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Sedgwick Maps Out Industry Trends for 2018

Finding alternatives for pain management, expanding autonomous claims processes and controlling the opioid prescription drug crisis are among the workers compensation issues and trends that employers should watch for in 2018, according to a report from Sedgwick Claims Management Services Inc.

Pain management will remain at the forefront of workers compensation industry discussions, and experts say they anticipate that there will be more collaboration between employers, physicians, pharmacists, claims specialists and patients as they move away from long-term drug therapy and test alternatives.

These may include physical therapy, pharmacy management, physician-patient opioid contracts, pain coaching partnerships, behavioral health networks or alternative therapies, Sedgwick said in its Navigating 2018 report, released Tuesday.

Sedgwick also says that the movement toward a whole health approach increases trust and engagement, and places less influence on individual providers in favor of a more holistic, consensus view of treatments and interventions. Under the new norm, centralized support links cross-disciplinary teams, all focused on quality care. More and more employers will be embracing principles of advocacy, empathy and responsiveness within a whole health environment.

The claims process will continue to become more autonomous, meaning on-demand claims adjusting services and smart interfaces that push low-touch claims through the process more efficiently and effectively, according to the report.

Smart interfaces that push low-touch claims through the process more efficiently and effectively are on the horizon. In addition, on-demand claims adjusting services will allow more flexibility and self-sufficiency when facing property claims. The goal: Speeding up the turnaround for high frequency/low severity claims and easing the process for consumers.

Chatbots and avatars will become more prevalent as support and service options for all lines of business; the industry is even seeing potential for these tools as virtual health coaches for workers’ compensation, disability and wellness programs. What are the possible advantages, limitations and liability risks of these cutting-edge virtual assistants?

To avoid getting caught in the compliance web of ERISA, MSA, FMLA, ADA and state requirements, collaboration becomes more necessary between disability, leave of absence and workers’ compensation. We expect regulatory complexity to continue to increase, and fines and litigation to be a looming threat for non-compliance.

Additionally, diversity and inclusion with claims management will be a key issue. With different populations and generations, the industry will need to adapt to address the needs of everyone, according to the report.

Operator of Assisted Living Facilities Cited for Wage Theft

The California Labor Commissioner issued citations totaling $7,137,036 to the operator of six adult care facilities in Los Angeles for wage theft and other labor law violations.

Adat Shalom Board & Care, Inc. was ordered to pay underpaid wages and penalties to 149 former and current employees who provided care to elderly residents 24 hours a day, six days a week. For years, officials say the caregivers were paid less than $3 an hour for their work.

The Labor Commissioner’s Office opened its investigation last June after receiving a report of labor law violations. The investigation uncovered that from July 2014 to July 2017, the caregivers at the six facilities in West Hills were:

– Paid less than the minimum wage for each hour they worked.
– Not paid overtime for working 24-hour shifts, six days a week.
– Not relieved from their duties to take meal or rest breaks.
– Provided pay stubs that withheld key information such as hourly rate of pay and total number of hours worked.

The live-in caregivers were responsible for monitoring and caring for elderly residents and hospice patients, many of them suffering from Alzheimer’s or dementia. The caregivers were paid fixed amounts ranging from $1,500 to $1,800 per month, or $2.40 to $2.88 per hour.

The citations issued against Adat Shalom Board & Care include $2,272,343 for under payment of minimum wages, $1,871,990 in overtime wages, $128,196 for meal period violations, and $2,689,907 in liquidated damages.

When workers are paid less than minimum wage, they are entitled to liquidated damages that equal the amount of underpaid minimum wages plus interest.

In addition to the money for the workers, $174,600 in civil penalties were levied for nonpayment of overtime and minimum wages, meal period violations as well as for failing to provide workers accurate itemized wage statements with their paychecks. The civil penalties collected will be transferred to the State’s General Fund, as required by law.

Visalia Public Employee Says Arrest was “Retaliation” for Comp Claim

Authorities arrested former Visalia Public Cemetery manager Dona Shores last month on charges of embezzling and laundering as much as $1.3 million over a five-year period between July 1, 2011, and June 30, 2016.

Shores was arrested on Dec. 22 on suspicion of embezzlement and money laundering charges after a year-long investigation by Visalia Police.

