Title: Claims and Medical Director, California Workers’ Compensation Institute
Resume: Ramirez became CWCI medical/rehab director in 2004, coming from State Compensation Insurance Fund, where her most recent assignment had been as medical reimbursement and networks manager. She began her California workers' comp career in 1991 as a claims adjuster at State Fund’s Bakersfield District Office, after which she was promoted to the home office in San Francisco. Ramirez took on various home office assignments at State Fund, including managing medical networks and medical reimbursements; legislative analyses; claims operations; and claims research and development. She has served on DWC, WCIRB, CHSWC and CWCI committees.
Schools: Ramirez has attended the Australian National University, the University of Michigan and Wayne State University. She holds bachelor's degrees in physics and psychology.
Boards and Commissions: As claims and medical director at the CWCI, she is responsible for developing information, coordinating educational activities, representing the institute on matters related to medical treatment, managed care, claims, and return-to-work, including serving as staff liaison to the institute’s Claims, Medical Care and Return-To-Work committees.
Favorite Book: Three Cups of Tea by Greg Mortenson and David Oliver Relin

Ramirez is one of the leading industry experts on all things medical and claims. Her responsibilities include developing information, coordinating educational activities, representing the institute on matters related to medical treatment, managed care, claims, and return-to-work. She has extensive claims experience, having worked at State Compensation Insurance Fund as a claims adjuster and working up the ranks to medical reimbursement and networks manager.

What are the top three issues in California workers’ comp today?  
My main focus is on regulations, so my top three issues are the RBRVS revision to the physicians’ fee schedule, medical billing and e-billing standards, and the various electronic submission systems—EAMS, WCIS, and Medicare Secondary Payer Mandatory Reporting. The first part of the proposed medical billing and e-billing regulations set general standards for medical billing, while the second part focuses on standards for when that billing is electronically transmitted. As for the fee schedule, the Division [of Workers’ Compensation] proposes moving to a Resource-Based Relative-Value Scale (RBRVS) schedule – one in which reimbursements are based on the resources each medical service requires as informed by an AMA committee. The relative value of each service is multiplied by a dollar amount (conversion factor) to generate its maximum reasonable fee. That would stand in sharp contrast to the current schedule, in which fees are largely based on historical charges. Under a true RBRVS schedule, one with a single conversion factor, the focus is more likely to remain on what medical services an injured employee might need, and less likely to be influenced by which services are more lucrative.

Are medical provider networks a help or a hindrance? How should they be improved?  
They’re a tool. They can be used to facilitate effective medical care and better return-to-work for injured employees by channeling them to excellent medical providers who are knowledgeable about workers’ comp. [The goal] is to minimize delays and to ensure that injured employees get appropriate treatment and the best possible results. As with any new undertaking, the devil is in the details, so it’s important that the regulations facilitate the creation of well-functioning networks of highly qualified physicians, as there are a lot of practical considerations when you’re dealing with a system that renders treatment to more than 600,000 injured employees a year. Over the past several years, I have made numerous comments about MPNs as the regulations were developed. Those comments are all on the record and posted on our website. My latest comments were on proposed changes to the MPN notice requirements.

How should utilization review be improved?  
That’s an issue that the division has been wrestling with, and is attempting to address through regulation. CWCI’s latest comments on proposed changes to the Medical Treatment Utilization Schedule are in the Regulation section of our website. In addition to those posted comments, it’s clear that physicians who submit requests for authorization sometimes fail to provide adequate or appropriate documentation, which results in delays. Some of this has improved as the various parties become accustomed to working within the UR system, but clearly the process could be streamlined through better communication and ongoing training so that claims administrators can get the information they need, medical providers can get their requests approved quickly, and injured employees can get the very best treatment without delay.

What needs to be done to improve return-to-work?  
First, I think we should acknowledge that there is evidence that return-to-work outcomes have improved under the reforms. The latest data show that both the average amount of TD paid and the average duration of temporary disability dropped sharply after the 2004 reforms, and remain well below pre-reform levels. That doesn’t mean that further improvement isn’t needed, though. For example, I think we need better coordination between the ADA statutes and regulations and the various requirements and time frames used in workers’ comp for offering regular or modified/alternative work.

What do you see, other than medical, as the next big cost driver?  
Clearly there are a number of cost drivers, but with my focus on regulations, I see a lot of proposals that simply add to the complexity of the system … and these inevitably add to the cost of administering the system and delivering benefits. Benefit notices are a prime example … an injured employee, even one with a simple medical-only claim can end up buried in a mountain of benefit notices. Too much administrative complexity can result in delays in benefits for injured employees, increase confusion, fuel litigation and increase costs. That’s an area that could be addressed.

Where do you see applicant attorneys focusing litigation in the future?  
I expect applicant attorneys will continue to focus on permanent disability and future medical care.

Now that the federal health care bill has become law, what impact, if any, do you see that having on workers’ comp and do you have any concerns?  
I think we’re all interested in how the federal health care program will unfold, but we need more details to know what the impacts will be on workers’ comp. One potential area [where we’ll see an impact] is comparative effectiveness research. That could result in better medical outcomes for patients nationally, including for injured employees in workers’ comp. That’s an area I’m watching. When injured employees receive appropriate treatment, they have better outcomes, fewer long-term complications, return-to-work more quickly, and costs are lower.

Is medical severity going to continue to climb or is it just a blip?  
Medical severity has been climbing pretty steadily. WCIRB estimated that ultimate medical losses per indemnity claim in California topped $39,000 last year … the fifth year in a row that the average cost of medical care per claim has risen and a 60% increase since 2004, so it’s hard to call it a blip. We don’t have a crystal ball for the future, so I don’t know, but the trend is certainly there.

Are there any changes to claims frequency?  
It’s been dropping steadily for quite some time. On the other hand, claim severity has been rising so rapidly that total loss costs in the system are still moving up despite the decline in claim frequency.

What trends are you seeing in controversial treatment, specifically items that are not covered by a fee schedule?  
Where there’s no fee schedule, or where there is a fee schedule loophole, there are more disputes and liens. Medical liens have become a big problem that consumes a lot of resources. Air ambulance services may become more of an issue because the Division [of Workers’ Compensation] is considering pulling air ambulance services out of the ambulance fee schedule. Interpreter services provided during medical treatment visits is a problem area that could benefit from guidance on appropriate fees. But [overall] the trend has been to see more medical services covered by fee schedules, which is a move in a good direction.

Are there treatments or practices—such as repackaged drugs—that are resurfacing maybe as something else?  
Certainly, I think there are. [Look at] compound drugs, medical foods, and convenience packs (“co-packs”). As soon as the repackaged drug regulatory loophole was closed, we saw the utilization of repackaged drugs plummet and an increase in the use of compound drugs, medical foods and co-packs.

Are there treatments that are not being put through utilization review? How many? Is that helping to control costs?  
A company’s utilization review plan can include prior authorization for certain providers or certain treatments, and in those cases a request for authorization is not required. This can be a little tricky because primary treating physicians are required to report their treatment plans in their first reports, and changes to their treatment plans in progress reports. These required reports are requests for authorization by definition. If a request for authorization is submitted, statutes and regulations require them to be addressed in writing. The Division [of Workers’ Compensation] is considering a new request for authorization format that may result in some changes. Since each company has its own utilization review plan on file with the division, the results vary quite a bit from company to company.