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New H-1B Restrictions Cause California Tech Industry Chaos

On September 19, 2025, President Donald J. Trump issued a presidential proclamation titled “Restriction on Entry of Certain Nonimmigrant Workers,” targeting perceived abuses of the H-1B visa program, which allows temporary entry for specialty occupation workers, particularly in STEM fields. The proclamation argues that the program has been exploited by employers – especially IT outsourcing firms – to displace American workers with lower-paid foreign labor, suppressing wages, exacerbating unemployment among U.S. graduates (e.g., 6.1% for computer science majors aged 22-27), and posing national security risks by discouraging Americans from pursuing tech careers. It cites examples of major tech layoffs coinciding with H-1B approvals, such as one company laying off 15,000 while securing 5,000 visas.

Key provisions include:

– – Entry Restriction: Effective 12:01 a.m. EDT on September 21, 2025, H-1B petitions for workers outside the U.S. require a $100,000 payment (per the proclamation) to be approved or supplemented; without it, entries are restricted for 12 months (expiring September 21, 2026, unless extended). This applies only to new entries post-effective date and does not retroactively affect existing visa holders or approved petitions.
– – Exceptions: The Secretary of Homeland Security can waive the restriction for individuals, companies, or industries in the “national interest” without security threats (e.g., critical sectors).
– – Implementation: Employers must document the fee before filing; USCIS and State Department will verify and deny non-compliant petitions. Guidance prevents B-1/B-2 visa misuse for early H-1B starts before October 1, 2026.
– – Further Actions: Directs the Secretary of Labor to revise prevailing wage levels upward via rulemaking; Secretary of Homeland Security to prioritize high-wage, high-skilled H-1B admissions. A joint agency report on extension is due 30 days after the next H-1B lottery.

The policy invokes INA sections 212(f) and 215(a) to protect U.S. economic and security interests, with no impact on current H-1B workers’ status or travel, per subsequent clarifications.

Effects on California Employers

California, home to Silicon Valley and the Bay Area’s tech ecosystem, relies heavily on H-1B visas – accounting for about 40% of all issuances annually, with firms like Google, Meta, and Apple sponsoring thousands. The $100,000 fee (a 20-50x increase from prior $2,000-$5,000 costs) is expected to impose steep financial and operational burdens, particularly on startups and mid-sized firms, while sparking panic, legal scrutiny, and talent pipeline disruptions. Here’s a breakdown based on recent media analyses:

– – Cost Escalation and Hiring Disruptions: The fee applies per new petition, potentially adding millions in costs for high-volume sponsors (e.g., a firm filing 1,000 H-1Bs faces $100 million). This could force California tech employers to slash foreign hires, pivot to domestic talent amid a reported 3.02% unemployment spike in computer occupations, or pass costs to workers via lower salaries – exacerbating wage suppression the policy aims to fix. Bay Area experts predict “major disruptions” to innovation, as startups – already cash-strapped – may abandon H-1B recruitment altogether.
– – Panic and Immediate Chaos: The announcement triggered a “fast and furious” rush of H-1B workers abroad to reenter the U.S. before September 21, with flights booked en masse and aborted international trips. Tech giants like Microsoft and Amazon (with major California footprints) urged employees to stay put, fearing reentry denials despite clarifications. Immigration attorneys reported “aborted takeoffs” and confusion, delaying projects and straining HR teams.
– – Disproportionate Hit to Startups and SMEs: Silicon Valley startups, which sponsor ~20% of H-1Bs but lack big-firm resources, fear being “put in a bind” and “shut out” of global talent, hindering growth in AI, software, and biotech. One venture-backed firm estimated a 30% drop in engineering hires, potentially stalling funding rounds.
– – Broader Economic and Legal Repercussions: California’s Attorney General criticized the policy as having an “adverse impact” on the state’s $500B+ tech economy, vowing to assess legal violations (e.g., under INA or equal protection). Business groups like the Chamber of Commerce predict lawsuits, while supporters argue it could boost U.S. worker employment by 6-11% in tech. Long-term, it risks eroding U.S. competitiveness, as foreign talent eyes alternatives like Canada.

Overall, while large employers may absorb costs via the national interest waiver, smaller California firms face the brunt, with effects unfolding in the FY2026 lottery (March 2026). According to Politico the demand for H-1B visas far surpasses the number available, which Congress has capped at 65,000 annually plus an additional 20,000 for people with advanced degrees.

