Category: Daily News

Saul Fox and Dexter Paine co-founded investment firm Fox Paine & Company, LLC (FPC). In 2006, after Paine launched a third investment fund, Fox Paine Management III, LLC, without Fox’s full participation, the relationship between the two collapsed. In August 2007, Fox and related entities (the Fox Parties) sued Paine and related entities (the Paine Parties) in Delaware, alleging Paine poached FPC employees and misrepresented that Fox had authorized various actions; the Paine Parties countersued, and years of litigation followed. That dispute triggered claims under a tower of insurance policies covering FPC and affiliated individuals: a $10 million primary policy from Houston Casualty Company (HCC), a $10 million first-layer excess policy from Twin City Fire Insurance Company, a $10 million second-layer excess policy from St. Paul Mercury Insurance Company, a $10 million third-layer excess policy from Twin City, and a $10 million fourth-layer excess policy from Liberty Mutual Insurance Company — a $50 million tower in which each excess policy attaches only once the insurance beneath it is exhausted.

According to the operative complaint, the Paine Parties came to control the insurance claim: HCC paid the Paine Parties its full $10 million primary limit without notifying the Fox Parties, and Twin City and St. Paul later settled with the Paine Parties for a combined $9 million (roughly $6 million allocated to Twin City’s first-layer policy and $3 million to St. Paul’s), again without telling the Fox Parties, who allege they learned of these developments only years later through a third-party docket alert. Plaintiffs Fox, FPC, and related entities sued Twin City, St. Paul, and Liberty Mutual for breach of contract, declaratory relief, breach of the implied covenant of good faith and fair dealing, and aiding and abetting breach of fiduciary duty, alleging they — not the Paine Parties — held the only legitimate claim to the excess coverage and had incurred more than $43 million in covered loss and interest defending the Delaware litigation and its aftermath.

All three excess insurers demurred to the operative complaint, arguing plaintiffs’ claims against the higher-layer policies failed because plaintiffs could not allege the underlying insurance had actually been exhausted. The San Francisco County Superior Court found plaintiffs had adequately alleged exhaustion of the primary HCC policy, allowing claims against Twin City’s first-excess-layer policy to proceed, but concluded exhaustion had not occurred as to St. Paul’s policy, Twin City’s third-layer policy, or Liberty Mutual’s policy, since only $6 million of Twin City’s $10 million first layer had been paid out. On that basis, the court sustained the demurrers of St. Paul and Liberty Mutual (and Twin City’s demurrer as to its third-layer policy) without further leave to amend, resulting in a judgment of dismissal as to those insurers.

The California Supreme Court granted review to examine (Fox Paine & Co., LLC v. Liberty Mutual Ins. Co. (2024) 104 Cal.App.5th 1034), a Court of Appeal published opinion, that agreed with the trial court, and held that the absence of actual exhaustion defeated any “actual controversy” under Code of Civil Procedure section 1060, treating the case as materially identical to Qualcomm, Inc. v. Certain Underwriters at Lloyd’s, London (2008) 161 Cal.App.4th 184.

In the case of Fox Paine & Company, LLC v. Twin City Fire Insurance Company, No. S287404 (Cal. Sup. Ct., July 2026) — the California Supreme Court reversed the judgment of the Court of Appeal and remanded the cause for further proceedings.

The Supreme Court disagreed with the Court of Appeal, holding that a lack of actual exhaustion does not categorically defeat an actual controversy regarding coverage under an excess policy. Applying the ripeness framework from Pacific Legal Foundation v. California Coastal Commission (1982) 33 Cal.3d 158, the Court explained that insurance coverage disputes routinely involve future contingencies, and that courts should ask whether it is practically or reasonably likely that a contingency will occur rather than treating any unresolved contingency as fatal. Because plaintiffs alleged a loss, identified the specific policy provisions covering it, and alleged they had submitted virtually all their invoices without reimbursement, the Court found the dispute concrete enough to support declaratory relief, and held that requiring insureds to litigate excess policies one layer at a time — suing, winning, executing, and then suing the next insurer up the tower — would impose serious and unnecessary hardship.

