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Pope Powell sustained an industrial injury to his shoulders and elbows while employed by respondent City and County of San Francisco. The injury caused permanent partial disability. The parties disputed the occupational group to be used in the rating formula for his injury.

Powell’s job title was Director of Fleet Management and Operations. He supervised five employees; dealt with budgets and requests for proposals; and wrote contracts, policies, and procedures. According to Powell’s undisputed testimony, to perform his job duties he spent 80 to 85 percent of his time on a computer performing tasks such as emailing, creating spreadsheets and budgets, and drafting various documents. The parties disputed the appropriate occupational group for Powell. Powell contended occupational group 112 applied; the City contended occupational group 212 applied. The WCJ agreed with the City, and a majority of the Board affirmed the WCJ. The dissenting Board member contended that a third group, 211, was the most appropriate.

The WCJ and the WCAB awarded benefits based upon group 212, which is undisputedly appropriate for Powell’s "managerial" duties: "Mostly Professional and Medical Occupations [¶] Work predominantly performed indoors, but may require driving to locations of business; less use of hands than 211; slightly higher demands on spine than 210 and 211. [¶] Typical occupations: Chemist, Dialysis Technician, Secondary School Teacher." (Schedule, supra, at p. 3-30.)

Group 112, which Powell argues is the most appropriate: "Mostly Clerical Occupations [¶] Highest demand for use of keyboard; prolonged sitting. [¶] Typical occupations: Billing Clerk, Computer Keyboard Operator, Secretary." (Schedule, supra, at p. 3-29.)

Group 211, which the dissenting Board member found the most appropriate: "Mostly Clerical Occupations [¶] Emphasis on frequent fingering, handling, and possibly some keyboard work; spine and leg demands similar to 210. [¶] Typical occupations: Bank clerk, Inventory clerk, License clerk." (Schedule, supra, at p. 3-30.)

The Board majority affirmed the WCJ’s classification of Powell in group 212, quoting with approval from the WCJ’s opinion. The dissenting Board member disagreed. While agreeing that Powell’s job was "managerial in nature," the dissenting member found "[h]is computer use . . . was necessary and integral to the successful performance of the duties and responsibilities inherent in his position." Applying the dual occupation rule, the dissenting member found occupational group 211 "the most appropriate." The Court of Appeal reversed in the unpublished case of Powell v WCAB.

More than one occupational group may apply to an applicant’s job. In such cases, "[t]he employee is entitled to be rated for the occupation which carries the highest factor in the computation of disability. Labor Code section 3202 provides that the provisions of the Workmen’s Compensation Act ‘shall be liberally construed by the courts with the purpose of extending their benefits for the protection of persons injured in the course of their employment.’ It has been determined that where the duties of the employee embrace the duties of two forms of occupation, the rating should be for the occupation which carries the higher percentage." (Dalen v. Workmen’s Comp. Appeals Bd. (1972) 26 Cal.App.3d 497, 505-506 (Dalen); accord, National Kinney v. Workers’ Comp. Appeals Bd. (1980) 113 Cal.App.3d 203, 215 (National Kinney).) "[N]o precise percentage of time for [performing the duties of the higher percentage occupation group] is required but rather the pertinent inquiry is whether [performance of those duties] is an ‘integral part of the worker’s occupation.’ " (National Kinney, supra, at p. 216.)

The Court of Appeal agreed with the dissenting Board member that the proper focus is on the claimant’s physical work activities. The Board majority’s statements that Powell’s " ‘integral job duties . . . were managerial in nature’ " and his "job required the use of a computer to fulfill the managerial responsibilities inherent in [his] position . . . , not as his core task," erroneously focus on a characterization of his job duties as "managerial." Group 212, which contemplates some small amount of keyboard use, is only partially appropriate in classifying Powell, who spent a substantial amount of his work time on a computer or other keyboard ...
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/ 2014 News, Daily News
Payments for pharmaceuticals and durable medical equipment (DME) in California workers’ compensation continue to increase sharply, adding pressure against the recent reforms to the system according to a new CWCI study that examines medical and indemnity payment trends from accident years (AY) 2002 to 2014.

The study, based on an analysis of 2.1 million claims involving $25.6 billion in benefit payments, breaks out results by accident year, noting average amounts paid for medical services at 3 through 60 months post injury. The latest data show that while average medical payments on lost-time claims in the first two years post injury grew a modest 2.3% between AY 2011 and AY 2012, average amounts paid for pharmaceuticals and DME increased 19.4% to $2,154 -- and that came on the heels of a 26% increase in the prior year. Following legislative reforms in 2003 and 2004, pharmaceutical and DME payments declined briefly, falling in both AY 2004 and 2005, but since then they have been the fastest growing medical component in California workers’ comp, increasing more than threefold over the past 7 years. In contrast to the ongoing double-digit increases in pharmaceutical and DME payments, the 2-year data on AY 2011 and AY 2012 claims show medical treatment expenses (i.e., payments to medical providers, hospitals, outpatient facilities, and for ancillary services such as X-rays and MRIs), which accounted for two-thirds of all medical payments on those claims, and medical management/cost containment expenses (i.e., medical bill review, medical case management, utilization review and medical network fees), registered only modest increases, while payments for medical-legal reports declined.

With growth rates varying among the medical subcategories over the past decade, medical treatment declined from 81.7% of all workers’ comp medical payments at 24 months in AY 2002 to 66.6% in AY 2012, while pharmaceutical/DME payments grew from 7.8% to 13.2%. Medical management payments grew from 6.6% to 14.2% over the same period, as those expenses escalated rapidly after AY 2005 as various managed care elements of the 2002-2004 reforms led to increased outlays for medical bill review, medical case management, and medical network access fees, though the 2-year data from AY 2011 and AY 2012 claims indicate they may have leveled off, albeit near record levels.

The study also offers a first view of medical experience for 2014 injury claims, showing total medical payments at 3 months post injury averaged $3,809, up 12% from $3,400 in the prior year, but such outcomes should be treated as preliminary as early treatment patterns often change due to market and regulatory factors. In addition to identifying medical payment trends, the Institute study also provided new trend data on indemnity benefits and length of temporary disability. Among the key findings at 24 months, total indemnity costs per claim for injury year 2012 were up 5.9 percent to $12,923. At 24 months, average temporary disability payments increased by 5.5 percent and paid temporary disability days increased by 2.9%.

