Latest news with #CWCI
Business Wire
08-07-2025
- Health
- Business Wire
CWCI Examines California's Proposed Presumption for Hospital Worker Injuries & Illnesses
BUSINESS WIRE)--A bill that would give a rebuttable presumption of compensability to a wide range of work injury and illness claims filed by workers who provide direct patient care in California's acute care hospitals would require the hospitals to accept injuries that would normally be denied after investigation and expend significant costs, increase litigation, and set an unsupported precedent by extending presumptions into the private sector according to a California Workers' Compensation Institute (CWCI) analysis. The analysis shows a lack of evidence supporting the need for hospital worker presumptions, especially given that it would open the door to private sector presumptions. Share Unlike other workers' compensation claims, in presumptive injury claims an injured worker does not need to prove that their injury or illness was caused by their job; instead, the employer must prove it was not work-related. Because this is very difficult, rebuttable presumptions have historically been reserved for public safety officers for injuries such as cancer or heart disease that may arise from the unique risks inherent in those public sector jobs, and even then, only when there is clear and compelling evidence of a lack of hazard abatement, a high incidence of injury, and a high claim denial rate. However, SB 632 (Arreguin), now pending in the California Assembly, would extend presumptions into the private sector by granting presumptions to direct care hospital workers for claims involving injuries and illnesses including musculoskeletal injuries, COVID-19 from SARS-CoV-2 and its variants, respiratory diseases (including asthma), cancer, and post-traumatic stress disorder (PTSD). Using accident year (AY) 2019 – 2024 claims data from its Industry Research Information System (IRIS) database, CWCI's analysis measured the percentage of workers' compensation claims by hospital workers that involved the injuries covered by SB 632 and compared that figure to the percentage of claims from the general workforce that involved those injuries. The Institute then determined the distribution of claims by injury category and calculated the claim denial rates for the hospital worker claims and compared the results to those for the general workforce. Among the findings: 1) 55.7% of all hospital worker claims from AY 2019 - 2024 would be presumptive injuries under SB 632. 2) Of the hospital worker claims, the most common were musculoskeletal injuries (32.1% of all hospital worker claims from the 6-year study period); COVID-19 (21.7%); and respiratory diseases (1.3%). Other injury categories that would be covered by the proposed presumptions together represented less than 1% of the hospital worker claims. 3) Similarly, for the general workforce, the most common injuries covered by SB 632 were musculoskeletal injuries (30.0%), COVID-19 (9.9%), and respiratory diseases (0.8%). As with the hospital worker claims, all other injuries covered by SB 632 represented less than 1% of all general workforce claims. 4) Claim denial rates for injuries and illnesses that would be covered by SB 632 are similar for hospital workers and the general workforce: for hospital workers the claim denial rate was 15.0%; for the general workforce, it was 15.7%. Thus, hospitals accept liability for the injuries at a slightly higher rate than they are accepted in the general workforce. Workers' compensation presumptions shift the burden of proving that a claim is work-related from the employee to the employer. Because they create exceptions to the grand bargain of workers' compensation, they have been limited to public safety officers for specific injuries that may result from the hazardous conditions associated with those public service jobs, where it is often difficult to safeguard the employee from the dangerous conditions inherent in their work. Such is not the case for hospitals, which have extensive loss control programs and safety procedures. Furthermore, CWCI's analysis found hospitals and the general workforce have similar injury distributions, except for COVID-19 claims, where hospital workers were covered by a presumption during the pandemic. This, combined with nearly identical claim denial rates for hospital worker and general workforce claims involving injuries covered by SB 632, shows a lack of evidence supporting the need for a presumption, especially given that it would open the door to private sector presumptions. CWCI's Impact Analysis report on SB 632 is available for free under the Research tab at
