Author: WorkCompAcademy

Dennis Lindsey was employed as a staff psychologist by the California Department of Corrections and Rehabilitation. He filed an Application for Adjudication alleging injury arising out of and in the course of employment to his psyche, hypertension, and aortic root dilation.

Dr. Anne Welty, the Agreed Medical Examiner in psychology. issued a report diagnosing the applicant with adjustment disorder with mixed disturbance of emotions and conduct. As to causation, Dr. Welty stated that with a reasonable degree of medical probability, over 51% of the applicant’s acute and presenting psychiatric symptoms developed as a result of the events that transpired during the course of his employment with the Chino Institute for Men. Based on the opinions of Dr. Welty, the WCJ found that the events of employment were the predominant cause of the applicant’s psychiatric injury.

Having determined that the applicant’s psychiatric injury involves actual events of employment and that some of those events of employment were lawful, nondiscriminatory, and made in good faith personnel actions, the WCJ was required to determine if those personnel actions were a substantial cause of the applicant’s psychiatric injury. Substantial cause is defined by the Labor Code to mean at least 35 to 40 percent of the causation from all sources combined.

Based on the medical opinion of Dr. Welty, the WCJ found that 15% of the cause of the applicant’s psychological injury was the result of the disciplinary action for the paperwork submission and timeliness of patient team meetings and scheduled appointments, 10% attributed to the disciplinary action for going outside the chain of command and for using profane language, and 10% attributed to the disciplinary action for going outside the chain of command when he submitted a complaint regarding a particular staff psychiatrist who was going to come work on the team.

When combined, these three events of employment total 35% of the causation from all sources combined and were a substantial cause of the applicant’s psychological injury, and the WCJ found that the defendant had no liability for the applicant’s psychological injury.

Applicant’s Petitioned for Reconsideration was dismissed in the panel decision of Lindsey v  California Department of Corrections and Rehabilitation -ADJ9111192 (January 2024).

The petition in this matter was filed on November 13, 2023. This was more than 25 days after the service of the WCJ’s September 16, 2022 decision and beyond whatever extension of time, if any, the petitioner might have been entitled to under WCAB Rule 10600. This time limit is jurisdictional and, therefore, the Appeals Board has no authority to consider or act upon an untimely petition for reconsideration.

Additionally the Petition for Reconsideration was not verified and notice of this defect was specifically given in both the WCJ’s Report and by the respondent’s answer. Moreover, a reasonable period of time has elapsed, but petitioner has neither cured the defect by filing a verification nor offered an explanation of why a verification cannot be filed.

However, the WCAB panel went on to say “If the petition had been timely, we would have denied it on the merits for the reasons stated in the WCJ’s report.” And added “In addition to the WCJ’s Report, we offer the following as further clarification regarding ‘events of employment’ and ‘personnel actions.’ “

When a psychiatric injury is alleged and the “good faith personnel action” defense has been raised, the WCJ must evaluate the defense according to a multilevel analysis. This is often referred to as a Rolda analysis, base on Rdolda v. Pitney Bowes, Inc. (2001) 66 Cal.Comp.Cases 241.

It is often helpful to break this analysis into discreet elements: (1) whether the alleged psychiatric injury involves actual events of employment, a factual/legal determination; (2) if so, whether such actual events were the predominant cause of the psychiatric injury, a determination which requires competent medical evidence; (3) if actual events of employment were the predominant cause of the psychiatric injury, whether any of the events of employment were personnel actions; (4) if so, were those personnel actions lawful, nondiscriminatory and in good faith; and (5) if so, whether the lawful, nondiscriminatory, good faith personnel actions were a “substantial cause” of the psychiatric injury.

In Larch v. Contra Costa County, the Appeals Board defined personnel action as conduct either by or attributable to management, which includes actions taken by someone who has the authority to review, criticize, demote, or discipline an employee. (Larch (Fleming) v. Contra Costa County (1998) 63 Cal.Comp.Cases 831, 833 [“conduct attributable to management in managing its business including such things as done by one in authority to review, criticize, demote, transfer or discipline an employee in good faith.”].)

It is not necessary that the action have a direct or immediate effect on the employment status. Not every action taken by someone who has the authority to review, criticize, demote, or discipline is necessarily a personnel action. The issue of whether the employee’s psychiatric injury occurred as a result of a personnel action is a factual and legal issue for the WCJ, as is the determination of whether a personnel action is lawful, nondiscriminatory, and made in good faith.

The WCAB dismissed the Petition as untimely and unverified. However, “if the petition had been timely and verified, we would have denied it on the merits for the reasons stated in the WCJ’s report.”