In the 2024 fiscal year, the U.S. Citizenship and Immigration Services approved nearly 400,000 employment petitions, with more than 70 percent coming from India and 12 percent from China. H-1B visas are awarded via lottery.

Irvine Couple Arrested for 21 Counts of Medical Insurance Fraud

Rebecca Juarez, 39, and Juan Pablo Rodriguez, 31, both of Irvine were arrested on two counts of conspiracy, 21 counts of medical insurance fraud, and 21 counts of identity fraud for allegedly running an insurance fraud scheme where the couple stole more than 21 patients’ identities and submitted false insurance claims.

Investigators with the California Department of Insurance began an investigation after several Orange County residents reported the unauthorized use of their personal information to the Orange County Sheriff’s Department when they noted charges on their explanation of benefits provided by their health insurers for medical testing and treatment they never received.

The investigation revealed that Juarez, on behalf of Rodriguez, unlawfully accessed the computerized medical records system of a Mission Viejo medical practice where she worked. Juarez allegedly stole the personally identifying information of over 21 patients, which she then shared with Rodriguez who had access to a San Jose medical practice’s billing system. Rodriguez created false medical records for medical testing including COVID tests that were never performed. Rodriguez submitted those records through the San Jose medical practice’s insurance billing system resulting in the submission of fraudulent insurance claims.

Investigators determined that the unauthorized billing charges were submitted to various medical insurers between August and November 2023. The total estimated intended loss to the insurance companies exceeded $10,000.

On September 16, 2025, both Rodriguez and Juarez were arraigned on a criminal complaint filed in the Orange County Superior Court, and granted conditional releases. The couple are due back in court December 3, 2025. The Orange County District Attorney’s Office is prosecuting this case.  

Westlaw Copyright Suit Win vs First AI Competitor on Appeal

The case Thomson Reuters Enterprise Centre GmbH and West Publishing Corporation v. Ross Intelligence Inc., No. 25-2153, is an interlocutory appeal pending before the United States Court of Appeals for the Third Circuit.

West Publishing Corporation, a subsidiary of Thomson Reuters, is a leading provider of legal research tools, notably the Westlaw database. It holds a significant share of the U.S. legal research market, estimated at 40-50% based on industry reports and its dominance alongside competitors like LexisNexis. The company serves millions of legal professionals, offering access to over 28 million case headnotes, statutes, and other legal materials. Exact revenue and employee figures are not publicly disclosed, but Thomson Reuters’ broader legal division reported $7.2 billion in revenue for 2024, with Westlaw as a core component. Its market strength stems from comprehensive content, proprietary annotations, and integration with legal workflows.

In 2014, Ross Intelligence Inc., built ROSS the world’s first AI legal search engine that allowed the public to ask a question in plain English and returned ranked excerpts from judicial opinions as answers. As part of training this engine, Ross paid for 25,000 legal memoranda. Each memo featured one question and four to six answers. As Ross claims it later learned, the questions in those memoranda were developed from a small fraction of Westlaw’s millions of headnotes – what Ross claims are verbatim or close-to-verbatim quotes from uncopyrightable judicial opinions.

Ross is no longer actively operating as a company. It ceased operations in 2021 amid the ongoing copyright litigation with Thomson Reuters, which drained its resources, and is now considered a deadpooled entity. The company raised approximately $8.82 million in funding prior to shutdown but has had no reported revival or new activities since. Its website remains online with outdated “About Us” content from its founding era, but no indications of current functionality. The recent 2025 court ruling and appellate briefing are handled through legal proceedings, not business operations.

This interlocutory appeal stems from a 2020 copyright infringement lawsuit originally filed in the U.S. District Court for the District of Delaware (No. 1:20-cv-00613). At its core, the dispute involves allegations that Ross Intelligence unlawfully scraped and copied thousands of proprietary “headnotes” (concise summaries of legal points from court opinions) from Thomson Reuters’ Westlaw database to train its AI-powered legal research tool, which aimed to compete with Westlaw.

Ross countered that its actions constituted fair use under 17 U.S.C. § 107, arguing the headnotes were not sufficiently original to be copyrightable and that the use was transformative for AI training.

