Author: WorkCompAcademy

The California Commission on Health and Safety and Workers’ Compensation (CHSWC) has announced the unanimous election of Commissioner Sean McNally as the Chair of the Commission for 2015.

Mr. McNally, appointed by the Governor to represent employers, is the President of KBA Engineering in Bakersfield, California. He has been certified by the State Bar of California as a specialist in workers’ compensation law. He is a licensed general contractor and serves as a trustee for the Self Insurer’s Security Fund. His community activities include serving on the Board of Directors of the Golden Empire Gleaners and the Board of Trustees for Garces Memorial High School. He is the past Vice President of Corporate and Government Affairs as well as past Vice President of Human Resources for Grimmway Farms.

He is a graduate of the University of the Pacific, McGeorge School of Law and was a partner at the law firm of Hanna, Brophy, MacLean, McAleer and Jensen. He graduated from the University of San Francisco with Bachelor of Arts degrees in English and Theology. Following that, he did graduate studies at Hebrew University in Jerusalem Israel.

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

The DIR has posted a CHSWC Historical Timeline on its website to celebrate the 20th anniversary of the Commission on Health and Safety and Workers’ Compensation. The CHSWC timeline is part of the concurrent celebration of the 100th anniversary of the Division of Workers’ Compensation (DWC), and the 40th anniversary of Cal/OSHA

The Department of Industrial Relations and its Division of Workers’ Compensation posted a progress report on the department’s implementation of Independent Medical Review, one of the most important provisions of Senate Bill 863. Independent Medical Review (IMR) is the medical dispute resolution process that uses medical expertise to obtain consistent, evidence-based decisions.

The “2014 Report on Independent Medical Review” describes the successful implementation of IMR and provides an analysis of data gathered since the process took effect on July 1, 2013. “SB 863 sought to replace a broken medical review process with one where injured workers receive timely care based on the best medical evidence,” said Labor Secretary David Lanier. “Fewer delays and vastly less litigation are better for injured workers and employers. This report shows we are on the right track.”

“Making evidence-based treatment the foundation for decisions about care was a significant change,” added DIR Director Christine Baker. “We are now seeing the tangible benefits of IMR and can expect further improvement to the process.”

Highlights of the report include the following:
1) First year numbers: In 2013, 73,282 IMR applications were filed, of which 22 percent were found to be ineligible; 3,723 IMR determinations were issued and contained on average two treatment requests per decision. IMR upheld 84 percent of UR decisions in 2013.
2) A considerable increase in the number of applications starting in the latter half of 2013 posed challenges to issuing timely determinations. Process changes resulted in IMR decisions being issued in a timely manner by October 2014.
3) Costs: The costs of IMR were reduced by 25 percent in April 2014.
4) Claims data: More than half of workers’ compensation claims as well as IMR applications came from the top 10 claims administrators

Dr. Rupali Das, DWC Medical Director, said, “this report demonstrates the great progress made in resolving medical necessity disputes affecting injured workers.” She added, “DWC will continue to collect information and monitor the results to make ongoing improvements to the program.”

Other findings:
1) Nearly a third of IMR applications as well as workers’ compensation claims originated from the Los Angeles area.
2) Most physician reviewers who provided decisions in 2013 were licensed in California.
3) Physical Medicine and Rehabilitation and Occupational Medicine specialists issued the majority of IMR determinations.
4) IMR decisions were primarily evidence-based and relied on the Medical Treatment Utilization Schedule or other clinical guidelines.
5) Nearly half of IMR treatment requests were for pharmaceuticals, most commonly opioids.

The progress report is posted on the DIR website.

Juliann Sum has been appointed by Governor Brown as chief of the California Division of Occupational Safety and Health (Cal/OSHA). Sum has served as acting Cal/OSHA chief since September 2013. Prior to that, she was a special advisor to Christine Baker, director of the state’s Department of Industrial Relations, which oversees Cal/OSHA.

“I am grateful for the opportunity as division chief to maintain and enhance safe workplaces and practices for workers and employers in California,” says Ms. Sum. “We will continue to consistently enforce Cal/OSHA standards, develop new standards based on scientific data and practical experience, and collaborate with labor and management organizations.”

