Author: WorkCompAcademy

Workers with low back pain (LBP) who received manual therapy (MT) early within two weeks of their physical therapy care (PT) had lower medical costs and fewer days away from work than those who received it later, according to a new study from the Workers Compensation Research Institute (WCRI). MT is hands-on therapy that improves range of motion and reduces pain.

“This is a unique study that addresses an unfamiliar but important health care issue in workers’ compensation,” said John Ruser, president and CEO of WCRI. “Although the findings only provide evidence of association between the use and early use of MT and outcomes, it helps fill information gaps in medical and health care policy research regarding this therapy.”

The study, Outcomes Associated with Manual Therapy for Workers with Non-Chronic Low Back Pain, focuses on LBP claims in 28 states. It compares costs and outcomes between claims with early and late MT and between claims with and without MT. The following are among the study’s findings:

– – Among workers with LBP who received MT, early MT (within 2 weeks of PT care) was associated with lower costs and shorter temporary disability (TD) duration as compared with late MT (after 2 weeks of PT care). Early MT was also associated with a lower likelihood of receiving magnetic resonance imaging (MRI), pain management injections, and opioids, as compared with late MT.
– – Among workers with LBP, those who received MT had higher costs and slightly longer TD durations than those who did not receive MT but received other PT services. These differences may partly reflect dissimilarities in injury severity or underlying health conditions that cannot be measured in the data. Also, longer periods of observation (more than 18 months) may be important to consider when addressing the cost effectiveness of MT treatment.
– – Large interstate variations in the utilization of MT services were seen across the 28 study states, which could be explained, to some extent, by differences in state policies influencing provider practices and billing.

The findings are based on statistical analysis that controls for various factors affecting treatment choice and outcomes. Data used for the analysis capture medical services and benefit payments at 18 months postinjury for workers with LBP who did not have surgery but received MT and other medical services provided by non-chiropractic providers.

The 28 study states are Arkansas, California, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Jersey, New Mexico, New York, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Wisconsin.

The owners of Sonoma County’s only psychiatric hospital, Aurora Santa Rosa Hospital, have agreed to pay $2.85 million to settle a lawsuit that alleges a number of state labor code violations, including significant understaffing that led to unsafe working conditions for nurses and other staff.

In 2018, the former director of nursing Teresa Brooke filed a lawsuit – Brooke v. Aurora Behavioral Healthcare-Santa Rosa, LLC et al. – alleging that understaffing and related issues caused pervasive Cal-OSHA violations at a Santa Rosa behavioral healthcare hospital operated by Signature Healthcare Services, LLC, one of the largest privately-held behavioral health hospital conglomerates in the U.S.

Using PAGA, the plaintiff sought to recover Labor Code penalties on behalf of the State of California for unlawful working conditions experienced by nurses and other hospital staff.

On August 25, the Superior Court of California approved a settlement including a Gross Settlement Fund of $2,850,000 – with $2,046,750 being paid to the State of California and $682,250 being paid to hospital staff, based on formulas mandated by the PAGA statute.

The court-approved settlement also includes various additional programmatic measures agreed to by the parties, including notice to employees that they will not face repercussions for speaking up regarding unsafe or unlawful practices.

The settlement further provides for the parties to jointly retain an outside expert to evaluate the hospital’s policies, practices, and procedures and make recommendations for any changes it may deem needed to improve working conditions for front-line staff who care for acute patients.

“This is the first of its kind, a significant PAGA settlement centering on occupational health and safety in a hospital,” said Xinying Valerian, one of Plaintiff’s lead attorneys and principal of Valerian Law. “The settlement is heavily focused on the employee population who have been most impacted – nurses and mental health workers, and we have not seen any other case of this kind. There’s still work to be done, but we’ve accomplished something through a civil penalties PAGA case that has not happened before.”

“In approving the settlement, the Court recognized that the settlement provides genuine and meaningful relief that will benefit the Santa Rosa hospital employees as well as the public,” according to Andrew Melzer, co-lead counsel and partner at Sanford Heisler Sharp LLP. “This case reinforces that we can and should be pursuing Labor Code and whistleblower actions aimed at deterring violations and improving conditions for hospital workers.”

Qiaojing Ella Zheng, a partner at Sanford Heisler Sharp’s San Francisco Office, added, “the resolution of this matter not only presents the employees in the Santa Rosa facility with an outstanding result, but also sets an example of how psychiatric hospitals all over the state should protect the health and safety of these frontline healthcare workers.”

Valerian and Melzer said staffing ratios of registered nurses to patients at the the hospital, at times 19 patients to one registered nurse and another licensed staff member, created unsafe working environment for nurses and other staff.

According to the law firms, other employment rights cases remain pending against Signature Healthcare.

Further information about the PAGA settlement will be made available to the 1,000 or so employees later in September.