On February 11, 2025, U.S. District Judge Colm F. Connolly granted partial summary judgment in favor of Thomson Reuters on direct copyright infringement for 2,243 specific headnotes, finding Ross had willfully copied them. The court rejected Ross’s fair use defense after weighing the four statutory factors: Purpose and Character of Use (Factor 1) – Nature of the Copyrighted Work (Factor 2) – Amount and Substantiality (Factor 3) – Effect on the Potential Market (Factor 4).

Overall, the court concluded fair use did not apply, denied Ross’s cross-motions, and rejected ancillary defenses like merger doctrine and copyright misuse. This marked one of the first rulings rejecting fair use for AI training on copyrighted materials. Ross was certified for interlocutory appeal under 28 U.S.C. § 1292(b) due to the substantial legal questions involved.

The Third Circuit docket opened on June 24, 2025, however briefing was delayed multiple times at Ross’s request, with the opening brief due September 22, 2025.

In its September 22, 2025, opening brief (filed in both sealed and redacted versions), Ross urges reversal, calling the district ruling the “first to examine fair use in the context of AI training materials” and arguing it contains “critical errors.” Key Ross arguments include:

– – Headnotes Not Copyrightable: They are near-verbatim quotes from uncopyrightable judicial opinions, lacking originality under precedents like Banks v. Manchester (1888) and Georgia v. Public.Resource.Org, Inc. (2020), which prohibit monopolizing the law. Protecting them would violate the merger doctrine.
– – Transformative Use: Ross’s AI training created a “spectacularly transformative” tool for semantic search, advancing technology without superseding Westlaw’s market – citing Authors Guild v. Google (2015) and Google v. Oracle (2021) for intermediate copying in innovation.
– – Minimal Amount Used: Only ~0.08% of headnotes (25,000 out of 28+ million) were involved, transformed into numerical data without retaining expressive content.
– – No Market Harm: No evidence of substitution; Westlaw doesn’t license headnotes for AI or sell them separately, and any impact is from lawful competition, not copyright infringement. – – Broader Implications: Affirming would stifle AI progress, harming public access to justice and U.S. innovation, as evidenced by Ross’s shutdown due to litigation costs.

Thomson Reuters’ response brief is due later, per the briefing schedule. No oral argument date has been set, and the case is actively monitored for its potential to shape fair use doctrine in AI copyright disputes. The district court proceedings are stayed pending appeal.

While no other companies have been directly sued yet, emerging players without exclusive licenses from incumbents like Thomson Reuters or LexisNexis could be vulnerable if their models ingest similar proprietary data.

UC Davis Awarded $2.8 Million Grant to Create AI Pathology Tool

UC Davis Health gastroenterology researchers have received a $2.8 million grant from the National Institute of Biomedical Imaging and Bioengineering (NIBIB) of the National Institutes of Health (NIH) to study the mechanisms of cell therapy using an AI-based digital pathology tool.

The four-year study will further investigate regenerative therapies, particularly using stem cells, to help treat chronic inflammatory conditions. It will also focus on how AI can assist pathologists in scoring damaged and affected tissue more quantitatively.

We’re excited to be advancing cell-based therapies while also developing new tools to more precisely measure and assess tissue damage,” said Maneesh Dave, professor of gastroenterology and principal investigator of the study. “By deepening our understanding of these treatments, we hope to pave the way for novel therapies that could transform how chronic inflammatory conditions are managed.”

In earlier studies, Dave and his team investigated the therapeutic effects and mechanisms of mesenchymal stem cells (MSCs) as treatments for Crohn’s disease. Their research revealed that MSCs promote sustained tissue healing through a two-stage process.

As part of the new grant, Dave will collaborate with Satish Viswanath at Emory University to develop an innovative tool called the Inflammation Digital Pathology Tool. This AI-powered platform aims to revolutionize how researchers analyze tissue samples in studies of intestinal inflammation.

The team is leveraging a collection of digitized histopathology slides from mouse models, including those used in MSC research and other studies of inflammatory bowel disease (IBD) and graft-versus-host disease (GVHD). These slides, scanned at ultra-high resolution, form a growing database of over 700 samples, with plans to expand to more than 1,000.

Traditionally, pathologists look at tissue slides and estimate how much of the area is affected. While this has long been considered the gold standard for assessing disease and treatment response, it is a time-consuming and subjective process that relies heavily on human judgement.

