Jurisdiction - Compensation Proceedings - Labor - CA

Section § 5300

In California, certain legal procedures related to workers' compensation must be handled by the appeals board, unless stated otherwise in Division 4. These include recovering compensation, determining employer or insurer responsibilities, deciding how to distribute compensation among dependents, identifying dependents of a deceased worker, and other matters the board is authorized to address. This ensures all related issues, including administration, are centralized under the Division of Workers' Compensation.

All the following proceedings shall be instituted before the appeals board and not elsewhere, except as otherwise provided in Division 4:

(a) For the recovery of compensation, or concerning any right or liability arising out of or incidental thereto.

(b) For the enforcement against the employer or an insurer of any liability for compensation imposed upon the employer by this division in favor of the injured employee, his or her dependents, or any third person.

(d) For the determination of any question as to who are dependents of any deceased employee, or what persons are entitled to any benefit under the compensation provisions of this division.

(e) For obtaining any order which by Division 4 the appeals board is authorized to make.

(f) For the determination of any other matter, jurisdiction over which is vested by Division 4 in the Division of Workers’ Compensation, including the administrative director and the appeals board.

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Section § 5301

The appeals board has complete power and authority to make final decisions on matters listed in Section 5300, but these decisions can be reviewed by the courts as outlined in this division.

The appeals board is vested with full power, authority and jurisdiction to try and determine finally all the matters specified in Section 5300 subject only to the review by the courts as specified in this division.

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Section § 5302

This law states that any decisions or rules made by the appeals board are assumed to be legal and reasonable. They remain valid unless the appeals board changes them or a court changes or overturns them through a specific review process.

All orders, rules, findings, decisions, and awards of the appeals board shall be prima facie lawful and conclusively presumed to be reasonable and lawful, until and unless they are modified or set aside by the appeals board or upon a review by the courts within the time and in the manner specified in this division.

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Section § 5303

This law explains that when a person is injured at work, there is only one legal claim for that injury under this division. It's possible to combine different claims related to that injury, like medical bills, disability payments, or death benefits, into one process with the approval of the appeals board. However, each injury is treated separately and can't be combined with another injury, whether it's a specific event or ongoing issue. Additionally, an award for ongoing injury cannot account for disability caused by specific or other ongoing injuries.

There is but one cause of action for each injury coming within the provisions of this division. All claims brought for medical expense, disability payments, death benefits, burial expense, liens, or any other matter arising out of such injury may, in the discretion of the appeals board, be joined in the same proceeding at any time; provided, however, that no injury, whether specific or cumulative, shall, for any purpose whatsoever, merge into or form a part of another injury; nor shall any award based on a cumulative injury include disability caused by any specific injury or by any other cumulative injury causing or contributing to the existing disability, need for medical treatment or death.

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Section § 5304

This law section gives the appeals board the power to handle disputes related to medical, surgical, or hospital treatment costs in workers' compensation cases. However, if there is already an agreement about the payment amounts for these treatments between the healthcare providers and the employer or insurer, the appeals board does not have jurisdiction over such disputes.

The appeals board has jurisdiction over any controversy relating to or arising out of Sections 4600 to 4605 inclusive, unless an express agreement fixing the amounts to be paid for medical, surgical or hospital treatment as such treatment is described in those sections has been made between the persons or institutions rendering such treatment and the employer or insurer.

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Section § 5305

This law section states that if a person who lives in California gets injured while working outside of California and was hired in California, they can bring their workers' compensation case in California. It means that even if the injury happened outside the state, the Division of Workers' Compensation and the appeals board in California can handle their case. The injured worker or their family can still receive compensation or death benefits according to California's workers' compensation rules.

The Division of Workers’ Compensation, including the administrative director, and the appeals board have jurisdiction over all controversies arising out of injuries suffered outside the territorial limits of this state in those cases where the injured employee is a resident of this state at the time of the injury and the contract of hire was made in this state. Any employee described by this section, or his or her dependents, shall be entitled to the compensation or death benefits provided by this division.

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Section § 5306

If a worker gets injured and their employer dies afterward, the worker can still pursue their claim against the employer's estate. The worker or their dependents don't have to present the claim to the executor or administrator of the estate to keep their rights to the claim.

The death of an employer subsequent to the sustaining of an injury by an employee shall not impair the right of the employee to proceed before the appeals board against the estate of the employer, and the failure of the employee or his dependents to cause the claim to be presented to the executor or administrator of the estate shall not in any way bar or suspend such right.

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Section § 5307

This law allows the appeals board to create and implement rules about how they operate in several areas, like their practice and procedure, how minors and people who are not mentally competent can appear in proceedings, and how evidence and notices should be managed. These decisions need approval from four board members.

Any changes to their rules require a public hearing. If someone requests a change to the rules, they will automatically consider it denied if a public hearing isn't scheduled within six months.

(a) The appeals board may, by an order signed by four members, do all of the following:

(1) Adopt reasonable and proper rules of practice and procedure.

(2) Regulate and provide the manner in which, and by whom, minors and incompetent persons are to appear and be represented before it.

(3) Regulate and prescribe the kind and character of notices, where not specifically prescribed by this division, and the service thereof.

(4) Regulate and prescribe the nature and extent of the proofs and evidence.

(b) No rule or regulation of the appeals board pursuant to this section shall be adopted, amended, or rescinded without public hearings. Any written request filed with the appeals board seeking a change in its rules or regulations shall be deemed to be denied if not set by the appeals board for public hearing to be held within six months of the date on which the request is received by the appeals board.

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Section § 5307.1

This California Labor Code section outlines how medical fees are determined for services given to injured employees covered by work-related injury claims. The administrative director sets official medical fee schedules, primarily based on Medicare and Medi-Cal payment systems, for non-physician services, physician services, and drugs. These fees must generally not exceed 120% of Medicare fees and can include special rules for pharmacy services and drugs. Facilities like outpatient departments and ambulatory surgical centers have specific maximum fee restrictions. Additionally, if a service isn't covered by Medicare, the administrative director will establish fees based on comparable services.