The Court did impose a real pleading requirement going forward: a plaintiff seeking a declaration of coverage under an excess policy must adequately allege that its covered losses are sufficient to reach that policy’s attachment point, and courts must not credit complaints that impermissibly commingle covered loss with other amounts, such as prejudgment interest, that do not themselves contribute to exhaustion. Applying that standard, the Court faulted plaintiffs’ own allegation of “$43,000,000 in covered Loss and recoverable interest” for blending two different things, but remanded for the Court of Appeal to determine in the first instance how much of that figure, if any, can reasonably be read as covered loss alone, and whether a reasonable-likelihood standard should apply given the record’s uncertainties. In reaching this holding, the Court disapproved two prior Court of Appeal decisions, Ludgate Ins. Co. v. Lockheed Martin Corp. (2000) 82 Cal.App.4th 592 and Lockheed Martin Corp. v. Continental Ins. Co. (2005) 134 Cal.App.4th 187, to the extent they could be read as excusing insureds from pleading any covered loss at all.

Turning to the bad faith claims, the Court also held that an insured suing an excess insurer for tortious breach of the implied covenant of good faith and fair dealing likewise need not allege prior exhaustion of all underlying insurance. The Court of Appeal had relied on Waller v. Truck Ins. Exchange, Inc. (1995) 11 Cal.4th 1 for the proposition that there can be no bad faith claim absent actual coverage. The Supreme Court explained that Waller addressed whether coverage would ever be due, not when coverage attaches, and that an excess insurer’s implied duty not to injure its insured’s right to policy benefits exists from the inception of the policy, not only once exhaustion occurs. It is enough, the Court held, for an insured to allege facts showing that coverage under the excess policy will attach — or would attach but for the insurer’s own bad-faith conduct — and that the insurer’s misconduct impaired the insured’s recovery of benefits owed. The Court declined to address whether plaintiffs’ specific allegations of misconduct were adequate, leaving that question for the Court of Appeal on remand.

Finally, the Court rejected the Court of Appeal’s separate holding that declaratory relief was “not necessary or proper” under Code of Civil Procedure section 1061 even if an actual controversy existed, including that court’s concerns about entangling excess insurers in litigation whose outcome depended on unresolved claims against Twin City and about upsetting excess insurers’ settled expectations. The Court found these rationales gave undue weight to speculative future defenses and were outweighed by the hardship serial litigation would impose on insureds, particularly in disputes involving “follow form” excess policies that adopt the primary policy’s terms, where requiring multiple courts to separately interpret identical language invites inconsistent rulings. Having rejected each ground the Court of Appeal relied on, the Supreme Court reversed and remanded the case for further proceedings consistent with its opinion.

A federal jury in San Francisco has convicted Simon Katz, the Boca Raton, Florida-based CEO of a Hayward, California home health agency, of conspiring to defraud Medicare — the fourth and final conviction in a case the government first brought more than two and a half years ago. The U.S. Attorney’s Office for the Northern District of California announced the July 23, 2026 verdict, which followed a six-day trial before U.S. District Judge James Donato.

Katz, 43, ran HealthNow Home Healthcare and Hospice alongside his wife, Veronica Katz, who served as the agency’s CEO of record. According to trial evidence, HealthNow provided in-home medical care to Bay Area patients and billed both Medicare and private insurers for that care. Beginning October 1, 2018, prosecutors say, the couple began submitting fraudulent documents to California Department of Public Health inspectors to keep HealthNow’s Medicare billing privileges intact, while running a scheme with several distinct components: having unqualified staff provide patient care outside their authorized scope of practice, billing Medicare for services never actually rendered, and directing former employees to lie to federal investigators. By the time the scheme ended in November 2020, HealthNow had collected more than $3 million in Medicare payments tied to the fraudulent claims, and Simon Katz personally received roughly $300,000 of that money, according to the government.

According to an earlier December 2024 sentencing announcement, a federal grand jury indicted Veronica Katz and two co-defendants on October 17, 2023. Under her subsequent plea agreement, she admitted the scheme involved using licensed medical practitioners’ names and credentials on electronic medical records and Medicare billing submissions without those practitioners’ knowledge or consent; directing staff who were not Registered Nurses to prepare mandatory “Start of Care” assessment forms that Medicare rules reserve for RNs; digitally altering patient records afterward to make it appear an RN had completed those assessments; and billing Medicare for physical therapy visits that were never provided at all. Prosecutors say the scheme unraveled in part because of an FBI interview in October 2019, when an employee was questioned about HealthNow’s billing and assessment practices; both Katzes learned of that interview and, according to trial evidence, Simon Katz personally instructed the employee to lie to the FBI and falsely claim she had been trained and supervised by an RN.