Business Wire
26-06-2025
- Business
- Business Wire
CWCI Finds California Workers' Comp Independent Medical Reviews Are Trending Up
BUSINESS WIRE)--After declining steadily from 2018 through 2022, the number of Independent Medical Review (IMR) decision letters issued in response to California workers' comp medical disputes is now trending up, increasing in 2023, 2024, and the first quarter of 2025 according to the California Workers' Compensation Institute (CWCI), but the uphold rate for medical service modifications and denials that are reviewed remains close to 90%. After declining from 2018 - 2022, California workers' comp Independent Medical Reviews are on the rise, and new data show the trend accelerating. CWCI's latest review of IMR activity and outcomes examined 1.57 million IMR decision letters issued from 2015 through March of this year in response to applications submitted to the state after a Utilization Review (UR) physician modified or denied a workers' comp medical service request. As in prior reviews, CWCI tracked the number of letters issued each quarter; determined the distribution and uphold rates for disputed treatment requests by type of medical service (and the distribution and outcomes of pharmaceutical IMRs by major drug group); measured IMR response times; and calculated the percentage of IMRs associated with high-volume physicians. IMR, introduced in 2013, was expected to reduce medical disputes by helping to ensure that workers' comp treatment met evidence-based medicine standards, but it was not until 2019 that the number of IMR disputes began a steady decline, with the number of IMR decision letters falling by 31% from the peak level of 184,385 in 2018 to 127,215 in 2022. That decline coincided with a reduction in the number of job injury claims during the pandemic and a drop in the number of pharmaceutical disputes after the state added Pain Management and Opioid Guidelines to its Medical Treatment Utilization Schedule (MTUS) in late 2017 and adopted the MTUS Drug Formulary in January 2018. More recent data, however, show IMR letter volume rose 2.9% in 2023 and 8.2% in 2024, and initial results for this year show the trend accelerating, with 38,393 IMR decision letters in the first 3 months of 2025, 13% more than in the same period last year. Even with the increase in IMR volume, the median IMR response time (from receipt of the application to the date of the decision letter) was 32 days in 2024, the same as in 2022. Furthermore, 25% of the letters were issued within 28 days, and 75% were issued within 38 days, all within the time allotted to the state's Independent Medical Review Organization to confirm the eligibility of the application; request, receive, and process medical records; assign the case to a physician reviewer; and issue a decision. Disputes over prescription drug requests represented 30.6% of all IMRs in the first quarter of this year – more than any other type of medical service, but down from 33.4% in 2024 and 50.7% in 2015. Much of that decline was due to the reduction in IMRs involving opioid requests, which dropped from 32% of all pharmaceutical IMRs in 2018 to 18.6% in the first quarter of this year. With prescription drugs representing a declining share of the IMR disputes, the percentage of IMRs involving disputes over other medical services has increased, with physical therapy disputes accounting for 13.6% of IMRs in the first quarter of 2025, injection disputes accounting for 12.9%, and disputes over durable medical equipment, prosthetics, orthotics and supplies accounting for 9.7%. A small number of physicians continue to drive much of the IMR activity, as the top 1% of requesting physicians (81 doctors) accounted for 42.2% of the disputed service requests that underwent IMR in the 12 months ending on March 30 of this year, and the top 10 individual physicians accounted for 10.9% of the disputed requests. CWCI found that 7 of the providers on the latest top 10 list were also on the top 10 list the prior year. IMR outcomes remain stable, as IMR physicians upheld 89.1% of UR doctors' treatment modifications or denials in the first quarter of 2025 compared to 88.0% in 2024. As in the past, uphold rates varied by type of service, ranging from 77.4% for evaluation/management services to 92.9% for acupuncture. CWCI members and subscribers will find a more detailed summary of IMR experience through March 2025 in Bulletin 25-09 at Institute members can also access updated IMR slides under the Research tab.
