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Juliann Sum has been appointed by Governor Brown as chief of the California Division of Occupational Safety and Health (Cal/OSHA). Sum has served as acting Cal/OSHA chief since September 2013. Prior to that, she was a special advisor to Christine Baker, director of the state’s Department of Industrial Relations, which oversees Cal/OSHA.

"I am grateful for the opportunity as division chief to maintain and enhance safe workplaces and practices for workers and employers in California," says Ms. Sum. "We will continue to consistently enforce Cal/OSHA standards, develop new standards based on scientific data and practical experience, and collaborate with labor and management organizations."

In 2014, Ms. Sum established a hiring task force to facilitate filling Cal/OSHA vacancies and enabling senior staff at the division to mentor new hires before retiring. She has also strengthened the training of field staff and managers, providing them with core classes in accident investigation, citation writing, case review and legal appeals. During her tenure as acting chief, Ms. Sum also initiated efforts to encourage more immediate correction of workplace safety hazards. Last month she led the division’s effort to finalize and publish specific guidance to protect workers in healthcare settings from exposure to the Ebola virus and other infectious diseases.

Ms. Sum, who joined DIR in 2012 as special advisor, was designated acting chief in September 2013. Previously, she served from 1994 to 2012 as project director with the Institute for Research on Labor and Employment at the University of California, Berkeley, and attorney and industrial hygienist with the Labor Occupational Health Program ...
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/ 2014 News, Daily News
A 41-year-old Salinas man was sentenced Thursday to five years’ probation and 40 days in the Monterey County Jail, according to the Monterey County District Attorney’s Office.

Alberto Hernandez was previously convicted of grand theft, willfully failing to file payroll tax returns with intent to evade taxes, failure to secure workers’ compensation insurance and violating the private patrol operator provisions. Hernandez owns Salinas Valley Private Security, a private patrol operation that provides security for businesses and special events.

In February 2013, investigators from the DA’s Workers’ Compensation Unit, the California Department of Insurance, the Employment Development Department and the Bureau of Security and Investigative Services conducted a joint operation. They targeted employers allegedly out of compliance with California Labor Code regulations regarding workers’ compensation insurance. While investigating SVPS, investigators said they discovered Hernandez had been in operation since 2007 and stopped purchasing workers’ compensation insurance in 2011. Further, he had been collecting employees’ payroll tax deductions but hadn’t reported all wages. Hernandez also hadn’t turned those deductions over to the EDD since 2008.

In addition to jail and probation, Hernandez was ordered to pay more than $30,000 in fines and a combined $93,153.10 in restitution to the EDD and the Franchise Tax Board.

Investigators included Martin Sanchez and George Costa, with the DA’s Office, CDI Detective Royce Armstrong and BSIS Investigator Laura Jestes ...
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/ 2014 News, Daily News
A woman who appeared on the reality TV series "Bridezillas" has surrendered to authorities on 14 felony counts of insurance fraud.

Anita Maxwell, 55, surrendered herself to the Superior Court of California, Division 30 in Los Angeles County on 14 felony counts associated with insurance fraud. A California Department of Insurance investigation revealed that Maxwell, featured in season four of the reality series "Bridezillas", allegedly submitted fraudulent documents and made false claims to receive more than $40,000 in undeserved workers' compensation benefits. She was also the only Bridezilla to have been left at the altar.

The department's investigation began in 2012 after Maxwell claimed she injured her neck, back, and shoulder while assisting a patient as a clinical partner. While out on workers' compensation, Maxwell allegedly lied to her doctor, denying she had prior injuries to her neck, back and shoulder. The investigation also revealed Maxwell had multiple prior injuries dating back to 1990. Prior to the 2012claim, Maxwell received $20,000 from similar workers' compensation claims. Upon learning of the prior injuries Maxwell's doctor said he would have changed the apportionment and disability amounts to reflect the past trauma, lowering her claim to only 25 percent related to her work injury.

In addition to lying about her injuries, Maxwell allegedly submitted false mileage forms for her supposed travel to and from doctors and physical therapy appointments. Surveillance conducted during the investigation showed Maxwell on more than a dozen occasions commuting to her appointments from a different location than the one she reported to her insurer. The fraudulent mileage forms submitted resulted in over $5,000 in undeserved mileage reimbursement.

This case will be prosecuted by the Los Angeles District Attorney's Office ...
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/ 2014 News, Daily News
Compression fractures in the spine due to osteoporosis, a common condition causing progressive bone loss and increased fracture risk, are especially common in older women. A new study appearing in the Journal of Bone and Joint Surgery (JBJS) found that patients who wore a brace as treatment for a spinal compression fracture had comparable outcomes in terms of pain, function and healing when compared to patients who did not wear a brace.

Nearly 700,000 men and women suffer from a spinal compression fracture each year. These fractures, which for the most part are stable fractures occurring on the front or anterior of the spine, are nearly twice as common as other fractures typically linked to osteoporosis such as broken hips and wrists. Women are at greater risk with more than 30 percent age 70 or older suffering at least one osteoporosis-related spinal fracture. Many patients with these fractures are instructed to wear a soft or rigid brace to stabilize the spine with the intent of reducing pain and preventing further deterioration and collapse of the fracture site.

