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Category: Daily News

Court of Appeal Denies Request to Remove WCAB Case to Superior Court

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April Williams was employed by The Home Depot. In 2003, she was injured on the job. Williams claimed workers’ compensation benefits and in December 2005, the parties signed a “Stipulation and Award and/or Order” by which The Home Depot agreed to provide “benefits and treatment [to Williams] in accordance with the opinions of the AME, Dr. Abeliuk.” Thereafter, Williams received medical treatment, including surgeries;

Williams disagrees that her condition is permanent and stationary, and claims she was “forced” to settle her claim; She made several appeals to the WCAB but the case has not resolved.

She then filed a pro-per request for removal of her case to the superior court,

Williams claimed in her civil action that the WCAB failed to require that she receive prompt and adequate medical treatment; She also claimed the WCAB allowed The Home Depot to hold her in involuntary servitude; Williams asserted that removal of her pending workers’ compensation matter to the superior court was necessary because she is mentally disabled, Her requests to the Department of Industrial Relations for reasonable accommodation under the Americans with Disabilities Act were not granted, and hence she claims her due process and civil rights have been violated;

Following a hearing, the trial court denied the request for removal, concluding that it has no jurisdiction over the matter. Williams appealed. The Court of Appeal sustained the dismissal in the unpublished case of Williams v. Home Depo.

The Court of Appeal concluded that the “trial court correctly ruled that it lacked jurisdiction to remove the workers’ compensation matter to the superior court.”

Labor Code 5955 provides, “No court of this state, except the Supreme Court and the courts of appeal to the extent herein specified, has jurisdiction to review, reverse, correct, or annul any order, rule, decision, or award of the [WCAB], or to suspend or delay the operation or execution thereof, or to restrain, enjoin, or interfere with the appeals board in the performance of its duties,” and gives the appellate courts the power to issue a writ of mandate “in all proper cases.”

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California Obamacare Launch Week Problems Continue

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The Los Angeles Times reports that California’s health insurance exchange vastly overstated the number of online hits it received Tuesday during the rollout of Obamacare. State officials said the Covered California website got 645,000 hits during the first day of enrollment, far fewer than the 5 million it reported Tuesday. The state exchange had cited the 5 million figure as a sign of strong consumer interest and a major reason people had so much difficulty using its $313-million online enrollment system.

Dana Howard, a spokesman for Covered California, said the error was the result of internal miscommunication. “Someone misspoke and thought it was indeed 5 million hits. That was incorrect,” he said. Howard said the revised Web traffic still represents a huge response. He said the number of unique online visitors Tuesday was 514,000 and the state received 19,000 calls.

Meantime, Californians were still running into computer problems and long hold times during the second day of enrollment under the federal healthcare law.

Those glitches have prompted Covered California to shut down its online enrollment system twice. First, the state took it down from 9 p.m. Tuesday until 7 a.m. Wednesday to make technical fixes. Then Covered California took enrollment offline for two hours Wednesday morning because information on health plans wasn’t loading properly, according to the state. People calling for information continued to face wait times of 30 minutes or more. Some call-center representatives at the exchange told people they were having trouble accessing the state system themselves, further slowing down the enrollment process.

State officials say they are taking steps to remedy these service issues. California has about 300 people answering calls now, and it plans to add an additional 150 employees next month at a call center opening in Fresno.

Other states have similar woes. Louisiana’s top health-insurance provider said that not a single person enrolled in a new health-care plan offered through the Affordable Care Act on its first day. An executive with Blue Cross Blue Shield of Louisiana told the Times-Picayune that the agency was unable to sell the plan because customers were unable to access the HealthCare.gov website due to its website’s sluggishness. “It was not as intense as we had anticipated,” the company’s vice president of communication said of the company’s sales.

WSMV, a Tennessee television station was unable to find a single person who had signed up. “We’re hearing not a single person locally has been successful getting through to the new health insurance exchange,” said a local reporter. “It seems to be a problem especially in states like Tennessee, where the state opted out and left it up to the federal government to run what is essentially an online shopping site.”

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DWC Says RBRVS Fee Schedule Takes Effect In 2014

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The Division of Workers’ Compensation will begin using a resource-based relative value scale (RBRVS) based physician fee schedule in 2014. On September 24, the OAL filed the Physician Fee Schedule with the Secretary of State which will be published in the California Code of Regulations. The adopted Physician Fee Schedule regulations are effective January 1, 2014, and will be applicable for services rendered on or after January 1.

