Education Certificates: A 60-Second Seminar in Workers’ Compensation Claims Handling

Allow us to begin today’s blog with a quick history lesson.  It was the year 2002. The California Department of Insurance was literally swamped with complaints from employers concerning the cost of workers’ compensation insurance.  In addition, injured workers complained about poor claims adjuster performance, while physicians squawked about medical bill reviewers improperly applying the state’s official medical fee schedule.  In response, Insurance Commissioner John P. Garamendi partnered with assemblywoman Barbara Matthews (D-Merced) to introduce AB 1262 that created Insurance Code § 11761, requiring mandatory education for claims adjusters and medical bill reviewers. Despite significant opposition, the bill worked its way through the legislature and ended up on Governor Gray Davis’s desk, where it was signed into law, effective 1/1/2003.  However, before the law could take effect several regulations first needed to be developed.  It took 3-1/2 years but finally, on February 22, 2006, Ins. Code § 11761 became operational on the same day the supporting regulations were finalized.

Upon completion of required education claims adjusters and medical bill reviewers would receive a certificate verifying compliance with Ins. Code § 11761 to demonstrate that person’s qualifications to adjust claims or review medical bills.  Under 10 CCR 2592.06(g) an injured worker or a policyholder is explicitly granted authority to request a copy of their adjuster or bill reviewer’s designation certificate.  Curiously, no other entity other than the insurance commissioner and the administrative director of the Division of Workers’ Compensation was granted authority under 10 CCR 2592.06(f) to request a copy of educational records or designation certificates.  That means work comp judges, attorneys, co-defendants, the Director of Self-Insured Plans, and medical providers are not authorized under the regulations to request proof that an adjuster or medical bill reviewer follows our state mandated educational requirements.  Of course, the requested document(s) may voluntarily be provided by the adjuster or bill reviewer as they may find it difficult to refuse a judge’s request.  In absence of such voluntary submission, refusal to provide a copy of a certificate is not a big deal, as a back door exists since the injured worker or the administrative director may always request a copy and then forward it to anyone so desired, including the judge.

What is somewhat mind boggling is trying to understand why the regulations do not allow medical providers to request a copy of a bill reviewer’s certificate.  The whole purpose of medical bill reviewer education was to address complaints from the medical profession.  Yet, medical providers are not allowed to verify that the bill reviewer analyzing their invoices received the mandatory training enabling them to legally perform these duties. 

Consistent with our commitment to provide our clients with “The Best Defense,” we at Friedman + Bartoumian provide our clients and friends with education that complies with the requirements of Ins. Code § 11761. As we have always said, “There is no better defense than education.”