Special provisions exist for compounded drugs, pharmacy goods dispensed by physicians, and certain drug and device reimbursements. The law emphasizes annual updates reflecting changes in Medicare, ensuring these rates are sufficient to provide a reasonable standard of care. Employers can negotiate different rates with providers, and some services like medical-legal expenses have exceptions to the fee schedule.

(a)

(1) The administrative director, after public hearings, shall adopt and revise periodically an official medical fee schedule that shall establish reasonable maximum fees paid for medical services other than physician services, drugs and pharmacy services, health care facility fees, home health care, and all other treatment, care, services, and goods described in Section 4600 and provided pursuant to this section. Except for physician services, all fees shall be in accordance with the fee-related structure and rules of the relevant Medicare and Medi-Cal payment systems, provided that employer liability for medical treatment, including issues of reasonableness, necessity, frequency, and duration, shall be determined in accordance with Section 4600. Commencing January 1, 2004, and continuing until the time the administrative director has adopted an official medical fee schedule in accordance with the fee-related structure and rules of the relevant Medicare payment systems, except for the components listed in subdivision (j), maximum reasonable fees shall be 120 percent of the estimated aggregate fees prescribed in the relevant Medicare payment system for the same class of services before application of the inflation factors provided in subdivision (g), except that for pharmacy services and drugs that are not otherwise covered by a Medicare fee schedule payment for facility services, the maximum reasonable fees shall be 100 percent of fees prescribed in the relevant Medi-Cal payment system. Upon adoption by the administrative director of an official medical fee schedule pursuant to this section, the maximum reasonable fees paid shall not exceed 120 percent of estimated aggregate fees prescribed in the Medicare payment system for the same class of services before application of the inflation factors provided in subdivision (g). Pharmacy services and drugs shall be subject to the requirements of this section, whether furnished through a pharmacy or dispensed directly by the practitioner pursuant to subdivision (b) of Section 4024 of the Business and Professions Code.

(2)

(A) The administrative director, after public hearings, shall adopt and review periodically an official medical fee schedule based on the resource-based relative value scale for physician services and nonphysician practitioner services, as defined by the administrative director, provided that all of the following apply:

(i) Employer liability for medical treatment, including issues of reasonableness, necessity, frequency, and duration, shall be determined in accordance with Section 4600.

(ii) The fee schedule is updated annually to reflect changes in procedure codes, relative weights, and the adjustment factor provided in subdivision (g).

(iii) The maximum reasonable fees paid shall not exceed 120 percent of estimated annualized aggregate fees prescribed in the Medicare payment system for physician services as it appeared on July 1, 2012, before application of the adjustment factor provided in subdivision (g). For purposes of calculating maximum reasonable fees, any service provided to injured workers that is not covered under the federal Medicare program shall be included at its rate of payment established by the administrative director pursuant to subdivision (d).

(iv) There shall be a four-year transition between the estimated aggregate maximum allowable amount under the official medical fee schedule for physician services prior to January 1, 2014, and the maximum allowable amount based on the resource-based relative value scale at 120 percent of the Medicare conversion factors as adjusted pursuant to this section.

(B) The official medical fee schedule shall include payment ground rules that differ from Medicare payment ground rules, including, as appropriate, payment of consultation codes and payment evaluation and management services provided during a global period of surgery.

(C) Commencing January 1, 2014, and continuing until the time the administrative director has adopted an official medical fee schedule in accordance with the resource-based relative value scale, the maximum reasonable fees for physician services and nonphysician practitioner services, including, but not limited to, physician assistant, nurse practitioner, and physical therapist services, shall be in accordance with the fee-related structure and rules of the Medicare payment system for physician services and nonphysician practitioner services, except that an average statewide geographic adjustment factor of 1.078 shall apply in lieu of Medicare’s locality-specific geographic adjustment factors, and shall incorporate the following conversion factors:

(i) For dates of service in 2014, forty-nine dollars and five thousand three hundred thirteen ten thousandths cents ($49.5313) for surgery, fifty-six dollars and two thousand three hundred twenty-nine ten thousandths cents ($56.2329) for radiology, thirty dollars and six hundred forty-seven ten thousandths cents ($30.0647) for anesthesia, and thirty-seven dollars and one thousand seven hundred twelve ten thousandths cents ($37.1712) for all other before application of the adjustment factor provided in subdivision (g).

(ii) For dates of service in 2015, forty-six dollars and six thousand three hundred fifty-nine ten thousandths cents ($46.6359) for surgery, fifty-one dollars and one thousand thirty-six ten thousandths cents ($51.1036) for radiology, twenty-eight dollars and six thousand sixty-seven ten thousandths cents ($28.6067) for anesthesia, and thirty-eight dollars and three thousand nine hundred fifty-eight ten thousandths cents ($38.3958) for all other before application of the adjustment factor provided in subdivision (g).

(iii) For dates of service in 2016, forty-three dollars and seven thousand four hundred five ten thousandths cents ($43.7405) for surgery, forty-five dollars and nine thousand seven hundred forty-four ten thousandths cents ($45.9744) for radiology, twenty-seven dollars and one thousand four hundred eighty-seven thousandths cents ($27.1487) for anesthesia, and thirty-nine dollars and six thousand two hundred five ten thousandths cents ($39.6205) for all other before application of the adjustment factor provided in subdivision (g).

(iv) For dates of service on or after January 1, 2017, 120 percent of the 2012 Medicare conversion factor as updated pursuant to subdivision (g).