“These regulations will provide a more responsive framework for appropriate medical care and returning injured employees to work,” said Christine Baker, the director of the Department of Industrial Relations.

“Adopting a payment schedule based on the RBRVS will increase fairness in reimbursement across the spectrum of medical services, help to reduce disputes regarding the reasonable value of medical services, and improve injured workers’ access to the most needed medical services,” said Dr. Rupali Das, Executive Medical Director of DWC.

In the RBRVS-based system, relative value units interact with payment ground rules and the conversion factor to determine the maximum fee in light of the resources to provide the service. Senate Bill 863 directs DWC’s administrative director to adopt a physician fee schedule based upon the federal RBRVS used in the Medicare payment system.

The Physician Fee Schedule will be updated before January 1, 2014, by Administrative Director Order, in accordance with Labor Code §5307.1(g)(2), to reflect 2014 changes in procedure codes, relative weights, and the adjustment factors in subdivision (g) (the Medicare Economic Index and any relative value scale adjustment factor), to be applicable for services rendered on or after January 1, 2014. The Administrative Director Order will be issued as soon as possible after CMS adopts the 2014 Medicare Physician Fee Schedule final rule. CMS usually publishes the Physician Fee Schedule final rule approximately the first of November.

This RBRVS based Physician Fee Schedule will be applicable for services rendered on or after January 1, 2014, instead of the earlier OMFS physician fee schedule. The earlier OMFS physician fee schedule has not been updated with new codes and relative value units since 1999. This newly adopted physician fee schedule uses current procedure codes and relative values, and provides a mechanism for annual updates to reflect changes in coding, practice patterns, and inflation.

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Obamacare Opens to Crashing Websites and Grumbling Users

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As tech launches go, Obamacare has been pretty bumpy, if not a downright Fail Whale-style debacle according to a report in Bloomberg Businessweek. The federally run website was unresponsive for much of Tuesday morning, and only four of 15 exchange websites being run by states and the District of Columbia were working from 9:30 a.m. to 10:30 a.m. In the days before the launch, meanwhile, insurers complained about errors in the premiums that shoppers would see online and certain functions had to be delayed because the software that determined eligibility remained a work-in-progress.

“Like every new law, there will be glitches we’ll fix,” President Obama said during a Rose Garden speech. “This morning the [federal] site has been running more slowly than it normally will. The reason is more than one million people visited healthcare.gov before 7 this morning. There were five times more users this morning than had ever been on healthcare.gov at one time.”

The San Jose Mercury News reported that the widely anticipated rollout of California’s online health insurance exchange witnessed sluggish access and spotty problems Tuesday, but that didn’t stop state officials from labeling it “a historic day” that will begin to allow millions of Californians to access quality health care for the first time. For many, the array of plans and prices offered under Obamacare proved to be a welcome surprise, but others experienced sticker shock from significantly higher costs.

On the first day of a six-month open enrollment period, the California website received one million page views in the first hour, followed by 800,000 page views every hour after, according to Covered California staff. The computer system that was designed to accommodate 2,000 concurrent users was getting 3,000, officials said, while the exchange’s two operative call centers in the state received nearly 9,000 calls by noon. But there were problems. Users reported “horrendously slow” response times, with Web pages sometimes never loading. Some of the problems mimicked those around the country, where a combination of high demand and technical glitches seemed to overwhelm other online systems early in the day. But California’s exchange didn’t crash.

Covered California officials estimate that during the initial open-enrollment period, which ends March 31, they will enroll 500,000 to 700,000 Californians who are eligible for subsidies to make their care more affordable.

New York officials said roughly two million people had visited their state-run site by mid-afternoon.

However, Washington state residents going to their state-run exchange were greeted with the words “Connection Refused.” Officials said the problems impacted only some visitors, but the site appeared down into Tuesday evening.

In Oregon, which has one of the country’s 16 state-based exchanges, ;glitches also materialized.Visitors were told: “Online enrollment is coming soon! Sign up to receive an email notification when it’s available.” Officials had warned earlier this week visitors would need an insurance agent or another third party to sign up in the first several weeks.

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CAAA Announces New Officers For Coming Year

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The California Applicants’ Attorneys Association (CAAA) announced that it has installed a new president and team of officers for the coming year. Incoming CAAA President Jim Butler of ButlerViadro, a Bay Area firm specializing in fighting for the rights of California’s injured workers, said his priorities would include “bringing out-of-control Utilization Review (UR) to heel, building strategic alliances with like-minded organizations to address workplace injuries, improving CAAA’s communication with our members and the outside world, and strengthening the rules of professional conduct as applicable to workers’ compensation advocates. CAAA is urging stronger standards for all parties to the workers’ compensation system, and strengthening penalties for unreasonable delay and denial of recommended medical treatment and approved disability compensation.”