However, patients often find the braces uncomfortable, and as a result, do not wear the braces consistently. In addition, prolonged use may result in muscular atrophy (muscle deterioration due to lack of use), deconditioning, skin irritation, as well as additional costs and delays in rehabilitation. In a Korean study, 60 patients (age 65 and older) with acute osteoporotic compression fractures were randomly assigned within three days of injury to wear a soft brace, a rigid brace or no brace. Outcomes then were measured at 12 weeks using Oswestry Disability Index (ODI) scoring, a common method for determining levels of pain and mobility in orthopaedic patients.

The overall ODI Visual Analog Pain Scale (VAS) scores that measure lower back pain and anterior (front) body compression ratios (the length of the spine) did not differ significantly among the groups after 12 weeks. The ODI and VAS scores for back pain significantly improved with time after the fractures, and the body compression ratios significantly decreased with time in all three groups.There was no difference in the compression ratio, as seen on radiographic image; general health status; and patient satisfaction rates among the three groups.

"In addition to the cost and discomfort associated with braces, the findings in this study suggest that brace treatment for osteoporotic compression fractures may not provide any additional improvement in fracture healing, mobility and pain," said Ho-Joong Kim, MD, PhD, orthopaedic surgeon and assistant professor, Seoul National University College of Medicine. "Moreover, the gradual deterioration in life quality, including mental and social wellbeing, associated with this condition reemphasizes the need for prevention of osteoporotic compression and other fractures," said Dr. Kim ...
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/ 2014 News, Daily News
A Los Angeles-area physician whose referrals led to more than $1.7 million in fraudulent Medicare billings was sentenced to 24 months in federal prison for his role in a conspiracy to defraud Medicare related to medically unnecessary power wheelchairs and other durable medical equipment.

Charles Okoye, a 52-year-old Carson resident who formerly operated a medical clinic in South Los Angeles, was sentenced by United States District Court Judge Michael W. Fitzgerald, who also ordered the defendant to pay $931,118 in restitution. Okoye pleaded guilty in August and admitted that he referred Medicare beneficiaries to a Gardena durable medical equipment supply company for power wheelchairs and other durable medical equipment (DME). These beneficiaries had been recruited by employees of Adelco Medical Distributors, Inc. and taken to see Okoye for a single, cursory examination, after which Okoye made the referrals to Adelco.

Adelco’s owner, Adeline Ekwebelem, paid Okoye an illegal kickback for every referral, and then billed Medicare more than $1.7 million for providing the DME, which the beneficiaries did not need or want and often never used. Medicare paid Adelco more than $820,000 on those claims. Ekwebelem was found guilty in September of conspiracy to commit health care fraud, health care fraud, and the payment of illegal kickbacks. Judge Fitzgerald is scheduled to sentence Ekwebelem on January 15.

Okoye admitted that he engaged in a similar unlawful arrangement with another DME company, Esteem Medical Supply.

As a result of his guilty plea and conviction, Okoye’s medical license will likely be suspended for at least three years, and he will likely lose his ability to bill Medicare and Medi-Cal for patient services in the future. The investigation into Okoye, Ekwebelem, and others involved with Adelco’s fraudulent scheme to defraud Medicare was conducted by the U.S. Department of Health and Human Services, Office of the Inspector General, and the Federal Bureau of Investigation ...
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/ 2014 News, Daily News
The Division of Workers’ Compensation (DWC) has posted proposed "Chronic Pain Medical Treatment Guidelines" to its online forum. Members of the public may review and comment on the proposal online until Thursday, December 18.

The current Medical Treatment Utilization Schedule (MTUS) Chronic Pain Medical Treatment Guidelines is based on a "frozen" 2009 adaptation of the Official Disability Guidelines (ODG) published by the Work Loss Data Institute.

The proposed guidelines consist of an edited version of the ODG "Treatment in Workers’ Compensation - Chapter on Pain (Chronic)," published April 10, 2014, which DWC has adapted with permission from the publisher. The proposed guidelines were developed in cooperation with the multidisciplinary Medical Evidence Evaluation Advisory Committee (MEEAC) and are based on the best available medical evidence and scientific studies.

"Chronic pain is a public health problem, a significant factor in delayed recovery, and the main reason for medical treatment disputes in the workers’ compensation system," said DWC Executive Medical Director Dr. Rupali Das. "A key goal of these guidelines is to incentivize a multidisciplinary approach to chronic pain treatment to restore function and reduce pain and ultimately to encourage return to work following injury. The guidelines promote an evidence-based, comprehensive approach to treating pain, emphasizing measures that prevent or reduce chronic pain, suffering, and disability."

The proposed MTUS "Chronic Pain Medical Treatment Guidelines" provide a set of best practices for considering a multidisciplinary approach to the management of chronic pain issuing from work-related injuries. The guidelines consist of an introduction (Part 1) and specific recommendations on interventions and treatments for chronic pain (Part 2), in addition to extensive bibliography and reference summaries. Specific guidance on opioid use is not contained in the "Chronic Pain Medical Treatment Guidelines" but is provided in a separate MTUS chapter. The proposed new guideline presents a 132 page "menu" of procedures in alphabetical order similar to the existing guideline. Next to each procedure or topic, the "Summary of Medical Evidence" is given with a conclusion such as "recommended" or "not recommended." After the procedure summary, the Guideline lists the citations to the scientific studies used to support the conclusion for a total of 964 pages contained in the proposed new guideline.

