Author: WorkCompAcademy

James Karty was working as a waiter at Filippi’s Pizza Grotto which was owned by Richard DePhilippis. One of Filippi’s pizza cooks, Marcos Sevilla, heated a pan in a 550-degree pizza oven before placing a pizza on the pan for Karty’s order. Because the pizza pans are generally cool, Karty picked up the pan with his uncovered hand intending to deliver it to a customer’s table. When he did so, Karty screamed and then dropped the pan. Karty suffered serious and permanent burn injuries. Shortly after the incident, Sevilla admitted he was responsible for the action, quit his job, and never returned to the restaurant.

In addition to receiving workers’ compensation benefits, Karty sued his employer, DePhilippis, and two of Karty’s coworkers asserted two causes of action: battery and intentional infliction of emotional distress. He alleged that his coworkers “deliberately and with intent to injure [him] . . . heated up a pizza pan . . . with full knowledge of the almost-certain likelihood that when [Karty] touched the heated [pan], he would be burned.” Karty sought to recover against DePhilippis based on two exceptions to workers’ compensation exclusivity rules: (1) section 3602(b)(1), which provides for employer liability if the employee’s injury is caused “by a willful physical assault by the employer” and (2) employer ratification principles.

Karty acknowledged that before his August 15 burn injury, there was substantial horseplay among the restaurant employees. Karty and the other employees routinely engaged in practical jokes and other similar activities. For example, Karty frequently placed spoons in other employees’ pockets and would throw small items at other employees, and the employees (including Karty and Lopez) would hit each other with menus and pizza boxes. Karty viewed these activities as innocent horseplay or “joking around” and did not believe these actions were hostile or improper.

After Karty completed his presentation of his case during a jury trial, DePhilippis moved for a nonsuit based on his argument that workers’ compensation was the exclusive remedy for Karty’s injuries. In response, Karty argued that his manager, Lopez, encouraged and/or directed the burn incident and thus her actions could be attributed to the employer for civil liability purposes. The court granted the nonsuit motion, finding that although Karty presented evidence sufficient to establish that Lopez ” ‘participated in a “willful physical assault” on Karty,’ ” Lopez’s involvement did not establish an exception to the workers’ compensation exclusive remedy rules. Karty appealed the dismissal of his case, and the Court of Appeals affirmed the dismissal in the unpublished case of Karty v Richard DePhilippis.

Generally, an employee suffering an injury during the course and scope of his or her employment is limited to recovery provided by the workers’ compensation system. Courts broadly construe the exclusivity provisions and narrowly interpret exceptions to those provisions. Section 3602(b)(1) creates an express exception to the workers’ compensation exclusivity rules “[w]here the employee’s injury or death is proximately caused by a willful physical assault by the employer.” (Italics added.) Under the undisputed facts, DePhilippis was Karty’s employer as defined in the Labor Code. Karty presented no evidence that DePhilippis committed a physical assault or had any involvement or knowledge of the burn incident, or that anyone else was acting on his behalf in committing the claimed assault.

The Division of Workers’ Compensation’s Medical Unit has made changes to the Qualified Medical Evaluator (QME) panel request process as a result of Senate Bill 863. Emergency QME regulations introduce the following new requirements for QME panel requests: The QME forms for both the unrepresented and represented requests have been updated. QME Form 105a applies to the unrepresented cases and must be used for dates of injury on and after Jan. 1, 2013. Likewise,QME Form 106a applies to represented cases and must be used for dates of injury on and after Jan. 1, 2013. Both forms will be formally adopted after they are approved by the Office of Administrative Law, at which time the form numbers will be renamed to QME Form 105 and QME Form 106, respectively, with the latest revision date and will apply to all dates of injury. Agreed Medical Evaluator (AME) offer letter is no longer required prior to panel request (Labor Code § 4062.2)

Disputes from utilization review (UR) determinations that delay, modify or deny medical treatment must be resolved through the independent medical review process for dates of injury on or after Jan. 1, 2013 and for all dates of injury for which UR determinations that delay, modify or deny medical treatment are issued on or after July 1, 2013 (Labor Code §§ 4062(b), 4610.5.)