Mr. Butler was born in Compton, California, the son of an attorney who represented plaintiffs in pharmaceutical malpractice and product liability cases. He lived in Central America for several years, and is fluent in Spanish.

Mr. Butler earned his law degree at the University of San Francisco. While in law school, he received awards for best brief and oral argument for the school’s Moot Court Competition. He has also received the American Jurisprudence Award in Professional Responsibility. He graduated with a Bachelor of Arts in rhetoric from the University of California at Berkeley. Butler is the author of the Injured Worker Survival Guide (1987 – 1995).

“CAAA has built a powerful digital platform over the past three years, and we will focus its power on improving our internal and external communications, and to distribute our education programs. As the premier workers’ compensation education provider, we want to make our expertise available to all interested parties to improve the treatment of injured workers,” said Butler. “We invite visitors to caaa.org, and we will be making some of our programs available there for free; For example, right now the public will find a free podcast on Independent Medical Review.”

CAAA’s leaders for 2013-2014 also include Larry Stern of Mallery and Stern as Legislative Chair, Bernardo De La Torre of the Law Office of Bernardo De La Torre, Bert Arnold of Boxer and Gerson as Treasurer and, Christel Schoenfelder of Rose, Klein and Marias as Secretary.

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DWC Proposes New UR/IMR Regulations

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The Division of Workers’ Compensation (DWC) has posted a 15-day notice of modification to the proposed utilization review (UR) and independent medical review (IMR) regulations 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. on October 11. The number of proposed changes are extensive. The following are some examples.

The new proposed rules set forth a revised Request for Authorization form (DWC Form RFA), emphasizing that it must be signed by the employee’s treating physician. There is a statement on the DWC Form RFA that it is not a separately reimbursable report under the Official Medical Fee Schedule.

One of the proposed changes that may be of concern to claim administrators is Section 9792.9.1(c)(2), Under this proposed language, a non-conforming request for authorization (i.e., an incomplete Form RFA or request that does not use the form) must be returned to the requesting physician within three business days or else be considered as complete and subject to all applicable timeframes and requirements. This provisions would seem to place a substantial burden on claim administrators. It would seem that a Request for Authorization buried in any document forwarded by a treating physician would have to be identified (by reading carefully every single word in the document) and then this obscure language would rise to the level of an official Request for Authorization unless the administrator objected in three days. It is difficult to see how a claim department could meet this burden.

Section 9792.10.4 of the proposed changes allow the independent review organization delegated the responsibility by the Administrative Director to conduct independent medical review pursuant to Labor Code section 139.5 (IMRO) may consolidate two or more eligible applications for independent medical review by a single employee for resolution in a single determination if the applications involve the same requesting physician and the same date of injury.

The new proposed regulations implement new procedures to impose sanctions. Section 9792.10.6(j) provides that upon receipt of credible information that the claims administrator has failed to has failed to comply with its obligations under the independent medical review requirements the Administrative Director shall, concurrent or subsequent to the issuance of the final determination issued by the independent review organization, issue an order to show cause for the assessment of administrative penalties against the claims administrator under new section 9792.12(c). Section Section 9792.10.7 provides that upon receipt of credible information that the claims administrator has failed to implement the final determination, the Administrative Director shall issue an order to show cause for the assessment of administrative penalties against the claims administrator under new section 9792.12(c).

Section 9792.12(c) is a new subdivision to provide for Independent Medical Review Administrative Penalties. The subdivision lists specific violations and the amount to be assessed as an administrative penalty for each.

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

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Researchers Find Little “Rhyme or Reason” Behind Physician Reimbursement

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Private insurance companies across the U.S. pay doctors dramatically different amounts for the same routine office visits and services, according to a new study reported by Reuters Health. Physicians at the high end of the reimbursement spectrum get more than twice as much as those at the low end for the same service, with little apparent reason for the difference, researchers say.

“We figured that if we looked at fairly similar office services across clinics, the amount received by doctors might not vary much,” said Laurence Baker, co-author of the study and chief of health services research at Stanford University in California. “But that was not true.”

In the push to contain healthcare costs, focusing on how much care patients use won’t solve the problem unless the market forces determining what doctors charge and what insurers pay are better understood, Baker and his colleagues write in the journal Health Affairs. Unlike other health care cost studies, theirs looks at actual reimbursement amounts to physicians, and not the amount billed.