"Chronic pain is a national concern. By issuing these guidelines, California continues to be on the forefront of providing appropriate care and improving outcomes," said Department of Industrial Relations (DIR) Director Christine Baker. DWC is a division of DIR.

The MTUS regulations can be found in Title 8 of the California Code of Regulations, beginning with section 9792.20. The proposed guidelines are in section 9792.24.2 ...
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/ 2014 News, Daily News
The WCIRB has completed its report on workers’ compensation insurer loss and premium experience through September 30, 2014. This report is based on data reported to the WCIRB by insurers who wrote almost 100% of the statewide market. The major findings of the report include:

1) California written premium (gross of deductible credits) for calendar year 2013 is approximately $14.8 billion. This is approximately 18% above the written premium reported for 2012 and 68% above the written premium reported for 2009. Written premium for the first nine months of 2014 is approximately $12.5 billion, which is approximately 12% above the written premium reported for the first nine months of 2013.
2) The projected industry average charged rate for policies written in the first nine months of 2014 is $2.93 per $100 of payroll, which is up approximately 2% since 2013 and up approximately 40% since 2009. Even so, the industry average charged rate remains approximately 53% less than it was for the second six months of 2003.
3) The WCIRB projects total ultimate losses and allocated loss adjustment expense (ALAE) for accident year 2013 to be $12.5 billion. While approximately 6% above the projection for accident year 2012 and 25% above the projection for accident year 2009, it remains below the highs experienced prior to the 2002 through 2004 reforms.
4) The WCIRB projects an ultimate accident year combined loss and expense ratio of 111% for 2013. This projection is below that of the last several accident years primarily as a result of increased premium levels and relatively low claim severity growth in 2013.
5) The calendar year combined loss and expense ratio for 2013 reported by insurers is 109%, which is somewhat below the combined ratios for the last few years but represents the sixth straight calendar year with a combined ratio of over 100%.
6) The WCIRB projects indemnity claim frequency for accident year 2013 to be 3.9% above the frequency for 2012 and approximately 14% above the frequency for 2009. The projected indemnity claim frequency for the first nine months of 2014 is 0.9% higher than that for the first nine months of 2013.
7) The WCIRB projects the average cost (or “severity”) of a 2013 indemnity claim to be approximately $85,000, which is generally consistent with the projected severities for the last several accident years. The projected 2013 average loss and ALAE severity reflects an increase of almost $30,000 (or more than 50%) since the full implementation in 2005 of the 2002 through 2004 reforms.
8) The WCIRB currently projects the total statewide ultimate losses on all injuries that occurred on or before December 31, 2013 to be approximately $9.6 billion more than the amounts reported by insurers.

The full report is available in the Research and Analysis section of the WCIRB website ...
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/ 2014 News, Daily News
Isaiah J. Kacyvenski is a former football linebacker of the National Football League. He was drafted by the Seattle Seahawks in the fourth round of the 2000 NFL Draft. Kacyvenski played six-plus seasons with the Seahawks recording 267 tackles in 90 games and was elected as the Special Teams Captain 3 years in a row. In 2002, Kacyvenski earned the starting job at Middle Linebacker, after battling for the position with Orlando Huff. In 2005, Kacyvenski was Special Teams Captain of the Seahawks and helped lead the team to Super Bowl XL, which was played in Detroit, Michigan. He was released by the team on September 30, 2006. Kacyvenski then signed a one-year contract with the St.Louis Rams on October 3, 2006, and played in ten games for them during the remainder of the 2006 season. As an unrestricted free agent in the 2007 off season, Kacyvenski then signed a one-year contract with the Oakland Raiders on July 11. He was placed on season-ending injured reserve on August 7 and released with an injury settlement a week later after undergoing microfracture surgery on his leg. In September 2008, it was reported that Kacyvenski had decided to retire.

On May 8, 2008, Kacyvenski filed an Application for Adjudication of Claim alleging that he sustained cumulative injury through 2007 to various body parts while a professional football player for the Raiders. The Raiders admitted left knee injury, and the Rams were joined as defendants. At the Mandatory Settlement Conference of July 8, 2014, Kacyvenski elected to proceed solely against the Raiders under Labor Code section 5500.5(c). As a result of the election against the Raiders, the Rams did not appear at the scheduled trial of August 20, 2014, during which time the Raiders and Kacyvenski entered into the Stipulations with Request for Award. The WCJ issued the Joint Award against the Raiders and Rams the same day based on stipulations between the Raiders and Kacyvenski.This Joint Award provided that applicant sustained cumulative injury to various body parts from October 3, 2006 through August 13, 2007 while employed as a professional athlete, resulting in 44% permanent disability and a need for medical treatment.

