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Claimant with Attendant Care Sentenced in Fraud Case

A San Diego father and daughter team were sentenced to local custody after pleading guilty to insurance fraud, grand theft and perjury in connection with a brazen insurance fraud scheme that lasted nine years. Yolandi Kohrumel, 35, was sentenced to one year in jail and her father, Anton Buitendag, 65, was sentenced to 180 days in jail by Superior Court Judge Duane Moring. Restitution in the amount of $1,558,653 was also ordered to be paid to ESIS, which administered the insurance claim.

Kohrumel broke her toe at work and claimed to be wheelchair bound due to complications from surgery on her foot. The defendant was paid $1.5 million in disability payments over a nine-year period until the insurance company was tipped off and obtained video of her standing, walking and lifting moving boxes for hours.

In 2002, Kohrumel worked as a manager at Staples. After working about three months, she claimed she injured her toe when a heavy box fell on her foot. In November of that year, she had surgery on her toe and was given crutches. When she claimed she could not use the crutches, she was given a wheelchair. The defendant claimed the wheelchair gave her carpal tunnel syndrome and she was given an electric wheelchair.

Despite this, she continued to represent herself as suffering from hypersensitivity of the feet, complex regional pain syndrome, depression, and anxiety. Doctors prescribed about 25 different medications for these symptoms. From the date of the surgery to the present, Kohrumel never returned to work and was paid temporary disability amounting to two-thirds of her salary, tax free.

She represented herself as needing care 24 hours a day, seven days a week since 2004. At first, care was provided by her husband until his death in September of 2011. Then, the defendant’s father, Anton Buitendag, took over her care. All of Kohrumel’s doctors believed she was totally disabled, entitling her to potential lifetime disability benefits. Given her young age, this could have totaled several million dollars.

Recently, Kohrumel and her father began demanding that he be reimbursed for the around-the-clock care they said she needed and he provided. Buitendag was seeking $324,000 in compensation for his claimed 24 hour-a-day, seven days a week care of his daughter from September 2011 through June 2013. He claimed his services were worth more than $21 an hour, which came to about $500 per day or about $182,500 a year.

The insurance company, ESIS/AIG, disputed the amount of care she needed and said they could not legally pay Buitendag because he is a South African citizen and does not have a work Visa. Kohrumel’s attorney sought to litigate this issue before the WCAB.

In addition to the benefits the defendant received, she said needed a larger place to live as her current two bedroom apartment was not large enough for her wheelchair to navigate. The insurance company hired movers to help her start the moving process and informed the workers they would have to do everything as Kohrumel was wheelchair bound. While helping Korhumel, the movers noticed she would get out of her wheelchair for extended periods of time and lift and move heavy boxes in her garage. The movers reported what they saw to the insurance company and later filmed the defendant standing for about two hours while continuously lifting, moving and looking through boxes in her garage. Korhumel was arrested and taken into custody.

On July 10, 2013, a search warrant was executed on Korhumel’s garage and more than 20 boxes of unused prescription medication were recovered. The next day both Kohrumel and Buitendag entered guilty pleas. Korhumel pleaded guilty to eight felonies counts including insurance fraud, preparing a false document, perjury and grand theft. Butiendag pleaded guilty to three felony counts of attempted grand theft.

Another “Politically Incorrect” Comp Claim

The public eye and caustic scrutiny moves quickly to claims of industrial injury made by workers who are perceived by the public or the press to be “politically incorrect.” Last week the press was hard on John Pike, a former U.S. Marine with 17 years of law enforcement experience, who gained worldwide notoriety after he pepper-sprayed seated, unarmed Occupy UC Davis protesters who blocked police on a Quad sidewalk on Nov. 18, 2011. Pike applied for worker’s compensation, claiming he suffered psychiatric injury from the 2011 confrontation. Protesters threatened to picket the WCAB district office where his August MSC was to be held. The parties took the MSC off calendar to circumvent the planned protest.

This week the focus is on the tale of Henry Alvarez’s departure from the imploding San Francisco Housing Authority. When Alvarez went on paid medical leave back in February, before being fired in April, he took heat for setting up a restaurant in Berkeley while presumably too ill to do his day job as the executive director for the city’s public housing agency.

