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Trucking Company Owner Sentenced to 300 Days

A Salinas trucking company owner was ordered to spend 300 days in jail and pay more than $60,000 in fines for falsifying the number of his employees and the scope of their work

Monterey County Superior Court Judge Russell Scott sentenced Ricardo Casillas, 33, on charges of insurance fraud, workers’ compensation fraud and payroll tax evasion, the District Attorney’s Office said.

Casillas owns Desert Express Transportation Lines and Casillas Transportation Services.

Casillas was also placed on probation for 10 years and ordered to pay about $350,000 in restitution to the state Employment Development Department for failing to file payroll taxes, prosecutors said. An insurance carrier is seeking another $108,000 in unpaid insurance premiums.

DWC Changes Panel QME Process to Comply With Nararro Decision

On April 2, 2014, the Workers’ Compensation Appeals Board issued an en banc decision in Navarro v. City of Montebello which invalidated part of QME Regulation 35.5(e) .

In 2009, Ismael Navarro filed an application and claim form alleging a cumulative injury from February 9, 2008 to February 9, 2009 to his back and ear and was evaluated by panel QME J. Yogaratnam, M.D., Then in 2010, applicant filed applications for adjudication with claim forms alleging a specific injury of June 1, 2010 to his back, lower extremities and legs and a specific injury of August 31, 2010 to his back and left leg.

In 2012, defendant petitioned to compel an evaluation of applicant’s two subsequent claims of injury by original panel QME Dr. Yogaratnam, but it did not seek to have applicant reevaluated regarding his previous claim of cumulative injury. Applicant objected. The WCJ found that applicant was entitled to a new panel QME in his specific injury cases and that QME Rule 35.5(e) that seems to require an applicant to return to the original QME did not apply. The WCAB agreed (using a slightly different rationale) and ruled that for subsequently filed claims, an applicant need no return to an original PQME.

Pursuant to the WCAB’s ruling that the applicable Labor Code provisions do not require an employee to return to t he same panel QME for an evaluation of a subsequent claim of injury, the DWC Medical Unit will now issue new QME panels for claims made after an evaluation has taken place. Initial QME panel requests must be submitted using QME Form 106 for represented cases or QME Form 105 for unrepresented cases.

To avoid unnecessary rejection of appropriate requests, in cases i n which additional panels are required in different specialties, parties and attorneys are reminded to use QME Form 31.7

DWC Posts More Proposed Changes to HOPD/ASC Fee Schedules

The Division of Workers’ Compensation (DWC) has posted a first 15-day notice of modification to the proposed hospital outpatient departments and ambulatory surgical centers (HOPD/ASC) fee schedule regulations to the DWC website.

Members of the public are invited to present written comments regarding the proposed modifications noticed in the first 15-day comment period until 5 p.m. on April 28, 2014. The proposed modifications include:

1. Updating the definitions of emergency room visit and surgical procedures to conform to Medicare and HCPCS coding changes.
2. Providing a base facility fee “formula” to give additional clarification regarding the payment methodology for “Other Services” that are determined solely on the non-facility practice expense relative value units.
3. Clarifying that the alternative payment methodology will be inapplicable for dates of service on or after the effective date of the proposed regulations.

The notice and text of the regulations can be found on the proposed regulations page.

Crawford Placed on Top 100 Business Technology Innovators List

Crawford and Company today announced that it has appeared on this year’s InformationWeek Elite 100 – list of the top business technology innovators in the U.S. Crawford is being recognized by InformationWeek for a suite of innovative online and mobile tools that accelerate claims management;. The tools are accessed globally via an online portal called Crawford Desktop.

“We are honored to be recognized by InformationWeek for the sixth consecutive year for our creative development of very effective technology,’ said Brian Flynn, Crawford executive vice president and global chief information officer. ‘Crawford Desktop is a robust, flexible platform and its numerous features contribute directly and measurably to increasing claim processing efficiency.”

Crawford Desktop uses mobile device geo-location to pinpoint the closest most qualified adjuster for a given claim site and claim type. The assignment is then electronically delivered to a qualified adjuster based on location, availability and performance scorecard. The adjuster accepts the assignment, travels to the site and documents each step of the claims management process (including uploading video, images and voice notes) to the Crawford Desktop portal from a mobile device.