The researchers analyzed more than 40 million claims filed in 2007 for nearly a dozen types of service ranging from five-minute check-ups to comprehensive exams. The most common claim filed was for a “problem-focused” exam lasting about 15 minutes with a patient the physician already knew. The lowest-paid 5 percent of doctors received $47 or less for the visit while the highest-paid 5 percent received $86 or more. The average reimbursement amount was $63. For more complex, yet identical, office visits lasting longer and involving a new patient, the reimbursements ranged from $103 or less to $257 or more.

The price differences couldn’t be explained by the patients’ age or sex, the physicians’ specialty, the patients’ insurance plan type – preferred provider organizations (PPO) or point of service (POS) – or whether the physician was in the plan’s network. Geographic location accounted for some of the price variation, but only about one-third of it. Even with location taken into account, researchers could not pinpoint differences among specific cities because Truven Health Analytics, the company that provided the data, did not allow precise location information to be published in the study. “The point is that (there is) very little that can explain these price differences, no matter what information you put into the model,” Dr. Renee Hsia, professor of emergency medicine at the University of California at San Francisco, told Reuters Health. “There is not much rhyme or reason as to why the prices are what they are,” Hsia, who was not involved in the research, said.

Baker suggested that some variables, such as the quality of service provided by physicians, or the market power of insurance companies, could influence payments, but these were not analyzed in the study. “The take-away message is to get a quote before you go to the doctor’s office and consider shopping around,” said Chapin White, a senior health researcher at Center for Studying Health System Change in Washington, D.C.

Comparison shopping on cost isn’t easy for consumers, however, because the information is not readily available. Companies trying to bring price information to the public include the San Francisco-based startup Castlight and FAIR Health in New York City. “We think it is important to push future analyses further to include information we were not able to look at here,” Baker told Reuters Health. For example, the team did not know the size of the physicians’ practices. Larger practices may be able to command higher reimbursements, he said.

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Medical Identity Theft Increased by 19%

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A new study reported in SC Magazine says that as the number of individuals impacted by medical identity theft continues to climb, so does the number of victims fooled by spurious emails and websites designed to purloin their sensitive information.

According to the “2013 Survey on Medical Identity Theft,” the number of people who’ve fallen victim to this type of fraud has increased by 19 percent since last year, accounting for more than 1.8 million victims in 2013. More than 300,000 new medical identity theft cases cropped up during the one-year period, the study found. The survey was conducted by the Ponemon Institute and sponsored by the Medical Identity Fraud Alliance (MIFA) and data breach prevention firm ID Experts.

The study, in its fourth year, surveyed nearly 800 adults in the U.S. who self-reported that they, or their close family members, were victims of medical identity theft.  Along with the rise in medical identity fraud, experts also saw a significant uptick in dubious websites being erected by saboteurs and spam emails being sent – all with the intent of tricking individuals into giving up their medical information.

Between 2012 and 2013, the percentage of medical identity theft victims reporting spoofed websites and phishing emails as the likely cause of their troubles doubled. This year, eight percent of respondents cited the cyber schemes as the cause of their issues, while only four percent of victims reported the same in 2012.

In the report, medical identity theft was defined as a person using an individual’s name or personal identity “to fraudulently receive medical service, prescription drugs and goods, including attempts to commit fraudulent billing.”

Larry Ponemon, chairman and founder of the Ponemon Institute, told SCMagazine.com earlier this week that in this study, and in other Ponemon studies, the frequency of spear phishing targeting medical identity theft victims has gone up. Furthermore, spear phishing, attempts to infiltrate an individual’s network or steal their data by crafting a targeted ruse they are likely to open via email, is likely under-reported among medical identity theft victims, Ponemon added.

“A lot of people aren’t even aware that they have fallen for a phishing scam because they were so sophisticated,” he said. “The ability to record it is difficult because people aren’t even aware that it’s happened to them.”

In the study, the groups also found that seven percent of medical identity theft victims believed a data breach suffered by their health care provider, insurer or related organizations, was the cause of fraud. Last year, six percent of respondents cited those reasons as the cause.

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Fed Panels Agree on Drug Compounding Bill

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House of Representatives and Senate committees have agreed on legislation that would give the Food and Drug Administration greater authority to regulate companies that compound sterile drugs and ship them across state lines. The legislation would also create a national set of standards to track pharmaceuticals through the distribution chain to help thwart the introduction of fake medication into the drug supply.