Attorney Kris Pederson, who represents the Visalia Cemetery, said she now believes the embezzlement dates back to 2005 when a new accounting system was adopted – and that more than $1.3 million was stolen.

Pederson said Shores was getting ready to retire at the end of 2016. Ahead of her retirement, Shores handed in the cemetery’s accounting books and a forensic audit revealed the allegedly missing funds, she said,

Shores, who managed the Visalia Cemetery for nearly 20 years, was fired in late 2016 before she could officially retire.

Citing the forensic audit’s findings, Pederson said cash funds had been recorded as received by the district for services, but the money was never deposited into the cemetery’s bank account.

Earlier this week, Shores appeared before Tulare County Superior Court Judge Brett Alldredge. During the quick hearing, Shores spoke only once, saying she agreed to a delay on the court procedures.

Attorney Charles Magill, who’s representing Shores, denied all charges. “I believe there’s a government conspiracy against Ms. Shores,” he said. “I believe it’s politically motivated.” Magill, whose office is in Fresno, said the conspiracy against Shores includes the Visalia police officers investigating the case.

Magill said Shores’ arrest was retaliation for a workers’ compensation case the former manager has filed. Shores was injured on the job when she was struck by a vehicle, Magill said.

Magill also lamented Shores’ arrest timing. “There’s no reason to arrest her on the Friday before Christmas,” Magill said. “She spent Christmas in jail. That was punitive.”

There’s also no evidence that proves the embezzlement, Magill said. “At no time was her accounting ever out of balance,” he said. “They have no evidence of money she received. Where’s the money?”

Magill plans to have a new forensic accounting investigation into the cemetery’s finances to help clear his client. “I will try this case and then sue the board, the cemetery and the county for malicious prosecution,” he said.

Proposed Law Expands Scope of Employment

Day laborers in California hired on a one-time basis would be covered by the state’s workers compensation laws under amendments to a year-old bill intended to extend coverage to more workers.

A.B. 206, introduced by Assemblywoman Lorena Gonzalez Fletcher, D-Chula Vista, in January 2017, was amended Thursday to include workers comp coverage mandates for a “person, including a day laborer, employed by the owner or occupant of a residential dwelling whose duties are incidental to the ownership, maintenance, or use of the dwelling, including the care and supervision of children, or whose duties are personal and not in the course of the trade, business, profession, or occupation of the owner or occupant,” according to the latest draft of the bill.

The draft defines a day laborer as “a person who is directly hired by the home owner or occupant on a one-time basis, to perform general maintenance, repairs, upgrades, gardening, or landscaping, and who does not have a valid business license or contractor’s license, or is not required to have those licenses for the work performed.”

This requirement would apply without regard to immigration status, according to the draft.

According to the Legislative Analysis, the proposed bill expands the definition of “employee” for workers’ compensation purposes thereby expanding the scope of standard homeowners’ insurance policies. Specifically, this bill deletes from the definition of “employee” the exclusion of workers who work for a homeowner for less than 52 hours in a 90 day period.

According to the author, “the 52 hour requirement is detrimental to day laborers because they are usually hired to work for short-term jobs. This outdated provision in the workers’ compensation system prevents legitimate day laborers who are injured on the job from obtaining workers’ compensation benefits because these workers are specifically defined as not ’employees.’ AB 206 is designed to remedy this anachronism in the law. “

There are a range of people who perform work in various contexts who are not eligible for workers’ compensation benefits because they are defined as “not employees.” One such group is excluded because the work they perform is covered by the “52-hour” rule in the Labor Code.In essence, this exclusion provides that certain workers are simply, as a matter of definitional law, “not employees” for workers’ compensation purposes..

By merely deleting the 52-hour rule, a fairly large actual list of workers, would now be “employees” eligible for workers’ compensation benefits. The Legislative Analysis points out that this would include the teenager you hire to mow your lawn; the high school girl who babysits twice a month for you and the man who congregates in the Home Depot parking lot who is hired on a 1 or 2 day basis by a roofing contractor; and the tax preparer who works in tax season out of her home, and who is hired from a Craigslist ad.

