Menu Close

Author: WorkCompAcademy

JPIA Warns City About Interference With Work Comp Claims

The Imperial Valley Press claims that past behavior of City Council members of the city of Calexico has put the city in some hot water with the California Joint Powers Insurance Authority, which issued the city a warning letter earlier this year.

The California Joint Powers Insurance Authority is an organization that provides members with coverage such as liability protection, a workers’ compensation program, property insurance program and more.

In a letter to City Manager Oscar Rodriquez, California JPIA Assistant Executive Officer Norman A. Lefmann wrote, “It has come to our attention that members of the City Council may be inserting themselves into the interactive process for workers’ compensation claims which is inconsistent with good governance.”

The California JPIA periodically reviews members’ risk management practices as part of the authority’s Loss Control Action Plan program. The city was evaluated in June 2009 and the action plan was presented in March 2010. However, “the city has made very little effort in reducing the number of action items,” Lefmann wrote in the letter.

“We believe that good governance is about the City Council largely being policy setting in terms of their actions and concerns and to leave it to the city administration to manage the affairs of the operations, including hiring and firing employees, reviews of workers compensation injuries, how they respond to claims, etc,” Lefmann explained. He did not cite any particular City Council member or specific action but said “when we see that the City Council is interfering with best practices and recruiting a police chief and creating potential divisiveness on who might replace the police chief,” there’s “another concern as potential claims may arise.”

The hiring of Police Chief Pompeyo Tabarez earlier this year was the end of a controversial hiring process that in many ways further divided the council.

Lefmann did say that the city has generally made a good effort to respond to the issues brought up and the city and the California JPIA is moving ahead to work more closely to address these kinds of concerns. Mayor Bill Hodge said Rodriquez has informed the council of the situation and “it has happened because of a series of incidents.”

He specifically cited “a lot of workman’s compensation claims” and the sexual harassment claims filed by council member Maritza Hurtado against councilmen Luis Castro, Joong Kim and Hodge. He said he was “surprised” by the reference to the police chief selection process. “It was an option for us as council people to participate in selection of a new chief which we did but they’re citing that also,” he said.

California JPIA representatives will be meeting with City Council members individually, he said, but added that he’s “not exactly sure what plans are to be carried out.”

DWC Lien Fee Collection System Earns Technology Award

The California Department of Industrial Relations (DIR) announced that the Division of Workers’ Compensation’s Lien Fee Collection System for the Electronic Adjudication Management System (EAMS) has won a 2013 Digital Government Achievement Award.

“This award recognizes our dedicated staff’s use of innovative technology to create efficiencies in California’s workers’ compensation system while implementing the reforms of SB 863,” said DIR Director Christine Baker.

“Allowing the public to access critical services without inconvenience continues to be one of our main goals,” said DWC Acting Director Destie Overpeck. “This award is well deserved. Special thanks to OIS for helping to get this developed and implemented without a hitch.”

The award was presented by the Center for Digital Government, a national research and advisory institute on information technology policies and best practices in state and local government. DIR was honored in the “Driving Digital Government” State Government category for its outstanding implementation of one of the directives in Senate Bill 863.

Among the changes SB 863 made to California’s workers’ compensation system was regarding the filing of liens. SB 863 mandated a fee for certain liens filed after January 1, 2013, and specified that these must be paid electronically. DWC and DIR’s Office of Information Services (OIS) added functionality to the EAMS public information search tool allowing lien filers to file liens and pay fees in one integrated process.

EAMS was developed in 2008 as a seamless case management process for different, but interrelated units of the workers’ compensation system. EAMS also allows external users to file documents over the Web and compiles information that helps move cases through the workers’ compensation court system without delay.

DWC Issues Warning About Interpreter Rules

The California Division of Workers’ Compensation (DWC) issued a notice reminding claims administrators that failure to provide a necessary interpreter at a medical treatment appointment may constitute a failure to provide medical treatment. Examples of a failure to provide medical treatment include a situation where the lack of an interpreter’s services prevents the exam from going forward or inhibits the injured worker’s ability to communicate with the primary treating physician. Such conduct could also result in penalties and/or sanctions against the claims administrator.

The notice goes on to say “It has come to DWC’s attention that some claims administrators are not responding timely to requests for provisional certification of interpreters, and not arranging for other interpreters to attend medical treatment appointments. As a result, some appointments are not going forward as scheduled.”