(b) In order to comply with the standards specified in subdivision (f), the administrative director may adopt different conversion factors, diagnostic-related group weights, and other factors affecting payment amounts from those used in the Medicare payment system, provided estimated aggregate fees do not exceed 120 percent of the estimated aggregate fees paid for the same class of services in the relevant Medicare payment system.

(c)

(1) Notwithstanding subdivisions (a) and (d), the maximum facility fee for services performed in a hospital outpatient department, shall not exceed 120 percent of the fee paid by Medicare for the same services performed in a hospital outpatient department, and the maximum facility fee for services performed in an ambulatory surgical center shall not exceed 80 percent of the fee paid by Medicare for the same services performed in a hospital outpatient department.

(2) The department shall study the feasibility of establishing a facility fee for services that are performed in an ambulatory surgical center and are not subject to a fee paid by Medicare for services performed in an outpatient department, set at 85 percent of the diagnostic-related group (DRG) fee paid by Medicare for the same services performed in a hospital inpatient department. The department shall report the finding to the Senate Labor Committee and Assembly Insurance Committee no later than July 1, 2013.

(d) If the administrative director determines that a medical treatment, facility use, product, or service is not covered by a Medicare payment system, the administrative director shall establish maximum fees for that item, provided that the maximum fee paid shall not exceed 120 percent of the fees paid by Medicare for services that require comparable resources. If the administrative director determines that a pharmacy service or drug is not covered by a Medi-Cal payment system, the administrative director shall establish maximum fees for that item. However, the maximum fee paid shall not exceed 100 percent of the fees paid by Medi-Cal for pharmacy services or drugs that require comparable resources.

(e)

(1) Prior to the adoption by the administrative director of a medical fee schedule pursuant to this section, for any treatment, facility use, product, or service not covered by a Medicare payment system, including acupuncture services, the maximum reasonable fee paid shall not exceed the fee specified in the official medical fee schedule in effect on December 31, 2003, except as otherwise provided in this subdivision.

(2) Any compounded drug product shall be billed by the compounding pharmacy or dispensing physician at the ingredient level, with each ingredient identified using the applicable National Drug Code (NDC) of the ingredient and the corresponding quantity, and in accordance with regulations adopted by the California State Board of Pharmacy. Ingredients with no NDC shall not be separately reimbursable. The ingredient-level reimbursement shall be equal to 100 percent of the reimbursement allowed by the Medi-Cal payment system and payment shall be based on the sum of the allowable fee for each ingredient plus a dispensing fee equal to the dispensing fee allowed by the Medi-Cal payment systems. If the compounded drug product is dispensed by a physician, the maximum reimbursement shall not exceed 300 percent of documented paid costs, but in no case more than twenty dollars ($20) above documented paid costs.

(3) For a dangerous drug dispensed by a physician that is a finished drug product approved by the federal Food and Drug Administration, the maximum reimbursement shall be according to the official medical fee schedule adopted by the administrative director.

(4) For a dangerous device dispensed by a physician, the reimbursement to the physician shall not exceed either of the following:

(A) The amount allowed for the device pursuant to the official medical fee schedule adopted by the administrative director.

(B) One hundred twenty percent of the documented paid cost, but not less than 100 percent of the documented paid cost plus the minimum dispensing fee allowed for dispensing prescription drugs pursuant to the official medical fee schedule adopted by the administrative director, and not more than 100 percent of the documented paid cost plus two hundred fifty dollars ($250).

(5) For any pharmacy goods dispensed by a physician not subject to paragraph (2), (3), or (4), the maximum reimbursement to a physician for pharmacy goods dispensed by the physician shall not exceed any of the following:

(A) The amount allowed for the pharmacy goods pursuant to the official medical fee schedule adopted by the administrative director or pursuant to paragraph (2), as applicable.

(B) One hundred twenty percent of the documented paid cost to the physician.

(6) For the purposes of this subdivision, the following definitions apply:

(A) “Administer” or “administered” has the meaning defined by Section 4016 of the Business and Professions Code.

(B) “Compounded drug product” means any drug product subject to Article 4.5 (commencing with Section 1735) of Division 17 of Title 16 of the California Code of Regulations or other regulation adopted by the State Board of Pharmacy to govern the practice of compounding.

(C) “Dispensed” means furnished to or for a patient as contemplated by Section 4024 of the Business and Professions Code and does not include “administered.”

(D) “Dangerous drug” and “dangerous device” have the meanings defined by Section 4022 of the Business and Professions Code.

(E) “Documented paid cost” means the unit price paid for the specific product or for each component used in the product as documented by invoices, proof of payment, and inventory records as applicable, or as documented in accordance with regulations that may be adopted by the administrative director, net of rebates, discounts, and any other immediate or anticipated cost adjustments.

(F) “Pharmacy goods” has the same meaning as set forth in Section 139.3.

(7) To the extent that any provision of paragraphs (2) to (6), inclusive, is inconsistent with any provision of the official medical fee schedule adopted by the administrative director on or after January 1, 2012, the provision adopted by the administrative director shall govern.

(8) Notwithstanding paragraph (7), the provisions of this subdivision concerning physician-dispensed pharmacy goods shall not be superseded by any provision of the official medical fee schedule adopted by the administrative director unless the relevant official medical fee schedule provision is expressly applicable to physician-dispensed pharmacy goods.

(f) Within the limits provided by this section, the rates or fees established shall be adequate to ensure a reasonable standard of services and care for injured employees.

(g)

(1) (A) Notwithstanding any other law, the official medical fee schedule shall be adjusted to conform to any relevant changes in the Medicare and Medi-Cal payment systems no later than 60 days after the effective date of those changes, subject to the following provisions:

(i) The annual inflation adjustment for facility fees for inpatient hospital services provided by acute care hospitals and for hospital outpatient services shall be determined solely by the estimated increase in the hospital market basket for the 12 months beginning October 1 of the preceding calendar year.