The portal may accessed from a variety of mobile devices, including iPads®, iPhones®, BlackBerry® or Android® phones, with the adjuster’s data transferring to Crawford’s claims management system. Another unique feature of Crawford Desktop is the integration of social media into the claims management process, which provides collaboration with clients and Crawford employees, allowing adjusters in the field to solve problems interactively and in real-time.

This is InformationWeek’s 26th year identifying and honoring the nation’s most innovative users of information technology. For 2014, this assessment was narrowed to a more elite 100 organizations. InformationWeek’s Elite 100 research tracks the technology-based investments, strategies, and results of some of the best-known organizations in the country. Unique among corporate rankings, the InformationWeek Elite 100 spotlights the power of business technology innovation. Additional details on the InformationWeek Elite 100 can be found online at the InformationWeek Website.

Bell Gardens Police Officer Convicted in Comp Fraud Case.

A former Bell Gardens police officer accused of filing a false workplace injury claim pleaded no contest in a case alleging he committed workers’ compensation fraud.

Deputy District Attorney Arunas Sodonis of the Healthcare Fraud Division said John Kovacs, 31, pleaded to one felony count of workers’ compensation insurance fraud. Los Angeles County Superior Court Judge Paul Suzuki ordered Kovacs to complete 400 hours of community service and pay a $4,000 fine to the state workers’ compensation fund. The defendant is scheduled to be sentenced on Oct. 2, 2014. Kovacs filed a false workers’ compensation claim for a knee injury he alleged occurred on the job. An internal investigation by his employer, however, revealed that Kovacs suffered the injury during off hours at a physical agility test for the Huntington Beach Police Department.

The case was investigated by the Bell Gardens Police Department and the District Attorney’s Bureau of Investigation

SF Bus Driver Charged With Felonies For Faking Robbery

A San Francisco Municipal Transportation Agency bus driver was charged Monday with allegedly lying about being injured in a 2012 robbery – an attack that authorities said never happened.

The report in SFGate says that Velma Louise Jones, 61, of Vallejo told San Francisco police she was robbed while working a shift on June 1, 2012, prosecutors said. She filed a workers’ compensation claim, saying she suffered head injuries.

But prosecutors said surveillance video from her bus contradicted her story. While three books of transfer tickets were stolen that day, Jones was allegedly taking a break away from the bus during the theft. The San Francisco district attorney’s office said it began investigating the case after being contacted in August by the insurance company dealing with the workers’ compensation claim.

Jones was charged with four felonies: workers’ compensation fraud, filing a fraudulent insurance claim, submitting documents in support of a fraudulent insurance claim and making false statements in connection with an insurance claim. District Attorney George Gascón described Jones as a city employee who “attempted to take a paid vacation from work at the expense of San Francisco taxpayers.”

Daniel Siegel, her attorney, said the case was a misunderstanding. Though Jones was not on the bus at the time of the attack, he said, she was outside it and the man who stole her transfers had shoved her out of the way, knocking her head against the bus. She withdrew her claim, Siegel said, when she “decided it wasn’t that big of a deal.”

Jones, released on $50,000 bail, appeared in court Monday. If convicted, she faces a maximum of eight years in state prison or county jail. She is on paid leave, according to the Municipal Transportation Agency.

Truck Driver Faces Decade In Prison After Jury Trial

Chip Kyle Bolton, 33, of Arizona and formerly of Salinas, has been convicted by a jury of two counts of false/fraudulent statements in order to obtain workers’ compensation benefits, one count of insurance fraud, one count of attempted perjury, one count of perjury, one count of welfare fraud and one count of grand theft, according to Monterey County District Attorney Dean D. Flippo.

The conviction was based upon surveillance footage of Bolton taken at a YMCA when he was exercising and playing sports, after testifying in his deposition that he was not able to perform these activities.

The amount of restitution for the worker’s compensation fraud is approximately $60,000 and for the welfare fraud, approximately $19,000. Bolton was remanded into custody and will be sentenced on May 2 by Judge Russel D. Scot. Bolton’s maximum sentence is 9 years and 10 months and fines for workers’ compensation fraud can be greater than $150,00 or double the amount of the fraud. Additionally, in insurance fraud cases, state law provides restitution be ordered and can include expenses such as attorney’s fees and the cost of the investigation.