The CWCI Research Update report, "California Workers’ Compensation Medical and Indemnity Benefit Trends, AY 2002 - 2014," is posted on the Institute’s website, and is available to CWCI members and Research subscribers who use their passwords to log in to the site ...
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/ 2014 News, Daily News
The phrase "What we've got here is failure to communicate" is a quotation from the 1967 Paul Newman film Cool Hand Luke. The WCAB said nearly the same phrase in the new significant panel decision of Bodam v San Bernardino County Department of Social Services as it invalidated the employer's UR decision. This famous film line should serve as a constant reminder about the implications of failing to follow the last steps of the UR process.

Timothy Bodam sustained industrial injury to his lower back on March 24, 2011 while employed by San Bernardino County Department of Social Services. His primary treating physician, Edward G. Stokes, M.D., referred applicant for a surgical consultation to Dr. Cheng of Loma Linda University Medical Center. On October 28, 2013, Dr. Cheng faxed an RFA to defendant’s adjuster State Compensation Insurance Fund (SCIF), requesting authorization to perform three-level fusion surgery at L3-S1.

SCIF referred the RFA to its UR agent Forté on October 28, 2013. On October 31, 2013, Forté made its UR decision to deny the treatment request based upon a report prepared by California-licensed and Board certified orthopedic surgeon David C Bachman, M.D., who reviewed the RFA and determined the surgery was not medically supported.

On November 5, 2013, defendant mailed written denial letters to applicant and to Dr. Cheng with copies to applicant’s attorney. There is no evidence that the October 31, 2013 UR decision was communicated to Dr. Cheng by fax, phone, or email within 24 hours after the UR decision was made. There is also no evidence that written notice of the October 31, 2013 UR decision was provided to applicant, Dr. Cheng, or applicant’s attorney within two business days after the UR decision was made.

The WCJ found after an expedited hearing that the Workers’ Compensation Appeals Board (WCAB) "has jurisdiction to adjudicate treatment when utilization review [UR] is untimely" and that defendant’s UR of the Request for Authorization (RFA) to perform spinal surgery submitted by one of applicant’s physicians, Wayne Cheng, M.D., was "untimely," and lacked a necessary signature. The WCJ further found that the record did not have substantial evidence to allow proper determination of the treatment request, and for that reason ordered the record "reopened" for development by submission of a supplemental report from Dr. Cheng concerning the proposed surgery.

The WCAB in what it classified as a "Significant Panel Decision" held that "the WCJ correctly determined that defendant’s UR decision was not timely communicated and therefore invalid. Further, the WCJ properly ordered further development of the record by directing the parties to obtain a supplemental report from Dr. Cheng." Accordingly removal was denied in the case of Bodam v San Bernardino County Department of Social Services.

After considering the provisions of Labor Code section 4610(g)(1) and (g)(3)(A) and AD Rule 9792.9.1(e)(3) the WCAB held that:

(1) A defendant is obligated to comply with all time requirements in conducting UR, including the timeframes for communicating the UR decision;
(2) A UR decision that is timely made but is not timely communicated is untimely;
(3) When a UR decision is untimely and, therefore, invalid, the necessity of the medical treatment at issue may be determined by the WCAB based upon substantial evidence.

Section 4610 provides time limits within which a UR decision must be made as well as when it must be communicated and the manner of transmittal. These time limits are mandatory. In Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Dubon II), the Appeals Board held that the WCAB has jurisdiction to determine whether a UR decision is timely. If found untimely, the UR decision is invalid. Under those circumstances, the WCAB may decide the issue of the medical necessity of the requested treatment based on substantial medical evidence. The employee bears the burden of proving that the treatment is reasonably required. (Cf. State Comp. Ins. Fund v. Workers’ Comp. Appeals Bd. (Sandhagen) (2008) 44 Cal.4th 230 [73 Cal.Comp.Cases 981] (Sandhagen).)

In the present case, the RFA was received on October 28, 2013 and the UR decision was timely made three days later on October 31, 2013. However, a UR decision not only must be timely made; it must be timely communicated. A UR decision that is not timely communicated is of no use and defeats the legislative intent of a UR "process that balances the interests of speed and accuracy, emphasizing the quick resolution of treatment requests...."(Sandhagen, supra, 44 Cal.4th at p. 241.). Thus, section 4610(g)(3)(A) imposes further mandatory time requirements for communicating a UR decision. These time limits run from the date the UR decision is made, even if the UR decision is made in less than the five days allowed under section 4610(g)(1) ...
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/ 2014 News, Daily News
Yeh Juin Tung hired Michael Waller, who owned Waller Tree Care, to perform services that included removing one tree and trimming four others. The price for the work was $400. Tung was unaware that Waller was not licensed; he knew only that Waller had advertised on Yelp.com as being bonded and insured. Waller did not have workers’ compensation insurance at that time.

On October 6, 2008, Waller appeared at Tung’s property to do the work. He was accompanied by Jose Luis Escalera. Escalara leaned a ladder against a tree and climbed up about 10 feet. As he began to cut branches with a handsaw, he fell. He did not know why he fell; as he stated in his deposition, "All I know is that the ladder went to one side and I wasn’t able to hold on."

Escalara filed a civil action in December 2009, alleging negligence against both Waller and Tung.

Tung moved for summary judgment, contending that plaintiff was not his employee but an employee of Waller, an independent contractor. He also disputed plaintiff’s negligence claim "because there is no evidence of any breach of any duty or any causation by Mr. Tung." In his opposition, plaintiff agreed that Waller was an independent contractor, but he raised the "peculiar risk" doctrine to argue that Tung was liable whether or not he was personally negligent, because plaintiff was performing "inherently dangerous work," and Tung must bear responsibility for all risks of injury to a worker, "regardless of fault." The parties debated the applicability of the exception to the peculiar-risk doctrine expressed in Privette v. Superior Court (1993) 5 Cal.4th 689.

The superior court ruled in Tung’s favor. Addressing plaintiff’s assertion that Tung was vicariously liable because Waller had not procured workers’ compensation insurance, the court reasoned that "an employee of a negligent contractor can recover under the workers’ compensation system even if the contractor is uninsured." As plaintiff had not established a triable issue under the peculiar risk doctrine or supported a theory of direct liability, Tung was entitled to summary judgment. From the ensuing judgment on July 13, 2012, plaintiff brought an appeal. The Court of Appeal affirmed the dismissal in favor of the homeowner in the unpublished case of Escalera v. Tung.

On appeal, plaintiff does not suggest that he was Tung’s employee under the workers’ compensation system; he acknowledges that the Workers’ Compensation Act (§ 3200 et seq.) is inapplicable because he worked less than 52 hours on Tung’s property. Plaintiff does, however, assert that Tung was his employer for purposes of civil tort liability under section 2750.5. Plaintiff cites the undisputed facts that "Waller was a contractor who did not have a contractor’s license," that "Waller advertized [sic] his tree care business on Yelp, and that he did not state in his advertisement that he was not licensed under the contractors’ licensing law." From those facts plaintiff asserts that Waller is "conclusively presumed to be Tung’s employee" under labor code section 2750.5.