(ii) The annual update in the operating standardized amount and capital standard rate for inpatient hospital services provided by hospitals excluded from the Medicare prospective payment system for acute care hospitals and the conversion factor for hospital outpatient services shall be determined solely by the estimated increase in the hospital market basket for excluded hospitals for the 12 months beginning October 1 of the preceding calendar year.

(iii) The annual adjustment factor for physician services shall be based on the product of one plus the percentage change in the Medicare Economic Index and any relative value scale adjustment factor.

(B) The update factors contained in clauses (i) and (ii) of subparagraph (A) shall be applied beginning with the first update in the Medicare fee schedule payment amounts after December 31, 2003, and the adjustment factor in clause (iii) of subparagraph (A) shall be applied beginning with the first update in the Medicare fee schedule payment amounts after December 31, 2012.

(C) The maximum reasonable fees paid for pharmacy services and drugs shall not include any reductions in the relevant Medi-Cal payment system implemented pursuant to Section 14105.192 of the Welfare and Institutions Code.

(2) The administrative director shall determine the effective date of the changes, and shall issue an order, exempt from Sections 5307.3 and 5307.4 and the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), informing the public of the changes and their effective date. All orders issued pursuant to this paragraph shall be published on the Internet Web site of the Division of Workers’ Compensation.

(3) For the purposes of this subdivision, the following definitions apply:

(A) “Medicare Economic Index” means the input price index used by the federal Centers for Medicare and Medicaid Services to measure changes in the costs of a providing physician and other services paid under the resource-based relative value scale.

(B) “Hospital market basket” means the input price index used by the federal Centers for Medicare and Medicaid Services to measure changes in the costs of providing inpatient hospital services provided by acute care hospitals that are included in the Medicare prospective payment system.

(C) “Hospital market basket for excluded hospitals” means the input price index used by the federal Centers for Medicare and Medicaid Services to measure changes in the costs of providing inpatient services by hospitals that are excluded from the Medicare prospective payment system.

(D) “Relative value scale adjustment factor” means the annual factor applied by the federal Centers for Medicare and Medicaid Services to the Medicare conversion factor to make changes in relative value units for the physician fee schedule budget neutral.

(h) This section does not prohibit an employer or insurer from contracting with a medical provider for reimbursement rates different from those prescribed in the official medical fee schedule.

(i) Except as provided in Section 4626, the official medical fee schedule shall not apply to medical-legal expenses, as that term is defined by Section 4620.

(j) The following Medicare payment system components shall not become part of the official medical fee schedule until January 1, 2005:

(1) Inpatient skilled nursing facility care.

(2) Home health agency services.

(3) Inpatient services furnished by hospitals that are exempt from the prospective payment system for general acute care hospitals.

(4) Outpatient renal dialysis services.

(k) Except as revised by the administrative director, the official medical fee schedule rates for physician services in effect on December 31, 2012, shall remain in effect until January 1, 2014.

(l) Notwithstanding subdivision (a), any explicit reductions in the Medi-Cal fee schedule for pharmacy services and drugs to meet the budgetary targets provided in Section 14105.192 of the Welfare and Institutions Code shall not be reflected in the official medical fee schedule.

(m) On or before July 1, 2013, the administrative director shall adopt a regulation specifying an additional reimbursement for MS-DRGs Medicare Severity Diagnostic Related Groups (MS-DRGs) 028, 029, 030, 453, 454, 455, and 456 to ensure that the aggregate reimbursement is sufficient to cover costs, including the implantable medical device, hardware, and instrumentation. This regulation shall be repealed as of January 1, 2014, unless extended by the administrative director.

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Section § 5307.2

This law requires the administrative director to hire a consulting firm every year to study the availability and quality of healthcare services for injured workers. If the study finds that access to quality healthcare, including prescription drugs and pharmacy services, is lacking, the director can adjust the fees for these services. The director is also allowed to increase fees beyond certain limits if there are significant access problems.

The administrative director shall contract with an independent consulting firm, to the extent permitted by state law, to perform an annual study of access to medical treatment for injured workers. The study shall analyze whether there is adequate access to quality health care and products, including prescription drugs and pharmacy services, for injured workers and make recommendations to ensure continued access. If the administrative director determines, based on this study, that there is insufficient access to quality health care or products for injured workers, including access to prescription drugs and pharmacy services, the administrative director may make appropriate adjustments to medical, prescription drugs and pharmacy services, and facilities’ fees. When there has been a determination that substantial access problems exist, the administrative director may, in accordance with the notification and hearing requirements of Section 5307.1, adopt fees in excess of 120 percent of the applicable Medicare payment system fee, or in excess of 100 percent of the fees prescribed in the relevant Medi-Cal payment system, for the applicable services or products.

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Section § 5307.3

The administrative director has the power to create, change, or remove rules necessary to enforce this division, unless this power is given to the appeals board. However, they can't make these changes without holding public hearings.

If someone files a written request to change a rule, and the director doesn't schedule a public hearing within six months, the request is considered denied.

The administrative director may adopt, amend, or repeal any rules and regulations that are reasonably necessary to enforce this division, except where this power is specifically reserved to the appeals board.

No rule or regulation of the administrative director pursuant to this section shall be adopted, amended, or rescinded without public hearings. Any written request filed with the administrative director seeking a change in its rules or regulations shall be deemed to be denied if not set by the administrative director for public hearing to be held within six months of the date on which the request is received by the administrative director.

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Section § 5307.4

This law section explains the procedures for public hearings related to certain rule changes or regulations. When there's a proposed rule to be adopted, amended, or rescinded, specific notices must be given to interested business and labor groups or individuals. This notice must include details about the hearing time and place, legal authority reference, and a summary of the proposed rule. People affected by or interested in the rule can provide input through written or oral submissions. However, rules related to agency policy or organization, without public impact, are not covered by these requirements. Notices must be sent at least 30 days before the hearing.