Now it turns out that Alvarez has filed a workers’ compensation claim contending he was injured from stress on the job – his full-time one at the Housing Authority, according to new stories. He is seeking disability payments, health care and a voucher worth up to $10,000 for job training. Alvarez contends that he was injured on Jan. 29, records show. That’s four days after he requested his leave of absence for “personal reasons” and indicated he would not seek to renew his contract, which expired in June.

The story in the San Francisco Chronicle characterizes his claim as “laced with irony.”

Alvarez filed the claim April 26, about two weeks after he was fired amid mounting concern about his leadership of the public housing agency, which was about to run out of money, was rated one of the two worst in the state, and was the subject of a federal probe into its contracting practices. The Housing Authority was also defending itself against lawsuits from three former employees, including two who said they were discriminated against for taking paternity or disability leave.

In one case, Beverly Bernell Myres, a workers’ compensation analyst with the Housing Authority, said she was fired while out on disability leave with a knee injury. Her lawsuit alleges Alvarez asked in a meeting, “How can the workers’ comp person be out on workers’ comp?” He also allegedly “made derisive comments” about her disability, the suit says. “We find it the height of hypocrisy that after an extensive record of saying that anyone who takes workers’ comp is a malingerer and a fraud, Mr. Alvarez then files for it,” said Heidi Machen, Myres’ attorney.

DWC Schedules Public Hearing on MPN Regulations

The Division of Workers’ Compensation (DWC) is issuing a notice of public hearing for the Medical Provider Network (MPN) regulations. The proposed rulemaking is to implement Senate Bill 863’s changes to Medical Provider Networks. A public hearing on the proposed regulations has been scheduled at 10 a.m., September 30, in the auditorium of the Elihu Harris Building, 1515 Clay Street, Oakland, CA, 94612. Members of the public may also submit written comment on the regulations until 5 p.m. that day.

The proposed amendments to the MPN regulations modify regulatory definitions, which include a definition of an entity that provides physician network services. The regulations also detail the changes to MPN plan requirements, which include physician acknowledgments, Internet postings of providers, medical access assistants, quality of care, geocoding and MPN disclosure requirements to medical providers. In addition, the regulations set the requirements for MPN approval for a period of four years and the procedural timelines for MPN re-approval.

Regarding compliance and enforcement, the proposed regulations set forth the process for filing a written complaint against an MPN, and the manner to petition DWC for the suspension or revocation of MPN status. Finally, the regulations detail more enforcement actions, establishing additional grounds for the probation, suspension, or revocation of an MPN, and the procedure by which MPNs are reviewed by the Division and assessed administrative penalties.

DWC will consider all public comments, and may modify the proposed regulations for consideration during an additional 15-day public comment period. The notices of rulemaking, text of the regulations, and the initial statements of reasons can be found on the MPN rulemaking page.

EK Health Moves to Larger Facility

San Jose-based EK Health Services Inc., a national workers’ compensation managed care company, has opened its locally based national medical bill review services office in a new, larger site.

Formerly operating at 2081 Arena Blvd. in Sacramento, the local office now comprises 10,000 square feet at 6970 Destiny Drive in Rocklin.

“We reached capacity in our previous location and lacked room for future expansion of staff and services,” said Kerri Lierman, EK Health’s operations vice president.

Employee of Ventura County Sheriff Pleads Guilty in Fraud Case

A Santa Paula woman who worked for the Ventura County Sheriff’s Office has pleaded guilty to four felony counts of workers’ compensation insurance fraud, prosecutors said Wednesday.

Keri Atwood (DOB 09/24/1984), of Santa Paula, entered guilty pleas to four felony counts of workers’ compensation insurance fraud. Michael Atwood (DOB 08/2811976), also of Santa Paula, entered a guilty plea to one felony count of conspiracy to commit workers’ compensation fraud. The case was investigated by the Valencia office of the California Department of Insurance.