The Alameda County District Attorney’s Office, along with the California Department of Insurance, announce that charges have been filed against multiple suspects in an organized insurance and workers’ compensation fraud scheme that defrauded insurance carriers over $5 million in estimated losses.

Former owners of Signature Painting and Construction Inc, Eric Andrew Oller and Brian Christopher Mitchell, were each charged with one felony count of conspiracy to commit a crime, six counts each of felony insurance fraud and two counts of workers’ compensation fraud. SPC is based in Walnut Creek, but operates throughout the Bay Area.

Defendant Yama Sekander, owner of A-1 World Class Painting, was also charged with one count of felony workers’ compensation fraud.

Oller is also the owner of Valhalla Consulting, which along with A-1, was used as a shell company by Mitchell to pay employees at SPC.

From 2017 to 2018, SPC allegedly paid its employees using VC’s bank account, with the intent to illegally reduce its workers’ compensation insurance premium. SPC misrepresented information or didn’t include information about its company structure and payroll costs to its insurance carriers in order to illegally reduce its insurance premiums.

“If a business creates an environment where they falsely pay a lower insurance premium, that company has an unfair competitive advantage over one that is law-abiding,” said District Attorney Nancy E. O’Malley.

It is alleged that Mitchell was illegally misclassifying employees and underreporting payroll costs to reduce workers’ compensation insurance premiums. The riskier the job, the higher premium an employer must pay for workers’ compensation. For example, a clerical worker costs less to insure than a worker engaged in a riskier job. It is alleged that Mitchell misclassified several of these employees to lower premium costs.

Mitchell and Oller are also accused of entering into agreements to move employees from one company to another, to save money on workers compensation insurance. Mitchell is accused of using Sekander’s company, A-1, to obtain a workers’ compensation insurance policy for his company, SPC.

The allegations also include that some employees at SPC were paid “under the table” so that the company could avoid paying or reporting the proper taxes. The defendants also allegedly instructed some injured employees to report working for one company, while in reality, they worked for another.

Insurance carrier SCIF suffered a loss of approximately $3.1 million in premium payments while AmTrust loss was approximately $1.9 million as a result of this fraud scheme.

The investigation into the defendants began in 2019 after the State Compensation Insurance Fund submitted a fraud referral to the California Department of Insurance. The fraud began in 2015.

Charges were filed in late August and all three defendants were arraigned the morning of September 20. Their next court date will be November 18 at the East County Hall of Justice in Dublin.

A strategically coordinated, six-week nationwide federal law enforcement action has resulted in criminal charges against 138 defendants, including 42 doctors, nurses, and other licensed medical professionals, in 31 federal districts across the United States for their alleged participation in various health care fraud schemes that resulted in approximately $1.4 billion in alleged losses.

The enforcement action includes criminal charges against four defendants in the Southern District of California, involving more than $129 million in intended losses.

Nationwide, this action includes more than $1.1 billion in fraud committed using telemedicine, more than $29 million in COVID-19 health care fraud, more than $133 million connected to substance abuse treatment facilities, or “sober homes,” and more than $160 million connected to other health care fraud and illegal opioid distribution schemes across the country

Telemedicine Fraud Cases – The largest amount of alleged fraud loss charged in connection with the announced  – over $1.1 billion in allegedly false and fraudulent claims submitted by more than 50 criminal defendants in 11 judicial districts nationwide – relates to schemes involving telemedicine: the use of telecommunications technology to provide health care services remotely.

COVID-19 Fraud Cases – Nine defendants are alleged to have engaged in various health care fraud schemes designed to exploit the COVID-19 pandemic, which resulted in the submission of over $29 million in false billings.

In the Southern District of California, Roselia Kubeck and Rosario Gonzalez pleaded guilty to having approached residents of senior complexes in El Centro and Calexico, California, who were Medicare beneficiaries, and offering COVID-19 screening tests for the residents. The defendants knew at the time that the tests would not actually test for COVID-19 but would be a general respiratory pathogens screening panel that tested for the presence of several kinds of respiratory pathogens. They also took urine samples from the Medicare beneficiaries without explaining that the urine samples were not necessary to conduct a COVID-19 test. The defendants then completed requisition forms for tests on the nasal swabs and urine samples, and inaccurately indicated on the forms that the beneficiaries needed the respiratory tests because they were suffering from acute respiratory infections and needed urine tests because the beneficiaries were long-term users of opiates or had urinary tract infections. The laboratories that performed the tests subsequently submitted inaccurate and medically unnecessary claims to Medicare based on the inaccurate diagnoses that the defendants put on the requisition forms.

