Author: WorkCompAcademy

The Division of Workers’ Compensation (DWC) Acting Administrative Director George Parisotto has appointed Ellen Sims Langille to serve as a member of the Workers’ Compensation Ethics Advisory Committee. The appointment is effective June 1, 2016.

Langille is general counsel of the California Workers’ Compensation Institute (CWCI). She will fill the position of a member of the public representing insurers previously held by Michael McClain of CWCI.

As civil servants, WCALJs are not subject to review by the California Commission on Judicial Performance,the agency responsible for investigating misconduct complaints directed at judges serving on the Supreme, Superior, and Appellate courts. Instead, they are subject to review by the Ethics Advisory Committee. The committee was established in 1995 by Title 8, California Code of Regulations, section 9722.  The committee is independent of the DWC.

The committee reviews all complaints without learning the names of complainant’s or judges, and then makes recommendations to the administrative director and the DWC court administrator. The committee meets quarterly and members serve without compensation.

The regulation provides that the committee must include: three members of the public individually representing organized labor, insurers and self -insured employers; an attorney who formerly practiced before the Workers’ Compensation Appeals Board and who usually represented insurers or employers; an attorney who formerly practiced before the Workers’ Compensation Appeals Board and who usually represented applicants; a presiding judge; a workers’ compensation administrative law judge (WCALJ) or retired WCALJ; and two members of the public outside the workers’ compensation community.

According to the committee’s 2015 annual public report, the EAC considered a total of 38 of the 44 new complaints it received in calendar year 2015, in addition to 6 complaints pending from 2014. Six complaints filed in 2015 are pending ongoing investigation, and six pending complaints were filed after the EAC final calendar meeting for 2015. The EAC also resolved 10 complaints pending ongoing investigation in 2014. The complaints set forth a wide variety of grievances. A large proportion of the complaints alleged legal error not involving judicial misconduct or expressed dissatisfaction with a judge’s decision.

A judicial ethics complaint form and instructions can be found on the forms page of the DWC website .

The Division of Workers’ Compensation (DWC) has added an easy-to-use search tool to help the public find Independent Medical Review (IMR) determinations quickly and efficiently. The DWC IMR search tool is available on the DWC website.

Over 300,000 IMR cases have been decided since the medical dispute resolution process was implemented on January 1, 2013. Following a determination by a physician reviewer, information for each case is posted to the DWC website. The public can use the new tool to search for decisions by case number, date of injury, specialty of reviewer, and/or category of treatment request.

“The DWC IMR search tool allows the public to easily research the database of IMR decisions,” said DWC Acting Administrative Director George Parisotto. “Increased knowledge about the program’s past performance will ultimately lead to a more effective IMR process.”

Each IMR case pertains to one or more requested treatments that were denied, delayed or modified following utilization review (UR). The IMRO’s expert reviewers useevidence-based guidelines contained in the DWC Medical Treatment Utilization Schedule (MTUS) to determine whether to uphold or overturn the UR decision. The rationale for a reviewer’s decision for each requested treatment is provided in the IMR final determination letter.

Maximus Federal Services is the current Independent Medical Review Organization (IMRO) contracted by DWC to conduct IMR.

Maximus is based in Reston, Virginia, and is a publicly-traded for-profit corporation that receives government contracts to provide “business process services” to government health and human services agencies in the United States, Australia, Canada, the United Kingdom, and Saudi Arabia. The company focuses primarily on “operating government-sponsored programs for vulnerable populations, such as Children’s Health Insurance Program (CHIP), Medicaid, health insurance exchanges and other health care reform initiatives under the Affordable Care Act, Medicare, welfare-to-work, and child support services,” according to its annual report.

And Maximus seems to be doing well. For the second quarter of fiscal 2016, Maximus revenue increased 26% to $606.5 million compared to $481.8 million reported for the same period last year. The increase in revenue was attributable to acquisitions that accounted for growth of 15% and organic growth of 13%, principally from the Health Services Segment. The increase in revenue was partially offset by a 2% decline from unfavorable foreign currency translation.

Health Services Segment revenue for the second quarter of fiscal 2016 increased 22% to $330.6 million compared to $270.9 million reported for the same period last year. The Company still expects revenue to range between $2.4 billion and $2.5 billion for fiscal 2016.