To ensure accuracy, the team is working closely with a veterinary pathologist to validate the AI’s findings and refine the system. The hope is that the tool will not only match human-level precision but also uncover subtle patterns that the human eye may miss.

Additional collaborators on the grant include Richard Levenson, professor of pathology and Laboratory Medicine; William Murphy, distinguished professor of immunology; and Pedro Ruivo, health sciences clinical assistant professor.

Starbucks Face Class Actions Over Costs of New Dress Code

Starbucks employees in California, along with those in Illinois and Colorado, have initiated legal action against the company over its updated dress code policy, which took effect on May 12, 2025. The core allegation is that the policy imposes unreimbursed financial burdens on workers for required attire and related items, violating state labor laws that mandate reimbursement for necessary job-related expenses.

While full class-action lawsuits have been filed in Illinois and Colorado, California workers have so far filed formal complaints with the state’s Labor and Workforce Development Agency (LWDA). If the LWDA declines to pursue penalties, the California employees plan to file a class-action lawsuit here as well. The actions are backed by Starbucks Workers United, the union organizing efforts at the chain.

Starbucks announced the policy update in April 2025 as part of its “Back to Starbucks” initiative, aiming to “simplify” the dress code for a “more consistent coffeehouse experience” and clearer guidance for employees (whom the company calls “partners”). Key requirements include:

– – Solid black short- or long-sleeved crewneck, collared, or button-up shirts worn under the signature green apron. – – Khaki, black, or blue denim bottoms (e.g., pants or skirts), or black dresses meeting specific fit criteria.
– – Closed-toe, non-slip shoes (no Crocs or similar casual footwear). – – Removal of visible facial piercings (e.g., one plaintiff sought $10 reimbursement for removing a nose piercing).

The previous dress code, in place since 2016, was more flexible, allowing patterned shirts in various colors and looser enforcement. Under the new rules, non-compliant employees cannot start their shifts and may face disciplinary action, including verbal warnings, write-ups, or termination.

Starbucks provided two free branded black t-shirts to employees ahead of the rollout but has not reimbursed other costs, such as pants, shoes, or piercing removal.

The change sparked backlash, including a strike involving over 1,000 workers at 75 U.S. stores in May 2025, and has been criticized by Starbucks Workers United (a union representing employees at about 640 of the company’s 10,000 U.S. stores) for not being subject to collective bargaining, despite ongoing unionization efforts since 2021 with no contracts yet finalized.

On September 18, 2025, California Starbucks workers filed formal complaints with the state’s Labor and Workforce Development Agency (LWDA), alleging violations of California Labor Code Section 2802, which mandates employer reimbursement for necessary work-related expenses. If the LWDA does not pursue penalties against Starbucks, the workers plan to escalate to a class-action lawsuit on behalf of all affected California employees, regardless of union status.

The complainant in this case is Brooke Allen, a barista in Davis, California, who spent $60.09 on compliant waterproof shoes after her Crocs were deemed unacceptable, plus $86.95 on black shirts and jeans to meet the standards. Allen requested reimbursement but was denied, and she has voiced frustration over the financial strain on low-wage workers (many earning around minimum wage and living paycheck to paycheck), as well as the loss of personal expression allowed under the old policy. The complaints seek back pay for unreimbursed costs, penalties, and attorney fees.

The company has not directly addressed the filings but issued a statement emphasizing the policy’s benefits: lower employee turnover (at record lows, half the industry average) and more desired shifts for workers. It reiterated that “partners received two shirts at no cost” and highlighted broader benefits like average $30/hour in pay and perks (free college, healthcare, paid leave). Starbucks frames the change as customer- and employee-friendly, without acknowledging reimbursement demands.

Bay Area Employers Guilty of Wage Theft and & Premium Fraud

The Alameda County District Attorney’s Office Consumer, Environmental, and Worker Protection Division secured a court order of restitution against Ferooz Nangeyali and Alexandra Nangeyali, the co-owners of Alfa Private Security in Union City. Defendant Ferooz Nangeyali pleaded guilty to felony wage theft and insurance premium fraud.