Although the Rams did not participate in the trial as the non-elected employer, the WCJ awarded benefits to applicant jointly and severally against the Oakland Raiders and against the Rams even though they did not sign the stipulation. The Rams filed a timely Petition for Reconsideration. In their petition, the Rams' contended that: (1) the Joint Award is based solely on the Stipulations between the Raiders and applicant; (2) the Rams are not a party to the Stipulations and Joint Award since Kacyvenski previously elected to proceed against the Raiders under Labor Code section 5500.5(c); (3) applicant.'s election precluded the Rams' participation at trial when the Raiders and applicant entered into the stipulated award; and (4) therefore the Joint Award against the Rams violates due process. The Rams contended that the Joint Award is in excess of the WCJ's powers under section 5903(a}, and request the WCAB to grant reconsideration and order an amended Joint Award solely against the Raiders.

The WCAB agreed in the panel decision of Kacyvenski v Oakland Raiders and granted reconsideration for purposes of amending the Award to remove the Rams from joint and several liability.

It is fundamental that due process requires opportunity to participate in the proceeding determining liability before liability is imposed. (Katzin v. Workers' Comp. Appeals Bd. (1992) 5 Cal.App.4th 703, 711-712 [57 Cal.Comp.Cases 230, 236]; Fidelity and Cas. Co. of New York v. Workers' Comp. Appeals Bd. (Harris) (1980) 103 Cal.App.3d 1001, 1015 [45 Cal.Comp.Cases 381).)

Here Kacyvenski elected to proceed solely against the Raiders, and further participation by the Rams at trial resulting in the Joint Award was precluded under section 5500.S(c).

In September 2008, Kacyvenski, the first of five other former NFL players that soon followed, agreed to donate his brain upon his death to the Center for the Study of Traumatic Encephalopathy, a joint program between the Boston University School of Medicine and Sports Legacy Institute in order to have research into the effects of concussions on the human brain performed. Kacyvenski was elected to the Board of Directors of Sports Legacy Institute in 2008, and has used this as a platform for awareness surrounding head trauma and making contact sports safer to play. Kacyvenski now works for cutting-edge conformal electronics technology company MC10, running their Sports Business. He developed the technology behind the CHECKLIGHT, a head impact measurement system, in a partnership with Reebok that launched in June 2013 ...
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/ 2014 News, Daily News
The Division of Workers’ Compensation has posted an example of a medical provider network (MPN) Application/Plan for Reapproval to help MPN applicants comply with SB 863’s statutory requirements and recent changes to MPN regulations that became effective August 27.

The DWC is no longer accepting paper submissions. When filing an MPN Application or Plan for Reapproval, MPN applicants shall submit two non-password-protected or unencrypted compact discs or flash drives in word-searchable PDF format that includes:

1. A completed section 9767.4 Cover Page for Medical Provider Network Application or Plan for Reapproval with an original signature (e-signatures are acceptable); and
2. A completed MPN Plan. Using the example described in this Newsline is advised. It can be found on the DWC website in the "Example Medical Provider Network (MPN) Application/Plan for Reapproval."

Please be aware that per Labor Code section 4616, any MPN that was approved prior to January 1, 2011 and has not been reapproved by January 1, 2015 will expire and will not be able to accept new claims. Additionally, the DWC will not accept an MPN Application or Plan for Reapproval that fails to follow the requirements set forth in the California Code of Regulations, Title 8, Section 9767.3 ...
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/ 2014 News, Daily News
A stubborn stigma persists toward injured workers who file workers' compensation claims, according to a new survey commissioned by Summit Pharmacy Inc. The survey revealed:

1) Nearly two in five Americans (37 percent) believe "most workers' compensation claims are made by people who don't want to work."
2) One in three American workers (34 percent) believe if they were injured on the job, "it would be a nightmare process to get the pain medication(s) my doctor prescribed."
3) More than one-third of Americans (35 percent) agreed with this statement: "You need a PhD to complete all the necessary paperwork associated with a worker's compensation claim."

Methodology: This survey was conducted online within the United States from September 29-October 1, 2014 among 2,016 adults ages 18 and older by Harris Poll on behalf of Summit via its Quick Query omnibus product. Figures for age, sex, race/ethnicity, education, region and household income were weighted where necessary to bring them into line with their actual proportions in the population. Propensity score weighting was used to adjust for respondents' propensity to be online.

Respondents for this survey were selected from among those who have agreed to participate in Harris Poll surveys. The data have been weighted to reflect the composition of the adult population. Because the sample is based on those who agreed to participate in the Harris Poll panel, no estimates of theoretical sampling error can be calculated ...
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/ 2014 News, Daily News
Since the implementation of tiered rating in March 2013, State Fund has broadened its pricing structure and allowed more accurate rating to an individual policyholder’s risk. Under tiered rating, State Fund is able to offer fair prices to a much broader range of employers, allowing it to remain a strong and stable provider of workers' compensation insurance for all California employers.

Throughout 2014, State Fund performed an in-depth evaluation to understand how the group insurance discount was working with tiered rating. Originally, State Fund introduced the group insurance discount to recognize and reward employers whose loss history demonstrated a culture of safety. Trade associations who had agreements with State Fund received an administrative fee, which averaged approximately four percent to six percent of premium.

The study concluded that the tiered rating plan has the same effect on policyholders as the group discount, reflecting individual performance and recognizing employers with demonstrated safety records with appropriate pricing.

