The Department of Industrial Relations (DIR) has posted proposed changes to the California Code of Regulations to implement the Return-to-Work Supplement Program, one of the workers’ compensation reforms mandated by SB 863. This program is intended to provide supplemental payments to workers whose permanent disability benefits are disproportionately low in comparison to their earnings loss. Public hearings on the proposed regulations have been scheduled on December 8, 2014 from 10 a.m. to 3 p.m. at 1515 Clay Street in Oakland and on December 9, 2014 from 1:30 p.m. to 4:30 p.m. at 320 West 4th Street, Suite 500 in Los Angeles. Members of the public may also submit written comment on the regulations until 5 p.m. on December 9, 2014. The notice, initial statement of reasons, and text of the proposed regulations can be found on the DIR website.
Under the proposed regulation, to be eligible for the benefit, an individual must have a work related injury that results in an inability to return to the work they were doing at the time of the injury. The regulation further requires that an individual who receives the Return-to-Work Supplement may not receive a second Return-to-Work Supplement unless that individual returns to the work force and suffers an additional injury that prevents that individual from continuing in that job. The Supplemental Job Displacement Benefit voucher triggers the application process for the Return-to-Work Supplement Program.
An individual who receives the Supplemental Job Displacement Benefit under Labor Code section 4658.7 because that individual cannot return to the job they were performing when they were injured receives a voucher evidencing the promise to make payments under section 4658.7. That voucher is on a form mandated by 8 C.C.R. § 10133.32. Section 25104 of the proposed regulations requires that the voucher include a notice that the individual may be eligible for the Return-to-Work Supplement and is intended to advise those individuals who may wish to apply for the Return-to-Work Supplement about the program and how to get additional information. The section also provides that the Director will arrange for publication of this notice targeted at those who have already received a voucher. Claim adjusters will have to use the new voucher 30 days after the regulations become effective.
An application for the Return-to-Work Supplement must be received by the Return-to-Work Supplement Program within one year from the date the Voucher was served on the individual or within one year from the effective date of these regulations, whichever is later. The application shall be made on the electronic form on the Department of Industrial Relations web site and shall include a declaration under penalty of perjury that the information provided is true and correct. Section.25l08 establishes a time frame of 60 days for reviewing applications and for making a decision on an application. It also provides for the method of notifying applicants of the decision.
The Return-to-Work Supplement Program will provide a supplement of $5,000.00 to each eligible individual who submits a complete application by the deadline. The payment will be made within 25 days of the date the decision of the Director on the application and will be paid in one lump sum. Payment shall be made directly to the individual and is not assignable before payment. The amount of this supplement may be adjusted by the Director from time to time based on further studies conducted by the Director in accordance with Labor Code section 139.48 and or based on consideration of the number of anticipated recipients.
Labor Code section 13 9.48 requires that appeals of decisions concerning the Return-to-Work Supplement be handled at the Workers' Compensation Appeals Board trial level. Section 25110 establishes a time frame for such appeals and allows the Return-to-Work Supplement Program to correct errors or otherwise modify decisions ...
Under the proposed regulation, to be eligible for the benefit, an individual must have a work related injury that results in an inability to return to the work they were doing at the time of the injury. The regulation further requires that an individual who receives the Return-to-Work Supplement may not receive a second Return-to-Work Supplement unless that individual returns to the work force and suffers an additional injury that prevents that individual from continuing in that job. The Supplemental Job Displacement Benefit voucher triggers the application process for the Return-to-Work Supplement Program.
An individual who receives the Supplemental Job Displacement Benefit under Labor Code section 4658.7 because that individual cannot return to the job they were performing when they were injured receives a voucher evidencing the promise to make payments under section 4658.7. That voucher is on a form mandated by 8 C.C.R. § 10133.32. Section 25104 of the proposed regulations requires that the voucher include a notice that the individual may be eligible for the Return-to-Work Supplement and is intended to advise those individuals who may wish to apply for the Return-to-Work Supplement about the program and how to get additional information. The section also provides that the Director will arrange for publication of this notice targeted at those who have already received a voucher. Claim adjusters will have to use the new voucher 30 days after the regulations become effective.