Labor Code Section 4600(g) provides that injured workers who cannot communicate effectively in English with their primary treating physician are entitled to the services of a qualified interpreter at all medical treatment appointments.

“Qualified interpreters” for purposes of medical treatment appointments may be, but are not required to be, formally certified. They can be provisionally certified by agreement of the employer prior to providing interpreting services. Employers are not required to pay for the services of interpreters who are not formally or provisionally certified.

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). Interpreter services FAQs and information on recently approved interpreter services regulations are posted on DWC’s website.

Juliann Sum New Acting Chief of Cal/OSHA

Christine Baker, Director of the Department of Industrial Relations (DIR), today announced that Juliann Sum will serve as the Acting Chief of Cal/OSHA. Sum will head the Division of Occupational Safety and Health following the resignation of Ellen Widess. Cal/OSHA is a division of DIR.

Widess expressed her appreciation of the men and women of the Division and their commitment to ensuring workplace safety. She will continue as Special Advisor to Director Baker.

Juliann Sum has worked for over 26 years to help workers understand and exercise their legal rights through numerous educational materials, training workshops, and consultation with legal aid groups that assist low-wage and immigrant workers. She joined DIR in May 2012 as a Special Advisor to Director Baker. Sum served at UC Berkeley from 1994 to 2012 as Project Director with the Institute for Research on Labor and Employment, and Consulting Attorney and Industrial Hygienist with the Labor Occupational Health Program. Her extensive experience includes work as an Associate Attorney with the Environmental Law Foundation and Industrial Hygienist and Business Representative with the International Brotherhood of Electrical Workers Local 1245.

Sum earned a law degree (with honors) from UC Hastings College of the Law, a Master of Science degree in environmental health sciences from the Harvard School of Public Health, and a Bachelor of Science degree in biophysics from Brown University.

“Juliann’s focus will be on prevention – strong enforcement, compliance, outreach and education,” said DIR Director Christine Baker. “I thank Ellen for her dedicated service and look forward to her knowledgeable advice in her new role. I am confident that Juliann’s extensive background and experience will further the Administration’s commitment to a comprehensive Cal/OSHA program.”

Five Thousand Dollar Surgery Costs Quarter Million – In Monterey Park!

When it comes to reducing one’s hospital bills, a key factor is location, location, location. A patient who undergoes joint-replacement surgery in Ada, Oklahoma, might receive a $5,300 hospital invoice for services rendered. But, according to an article in The Atlantic Cities, somebody who gets the same operation in Monterey Park, California, could be staring down the barrel of a much huger bill – $223,000, to be exact.

These were the average lowest and highest prices in 2011 for one particular joint-swapping procedure in the United States, according to federal data. They show in stark light how hospitals charge vastly different amounts for almost identical services, a peculiarity of the American healthcare system that Steven Brill wrote about this year in a Time cover story. Brill spent months investigating how hospitals calculate the bills they stick to patients; here’s Time describing one of his findings:

“Hospitals arbitrarily set prices based on a mysterious internal list known as the “chargemaster.” These prices vary from hospital to hospital and are often ten times the actual cost of an item. Insurance companies and Medicare pay discounted prices, but don’t have enough leverage to bring fees down anywhere close to actual costs. While other countries restrain drug prices, in the United States federal law actually restricts the single biggest buyer – Medicare – from even trying to negotiate the price of drugs.”

While some people have taken issue with Brill’s facts, the basic point that hospital pricing is opaque and often unfair is on target. The Centers for Medicare and Medicaid Services seem to be on board with this assessment. After Brill’s article appeared, the centers disgorged a trove of information dealing with what hospitals charged and what Medicare actually paid for 100 common procedures in 2011. The data revealed not just major differences among the states, but local variations as well. Reports Health 2.0: “For example, average inpatient hospital charges for services that may be provided to treat heart failure range from a low of $21,000 to a high of $46,000 in Denver, Colo., and from a low of $9,000 to a high of $51,000 in Jackson, Miss.”

The higher-value hospitals are clumped in the center of the United States. Two of the best-ranked ones hail from Arkansas – the Surgical Hospital in Little Rock and the Physicians’ Specialty Hospital in Fayetteville – followed by medical centers in Villa Rica, Georgia; Grinnell, Iowa; Paola, Kansas; Boise, Idaho; and Wichita.

