Author: WorkCompAcademy

The WCIRB has completed its report on workers’ compensation insurer loss and premium experience through December 31, 2014. This report is based on data reported to the WCIRB by insurers who wrote almost 100% of the statewide market.

The major findings of the report include:

1) California written premium for calendar year 2014 is approximately $16.5 billion – approximately 11% above the written premium reported for 2013 and 88% above the written premium reported for 2009.
2) The projected industry average charged rate per $100 of payroll for 2014 is $2.93. This is approximately 2% above the average rate charged for 2013 and 40% above the average rate charged for 2009. However, the average rate charged for 2014 remains approximately 53% less than the average rate charged for the second six months of 2003.
3) The WCIRB projects total ultimate losses and allocated loss adjustment expense (ALAE) for accident year 2014 to be $12.6 billion. While approximately 4% above the projection for accident year 2013 and 27% above the projection for accident year 2009, it remains below the highs experienced prior to the 2002 through 2004 reforms.
4) The WCIRB projects a preliminary ultimate accident year combined loss and expense ratio of 103% for 2014. Of this, 61% is attributable to the indemnity and medical loss ratio and 42% is attributable to the loss adjustment and other expense ratio. Like the projected 2014 loss and ALAE ratios, this projection is primarily a result of increased premium levels and relatively low claim severity growth in 2014.
5) The preliminary calendar year combined loss and expense ratio for 2014 reported by insurers is 105%, which is somewhat below the combined ratios for the last several years, but 2014 is the seventh consecutive year with a combined ratio over 100%.
6) The WCIRB projects indemnity claim frequency for accident year 2014 to be 1.2% above the frequency for 2013 and approximately 12% above the frequency for 2009. The frequency increases experienced over the last few years are largely attributed to increases in cumulative injury claims, late reported indemnity claims, claims involving injuries to multiple body parts, and claims originating in the Los Angeles area. See related report, Analysis of Changes in Indemnity Claim Frequency – January 2015 Update Report in the Research and Analysis section of the WCIRB website (www.wcirb.com).
7) The WCIRB projects the average severity of a 2014 indemnity claim to be approximately $84,000, which is generally consistent with the projected severities for the last several accident years.
8)The WCIRB currently projects the total statewide ultimate losses on all injuries that occurred on or before December 31, 2014 to be approximately $6.8 billion more than the amounts reported by insurers. These estimates are somewhat below those presented in recent prior summaries as a result of favorable loss development experienced in recent quarters.

The full report is available in the Research and Analysis section of the WCIRB website (www.wcirb.com).

United States Attorney Melinda Haag and United States Postal Service-Office of Inspector General Special Agent in Charge Eileen Neff announced that bay area psychologist Helena Weil was sentenced to four months in prison and ordered to pay restitution of $496,101 related to her submission of billings to the federal Office of Workers’ Compensation Programs (OWCP). Weil, 64, of Kensington, California, pleaded guilty on July 2, 2014, to one count of 18 U.S.C. § 1519, which prohibits alteration or falsification of records.

Weil was a psychologist licensed to practice by the State of California and maintained a practice in the San Francisco Bay Area. She treated numerous U.S. Postal Service and other U.S. Government employee-patients for which she was compensated through the OWCP, which administers Federal Employee Compensation Act programs. Weil was required to submit bills truthfully setting forth (a) the Current Procedural Terminology (“CPT”) codes corresponding to the services she provided to the patients, (b) the names of the U.S. Postal Service and other U.S. Government employees for whom she was providing services; and (c) the date of those services.

Psychologist Weil admitted that on various dates between approximately March 2006 and December 2009, she submitted bills to the OWCP related to in-person services she supposedly provided to patients while she either was away from California or was in training. In all, Weil admitted that she submitted over 1,100 such billings. The amount of these billings exceeded $175,000. Weil was charged in an information filed on May 23, 2014, and she formally waived indictment on May 29, 2014. The information charged her with one count of alteration or falsification of records in violation of 18 U.S.C. § 1519.