Under this statute Waller would be presumed to be an employee of Tung by performing a service for which a license was required, and plaintiff, by working for Waller, would then also be deemed an employee of Tung. A license is not required, however, for small jobs costing the hirer less than $500. (Bus. & Prof. Code, § 7048.) It was undisputed that the contract price for the tree trimming was $400; accordingly, the presumption would not have applied ...
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/ 2014 News, Daily News
Narinder S. Grewal MD, who operates the Santa Clarita Surgery Center for Advanced Pain Management on the 23800 block of McBean Parkway in Valencia, agreed to pay $1,087,176.09 to the United States and $112,823.91 to California. The settlement concludes a federal "whistleblower" lawsuit filed by Chandana Basu, who used to provide billing and collection services to the Grewal’s clinic, according to the U.S. Attorney’s Office.

Basu’s lawsuit alleged that Grewal and his clinic obtained improper reimbursements from government-run health insurance programs, including Medicare, Medi-Cal and Tricare, a federal health insurance program for military and related military personnel, according to a statement Wednesday from federal prosecutors. The lawsuit also alleged that Grewal and his clinic submitted fraudulent claims by "upcoding" medical services, which means that he allegedly submitted bills that were not justified by the services that were actually provided.

The settlement was announced this month after United States District Judge Andrew J. Guilford unsealed the lawsuit. The parties have asked the court to dismiss the suit, which was filed pursuant to federal and state False Claims Acts.

The whistleblower provisions of the False Claims Acts permit a private person to sue on behalf of the United States and California, and to share in the proceeds of the suit. As a result of the settlement announced today, Basu will receive a total of $204,000.

The case was handled by the United States Attorney’s Office and the California Attorney General’s Office, in conjunction with the Department of Health and Human Services, Office of Inspector General, and the Department of Defense, Defense Criminal Investigative Service ...
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/ 2014 News, Daily News
Severe spine injury cases involving paralysis are among the most costly industrial injuries But now, Case Western Reserve researchers have developed a procedure that restores function to muscles involved in the control of breathing - even when they have been paralyzed for more than a year. The breakthrough offers hope that one day patients with severe spinal cord injuries will be able to breathe again without the assistance of a ventilator.

According to the report in Medical News Today, principal investigator Philippa M. Warren, PhD, presented the results at Neuroscience 2014, the annual meeting of the Society for Neuroscience. "We show that respiratory paralysis can be reversed at long intervals after spinal cord injury," said Warren, a neurosciences researcher at MetroHealth Medical Center, which is affiliated with Case Western Reserve University School of Medicine. "This has the potential to alleviate the long suffering of currently injured patients, improving their quality, and potentially length, of life."

Investigators focused their research on a group of nerves that extend from the respiratory control center in the brain stem down to the C3 through C5 vertebral levels of the spinal cord located in the middle of the neck. These fibers, or brain axons, control the diaphragm muscle in its critical function of breathing. Any injury to the spinal cord above the C3 vertebra can cause widespread muscle paralysis leading to difficulties in breathing, but also moving, regulation of cardiac output, and sexual function. Unfortunately, these injuries high in the neck are the most common among sufferers of spinal cord trauma.

Following injury to the spinal cord, damaged nerve fibers die, causing loss of the connections between the brain and muscles of the body. To help preserve tissue immediately after injury, a scar forms at the site of the trauma and extends the distance of several inches up and down the spinal cord. This scar tissue is very dense, contains sugars that inhibit new neuronal growth, and does not reduce in length or intensity over time. The consequence is that new connections cannot form to enable muscle function after injury, which is exceptionally important to breathing.

Spinal cord injury-induced paralysis of the respiratory muscles causes low oxygen in the blood, increases the body's drive to breathe and drives any functioning respiratory muscles to work harder. The breathing capacity of the spinal cord-injured is often not enough to fully support a patient's life. However, if new nerve fibers or connections can form in the spinal cord, then pathways can be activated to restore respiratory function. So Case Western Reserve researchers devised a technique to treat the injury site with a specially designed enzyme to reopen connections and to apply respiratory therapy to strengthen the remaining functioning respiratory muscles.

In laboratory animals, investigators used the combination technique to restore respiratory function many months after the injury. First, they injected the chondroitinase enzyme at the site of respiratory nerves in the spinal cord to remove the inhibiting sugars from scar tissue. The action of the enzyme enabled both the formation of new connections and stimulation of latent pathways in the respiratory motor system. Second, the animals were exposed to brief periods of conditions with low oxygen, making them breathe harder and faster to rehabilitate the respiratory muscles. This treatment approach is referred to as intermittent hypoxia.

The combination enzyme injection and intermittent hypoxia treatment boosts levels of serotonin. Commonly known to help relieve anxiety disorders, serotonin also acts more broadly as a neurotransmitter to help stimulate nerve cells. By increasing serotonin at nerve connections and at the specific receptors on the fibers themselves, the researchers were able to help restore diaphragm function back to normal levels in the animals. This finding is extraordinary not only because function to the paralyzed muscle was completely restored, but also because researchers were able to achieve breathing in animals that had been injured for a year and a half.

"It is remarkable to reactivate the diaphragm and breathing in a chronically injured animal that has had a paralyzed half diaphragm most of its life," said Jerry Silver, PhD, a Case Western Reserve professor of neurosciences who collaborated in the research.

While these results are encouraging, more research is required to perfect the treatment. More than two-thirds of the animals in the study responded to the combined treatment strategy, while the treatment had no effect on the remaining animals. Two thirds of the animals that responded to the combined treatment resumed normal breathing, while the other third experienced erratic breathing in the injured muscle ...
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/ 2014 News, Daily News
Antoian Griffin, retained Fresno attorney Alex Berlin, to represent him before the Workers’ Compensation Appeals Board. Griffin claimed he was entitled to workers’ compensation benefits for a low back injury sustained during a one day job on December 7, 2009. Although Griffin claimed that he experienced severe low back pain the next day, he did not seek treatment until December 11, 2009. He notified the employer of the alleged industrial injury on December 15, 2009.

John Branscum, M.D., examined Griffin and prepared a qualified medical evaluation report. Dr. Branscum reviewed medical records pertaining to this particular injury. Griffin described the event, his current symptoms, and past medical history during the examination. Dr. Branscum noted that Griffin denied having any prior symptoms, injuries or disability to his low back; having any prior work-related injuries; or being the recipient of any prior industrial or nonindustrial awards or settlements. Based on his examination and the information provided to him, Dr. Branscum concluded that Griffin "strained his back on December 7, 2009 and therefore, the injury is AOE/COE," Griffin began receiving treatment for a back injury through the Pain Relief Health Center. Appellant’s treating physician placed him on total temporary disability with a diagnosis of lumbar spine disc bulge and lower back pain.

