Author: WorkCompAcademy

The Division of Workers’ Compensation announces its emergency regulations 36.7 and 46.2 for medical-legal evaluations, which became effective on May 14, 2020, will now expire on March 12, 2021.

The expiration date is in accordance with Executive Orders N-40-20 and N-66-20.

There are two possible 210-day extensions if those Executive Orders remain in effect. The emergency regulations can be found on the DWC website.

The regulations concern how medical-legal evaluations and payment for those evaluations can occur during this emergency period. Also provided in the regulations are alternative forms of service for required forms related to medical-legal evaluations and reports.

— QME Regulation 36.7 specifies how and under what circumstances the parties may serve documents electronically.

— QME Regulation 46.2 specifies how and under what circumstances QME, AME and other evaluations may be conducted by telehealth.

These emergency regulations help injured workers and employers continue to move their workers’ compensation claims toward a resolution and avoid additional and undue delay.

The Division of Workers’ Compensation (DWC) has posted an order adjusting the pathology and clinical laboratory section of the Official Medical Fee Schedule (OMFS) to conform to changes in the Medicare payment system, as required by Labor Code section 5307.1.

The update includes fee schedule changes identified in CMS Transmittal 10367, Change Request 11937, which may be accessed on the Medicare website. The pathology and clinical laboratory fee schedule update order adopts the following Medicare change:

— CY 2020 Q4 Release: Revised for October 2020 (20CLABQ4)

The order adopting the updated OMFS pathology and clinical laboratory fee schedule can be found on the DWC fee schedule web page.

Mitchell, announced the new Mitchell Provider Data Explorer solution, which provides a holistic view of medical provider behavior in the P&C industry. Using data visualization, Provider Data Explorer enables both auto casualty and workers’ compensation claims organizations to analyze medical provider treatment and billing behaviors to identify irregular activities that may signal fraud, waste and abuse.

Fraud accounts for 5% to 10% of claims costs for U.S. and Canadian insurers, costing about $80 billion per year for all lines of insurance, according to the Coalition Against Insurance Fraud.

By providing visual depictions of claims data, the visualization tool compares medical provider behavior to that of their peers. Users can see provider peer-to-peer comparisons that can be used in a variety of ways, including easily pinpointing outliers in order to help identify potential fraudulent or abusive medical provider treatment or billing behaviors for investigation.

The new data visualization tool tracks a variety of metrics related to provider behavior, including but not limited to treatment duration, treatment frequency, billing and adjustment behaviors, and procedure codes that, if incorrect, may disproportionately drive up the charged amount.

In addition to helping to detect potential fraud, waste and abuse, Mitchell’s customers have already reported success using Provider Data Explorer for a variety of purposes.

— Validation: Provider Data Explorer allowed one large insurance carrier to validate the charges of a provider compared to its peers across multiple counties. “We were able to visually see just how much that provider was an outlier,” the carrier said. “The ability to then see the actual claim-level detail and the specifics of the codes allowed us to hone in further and get some more detail around the provider’s billing habits.”
— Identification: Another large insurance carrier used Provider Data Explorer to help a claimant find a local physician who was accepting auto insurance medical benefits. “One of our adjusters had a claimant that was injured in an accident but couldn’t find a doctor that would accept auto insurance,” the carrier said. “With just a few clicks, we were able to use Provider Data Explorer to identify multiple providers that had billed us for auto claims in the claimant’s zip code and surrounding areas. The adjuster was then able to provide a list to the claimant of providers in his area willing to accept auto insurance.”

Medical provider data quality is a chronic issue, with the healthcare industry spending $2.1 billion annually to maintain provider databases. Provider Data Explorer utilizes Mitchell’s foundational provider data management capabilities, which work to resolve provider data quality issues, including duplicate records and inaccurate information.

Mitchell Provider Data Explorer is currently available to Mitchell DecisionPoint® bill review customers and will be rolled out to Mitchell SmartAdvisor® bill review customers in phases through the end of 2020.

Headquartered in San Diego, California, Mitchell International, Inc. delivers smart technology solutions that simplify and accelerate claims handling and repair processes, driving more accurate, consistent and cost-effective resolutions.

Charles Lewis filed a claim for an injury against Horizon Christian Fellowship that occurred on May 11, 2015 and also filed a cumulative trauma, a lower back injury, that he alleged occurred from April 11, 2016 to April 11, 2017.

Horizon was insured by GuideOne Mutual Insurance From March 1, 2015 to June 1, 2017, and was insured by Brotherhood Mutual Insurance Company from February 28, 2013 to February 28, 2015. On August 30, 2018 GuideOne filed a Petition for Joinder of Brotherhood as an additional party under Labor Code section 5500.5.

GuideOne and Lewis entered a Joint Compromise and Release which the WCJ approved on September 17, 2018. Brotherhood was joined as a party on October 16, 2018.

On January 18, 2019, GuideOne filed a Declaration of Readiness to Proceed on the issues of “Joinder Order issued 10/16/2018,” and that the complete file had been served on Brotherhood on 11/19/2018.

On January 31, 2019, Brotherhood filed an objection to the Declaration of Readiness to Proceed, stating it had not received the complete file and that it had subpoenaed additional records, which were needed before a hearing takes place on contribution issues.

on October 21, 2019, GuideOne filed another Declaration of Readiness for a Mandatory Settlement Conference (MSC) on the issue of Contribution/Arbitration and the conference was set for December 18, 2019. During the conference, Brotherhood “reserved its defense of untimely filing of the Petition for Contribution” as an issue for the arbitrator.