CNN reports that America’s addiction to opioid-based painkillers and heroin just got exponentially more dangerous. The most potent painkiller on the market, prescribed by doctors for cancer treatment, is being made illicitly and sold on the streets, delivering a super high and, far too often, death.

The drug, fentanyl, has been around since the 1960s. Its potency works miracles, soothing extreme pain in cancer patients who are usually prescribed patches or lozenges. But an illicit version of the drug is flooding into communities across America, and casual users are finding out that their fentanyl pills and powder are delivering a powerful high that is easy to overdose on. It can even kill. The Drug Enforcement Administration and the Centers for Disease Control say we have another national health crisis on our hands.

Fentanyl, a synthetic and short-acting opioid analgesic, is 50-100 times more potent than morphine. Although pharmaceutical fentanyl can be diverted for misuse, most cases of fentanyl-related morbidity and mortality have been linked to illicitly manufactured fentanyl and fentanyl analogs, collectively referred to as non-pharmaceutical fentanyl (NPF). NPF is sold via illicit drug markets for its heroin-like effect and often mixed with heroin and/or cocaine as a combination product – with or without the user’s knowledge – to increase its euphoric effects. While NPF-related overdoses can be reversed with naloxone, a higher dose or multiple number of doses per overdose event may be required to revive a patient due to the high potency of NPF. [

The latest state statistics on fentanyl-related deaths compiled by the CDC tell a sobering story. It first showed up in deadly doses on the streets in 2007. The DEA traced the illicit fentanyl to a single lab in Mexico and shut it down. Fentanyl drug seizures subsided for a while, but in 2014, they spiked in 10 states. It’s been an uphill battle. Americans are buying it in record numbers, and highly organized drug cartels are spreading it far and wide. What is curious is where the drug or elements to make it originate. Its street nickname is “China White” or “China girl,” offering a hint at where most of it is coming from.

Illicit fentanyl is a bestseller on the streets and a prolific killer. It is so potent that when law enforcement goes in to seize it, officers have to wear level A hazmat suits, the highest protection level made, the same kind of suits health care workers use to avoid contamination by the deadly Ebola virus. “Just micrograms can make a difference between life and death. It’s that serious,” said DEA Special Agent John Martin, who is based in San Francisco. An amount the size of a few grains of sand of fentanyl can kill you. “All you have to do is touch it. It can be absorbed through the skin and the eyes.”

And as far as profits go, the other opioids commonly sold on the streets — heroin, hydrocodone, OxyContin and Norco — can’t even touch fentanyl. Hydrocodone sells for about $30 a pill on the street. A fentanyl pill may look and cost the same but requires only a fraction of the narcotic to give users an even stronger reaction. The DEA estimates that drug traffickers can buy a kilogram of fentanyl powder for $3,300 and sell it on the streets for more than 300 times that, generating nearly a million dollars. Fentanyl is often trafficked through the cartels’ standard maze of routes through Mexico and into the U.S. But sometimes it’s simply ordered on the notorious dark web and shows up straight from China in the buyer’s mailbox.

“They look like what you’re getting from the pharmacy,” forensic scientist Terry Baisz said. She was taken aback by just how much the counterfeit pills look like the ones sold by pharmaceutical companies. After 26 years in the Orange County crime lab, south of Los Angeles, she has never seen anything like what is coming in these days. It worries her. “I was shocked the first time I tested this stuff and it came back as fentanyl. We hadn’t seen it before 2015,” Baisz said, “and now we’re seeing it a lot.” Fentanyl had entered Orange County, and it was killing people.

“It’s so dangerous and so lethal, I had to get involved,” California state Sen. Patricia Bates said. “Two minutes, and you could be in respiratory arrest and be dead. It’s kind of like, get high and die.” Bates knows those details because the fentanyl overdose deaths started racking up in one of the areas she represents, South Orange County. She is trying to push through a bill that would put harsher penalties on high-volume sellers of fentanyl. The bill “will enhance the penalties, by weight,” Bates said. “We’re talking about … catching the big guys, because when you take them out of the food chain, you really do reduce the incidents of the trafficking and what’s available on the streets.” She knows it’s a tough sell in a time when California voters have passed laws to lessen prison sentences for nonviolent offenders. And, of course, there is the matter of prison overcrowding in the state. But Bates is pushing it forward because she is certain this is the next epidemic, similar to what is happening with heroin but more deadly.