However at an MSC prior to the WCAB trial, the medical records submitted by the defense revealed that: Griffin suffered a work-related back injury in 1985 and received workers’ compensation benefits; sought treatment for chronic back pain in 1990; received care for pain in the lumbar area in 2001; and underwent an evaluation for persistent back pain, "felt to be of musculoskeletal origin," in 2006. ,

After receiving the above evidence, attorney Berlin initiated settlement negotiations in the workers’ compensation matter. The defense offered $13,000 to settle. Mr. Berlin conveyed this offer to Griffin multiple times and recommended that he accept it. Griffin refused this offer and denied the existence of the medical records and claimed that he never had an earlier back injury. Griffin dismissed Berlin as his attorney after trial, but before the workers’ compensation matter was ruled on.

The WCJ found that Griffin did not meet his burden to establish, by a preponderance of the evidence, that he sustained an industrial injury to his back on December 7, 2009. The WCJ questioned his credibility noting that he changed his testimony several times during trial and gave a false and contradictory medical history to Dr. Branscum. The WCJ further observed that, despite his denials, it was clear from the medical records that he sustained a substantial industrial back injury in 1985 that kept him off work until 1988.

Griffin then filed civil action against his worker's compensation attorney in Superior Court alleging that Mr. Berlin committed legal malpractice and breached his fiduciary duty. The trial court granted summary judgment in Berlin's favor. The court concluded that Mr. Berlin met his burden of showing there was no evidence that either he or his associate Christopher White fell below the standard of care or breached any fiduciary duty in representing Griffin. The court further found that Griffin did not meet his burden to show the existence of a triable issue of material fact as he did not present any admissible evidence in opposition to the motion. Griffin appealed the dismissal of his malpractice case. The Court of Appeal affirmed the dismissal in the unpublished case of Griffin v Berlin.

Griffin based his legal malpractice claim on two alleged errors committed by respondent Alex Berlin. According to appellant, respondent did not present certain evidence as requested by appellant, specifically a June 3, 2011, letter from Dr. Justin Paquette stating that appellant’s injury was attributable to the December 7, 2009 injury and the two most recent reports from appellant’s treating physician. Appellant further argues that respondent erred by failing to object to the admission of appellant’s medical records that predated the accident.

In support of his summary judgment motion, respondent Berlin submitted the expert declaration of Thomas Tusan, an experienced workers’ compensation attorney. Tusan opined that neither respondent nor his associate fell below the standard of care for providing legal services to applicants before the Workers’ Compensation Appeals Board. Specifically, Tusan noted that the letter from Dr. Paquette was duplicative of the report from Dr. Branscum and contained the same inherent flaw in that it was also based on appellant’s self report that he did not have any prior injuries. According to Tusan, the remaining documents were duplicative and were created after discovery was closed. Tusan further explained that there were no grounds for objection to the admission of appellant’s earlier medical records.

Tusan’s declaration demonstrated that Griffin's representation did not fall below the standard of care and thus negated his legal malpractice claim. In opposing the motion, appellant failed to submit any admissible evidence and thus did not establish the existence of a triable issue of material fact. Accordingly, the trial court properly granted summary judgment ...
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/ 2014 News, Daily News
58 year old Sri Jayantha Wijegunaratne MD, (aka Wijegoonaratne) an Anaheim Hills-based doctor who practices out of a medical marijuana clinic has been court-ordered to stop practicing medicine while he is out on bail for the alleged sexual assault of a female patient. But he was already out on a bail in a separate case after losing in a jury trial that accuses him of having defrauded Medicare by prescribing powered wheelchairs to patients who did not need them. Meanwhile, based on the Medicare fraud case, the California Medical Board has recommended he permanently be stripped of his license to practice. As with the sexual assault case, that matter is pending and Wijegunaratne is mounting a legal fight.

According to the story on OCWeekly.com, Federal prosecutors claim Wijegunaratne prescribed powered wheelchairs, at a cost of about $2,800 each, to six patients who did not need them. His chosen medical equipment supplier billed Medicare, got reimbursed and paid the physician kickbacks, according to the feds. According to a U.S. Attorney press release, Wijegoonaratna was a key player in an insurance scam with co-conspirators 48-year-old Heidi Morishita of Valencia, and 49-year-old Godwin Onyeabor of Ontario, who were also found guilty. The scam involved a number of crimes, including illegally prescribing expensive electric wheelchairs to patients who had no need for them, then billing Medicare for more than $1,500,000, in an ongoing insurance theft that began in January, 2007 and last for five years. Investigators were able to prove that Onyeabor, a manager at Fendih Medical Supply in San Bernardino, paid cash kickbacks to Doctor Wijegoonaratna and Morishita in exchange for fraudulent prescriptions for medical equipment, including the wheelchairs, which generally cost more than $6,000 each.

A jury in the spring of 2013 found Wijegunaratne guilty of six counts of health care fraud and two counts of conspiracy. He was sentenced to 27 months in federal prison, but federal appellate judges ruled he did not have to serve the sentence while he appealed the conviction on the grounds he was not likely to flee and did not pose a danger to the community.

For nearly a year, Wijegunaratne had been allowed to stay out of federal prison and practice medicine as he appealed a conviction of defrauding Medicare.He was still licensed to practice medicine, and that's what he was doing at a medical marijuana clinic in Riverside, where, according to that inland city's cops and prosecutors, Wijegunaratne allegedly sexually assaulted a woman patient in May. He pleaded not guilty to counts of felony forcible penetration and sexual battery. A Riverside County Superior Court judge just ordered Wijegunaratne to stop practicing medicine until the sexual assault case is resolved. He had to turn over his prescription pads as well.