In September of 2021, the California Department of Insurance opened an investigation into workers’ compensation insurance fraud and employee wage theft committed by the owners of Alfa Private Security, an armed security company operating in the Bay Area. The 4-year joint investigation with the California Department of Insurance and the California Labor Commissioner’s Office, in conjunction with the Alameda County District Attorney’s Office, involved an extensive review of Alfa’s workers’ compensation policies, its financial records, and interviews of former employees who claimed they were not lawfully compensated for working regular and overtime hours.  

The resolution in this case is the result of a successful collaboration between the California Department of Insurance, the California Labor Commissioner’s Office, and the Alameda County District Attorney’s Office. “We are grateful for the assistance of the California Labor Commissioner’s Office and the Department of Insurance. Through our joint efforts, over $200,000 will be returned to dozens of workers who were cheated out of their hard-earned income,” said DA Jones Dickson.

“The resolution of this case is a major win for the employees who were victimized by greedy individuals looking to profit at the physical and emotional expense of others,” said Insurance Commissioner Ricardo Lara. “I would like to thank the Alameda District Attorney’s Office and the California Labor Commissioner’s Office for their hard work and dedication on this case, as they partnered with my detectives to put a stop to the egregious actions of these individuals. Together, we are sending a clear message that insurance fraud is a crime and punishable in a court of law.”  

California Labor Commissioner Lilia Garcia-Brower applauded the outcome of this investigation. “Wage theft and insurance fraud not only create unfair competition, they also rob workers of the pay and protections they deserve. By working closely with the Alameda County District Attorney’s Office and other enforcement partners, we are holding violators accountable and safeguarding the rights of workers across California,” said Garcia-Brower.

The prosecution has located 37 of the 81 individuals identified as victims of wage theft. The court ordered that the defendants pay restitution of $210,652 to those defrauded workers, and to repay $80,872 to the State Compensation Insurance Fund, reflecting their loss based on ongoing criminal misrepresentations by defendant Ferooz Nangeyali and his wife, Alejandra.

Ferooz Nangeyali and Alejandra Nangeyali are scheduled to return to court for further proceedings on November 4, 2025, in Department 11 of the René C. Davidson Courthouse in Oakland. Mrs. Alejandra Nangeyali is responsible, along with her husband, for full restitution to all victims, and will have her charges dismissed in a year if the victims are repaid and she is of good conduct.  If you were an employee of Alfa Security and believe you are owed back wages, please contact the Alameda County District Attorney’s office at Ask.CEPD@acgov.org or by calling 510-383-8600.

California to Pay $3.3M in FEHA Damages + $4.9M Attorney Fees

In January 2019, Diana Bronshteyn, whom a doctor had diagnosed with fibromyalgia, sued the California Department of Consumer Affairs under the California Fair Employment and Housing Act, section 12900 et seq. She sued for failure to accommodate, failure to engage in an interactive process, disability discrimination, and failure to prevent discrimination.

The case was a long shot. Jean Hyams, one of Bronshteyn’s lead attorneys, admitted to a “significant risk that the jury might be swayed by the fact that the [Department] permitted [Bronshteyn] to take a long leave of absence and, on paper at least, offered her all of the accommodations she had previously requested.” From her work in disability rights, Hyams was aware that “women with fibromyalgia are often stigmatized and stereotyped as exaggerating or making up their symptoms.” Hyams also conceded the doctor’s notes Bronshteyn relied on in requesting leave were “ambiguous,” which compounded the risk in taking the case.

The Department fought the case hard from the start. The Department refused to discuss settlement. Many of plaintiffs motions were unsuccessfully opposed. The Department moved for summary adjudication. The court denied the motion in July 2021. Discovery was contentious. Both sides propounded multiple sets of written discovery requests, and both sides filed multiple ex parte applications and motions to compel further responses and documents.

In June 2022, Bronshteyn made a Code of Civil Procedure section 998 offer to compromise for $600,000 and for reasonable attorneys’ fees and costs. The Department rejected the section 998 offer and did not counter.

Trial by jury went for six weeks in the summer of 2022. It too was contentious. The jury found for Bronshteyn on all counts. Its verdict was $3,324,262 in damages. This sum is more than five times greater than Bronshteyn’s section 998 offer. The Department filed a motion for judgment notwithstanding the verdict. The court denied the motion. The Department moved for a new trial. The court denied the motion. The Department appealed the verdict. It lost. (See Bronshteyn v. Dept. of Consumer Affairs (May 12, 2025, B325678) [nonpub. opn.] (Bronshteyn I).) This was in 2025. By now the case was more than six years old.