(a) Public hearings required under Sections 5307 and 5307.3 shall be subject to the provisions of this section except to the extent that there is involved a matter relating to the management, or to personnel, or to public property, loans, grants, benefits, or to contracts, of the appeals board or the administrative director.

(b) Notice of the rule or regulation proposed to be adopted, amended, or rescinded, shall be given to such business and labor organizations and firms or individuals who have requested notice thereof. The notice shall include all of the following:

(1) A statement of the time, place, and nature of the public hearings.

(2) Reference to the legal authority under which the rule is proposed.

(3) Either the terms or substance of the proposed rule, or a description of the subjects and the issues involved.

(c) Except where the proposed rule or regulation has a significant impact on the public, this section shall not apply to interpretive rules, general statements of policy, or rules of agency organization.

(d) After notice required by this section, the appeals board or the administrative director shall give interested persons the opportunity to participate in the rulemaking through submission of written data, views, or arguments, with opportunity for oral presentation. If, after consideration of the relevant matter presented, the appeals board or the administrative director adopts a rule, it or he shall publish a concise, general statement of reasons for the adoption of the rule. The rule and statement of reasons shall be given to the same individuals and organizations who have requested notice of hearings.

(e) The notice required under this section shall be made not less than 30 days prior to the public hearing date.

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Section § 5307.5

This section allows a workers' compensation judge or appeals board to appoint a trustee or guardian to represent minors or those unable to represent themselves in workers’ compensation cases. The appointed guardian must provide a bond similar to what a court-appointed guardian would need. This bond has to be approved by the appeals board and the guardian remains accountable until they submit a financial report that receives approval. The guardian's payment for their services is decided by the appeals board or court.

The section also allows all relevant parties in a workers' compensation case, such as employers, employees, insurers, dependents, or creditors, to be joined in the same proceeding.

The appeals board or a workers’ compensation judge may:

(a) Appoint a trustee or guardian ad litem to appear for and represent any minor or incompetent upon the terms and conditions which it deems proper. The guardian or trustee shall, if required by the appeals board, give a bond in the form and of the character required by law from a guardian appointed by a superior court and in the amount which the appeals board determines. The bond shall be approved by the appeals board, and the guardian or trustee shall not be discharged from liability until he or she files an account with the appeals board or with the superior court and the account is approved. The trustee or guardian shall receive the compensation for his or her services fixed and allowed by the appeals board or by the superior court.

(b) Provide for the joinder in the same proceeding of all persons interested therein, whether as employer, insurer, employee, dependent, creditor, or otherwise.

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Section § 5307.6

This law requires the administrative director to set a fee schedule for medical-legal expenses, which are costs associated with medical evaluations used for legal purposes, like worker's compensation claims. This fee schedule ensures that the charges are reasonable and comparable to similar medical work, considering evaluation complexity and time spent. Providers cannot charge more than these fees unless they justify higher costs due to extraordinary circumstances. Both employers and employees can challenge fees that exceed the schedule. If disputes arise over fees, a provider might get a reasonable fee for courtroom testimony if it's deemed justified. Providers cannot accept extra compensation beyond the set fees, and breaking this rule can lead to disciplinary action by licensing boards. However, this rule does not apply to situations where no fee schedule exists.

(a) The administrative director shall adopt and revise a fee schedule for medical-legal expenses as defined by Section 4620, which shall be prima facie evidence of the reasonableness of fees charged for medical-legal expenses at the same time he or she adopts and revises the medical fee schedule pursuant to Section 5307.1.

The schedule shall consist of a series of procedure codes, relative values, and a conversion factor producing fees which provide remuneration to physicians performing medical-legal evaluations at a level equivalent to that provided to physicians for reasonably comparable work, and which additionally recognizes the relative complexity of various types of evaluations, the amount of time spent by the physician in direct contact with the patient, and the need to prepare a written report.

(b) A provider shall not be paid fees in excess of those set forth in the fee schedule established under this section unless the provider provides an itemization and explanation of the fee that shows that it is both a reasonable fee and that extraordinary circumstances relating to the medical condition being evaluated justify a higher fee; provided, however, that in no event shall a provider charge in excess of his or her usual fee. The employer and employee shall have standing to contest fees in excess of those set forth in the fee schedule.

(c) In the event of a dispute between the provider and the employer, employee, or carrier concerning the fees charged, the provider may be allowed a reasonable fee for testimony if the provider testified pursuant to the employer’s or carrier’s subpoena and the judge or referee determines that the fee charged was reasonable and justified by extraordinary circumstances.

(d)

(1) No provider may request nor accept any compensation, including, but not limited to, any kind of remuneration, discount, rebate, refund, dividend, distribution, subsidy, or other form of direct or indirect payment, whether in money or otherwise, from any source for medical-legal expenses if such compensation is in addition to the fees authorized by this section. In addition to being subject to discipline pursuant to the provisions of subdivision (k) of Section 139.2, any provider violating this subdivision is subject to disciplinary action by the appropriate licensing board.

(2) This subdivision does not apply to medical-legal expenses for which the administrative director has not adopted a fee schedule.

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Section § 5307.7

This law requires that by January 1, 2013, a fee schedule should be established to determine reasonable fees for vocational experts. These fees cover services like evaluations and expert testimony judged necessary by the appeals board.

Moreover, vocational experts cannot charge more than what is deemed reasonable or necessary, and fees must align with the adopted fee schedule.

(a) On or before January 1, 2013, the administrative director shall adopt, after public hearings, a fee schedule that shall establish reasonable fees paid for services provided by vocational experts, including, but not limited to, vocational evaluations and expert testimony determined to be reasonable, actual, and necessary by the appeals board.

(b) A vocational expert shall not be paid, and the appeals board shall not allow, vocational expert fees in excess of those that are reasonable, actual, and necessary, or that are not consistent with the fee schedule adopted by the administrative director.

