Author: WorkCompAcademy

The National Council on Compensation Insurance (NCCI) Annual Insights Symposium (AIS) 2023 presentation titled Under the Microscope: Medical Trends in Comp Guide described changes in the utilization of physician services over time, from 2012 to 2022.

During that period, average utilization per claim over studied states increased modestly. A decrease in utilization due to less severe diagnoses and fewer major surgeries was more than offset by increased physical therapy. NCCI’s Physician Service Utilization – A Multistate Review extends the AIS research to consider variations in the utilization of physician services across states in a given year.

NCCI’s Physician Service Utilization – A Multistate Review webinar examines an analytic method to deconstruct differences in physician service utilization between states into contributions from differences in injury mix and medical treatment. The Physician Service Utilization – A Multistate Review Guide provides a slide-by-slide examination of the key insights, data sources, and background underlying the presentation.

– – Physician service utilization differs across states. They range from a low of $800 to around $3,000, with the all-state average right about $1,800.
– – Patterns of interstate variation have been stable over the past decade.
– – Utilization variations reflect state differences in injury mix, likelihood of major surgery, and service intensity.
– – Interstate variations bigger than +/ 10% are mainly driven by differences in the intensity of nonsurgical medical services.
– – Differences in injury mix and likelihood of major surgery are lesser drivers of utilization variation, though significant in some states.
– – For most states, the change in utilization between 2012 and 2022 was modest.
– – Interstate physician utilization variations have remained stable over the past decade – the order of state differences has remained consistent between 2012 and 2022.
– – Service intensity emerges as the primary factor behind interstate variations in physician utilization for many states.
– – While differences in injury mix and the likelihood of major surgery do play a role, their impact on utilization variation is comparatively smaller, although notable in specific states.
– – In many states, physical therapy (PT) drives physician service intensity – especially for claims without surgery.
– – Three major body systems – back/neck, shoulder, and leg/foot (includes leg, knee, ankle, and foot) account for nearly 60% of injuries in 2022 for the all-state category.
– – The mix in individual body systems does not have a particular correlation with the differences in utilization. Instead, they uniformly contribute, to some extent, to the percentage difference in physician service utilization.

NCCI has looked to see if common features of state medical regulation correlate with or explain these variations. Examples are features such as workers compensation treatment guidelines, the use of fee schedules, network penetration, and the like. That investigation led it to understand that there was not any single feature that can explain these variations.

For additional insights, check out the Physician Service Utilization – A Multistate Review Guide. This comprehensive resource is a companion to the webinarand offers a slide-by-slide examination of the key insights, data sources, and background underlying the presentation.

Jeremy Gober, 42, of Hanford, pleaded guilty on November 6 to health care fraud and aggravated identity theft charges for submitting more than $1.5 million in fraudulent claims to Medicare and Medi-Cal for sleep studies, U.S. Attorney Phillip A. Talbert announced.

Jeremy Gober co-owned and co-operated Got Sleep Inc., which operated sleep clinics in Fresno and Orange Counties in California. Sleep clinics perform diagnostic sleep studies to identify disorders like sleep apnea and narcolepsy.

According to court documents, between August 2016 and July 2020, Gober caused Got Sleep to submit thousands of claims to Medicare and Medi-Cal for sleep studies that were not actually performed on patients. The claims also stated falsely that the patients had been referred for the sleep studies by physicians with whom Gober had previously worked. This was done because Medicare and Medi-Cal will not pay for a sleep study unless the patient was referred by a physician.

This case is the product of an investigation by the U.S. Department of Health and Human Services Office of Inspector General, the Federal Bureau of Investigation, and the California Department of Health Care Services. Assistant U.S. Attorney Joseph Barton is prosecuting the case.

U.S. District Judge Ana de Alba is scheduled to sentence Jeremy Gober on March 4, 2024. He faces a maximum statutory penalty of 10 years in prison for the health care fraud conviction and an additional, mandatory two years in prison for the identity theft conviction.

In September 2023, Jeremy Gober’s brother, Travis Gober, pleaded guilty to similar health care fraud and aggravated identity theft charges related to other sleep clinics in the Central Valley. He is scheduled to be sentenced on Jan. 16, 2024. Travis Gober faces a maximum statutory penalty of 10 years in prison for the health care fraud conviction, and an additional, mandatory two years in prison for the identity theft conviction.

Governor Newsom has signed AB 716, a new law that takes effect on January 1, which modifies ambulance billing practices to prevent out-of-network patients from receiving unanticipated medical bills for emergency medical ground transportation.