Bronshteyn moved for statutory attorney fees and costs as the prevailing party under the Act, pursuant to section 12965, subdivision (c)(6). Her counsel requested a lodestar amount of $2,987,583.11, reflecting the number of hours they worked on the case, multiplied by the requested hourly rates: $1,000 for Wendy Musell; $1,100 for Jean Hyams; $1,200 for Leslie Levy; $1,100 for Sharon Vinick; $1,050 for Darci Burrell; $900 for Maraka Willits; $425 for Brittany Wightman; $350 for bar-certified law students; and $225 for paralegal and legal assistants.

Bronshteyn’s attorneys noted they had put more than 3000 hours into the case. They submitted contemporaneous and precise timesheets recorded in six-minute intervals, with breakdowns by day and person. They also filed detailed declarations describing their litigation backgrounds, past fee awards, the work on Bronshteyn’s case, the division of labor, and their efforts to limit duplication. Counsel voluntarily applied a five percent reduction to account for clerical work and travel time.

There was a contentious battle between the parties over the amount attorney fees. At the end of the day, the total fee award was $4,889,786.03. In justifying its decision to award rates at the higher end of Los Angeles rates, the court noted: “[t]he quality of lawyering was high; far beyond what the court would expect of an average lawyer – even with the years of experience the lawyers here exhibited.”

The Department appealed (again). The court of appeal affirmed the trial court award of attorney fees in the published case of Bronshteyn v. Dept. of Consumer Affairs -B329890 (Sept 2025).

In affirming the trial court, the opinion noted “In this second appeal, the Department argues the trial court abused its discretion in awarding $4,889,786.03 in attorney fees to Bronshteyn’s counsel. As the trial court aptly observed: ‘[t]he fact that [the Department] did not settle the case early might or might not be good litigation strategy or bad litigation strategy . . . But the biggest thing it does is it makes it hard for [the Department] to claim that [Bronshteyn] shouldn’t have spent money litigating to try the case, which is reflected in the number of hours that [counsel] billed.’ ”

“We affirm the trial court’s careful and well-reasoned ruling.”

Feds Sue Inland Empire Health Plan (IEHP) for False Medi-Cal Claims

The United States has filed a complaint under the False Claims Act in a lawsuit against Local Initiative Health Authority for Inland Empire Health Plan doing business as Inland Empire Health Plan (IEHP), a California Local Initiative Health Plan based in Rancho Cucamonga.

IEHP contracted with California’s Department of Health Care Services (DHCS) to arrange for the provision of health care services to Riverside County and San Bernardino County residents under Medi-Cal, California’s Medicaid program.

The government’s complaint alleges that IEHP violated the False Claims Act by making false statements to Medi-Cal and knowingly retaining overpayments.

Beginning in January 2014, Medi-Cal was expanded to cover the previously uninsured “Medi-Cal Expansion” population: adults between the ages of 19 and 64 without dependent children with annual incomes up to 133% of the federal poverty level. The federal government fully funded the expansion coverage for the first three years of the program. Under its contractual arrangement with DHCS, IEHP received funding to serve the Medi-Cal Expansion population. If IEHP did not spend at least 85% of those funds on “allowed medical expenses,” IEHP was required to pay back to the state the difference between 85% and what it actually spent. California, in turn, was required to return that amount to the federal government.

The United States’ complaint alleges that IEHP developed schemes to misuse surplus Medi-Cal Expansion funding, falling into two broad categories: (1) sham incentive programs and (2) an extra-contractual retroactive rate increase. Through these schemes, IEHP misspent Medi-Cal Expansion funding for impermissible purposes, including spending on administrative expenses, other patient populations, and simply giving away federal funding in exchange for no value in return. The complaint further alleges that IEHP was motivated by a desire to conserve its other funding, thus enriching itself.

The complaint alleges that, to make the spending appear legitimate, IEHP deceived the state by making false statements – which it knew would be relayed to the federal government – about the nature, timing, and purpose of its payments to providers. For example, IEHP internally admitted it was giving providers “free money” but asserted to DHCS that the payments were part of a metric-based incentive program rewarding providers with good performance. IEHP also disguised payments for consultants and technology services as incentive payments by funneling those payments through providers and backdated spending to fall during earlier time periods. According to the United States’ complaint, those payments allegedly were not “allowed medical expenses” permissible under the contract between DHCS and IEHP.