Veronica Katz pleaded guilty to one count of health care fraud on April 18, 2024, and was sentenced that December to two years in federal prison, three years of supervised release, $543,634.34 in restitution to Medicare, and a $50,000 fine; she began serving her sentence on January 6, 2025. Two former HealthNow employees, Vennesa Herrera and Pharadja Andrews, pleaded guilty in August 2021 to conspiracy to commit health care fraud (Herrera also pleaded guilty to a substantive health care fraud count); both are scheduled for status hearings on August 3, 2026. Simon Katz, convicted after contesting the charges through trial, is currently in federal custody with no sentencing date yet set; he faces a statutory maximum of 20 years in prison and a $250,000 fine under 18 U.S.C. section 3553’s sentencing framework. Assistant U.S. Attorneys Chris Highsmith and Kevin Yeh prosecuted the trial, with assistance from Kevin Costello and Lynette Dixon; the investigation was conducted by the FBI, HHS-OIG, and the California Department of Public Health.

The new Simon Katz jury verdict lands amid a marked escalation in federal health care fraud enforcement on the West Coast and nationally. The Department of Justice created a new National Fraud Enforcement Division (NFED) on April 7, 2026, consolidating the department’s health care fraud prosecutors into a single coordinating hub tied to the administration’s broader Task Force to Eliminate Fraud, chaired by Vice President J.D. Vance. Three weeks later, on April 30, 2026, NFED and the U.S. Attorney’s Offices for the Northern District of California, Nevada, and Arizona launched a new West Coast Health Care Fraud Strike Force, staffed by at least ten NFED prosecutors and modeled on the long-running national Medicare Fraud Strike Force program, which has collectively prosecuted more than 6,200 defendants since its creation. That regional push has run alongside a larger national effort: DOJ’s 2026 National Health Care Fraud Takedown, announced June 23, 2026, charged 455 defendants — including 90 doctors and other licensed medical professionals — across 56 federal districts and 45 states and territories in connection with more than $6.5 billion in alleged false claims, with 50 state Medicaid Fraud Control Units participating, the most in the takedown’s history.

U.S. Attorney Craig H. Missakian tied the Katz conviction directly to that broader push, framing the case as part of what he called the administration’s “War on Fraud” and pledging continued prosecution of anyone who steals from federal health programs. FBI Special Agent in Charge Scott Schelble and HHS-OIG Special Agent in Charge Robb R. Breeden likewise pointed to the case as an example of sustained interagency work, with Breeden noting the investigation reflected “years of determined investigative work and close coordination among federal and state partners.” For home health agencies and their insurers, the case is a reminder that Medicare’s documentation requirements around who may perform and sign off on patient assessments — particularly Start of Care evaluations reserved for Registered Nurses — remain a frequent and closely scrutinized target of federal fraud enforcement, and that obstruction of an active investigation, not just the underlying billing fraud, can add substantially to a defendant’s eventual exposure.

Sudarshan b in Fremont, California. The policy’s “Suit Against Us” provision, tracking the standard fire policy language in Insurance Code section 2071, required that any lawsuit on the policy be brought within one year of the loss, extended to two years for losses related to a declared state of emergency.

In January 2021, after a tenant vacated the property, Kumar discovered water damage and mold in the garage, apparently caused by a leaking water heater, and reported the loss to Mid-Century on February 3, 2021. On February 10, Mid-Century mailed a letter denying coverage for the mold and wear-and-tear damage, but continued investigating potential coverage for related water damage; on February 16, following a follow-up inspection, Mid-Century mailed Kumar a second letter along with a $5,010.93 payment for covered drywall damage, again stating that it had “completed the adjustment” and was “closing” the claim, and that the claim would not be reopened absent written notice.

Over the following two years, Kumar intermittently submitted additional information and a $555,700 rebuild estimate, and Mid-Century responded in writing each time — requesting supporting documentation, quoting the one-year suit provision, and in an April 2021 letter stating it would “be happy to reopen” the claim if Kumar provided the requested materials within the policy deadline. Kumar never provided that documentation, and Mid-Century’s contractor-verification efforts and a July 2021 engineering inspection both confirmed no additional coverage existed.

On January 18, 2023, one day after his last email exchange with Mid-Century, Kumar, representing himself, sued for breach of contract, breach of the covenant of good faith and fair dealing, misrepresentation, fraud, and unfair competition, seeking repair costs and loss-of-use damages.