Psychiatric AME Must Separately List and Assess Each Claimed Stressfull Event

Jeffrey Fujimoto claimed that he suffered a continuous trauma psychiatric injury while employed as a body technician for Caliber Collision Centers. The parties agreed to use Myron L. Nathan, M.D., as the AME in this case. Dr. Nathan attributed 90% apportionment of the causation of the Applicant’s psychological injury to work-related stress. After a hearing in the case, the WCJ instructed the parties to obtain a definitive report from the AME, regarding factors of causation pursuant to [Rolda v. Pitney Bowes. Inc. (2001) 66 Cal. Comp.Cases 241, 247 (Appeals Board en banc)].”

Specifically the WCJ instructed Dr. Nathan as follows. “[P]lease provide a supplemental report that describes in detail, in accordance with Rolda, all the workplace and all the non-industrial related events and/or issues that combined caused the Applicant’s psychological injury. You are then to assign a percentage of causation separately to each individual work-related and/or non-industrial event(s) and/or issue(s) that, when combined, equal 100% of the causation of the Applicant’s psychological injury. You are not to combine percentages as to any multiple factors and/or issues, either industrial or non-industrial.

It will ultimately be up to me to decide which workplace activities are actual events (i.e., which of the event(s) described by the Applicant happened or not) and whether those events that I have deemed to be actual events are otherwise legitimate, non-discriminatory, good faith personnel actions. Based on this, I can determine if the actual events of employment, if added together, will result in them being the predominant cause (i.e., more than 50%) of the Applicant’s psychological injury and, whether those actual causes were substantially caused (i.e., 35% to 40%) by lawful, nondiscriminatory, good faith personnel actions.” The instruction provided the format for the AME to list and number each industrial and non-industrial event and assign a separate percentage of causation to each numbered event.

In response to the WCJ’s correspondence Dr. Nathan provided a list of 13 separately listed stressful events, and the percentage of causation of each event. After reviewing the evidence, and the 13 item list. the WCJ found that only item number 4 pertaining to a graffiti incident was an “actual event of employment” and this item caused 4% of the psychiatric injury according to the opinion of Dr Nathan. The WCJ issued his Findings of Fact and Order and Opinion on Decision finding that, in accordance with Labor Code § 3208.3(b)(1) and Rolda, that the Applicant did not sustain industrial injury to his psychological system.

The applicant’s Petition for Reconsideration was denied in the panel decision of Jeffrey Fujimoto v Caliber Collision Centers; Hartford Accident and Indemnity Company.

A WCJ is not compelled to blindly accept the testimony of any witness deemed to be untruthful given that he or she is the ultimate finder of fact and is entitled to make his or her own credibility determinations. [Garza v. Workmen’s Comp. Appeals Bd. (1970) 35 Cal. Comp. Cases 500, 505] While the WCAB may reject the findings of a WCJ and enter its own findings on the basis of its review of the record, [Labor Code § 5907] when a WCJ’s findings are supported by solid, credible evidence, they are to be accorded great weight and should be rejected only on the basis of contrary evidence of considerable substantiality. [Lamb v. Workers’ Comp. Appeals Bd. (1974) 39 Cal. Comp. Cases 310, 314]

The multilevel analysis to establish compensability for claims of injury based on personnel actions, in accordance with Rolda v. Pitney Bowes. Inc. (2001) 66 Cal. Comp. Cases 241, 247 (en banc), is as follows:
(1) whether the alleged psychological injury involves actual events of employment, a factual/legal determination;
(2) if so, whether such actual events were the predominant cause (i.e., accounting for 51% or more) of the psychological injury, a determination which requires medical evidence;
(3) if so, whether any of the actual employment events were personnel actions that were lawful, nondiscriminatory and in good faith, a factual/legal determination; and
(4) if so, whether the lawful, nondiscriminatory, good faith personnel action were a “substantial cause” (i.e., accounting for at least 35% to 40%) of the psychological injury, a determination which requires medical evidence.

Having reviewed all of Dr. Nathan’s reports and considering the Applicant’s lack of credibility in his testimony, the WCJ could not conclude that any of the Applicant’s claimed employer actions, except the graffiti were ‘actual events.’

California Economy Report Card – Is Comp Our Only Problem?