An Accusation was filed against him by the Office of the Attorney General of California before the Medical Board of California on October 6, 2014. The allegations are based upon the facts giving rise to his federal jury trial and conviction, and seeks revocation of suspension of his physicians and surgeons certificate. One month later, on November 6, 2014, an Order was issued in Superior Court of the State of California, Riverside County Superior Court, Case No. RIF 1403899. Under the Order, as a condition of bail or Own Recognizance release, Sri J. Wijengoonaranta M.D. (Physician's and Surgeon's Certificate Number A-100580) was ordered to cease and desist from the practice of medicine as of November 6, 2014 ...
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/ 2014 News, Daily News
Earlier this year, workers' compensation claims leaders once again participated in a nationwide survey about some of their most pressing operational challenges. Up 57 percent in survey participation from 2013, the confidential results - with insights from over 400 manager, director, and executive-level claims leaders - have now been published in the 2014 Workers' Compensation Benchmarking Study Report. Top issues confronting claims organizations involve addressing the rapidly shrinking talent pool, grappling with emerging technology trends, and operationalizing performance measures...all while improving productivity and reducing costs. Strikingly similar to the 2013 Study findings, the 2014 Study reflects an industry facing critical hurdles, many of which are not getting better. Based on 70-plus data points, the 2014 results further quantify how claims organizations focus resources to address these substantial hurdles. Key findings reveal:

1) Challenges measuring best practices within top ranked core competencies
2) Declining investment in current and future talent development
3) Low adoption of disruptive technologies, such as predictive analytics
4) Continued obstacles with claims system integrations
5) Limited use of outcome measures and risk/reward strategies to propel top performance from internal staff, vendor partners and medical providers
6) Observed impact of the Affordable Care Act on claims

The study found broad consensus among respondents about what matters most in claims management. For instance, the top two most valued core competencies are disability management and medical management. However, formal training programs are modest relative to the complexity of these and other tasks. Less than half of respondents provide training to senior level claims staff and a smaller percentage, 42%, invest in training new hires. Among those who have formal training for new hires, 39% say that training ends within three months and another 28% say it ends four to six months post-hire. The majority of respondents say it takes up to four years for new employee investment in training to pay off. Specifically, 32% expect a reasonable ROI within two years and another 44% within three to four years.

The industry has struggled to bring technology tools to the adjuster in a streamlined, user-friendly way. Unfortunately, systems can be very difficult to integrate. A symptom of sub-optimal solutions can be called the "three screen scenario," wherein adjusters might use three computer screens to access multiple systems throughout the day as they manage streams of phone calls and emails.

Less than a third of respondents say they measure provider performance. This low rate extends across all classes of respondents. When provider performance measures are used, return-to-work outcomes and claim costs are most common, while less than quarter of respondents measure average narcotic use ...
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/ 2014 News, Daily News
Over the weekend, an investigation by the DEA of several NFL teams was triggered by a class-action lawsuit filed in federal court in May by more than 1,300 retired NFL players. In the suit, they allege that NFL medical staffs regularly violate federal and state laws in plying their teams with powerful addictive narcotics such as Percocet and Percodan, sleeping pills such as Ambien and the non-addictive painkiller Toradol to help them play through injuries on game days. Federal law prohibits anyone but a physician or nurse practitioner from distributing prescription drugs, and they must meet myriad regulations for acquiring, storing, labeling and transporting them. It is also illegal for a physician to distribute prescription drugs outside of his geographic area of practice. And it is illegal for trainers to dispense or even handle controlled substances in any way.

According to the report in the Washington Post, drug agents conducted surprise inspections of National Football League team medical staffs on Sunday as part of an ongoing investigation into prescription drug abuse in the league. The inspections, which entailed bag searches and questioning of team doctors by Drug Enforcement Administration agents, were based on the suspicion that NFL teams dispense drugs illegally to keep players on the field in violation of the Controlled Substances Act. The medical staffs were part of travel parties whose teams were playing at stadiums across the country.

The San Francisco 49ers confirmed they were inspected by federal agents following their game against the New York Giants in New Jersey but did not provide any details. "The San Francisco 49ers organization was asked to participate in a random inspection with representatives from the DEA Sunday night at MetLife Stadium," team spokesman Bob Lange said in an e-mailed statement. "The 49ers medical staff complied and the team departed the stadium as scheduled." An NFL official said multiple teams met with federal authorities on Sunday. "Our teams cooperated with the DEA today and we have no information to indicate that irregularities were found," league spokesman Brian McCarthy said in a statement.

The class action lawsuit led by former stars Jim McMahon and Richard Dent, filed in U.S. District Court in San Francisco alleges the league illegally supplied them with painkillers to conceal injuries and mask pain. The players say addictive drugs were administered without proper prescriptions, in illegal doses, without medical supervision and with little or no explanation of risks and dangers. "Rather than allowing players the opportunity to rest and heal, the NFL has illegally and unethically substituted pain medications for proper health care to keep the NFL’s tsunami of dollars flowing," the complaint reads. The lawsuit alleges that dependency on pain medication outlasts football careers. One plaintiff, J.D. Hill, an NFL wide receiver from 1971 to ’79, says after he retired from football, he "was forced to purchase [drugs] on the streets to deal with his football-related pain" and eventually became homeless.

The NFL reached an agreement last year to settle concussion-related litigation with former players. Many of these former players also filed concussion related workers' compensation claims in California. The league now faces this new courtroom challenge. Worker's compensation defense attorneys also expect claims based upon the new pain medication allegations. The surprise DEA investigations may shed some light on the current practices ...
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/ 2014 News, Daily News
An Orange County employee was arraigned for committing insurance fraud and perjury by making false statements and concealing information related to his worker’s compensation claim.

William Parker, 43, Corona, is charged with 15 felony counts of insurance fraud, four felony counts of making a fraudulent statement, two felony counts of attempted perjury under oath, and one felony count of perjury by declaration. If convicted, Parker faces a maximum sentence of 17 years and six months in state prison. Parker is being held on $50,000 bail.

On June 4, 2005, Parker was hired by the Orange County Probation Department (OCPD) as a Deputy Juvenile Corrections Officer. On Oct. 5, 2007, Parker was involved in a non-work related motor vehicle accident which caused injuries to his back and resulted in loss of time from work. Parker filed an insurance claim as a result of that automobile accident and received a settlement.

On Sept. 28, 2010, Parker claimed he suffered a back injury while working for the OCPD. Parker filed a Worker’s Compensation Claim and was taken off work by his treating doctors after the county accepted the claim. Parker did not return to work until late February 2013 when he returned as an Office Specialist due to his claimed injuries.

In February 2012, Parker filed a lawsuit against a citizen for personal injuries where the defendant claimed injuries to his back after sustaining another motor vehicle accident. During the pendency of this lawsuit, Parker is accused of making material misrepresentations and perjuring himself during his depositions and in his responses to interrogatories.

Between 2010 and 2013, Parker was treated by various doctors as a result of his claim. While being treated by doctors, Parker is accused of denying and failing to disclose the prior injuries about his back.