The United States’ pursuit of this lawsuit illustrates the government’s emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse and mismanagement can be reported to the Department of Health and Human Services, at 800 HHS TIPS (800-447-8477).

This case is being handled by the Civil Division’s Commercial Litigation Branch, Fraud Section and the U.S. Attorney’s Office for the Central District of California, in coordination with the California Department of Justice and with valuable assistance from HHS-OIG and DHCS.

The United States is represented in this matter by Assistant United States Attorneys S. Desmond Jui and Jack D. Ross of the Civil Division’s Civil Fraud Section and Justice Department Fraud Section Trial Attorney Mary Beth Hickcox-Howard.

Standford Study Shows Shift From AI as Tool to Physician Teammate

Although large language models (LLMs) have performed well on the United States Medical Licensing Examination (USMLE) and at answering medical-related questions in studies, there was currently no benchmark testing how well LLMs can function as agents by performing tasks that a doctor would normally do, such as ordering medications, inside a real-world clinical system where data input can be messy.

Thus a team of Stanford University researchers recently developed benchmarks for measuring the accuracy and effectiveness of AI agents to assist physicians and published their findings in the New England Journal of Medicine AI.

While the researchers note the enormous potential of this new technology to transform medicine, the tech ethos of moving fast and breaking things doesn’t work in healthcare. Ensuring that these tools are capable of doing these tasks is vital, and then they can be used as tools that augment the care clinicians provide every day.

“Working on this project convinced me that AI won’t replace doctors anytime soon,” said Kameron Black, co-author on the new benchmark paper and a Clinical Informatics Fellow at Stanford Health Care. “It’s more likely to augment our clinical workforce.

Black is one of a multidisciplinary team of physicians, computer scientists, and researchers from across Stanford University who worked on the new study, MedAgentBench: A Virtual EHR Environment to Benchmark Medical LLM Agents. Unlike chatbots or LLMs, AI agents can work autonomously, performing complex, multistep tasks with minimal supervision. AI agents integrate multimodal data inputs, process information, and then utilize external tools to accomplish tasks, Black explained.

While previous tests only assessed AI’s medical knowledge through curated clinical vignettes, this research evaluates how well AI agents can perform actual clinical tasks such as retrieving patient data, ordering tests, and prescribing medications.

Chatbots say things. AI agents can do things,” said Jonathan Chen, associate professor of medicine and biomedical data science and the paper’s senior author. “This means they could theoretically directly retrieve patient information from the electronic medical record, reason about that information, and take action by directly entering in orders for tests and medications. This is a much higher bar for autonomy in the high-stakes world of medical care. We need a benchmark to establish the current state of AI capability on reproducible tasks that we can optimize toward.”

The study tested this by evaluating whether AI agents could utilize FHIR (Fast Healthcare Interoperability Resources) API endpoints to navigate electronic health records.

The team created a virtual electronic health record environment that contained 100 realistic patient profiles (containing 785,000 records, including labs, vitals, medications, diagnoses, procedures) to test about a dozen large language models on 300 clinical tasks developed by physicians. In initial testing, the best model, in this case, Claude 3.5 Sonnet v2, achieved a 70% success rate.

“We hope this benchmark can help model developers track progress and further advance agent capabilities,” said Yixing Jiang, a Stanford PhD student and co-author of the paper.

Many of the models struggled with scenarios that required nuanced reasoning, involved complex workflows, or necessitated interoperability between different healthcare systems, all issues a clinician might face regularly.

“Before these agents are used, we need to know how often and what type of errors are made so we can account for these things and help prevent them in real-world deployments,” Black said.

What does this mean for clinical care? Co-author James Zou and Dr. Eric Topol claim that AI is shifting from a tool to a teammate in care delivery. With MedAgentBench, the Stanford team has shown this is a much more near-term reality by showcasing several frontier LLMs in their ability to carry out many day-to-day clinical tasks that a physician would perform.