Some of the lowest-ranked hospitals can be found in California locales like Porterville, Hemet, and Fresno, and in Floridian burgs like Dade City, Fort Myers, and Saint Petersburg, with others in Illinois, Oklahoma, Tennessee, New Mexico and elsewhere:

Lawmakers Back Off Of Medical Board Overhaul

Legislation once seeking major reform of the Medical Board of California was gutted and passed by a key Assembly committee last week

The state agency that regulates doctors is facing sunset review this year, meaning it will cease to exist if lawmakers and the governor don’t reauthorize it.

Senate Bill 304 is a vehicle to make changes and unwind or reauthorize the agency. Initially authored by Sen. Curren Price, it is now carried by Sen. Ted Lieu. Price left office to take a seat on the Los Angeles City Council on July 1. This bill includes numerous provisions related to the Medical Board of California (MBC) that emerged during sunset review of the Board in 2012; The bill as it is now written, extends the Medical Board’s sunset date until January 1, 2018 and makes MBC subject to review by the appropriate policy committees of the Legislature.

Amendments approved Tuesday eliminated a key enforcement reform that would have moved all staff investigating dangerous doctors to the California Department of Justice. The bill now moves investigative staff to Division of Investigation in the California Department of Consumer Affairs, keeping enforcement split between that department and the medical board staff.

The bill was also amended to extend Medical Board operations for four years. Price had threatened to pull the plug on the agency if serious changes were not made.

San Jose Doctor Arrested for Controlled Substances Trafficking

The Medical Board of California’s Prescription Drug Strike Force arrested Dr. Duke D. Fisher at his San Jose office for allegedly prescribing controlled substances without a legitimate purpose.

The probable cause arrest came after the Board received a complaint alleging that Dr. Fisher would prescribe any medication the customer requested in exchange for cash. Multiple undercover operations were conducted. It was found that Dr. Fisher prescribed controlled substances without a legitimate medical purpose and prescribed controlled substances to a customer who admitted to using heroin and methamphetamines.

Fisher was charged with violations of Health and Safety Code sections 11153, prescribing without a legitimate medical purpose, and 11156, prescribing to an addict; and Business and Professions Code section 725, excessive prescribing of drugs.

Fisher has two offices, one in San Jose and one in Monterey, California. His bail is set at $64,000.

Redding Pain Doctor Arrested

Investigators from the Medical Board of California’s Prescription Drug Strike Force along with t he Redding Police Department , arrested Dr. James Gregory White for prescribing drugs without a legitimate purpose, prescribing to a known addict, and excessive prescribing. Dr. White along with his physician assistant , Cheri Hougland , were arrested at his place of business the North Valley Medical Corporation at 473 South Street in Redding, California.

According to a representative from the Medical Board of California, White and Hougland are being charged on nine counts including prescribing a controlled substance without a legitimate purpose, prescribing to a known addict, and excessive prescribing.

After the arrest, the Drug Enforcement Agency, the Office of the Inspector General and the Bureau of Medi-cal Fraud and Elder Abuse served a search warrant on the business and seized medical files. White and Hougland are being accused of aiding and abetting and filing fraudulent claims.

White’s medical license was suspended back in May. The California State Medical Board was asked to revoke White’s license, citing 18 causes for discipline including gross negligence and over-prescribing pain-killing drugs that led to death.

White is a pain doctor who had his license revoked back in 2005 as well for issues surrounding his prescribing practices.

Medical Billing Company Resolves Fraudulent Comp Claims for $3.4 Million

United States Attorney Melinda Haag announced that a billing manager, her billing company, and her son have agreed to pay $1.7 million to settle allegations that they violated the civil False Claims Act in connection with claims submitted to the Department of Labor, Office of Workers’ Compensation Programs (DOL-OWCP).

The settlement resolves a whistleblower lawsuit filed in the United States District Court for the Northern District of California. In July 2012, the United States settled with six other defendants for $3.15 million — Advanced Physical Medicine and Rehab Group Inc. (located in Oakland, Calif. and Rhonert Park, Calif.), Advanced Occupational Rehabilitation, Inc. (located in Oklahoma), Advanced Medicine and Rehabilitation of Texas, Inc. (located in Texas), Advanced Medicine and Rehabilitation of Texas, P.A. (located in Texas), and the two physicians located in Oakland who own these clinics. The remaining three defendants — Farideh Heidarpour, her billing company A.B.C. Billing Inc., and her son Ali Heidarpour (who was also her employee) – will pay an additional $1.7 million.