Deputy District Attorney Pam Leitao of the Insurance Fraud Unit is prosecuting this case ...
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Insurance Commissioner Dave Jones adopted an advisory average pure premium rate of $2.74 per $100 of employer payroll for workers' compensation rates effective January 1, 2015. The adopted amount is a 2.2% increase, but lower than that proposed by the Workers' Compensation Insurance Rating Bureau of California (WCIRB). The WCIRB's proposed advisory average rate was $2.77 per $100 of payroll. After a public hearing and careful review of the testimony and evidence submitted, the Department of Insurance recommended adoption of a pure premium rate amount lower than the WCIRB on the basis that a greater reduction in medical losses should be used in the actuarial model due to the anticipated savings from SB 863 (De León) signed in 2012.

The WCIRB's proposed advisory average pure premium rate is 7.9 percent ($2.77 per $100 of payroll) above the industry's average filed rates as of July 1, 2014 and the adopted pure premium rate ($2.74 per $100 of payroll) is 6.7 percent above the industry's average filed rates as of July 1, 2014.

Commissioner Jones, the WCIRB and the public members' actuary all agree that the overall impact of SB 863 continues to result in savings for the workers' compensation system. The California Department of Insurance continues to observe that medical and indemnity losses are outpacing wage growth and consequently, the average advisory pure premium will increase in 2015.

The commissioner's pure premium decision is advisory only. Pursuant to California law, the commissioner does not set or have authority over workers' compensation insurance rates. The commissioner's advisory pure premium rate is not predictive of what an individual insurance company may charge its policyholders because the review of pure premium rates is just one component of insurance pricing ...
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/ 2014 News, Daily News
The Division of Workers’ Compensation has made further changes to its California EDI Implementation Guide, Version 2.0, pursuant to revision of the Workers’ Compensation Information System (WCIS) regulations. The changes are subject to an additional public comment period of 15 days. The comment period will close on November 28, 2014.

The California legislature enacted sweeping reforms to California’s workers’ compensation system in 1993. The legislature directed the DWC to put together comprehensive information about workers’ compensation in California. The result is the WCIS. The WCIS has four components: the First Reports of Injury (FROI) reporting guidelines were implemented March 1, 2000. The Subsequent Reports of Injury (SROI) reporting guidelines were implemented July 1, 2000. Reporting of annual summary of benefits began January 31, 2001

Medical bill payment reporting regulations were adopted on March 22, 2006. The regulations require medical bill payment records for services with a date of service on or after September 22, 2006 and a date of injury on or after March 1, 2000 to be transmitted to the DWC. The medical services are required to be reported to the WCIS by all claims administrators handling 150 or more total claims per year.

California workers’ compensation medical bill payment records are processed by diverse organizations: large multi-state insurance companies, smaller specialty insurance carriers, self-insured employers or insurers, third-party administrators handling claims on behalf of self-insured employers, as well as bill review companies. The organizations have widely differing technological capabilities, so the WCIS is designed to be as flexible as possible in supporting EDI medical transmissions. EDI is the computer-to-computer exchange of data or information in a standardized format. In California, workers’ compensation, medical EDI refers to the electronic transmission of detailed medical bill payment records information from trading partners, i.e., senders, to the California DWC.

The DWC incorporated the primarily technical changes to the California EDI Implementation Guide, Version 2.0 proposed by members of the workers’ compensation community, including these new proposed changes:

1) Adding a table showing California-adopted IK4 error codes for 999 acknowledgements
2) Editing the California Edit Matrix table to correspond to entries in the IK4 error code for 999 acknowledgements table
3) Further clarifying procedures for reporting lump-sum lien settlement payment data.

The DWC believes that these updates will allow WCIS to collect more robust and useful data that will assist with research regarding workers’ compensation issues. The notice and text of the regulations can be found on the proposed regulations page ...
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Cal/OSHA has cited fuel distribution company National Distribution Services Inc. (NDS) $99,345 following an investigation into an explosion at the company’s Corona facility that killed one employee and left another with severe burns. The owner of the company has been previously cited for similar incidents.

On May 6, 2014, two employees attempted welding operations on a 9,000-gallon tanker truck containing an unknown amount of crude oil. The tank had not been purged or tested for flammable vapors, resulting in the explosion. Samuel Enciso, 52, was a welder who had been with NDS for four years. He was found dead on the floor of the facility with his right hand and lower arm completely severed. A second employee with five years of experience suffered burns to more than 50 percent of his body.

Investigators from the San Bernardino Cal/OSHA District Office determined that NDS contributed to this incident by failing to have required safety procedures in place for working with flammable vapors. Additionally, investigators found that NDS failed to train employees on the dangers of welding near combustible materials.

"California requires employers to have and adhere to an Injury and Illness Prevention Program" said Christine Baker, Director of the Department of Industrial Relations (DIR). Cal/OSHA, formally known as the Division of Occupational Safety and Health, is a division of DIR. "This preventable death is a reminder of what can happen when that requirement is ignored," said Baker.

While investigating the May 6 event, investigators learned about a previous explosion at the Corona facility that occurred under similar circumstances, and involved the same two NDS employees. On September 25, 2012, the lid of a fuel tanker blew through the ceiling of the repair facility after the employees commenced welding on a truck filled with flammable vapors. No injuries occurred on that date.

The owner of NDS, Carl Bradley Johansson, served prison time following a previous similar incident. In the 1990s, Johansson operated a business in Montebello known as Atlas Bulk Carriers. On September 27, 1993 there was an explosion involving welding operations on a fuel tanker that had also not been purged or tested. This incident also took the life of a welder employed by the company. Atlas Bulk Carriers was cited by Cal/OSHA for this incident ...
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/ 2014 News, Daily News
The California workers' compensation community recently learned of questions raised about the authenticity of surgical screws used in spine implants at various hospitals in Southern California as a result of litigation brought by claimants who claim they received counterfeit hardware implants. The topic of questioning the manufacturing credentials of medical suppliers is now proving to potentially have significant benefits in claims administration strategies. It may be important to know more about what is at the forefront of implant technologies so that better treatment choices can be made. Unfortunately, the UR/IMR process typically answers the question "should someone have a surgery?" but typically omits answering the question "what brands of surgical implant devices are the best choice for the job?" To add to our knowledge about the surgical implant industry, here is some news about the latest surgical products recently approved by the FDA for spine surgeries.

The MEDICREA group, a company that specializes in the development of personalized implants produced for a patient's specific need in the treatment of spinal pathologies, has announced the company has received 510(k) clearance from the U.S. Food and Drug Administration for UNiD, the world's first patient-specific spinal osteosynthesis rod. The technology will be premiered at the 2014 North American Spine Society (NASS) Annual Meeting taking place on November 12-15 in San Francisco. The first U.S. patient underwent surgery to have personalized UNiD rods implanted earlier this month in New York.