Defendant Keri Atwood reported to her supervisors that she sustained an injury to her left ankle. She said the injury occurred when another employee accidentally hit the back of her foot with a mail cart. She was placed on Temporary Total Disability (TTD) status. Over the next several months, Atwood remained on TTD and received over $29,000 in disability pay.

Keri Atwood used crutches or a wheel chair to get to her medical appointments. After her medical appointments, she was seen walking freely without the aid of crutches or a wheel chair. She was also observed engaging in a number of physical activities that she told her treating her physicians she could not perform. Michael Atwood drove Keri Atwood to her doctors’ visits and failed to disclose her true physical condition.

Final SB 863 Interpreter Regulations Now in Effect

The Office of Administrative Law has approved the DWC final version of interpreter services regulations, one of the sections that implemented major reform provisions of Senate Bill 863. The interpreter services regulations went into effect on August 13. The final version of the interpreter services regulations differs from the emergency regulations as follows:

The regulations specify different standards for interpreters based on where services are provided. The first standard applies to interpreters providing services at a hearing, deposition or arbitration; while the second set applies for those interpreting for a medical appointment or medical legal exam.

Interpreting at a hearing, deposition or arbitration:
Interpreters must be certified or provisionally certified to qualify to be paid for interpreter services at a hearing, deposition or arbitration. Names of certified interpreters are listed on the State Personnel Board webpage or the California Courts webpage.

Provisional certification indicates that the individual has been deemed qualified to perform interpreter services when a certified interpreter cannot be present. Provisional certification is made by agreement of the parties, based on a finding by the workers’ compensation administrative law judge conducting a hearing that the individual is qualified to interpret at the hearing, or by an arbitrator conducting an arbitration that the interpreter is qualified to interpret at the arbitration.

Interpreting for a medical appointment or medical legal exam:
Interpreters must be certified, certified for medical treatment appointments or medical legal exams, or provisionally certified in order to be paid for interpreter services at a medical treatment appointment or medical legal exam.

Certified interpreters’ names are listed on the State Personnel Board webpage or the California Courts webpage.

Interpreters certified for medical treatment appointments or medical legal exams qualify through successfully passing the Certification Commission for Healthcare Interpreters (CCHI) exam or by passing the National Board of Certification for Medical Interpreters (National Board). A CCHI certification or credential indicates the name of the interpreter and the language for which he or she is certified to provide interpreter services. The certification procedure is detailed on the CCHI website. CCHI credentials are valid for four years and specify the language the interpreter for which the interpreter is certified. The National Board certification is valid for five years.

Interpreters can also be provisionally certified as an interpreter in this category is the claims administrator has given prior written consent to the interpreter providing services or if the injured worker requires interpreter services in a language other than Spanish, Tagalog, Arabic, Cantonese, Japanese, Korean, Portuguese, and Vietnamese. In this case, the physician may use a provisionally certified interpreter if the record of the medical evaluation documents the need and the language required

Interpreter directories are maintained as follows:
–  Certified interpreters are listed at on the State Personnel Board webpage or the California Courts webpage;
–  Certified interpreters for the purposes of medical treatment appointments and medical legal exams are listed in the registry for Certification Commission for Healthcare Interpreters (CCHI) or National Board of Certification for Medical Interpreters (National Board).

Proof of certification may be requested by the claims administrator and shall be provided by the certified interpreter for the purposes of medical treatment appointments and medical legal exams if the interpreter is not listed on the CCHI or National Board website directory.

Interpreter services FAQs with additional information on the new regulations are posted here.

Supreme Court Sets Oral Arguments in Valdez Case

The California Supreme Court has agreed to review the controversial Court of Appeal decision that allowed unauthorized non-MPN physician reports into evidence. The Court has scheduled oral argument for Wednesday, September 4, 2013, at 9:00 a.m., in San Francisco.

After Elayne Valdez filed a claim for industrial injury, the employer admitted her claim to most of the alleged body parts injured and she was sent for medical treatment to the employer’s MPN, where she was seen by Dr. Nagamoto, who treated her from approximately October 9, 2009 to October 31, 2009. Applicant then began treating with Dr. Nario, a non-MPN physician, upon referral from her attorney.