Mid-Century moved for summary judgment on the ground that Kumar’s suit was barred by the policy’s one-year limitations period. Kumar opposed, arguing Mid-Century never issued an “unequivocal” denial sufficient to end the tolling period, and alternatively that the limitations period was equitably tolled, that Mid-Century was estopped from asserting the defense, and that the COVID-19 state of emergency extended the deadline to two years. In support, Kumar submitted a declaration stating that unidentified Mid-Century representatives told him orally in early 2021 that he had two years to sue, and that his limited English proficiency required him to rely on those oral statements over the written notices.

The Alameda County Superior Court granted summary judgment, finding Mid-Century’s February 2021 correspondence an unequivocal denial that started the one-year clock, making Kumar’s January 2023 complaint untimely, and entered judgment for Mid-Century in March 2025.

In the published case of Kumar v. Mid-Century Insurance Company, No. A173097 (Cal. Ct. App., 1st Dist., Div. 2, July 2026) — the Court of Appeal affirmed the trial court’s grant of summary judgment in favor of Mid-Century. This opinion was originally filed on June 30, 2026 and was not initially certified for publication; on July 22, 2026, the First Appellate District, Division Two, ordered it published in the Official Reports. It is now citable authority.

The summary judgment was reviewed de novo, applying the settled rule that an insurance policy’s limitations period is tolled “from the time the insured files a timely notice … to the time the insurer formally denies the claim in writing,” citing Hydro-Mill Co., Inc. v. Hayward, Tilton & Rolapp Ins. Associates, Inc. (2004) 115 Cal.App.4th 1145 and Prudential-LMI Com. Insurance v. Superior Court (1990) 51 Cal.3d 674. That formal-denial requirement means an “unequivocal” written denial, and neither an insurer’s invitation for further information nor an insured’s request for reconsideration reopens the tolling period, citing Migliore v. Mid-Century Ins. Co. (2002) 97 Cal.App.4th 592 and Singh v. Allstate Ins. Co. (1998) 63 Cal.App.4th 135.

Applying that framework, the panel held Mid-Century’s February 16, 2021 letter — which stated the adjustment was complete, the claim was closed, and it would not be reopened absent written notice, while accompanying a settlement payment — was an unequivocal denial as a matter of law, eliminating any pending claim to which tolling could still apply. The court rejected Kumar’s argument that Mid-Century’s repeated invitations for additional information created ambiguity, explaining that Migliore squarely rejected the identical argument on nearly identical facts, and that Kumar’s own subjective understanding of the correspondence was not a basis for finding a denial equivocal. Because the record showed at least five separate written statements from Mid-Century that the claim was closed, each accompanied by the “Suit Against Us” language, the court found no triable issue on this point.

The panel likewise rejected Kumar’s remaining defenses. His estoppel argument failed both because he never pleaded estoppel in his complaint, foreclosing it as a basis to oppose summary judgment, and because Mid-Century’s invitations to submit further information, made only in response to Kumar’s own requests and paired with repeated disclosure of the limitations period, could not support the intent-to-mislead element estoppel requires. Finally, the panel held Kumar’s fraud, misrepresentation, and unfair competition claims were, at their core, claims seeking policy benefits and therefore governed by the same one-year period, since “the applicable limitations period is determined by the gravamen of the complaint rather than the named cause of action,” citing Jang v. State Farm Fire & Casualty Co. (2000) 80 Cal.App.4th 1291 — and that Kumar had, in any event, forfeited any argument for treating those claims as independent torts by failing to raise it in the trial court.

The Centers for Medicare & Medicaid Services has begun the machinery that, for the first time in the roughly 15-year history of mandatory Section 111 reporting, can turn a late Medicare Secondary Payer filing into a real dollar penalty. According to CMS’s own civil money penalty guidance pages, the agency began randomly auditing Section 111 records in January 2026 and is now working through its first round of noncompliance notices to insurers, self-insured employers, and workers’ compensation payers.

The penalties trace back to a final rule CMS published in the Federal Register on October 11, 2023, which took effect December 11, 2023, became applicable to new coverage events on October 11, 2024, and became enforceable, meaning penalties could actually attach, on October 11, 2025. The rule fills in details that Congress left to CMS’s discretion when it authorized penalties for Section 111 noncompliance back in 2013’s SMART Act.