According to the California Health Benefits Review Program (CHBRP), California has 715 total public and private ambulance services statewide, with 3,600 licensed ambulances. There are 337 emergency ambulance service areas (zones) statewide, of which more than 220 are served by private ambulance companies.

The estimated total annual expenditures for ground ambulance services in California is approximately $2 billion.

Though the federal Patient Protection and Affordable Care Act requires health plans to cover out-of-network emergency ground medical transport (EGMT) at usual and customary rates (UCR), there are no specific standards regarding UCR.

Health plans often set their UCR much lower than what an ambulance provider charges, leaving patients open to financial liability for the remainder of the charges. For enrollees in Department of Managed Health Care (DMHC)-regulated plans and California Department of Insurance (CDI)-regulated policies, health professionals and facilities are categorized as in- network or out-of-network, based on whether they have an existing contract with specific health plans or insurers to provide service to their enrollees for a specific payment amount. In-network health facilities and professionals have a contract with the enrollee’s plan or insurer that defines a contracted rate for payment for services (and no balance billing of the enrollee is allowed).

However, when an out-of-network provider’s billed charge is more than the plan or insurer will pay, the provider may then seek to recoup the difference, or balance bill, directly from the enrollee.

After January 1, under AB 716, a health care service plan contract or a health insurance policy issued, amended, or renewed on or after January 1, 2024, an enrollee or insured who receives covered services from a non- contracting ground ambulance provider will be required to pay no more than the same cost-sharing amount that the enrollee or insured would pay for the same covered services received from a contracting ground ambulance provider.

A noncontracting ground ambulance provider will be prohibited from billing or sending to collections a higher amount, and would prohibit a ground ambulance provider from billing an uninsured or self-pay patient more than the established payment by Medi-Cal or Medicare fee-for-service amount, whichever is greater.

Under the federal “No Surprises Act,” which Congress passed in 2020, prohibits most surprise out-of-network bills when a patient receives out-of-network services during an emergency visit or at an in-network hospital without advance notice. The “No Surprises Act” includes air ambulances, but does not include ground ambulance services.

California is the 14th state to provide some protection against balance billing for ground ambulance rides.

Rose Jones was employed at the University of California, Irvine campus as the Director of Scholarship Opportunities .

On the day of the incident, at the end of her workday, she exited her office suite at UCI’s science library, walked her bike a short distance to the bike path on Outer Ring Road, mounted her bike, and began riding toward her home. After riding for about 10 seconds, Jones reached a trench, cordoned off with orange posts and caution tape. Upon noticing the obstacle, she swerved and attempted to brake but fell off her bike and sustained injuries.

She subsequently sued the University alleging premises liability and negligence, and her husband alleging loss of consortium. The parties and the trial court subsequently treated Jones’s claims as a claim for dangerous condition of public property under Government Code section 835.

The University moved for summary judgment, claiming that Jones’s injuries occurred within the course of her employment and that the workers’ compensation exclusivity rule therefore barred this action. It noted Jones was still on the University’s premises and argued her injuries were subject to the workers’ compensation scheme under the premises line rule. The University alternatively contended Jones could not recover under Government Code section 835 because she did not exercise due care at the time of the accident.

The trial court granted the University’s motion for summary judgment. It concluded the exclusivity rule barred Jones’s claim because her injuries occurred within the course of her employment as a matter of law based on the premises line rule. It further concluded that, as a matter of law, Jones did not use due care at the time of the accident.

The Court of Appeal affirmed the trial court in the unpublished case of Jones v. Regents of the University of California -G061787 (October 2023)

Under the judicially created “going and coming rule” an employee’s injury while commuting to and from work is not compensable under the workers’ compensation system absent “special or extraordinary circumstances.”

In an effort to create a sharp line of demarcation as to when the employee’s commute terminates and the course of employment commences, courts adopted the premises line rule, which provides that the employment relationship generally commences once the employee enters the employer’s premises. The same rule applies when the employee is leaving the work premises, provided he does not unnecessarily loiter thereon.

Highlighting the merits of the premises line rule, our Supreme Court explained in General Ins. Co. v. Workers’ Comp. Appeals Bd. (1976) 16 Cal.3d 595 “The ‘premises line’ has the advantage of enabling courts to ascertain the point at which employment begins-objectively and fairly.”