In light of this analysis, State Fund has decided to discontinue group insurance and will not be renewing group agreements in 2015. Additionally, the group insurance discount will be eliminated April 1, 2015 for all groups, including the California Farm Bureau Federation.

State Fund underwrites many Alternative Dispute Resolution (ADR) groups. Beginning in 2015, specialized claims handling for these groups, but we will no longer discount the policies nor pay administrative fees.

"The workers’ compensation market has changed dramatically and the decision to discontinue the group insurance program is not a reflection on the quality of the employer associations’ value to their industry and members, but rather supports our efforts to manage costs and support fair pricing for all California employers," said Jennifer Vargen, Executive Vice President, Public Affairs. "State Fund recognizes the value employer associations bring to California and will seek opportunities to collaborate with them on safety and other issues important to California employers." ...
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/ 2014 News, Daily News
A former Ventura County neurosurgeon who was last based in Detroit, allegedly defrauded the Medicare health care program of millions of dollars by performing unnecessary spinal surgeries on patients, according to a criminal complaint recently unsealed in federal court. Neurosurgeon Dr. Aria Sabit is accused of performing lumbar spinal fusions on numerous patients and billing insurers despite failing to install medical devices in patients whose pain continued after surgery. The 40-page criminal complaint caps a lengthy investigation by the Federal Bureau of Investigation and U.S. Department of Justice that spanned at least two states, and involved multiple patients and tens of millions of dollars. The criminal complaint follows a civil case filed against the same doctor, and others, in Los Angeles federal court last September.

A disheveled, unshaven Sabit, dressed in jeans and a white T-shirt and wearing handcuffs and leg shackles, made a brief court appearance after his arrest. He could face 10 years or more in prison, if convicted.

According to the report in the Detroit News, Sabit, 40, was the focus of a front-page article in the Wall Street Journal last year that concluded he profited from implants he used in dozens of surgeries on patients, including at least one who died. The charges come two months after the Justice Department sued Sabit and a medical network over the alleged fraud. He is accused of using various businesses and medical practices to perpetuate the alleged fraud, including Southfield-based Michigan Brain and Spine Physicians Group. The firm allegedly billed health care programs for services that were not provided or overcharged for the services, according to the criminal complaint.

Sabit performed surgery on almost everyone who walked through his office, an unnamed employee told an FBI agent. Sabit previously was licensed in California and was the subject of more than two dozen medical malpractice lawsuits between 2009-10. In July, he agreed to surrender his California medical license. The new criminal complaint references five former Michigan patients, four of whom were told by Sabit that they needed to undergo spinal fusion surgery. Subsequently, after continuing pain, all patients received second opinions from other doctors stating that no such spinal fusion had been performed and there was no evidence of any screw, or any medical device in the spinal column of the patient,

The United States has also filed civil complaints in a federal district court in Los Angeles, under the False Claims Act against Sabit, spinal implant company Reliance Medical Systems, a Utah company, two Reliance distributorships - Apex Medical Technologies and Kronos Spinal Technologies, both , Florida companies - and the companies’ owners, Brett Berry, John Hoffman and Adam Pike. Reliance Medical Systems allegedly sold spinal implants in Southern California through distributorships that it controlled, including Apex Medical Technologies and Kronos Spinal Technologies. Drs. Aria Sabit and Sean Xie were physician-investors in Apex, and Drs. Gowriharan Thaiyananthan who practices neurosurgery in Orange California and Ali Mesiwala who practices in Pomona California were allegedly physician-investors in Krons. The Los Angeles civil complaints allege that Apex Medical and Kronos Spinal paid physicians, including Sabit, to induce them to use Reliance spinal implants in the surgeries they performed. The litigation also involves Ventura County neurosurgeon Moustapha Abou-Samra, M.D. and Community Memorial Health System hospital in Oxnard. The private complaint alleges that in the spring of 2009, defendant Moustapha Abou-Samra, M.D. a Board Certified neurosurgeon and president of Ventura County Neurosurgical Associates with full privileges at Community Memorial Health System (CMH), recruited Aria Omar Sabit, M.D., a non-board certified neurosurgeon, to relocate from New Jersey to Ventura County, California to be employed by Abou-Samra's corporation. Sabit was allegedly allowed to perform highly specialized neurosurgical operative procedures including spinal surgeries with open reduction and internal fixation, spinal fusions, laminectomies and pedicle screw implantation at CMH despite demonstrations that his surgeries were allegedly plagued with high infection rates, high return-to-surgery rates, violations of operating room protocols, failures in instrumentation, surgical mishaps, inappropriate case selection and high complication rates. Sabit had allegedly performed over 375 procedures from June 2009 to December 2010 while under provisional privileges at CMH. Some 27 patients who were injured by Sabit's procedures brought individual lawsuits in the Superior Court of the State of California for the County of Ventura against Sabit and some of the other defendants for medical malpractice.