In addition to agreeing to pay restitution for the $175,174 in billings at issue in the information, Weil also agreed under the terms of the plea agreement to pay civil restitution to the United States for (1) $136,529 in billings she made to the OWCP on various other dates in 2008 and 2009 on which she did not provide in-person psychological services and (2) $184,398 in billings to the OWCP in which she improperly billed CPT codes. The four-month prison sentence was handed down by the Honorable Charles R. Breyer, U.S. District Judge. Judge Breyer also sentenced the defendant to a three-year period of supervised release. The court ordered that the first six months of Weil’s supervised release will be served in home detention. The defendant was ordered to begin serving the sentence on July 24, 2015.

Assistant U.S. Attorney Kyle F. Waldinger is prosecuting the case with the assistance of Jessica Meegan. The prosecution is the result of an investigation by the United States Postal Service-Office of Inspector General.

The California Board of Psychology online records reflect that she continues to hold a license in psychology with no pubic record actions pending against her.

Doctors in California’s workers’ compensation system are required to provide evidence-based medical treatment. That means they must choose treatments scientifically proven to cure or relieve work-related injuries and illnesses. When evidence based medicine became the standard in California Worker’s Compensation it started with the American College of Occupational and Environmental Medicine (ACOEM) Guideline. The California use of the ACOEM Guideline evolved by the addition of missing components to what is now known as the Medical Treatment Utilization Schedule (MTUS).Today, approved treatments are laid out in the Medical Treatment Utilization Schedule (MTUS), which contains a set of guidelines that provide details on which treatments are effective for certain injuries, as well as how often the treatment should be given, the extent of the treatment, and for how long, among other things. The MTUS is based in part on the ACOEM Guidelines.

The improvements to the MTUS are made over time by the DWC rule making process. The Office of Administrative Law has just approved the Division of Workers’ Compensation’s (DWC) final version of the Medical Treatment Utilization Schedule (MTUS) amended regulations. The MTUS regulations went into effect April 20, 2015.

“These regulations will clarify the process to be used to evaluate medical evidence and are required to be applied when there are competing recommendations and a dispute about which recommendation shall guide the injured worker’s medical care,” said Dr. Rupali Das, DWC Executive Medical Director. “The clarity will allow treating physicians, reviewing physicians and claims administrators to make better informed decisions and should reduce disputes over medical treatment.”

The new MTUS regulations include:

1) Clarification of the role of the MTUS as the primary source of guidance for treating physicians and physician reviewers for the evaluation and treatment of work-related illness or injury, and that the MTUS constitutes the standard of care for the provision of medical care in accordance with Labor Code section 4600.
2) A description of the two limited situations that may warrant treatment based on recommendations found outside of the MTUS: (1) if the medical condition or injury is not addressed by the MTUS, or (2) if the MTUS’ presumption of correctness is successfully rebutted.
3) Guidance in how to conduct a search for medical evidence in order for treating physicians and reviewing physicians to consistently and efficiently navigate the vast array of medical literature.
4) Requirements for treating physicians and reviewing physicians to properly complete and document Requests for Authorizations, Utilization Review Decisions and Independent Medical Review Decisions as it relates to the medical evidence that the physician believes guides the reasonableness and necessity of the requested treatment.
5) The methodology that shall be applied by reviewing physicians to evaluate the quality and strength of evidence used to support competing recommendations. 6) An amendment to the composition of the Medical Evidence Evaluation and Advisory Committee to include two additional members, one from the pharmacology field and one from the nursing field.

The final regulations are posted on the DWC website.

An indictment charged a Valencia doctor and former Workers’ Compensation toxicology expert with operating a $6.5 million scheme to defraud the Medicare program by billing Medicare for medical services that were not actually provided. Gary J. Ordog M.D., 60, was indicted by a federal grand jury for nine counts of health care fraud. Some of Ordog’s history and reputation was featured in a 2005 Forbes “Dr. Mold” article..

Ordog allegedly assisted beneficiaries with various toxicological symptoms, including those related to mold and chemical exposures. Ordog would allegedly see a beneficiary at least once in connection with the potential evaluation and management of his or her conditions. Subsequently, often several years after the last time he saw a particular beneficiary, Ordog would allegedly submit false claims to Medicare for purported additional visits with the same beneficiary, when the visits never actually occurred. In certain instances, Ordog allegedly billed Medicare for services provided to beneficiaries who were deceased as of the claimed date of service.