The Court of Appeal wrote we “conclude the worker’s compensation exclusivity rule barred appellants’ claims because Jones’s injuries occurred in the course and scope of her employment as a matter of law. Her accident occurred on UCI’s campus, undisputedly owned by the University, just after she left her workstation. Under these circumstances, the premises line rule brought Jones’s injuries within the worker’s compensation scheme. (General Ins. Co., supra, 16 Cal.3d at p. 598.)”

Henry Geoffrey Watson, a medical doctor residing in Oakland, California, was convicted by a federal jury of charges that included accepting kickbacks for patient referrals to home health agencies, health care fraud, and false statements relating to a health care matter.

The jury found that 67 year old Watson engaged in three health care kickback schemes from 2013 to 2019, using his position as a licensed medical doctor. The first scheme involved a conspiracy in which Watson agreed to refer patients to home health agency Amity Home Health Carein exchange for illegal kickback payments. The evidence at trial proved that Watson and employees of Amity and its CEO, Amanda Singh, conspired to pay Watson regular and recurring amounts, sometimes in the form of cash payments of $3,000 a month, to ensure that Watson referred Medicare patients to Amity each month.

Title 42, United States Code, Section 1320a-7b, the Anti-Kickback Statute, makes it a crime for any person to knowingly solicit, offer, or pay a kickback, bribe, or rebate for furnishing services under a Federal health care program including Medicare.

In the second scheme proved at trial, Watson accepted kickback payments from an undercover FBI agent posing as a home health agency representative seeking Watson’s agreement to refer his patients to a particular Bay Area home health agency. The evidence at trial included video recordings of Watson accepting envelopes of cash, for a total of more than $10,000, at four meetings in 2017. The jury heard evidence that Watson also suggested other doctors who he believed would be willing to accept illegal payments for referrals from the undercover agent.

The third scheme proved at trial involved a conspiracy between Watson and others to repeatedly and falsely certify individuals for Medicare-funded home health services that the individuals did not seek and did not need. The evidence at trial showed that Watson and co-conspirators arranged for Watson to briefly meet large numbers of unwitting elderly residents of Bay Area retirement homes. After these meetings, held in common areas or recreation rooms, Watson certified that each and every resident he met was homebound, meaning they had a normal inability to leave the home. In fact, according to the evidence and the jury’s verdict, Watson knew that the patients were not homebound and did not need the services he prescribed.

Watson did not conduct any tests or conduct any inquiry about whether they were homebound, according to trial evidence, but he nevertheless made fraudulent referrals to the three home health agencies. During time periods that Watson repeatedly certified that certain individuals were homebound, testimony from these individuals and their regular primary care doctors showed that the individuals were generally healthy and active, engaging in activities such as traveling internationally, shopping, walking stairs, and jogging. The evidence proved Watson falsely billed Medicare for certifying these individuals for home health and for supervising their home health care, despite the fact that the individuals did not need that care. As part of the conspiracy, Watson was paid illegal kickbacks of $100 per patient referral by a co-conspirator working for the three home health agencies.

Criminal charges against Watson were unsealed on September 5, 2019, when the United States Attorney’s Office announced charges by criminal complaint against 30 defendants in a wide-ranging, patients-for-kickback scheme. Those charges included criminal kickback charges against Amity Home Health Care, which was then the largest home health care provider in the San Francisco Bay Area, and Advent Care, a provider of hospice care. In relation to the investigation that led to the charges and conviction of Watson, other individuals and doctors were also convicted of illegal kickbacks:

– – Amity’s CEO, Ridhima Amanda Singh pled guilty to charges of conspiracy to pay kickbacks for the referrals of Medicare beneficiaries on August 5, 2022, in Court Case No. 22-CR-267 CRB.
– – Dr. Bhupinder Bhandari pled guilty to violations of the Anti-Kickback Statute on June 6, 2022, in Court Case No. 20-CR-374 JD.
– – Dr. Zheng Zhang pled guilty to violations of the Anti-Kickback Statute on April 25, 2022, in Court Case No. 22-CR-090 VC.
– – Dr. Gerald Myint pled guilty to violations of the Anti-Kickback Statute on November 18, 2020, in Court Case No. 20-CR-408 CRB.
– – Dr. Juan Posada pled guilty to violations of the Anti-Kickback Statute on January 27, 2021, in Court Case No. 20-CR-420 RS.

All those defendants have been sentenced by the judges assigned to those cases.

Watson remains released on bond pending sentencing. Watson’s sentencing hearing is scheduled for February 28, 2024, before Judge Breyer in San Francisco. Any sentence will be imposed by the court after consideration of the U.S. Sentencing Guidelines and the federal statute governing the imposition of a sentence, 18 U.S.C. § 3553.