An application for the Return-to-Work Supplement must be received by the Return-to-Work Supplement Program within one year from the date the Voucher was served on the individual or within one year from the effective date of these regulations, whichever is later. The application shall be made on the electronic form on the Department of Industrial Relations web site and shall include a declaration under penalty of perjury that the information provided is true and correct. Section.25l08 establishes a time frame of 60 days for reviewing applications and for making a decision on an application. It also provides for the method of notifying applicants of the decision.
The Return-to-Work Supplement Program will provide a supplement of $5,000.00 to each eligible individual who submits a complete application by the deadline. The payment will be made within 25 days of the date the decision of the Director on the application and will be paid in one lump sum. Payment shall be made directly to the individual and is not assignable before payment. The amount of this supplement may be adjusted by the Director from time to time based on further studies conducted by the Director in accordance with Labor Code section 139.48 and or based on consideration of the number of anticipated recipients.
Labor Code section 13 9.48 requires that appeals of decisions concerning the Return-to-Work Supplement be handled at the Workers' Compensation Appeals Board trial level. Section 25110 establishes a time frame for such appeals and allows the Return-to-Work Supplement Program to correct errors or otherwise modify decisions ...
Following a public hearing on July 1 and a review of comments from a previous 15-day public comment period, the Division of Workers’ Compensation (DWC) has made additional revisions to its Copy Service Fee Schedule regulations. Members of the public are invited to present written comments regarding the proposed modifications to dwcrules@dir.ca.gov until 5 p.m. on Saturday, November 8. Proposed revisions include:
1) Reinstating authorizations into the fee schedule to avoid a loophole that would have allowed for billing outside of the schedule. Additionally, authorizations have been defined including stating the specific uses and limitations on the type of information to be disclosed and a specific date after which the provider is no longer authorized to disclose the information.
2) Clarifying the regulations regarding records obtained from the Workers’ Compensation Insurance Rating Bureau (WCIRB) and Employment Development Department (EDD). Claims adjusters will not be liable for subpoenaed records from the WCIRB and EDD when such records can be obtained without a subpoena at lower cost. Twenty dollars is allowed for records from EDD and $30 allowed for records from WCIRB.
3) Replacing the requirement that professional photocopier certificates be attached to each bill with supplying professional photocopier registration numbers.
The public can access WCIRB coverage information for employers for the past five years for free online. For coverage information beyond the past five years, the WCIRB charges $10 per year of coverage requested by way of a Coverage Research Service request. Over the last several years, the WCIRB has seen a marked increase in the number of subpoenas received requesting coverage information for cases before the WCAB. The number jumped from a low of approximately 1,300 in 2010 to a record high of 4,000 in 2013, 90% of which were to determine the identity of the insurer for a specific employer as of a specific date and which is readily available to the public at no cost on the WCIRB’s coverage website. The impact of the cost of these subpoenas on the system is a concern, particularly in view of the comment in Martinez v. Terrazas (2013) 78 Cal. Comp. Cases 444, 447, fn. 3 (Appeals Board en banc) that "in the context of a subpoena to recover costs associated with a subpoena to the WCIRB, the copy service would need to establish the expenses were incurred to prove or disprove a contested claim and that they were reasonable and necessary at the time incurred." In that case, the parties participated in an agreed medical evaluation before the subpoena was served on the WCIRB requesting coverage information. Consequently, it appeared to the court that the identity of the employer’s insurer had been identified prior to the subpoena for coverage information being requested and was therefore not necessary.
In regards to EDD records, Unemployment Insurance Code section 2111 provides that EDD is only authorized to provide EDD records only if EDD has an existing lien in the WCAB case. If EDD does not have a lien, then no records can be provided, even if EDD receives a subpoena. If EDD has a lien, the records can be obtained for free upon request from the injured worker’s attorney. Attorneys can also request records with an Authorization signed by the injured worker for $15 ...
1) Reinstating authorizations into the fee schedule to avoid a loophole that would have allowed for billing outside of the schedule. Additionally, authorizations have been defined including stating the specific uses and limitations on the type of information to be disclosed and a specific date after which the provider is no longer authorized to disclose the information.