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Section § 5307.8

This law requires that a payment schedule for home health care services be established for those not already covered by existing Medicare or official medical fee schedules. This schedule will be set after public hearings and can use state or federal home health care service fee schedules as a basis.

Payments cannot be made for services that the injured person's household already did in the same way before the injury. Attorney fees for recovering these service payments can be granted under certain conditions.

(a) Notwithstanding Section 5307.1, the administrative director shall adopt, after public hearings, a schedule for payment of home health care services provided in accordance with Section 4600 that are not covered by a Medicare fee schedule and are not otherwise covered by the official medical fee schedule adopted pursuant to Section 5307.1. The schedule shall set forth fees and requirements for service providers, and may be based upon, but is not limited to, being based upon, either of the following:

(1) The maximum service hours and fees as set forth in regulations adopted pursuant to Article 7 (commencing with Section 12300) of Chapter 3 of Part 3 of Division 9 of the Welfare and Institutions Code.

(2) A state or federal home health care services fee schedule other than the schedule described in paragraph (1), including a fee schedule authorized for purposes of the Medi-Cal program or a fee schedule administered by the federal Office of Workers’ Compensation Programs.

(b) Fees shall not be provided for any services, including any services provided by a member of the employee’s household, to the extent the services had been regularly performed in the same manner and to the same degree prior to the date of injury. If appropriate, attorney’s fees for recovery of home health care services fees under this section may be awarded in accordance with Section 4906 and any applicable rules or regulations.

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Section § 5307.9

By the end of 2013, California required a standardized fee schedule for services related to copying and providing documents in various formats for workers' compensation cases. This schedule, established after public hearings, ensures that fees are reasonable and specific. It prohibits payment for copies provided within 30 days of a request by an injured worker or their representative to the employer or insurer. This rule applies to all claims, except if there's a specific contract between the employer and the copy service provider.

On or before December 31, 2013, the administrative director, in consultation with the Commission on Health and Safety and Workers’ Compensation, shall adopt, after public hearings, a schedule of reasonable maximum fees payable for copy and related services, including, but not limited to, records or documents that have been reproduced or recorded in paper, electronic, film, digital, or other format. The schedule shall specify the services allowed and shall require specificity in billing for these services, and shall not allow for payment for services provided within 30 days of a request by an injured worker or his or her authorized representative to an employer, claims administrator, or workers’ compensation insurer for copies of records in the employer’s, claims administrator’s, or workers’ compensation insurer’s possession that are relevant to the employee’s claim. The schedule shall be applicable regardless of whether payments of copy service costs are claimed under the authority of Section 4600, 4620, or 5811, or any other authority except a contract between the employer and the copy service provider.

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Section § 5307.11

This section of the law allows health care providers or facilities, along with employers and insurance carriers, to agree on different reimbursement rates for medical services than those set in the official medical fee schedule. This means they can negotiate their own rates. When such agreements are made, the standard fee schedule does not apply to these negotiated rates. However, outside of these agreements, the official fee schedule sets the highest rates providers can charge for services related to work-related injuries.

A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates. Except as provided in subdivision (b) of Section 5307.1, the official medical fee schedule shall establish maximum reimbursement rates for all medical services for injuries subject to this division provided by a health care provider or health care facility licensed pursuant to Section 1250 of the Health and Safety Code other than those specified in contracts subject to this section.

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Section § 5307.12

If a healthcare provider or facility in California contracts with a network service entity to get paid over 20% less than the official fee schedule for services—excluding goods and medicines—they must disclose their reimbursement rates to the payer. This disclosure must be in writing, using a form from the administrative director.

The network service entity can ask the payer to sign a confidentiality agreement to keep this information private. However, such agreements can't prevent the division from accessing this info. This law doesn't apply if the pricing information is disclosed to both the healthcare provider and the payer. It took effect on July 1, 2021.

(a) If a health care provider or health facility, licensed pursuant to Section 1250 of the Health and Safety Code, and an entity that provides physician network services, as defined in subdivision (b) of Section 4616.5, or an entity that provides ancillary network services, as defined in subdivision (c) of Section 4616.5, contract for a reimbursement rate that is more than 20 percent below the official medical fee schedule, excluding goods and pharmaceuticals, the entity that provides physician or ancillary network services shall provide the payor with a written disclosure, on a form promulgated by the administrative director, of the reimbursement amount paid to the provider.

(b) Before providing the disclosure required pursuant to subdivision (a), the entity that provides physician or ancillary network services may require the payor to sign a nondisclosure agreement with the entity that provides physician or ancillary network services agreeing to maintain the confidentiality of the disclosed information.

(c) A nondisclosure agreement signed pursuant to subdivision (b) shall not prohibit the division from obtaining the information disclosed pursuant to subdivision (a). This subdivision is declaratory of existing law.

(d) This section does not apply to an entity that provides physician or ancillary network services that discloses, or arranges for the disclosure of, the same pricing and payment information to both the health care provider or health facility and the person or entity paying for the services.

(e) This section shall become operative on July 1, 2021.

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Section § 5307.27

This law requires the administrative director to set up a medical treatment schedule for workers' compensation cases. This schedule uses evidence-based, recognized care standards to guide how treatments should be performed. The public must have a chance to comment before any updates are made, and these updates will be published online.

By July 1, 2017, this schedule must also include a drug formulary, a list of approved medications based on scientific evidence. Medications not on the list can still be approved if justified.

There will be a gradual introduction of this formulary for workers injured before the date to ensure a smooth and safe transition. These rules apply to all who prescribe or dispense medications to injured workers within the workers' compensation system.

