Author: WorkCompAcademy

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.

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:

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.

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.

Fox News reports that the NFL and more than 4,500 former players want to resolve concussion-related lawsuits with a $765 million settlement that would fund medical exams, concussion-related compensation and medical research. The plaintiffs include at least 10 members of the Pro Football Hall of Fame, including former Dallas Cowboys running back Tony Dorsett. They also include Super Bowl-winning quarterback Jim McMahon and the family of Pro Bowl linebacker Junior Seau, who committed suicide last year.

Many former players with neurological conditions believe their problems stem from on-field concussions. The lawsuits accused the league of hiding known risks of concussions for decades to return players to games and protect its image. The NFL has denied any wrongdoing and has insisted that safety has always been a top priority. Many have also filed workers’ compensation claims in California, even if they only played one game here.

Senior U.S. District Judge Anita Brody in Philadelphia announced the proposed settlement Thursday after months of court-ordered mediation. She still must approve it at a later date. The settlement likely means the NFL won’t have to disclose internal files about what it knew, when, about concussion-linked brain problems. Lawyers had been eager to learn, for instance, about the workings of the league’s Mild Traumatic Brain Injury Committee, which was led for more than a decade by a rheumatologist.

In court arguments in April, NFL lawyer Paul Clement asked Brody to dismiss the lawsuits and send them to arbitration under terms of the players’ contract. He said that individual teams bear the chief responsibility for health and safety under the collective bargaining agreement, along with the players’ union and the players themselves.

Players lawyer David Frederick accused the league of concealing studies linking concussions to neurological problems for decades. Brody had initially planned to rule in July, but then delayed her ruling and ordered the two sides to meet to decide which plaintiffs, if any, had the right to sue. She also issued a gag order, so it has been unclear in recent weeks whether any progress was being made. The lawyers were due to report back to her Tuesday, but Brody instead announced in court files Thursday that the case had settled.

In recent years, a string of former NFL players and other concussed athletes have been diagnosed after their deaths with chronic traumatic encephalopathy, or CTE. Those ex-players included Seau and lead plaintiff Ray Easterling, who filed the first suit in Philadelphia in August 2011 but later committed suicide.About one-third of the league’s 12,000 former players have joined the litigation since 2011. They include a few hundred “gap” players, who played during years when there was no labor contract in place, and were therefore considered likely to win the right to sue.

The timing of the settlement allowed the NFL to drop the issue from the national conversation before the start of the new season. All 32 clubs were scheduled to play their final exhibition games Thursday night, in preparation for the start of the regular season next week. The first real game is next Thursday, with the reigning Super Bowl champion Baltimore Ravens playing at the Denver Broncos.