This is not his first brush with regulators. According to public documents posted online by the Medical Board of California, Ordog’s medical license was suspended for 90 days in 2006 and he was placed on seven years of probation following accusations of gross negligence and dishonesty. The Factual Findings in that case indicate that Ordog established a medical-legal practice, offering himself as an expert witness in a variety of legal settings, in 1980. He evaluated civil, criminal and workers’ compensation cases for attorneys representing both plaintiffs and defendants, and for insurance companies. He has testified in deposition and trial more than 100 times.

The 2006 Accusation under the topic of “Quality of Care” reviews the cases of four patients referred in 1999 by a Long Beach attorney named Eric Hoerchner for evaluations of workers’ compensation claims his clients made against their employer, ALCOA Vernon Works, in Vernon, California. Each of the patients claimed a compensable on-the-job injury due to exposure to toxic substances. After a careful review of his examination and findings, the Administrative Law Judge concluded “Taken together, respondent’s diagnoses of toxic encephalopathy and neuropathy, bacterial sepsis, multiple viral, fungal and bacterial infections, chronic fatigue syndrome and fibromyalgia were not medically indicated and represented extreme departures from the standard of practice and gross negligence. The departures are deemed extreme departures due to the lack of any colorable, documented indications for their rendering.”

The 2006 Accusation also included a section on “Allegations of Dishonesty” and this section indicated that Ordog provided expert witness services for many plaintiffs who claimed to have suffered personal injury due to exposure to toxic substances, including molds. In one of his forensic cases involving the Gelderbloom family, he authored a letter which was introduced into evidence in a jury trial over which Superior Court Judge Barbara Scheper presided. Judge Scheper was the individual who referred this case to the MBC as a result of her concerns of possible insurance fraud. Ordog later admitted in a deposition that this letter was a form letter that he signed but may not have read. He also admitted that his patients were improving by March 8, 2002, contrary to the content of the letter. The Administrative Law Judge found “Respondent committed a dishonest or corrupt act in connection with the March 8, 2002 letter he provided in the Gelderbloom matter. Taken alone, the letter might be dismissed as merely careless. But in the context of respondent’s other transgressions, all committed in furtherance of his medical-legal practice, the form letter cannot be dismissed as a mere oversight. Moreover, the letter contains misrepresentations that had significance to his patients’ health management and represented a corruption of the legal system.”

Ordog indicated at times in testimony that he was co-author of the medical school textbook, Ellenhom’s Medical Toxicology: Diagnosis and Treatment of Human Poisoning, first published in 1988. However at the hearing, “Mrs. Sylvia Ellenhorn testified credibly in this hearing that she had, indeed, typed all of the Second Edition from her husband’s handwritten text. She sent “hard copies” of her work product to the publisher and never dealt with respondent at all.” The Administrative Law Judge found “By clear and convincing evidence, respondent was guilty of dishonesty on multiple occasions regarding his claim of authorship of Ellenhom’s text.

Ordog was placed on probation in 2006 by the Medical Board. One of the terms of his probation said “Respondent shall be prohibited from engaging in a medical-legal or forensics practice of medicine during the period of probation. Unfortunately, the Medical Board filed a Petition to Revoke his probation in 2011 alleging he violated this provision by evaluating four Workers’ Compensation cases between 2006 and 2008 while on probation. Ordog stipulated to resolve this Petition to Revoke by the extension of his probation for an additional term of 18 months.

The Medical Board probation has recently been completed. Ordog now faces federal charges of nine counts of health care fraud.

Michael Drobot pleaded guilty just over a year ago to criminal charges related to paying more than $20 million in kickbacks and bribing California state Sen. Ron Calderon to preserve a loophole in state law that enabled him to charge insurers sky-high prices for spinal hardware used at the Pacific Hospital of Long Beach. The FBI has said the kickbacks-for-surgeries scam is believed to be the largest in California history. He is scheduled to be sentenced in October.