(a) The administrative director, in consultation with the Commission on Health and Safety and Workers’ Compensation, shall adopt, after public hearings, a medical treatment utilization schedule, that shall incorporate the evidence-based, peer-reviewed, nationally recognized standards of care recommended by the commission pursuant to Section 77.5, and that shall address, at a minimum, the frequency, duration, intensity, and appropriateness of all treatment procedures and modalities commonly performed in workers’ compensation cases. Evidence-based updates to the utilization schedule shall be made through an order exempt from Sections 5307.3 and 5307.4, and the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), but the administrative director shall allow at least a 30-day period for public comment and a public hearing. The administrative director shall provide responses to submitted comments prior to the effective date of the updates. All orders issued pursuant to this subdivision shall be published on the Internet Web site of the Division of Workers’ Compensation.

(b) On or before July 1, 2017, the medical treatment utilization schedule adopted by the administrative director shall include a drug formulary using evidence-based medicine. Nothing in this section shall prohibit the authorization of medications that are not in the formulary when the variance is demonstrated, consistent with subdivision (a) of Section 4604.5.

(c) The drug formulary shall include a phased implementation for workers injured prior to July 1, 2017, in order to ensure injured workers safely transition to medications pursuant to the formulary.

(d) This section shall apply to all prescribers and dispensers of medications serving injured workers under the workers’ compensation system.

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Section § 5307.28

This law section outlines a process for creating a drug formulary, which is a list of medications covered, required by another section. Before finalizing this formulary, the administrative director must meet with various groups like employers, insurers, doctors, and injured workers to get their input. The goal is to ensure that all parties involved have a say.

Starting from July 1, 2016, and until the formulary is in place, the director has to release at least two progress reports online to update the public on how the formulary is coming along. These reports will be accessible through the Division of Workers’ Compensation's website.

(a) Prior to the adoption of a drug formulary as required by Section 5307.27, the administrative director shall meet and consult regarding the establishment of a formulary with stakeholders, including, but not limited to, employers, insurers, private sector employee representatives, public sector employee representatives, treating physicians actively practicing medicine, pharmacists, pharmacy benefit managers, attorneys who represent applicants, and injured workers.

(b) Commencing July 1, 2016, and concluding with the implementation of the formulary, the administrative director shall publish at least two interim reports on the Internet Web site of the Division of Workers’ Compensation describing the status of the creation of the formulary.

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Section § 5307.29

This law requires the administrative director to update the drug formulary at least every quarter to ensure the inclusion of all suitable medications, including new drugs. Any changes to the drug formulary must be publicly announced online with the effective dates, bypassing certain procedural laws. An independent committee, made up of qualified medical professionals and pharmacists, will oversee the formulary updates. This committee must be free from conflicts of interest, maintain confidentiality on proprietary information, and will provide guidance based on evidence of drug safety and effectiveness.

(a) The administrative director shall make provision for no less than quarterly updates to the drug formulary to allow for the provision of all appropriate medications, including those new to the market.

(b) Changes made to the list of drugs in the drug formulary described in Section 5307.27 shall be made through an order exempt from Sections 5307.3 and 5307.4, and the rulemaking provisions of the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), informing the public of the changes and their effective date. All orders issued pursuant to this subdivision shall be published on the Internet Web site of the Division of Workers’ Compensation.

(c) The administrative director shall establish an independent pharmacy and therapeutics committee to review and consult with the administrative director on available evidence of the relative safety, efficacy, and effectiveness of drugs within a class of drugs in the updating of an evidence-based drug formulary, as required by Section 5307.27.

(1) The committee shall consist of six members and the Executive Medical Director of the Division of Workers’ Compensation. The committee shall consist of medical doctors or doctors of osteopathy holding a physician and surgeon license pursuant to Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code, and pharmacists licensed pursuant to Chapter 9 (commencing with Section 4000) of Division 2 of the Business and Professions Code. A committee member shall have knowledge or expertise in one or more of the following:

(A) Clinically appropriate prescribing of covered drugs.

(B) Clinically appropriate dispensing and monitoring of covered drugs.

(D) Evidence-based medicine.

(2) Committee members shall not be employed by a pharmaceutical manufacturer, a pharmacy benefits management company, or a company engaged in the development of a pharmaceutical formulary for commercial sale during his or her term, and shall not have been so employed for 12 months prior to his or her appointment.

(3) A committee member shall not have a substantial financial conflict of interest pursuant to standards established by the administrative director. The administrative director may, in his or her sole discretion, disqualify a potential or current member of the committee if the administrative director determines that a substantial conflict of interest exists.

(4) A committee member shall agree to keep all proprietary information confidential to the extent required by existing law.

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Section § 5308

This law gives the appeals board the power to handle disputes related to insurance policies for self-employed individuals. If there's a disagreement over such a policy, the parties involved can agree to let the appeals board decide the matter, similar to an arbitration process. The board can act on an agreement by both parties or if one applies and the other accepts its authority. It can function as an arbitrator, utilizing the same powers it has in compensation cases, and its decisions are equally binding. Importantly, the appeals board does not charge fees for this arbitration service.

The appeals board has jurisdiction to determine controversies arising out of insurance policies issued to self-employing persons, conferring benefits identical with those prescribed by this division.

The appeals board may try and determine matters referred to it by the parties under the provisions of Title 9 (commencing with Section 1280) of Part 3 of the Code of Civil Procedure, with respect to controversies arising out of insurance issued to self-employing persons under the provisions of this division. Such controversies may be submitted to it by the signed agreement of the parties, or by the application of one party and the submission of the other to its jurisdiction, with or without an express request for arbitration.

The State Compensation Insurance Fund, when the consent of the other party is obtained, shall submit to the appeals board all controversies susceptible of being arbitrated under this section.

In acting as arbitrator under this section, the appeals board has all the powers which it may lawfully exercise in compensation cases, and its findings and award upon such arbitration have the same conclusiveness and are subject to the same mode of reopening, review, and enforcement as in compensation cases. No fee or cost shall be charged by the appeals board for arbitrating the issues presented under this section.