Yahoo
03-06-2025
- Business
- Yahoo
CWCI: Long COVID Accounts for Three Quarters of California Workers' Comp COVID Claim Payments
OAKLAND, Calif., June 03, 2025--(BUSINESS WIRE)--Only one out of every 21 California workers' compensation COVID-19 claims from accident years (AY) 2020-2022 involved medical treatment beyond 90 days from the injury date, but that small number of "Long COVID" cases consumed 82.1% of the treatment payments on COVID claims and 73.7% of all COVID claim payments according to a new California Workers' Compensation Institute (CWCI) study. While the number of new COVID claims in California workers' compensation has gone from a flood shortly after Governor Newsom declared a COVID-19 state of emergency in March 2020 to a trickle over the last year, the new study comes amid growing concern about a potential COVID surge after the CDC adopted new guidelines that may make it more difficult to obtain COVID-19 vaccines just as the summer travel season hits and the new NB.18.1 COVID variant has been detected in multiple locations around the U.S. The study, based on a review of 126,397 insured and self-insured COVID-19 claims found that most were relatively inexpensive due to little to no medical intervention (only 14.6% involved medical treatment), but 4.7% – or nearly 6,000 of them – were Long COVID claims that involved long-term medical conditions that impeded or prevented the claimants from returning to their jobs and resulted in significant costs. Medical payments for the COVID-19 claims in the study sample totaled $128.4 million, with Long COVID claims accounting for $105.5 million, or 82.1%; while total payments on the COVID-19 claims, including medical treatment, indemnity costs, and expenses, were $350.6 million, with Long COVID claims consuming $258.3 million, or 73.7%. Overall, average medical payments were 105 times higher on Long COVID cases than on shorter duration COVID claims, and average indemnity payments were 37 times higher. Long COVID claim payments were significantly higher regardless of the body part involved, though the difference was most pronounced for injuries involving the lungs, multiple body parts, and "other" body parts. The top 10 diagnostic categories for Long COVID claims encompassed a wide range of organ systems, including respiratory (17.8%); circulatory (9.0%); nervous (8.7%); connective, soft tissue and bone disorders (5.2%); endocrine systems (4.9%); as well as mental health (4.4%), and digestive conditions (3.4%). Together the top 10 diagnostic categories associated with the Long COVID claims in the study sample accounted for 80.3% of all the diagnoses on these claims, highlighting the multisystem nature of Long COVID. The Institute has included more details and graphics from the study in a report, Long COVID-19 Claim Characteristics and Treatment in California Workers' Compensation. CWCI members and subscribers can log on to to access the report under the Research tab on the home page, others can purchase a copy from CWCI's online Store. View source version on Contacts Bob Young(510) 251-9470
Business Wire
03-06-2025
- Business
- Business Wire
CWCI: Long COVID Accounts for Three Quarters of California Workers' Comp COVID Claim Payments
OAKLAND, Calif.--(BUSINESS WIRE)--Only one out of every 21 California workers' compensation COVID-19 claims from accident years (AY) 2020-2022 involved medical treatment beyond 90 days from the injury date, but that small number of 'Long COVID' cases consumed 82.1% of the treatment payments on COVID claims and 73.7% of all COVID claim payments according to a new California Workers' Compensation Institute (CWCI) study. Long COVID claims comprised only 4.7% of all California workers' comp COVID claims but accounted for 82% of COVID claim medical treatment dollars. While the number of new COVID claims in California workers' compensation has gone from a flood shortly after Governor Newsom declared a COVID-19 state of emergency in March 2020 to a trickle over the last year, the new study comes amid growing concern about a potential COVID surge after the CDC adopted new guidelines that may make it more difficult to obtain COVID-19 vaccines just as the summer travel season hits and the new NB.18.1 COVID variant has been detected in multiple locations around the U.S. The study, based on a review of 126,397 insured and self-insured COVID-19 claims found that most were relatively inexpensive due to little to no medical intervention (only 14.6% involved medical treatment), but 4.7% – or nearly 6,000 of them – were Long COVID claims that involved long-term medical conditions that impeded or prevented the claimants from returning to their jobs and resulted in significant costs. Medical payments for the COVID-19 claims in the study sample totaled $128.4 million, with Long COVID claims accounting for $105.5 million, or 82.1%; while total payments on the COVID-19 claims, including medical treatment, indemnity costs, and expenses, were $350.6 million, with Long COVID claims consuming $258.3 million, or 73.7%. Overall, average medical payments were 105 times higher on Long COVID cases than on shorter duration COVID claims, and average indemnity payments were 37 times higher. Long COVID claim payments were significantly higher regardless of the body part involved, though the difference was most pronounced for injuries involving the lungs, multiple body parts, and 'other' body parts. The top 10 diagnostic categories for Long COVID claims encompassed a wide range of organ systems, including respiratory (17.8%); circulatory (9.0%); nervous (8.7%); connective, soft tissue and bone disorders (5.2%); endocrine systems (4.9%); as well as mental health (4.4%), and digestive conditions (3.4%). Together the top 10 diagnostic categories associated with the Long COVID claims in the study sample accounted for 80.3% of all the diagnoses on these claims, highlighting the multisystem nature of Long COVID. The Institute has included more details and graphics from the study in a report, Long COVID-19 Claim Characteristics and Treatment in California Workers' Compensation. CWCI members and subscribers can log on to to access the report under the Research tab on the home page, others can purchase a copy from CWCI's online Store.