For disputes over the existence or extent of permanent impairment and limitations or the need for future medical care; or concerning any medical issues not over covered by section 4060 or 4061 and not subject to section 4610: a QME panel request must include a written objection that identifies (Regulation 30(b)):

• The name of the primary treating physician (PTP)
• The date of the PTP’s report that is the subject of the objection
• A description of the medical dispute requiring a comprehensive medical legal exam is necessary

For disputes over the compensability of any injury under Labor Code section 4060: a QME panel request must include a written objection that specifies that a compensability examination is required (Regulation 30(b)).

QME panel requests for disputes contained in Labor Code § 4062.2(b) cannot be submitted until 10 days after the objection letter has been sent. That period is extended by five days if the objection was made by mail within California. Substantive objections under Labor Code §§ 4060, 4061 and 4062 may be resolved using the process under Labor Code section 4062.2.

Requests submitted that do not contain all these components will be considered incomplete and will be rejected. When resubmitting a complete represented panel request please attach a copy of the rejection letter.

More helpful tips to ensure valid panel requests will be coming soon to the DWC Medical Unit website.

Twelve Los Angeles-area residents-including California’s second-largest biller for chiropractic services, a physician’s assistant, and owners of durable medical equipment (DME) and ambulance companies-were taken into custody in relation to seven criminal cases that allege they cumulatively submitted more than $22 million in false billings to Medicare. The charges filed in Los Angeles are part of a nationwide “takedown” by Medicare Fraud Strike Force operations in eight cities that led to charges against 89 individuals for their alleged participation in schemes to collectively submit about $223 million in fraudulent claims to Medicare.

Dr. Houshang Pavehzadeh, of the Sylmar Physician Medical Group, allegedly billed Medicare more than $1.7 million for chiropractic treatments he never performed. During the scheme, which ran from 2005 through 2012, Dr. Pavehzadeh, 40, of Agoura Hills, became the second-largest Medicare biller in California for chiropractic services-even though he was not in the United States when some of the alleged services were performed. In addition to being charged with health care fraud, Pavehzadeh is charged with aggravated identity theft related to Medicare beneficiaries whose information he used to bill Medicare as a part of the scheme. When investigators tried to conduct an audit of Pavehzadeh’s claims, he falsely reported to the Los Angeles Police Department that he had been carjacked and that patient files requested by the auditors had been stolen from his car. Nine defendants affiliated with DME companies were also charged in five separate indictments.

Olufunke Fadojutimi, 41, of Carson, a registered nurse; Ayodeji Temitayo Fatunmbi, 41, formerly of Carson and now believed to be residing in Nigeria; and Maritza Velazquez, 40, of Las Vegas, were charged with health care fraud. The scheme allegedly revolved around Lutemi Medical Supplies, a DME company Fadojutimi owned and where Fatunmbi and Velazquez worked. According to the indictment in this case, Lutemi billed Medicare more than $8.3 million in claims, primarily for medically unnecessary power wheelchairs. Fadojutimi and Fatunmbi allegedly laundered Medicare funds in order to purchase fraudulent prescriptions for those power wheelchairs and pay illegal kickbacks to recruit Medicare beneficiaries. Fadojutimi was arrested in Los Angeles, while Velazquez was arrested in Las Vegas. Fatunmbi is currently a fugitive being sought by federal authorities.

Susanna Artsruni, 45, of North Hollywood, and Erasmus Kotey, 76, of Montebello, a licensed physician’s assistant, allegedly worked together to commit health care fraud out of a medical clinic on Vermont Avenue where they both worked. Kotey allegedly prescribed medically unnecessary DME, including power wheelchairs, for Medicare beneficiaries. Many of those power wheelchair prescriptions were then used by Artsruni’s DME company, Midvalley Medical Supply, to support fraudulent claims to Medicare. In only four months, the clinic and Midvalley billed Medicare more than $525,000 for these fraudulent claims. Artsruni has previously been convicted of health care fraud and was on pre-trial supervision at the time she allegedly laundered some of the proceeds of this fraud. Artsruni was arrested this morning, while Kotey self-surrendered.