Sabit is originally from Afghanistan and is accused of illegally obtaining U.S. citizenship last year. Sabit allegedly failed to disclose that he knowingly committed health care fraud, prosecutors said. The government wants Sabit held in jail pending trial, noting that he was questioned in September in Atlanta while trying to fly to Dubai. Sabit told a customs officer that he owned a company involved in mining in Afghanistan. In his luggage, officers found a ruby and a 3.6-carat emerald, according to the complaint.
...
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/ 2014 News, Daily News
Sedgwick Claims Management Services, Inc. has acquired Absentys, LLC., a Chattanooga-based software application developer and service provider. Absentys' LeaveLink and ADALink software platforms will benefit Sedgwick's claims services within the framework of the Family and Medical Leave Act, state-specific leave laws, the Americans with Disabilities Act and the ADA Amendment Act of 2008.

Absentys builds technology platforms designed to help employers ensure compliance with federal and state leave and accommodation regulations. Its proprietary, web-based LeaveLink® and ADALink® software solutions help companies navigate the framework of the Family and Medical Leave Act (FMLA), state-specific leave laws, the Americans with Disabilities Act (ADA) and the ADA Amendments Act of 2008 (ADAAA). The press release notes that Absentys’s state-of-the-art software solutions are easily configured to meet each employer’s unique needs and allow for self-administration or co-sourcing of leaves of absences and accommodation requests. The company’s software platforms currently administer leaves of absence and accommodation requests for more than 500 organizations and 3 million workers.

"Combining Absentys' powerful software solutions with Sedgwick's current capabilities allows us to not only bring our industry-leading expertise to organizations seeking to self-administer their employee absence and accommodation programs but also to augment our technology-enabled claims and productivity service offerings for large employers," said David North, Sedgwick president and CEO.

In October, Sedgwick Claims Management Services, Inc. made another significant acquisition, of T and H Global Holdings. According to a release, this acquisition includes membership in the global vrs Adjusters' organization, which is one of the top organizations in corporate and complex loss adjustment and claims management worldwide. Sedgwick's move will expand the company's international footprint beyond North America. T and H subsidiaries have a presence in all 50 states and the U.K. It includes VeriClaim Inc.; VRS VeriClaim U.K Ltd; Unified Investigations and Sciences, Inc.; Cramer, Johnson, Wiggins and Associates, Inc.; and Ellis May Chartered Loss Adjusters.

In 2010, Sedgwick was acquired by Affiliates of Stone Point Capital LLC and Hellman and Friedman LLC ...
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/ 2014 News, Daily News
About 50,000 people are alive today because U.S. hospitals committed 17 percent fewer medical errors in 2013 than in 2010, according to a report in Reuters Health. The lower rate of fatalities from poor care and mistakes was one of several "historic improvements" in hospital quality and safety measured by the Centers for Medicare and Medicaid Services. They included a 9 percent decline in the rate of hospital-acquired conditions such as infections, bedsores and pneumonia from 2012 to 2013.

Secretary of Health and Human Services Sylvia Burwell is scheduled to announced the data at the CMS Healthcare Quality Conference in Baltimore. It is based on a detailed analysis of tens of thousands of medical records, but because data was collected differently before 2010, it is not possible to compare pre-2010 figures to later ones. CMS is a unit of Burwell's department.

The deadly problem of hospital error burst into the national spotlight in 1999, when the Institute of Medicine estimated that as many as 98,000 people die every year because of hospital mistakes that allow patients to contract infections, fall, develop pneumonia from being on a ventilator, or suffer other serious but preventable harm.

In 2010, the HHS inspector general estimated that poor care in hospitals contributed to the deaths of 180,000 patients covered by Medicare, which insures the disabled and those 65 or older, every year. Officials offered several possible explanations for the steep decline in sometimes-fatal hospital-acquired injuries, infections and other conditions. Hospitals have made a concerted effort to improve safety, spurred in large part by changes in how Medicare pays them. President Barack Obama's healthcare reform law requires CMS to reduce the reimbursement rate for hospitals that re-admit too many patients within 30 days, an indication of poor care the first time. As a result of the improvements in hospital safety, 1.3 million fewer patients suffered a hospital-acquired condition in 2013 than if the 2010 rate had remained steady, CMS Deputy Administrator Dr. Patrick Conway told reporters. That produced savings of some $12 billion from avoidable costs, such as for treating a single bloodstream infection due to a catheter, at a $17,000 ...
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/ 2014 News, Daily News
This past summer, Express Scripts began blocking coverage for approximately 1,000 active ingredients used to make a variety of compounded medicines, mostly ointments, creams and powders that are found in topical treatments. The move by the nation’s largest pharmacy benefit manager was made in response to the growing cost of some of these medicines. At the time, Express Scripts official said the average cost for each prescription had risen to about $1,100 from $90. Express Scripts officials maintained that less expensive prescription medicines are readily available.

But according to the story in the Wall Street Journal, three compounding pharmacies are fighting back. Last week, three compounders filed a lawsuit charging Express Scripts is illegally blocking legitimate prescriptions and unfairly forcing patients to seek more expensive treatments or forgo medical care.

An Express Scripts spokesman declined to comment on the lawsuit and referred us to a page on the company web site in which an explanation for the policy change was made.