City of L.A. Files Misclassification Lawsuit in Port Trucking Dispute

The City of Los Angeles sued three port trucking companies Monday, alleging the firms exploit their drivers by misclassifying them as independent contractors.

The City alleged that CMI Transportation, K&R Transportation California and Cal Cartage Transportation Express have engaged in schemes to avoid paying minimum wage and employee benefits by classifying hundreds of workers as independent contractors even though the companies “exert near complete control” over the drivers’ schedule.

According to the report in the Los Angeles Times, all three companies are owned by NFI Industries, a New Jersey-based logistics firm. NFI purchased the businesses from Long Beach-based California Cartage in October.

The suits are the latest in a long-running dispute at the twin ports of Los Angeles and Long Beach, where many port truck drivers say they are improperly classified as independent contractors and must lease their rigs under unfair terms.

The terms, they say, are so onerous that for some pay periods they make nothing and actually end up owing the trucking company money.

A large part of the problem, the lawsuits say, are lease programs the companies established to comply with 2008 city rules mandating low-emission trucks be used to deliver goods to and from the ports of Los Angeles and Long Beach.

The city attorney alleged the leases place strict requirements on how many loads must be undertaken for the company, essentially chaining a so-called independent contractor to one firm.

At the end of the leases, the lawsuits allege drivers do not own their truck but are given an opportunity to purchase it for a “significant lump sum.” That leads many drivers to refinance the lease, once again binding the worker to one company.

Last decade, the Port of Los Angeles tried to mandate truckers be employees of companies, fearful that workers couldn’t afford the newer, cleaner rigs. But that mandate was struck down by federal courts, a decision that driver advocates blame for exacerbating an existing problem of abusive leases.

Though ongoing for years, the issue received renewed attention following a series of stories last year in USA Today.

In December, the Los Angeles City Council approved a plan to investigate claims of wage theft by port truck companies and look into whether the city could deny port access to companies in violation of labor laws.

Asked why the suit was filed against the three NFI companies when drivers allege misclassification among many operators, the City Attorney said his office is investigating “additional companies as well.”

Since 2011, the California labor commissioner’s office has awarded port truck drivers more than $46 million in cases where they contended they were misclassified as contractors.

Drivers and the Teamsters union have also organized numerous strikes to put pressure on trucking companies, as well as politicians.

Allianz Invests $59M in Digital Telehealth Platform

Allianz has agreed to a $59.2 million investment and strategic partnership with leading telehealth platform American Well to develop digital solutions that will widen access, lower cost and improve quality of healthcare for millions of patients worldwide.

Allianz X, the digital investment unit of Allianz, led the investment and will join American Well’s Board of Directors.

Allianz and American Well will develop digital health solutions that build on American Well’s platform and leverage Allianz’s international expertise by combining wearable sensors, remote monitoring, and virtual visits. Working with local healthcare stakeholders, the partnership will deliver healthcare to both developed and emerging markets, addressing local regulations, clinical preferences and financing choices.

This global telehealth system will allow providers to treat patients more successfully in the transforming world of connected care.

Boston-headquartered American Well has developed a telehealth platform that connects patients live with doctors, specialists and other healthcare providers over secure video. It handles clinical, administration, and security requirements consistent with US healthcare regulations and best practices.

American Well serves millions of patients, working with national health plans, hospitals, employers and pharmacies in the United States.

Allianz X, led the investment and was supported by the Health Innovation Center of Allianz Partners, the B2B2C unit of the Allianz Group dedicated to developing protection and care solutions.

Allianz has local knowledge of healthcare financing, regulation and delivery, and a qualified network of more than 800,000 medical providers across the world.

The joint effort of Allianz X and Allianz Partners should enable Allianz to deliver the greatest value from Allianz to American Well and strengthens the Group’s ability to provide best-in-class healthcare in a mobile, digital world.

“Allianz X’s investment with American Well will result in better access, lower cost and more connected care for our customers through a leading-edge health platform. This collaboration emphasizes Allianz’s commitment to digitalization, our goal of investing in digital frontrunners and encourages advancements within the whole healthcare ecosystem,” said Solmaz Altin, the Chief Digital Officer of Allianz Group.