The WCAB in a split en banc decision ruled that non MPN physician reports are not admissible when the employer has properly complied with MPN regulations. The WCAB reasoned that Labor Code 4616.6 provides: “No additional examinations shall be ordered by the appeals board and no other reports shall be admissible to resolve any controversy arising out of this article” and thus precludes the admissibility of non-MPN medical reports with respect to disputed treatment and diagnosis issues, i.e., “any controversy arising out of this article.”

The Court of Appeal reversed and remanded in the unpublished opinion of Elayne Valdez v WCAB and Warehouse Demo Services

In ruling that non MPN reports are indeed admissible, the Court reasoned that “It does not makes sense, however, to construe section 4616.6 as a general rule of exclusion, barring any use of medical reports other than those generated by MPN physicians. Section 4616.6 states nothing of the sort. If the Legislature intended to exclude all non-MPN medical reports, the Legislature could have said so; it did not.”

Recently enacted S.B. 863 partially addressed this outcome. Effective 1/1/2013 LC 4605 provides that “Any report prepared by consulting or attending physicians pursuant to this section shall not be the sole basis of an award of compensation. A qualified medical evaluator or authorized treating physician shall address any report procured pursuant to this section and shall indicate whether he or she agrees or disagrees with the findings or opinions stated in the report, and shall identify the bases for this opinion.”

Study Says Fearful Doctors Order More Tests

Doctors who are the most worried about malpractice suits are more likely than less fearful colleagues to order extra diagnostic tests and refer patients to emergency rooms, even if the real threat of a lawsuit is low, according to a new U.S. study reported in Reuters Health.

The practice of so-called defensive medicine “is one of those things that everyone knows goes on, but doesn’t know how to control,” said Michelle Mello, senior author of the new analysis and a professor of law and public health at the Harvard School of Public Health in Boston. The problem is a driver of excessive healthcare costs, but tackling it effectively requires a better understanding of what drives defensive medicine, Mello and her colleagues write in the journal Health Affairs.

In earlier research, Mello found that medical liability and defensive medicine accounted for approximately $55.6 billion or 2.4 percent of U.S. healthcare spending in 2008. “It’s an area where we can chip away at healthcare costs without causing pain to the patient, since these are services ordered not primarily because doctors think they’re medically necessary,” Mello told Reuters Health.

Past research has surveyed doctors about their behavior or their level of concern about malpractice, according to Emily Carrier, a senior researcher at the Center for Studying Health System Change in Washington D.C. and lead author of the new study. Other researchers have gauged the amount of defensive medicine in everyday practice by looking at insurance claims, she said.

To get a better sense of the reasons doctors may engage in defensive medicine, Carrier, Mello and their coauthors combined both approaches. The researchers started with a database of 1.9 million Medicare claims for 2008 as well as responses to a survey that same year that asked some 3,400 doctors about their malpractice concerns. Among the Medicare patients in the database, there were 29,000 who had visited an office-based physician that year for one of three complaints: chest pain, lower back pain or headache, but who were not later diagnosed with a serious illness related to that complaint. “The three complaints were chosen, in part, because each could indicate relatively minor problems, but could also suggest more severe and even life-threatening issues that would be likely to trigger testing in a risk-averse provider,” Carrier told Reuters Health in an email.

Based on the survey results, the researchers designated doctors as having a low, medium or high level of concern about malpractice, and then linked those doctors using the claims data to the tests they had ordered for patients. The team found that patients with a headache who saw a physician with a high level of malpractice concern were more likely to receive advanced imaging like a CT scan, than patients who saw a doctor less worried about malpractice. More than 11 percent of the headache patients seen by a physician with a high level of concern got additional services and testing, versus 6 percent of patients seen by a physician with a low level of concern.

Almost 30 percent of patients with lower back pain seen by a physician with high malpractice concern were given additional imaging services, compared with 18 percent of patients who saw a physician with low concern.

For chest pains, however, the less worried physicians were about malpractice, the more likely they were to order a stress test. Stress tests can involve running on a treadmill, or taking medication to make the heart work harder. Carrier said physicians who are already nervous about medical liability might avoid this test and instead choose to admit the patient to a hospital for more evaluation.

