited to, serious pain, the potential
loss of life, limb, or major bodily function, or the immediate and
serious deterioration of the injured employee, the report shall be
expedited and rendered within three days of the examination by the
independent medical reviewer. Subject to the approval of the
administrative director, the deadlines for analyses and
determinations involving both regular and expedited reviews may be
extended by the administrative director for up to three days in
extraordinary circumstances or for good cause.
   (g) The independent medical reviewer's analysis shall cite the
injured employee's medical condition, the relevant documents in the
record, and the relevant findings associated with the documents or
any other information submitted to the reviewer in order to support
the determination.
   (h) The administrative director shall immediately adopt the
determination of the independent medical reviewer, and shall promptly
issue a written decision to the parties.
   (i) If the determination of the independent medical reviewer finds
that the disputed treatment or diagnostic service is consistent with
Section 5307.27 or the American College of Occupational and
Environmental Medicine's Occupational Medicine Practice Guidelines,
the injured employee may seek the disputed treatment or diagnostic
service from a physician of his or her choice from within or outside
the medical provider network. Treatment outside the medical provider
network shall be provided consistent with Section 5307.27 or the
American College of Occupational and Environmental Medicine's
Occupational Practice Guidelines. The employer shall be liable for
the cost of any approved medical treatment in accordance with Section
5307.1 or 5307.11. 
  SECTION 1.    Section 139.45 of the Labor Code is
amended to read:
   139.45.  (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 that mislead the public with
respect to workers' compensation. In promulgating rules with respect
to advertising, the State Bar of California 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. A free medical evaluation or
treatment shall not be offered for the purpose of defrauding any
entity.