2) Clarifying the regulations regarding records obtained from the Workers’ Compensation Insurance Rating Bureau (WCIRB) and Employment Development Department (EDD). Claims adjusters will not be liable for subpoenaed records from the WCIRB and EDD when such records can be obtained without a subpoena at lower cost. Twenty dollars is allowed for records from EDD and $30 allowed for records from WCIRB.
3) Replacing the requirement that professional photocopier certificates be attached to each bill with supplying professional photocopier registration numbers.
The public can access WCIRB coverage information for employers for the past five years for free online. For coverage information beyond the past five years, the WCIRB charges $10 per year of coverage requested by way of a Coverage Research Service request. Over the last several years, the WCIRB has seen a marked increase in the number of subpoenas received requesting coverage information for cases before the WCAB. The number jumped from a low of approximately 1,300 in 2010 to a record high of 4,000 in 2013, 90% of which were to determine the identity of the insurer for a specific employer as of a specific date and which is readily available to the public at no cost on the WCIRB’s coverage website. The impact of the cost of these subpoenas on the system is a concern, particularly in view of the comment in Martinez v. Terrazas (2013) 78 Cal. Comp. Cases 444, 447, fn. 3 (Appeals Board en banc) that "in the context of a subpoena to recover costs associated with a subpoena to the WCIRB, the copy service would need to establish the expenses were incurred to prove or disprove a contested claim and that they were reasonable and necessary at the time incurred." In that case, the parties participated in an agreed medical evaluation before the subpoena was served on the WCIRB requesting coverage information. Consequently, it appeared to the court that the identity of the employer’s insurer had been identified prior to the subpoena for coverage information being requested and was therefore not necessary.
In regards to EDD records, Unemployment Insurance Code section 2111 provides that EDD is only authorized to provide EDD records only if EDD has an existing lien in the WCAB case. If EDD does not have a lien, then no records can be provided, even if EDD receives a subpoena. If EDD has a lien, the records can be obtained for free upon request from the injured worker’s attorney. Attorneys can also request records with an Authorization signed by the injured worker for $15 ...
Michael D. Drobot, Chief Executive Officer of Pacific Hospital of Long Beach, filed a $50 million dollar defamation lawsuit against a group of plaintiff's attorneys who he alleges have falsely claimed in broadcast comments that he and Pacific Hospital of Long Beach directed surgeons to install "counterfeit'' screws in "thousands'' of spinal-surgery patients.
The lawsuit, filed in Orange County Superior Court alleges that lawyers Brian Kabatek and Robert Hutchinson and the law firms of Kabateck Brown Kellner, Cotchett Pitre and McCarthy and Knox Ricksen made false claims in press statements "in an effort to disparage Michael D. Drobot and Pacific Hospital of Long Beach's good name and reputation, and disrupt business operations for their own personal benefit."
According to his press release Drobot claims "I never envisioned filing a lawsuit against a group of attorneys,,'' said Drobot. "But these allegations are malicious and, most importantly, patently false. Not only do they portray me as someone I am not, but they needlessly create incredible anxiety for hundreds of former patients at Pacific Hospital. We did not compromise patient care at PHLB.''
The lawsuit alleges that Kabateck, during a July television interview with Fox 11, made multiple false and defamatory statements about "counterfeit'' and "unsterilized'' screws used on a patient during two 2010 surgeries. Several weeks later, attorney Hutchinson allegedly made many of the same defamatory remarks in a radio interview on CBS 2. The lawsuit alleges that the lawyers made the remarks as a solicitation for patients to join in their pending lawsuits against Drobot and Healthsmart Pacific, Inc. Among their claims: that Michael D. Drobot bribed government officials with money and prostitutes to sell and install the counterfeit screws into patients.
Drobot blasted the defamatory remarks in his defamation lawsuit, affirming under oath in a verified complaint that he and Pacific Hospital of Long Beach "never purchased or used any non-FDA-approved screws or other related parts made with non-FDA-approved materials for use in PHLB spinal surgeries.''
According to Drobot "Defendants made up the aforementioned false and defamatory statements broadcast on television, radio and Internet out of whole cloth,'' the lawsuit alleges. "Ironically, Defendants' false and defamatory statements likely will cause many PHLB spinal surgery patients to request and possibly undergo wholly unnecessary spinal surgeries simply to determine whether they, too, have received 'counterfeit' screws from PHLB.''