One of the next chapters in the story involves the State Compensation Insurance Fund Rico case against Drobot and others. Its 103 page Second Amended Complaint in the RICO case was filed in federal court this February. State Fund alleges it brought this action to recoup payments made to Defendants, who concealed the system of illegal kickbacks, fee-splitting, corporate practice of medicine, and other misconduct. The Complaint alleges detail on various illegal kickback and referral fees, and other “Fraudulent Schemes” such as overbilling, unbundling/upcoding, duplicate radiology billing, and issues with pharmaceutical billing. The lawsuit in effect alleges that Drobot created sham contracts with doctors and marketers that were dubbed research, management or option agreements. In reality, the lawsuit says, they were payola accounts to reward doctors for using Drobot’s medical firms.The State Fund Second Amended Complaint makes an interesting read if not a well documented tutorial on the dark side of the practice of medicine.

Michael Drobot now adds yet another interesting chapter in the legal struggle. A few weeks ago he filed a 15 page third-party complaint for equitable indemnity and declaratory relief against 22 doctors, health executives, chiropractors and a lawyer. Equitable indemnity says in theory that Drobot should not have to pay the State Fund, but if it ends up that he does, then he wants others to share the blame with him and pay the damages. Thus Drobot in his indemnity lawsuit is alleging that these 22 defendants are somehow involved in what the State Fund alleges he did. The lawsuit, in essence, says that if he has to pay any money to the State Fund, they should, also.  So he has in effect implicated these entities and individuals.

One of Drobot’s defendants is California physician Faustino Bernadett who allegedly purchased the shares of Healthsmart through related companies, and was Chairman of the Board for several years. Healthsmart was a California corporation, with its principal place of business in Newport Beach, California, that operated and did business as Pacific Hospital of Long Beach. Bernadette claims to be board certified in anesthesiology and practices pain medicine in Long Beach. Of all the named defendants, Drobot is more specific in his allegations against Faustino Bernadett than he was against the others. Drobot alleges that Bernadett as Chairman and one of the Pacific Hospital owners was thus “knowledgeable of, and authorized, ratified and approved the acts and omissions of Healthsmart, PSPM, and FMM alleged in the SAC (Second Amended Complaint) to be unlawful.” Drobot therefore alleges that Bernadett was in effect one of the architects of the schemes.

Other physicians he implicates in the 15 page complaint are Mitchell G. Cohen, M.D., Philip A. Sobol M.D. who practices on Los Angeles as Sobol Orthopedic Medical Group, Inc., a California corporation, Alan C. Ivar a chiropractor doing business as Griffin Medical Group, Inc., a California corporation, and South Coast Rehabilitation Center, Inc., Jacob E. Tauber, M.D., as well as physicians Assad Michael Moheimani, Jeffery D. Gross, Timothy J. Hunt, Randy S. Rosen, Gerald J. Alexander, Riverside county physician Gurvinder S. Uppal, Ian I. Armstrong, Jack H. Akmakjian a physician in Riverside. Lokesh S. Tantuwaya M.D. from San Diego and Edward Komberg an Orange County Chirorpactor,

Paul Randall, Andy Navid, and Jason Bernard are named as a defendants because they were “marketers.” Michael E. Barri was a chiropractor and was a principal of, and did business as Jojaso Management, Inc., a California corporation. William Parker was a chiropractor and principal of, and did business as Union Choice Therapy Network. Samuel Vidaurreta was a principal of, Prospice Group, Inc., that referred business to Pacific Hospital.

Attorney Sean E. O’Keefe is also named in the Drobot complaint, He was an individual who allegedly referred patients to Pacific Hospital of Long Beach. He is an attorney in San Diego and a Certified Specialist in Workers Compensation. According to the Drobot allegations he also “engaged in acts and omissions alleged in the SAC to be unlawful” but these “acts” were not specified.

Without being specific, Drobot alleges that each of the above individuals and entities in some manner “engaged in acts and omissions alleged in the SAC to be unlawful” Keep in mind that these are at this point only allegations, and none of these allegations should be assumed to be true until proven in a court of law.

Thomas T. Haider M.D. was named in the case, but has now been dismissed. Dr. Haider has said that he has not taken any money of any kind from anyone for kickbacks.