The study also found that physicians’ level of malpractice concern didn’t change, even if they were practicing in a state with medical liability reforms like caps on how much money patients can claim in damages. “Even with caps or other reform measures, it’ doesn’t make physicians feel safer,” Mello said. “We are finding that the focus should be on how physicians are feeling – that has real implications for future policies.”

OSIP Launches E-filing Portal for Self-Insured Public Agencies

The Office of Self Insurance Plans (OSIP) launched a new e-filing portal for public self-insured annual reports. This new feature enables public agencies to submit their employer’s annual reports and workers compensation claims totals electronically. Both reports are required by regulation and must be filed annua lly by October 1st.

“This e-filing tool provides a faster, more efficient method for public agencies to meet their requirements for self-insurance,” said Christine Baker, Director of the Department of Industrial Relations (DIR). OSIP is a program within DIR.

A user’s guide is posted online containing detailed instructions on how to access the portal, as well as short cuts for e – filers . The OSIP office also mailed u ser IDs and passwords to the registered contact persons for each agency last week . The e-filing portal can be found here.

Self-Insured Public agencies in California employ approximately 1.9 million employees. One of every eight California workers is employed by a public agency, such as a school district, city, county, police, fire, university, local district or member of a joint power authority.

OSIP is responsible for the oversight and regulation of workers compensation self-insurance within California . OSIP establishes and insures that required security deposits are posted by self insurers in amounts sufficient to collateralize against potential defaults by self-insured employers and groups

Comp Industry Mulls Over Change to ICD-10

ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. The deadline for the United States to begin using Clinical Modification ICD-10-CM for diagnosis coding and Procedure Coding System ICD-10-PCS for inpatient hospital procedure coding is currently October 1, 2014. The deadline was previously October 1, 2013. All HIPAA “covered entities” must make the change.

They might not have to play by all the same rules, but healthcare providers should not forget the impact ICD-10 will have on non-HIPAA covered entities such as workers compensation, nursing homes, and home health agencies. While non-HIPAA entities are not mandated to switch to the new code set on October 1, 2014, the changing tide will sweep them along with the complex transition whether they like it or not. Medical providers should be aware of the struggles of their non-HIPAA partners, especially as the care coordination spectrum expands to include more and more external organizations that may not always be on the same page.

It may seem like those entities that are allowed to stick with ICD-9 would be happy to do so. But in fact, staying with the old code set, which will not be maintained or updated after 2014, might be more trouble than it’s worth. Technically, workers compensation insurance could demand all provider claims to contain ICD-9 codes for as long as they please, but the undue hardship that would place on medical professionals has been deemed too great by some large insurance plans such as the Ohio Bureau of Workers Compensation (OBWC), which is planning to use ICD-10 after the implementation date.

Non-HIPAA entities could also choose to accept ICD-10 codes from providers but crosswalk them back to ICD-9 if they don’t want to upgrade their systems. But the extra work to create accurate and reliable mappings from a very detailed code to a broader ICD-9 one seems a little pointless. “Even though claims professionals don’t have to be immediately fluent in ICD-10, they should be forward-thinking and follow the market in the direction it’s headed,” suggests John Sarich, VP of Strategy for VUE Software in a post for Claims Journal. “It will require some upfront investment, but will ultimately outweigh the lost time that accompanies translating every medical record you encounter.”

And payers such as workers compensation and property and casualty insurance do have a vested interest in the detail and specificity provided by ICD-10, mandate or no. They will spend less time pestering physicians for more and more documentation to validate a claim for an injury, reducing the administrative burden for everyone involved – assuming payer claims processors are properly trained in the new code set and don’t need to return to the provider to ask for clarification.

Insurance industry groups have been planning for the ICD-10 switch alongside their medical peers, with major organizations such as the Work Loss Data Institute and the National Council on Compensation Insurance updating their documentation and handbooks accordingly. But just as medical providers and payers are struggling with the requirements for the complex and costly transition, non-HIPAA entities are also facing challenges.