Insurance Broker Sentenced for Stealing Comp Premiums

Former licensed insurance agent Frederick Donald Rollins, 42, of Moreno Valley, was sentenced after pleading guilty to one felony count of grand theft, two counts of securities fraud and an aggravated white-collar crime enhancement for stealing more than $100,000 in insurance premiums and investment funds from 10 victims. Rollins has been sentenced to one year in custody and to pay $100,363 in restitution to his victims.

The California Department of Insurance launched an investigation after receiving multiple complaints, including one from an insurance carrier after a company attempted to file a claim for its injured employee under what turned out to be a non-existent policy number and the other from a business owner who discovered they had no legitimate workers’ compensation or liability coverage.

The investigation revealed that Rollins, while working as a licensed agent at an insurance agency, collected premium payments from several clients for workers’ compensation and commercial general liability coverage, but failed to place coverage with any insurance carrier.

After leaving that insurance agency, Rollins continued to sell fraudulent policies under a corporation he registered with the Nevada Secretary of State, but never licensed by the California Department of Insurance. The investigation revealed over $20,000 in premium payments Rollins collected from his victims, either made payable directly to him or to FDR Presidential Services, were spent on personal expenses and not forwarded to insurance carriers to obtain insurance coverage.

To conceal the scheme, Rollins issued false Certificates of Insurance, which listed the names of valid insurance carriers as the insurance providers of the fraudulent policies.

In addition to collecting premium payments for policies that were never placed, Rollins also allegedly presented himself as a registered stockbroker and accepted funds for investments from several victims. Rollins collected nearly $80,000 from various individuals, including insurance clients, under the guise that he was investing their money in stocks.

The Financial Industry Regulatory Authority, a non-governmental organization that regulates stockbrokers and brokerage firms, verified that Rollins has never been licensed in any capacity to act as a stockbroker.

Rollins is no longer licensed as he failed to renew his license after it expired in March 2014. The Department of Insurance is taking appropriate administrative action against Rollins’ license. The case was prosecuted by the Riverside County District Attorney’s Office.

So. Cal. DME Suppliers Arrested in $24M Fraud

The operator of two now-defunct medical supply companies in Hawthorne and Ventura, as well as two former employees, have been arrested on federal healthcare fraud charges for allegedly billing Medicare well over $24 million for medically unnecessary power wheelchairs (PWC) and the repair of medical equipment.

The scheme is outlined in a 29-count indictment that was returned by a federal grand jury on December 14. According to the indictment, Tamara Yvonne Motley operated Action Medical Equipment and Supplies, which was based in Hawthorne until 2014, and Kaja Medical Equipment & Supply, which was based in Ventura until late 2016. Motley allegedly orchestrated a scheme in which corrupt physicians prescribed medically unnecessary durable medical equipment (DME), such as PWCs, and Motley oversaw the submission of fraudulent bills to Medicare.

In January 2011, when Medicare changed the reimbursement rules for PWCs, Action largely stopped Medicare billing for PWCs and, instead, started billing Medicare for PWC repairs. Action and Kaja allegedly submitted bills for PWC repair or replacement services that were not medically necessary, were not needed to make the PWCs serviceable, and often simply were not performed. The majority of bills submitted in this case allegedly involve fraudulent repair work.

According to the indictment, over a nearly eight-year period, Action billed Medicare more than $18.2 million for DME – most for PWCs, but also for PWC accessories, knee braces and back braces – and the repair or replacement of PWCs. Medicare paid Action nearly $10.3 million.

Between July 2013 and November 2016, Kaja billed Medicare $6.3 million for PWCs, PWC-related accessories, and the repair or replacement of PWCs. Medicare paid Kaja approximately $2.8 million for those claims, the indictment alleges.

The indictment charges all three defendants with 20 counts of healthcare fraud and one count of conspiring to launder money.

Motley and Marquez are further charged with two counts of aggravated identity theft in relation to the use of other persons’ names to operate the medical supply companies. Motley is additionally charged with six counts of structuring cash transactions to avoid federal reporting requirements for transactions of more than $10,000.

If convicted, each of the three defendants would potentially face decades in federal prison. Each count of healthcare fraud carries a statutory maximum sentence of 10 years in federal prison.