The Department of Industrial Relations (DIR) and the Commission on Health and Safety and Workers’ Compensation (CHSWC) announced the reappointment of Martin Brady to the commission, where he has served since 2012.

Governor Brown reappointed Brady as the public employer representative.

CHSWC Commissioners are appointed by the Governor and the Legislature. Labor Code 75 establishes that two of the employer members and two of the labor members of the Commission shall be appointed by the Governor for a total of four members.

Brady has been executive director at the Schools Insurance Authority since 1997, where he was a risk management and prevention manager from 1988 to 1997. He is a director of the California Association of Joint Powers Authority and the California Coalition on Workers Compensation. He earned a Master of Arts degree in physical education from California State University, Fresno.

CHSWC is a joint labor-management body created by the workers’ compensation reform legislation of 1993. CHSWC is charged with examining the health and safety and workers’ compensation systems in California and recommending administrative or legislative modifications to improve their operation. The Commission was established to conduct a continuing examination of the workers’ compensation system and of the state’s activities to prevent industrial injuries and occupational illnesses and to examine those programs in other states.

CHSWC also administers the Worker Occupational Safety and Health Training and Education Program (WOSHTEP), which sponsors workplace health and safety training programs and distributes educational materials on job safety.

This position does not require Senate confirmation.

After a two-week trial in Los Angeles, two doctors were found guilty of federal health care fraud charges for falsely certifying that Medicare patients were terminally ill, and therefore qualified for hospice care, when the vast majority of them were not actually dying. The doctors were found guilty of participating in a scheme related to the Covina-based California Hospice Care (CHC). CHC submitted approximately $8.8 million in fraudulent bills to Medicare and Medi-Cal for hospice-related services.

Sri Wijegoonaratna, known as Dr. J., 61, of Anaheim, who was found guilty of seven counts of health care fraud; and Boyao Huang, 43, of Pasadena, was found guilty of four counts of health care fraud. The two are scheduled to be sentenced on August 15, at which time each will face a statutory maximum sentence of 10 years in federal prison for each count of health care fraud.

“A number of patients admitted to California Hospice Care testified at trial, showing that they did not require end-of-life care,” said United States Attorney Eileen M. Decker. “In fact, only a small percentage of patients later died – notwithstanding the two doctors declaring that they needed hospice care. This scheme is one of many that has victimized public health care programs and, in the end, the taxpayers who fund these important programs. We will continue to investigate these fraudulent schemes, shut down the operations and incarcerate those responsible for stealing from the system.”

Four other defendants who were named in a federal grand jury indictment in September 2014 have pleaded guilty to health care fraud charges and are pending sentencing (except for one defendant who has been accepted into a diversion program). Those other defendants include a Placentia woman who purchased CHC in 2007 and operated the facility after being charged and incarcerated in another health care fraud scheme. Priscilla Villabroza, 70, previously pleaded guilty in December to one count of health care fraud and is scheduled to be sentenced on June 20.

As part of the CHC fraud scheme, Villabroza and her daughter – who was the nominal owner while Villabroza was in custody – paid patient recruiters known as “marketers” or “cappers” to bring in Medicare and Medi-Cal beneficiaries. CHC nurses performed “assessments” to determine whether the beneficiaries were terminally ill and, regardless of the outcome, Wijegoonaratna and Huang certified that the beneficiaries were terminally ill – even though the vast majority of them were not dying. CHC personnel altered medical records in response to Medicare audits to make the beneficiaries appear sicker.

The evidence at trial showed that Wijegoonaratna also recruited patients into the scheme and received tens of thousands of dollars in kickbacks. “Not only did defendant Wijegoonaratna refer beneficiaries to CHC in exchange for illegal kickbacks, but he also created fraudulent diagnoses and falsely certified that the referred beneficiaries were terminally ill, even though the overwhelming majority of CHC beneficiaries were not terminally ill, so that CHC could qualify for reimbursement from Medicare,” prosecutors wrote in court documents filed in relation to the trial. The California Medical Board has revoked Wijegoonaratna’s medical license.

The investigation into California Hospice was conducted by the United States Department of Health and Human Services, Office of Inspector General; the Federal Bureau of Investigation; the California Bureau of Medi-Cal Fraud & Elder Abuse; and IRS Criminal Investigation.