The United States alleges that, from 2005 through 2008, Heidarpour, her company, and her son submitted or caused to be submitted to DOL-OWCP false claims by the clinics for supplies and services not provided, not supported by medical documentation and/or not medically necessary, resulting in millions of dollars of damages to the United States. The majority of the patients at issue were United States Postal Service (USPS) employees claiming work-related injuries.

U.S. Attorney Haag, said. that “this settlement demonstrates this office’s continued commitment to protecting the federal health care programs from fraud and false claims.”

A physician who formerly worked at the clinic in Texas filed the case pursuant to the qui tam provisions of the False Claims Act. Under those provisions, private citizens, called “relators,” may file lawsuits on behalf of the United States and receive a portion of the proceeds of a settlement or judgment. The relator will receive $323,000 as her share of the government’s recovery from the three defendants. This is in addition to the relator’s share of $598,000 from the earlier settling defendants.

Assistant U.S. Attorneys Sara Winslow and Melanie Proctor handled the matter on behalf of the U.S. Attorney’s Office for the Northern District of California, with assistance from Financial Fraud Investigator Michael Zehr and Legal Assistants Yvette Baird and Kathy Terry. The matter was investigated by DOL-OWCP and the USPS Office of Inspector General.

Skid Row Capper Sentenced to Federal Prison

Estill Mitts, 68, who lives near the Miracle Mile district of Los Angeles, recruited homeless people from the “Skid Row” section of Los Angeles as part of a widespread scheme to defraud Medicare and Medi-Cal by providing unnecessary health services. He was sentenced this week to 18 months in federal prison and ordered Mitts to pay more than $9.8 million in restitution. In sentencing Mitts the federal judge stated that Mitts’ conduct was “fueled by greed to enrich himself,” and “breeds contempt for, leads to a lack of confidence in, and threatens the stability of” the Medicare program.

The Skid Row “capping” — or illegal referral — scheme was discovered in the fall of 2006 after local authorities observed some patients discharged from a local hospital being “dumped” on Skid Row. The patients subsequently reported that they had been paid to go to the hospital.

Mitts “was a ring-leader in a significant, long-term, serious crime that used the homeless as fodder for exploiting the Medicare and Medi-Cal programs,” prosecutors wrote in a sentencing memo filed with the court. Mitts admitted that he received more than $1 million in kickbacks from three hospitals that took in the illegally referred patients from Skid Row.

From 2004 until October 2007, Mitts operated the Assessment Center, a facility on East Seventh Street in downtown Los Angeles that was also known as 7th Street Christian Day Center. “Mitts employed individuals he called ‘stringers’ to recruit homeless people with promises of small payments,” according to the sentencing memorandum. “The Assessment Center was not a medical clinic, but a site that defendant used for the purpose of recruiting homeless Medicare and Medi-Cal beneficiaries for referral to three hospitals — City of Angels Hospital, Los Angeles Metropolitan Medical Center, and Tustin Hospital and Medical Center. Defendant and others working for him would recruit homeless beneficiaries for in-patient hospital admissions whether or not such hospitalizations were medically necessary.”

In relation to the tax evasion count, Mitts admits in the plea agreement that he failed to report more than $479,000 in income in 2005 and more than $620,000 in income in 2006. By failing to report this income, the Internal Revenue Service suffered losses of $349,857.

Mitts pleaded guilty in 2008 to conspiracy to commit health care fraud, money laundering and tax evasion. Mitts’ sentencing was delayed a number of times as he provided assistance to the government’s investigation that has led to 11 defendants being charged and convicted.

Mitts is the latest in a series of defendant to be sentenced in relation to the Skid Row investigation. For example, Robert Bourseau, one of the owners of City of Angels, was sentenced to 37 months in prison, and Dante Nicholson, the director of marketing at City of Angels, who also cooperated with the government in its investigation, was sentenced to one year in prison. Late last year, a doctor who admitted homeless patients to the Tustin Hospital and Medical Center after they had been driven from Skid Row was sentenced to one year in federal prison.