CWCI Reports Functional Restoration Programs 59% More Costly

A new California Workers’ Compensation Institute (CWCI) study offers some of the first comprehensive data on the use of Functional Restoration Programs (FRPs) to treat California injured workers. FRPs are multi-disciplinary programs used to treat injuries that involve chronic pain and improve patient function when the injuries do not respond adequately to traditional therapies.

For its study, CWCI analyzed 635 indemnity claims that involved FRPs compiled from the utilization review (UR) systems of 6 California workers’ comp insurers. Using demographic, bill review, and medical management data, the authors compared the FRP claim sample to 270,165 non-FRP indemnity claims to determine how they differ in terms of claim characteristics, geographic region, and clinical conditions. In addition, to gain a more precise assessment of FRP vs. non-FRP treatment costs, temporary disability (TD) duration, and claim durations, the FRP claims were compared to a matched sample of 2,361 non-FRP indemnity claims that had similar clinical, demographic, and claim characteristics to those of the FRP claims. The analysis found that unlike the broader indemnity claim population, which is primarily based in Southern California, FRP claims are heavily concentrated in the Bay Area, which represented nearly half of the FRP claims, and the Central Valley, which accounted for more than a quarter of the claims. In addition, the FRP claims were far more likely to involve attorney representation (94.0%) than other indemnity claims (50.8%), and despite the MTUS guideline criteria that FRPs be used for chronic pain patients, only 42.8% involved a chronic pain diagnosis, though it is unclear whether this was due to clinical inattentiveness in coding, or because some FRP participants did not have chronic pain.    

FRPs typically began after extended periods of conventional treatment, with an average of 792 days between the first medical service date on the claim to the first FRP service date, during which time the injured workers averaged 37 conventional physical medicine visits. Though the Medical Treatment Utilization Schedule (MTUS) treatment guidelines recommend that FRPs run for 4 to 6 weeks, the study found that they tend to run longer, with a median duration of 8 weeks. While that exceeds the MTUS recommended level, it was consistent with the intent of typical UR approvals for FRPs. In addition, while the MTUS does not recommend a set number of days for an FRP, most injured workers in these programs received 20 to 40 days of FRP services, which was also consistent with the number of days approved by UR. On the other hand, injured workers in FRPs averaged 3.8 days of treatment per week, which was less than the MTUS recommendation of at least 5 days per week for tertiary rehab programs, but they averaged a total of 29.1 FRP treatment days. The study’s review of 2,896 FRP-related UR decisions across 1,059 claims (2.8 decisions per claim) found that 25.3% were denied and 4.8% were modified, significantly higher than the 7.7% denial/modification rate for non-FRP medical services noted in prior Institute research.

The cost data showed that FRP claims averaged $234,003, or 59.3% more than the similar non-FRP claims, as they were more expensive across all cost categories, with medical costs averaging twice as high, and indemnity costs and expenses each averaging 28% higher. Total inpatient and outpatient medical costs on FRP claims averaged $127,816, with FRP medical service costs alone averaging $59,106, or 72.6% of total outpatient payments on those claims. In contrast, inpatient and outpatient medical costs on the matched non-FRP claims averaged $64,062, with outpatient costs averaging $38,613.

A key reason for the higher outpatient costs on the FRP claims was that a third of the procedure codes used to bill FRP services were not listed in the Official Medical Fee Schedule, and payments associated with unlisted codes accounted for 84.3% of total treatment costs on the FRP claim. The payment data also show that unlisted procedure codes used for bundled FRP services led to much higher payments than conventional services, averaging $1,751 per code or an estimated $350 per hour of treatment.

FRP claim durations were also longer as these claims averaged 520 temporary disability (TD) days, 25.2% more than the 415-day average for the matched non-FRP claims, which helped push average indemnity costs on the FRP claims to $87,855 vs. $68,533 for the matched claims. Average claim durations measured from the first medical service date to the claim closure date were considerably longer than the average number of TD days for both the FRP claims (1,287 days) and the matched non-FRP claims (1,013 days) as TD for most injuries in California is capped at 104 weeks (728 days) within a 5-year period from the date of injury, though the average duration of the FRP claims was still 27.0% longer than for the matched non-FRP claims.

CWCI has published its FRP analysis in a Report to the Industry which CWCI members and research subscribers can access under the Research tab at www.cwci.org. Others may purchase a copy from CWCI’s online store.