The former president and CEO of a Whittier medical clinic was sentenced today to 124 months in federal prison for submitting fraudulent billings to a Medi-Cal health care program that provides family planning services to low-income Californians who lack health insurance.

Vincenzo Rubino, 59, of Valencia, was sentenced by United States District Judge Otis D. Wright II, who also ordered him to pay $3,815,478 in restitution and entered a money judgment of $2,308,028.

Rubino pleaded guilty in August 2023 to nine counts of health care fraud and two counts of aggravated identity theft. Rubino pleaded guilty mid-trial when the prosecution had nearly finished presenting its case to the jury.

Rubino founded, owned and operated Santa Maria’s Children and Family Center, a Whittier-based medical clinic based registered as a non-profit public benefit corporation and enrolled as a Family Planning, Access, Care and Treatment (Family PACT) provider run through Medi-Cal.

From November 2014 to August 2017, the center submitted fraudulent claims totaling nearly $5 million to the Family PACT program for family planning services that were never provided, often using the information of patients who were recruited at off-site locations with offers of free diabetes testing.

To submit many of these claims, Rubino used the names of two medical providers who were not employed at Santa Maria’s. The patients did not see these providers – a physician’s assistant and an elderly doctor who was himself a patient in a skilled nursing facility during much of the scheme.

The Medi-Cal program paid more than $2.3 million dollars on the fraudulent claims, as well as an additional approximately $1.5 million to a pharmacy and laboratory for claims stemming from referrals from Santa Maria based on the same services that were never delivered.

“This defendant took advantage of health-care services intended for people in need,” said United States Attorney Martin Estrada. “Instead of allowing that money to go where it was intended, Rubino stole millions of dollars through sham claims to Medi-Cal for family planning services that either were unnecessary or unprovided. Today’s sentence highlights my office’s resolve to protect the most vulnerable in our community.”

The United States Department of Health and Human Services Office of Inspector General and the California Department of Justice investigated this matter.

Assistant United States Attorneys Kristen A. Williams of the Major Frauds Section and David H. Chao of the General Crimes Section prosecuted this case. Assistant United States Attorney Tara B. Vavere of the Asset Forfeiture and Recovery Section is handling the asset forfeiture portion of this case.

Many studies have documented US health care’s high administrative costs, with several studies pointing to complex billing processes as drivers of those costs. Several analyses have compared US administrative costs or staffing with those in other nations,but none have examined Veterans Health Administration (VHA) facilities.

A new study published in the journal JAMA Network Open, by researchers at Hunter College of the City University of New York, Harvard Medical School, the Veterans Health Administration, and the University of Washington, points fingers at profit-driven private facilities and insurers, where a whopping 30% of staff are stuck in the tangled web of paperwork, while the VHA shines with a lean 22.5% administrative staff.

That means nearly 900,000 fewer paper pushers would be needed if private hospitals, clinics, and insurers took a page from the VHA’s playbook. And most of the bloat comes because profit-seeking insurers try to avoid paying for care by imposing complex rules and documentation requirements.

The VHA’s leaner administrative staffing likely reflects the agency’s simpler financing scheme. High administrative costs in the private sector have been attributed to the complexity of collecting revenues. Health care institutions bill for individual patients and services and interact with insurers that have varying fee schedules, deductibles, prior-approval requirements, formularies, and referral networks.

Even capitation payment schemes generally entail risk-adjustment calculations requiring detailed tracking of each patient’s service use, diagnoses, and costs. In this context, investments in administration may make financial sense, for example, increasing revenue by documenting more diagnoses.

Financial success is key to private sector institution growth and even survival, and executive compensation is often linked to financial metrics. This could incentivize efforts to improve efficiency but could also encourage revenue-enhancing administrative activities that add little clinical value (eg, marketing and upcoding).

In contrast, VHA hospitals and clinics are funded mostly through lump-sum budgets. The VHA does not bill Medicare or Medicaid and collects only 2.7% of its revenues from private insurers and 0.3% from patients,minimizing the need to attribute costs and charges to individual patients. In the VHA, all facilities are in network, 1 formulary applies to all patients, and few services require prior authorization. While managers must adhere to budgetary constraints and provide a volume of clinical services commensurate with their budgets, incentives based on financial metrics are minimal for hospital leaders and their institutions.

“Our profit-oriented system rewards providers for devoting more resources to gaming the payment system,” said lead author Dr. Steffie Woolhandler.

“In the VHA, caring for our patients – not money – is at the center of our mission,” said Dr. Andrew Wilper, chief of staff at the Boise, Idaho, VHA and associate professor of medicine at the University of Washington. “We strive to care for those who have served in our nation’s military and for their families, caregivers, and survivors.”