Brotherhood argued that GuideOne’s claim for contribution was barred because it had not timely submitted a pleading titled “Petition for Contribution” by September 17, 2019, one year after the Compromise and Release was approved. GuideOne argued that its January 18, 2019 Declaration of Readiness was sufficient to initiate contribution proceedings.

The arbitrator issued an order rejecting Brotherhood’s arguments, and noted in his decision that although a better practice is the filing of an actual petition for contribution that clears any confusion, he concluded that the Declaration of Readiness was sufficient to initiate the contribution proceeding.

The WCAB denied reconsideration. The fourth district Court of Appeal affirmed the arbitrator in its minute order of a Summary Denial in the case of Brotherhood Mutual Insurance Company v. WCAB, Guideone Mutual Insurance Company et al. Case Number D 077799.

In general the WCAB has inherent power to control its practice and procedure to prevent frustration, abuse, or disregard of its processes.” (Crawford v. Workers’ Comp. Appeals Bd. (1989) 213 Cal.App.3d 156, 164.) A review of a decision of the WCAB is limited to whether the WCAB acted without or in excess of its powers and whether the order, decision or award was unreasonable, not supported by substantial evidence or procured by fraud. (Lab. Code § 5952.)

Rule 10510 states, “After jurisdiction of the Workers’ Compensation Appeals Board is invoked pursuant to rule 10450, a request for action by the Workers’ Compensation Appeals Board, other than a rule 10500 form pleading, shall be made by petition.”

The WCAB has previously concluded a Declaration of Readiness is sufficient under that statutory provision and rule 10510 to initiate proceedings. (See Old Republic Ins. Co. v. Workers’ Comp. Appeals Bd. (Bennett) (2010) 75 Cal.Comp.Cases 168, 169 (Bennett).) As the WCAB found in Bennett, neither section 5500.5, subdivision (e) or rule 10510 specify that a petition is required in this circumstance. Section 5500.5, subdivision (e) does not specify what document must be used to initiate a contribution proceeding and rule 10510 contains an explicit exception for the use of a Declaration of Readiness.

Federal officials announced a historic nationwide enforcement action involving 345 charged defendants across 51 federal districts, including more than 100 doctors, nurses and other licensed medical professionals.

These defendants have been charged with submitting more than $6 billion in false and fraudulent claims to federal health care programs and private insurers, including more than $4.5 billion connected to telemedicine, more than $845 million connected to substance abuse treatment facilities, or “sober homes,” and more than $806 million connected to other health care fraud and illegal opioid distribution schemes across the country.

“This nationwide enforcement operation is historic in both its size and scope, alleging billions of dollars in healthcare fraud across the country,” said Acting Assistant Attorney General Brian C. Rabbitt.

The largest amount of alleged fraud loss charged in connection with the cases – $4.5 billion in allegedly false and fraudulent claims submitted by more than 86 criminal defendants in 19 judicial districts – relates to schemes involving telemedicine: the use of telecommunications technology to provide health care services remotely.

According to court documents, certain defendant telemedicine executives allegedly paid doctors and nurse practitioners to order unnecessary durable medical equipment, genetic and other diagnostic testing, and pain medications, either without any patient interaction or with only a brief telephonic conversation with patients they had never met or seen.

Durable medical equipment companies, genetic testing laboratories, and pharmacies then purchased those orders in exchange for illegal kickbacks and bribes and submitted false and fraudulent claims to Medicare and other government insurers.

The continued focus on prosecuting health care fraud schemes involving telemedicine builds on the efforts and impact of the 2019 “Operation Brace Yourself” Telemedicine and Durable Medical Equipment Takedown, which resulted in an estimated cost avoidance of more than $1.5 billion in the amount paid by Medicare for orthotic braces in the 17 months following that takedown.

The “sober homes” cases include 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 subjects of the charges include physicians, owners and operators of substance abuse treatment facilities, as well as patient recruiters (referred to in the industry as “body brokers”).

The cases involving the illegal prescription and/or distribution of opioids or that fall into more traditional categories of health care fraud include charges and guilty pleas involving more than 240 defendants who allegedly participated in schemes to submit more than $800 million in false and fraudulent claims to Medicare, Medicaid, TRICARE, and private insurance companies for treatments that were medically unnecessary and often never provided.

According to court documents, in many cases, patient recruiters, beneficiaries and other co-conspirators were allegedly paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could then submit fraudulent bills to Medicare. Also included are charges against medical professionals and others involved in the distribution of more than 30 million doses of opioids and other prescription narcotics.

The Department of Justice also announced the creation of the National Rapid Response Strike Force of the Health Care Fraud Unit of the Criminal Division’s Fraud Section. The National Rapid Response Strike Force’s mission is to investigate and prosecute fraud cases involving major health care providers that operate in multiple jurisdictions, including major regional health care providers operating in the Criminal-Division-led Health Care Fraud Strike Forces throughout the United States.

Prior to the charges announced as part of this historical nationwide enforcement action and since its inception in March 2007, the Health Care Fraud Strike Force program had charged more than 4,200 defendants who have collectively billed the Medicare program for approximately $19 billion.

Further information:
— Graphics, Images and Resources.
— Case Descriptions.  
— Court Documents.