UNiD is the first patient-specific device cleared to treat degenerative spine conditions including scoliosis and other type of deformities. According to the National Scoliosis Foundation, an estimated six million people in the U.S. have scoliosis. Each year scoliosis patients make more than 600,000 visits to private physician offices, and an estimated 38,000 patients undergo spinal fusion surgery. Adult spinal deformity surgery is likely to increase in frequency with as much as 32 percent of the adult population suffering from scoliosis and a prevalence of 60 percent among the elderly. Hospital costs of adult spinal deformity surgery can exceed $100,000 per patient. Revisions and reoperations place a large financial burden on the health care system - increasing the average cost of adult spinal deformity surgery by more than 70 percent.

UNiD patient-specific rods are universal implants available in two alloys (Titanium TA6V ELI/Cobalt Chromium) and two diameters (5.5 mm/6 mm), that match global standards. UNiD naturally fits into the PASS LP® thoraco-lumbar fixation system. The PASS LP® system is already used by numerous spine surgeons in 35 countries, and notably in the United States where this product accounts for the majority of MEDICREA USA Corporation’s sales. MEDICREA’s customized spine implant platform also includes the UNiD anterior lumbar interbody fusion (ALIF) spine cages created with a 3-D printer. With the support of specific software and advanced imaging, the UNiDTM ALIF customized cages made of Poly Ether Ketone Ketone (PEKK) exactly reproduce the anatomic details of a patient’s vertebral endplates. The world’s first spinal fusion surgery using the UNiD ALIF customized 3-D printed spine cages was performed on May 28, 2014 in France.

UNiDTM features a software tool to help surgeons preoperatively plan their surgery and order customized, industrially-produced rods to fit the specific spinal alignment needed for each individual patient. UNiDTM eliminates the need to manually contour a rod during surgery, providing surgeons with a precisely aligned rod prior to surgery and reducing the amount of time patients spend in the operating room, which directly impacts infection rate and quality of recovery.

The customized rod, according to the manufacturer, claims to offer numerous benefits to surgeons and patients undergoing spine surgery. The primary benefit is it allows surgeons to plan and then execute their operating strategy without compromises or approximation errors. Surgeons can improve their success rate in terms of global sagittal patient alignment, and reduce the risk of spinal implant failure ...
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/ 2014 News, Daily News
The technology glitches may be a thing of the past. But people shopping online for health insurance plans under Obama's healthcare law may encounter a new set of problems early next week, one of them being unexpected new costs. HealthCare.gov, the federal website where people enroll for insurance under the Affordable Care Act, opens for sign-ups for policies covering 2015 this Saturday, the so-called open enrollment period.

The site launched for the first time a year ago but tech snafus made it virtually unuseable for weeks, giving plenty of ammunition for critics of the 2010 law that aimed to make healthcare more affordable for millions of Americans. The website is now much improved, but many consumers may find themselves early in the new year beset by higher costs, unexpected demands for return of subsidies and double-billings.

According to the report in Reuters News, Insurance industry officials, congressional aides and analysts say potential problems will mainly affect current Obamacare policyholders and could intensify public hostility toward the law, just as Republicans - long opposed to the law - take over as a majority in the U.S. Senate in January. The Nov. 15-Feb. 15 open enrollment period allows qualified Americans to obtain private health coverage, often with federally subsidized premiums. Premiums overall appear stable, although some existing plans may rise in price and newer policies may offer consumers better terms.

But there is concern about how smoothly the administration will handle the some 5.9 million 2014 policyholders expected to re-enroll. Some experts say the challenge of re-enrolling millions while adding millions of newcomers could be behind this week's sharp reduction in official enrollment forecasts for 2015. An estimated 4.4 million people could opt simply to have their policies renewed automatically by Dec. 15, according to the consulting firm Avalere. But many of those could wind up with unexpectedly higher costs as insurers raise premiums on existing policies, experts say.

Even those who actively hunt for cheaper plans could still face issues. Some consumers who cancel existing coverage could initially be billed twice - once for each plan - because the government has no automated system for notifying insurers of such changes, said one insurance industry official, speaking on condition of anonymity.

And policyholders who got subsidies to help pay for 2014 coverage could also be told to return some of that money, if their incomes rose later in the year and they did not notify the government ...
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/ 2014 News, Daily News
Kimberly Rivera injured her back while working for Valley Radiology in 2010. Dr. Norman Kahan is the primary treating physician.

On June 13, 2013, Dr. Kahan issued a request for authorization (RFA) requesting acupuncture and medications (Flexeril, Norco, Neurontin, Terocin and a Theramine medical supplement). The parties dispute the date that defendant received the RFA. Applicant claims July 5, 2013 and defendant claims July 8, 2013. The UR non-certification is dated on 07/16/2013, yet it indicates a determination date of 07/15/2013, and has a proof of service date of 07/15/2013. Thus the WCJ characterized it as "internally inconsistent."

The parties attended an expedited hearing and submitted the medical treatment issue framed by the UR dispute for determination. The WCJ determined that UR was untimely, and therefore the underlying medical treatment issue was not subject to Independent Medical Review (!MR). Defendant disputes the determination that UR was untimely and Petitioned for Reconsideration which was denied in the panel decision of Rivera v Valley Radiology.

Pursuant to 8 CCR Section 9792.9(a)(J) the RFA shall be deemed to have been received by Defendant by facsimile on the date the request was received if the receiving facsimile electronically date stamps the transmission. If there is no electronically stamped date recorded, then the date the request was transmitted is deemed the date upon which the RFA was received. Here, Defendant offered no evidence of what the receiving facsimile recorded or when. As such, the Regulations are clear that the received date is deemed to be 07/05/2013. Based on the Regulations as applied to the evidence offered, the UR determination was due by 07/12/2013. The UR letter is dated 07/16/2013 and an internally inconsistent proof of service dated 07/15/2013. The WCJ reasoned that "Utilizing either the 07/15/2013 date or the 07/16/2013 date really makes no difference as the UR determination was due by 07/12/2013 and therefore in either case Defendant's UR is untimely."

On Reconsideration Defendant claimed for the first time that it has an additional 24 hours pursuant to Section 4610(g)(l)(A) in which to communicate the decision, and therefore the 07/15/2013 determination was timely communicated on 07/16/2013. This argument was not raised at trial. The WCAB panel noted that the parties dispute the date that defendant received the RFA. "However, based on our review of the record, even assuming that defendant received the RFA on July 8, 2013, we find the UR untimely."

Labor Code Section 4610 (3)(A) provides that "Decisions resulting in modification, delay, or denial of all or part of the requested health care service shall be communicated to physicians initially by telephone or facsimile, and to the physician and employee in writing within 24 hours for concurrent review, or within two business days of the decision for prospective review, as prescribed by the administrative director."