The compounders maintain that Express Scripts is violating federal law, because the pharmacy benefits manager allegedly lacks the authority to alter the terms of the affected health plans, according to the lawsuit. As an example, the lawsuit cites a health plan served by Express Scripts in which compounded medicines and ingredients have not been listed as excluded. "In order to cover up its financially driven scheme, Express Scripts..... is issuing intentionally deceptive and misleading letters to patients informing them that there is an unspecified change in their compound medication benefits and that there is a purported lack of FDA approval for compound medications, which is untrue," the lawsuit states. The lawsuit goes on to argue that, until now, Express Scripts "routinely paid" for compounded drugs as "medically necessary, efficacious and properly prescribed by patients. The letters are a misleading scare tactic and pretext invented to cover up its true financial goal behind the scheme." The lawsuit cites a document indicating the move is designed to cut compound spending by 95%.

The safety of some compounded medications became a hot topic two years ago after an outbreak of fungal meningitis was traced to a compound pharmacy in Massachusetts and led to dozens of deaths. This prompting Congress to pass a law called the Drug Quality & Security Act to boost oversight. The FDA, meanwhile, has responded by increasing inspections and issuing warning letters.

Compound pharmacies, however, have been chafing over the law, which creates two classes of compounders - one that voluntarily chooses to register with the FDA and another that may decline to do so. The first group is subject to certain conditions, such as meeting good manufacturing practices, but the FDA hopes the requirements will give hospitals and physicians the confidence needed to purchase needed compounded medicines.

Recently, the International Academy of Compounding Pharmacists, a trade group, began lobbying Congress to alter the law and make "technical corrections." In response, a group of trade groups for drug makers, along with the Pew Trust, wrote to the FDA to express support for the law in its existing form ...
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/ 2014 News, Daily News
In research published in the medical journal Brain, Saint Louis University researcher Daniela Salvemini, Ph.D. and colleagues within SLU, the National Institutes of Health (NIH) and other academic institutions have discovered a way to block a pain pathway in animal models of chronic neuropathic pain including pain caused by chemotherapeutic agents and bone cancer pain suggesting a promising new approach to pain relief.

The scientific efforts led by Salvemini, who is professor of pharmacological and physiological sciences at SLU, demonstrated that turning on a receptor in the brain and spinal cord counteracts chronic nerve pain in male and female rodents. Activating the A3 receptor -- either by its native chemical stimulator, the small molecule adenosine, or by powerful synthetic small molecule drugs invented at the NIH -- prevents or reverses pain that develops slowly from nerve damage without causing analgesic tolerance or intrinsic reward (unlike opioids).

Pain is an enormous problem. As an unmet medical need, pain causes suffering and comes with a multi-billion dollar societal cost. Current treatments are problematic because they cause intolerable side effects, diminish quality of life and do not sufficiently quell pain. The most successful pharmacological approaches for the treatment of chronic pain rely on certain "pathways": circuits involving opioid, adrenergic, and calcium channels.

For the past decade, scientists have tried to take advantage of these known pathways -- the series of interactions between molecular-level components that lead to pain. While adenosine had shown potential for pain-killing in humans, researchers had not yet successfully leveraged this particular pain pathway because the targeted receptors engaged many side effects.

In this research, Salvemini and colleagues have demonstrated that activation of the A3 adenosine receptor subtype is key in mediating the pain relieving effects of adenosine. "It has long been appreciated that harnessing the potent pain-killing effects of adenosine could provide a breakthrough step towards an effective treatment for chronic pain," Salvemini said. "Our findings suggest that this goal may be achieved by focusing future work on the A3AR pathway, in particular, as its activation provides robust pain reduction across several types of pain."

Researchers are excited to note that A3AR agonists are already in advanced clinical trials as anti-inflammatory and anticancer agents and show good safety profiles. "These studies suggest that A3AR activation by highly selective small molecular weight A3AR agonists such as MRS5698 activates a pain-reducing pathway supporting the idea that we could develop A3AR agonists as possible new therapeutics to treat chronic pain," Salvemini said ...
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/ 2014 News, Daily News
The Division of Workers’ Compensation announced it will initiate the procedure to assess administrative penalties for claims administrator failure to timely submit relevant medical records in cases currently pending Independent Medical Review (IMR).

Under Labor Code section 4610.5(i), DWC is authorized to assess penalties against claim administrators whose conduct has the effect of delaying the IMR process. Under current regulations, Maximus Federal Services, Inc., the organization designated by DWC to conduct IMR reviews, sends the claims administrator a Notice of Assignment and Request for Information (NOARFI) in an IMR case. The notice advises of the relevant medical records to be submitted, which must be provided to Maximus within 15 days of the date on the NOARFI. The regulatory requirements for submitting records can be found at California Code of Regulations, title 8, section 9792.10.5.

Under California Code of Regulations, title 8, section 9792.12(c)(6), failure to submit the records within those 15 days will subject a claims administrator to an administrative penalty of $500 for each day the records are untimely, up to a maximum of $5,000. DWC will send an Order to Show Cause to claims administrators who may be liable for a penalty, with the facts upon which the penalty is based, the penalty amount, and the administrative process for contesting a penalty.

The procedure to assess administrative penalties will commence in cases where there is a failure to timely submit medical records dated on and after December 1, 2014. For IMR cases currently pending at Maximus as of December 1, 2014, the penalty procedure will commence if the relevant medical records are not received on or before December 15, 2014.

