Author: WorkCompAcademy

Patients may think they understand everything doctors tell them when they are released from the hospital, but a new U.S. study summarized by Reuters Health found several gaps in what they remember and areas where instructions could be clearer. Out of nearly 400 patients discharged from a large academic medical center, 96 percent reported knowing why they had been hospitalized, but only about 60 percent could accurately describe their diagnoses, for instance. “Patients were very positive, but when we asked them about actual facts, they could not tell us,” said Dr. Leora Horwitz, the study’s lead author from the Yale School of Medicine in New Haven, Connecticut.

For the new study, Horwitz and her colleagues asked 395 people age 65 and older about their experience after being discharged from Yale-New Haven Hospital between May 2009 and April 2010. They compared those patients’ responses to what was written in their medical charts and the instructions they were given when they were released.

The majority received instructions that included easy-to-understand language about what symptoms to watch out for and advice about activities and diet, but about a quarter of the instructions used medical jargon to explain the patient’s medical condition. For example, instead of saying the person had a “heart attack,” the instructions used the technical term “myocardial infarction.” About 35 percent of patients had trouble explaining why they were in the hospital. What’s more, about half of the patients recalled their doctor having scheduled a follow up visit while the medical records showed only about 33 percent actually had one scheduled. Also, less than one third of patients reported being told while hospitalized about their upcoming discharge more than a day in advance. Two-thirds of patients did recall being asked whether they would have the support they needed at home after discharge.

Hospitals are currently looking at ways to reduce the number of people who have to come back for additional care – something the U.S. government and economists say can be prevented to reduce overall healthcare spending. For people on Medicare, the government-run health insurance program for the elderly and disabled, hospital readmissions increase spending by an estimated $26 billion per year, according to federal figures. About $17 billion of that is thought to be potentially preventable. Much focus has been put on hospitals following recommended medical guidelines to reduce readmissions, though there is also some attention toward making sure patients know what to do after they leave the hospital.

A San Diego father and daughter team were sentenced to local custody after pleading guilty to insurance fraud, grand theft and perjury in connection with a brazen insurance fraud scheme that lasted nine years. Yolandi Kohrumel, 35, was sentenced to one year in jail and her father, Anton Buitendag, 65, was sentenced to 180 days in jail by Superior Court Judge Duane Moring. Restitution in the amount of $1,558,653 was also ordered to be paid to ESIS, which administered the insurance claim.

Kohrumel broke her toe at work and claimed to be wheelchair bound due to complications from surgery on her foot. The defendant was paid $1.5 million in disability payments over a nine-year period until the insurance company was tipped off and obtained video of her standing, walking and lifting moving boxes for hours.

In 2002, Kohrumel worked as a manager at Staples. After working about three months, she claimed she injured her toe when a heavy box fell on her foot. In November of that year, she had surgery on her toe and was given crutches. When she claimed she could not use the crutches, she was given a wheelchair. The defendant claimed the wheelchair gave her carpal tunnel syndrome and she was given an electric wheelchair.

Despite this, she continued to represent herself as suffering from hypersensitivity of the feet, complex regional pain syndrome, depression, and anxiety. Doctors prescribed about 25 different medications for these symptoms. From the date of the surgery to the present, Kohrumel never returned to work and was paid temporary disability amounting to two-thirds of her salary, tax free.

She represented herself as needing care 24 hours a day, seven days a week since 2004. At first, care was provided by her husband until his death in September of 2011. Then, the defendant’s father, Anton Buitendag, took over her care. All of Kohrumel’s doctors believed she was totally disabled, entitling her to potential lifetime disability benefits. Given her young age, this could have totaled several million dollars.

Recently, Kohrumel and her father began demanding that he be reimbursed for the around-the-clock care they said she needed and he provided. Buitendag was seeking $324,000 in compensation for his claimed 24 hour-a-day, seven days a week care of his daughter from September 2011 through June 2013. He claimed his services were worth more than $21 an hour, which came to about $500 per day or about $182,500 a year.

The insurance company, ESIS/AIG, disputed the amount of care she needed and said they could not legally pay Buitendag because he is a South African citizen and does not have a work Visa. Kohrumel’s attorney sought to litigate this issue before the WCAB.

In addition to the benefits the defendant received, she said needed a larger place to live as her current two bedroom apartment was not large enough for her wheelchair to navigate. The insurance company hired movers to help her start the moving process and informed the workers they would have to do everything as Kohrumel was wheelchair bound. While helping Korhumel, the movers noticed she would get out of her wheelchair for extended periods of time and lift and move heavy boxes in her garage. The movers reported what they saw to the insurance company and later filmed the defendant standing for about two hours while continuously lifting, moving and looking through boxes in her garage. Korhumel was arrested and taken into custody.