Reuters Health reports that the bill, called the Drug Quality and Security Act, comes in response to a deadly outbreak last year of fungal meningitis that killed more than 50 people and was traced to a tainted steroid sold by the New England Compounding Center in Framingham, Massachusetts.

The legislation is expect to pass smoothly and quickly through the full House and Senate.

Traditionally, pharmacists who compound medication mix tailored doses for individual patients in response to specific prescriptions. Over the last decade the practice has mushroomed, with some pharmacies selling thousands of doses of regularly used mixtures without prescriptions for physicians to keep for future use. The legislation would draw a distinction between traditional compounding pharmacies and those such as NECC which ship sterile products across state lines. These larger organizations, to be known as “outsourcing facilities,” would be regulated by the FDA but be exempt from the full spectrum of regulations that apply to traditional pharmaceutical companies. Traditional compounding pharmacies would continue to be regulated by state boards of pharmacy.

Previous attempts to create national standards to track and trace drugs have foundered amid complaints from companies that they would be too costly to implement. But concerns over counterfeit drugs have been growing. Last year, fake vials of Roche Holding AG’s cancer drug Avastin appeared in the United States from Britain where it was purchased from a Turkish wholesaler.

The World Health Organization estimates that less than 1 percent of medicines available in the developed world are likely to be counterfeit. Globally, that number is around 10 percent.

In the United States, dozens of states have some type of regulation designed to track a drug’s pedigree, but the rules are inconsistent. The bill is designed to resolve the current patchwork of federal regulation by applying a uniform standard nationwide.

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Sexual Conviction Restricts L.A. Orthopedic AME/QME Medical License

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Fred F. Hafezi, M.D. is currently listed on the DWC QME database as a spine specialist with offices in Azusa and Ontario California. The Medical Board of California reflects that he holds Physicians and Surgeons certificate G19337 originally issued in October 1970. The Board records reflect that he is certified in Orthopedic Surgery.

Medical Board records also reflect that on June 25, 2013 the office of the Attorney General of California filed an Accusation against Dr. Hafezi asking that the Board revoke or suspend his Physician and Surgeon’s Certificate,

In support of this request, the Accusation alleged that “on April 25, 2013, in the case of The People of the State of California v. Farhad Fred Hafezi, Los Angeles County Superior Court case number KA090841, Respondent (Hafezi) was ordered, as part of his sentence, to register as a sex offender pursuant to the provisions of Penal Code section 290. As a result of his being ordered to register as a sex offender, Respondent’s Physician’s and Surgeons’ Certificate No. 019337 is subject to mandatory revocation pursuant to the provisions of Business and Professions Code Section 2232.”

The Accusation continues to allege the circumstances of the criminal prosecution. “Respondent was charged with several counts of oral copulation, contact with a minor with intent to commit a sexual offense, unlawful sexual intercourse with a person under the age of 18, all violations of the Penal Code. On April 1, 2011, Respondent did an “open plea” and pled nolo contendere to all 4 counts. Then on May 26, 2011, Respondent withdrew his plea of guilty. On April 5, 2013, the court denied Respondent’s motion to withdraw his guilty plea. As a result of his plea, he now stands convicted of several counts of oral copulation and a count of unlawful sexual intercourse with a person under 18. Respondent was sentenced on May 23, 2013. Imposition of sentence was suspended, and Respondent was placed on formal probation for 36 months, ordered to serve 180 days in the Los Angeles County Jail and required to register as a sex offender pursuant to Penal Code section 290. Respondent is currently out of jail as he was given credit for time served for his county jail sentence.”

On August 6, 2013, while being represented in the Matter of the Accusation by the Law Offices of Richard A. Moss, Hafezi and his attorney signed a Stipulation for Restricted Practice. The purpose of the Stipulation was to restrict his Physicians and Surgeons certificate pursuant to Government Code section 11529.

Pursuant to the Stipulation, on August 16, Hafezi was ordered to “cease performing any activity for which a license as a physician is required in the State o! California with the sole and singular exception he may complete reports on patients seen as workers compensation referrals who were referred to him prior to the date of endorsement of this Stipulation by the administrative law judge.”

It is further stipulated and agreed that the Stipulation would be posted on the Boards website as a public document. The Stipulation is to remain in effect until completion of the administrative proceedings against him, and the issuance of a final decision of the Medical Board thereon.

A Medical Board “Action Report” dated July 1997 reflects prior discipline for Dr. Hafezi based upon Business and Professions Code §2234(b)(c)(d) “Negligent and incompetent treatment of a patient with a back injury.”

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