DWC will continue to post updates and notifications regarding the IMR system on the IMR page ...
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/ 2014 News, Daily News
A workers’ compensation fraud defendant was sentenced to six years of local custody after being convicted by a jury of 12 felony counts including perjury and insurance fraud for her role in defrauding her employer out of more than $300,000 over a seven-year period. Golnaz Gholipour, 35, was sentenced to three years in local prison and three years of mandatory supervision. A restitution hearing will be held at a future date to determine how much she will pay in restitution to Sharp Healthcare for costs they incurred in handling her fraudulent claim.

Gholipour was a nurse at Sharp Hospital who initially told her doctors in January 2007 that she injured her back while waking up from a nightmare. She first filed for state disability benefits, but after learning that the most she could receive from state disability was $4,515 based on the fact that she’d only been employed in California a few months, she filed for workers’ compensation benefits.

All of the defendant’s medical expenses were covered and she received more than $88,000 for the two years she claimed she could not work after her injury. In May 2010, after all conservative care was exhausted, Gholipour had back surgery. By April 2013, when Ghoilpour continued to claim she was worse off than before the surgery, the insurance company hired a private investigator.

The defendant was filmed on several occasions in a normal state with no apparent injuries. Only when she was going to doctor’s visits or attending legal meetings did Gholipour appear hurt and in need of a walker. At her deposition, Gholipour testified that she lived with her parents and that her mother had to bathe her and help her get dressed. She claimed to need to use the walker at all times, that she was depressed, had not gone out on any dates and was not involved in any relationships. She also said she had significant gastro-intestinal problems and generally stayed at home groggy from her medications.

After her deposition, Gholipour was filmed over an eight-hour period as she went shopping, dined at restaurants, and moved about in a normal fashion without any sign of pain or discomfort and without a walker. On another occasion, she was filmed during a 12-hour period during which she moved potted plants on her balcony, went shopping, walked several hundred yards to go to a picnic and back and went to a movie. In the videos, she was observed with the same man who is now her husband and they appeared to be living together.

After a two-week jury trial, the defendant was convicted on eight counts of perjury and four counts of insurance fraud ...
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/ 2014 News, Daily News
Jose Valdez, 41 of Seaside, has been sentenced on one felony count of fraudulent use of a contractor’s license and one misdemeanor count of failing to secure workers’ compensation insurance, according to Monterey County District Attorney Dean D. Flippo.

Valdez was doing business as Angel Valdez Landscaping. The defendant was also sentenced on a misdemeanor violation of probation case involving the same and similar charges.

Judge Larry E. Hayes sentenced Valdez to five years probation on the new case and reinstated his probation in the earlier case on the same terms as previously ordered. He was then sentenced to 180 days in jail on the new case with that term suspended and 180 days on the violation of probation to run consecutive. His terms and conditions of probation include, but are not limited to, obey all laws including Labor Code and Business & Professions Code laws, regulations and other ordinances and pay over $20,000 in fines ...
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/ 2014 News, Daily News
The Division of Workers’ Compensation has posted a second 15-day notice of modification to the proposed Medical Treatment Utilization Schedule (MTUS) regulations to the DWC website. Members of the public are invited to present written comments regarding the proposed modification to dwcrules@dir.ca.gov until 5 p.m. on Tuesday, December 9. The proposed modifications include:

1) Re-organization of section 9792.21 to clarify the MTUS shall be the primary source of guidance for treating physicians and physician reviewers for the evaluation and treatment of injured workers.
2) Addition of a new section, 9792.21.1 - The Medical Evidence Search Sequence. The Medical Evidence Search Sequence was separated from section 9792.21 to clarify the steps required to find medical evidence. Any search for medical evidence begins, and likely ends, with the MTUS. Searching for medical evidence outside the MTUS is limited to situations where a medical condition or injury is not addressed by the MTUS or if the MTUS’ presumption of correctness is being challenged. (Note: A flow chart is included in the Notice of Modification to Text of the Proposed Regulations to provide a visual aid for the Medical Evidence Search Sequence.)
3) Specification that a treating physician who seeks treatment outside of the MTUS bears the burden of rebutting the MTUS’ presumption of correctness by a preponderance of scientific medical evidence.
4) Requirements that shall be included in a Request for Authority, Utilization Review Decision and Independent Medical Review Decision. Any citation provided by a treating physician or medical reviewer shall be the primary source relied upon which contains the recommendation that guides the reasonableness and necessity of the requested treatment that is applicable to the injured worker’s medical condition or injury. If more than one citation is provided, then a narrative shall be included in the three aforementioned documents explaining how each guideline or study cited provides additional information that guides the reasonableness and necessity of the requested treatment applicable to the injured worker’s medical condition or injury but is not addressed by the primary source.
5) Details of the citation format requirements.
6) Revision of The MTUS Methodology for Evaluating Medical Evidence to clarify when it must be applied by a reviewing physician and how to evaluate the quality and strength of medical evidence used to support a recommendation.
7) Amendments to citations in sections 9792.23, 9792.24.1 and 9792.24.3 referencing the sections currently being revised in rulemaking to sections 9792.20 - 9792.26.

The DWC has also prepared a graphical flowchart that depicts the decision making process of a medical treatment review.

The notice and text of the regulations can be found on the proposed regulations page ...
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/ 2014 News, Daily News