Sober Homes Cases – The sober homes cases are announced on the one-year anniversary of the first ever national sober homes initiative in 2020, which included charges against more than a dozen criminal defendants in connection with more than $845 million of allegedly false and fraudulent claims for tests and treatments for vulnerable patients seeking treatment for drug and/or alcohol addiction. The over $133 million in false and fraudulent claims that are additionally alleged in cases just  announced reflect the continued effort by the National Rapid Response Strike Force and the Health Care Fraud Unit’s Los Angeles Strike Force, with the participation of the U.S. Attorney’s Offices for the Central District of California and the Southern District of Florida, to prosecute those who participated in illegal kickback and bribery schemes involving the referral of patients to substance abuse treatment facilities; those patients could be subjected to medically unnecessary drug testing – often billing thousands of dollars for a single test – and therapy sessions that frequently were not provided, and which resulted in millions of dollars of false and fraudulent claims being submitted to private insurers.

Cases Involving the Illegal Prescription and/or Distribution of Opioids and Cases Involving Traditional Health Care Fraud Schemes

In the Southern District of California, Ronald Charles Green Jr. and Melinda Elizabeth Green were charged with conspiring to defraud TRICARE and Medicare out of more than $129 million. In connection with a compounding pharmacy fraud, the defendants allegedly engaged in a scheme involving the submission of false and fraudulent claims to TRICARE for expensive and medically unnecessary pain creams, scar creams and multi-vitamins, which were billed through compound pharmacies. Thereafter, the defendants allegedly launched multiple durable medical equipment companies, and carried out a scheme to defraud Medicare through the submission of false and fraudulent claims for expensive durable medical equipment which were induced through a system of illegal kickbacks. Out of the $129 million in claims, Medicare paid the defendants’ companies more than $69 million.

Prior to the charges announced as part of the nationwide enforcement action and since its inception in March 2007, the Health Care Fraud Strike Force, which maintains 15 strike forces operating in 24 districts, has charged more than 4,600 defendants who have collectively billed the Medicare program for approximately $23 billion.

The delta variant of the coronavirus roared into California midsummer, striking hard even in places where many people were vaccinated. Cases spiked. Hospitals again began to swell with patients. The daily death toll climbed into the triple digits for the first time in months.

But after a season in which the highly transmissible variant wreaked havoc on the nation, the Washington Post reports that California is reporting sustained progress against delta. And this is also good news for workers’ compensation claims in the state.

Earlier this week, California dropped from “high” to “substantial” virus spread, according to the Centers for Disease Control and Prevention. It later bounced back up, but total new cases per 100,000 residents are still lower than any other state. The change in CDC designation – a barometer of how well states are doing in combating the virus – was celebrated by public health officials, who suggested it was a signal that California could be close to a turning point.

An aggressive push for vaccines, coupled with masks mandates at the local level and a public largely willing to go along with them, appear to have helped flatten the state’s curve, experts said.

“California, as compared to many other states in the nation, took rapid steps to recognize the extent of the problem and to apply more covid control measures,” said Robert Kim-Farley, a infectious-disease expert at UCLA Fielding School of Public Health. “I think if California had not taken these steps to curb transmission, we could have ended up with much higher levels.”

The fight against delta is far from over in the Golden State, which still faces a host of challenges in containing cases. Though infections have dropped in California’s population hubs in recent weeks, they remain high in parts of the Central Valley and rural north. An influx of patients has overwhelmed some intensive care units in those regions.

Compounding the problem, California hospitals are facing staffing shortages. Medical workers have struggled with burnout, and surges in other states have created intense competition for nurses, said Bryan Bucklew, president and chief executive of Hospital Council of Northern & Central California, a nonprofit trade association.

“The numbers may be flattening, but the impact to the health-care system is extremely challenging,” he said. “We have a good handle on how to treat covid, with monoclonal antibodies, vaccines. We just have a lot less staff. It’s more of a workforce issue for us than a covid issue.”

Statewide, infections are still far higher than they were early in the summer, averaging about 9,300 new cases per day compared with 758 on July according to tracking by The Washington Post.

But they’re down from a summer peak of about 14,400 per day on average, the data shows. Hospitalizations have fallen statewide by about 10 percent over the past week. Positivity rates have also dropped recently, at a time when the state is administering more tests than at almost any point in the pandemic – another indicator that the spread is slowing.

At its worst point over the summer, cases per 100,000 people in California rose to about 35 per day on average, according to The Post’s analysis of state data. In Florida, where the governor has sought to ban public health mandates, per capita cases topped 100 during the peak of infections, and in Texas they’ve hovered around 60 for weeks, the data shows.

As of Thursday, California had 24 cases per 100,000 residents, less than half as many as Florida, with 55 per capita, and Texas with 59, according to The Post’s data.

John Swartzberg, an infectious-disease expert at the University of California at Berkeley, said California has benefited from a population that’s generally receptive to public health directives. He said the attitude was rooted in the public health response to the AIDS crisis in the early 1980s.