All three defendants entered not guilty pleas to the charges in the indictment and a trial was scheduled for February 13. A United States Magistrate Judge set bond for Motley and Murillo, and Marquez was ordered detained.

Cal/OSHA Fines Employer $31K for Bee Sting Fatality

Cal/OSHA has issued citations to Hadley Date Gardens Inc. of Thermal for serious workplace safety and health violations following a bee swarm that stung and killed a tree worker.

On July 3, 2017, a tree worker, Gerardo Balbuena, 49,  was spraying water on date palm fruit from the elevated bucket of a spraying rig when a beehive was disturbed. The bees repeatedly stung the worker, who suffered anaphylactic shock and died at the site.

After he was attacked, Balbuena went into cardiac arrest, said Tawny Cabral, a spokeswoman for the Riverside County Fire Department. He was pronounced dead at the scene.

Balbuena, a native of Morelos, Mexico, worked at Hadley Date Gardens for 27 years, said Albert P. Keck, the company’s president. He said Balbuena was a talented and hardworking employee with a loving family. “He is an immigrant that we should be very proud of as Americans,” Keck said.

Keck said he has been working alongside Balbuena since his family acquired the gardens. He recently told Balbuena they were “going to grow old together.”

“Recognized workplace hazards for tree workers include bee and other harmful insect exposure,” said Cal/OSHA Chief Juliann Sum. “Employers must identify and evaluate workplace hazards, and provide appropriate personal protective equipment and effective training to their workers.”

Cal/OSHA issued four citations totaling $41,310 in proposed penalties for workplace safety and health violations, two of which were classified as serious accident-related.

Hadley Date Gardens, Inc. failed to evaluate the worksite for hazardous bee and insect exposure, and failed to establish appropriate safety protocols, which include providing appropriate personal protective equipment and training that could have prevented this incident.

Cal/OSHA’s Tree Work Safety guidelines specifically cite bee stings as a potentially fatal hazard of which employers must be aware.

“Legal” Medical and Recreational Marijuana – or Maybe Not

The U.S. Justice Department on Thursday will rescind a marijuana policy begun under Democratic former President Barack Obama that eased enforcement of federal laws as a growing number of states and localities legalized the drug, a source familiar with the matter said.

The Obama-era policy, outlined in 2013 by then-Deputy Attorney General James Cole, recognized marijuana as a “dangerous drug,” but said the department expected states and localities that authorized various uses of the drug to effectively regulate and police it.

Going forward, federal prosecutors around the country will have deference to enforce U.S. laws on marijuana as they see fit in their own districts, added the source, speaking on condition of anonymity.

The upcoming policy change comes just days after California formally launched the world’s largest regulated commercial market for recreational marijuana.

Besides California, other states that permit the regulated sale of marijuana for recreational use include Colorado, Washington, Oregon, Alaska and Nevada. Massachusetts and Maine are on track to follow suit later this year.

The policy being reversed had sought to provide more clarity on how prosecutors would enforce federal laws that ban marijuana in states that have legalized it for medicinal or recreational use. Its rescission could sow confusion and potentially hamper efforts to cultivate local marijuana businesses.

U.S. Attorney General Jeff Sessions has made no secret about his disdain for marijuana. He has said the drug is harmful and should not be legalized. He also described marijuana as a gateway drug for opioid addicts.

A task force created under a February 2017 executive order by Trump and comprised of prosecutors and other law enforcement officials was supposed to study marijuana enforcement, along with many other policy areas, and issue recommendations.

Its recommendations were due in July 2017, but the Justice Department has not made public what the task force determined was appropriate for marijuana.

Sessions and some law enforcement officials in states such as Colorado blame legalization for a number of problems, including drug traffickers who have taken advantage of lax marijuana laws to illegally grow and ship the drug across state lines, where it can sell for much more. The decision was a win for marijuana opponents who had been urging Sessions to take action.

“There is no more safe haven with regard to the federal government and marijuana, but it’s also the beginning of the story and not the end,” said Kevin Sabet, president and CEO of Smart Approaches to Marijuana, who was among several anti-marijuana advocates who met with Sessions last month. “This is a victory. It’s going to dry up a lot of the institutional investment that has gone toward marijuana in the last five years.”