Similarly, Administrative Director Rule 9792.9.1 states that: "For prospective, concurrent, or expedited review, a decision to modify, delay, or deny shall be communicated to the requesting physician within 24 hours of the decision, and shall be communicated to the requesting physician initially by telephone, facsimile, or electronic mail. The communication by telephone shall be followed by written notice to the requesting physician, the injured worker, and if the injured worker is represented by counsel, the injured worker's attorney within 24 hours of the decision for concurrent review and within two (2) business days for prospective review and for expedited review within 72 hours of receipt of the request."

The WCAB panel thus concluded "There is no evidence in this case that defendant communicated their decision "initially by telephone, facsimile, or electronic mail" before it served written notice on July 15, 2013. Therefore, we find defendant's UR untimely. Accordingly, for the reasons stated herein, we affirm the September 26, 2013 Findings and Award." ...
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/ 2014 News, Daily News
Selena Edwards, 38, of Victorville claimed that an unsecured lid caused steaming hot McDonald’s coffee to spill on her right hand, severely burning it. As supporting evidence, she provided pictures of second-degree burns. But the only burns Edwards may suffer from are the prosecutorial ones she now faces for allegedly faking her injuries.

State insurance officials said Edwards looked to the golden arches in Fontana on Jan. 28, 2013, to allegedly commit the crime to extract easy money from McDonald’s Corp. The woman claimed coffee had spilled on her right hand when she was handed a cup with an unsecured lid at the McDonald’s drive-through. The photos and medical documents Edwards provided to bolster her case came from the Internet. "We discovered that some of the photos were from a hospital website," state Insurance Commissioner Dave Jones said. Edwards also submitted counterfeit documentation for treatment that she claimed to have received from a local hospital. "We contacted her medical provider and discovered she hadn’t received any medical treatment." The San Bernardino County district attorney charged Edwards with 21 felony counts of insurance fraud and workers' compensation fraud.

The prosecution of Edwards comes 20 years after a jury awarded $2.9 million to a 79-year-old woman who was badly burned after hot coffee spilled into her lap at a McDonald’s in Albuquerque. The 1994 verdict attracted international attention, was mocked by radio and television talk-show hosts and was even used as a plot point in the TV comedy "Seinfeld." ABC News called the case "the poster child of excessive lawsuits", while the legal scholar Jonathan Turley argued that the claim was "a meaningful and worthy lawsuit". In June 2011, HBO premiered Hot Coffee, a documentary that discussed in depth how the Liebeck case has centered in debates on tort reform. Despite the controversy, the woman in that case, Stella Liebeck, actually did suffer severe third-degree burns and required skin graft surgery.

In January, a woman filed a lawsuit against McDonald’s, saying she was burned when coffee spilled on her at one of the fast-food chain’s Los Angeles restaurants. Paulette Carr claimed she was burned on January 2012 because the lid on her cup was not properly secured. The lawsuit did not describe the severity of Carr’s injuries.

The merit of those cases aside, Jones said that every year tens of thousands of cases that potentially involve fraud are referred to his agency. In the last 11 months there have been 26,415 cases, about 1,549 of which remain open, officials say ...
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Martha Reyes sustained and admitted industrial injury while working for Target. Her primary treating physician Dr. Sobol submitted a Request for Authorization on 02/25/2014 seeking authority for "home care assistance 4 hrs/day x 3 days/wk x 6 wks for cooking/cleaning/laundry/med [illegible]." Utilization Review evaluated the request and denied it on 03/28/2014. The applicant did not claim any material defect in the UR decision. Applicant claims to have sought IMR of the UR decision which had not been decided as of the following events.

The Sobol Orthopedic Medical Group then submitted a second similar request on 05/22/2014. He again requested "Home Care Assistance, 4 hours/ day, 3 days/week for 6 weeks," The form indicates it to be a "New Request'' rather than a "Resubmission - Change in Material Facts." The request was untimely denied by Utilization Review on 06/17 /2014. This untimely 06/17 /2014 UR denial forms the basis of the present controversy.

Applicant filed a 07/10/2014 Declaration of Readiness to proceed to Expedited Hearing, voicing an objection to the 06/17 /2014 Utilization Review Determination as being untimely, and not based on substantial medical evidence. Defendant filed a timely objection to the DOR.

The matter proceeded to Expedited Hearing on 08/21/2014. Submitted for decision was the applicant's need for further medical treatment generally (in the context of the 06/17 /2014 utilization review decision.) The WCJ determined that Labor Code § 4610(g)(6) bars applicant from litigating the 06/17 /2014 Utilization Review denial, as the same requested treatment was previously denied by Utilization Review on 03/28/2014, and there had been no showing of material change in circumstance necessitating another utilization review. Applicant filed the instant Petition for Reconsideration on 09/16/2014 which was denied in the panel decision of Reyes v Target Inc.

The WCAB panel concluded "Because the March 28, 2014 UR decision was not invalid, then in the absence of changed circumstances (not alleged here), that UR decision "shall remain effective for 12 months from the date of the decision without further action by the employer with regard to any further recommendation by the same physician for the same treatment." (Lab. Code, § 4610(g)(6).) Accordingly, it is immaterial that applicant's physician's May 22, 2014 request for authorization (RFA) was not denied by defendant until June 17, 2014, even though that denial otherwise might have been deemed untimely had it been an initial RFA. (Lab. Code,§ 4610(g)(3).) Under section 4610(g)(6), defendant could properly have disregarded the new RFA and not issued a UR decision at all." ...
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/ 2014 News, Daily News
A former clerical employee for the Loma Linda University Medical Center was arraigned on four felony counts of Workers’ Compensation Insurance Fraud and one count of Perjury

According to the District Attorney, and allegations in the criminal complaint, 44-year-old Tameca Lavonne Tyler-Willie of San Bernardino filed a workers’ compensation insurance claim in 2012 for an injury at work. According to Senior Investigator Jose Guzman, who is assigned to the case, Tyler-Willie was untruthful about the manner in which she was injured and as to the extent of those injuries, in both written and oral statements made in support of the claim, and to her physicians, Doctor Juma and Dr. Chun, regarding her injury and physical condition, and at a deposition under oath. Tyler-Willie is accused of attempting to defraud Loma Linda University Medical Center.

"As a result of these lies, Ms. Tyler-Willie received workers’ compensation insurance benefits that that she was not entitled to receive," Guzman said.

Tyler-Willie pleaded not guilty to all counts. If convicted, she faces 8 years and 8 months in County Prison and a fine of up to $150,000. A Disposition/Reset Hearing has been set for Jan. 16, 2015. This case is being prosecuted by Deputy District Attorney David Simon ...
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/ 2014 News, Daily News