In February 2014, Drobot pled guilty to government allegations that he paid kickbacks to surgeons for referring patients to Pacific Hospital of Long Beach. The criminal case did not include allegations of providing counterfeit parts or devices to patients.
Hutchinson, in an interview with the Long Beach Press Telegram said the lawsuit is an attempt to intimidate him and other attorneys named, and to intimidate patients from coming forward in a pending lawsuit against Drobot and the company that previously owned Pacific Hospital. "(Drobot is) an admitted felon," Hutchinson said. "This raises the issue of how can we defame someone when their own actions have tainted them far worse than any comments. He should know it’s not going to work." The lawsuit is characteristic of a Strategic Lawsuit Against Public Participation, commonly known as SLAPP, used to try and censor, intimidate or silence critics by hampering them with legal costs until they abandon their criticism, Hutchinson said.
Drobot, 69, of Corona del Mar, was charged by the U.S. Attorney’s Office with orchestrating a conspiracy from 1997 to 2013 in which tens of millions of dollars in illegal kickbacks were paid to doctors, chiropractors, marketers and others who referred patients to the former Pacific Hospital for spinal surgery. Prosecutors said that Drobot also paid $28,000 in bribes to state Sen. Ron Calderon, D-Montebello, to support legislation delaying or limiting changes in workers’ compensation laws that would have directly affected Drobot’s scheme. The hospital submitted more than $500 million in fraudulent bills between 2008 and last year. Much of the total was paid by the California workers’ compensation system, according to the U.S. Attorney’s Office. Drobot pleaded guilty in April to counts of conspiracy and payment of kickbacks for his activities in the scheme, and he faces 10 years in prison when he is sentenced in October 2015 ...
The lawsuit, filed in Orange County Superior Court alleges that lawyers Brian Kabatek and Robert Hutchinson and the law firms of Kabateck Brown Kellner, Cotchett Pitre and McCarthy and Knox Ricksen made false claims in press statements "in an effort to disparage Michael D. Drobot and Pacific Hospital of Long Beach's good name and reputation, and disrupt business operations for their own personal benefit."
According to his press release Drobot claims "I never envisioned filing a lawsuit against a group of attorneys,,'' said Drobot. "But these allegations are malicious and, most importantly, patently false. Not only do they portray me as someone I am not, but they needlessly create incredible anxiety for hundreds of former patients at Pacific Hospital. We did not compromise patient care at PHLB.''
The lawsuit alleges that Kabateck, during a July television interview with Fox 11, made multiple false and defamatory statements about "counterfeit'' and "unsterilized'' screws used on a patient during two 2010 surgeries. Several weeks later, attorney Hutchinson allegedly made many of the same defamatory remarks in a radio interview on CBS 2. The lawsuit alleges that the lawyers made the remarks as a solicitation for patients to join in their pending lawsuits against Drobot and Healthsmart Pacific, Inc. Among their claims: that Michael D. Drobot bribed government officials with money and prostitutes to sell and install the counterfeit screws into patients.
Drobot blasted the defamatory remarks in his defamation lawsuit, affirming under oath in a verified complaint that he and Pacific Hospital of Long Beach "never purchased or used any non-FDA-approved screws or other related parts made with non-FDA-approved materials for use in PHLB spinal surgeries.''
According to Drobot "Defendants made up the aforementioned false and defamatory statements broadcast on television, radio and Internet out of whole cloth,'' the lawsuit alleges. "Ironically, Defendants' false and defamatory statements likely will cause many PHLB spinal surgery patients to request and possibly undergo wholly unnecessary spinal surgeries simply to determine whether they, too, have received 'counterfeit' screws from PHLB.''
In February 2014, Drobot pled guilty to government allegations that he paid kickbacks to surgeons for referring patients to Pacific Hospital of Long Beach. The criminal case did not include allegations of providing counterfeit parts or devices to patients.