In 2014, Ms. Sum established a hiring task force to facilitate filling Cal/OSHA vacancies and enabling senior staff at the division to mentor new hires before retiring. She has also strengthened the training of field staff and managers, providing them with core classes in accident investigation, citation writing, case review and legal appeals. During her tenure as acting chief, Ms. Sum also initiated efforts to encourage more immediate correction of workplace safety hazards. Last month she led the division’s effort to finalize and publish specific guidance to protect workers in healthcare settings from exposure to the Ebola virus and other infectious diseases.

Ms. Sum, who joined DIR in 2012 as special advisor, was designated acting chief in September 2013. Previously, she served from 1994 to 2012 as project director with the Institute for Research on Labor and Employment at the University of California, Berkeley, and attorney and industrial hygienist with the Labor Occupational Health Program.

A woman who appeared on the reality TV series “Bridezillas” has surrendered to authorities on 14 felony counts of insurance fraud.

Anita Maxwell, 55, surrendered herself to the Superior Court of California, Division 30 in Los Angeles County on 14 felony counts associated with insurance fraud. A California Department of Insurance investigation revealed that Maxwell, featured in season four of the reality series “Bridezillas”, allegedly submitted fraudulent documents and made false claims to receive more than $40,000 in undeserved workers’ compensation benefits. She was also the only Bridezilla to have been left at the altar.

The department’s investigation began in 2012 after Maxwell claimed she injured her neck, back, and shoulder while assisting a patient as a clinical partner. While out on workers’ compensation, Maxwell allegedly lied to her doctor, denying she had prior injuries to her neck, back and shoulder. The investigation also revealed Maxwell had multiple prior injuries dating back to 1990. Prior to the 2012claim, Maxwell received $20,000 from similar workers’ compensation claims. Upon learning of the prior injuries Maxwell’s doctor said he would have changed the apportionment and disability amounts to reflect the past trauma, lowering her claim to only 25 percent related to her work injury.

In addition to lying about her injuries, Maxwell allegedly submitted false mileage forms for her supposed travel to and from doctors and physical therapy appointments. Surveillance conducted during the investigation showed Maxwell on more than a dozen occasions commuting to her appointments from a different location than the one she reported to her insurer. The fraudulent mileage forms submitted resulted in over $5,000 in undeserved mileage reimbursement.

This case will be prosecuted by the Los Angeles District Attorney’s Office.

A Los Angeles-area physician whose referrals led to more than $1.7 million in fraudulent Medicare billings was sentenced to 24 months in federal prison for his role in a conspiracy to defraud Medicare related to medically unnecessary power wheelchairs and other durable medical equipment.

Charles Okoye, a 52-year-old Carson resident who formerly operated a medical clinic in South Los Angeles, was sentenced by United States District Court Judge Michael W. Fitzgerald, who also ordered the defendant to pay $931,118 in restitution. Okoye pleaded guilty in August and admitted that he referred Medicare beneficiaries to a Gardena durable medical equipment supply company for power wheelchairs and other durable medical equipment (DME). These beneficiaries had been recruited by employees of Adelco Medical Distributors, Inc. and taken to see Okoye for a single, cursory examination, after which Okoye made the referrals to Adelco.

Adelco’s owner, Adeline Ekwebelem, paid Okoye an illegal kickback for every referral, and then billed Medicare more than $1.7 million for providing the DME, which the beneficiaries did not need or want and often never used. Medicare paid Adelco more than $820,000 on those claims. Ekwebelem was found guilty in September of conspiracy to commit health care fraud, health care fraud, and the payment of illegal kickbacks. Judge Fitzgerald is scheduled to sentence Ekwebelem on January 15.

Okoye admitted that he engaged in a similar unlawful arrangement with another DME company, Esteem Medical Supply.

As a result of his guilty plea and conviction, Okoye’s medical license will likely be suspended for at least three years, and he will likely lose his ability to bill Medicare and Medi-Cal for patient services in the future. The investigation into Okoye, Ekwebelem, and others involved with Adelco’s fraudulent scheme to defraud Medicare was conducted by the U.S. Department of Health and Human Services, Office of the Inspector General, and the Federal Bureau of Investigation.