Under the final rule, CMS narrowed what can trigger a penalty considerably from what it originally proposed. Early drafts would have allowed penalties for late reporting, for reporting that contradicted an entity’s earlier submissions during a recovery dispute, and for exceeding a data-quality error threshold in four of eight consecutive quarters. In the final version, CMS dropped the latter two triggers entirely; the sole basis for a civil money penalty now is late reporting, measured against a 365-day deadline running from a settlement date or the date an entity assumes ongoing responsibility for a claimant’s medical care.

The dollar amounts differ depending on the type of reporting entity. Group health plans face a flat penalty, currently $1,512 per day of noncompliance after inflation adjustment, with no discretion for CMS to reduce it, since the statute sets that rate directly. Non-group health plan entities, meaning liability insurers, no-fault carriers, and workers’ compensation payers, are subject to a tiered structure instead: $378 per day (2025, inflation-adjusted) for a record reported one to two years late, $756 per day for two to three years late, and $1,512 per day beyond three years, capped at $365,000 for any single record. CMS says it adopted the tiered approach, rather than mirroring the flat GHP rate, specifically in response to industry comments asking that penalty size track the severity of the delay.

To find violations, CMS is not scanning every submission. Instead, beginning in January 2026 and continuing every quarter, the agency randomly selects 250 records nationwide from newly accepted Section 111 filings, proportioned to reflect the actual mix of GHP and NGHP submissions that quarter. With roughly 20,800 active reporting entities registered, any individual company’s odds of being pulled into a given quarter’s sample are low, though CMS notes multiple records from the same entity can theoretically be selected.

An entity flagged in the audit receives an Informal Notice first, not an actual penalty, and has 30 days to submit mitigating evidence, such as documentation that a delay stemmed from a technical issue outside its control or from a beneficiary who refused to provide identifying information despite good-faith outreach. If CMS rejects that explanation or receives no response, the case proceeds to a formal Notice of Proposed Determination, and the entity can request a hearing before an administrative law judge within 60 days, followed by a further appeal to the Departmental Appeals Board’s Appellate Division. Notices go only to the entity’s Authorized Representative and Account Manager on file, according to CMS, and outdated contact information is not treated as an acceptable defense.

CMS reportedly told attendees at a January 15, 2026 webinar that its first informal notices for liability and no-fault claims were expected to go out in March 2026. Workers’ compensation reporting is on a delayed track: because CMS added new Medicare Set-Aside data fields to workers’ comp reporting requirements in April 2025, the earliest date CMS could issue a workers’-comp-related penalty notice is July 2026, according to that same account of CMS’s guidance. Those dates come from CMS’s public webinar remarks as relayed by outside counsel, not from the final rule’s text itself, and CMS’s own published materials describe the audit and notice cadence in general terms without committing to those specific calendar dates.

For employers and the insurance industry, the practical takeaway is that a rule which has existed on paper for more than two years is now generating actual audit activity, with real money attached for the first time. Self-insured employers and carriers that serve as Responsible Reporting Entities have reason to confirm their Section 111 profile contacts are current, and to review internal procedures with any third-party reporting agents, since CMS notices go to the RRE itself and reporting agents are not copied.

CMS’s own regulatory impact analysis, included in the final rule, flagged that the agency does not expect the penalty regime to be economically significant. Modeling the rule against 2022 reporting behavior, CMS estimated a worst-case aggregate of $128.8 million in penalties across the entire industry in a given year, below the $200 million threshold that would have required a fuller economic impact analysis, and CMS cautioned that the 2022 data likely overstates typical noncompliance since it predates entities’ efforts to come into compliance ahead of the rule.

This summary is for general informational purposes only; readers should consult the primary CMS guidance and Federal Register final rule linked above for complete, current data and methodology.

A new RAND Corporation study, Examining the Impact of Senate Bill 1160 on Utilization Review and Medical Treatment in California Workers’ Compensation, offers the first empirical look at whether a decade-old reform aimed at speeding up early medical care for injured workers actually worked. The report, published July 20, 2026 and sponsored by the California Department of Industrial Relations (DIR), finds that the 2016 law delivered a modest, measurable improvement in one key treatment area — but that utilization review (UR) was rarely the barrier the law was designed to remove in the first place.