Hutchinson, in an interview with the Long Beach Press Telegram said the lawsuit is an attempt to intimidate him and other attorneys named, and to intimidate patients from coming forward in a pending lawsuit against Drobot and the company that previously owned Pacific Hospital. "(Drobot is) an admitted felon," Hutchinson said. "This raises the issue of how can we defame someone when their own actions have tainted them far worse than any comments. He should know it’s not going to work." The lawsuit is characteristic of a Strategic Lawsuit Against Public Participation, commonly known as SLAPP, used to try and censor, intimidate or silence critics by hampering them with legal costs until they abandon their criticism, Hutchinson said.
Drobot, 69, of Corona del Mar, was charged by the U.S. Attorney’s Office with orchestrating a conspiracy from 1997 to 2013 in which tens of millions of dollars in illegal kickbacks were paid to doctors, chiropractors, marketers and others who referred patients to the former Pacific Hospital for spinal surgery. Prosecutors said that Drobot also paid $28,000 in bribes to state Sen. Ron Calderon, D-Montebello, to support legislation delaying or limiting changes in workers’ compensation laws that would have directly affected Drobot’s scheme. The hospital submitted more than $500 million in fraudulent bills between 2008 and last year. Much of the total was paid by the California workers’ compensation system, according to the U.S. Attorney’s Office. Drobot pleaded guilty in April to counts of conspiracy and payment of kickbacks for his activities in the scheme, and he faces 10 years in prison when he is sentenced in October 2015 ...
Cynthia Wesley, 46, of Claremont, was arrested by Los Angeles Sheriff's Deputies on two felony counts of insurance fraud after allegedly altering workers' compensation documents and illegally collecting $1,036 in disability payments.
"Falsifying documents to receive unearned disability payments is a serious offense," said Commissioner Dave Jones. "The fact that Wesley was a trusted member of law enforcement adds insult to injury in this case. We will investigate and bring to justice anyone that commits insurance fraud, regardless of where they are employed."
An investigation by the California Department of Insurance Fraud Division revealed Wesley, a Los Angeles probation officer, filed an altered workers' compensation return to work slip. Wesley submitted a workers' compensation form extending her total temporary disability period. The same altered documents were submitted to her supplemental disability insurance company.
Wesley was double dipping and received three months of fraudulent disability benefits from the Los Angeles County Probation Department and her supplemental disability insurance policy. Wesley's insurer was unaware of the over payment and the altered documentation until notified by department investigators.
If convicted Wesley faces a max sentence of five year, eight months in county jail ...
"Falsifying documents to receive unearned disability payments is a serious offense," said Commissioner Dave Jones. "The fact that Wesley was a trusted member of law enforcement adds insult to injury in this case. We will investigate and bring to justice anyone that commits insurance fraud, regardless of where they are employed."
An investigation by the California Department of Insurance Fraud Division revealed Wesley, a Los Angeles probation officer, filed an altered workers' compensation return to work slip. Wesley submitted a workers' compensation form extending her total temporary disability period. The same altered documents were submitted to her supplemental disability insurance company.
Wesley was double dipping and received three months of fraudulent disability benefits from the Los Angeles County Probation Department and her supplemental disability insurance policy. Wesley's insurer was unaware of the over payment and the altered documentation until notified by department investigators.
If convicted Wesley faces a max sentence of five year, eight months in county jail ...
In sweeping charges alleging public contract fraud, forged real estate deals and identity theft stretching from Alameda to Orange counties, authorities arrested a Black Muslim minister, his mother and five others, saying they ran a wide-ranging scam through a private security firm, known as Black Muslim Temple (BMT) International Security Services, that falsely claimed its guards were retired Navy SEALs and its leader a former FBI agent.
Alameda County District Attorney Nancy O'Malley said the charges involved "not only large-scale bid fraud victimizing local communities and cities and counties around the state, but also real estate fraud, insurance fraud, bankruptcy fraud, income tax evasion and the exploitation of workers by evading workers' compensation insurance and payroll." O'Malley said the group led "an organized and sophisticated criminal enterprise conducting an extraordinary variety of fraudulent activities." The charges, detailed in a 118-page affidavit, allege the firm faked insurance and state license documents and made fanciful claims of expertise it did not possess.