On July 10, 2013, a search warrant was executed on Korhumel’s garage and more than 20 boxes of unused prescription medication were recovered. The next day both Kohrumel and Buitendag entered guilty pleas. Korhumel pleaded guilty to eight felonies counts including insurance fraud, preparing a false document, perjury and grand theft. Butiendag pleaded guilty to three felony counts of attempted grand theft.

The Division of Workers’ Compensation (DWC) is issuing a notice of public hearing for the Medical Provider Network (MPN) regulations. The proposed rulemaking is to implement Senate Bill 863’s changes to Medical Provider Networks. A public hearing on the proposed regulations has been scheduled at 10 a.m., September 30, in the auditorium of the Elihu Harris Building, 1515 Clay Street, Oakland, CA, 94612. Members of the public may also submit written comment on the regulations until 5 p.m. that day.

The proposed amendments to the MPN regulations modify regulatory definitions, which include a definition of an entity that provides physician network services. The regulations also detail the changes to MPN plan requirements, which include physician acknowledgments, Internet postings of providers, medical access assistants, quality of care, geocoding and MPN disclosure requirements to medical providers. In addition, the regulations set the requirements for MPN approval for a period of four years and the procedural timelines for MPN re-approval.

Regarding compliance and enforcement, the proposed regulations set forth the process for filing a written complaint against an MPN, and the manner to petition DWC for the suspension or revocation of MPN status. Finally, the regulations detail more enforcement actions, establishing additional grounds for the probation, suspension, or revocation of an MPN, and the procedure by which MPNs are reviewed by the Division and assessed administrative penalties.

DWC will consider all public comments, and may modify the proposed regulations for consideration during an additional 15-day public comment period. The notices of rulemaking, text of the regulations, and the initial statements of reasons can be found on the MPN rulemaking page.

A Santa Paula woman who worked for the Ventura County Sheriff’s Office has pleaded guilty to four felony counts of workers’ compensation insurance fraud, prosecutors said Wednesday.

Keri Atwood (DOB 09/24/1984), of Santa Paula, entered guilty pleas to four felony counts of workers’ compensation insurance fraud. Michael Atwood (DOB 08/2811976), also of Santa Paula, entered a guilty plea to one felony count of conspiracy to commit workers’ compensation fraud. The case was investigated by the Valencia office of the California Department of Insurance.

Defendant Keri Atwood reported to her supervisors that she sustained an injury to her left ankle. She said the injury occurred when another employee accidentally hit the back of her foot with a mail cart. She was placed on Temporary Total Disability (TTD) status. Over the next several months, Atwood remained on TTD and received over $29,000 in disability pay.

Keri Atwood used crutches or a wheel chair to get to her medical appointments. After her medical appointments, she was seen walking freely without the aid of crutches or a wheel chair. She was also observed engaging in a number of physical activities that she told her treating her physicians she could not perform. Michael Atwood drove Keri Atwood to her doctors’ visits and failed to disclose her true physical condition.

The California Supreme Court has agreed to review the controversial Court of Appeal decision that allowed unauthorized non-MPN physician reports into evidence. The Court has scheduled oral argument for Wednesday, September 4, 2013, at 9:00 a.m., in San Francisco.

After Elayne Valdez filed a claim for industrial injury, the employer admitted her claim to most of the alleged body parts injured and she was sent for medical treatment to the employer’s MPN, where she was seen by Dr. Nagamoto, who treated her from approximately October 9, 2009 to October 31, 2009. Applicant then began treating with Dr. Nario, a non-MPN physician, upon referral from her attorney.

The WCAB in a split en banc decision ruled that non MPN physician reports are not admissible when the employer has properly complied with MPN regulations. The WCAB reasoned that Labor Code 4616.6 provides: “No additional examinations shall be ordered by the appeals board and no other reports shall be admissible to resolve any controversy arising out of this article” and thus precludes the admissibility of non-MPN medical reports with respect to disputed treatment and diagnosis issues, i.e., “any controversy arising out of this article.”

The Court of Appeal reversed and remanded in the unpublished opinion of Elayne Valdez v WCAB and Warehouse Demo Services

In ruling that non MPN reports are indeed admissible, the Court reasoned that “It does not makes sense, however, to construe section 4616.6 as a general rule of exclusion, barring any use of medical reports other than those generated by MPN physicians. Section 4616.6 states nothing of the sort. If the Legislature intended to exclude all non-MPN medical reports, the Legislature could have said so; it did not.”

Recently enacted S.B. 863 partially addressed this outcome. Effective 1/1/2013 LC 4605 provides that “Any report prepared by consulting or attending physicians pursuant to this section shall not be the sole basis of an award of compensation. A qualified medical evaluator or authorized treating physician shall address any report procured pursuant to this section and shall indicate whether he or she agrees or disagrees with the findings or opinions stated in the report, and shall identify the bases for this opinion.”