Senate Bill 1160, enacted in 2016 and effective for injuries on or after January 1, 2018, exempted certain treatments provided in the first 30 days after a work injury from prospective UR — the process by which claims administrators approve, modify, or deny a treatment recommendation before care is delivered. Under the law, treatment for an accepted, compensable injury that is consistent with the Medical Treatment Utilization Schedule (MTUS) and delivered by a provider in the employer’s medical provider network is automatically authorized during that first month, without needing prospective sign-off. Claims administrators can still review those treatments retrospectively to check MTUS consistency, and a provider found to have a pattern of inconsistent care can be required to go back through prospective UR. The exemption reaches common early-stage treatments such as physical therapy and initial X-rays, but Labor Code section 4610(c), as amended by SB 1160, carved out several categories that remain subject to prospective UR even in the first 30 days, including surgery, pharmaceuticals, imaging other than X-rays, psychological treatment, home health care, and certain injections. All employers remain required to maintain a UR plan consistent with Labor Code section 4610 and its implementing regulations at 8 California Code of Regulations section 9792.6 et seq.

To evaluate the law’s effects, the RAND team — led by Stephanie Rennane and Michael Dworsky — combined four data sources: individual-level treatment-authorization records from two large claims administrators covering Northern and Southern California, statewide Independent Medical Review (IMR) data from DIR, DIR’s own UR audit reports, and medical billing data from the California Workers’ Compensation Information System (WCIS). The study period ran from January 2017 through January 2024, covering a full year before the law’s effective date and six years after. Researchers used interrupted time-series models to test for statistically significant shifts in UR approval rates, receipt of guideline-concordant care, and time to first treatment, before and after the January 1, 2018 implementation date.

The headline finding is that UR approval rates for treatment requested in the first 30 days after injury were already high before the law took effect — consistently above 90% at both claims administrators the researchers studied — and did not change in any statistically meaningful way afterward. That held true across nearly every treatment category the researchers examined, including physical therapy, imaging, surgery, and durable medical equipment. Approval rates for requests submitted later in a claim, by contrast, ran several percentage points lower throughout the study period, and treatment categories that SB 1160 left subject to full prospective review — imaging other than X-rays, injections, and psychiatric or psychological services — consistently showed the lowest approval rates of all, in the 70% to 90% range depending on the data source and category. In other words, the study suggests UR was rarely denying or slowing early, routine care even before SB 1160 removed the requirement to review it in advance. The researchers also found that many claims administrators already ran informal “prior authorization” programs that let common early treatments bypass the formal request-for-authorization process entirely, further reducing the friction SB 1160 was designed to eliminate.

Where the law did leave a measurable mark was physical therapy. Among injured workers with diagnoses for which physical therapy is clinically recommended, the odds of receiving it within 30 days of injury rose 13% after SB 1160 took effect, and the average time to a first physical therapy visit within that window dropped from 13.4 days before the law to 11.9 days after. Guideline-concordant use of braces and other immobilizers also rose modestly, with 8% higher odds of receipt within 30 days, though the timing of that care didn’t measurably speed up. Effects elsewhere were smaller and more mixed: receipt of guideline-concordant X-rays didn’t change significantly, consistent with X-rays already being commonly pre-authorized before the law; guideline-discordant acupuncture — treatment given for diagnoses where it isn’t recommended — actually rose 24% in relative terms after the law, though it remained rare in absolute terms, staying under 3% of cases throughout the study; and MRI use in the first 30 days declined slightly even though MRIs were explicitly excluded from SB 1160’s reduced-review provisions, a pattern the researchers attribute to unrelated trends rather than the law itself. Overall, the study concludes that SB 1160’s clearest, most defensible effect was on physical therapy access, and that the modest size of the effects generally reflects a system in which common early treatment was already flowing fairly freely before the reform.

The report closes with three recommendations for DIR and the Legislature. First, DIR should systematically document the informal prior-authorization programs claims administrators already run, since the report found meaningful, unexplained variation in which treatments different administrators pre-approve without any authorization request at all. Second, because most UR activity and most denials happen well after the first 30 days — and because treatments SB 1160 left fully subject to prospective review, particularly imaging and psychological services, have distinctly lower approval rates — the report suggests the Legislature examine whether reduced-review treatment could be extended further into a claim, or targeted more by treatment type and evidence strength than by a fixed 30-day window. Third, the researchers recommend DIR build out its planned systemwide UR database with standardized diagnosis and procedure codes and consistent claim identifiers, arguing that the absence of any comprehensive, uniform dataset on UR decisions was itself one of the central limitations of this study and remains an obstacle to evaluating future reforms.