The California Workers’ Compensation system is often the scapegoat for the current (and past) statewide dismal business climate. This perception fuels the battle cry for more comp reform. So, let us look at the report card for the first quarter of 2014. Is Workers Compensation costs the singular issue of concern to state citizens? As of April 1st, 2014, according to a story on Breitbart News, California is noteworthy because it has:

  • the third highest workers compensation costs,
  • the most progressive personal income tax schedule,
  • the highest state personal income and capital gains tax rate, and
  • the highest state-only sales tax rate,
  • the fourth highest state and local tax burden in the country,
  • the fourth highest unemployment rate in the nation,
  • the highest poverty rate in the nation,
  • the third highest educational employee pay in the nation with the fourth lowest student test scores in the nation (according to Laffer Associates analysis of U.S. Department of Education NAEP test scores),
  • the most restrictive regulatory burden,
  • the California’s teachers union has been the single largest contributor to political campaigns in California over the past decade ($212 million)–double that of the next largest contributor, also a state government employees union.
  • the seventh highest share of public employee unionization,
  • the highest paid public employees, and
  • the fourth worst highways in the country,
  • the greatest net outflow of state adjusted gross income.

There is a lot of work to improve the problems shown on this report card in order to improve the business climate and the State economy as a whole. Certainly there are more problems other than Workers’ Compensation.costs; This is a very painful report card to digest in 2014 as the rest of the country recovers from the great recession. A singular focus on Workers’ Compensation reform is not the answer.

FDA Approves Painkiller Overdose Emergency Device

Reuters News reports that U.S. regulators just approved a portable device to treat painkiller overdoses that people without medical training can use in emergency situations, a move to combat the rise of deaths from the abuse of opioids, including heroin. The Food and Drug Administration said making the cellphone-sized device with the recovery drug naloxone available for wider use could help save lives as opioid drug overdoses increase. The approval means emergency responders or even family members could have an easy-to-use treatment in cases of suspected overdose of opioids, which include pain drugs like oxycodone, morphine, codeine and hydrocodone as well as heroin. “It’s really an effort to make this very usable,” FDA Commissioner Margaret Hamburg said.

More than 16,000 people die each year from prescription opioid overdose in the United States, according to the FDA and the device’s maker, privately held drugmaker kaleo Inc. Opioid overdoses are mostly tied to those addicted to painkillers and heroin, but they can also happen accidentally in patients using the prescription medicines legitimately to treat pain.

The hand-held device is called Evzio and automatically delivers a set dose of naloxone, a drug ingredient already approved to treat overdose patients that works by quickly restoring breathing. Naloxone is now typically given through a nasal spray or a syringe that must be injected under the skin or into the muscle, and has been limited mostly to medical professionals at hospitals and emergency rooms as well as a growing number of police officers and other emergency responders. The version approved on Thursday is small enough to be carried in a pocket, the FDA said. Relatives and caregivers would still need training and practice on how to use the device, and several doses may be needed to revive someone, the agency added. “Making this product available could save lives by facilitating earlier use of the drug in emergency situations,” Bob Rappaport, head of the FDA division that reviews such products.

Health experts and other advocates trying to combat the effects of drug addiction welcomed the device’s approval in a conference call with the FDA, and some even suggested doctors prescribe it along with initial opioid painkiller prescriptions. But some also worried the injector could cause some people to dismiss the risks of opioid use because an antidote would be easier to access. FDA and other federal drug officials said Evzio was not a substitute for medical care and that it was essential that people who overdose still get quick medical attention.

It was not immediately clear how much the injector would cost or whether health insurance companies, including the government’s Medicare and Medicaid programs, would cover it. The device will require a prescription and will be available at pharmacies this summer, the company said, adding it had not yet set a price. Meghan Ralston of the Drug Policy Alliance advocacy group, expressed concern in a statement about costs and said people should use “whichever form of naloxone is most convenient and affordable for them.” She called on manufacturers to ensure affordability.

A growing number of municipalities have stocked other naloxone treatments and have begun training firefighters, police officers and other emergency medical personnel on how to deliver the antidote. Separately on Thursday, New York Attorney General Eric Schneiderman said the state would equip every law enforcement officer in the state with naloxone to help fight a surge in heroin overdoses. The effort would be funded with $5 million recovered from drug traffickers. Schneiderman cited data from police in Quincy, Massachusetts, which began requiring officers to carry naloxone in 2010. Since that time, the police department has used the drug 221 times and reversed overdoses in 95 percent of those cases. Last week, Massachusetts Governor Deval Patrick, in a speech declaring a public health emergency stemming from the abuse of opioids, said his state would also make naloxone more widely available.