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Section § 5309

This law describes the powers of the appeals board related to workers' compensation cases. It allows the board to instruct a workers’ compensation judge to hold trials and make decisions on issues of fact or law. The judge can hold necessary hearings to help the board understand and decide on proceedings or orders. The judge is also authorized to issue legal documents like writs and warrants to manage direct and hybrid contempt situations, which occur both in and out of their immediate presence.

The appeals board may, in accordance with rules of practice and procedure which it shall adopt and upon the agreement of the parties, on the application of either, or of its own motion, and with or without notice, direct and order a workers’ compensation judge:

(a) To try the issues in any proceeding before it, whether of fact or of law, and make and file a finding, order, decision, or award based thereon.

(b) To hold hearings and ascertain facts necessary to enable the appeals board to determine any proceeding or to make any order, decision, or award that the appeals board is authorized to make under Divisions 4 or 5, or necessary for the information of the appeals board.

(c) To issue writs or summons, warrants of attachment, warrants of commitment, and all necessary process in proceedings for direct and hybrid contempt in a like manner and to the same extent as courts of record. For the purposes of this section, “hybrid contempt” means a charge of contempt which arises from events occurring in the immediate presence of the workers’ compensation judge for reasons which occur outside the presence of the workers’ compensation judge.

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Section § 5310

This section explains that the appeals board has the power to appoint workers’ compensation judges for any case if needed. The board can also choose to handle a case itself or assign it to one of these judges. Additionally, the administrative director can appoint such judges as well. When appointed, these judges have specific legal powers and authority outlined by law and the appeals board's rules.

The appeals board may appoint one or more workers’ compensation administrative law judges in any proceeding, as it may deem necessary or advisable, and may refer, remove to itself, or transfer to a workers’ compensation administrative law judge the proceedings on any claim. The administrative director may appoint workers’ compensation administrative law judges. Any workers’ compensation administrative law judge appointed by the administrative director has the powers, jurisdiction, and authority granted by law, by the order of appointment, and by the rules of the appeals board.

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Section § 5311

If you're involved in a workers' compensation case and don't want it handled by a specific judge, you can object based on certain reasons similar to those in the Code of Civil Procedure. The appeals board will decide on your objection, and you're allowed to present affidavits or have witnesses to support your case.

Any party to the proceeding may object to the reference of the proceeding to a particular workers’ compensation judge upon any one or more of the grounds specified in Section 641 of the Code of Civil Procedure and the objection shall be heard and disposed of by the appeals board. Affidavits may be read and witnesses examined as to the objections.

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Section § 5311.5

This law mandates that all workers' compensation administrative law judges in California must take ongoing education courses to improve their skills. These courses cover topics like ethics and handling conflicts of interest. The education requirements may be aligned with similar requirements for attorneys by the State Bar.

The administrative director shall require all workers’ compensation administrative law judges to participate in continuing education to further their abilities as workers’ compensation administrative law judges, including courses in ethics and conflict of interest. The director may coordinate the requirements with those imposed upon attorneys by the State Bar in order that the requirements may be consistent.

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Section § 5312

Before starting their job, a workers' compensation judge must take an oath to honestly and impartially review cases, make fair decisions, and report based on their understanding.

Before entering upon his or her duties, the workers’ compensation judge shall be sworn, before an officer authorized to administer oaths, faithfully and fairly to hear and determine the matters and issues referred to him or her, to make just findings and to report according to his or her understanding.

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Section § 5313

This law section states that a workers' compensation judge or an appeals board must make and file their decisions within 30 days after reviewing a case. They need to include their findings on all the facts, as well as the award, order, or decision regarding the parties' rights. Participants in the case must also receive a summary of the evidence considered and the reasons behind the decision.

The appeals board or the workers’ compensation judge shall, within 30 days after the case is submitted, make and file findings upon all facts involved in the controversy and an award, order, or decision stating the determination as to the rights of the parties. Together with the findings, decision, order or award there shall be served upon all the parties to the proceedings a summary of the evidence received and relied upon and the reasons or grounds upon which the determination was made.

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Section § 5315

This law says that after a workers' compensation judge makes a decision, the appeals board has 60 days to either agree with, change, or cancel that decision. They can do this without holding more hearings or notifying anyone and can make their decision based on the existing case records.

Within 60 days after the filing of the findings, decision, order or award, the appeals board may confirm, adopt, modify or set aside the findings, order, decision, or award of a workers’ compensation judge and may, with or without further proceedings, and with or without notice, enter its order, findings, decision, or award based upon the record in the case.

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Section § 5316

This law explains how notices, orders, or decisions related to proceedings before the appeals board need to be served to individuals. Generally, these documents are served according to certain procedures in the Code of Civil Procedure. However, the appeals board can specify a different method of serving these documents. If necessary, service can also be done by publishing a notice about the hearing’s date and place, and the hearing can be scheduled for more than 30 days after the application is filed.

Any notice, order, or decision required by this division to be served upon any person either before, during, or after the institution of any proceeding before the appeals board, may be served in the manner provided by Chapter 5, Title 14 of Part 2 of the Code of Civil Procedure, unless otherwise directed by the appeals board. In the latter event the document shall be served in accordance with the order or direction of the appeals board. The appeals board may, in the cases mentioned in the Code of Civil Procedure, order service to be made by publication of notice of time and place of hearing. Where service is ordered to be made by publication the date of the hearing may be fixed at more than 30 days from the date of filing the application.

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Section § 5317

This law states that any official notice, order, or decision that impacts state, county, city, school district, or public corporations must be served to the individual who is legally designated to receive such documents, as described by the law.

Any such notice, order or decision affecting the State or any county, city, school district, or public corporation therein, shall be served upon the person upon whom the service of similar notices, orders, or decisions is authorized by law.

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