Three other DME cases were also charged, alleging fraudulent Medicare billing for medically unnecessary power wheelchairs that were sometimes never even delivered. In one case, Akinola Afolabi, 53, of Long Beach, the owner of Emmanuel Medical Supply, allegedly submitted more than $2.6 million in false and fraudulent billing to Medicare. In another case, Queen Anieze-Smith, 52, of Encino, and Abdul King-Garba, 47, of Westwood, the owners and operators of ITC Medical Supply, allegedly submitted more than $1.8 million in false and fraudulent billing to Medicare. In the third case, Clement Etim Aghedo, 53, of Fontana, the owner of Ace Medical Supply Company, allegedly submitted more than $1.8 in false and fraudulent claims to Medicare. Afolabi, Anieze-Smith, and King-Garba were all arrested, while Aghedo self-surrendered.

In the seventh case brought as part of the takedown, three defendants affiliated with Gardena-based ProMed Medical Transportation, an ambulance company, were charged with submitting more than $5.9 million in false claims to Medicare between 2008 and 2011. ProMed’s owner, Yaroslav Proshak, 45, of Valley Village; general manager Sharetta Wallace, 35, of Inglewood; and office manager and biller Sergey Mumjian, 40, of West Hollywood, submitted claims for medically unnecessary transportation services and then created fake documentation purporting to support those claims. Proshak, Wallace, and Mumjian were arrested this morning.

The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention and Enforcement Action Team (HEAT), a joint initiative announced in May 2009 between the Department of Justice and the Department of Health and Human Services to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country.

Sergio Perez, an Arizona resident, was hired by Hilltown Packing, a California based company to work at their facility in Arizona. The job offer and the acceptance of that offer were both made in Arizona. While working in Arizona, Perez had an industrial injury. He received medical treatment in Arizona.

He then moved on his own back to his primary residence in California where he continued to receive treatment and ultimately filed a California Workers’ Compensation claim. When he was released for light duty work, he returned to Arizona.

More than 90 days after the injury, the employer denied the California claim based upon the argument that there was no jurisdiction to proceed before the California WCAB. The WCJ agreed with the employer and found that there was no California jurisdiction over the Arizona injury and dismissed the application. Sergio Perez filed a petition for reconsideration.

The WCAB panel agreed with the WCJ, finding that there was no jurisdiction to proceed in California in the case of Perez v. Workers’ Comp. Appeals Bd., 2013 Cal. Wrk. Comp. LEXIS 91.

The ruling on jurisdiction was consistent with well established law. Support for the finding exists in a number of published opinions such as Ledbetter Direction Corp. v. W.C.A.B. (Salvaggio) (1984) 156 Cal. App. 3d 1097, 203 Cal. Rptr. 396, 49 Cal. Comp. Cases 447.which was cited by the WCAB panel.

Another one of the issues raised by Perez in his Petition for Reconsideration was that the employer was “estopped” from raising jurisdiction as an issue since that issue was raised for the first time more than 90 days following the injury. The WCAB disagreed holding that Labor Code § 5402 “merely creates a presumption that a compensable industrial injury was sustained if not denied within 90 days. It does not establish that the WCAB has jurisdiction to award benefits for that compensable injury.” The WCAB also pointed out, as did the WCJ, that objections to subject matter jurisdiction may be raised at any time and that jurisdiction cannot be conferred by consent, waiver, or estoppel.

A second 15-day notice of modification to the supplemental job displacement benefit regulations has been distributed to interested parties and posted to the DWC website. Members of the public are invited to present written comments regarding the proposed modifications to dwcrules@dir.ca.gov until 5 p.m., June 21.

The proposed modifications include:

• The Physician’s Return to Work and Voucher Report (DWC-AD Form 10133.36) is modified to clarify the descriptors for the activity restrictions and to reflect that any job descriptions provided to the physician would discuss physical requirements rather than activity restrictions.
• Section 10117 is modified to delete “employer has knowledge that the” from subdivision (b).
• Section 10133.31 is modified to include the 60 day time frame for making an offer of work.
• Section 10133.34 is modified to include subdivision (b) which discusses the 60 day time frame for making an offer of work.

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