A 2014 Congressional Budget Office review found suggestive but not conclusive evidence that VHA care was cheaper than private sector care. A 2022 quasi-experimental study of patients with myocardial infarction who had both Medicare and VHA coverage found 21% lower costs and lower mortality in the VHA. This finding was consonant with an analysis that found fewer complications among patients who underwent knee replacement in the VHA. A 2023 comprehensive review concluded that VHA care was generally of equal or better quality compared with the private sector.

On January 18, 2024, the Centers for Medicare & Medicaid Services (CMS) announced the Innovation in Behavioral Health (IBH) Model.  This model is intended to prepare practices for more advanced alternative payment models and accountable care arrangements in the future.

IBH is focused on improving quality of care and behavioral and physical health outcomes for Medicaid and Medicare populations with moderate to severe mental health conditions and substance use disorder (SUD). Medicare and Medicaid populations experience disproportionately high rates of mental health conditions and/or substance use disorders (SUD), and as a result are more likely to experience poor health outcomes and experiences, like frequent visits to the emergency department and hospitalizations, or premature death.

The IBH Model seeks to bridge the gap between behavioral and physical health; practice participants under the IBH Model will screen and assess patients for select health conditions, as well as mental health conditions and/or SUD, in community-based behavioral health practices. IBH is a state-based model, led by state Medicaid Agencies, with a goal of aligning payment between Medicaid and Medicare for integrated services.

The model works to improve care through four key program pillars:

– – Care Integration: Behavioral health practice participants will screen, assess, refer, and treat patients, as needed, for the services they require.
– – Care Management: An inter-professional care team, led by the behavioral health practice participant, will identify, and as appropriate address, the multi-faceted needs of patients and provide ongoing care management.
– – Health Equity: Behavioral health practice participants will conduct screenings for HRSNs and refer patients to appropriate community-based services. Participating practices will be required to develop a health equity plan (HEP). The HEP should stipulate how the practice participant will address disparities that impact their service populations.
– – Health Information Technology: Expansion of health IT capacity through targeted investments in inter-operability and tools (including electronic health records) will allow participants to improve quality reporting and data sharing.

CMS will release a Notice of Funding Opportunity (NOFO) in Spring 2024, and up to eight states will be selected to participate. The model will launch in Fall 2024 and run for eight years.

The Innovation in Behavioral Health (IBH) Model is designed to deliver person-centered, integrated care to Medicaid and Medicare populations with moderate to severe mental health conditions and/or substance use disorder (SUD). The practice participants in the IBH Model will be community-based behavioral health organizations and providers, including Community Mental Health Centers, opioid treatment programs, safety net providers, and public or private practices, where individuals can receive outpatient mental health and/or SUD services. These practice participants may include safety net providers who ensure that vulnerable populations are able to access care.

Practice participants will lead an inter-professional care team and be responsible for coordinating with other members of the care team to comprehensively address a patient’s care to include behavioral and physical health, and health-related social needs (HRSN) such as housing, food, and transportation.

The practice participants will conduct an initial screening and assessment, offer treatment or referrals to other care specialists and community-based resources, and monitor ongoing behavioral and physical health conditions and HRSNs. In this value-based care approach, the practice participants will be compensated based on the quality of care provided and improved patient outcomes.

IBH is a state-based model focused on community-based behavioral health practices that treat Medicaid and Medicare beneficiaries and includes both Medicaid and Medicare-aligned payment models. CMS will first issue awards to Medicaid agencies in up to eight states to implement the model. Practice participants within selected states may volunteer to participate in the Medicare payment model. The selected states will partner with their state’s agencies for mental health and/or SUD to ensure alignment in clinical policies, as well as work with at least one partnering Medicaid Managed Care Organization (MCO) or another intermediary partner, where applicable, to develop and implement the IBH Model in their state.

IBH supports behavioral health practices in delivering integrated care in outpatient settings. This person-centered approach to addressing whole-person health represents a “no wrong door” approach that prioritizes close collaboration with primary care and other physical health providers to support all aspects of a patient’s care.

The IBH Model is projected to run for eight years and includes a pre-implementation period (model years 1-3). During this period, states and practice participants will receive funding to develop and implement model activities and capacity building. During model year 1, states will conduct outreach and recruit behavioral health practice participants into the model. Practice participants will receive funding to support necessary upgrades to health IT and electronic health records, as well as practice transformation activities, and staffing to implement the model. Practice participants who elect to participate in the Medicare payment model may also be eligible for additional funding to support model activities.