O'Malley's staff and the state Department of Consumer Affairs began investigating BMT in March.The Port of Oakland that month was in the final stages of agreeing to terms with the company when it terminated negotiations, citing reporting by the San Jose Mercury News on the bogus credentials. The city of Oakland also backed off on a proposal to award the firm part of a contract to guard City Hall. The Housing Authority of the city of Los Angeles rescinded a BMT contract after the investigation by the newspaper.The group sought and at times obtained lucrative contracts with Los Angeles agencies, Alameda County, Vallejo, Oakland, the Port of Oakland and Newport Beach.
Alameda County canceled its contract with the firm back in 2012 after a BMT guard beat up a guard from a rival company on the first day of the county contract to protect a public works building in Hayward. A lawsuit by the injured guard, Robert Chamberlin, helped expose the fraudulent credentials that government procurement officials had failed to vet when awarding the contracts. Upon learning that BMT was still listing it as its insurance carrier, the insurance company in that lawsuit contacted district attorney's investigators to alert them to the discrepancy. The policy had been canceled in 2009 for non-payment of premiums, according to the complaint..
Those arrested include Black Muslim minister Dahood Sharieff Bey, 42, and his mother, Rory Parker, 63, Basheer Fard Muhammad, 62, Qadirah Najeebah Bey, 39, Jameelah Aasma Muhammad Bey, 39, Billie Latrice Poindexter, 33, and Ira Barnard Dickerson Jr., 53. among those who were arrested. District attorney's inspector Patrick Johnson requested in an affidavit that the seven defendants be denied bail because he suspects their means of income for years has been fraudulent.
A spokesman for the state Department of Consumer Affairs said it should not be blamed. BMT had fraudulently taken over the security license of a retired Oakland police officer who had moved out of state. "We had no way of knowing the license had essentially been hijacked," said the spokesman, Russ Heimerich ...
Alameda County District Attorney Nancy O'Malley said the charges involved "not only large-scale bid fraud victimizing local communities and cities and counties around the state, but also real estate fraud, insurance fraud, bankruptcy fraud, income tax evasion and the exploitation of workers by evading workers' compensation insurance and payroll." O'Malley said the group led "an organized and sophisticated criminal enterprise conducting an extraordinary variety of fraudulent activities." The charges, detailed in a 118-page affidavit, allege the firm faked insurance and state license documents and made fanciful claims of expertise it did not possess.
O'Malley's staff and the state Department of Consumer Affairs began investigating BMT in March.The Port of Oakland that month was in the final stages of agreeing to terms with the company when it terminated negotiations, citing reporting by the San Jose Mercury News on the bogus credentials. The city of Oakland also backed off on a proposal to award the firm part of a contract to guard City Hall. The Housing Authority of the city of Los Angeles rescinded a BMT contract after the investigation by the newspaper.The group sought and at times obtained lucrative contracts with Los Angeles agencies, Alameda County, Vallejo, Oakland, the Port of Oakland and Newport Beach.
Alameda County canceled its contract with the firm back in 2012 after a BMT guard beat up a guard from a rival company on the first day of the county contract to protect a public works building in Hayward. A lawsuit by the injured guard, Robert Chamberlin, helped expose the fraudulent credentials that government procurement officials had failed to vet when awarding the contracts. Upon learning that BMT was still listing it as its insurance carrier, the insurance company in that lawsuit contacted district attorney's investigators to alert them to the discrepancy. The policy had been canceled in 2009 for non-payment of premiums, according to the complaint..
Those arrested include Black Muslim minister Dahood Sharieff Bey, 42, and his mother, Rory Parker, 63, Basheer Fard Muhammad, 62, Qadirah Najeebah Bey, 39, Jameelah Aasma Muhammad Bey, 39, Billie Latrice Poindexter, 33, and Ira Barnard Dickerson Jr., 53. among those who were arrested. District attorney's inspector Patrick Johnson requested in an affidavit that the seven defendants be denied bail because he suspects their means of income for years has been fraudulent.
A spokesman for the state Department of Consumer Affairs said it should not be blamed. BMT had fraudulently taken over the security license of a retired Oakland police officer who had moved out of state. "We had no way of knowing the license had essentially been hijacked," said the spokesman, Russ Heimerich ...
The Division of Workers’ Compensation (DWC) is now accepting nominations for its annual Carrie Nevans community service awards which will be presented at the 22th annual educational conference luncheons in February 2015.
The awards, which began in 2010, were renamed in memory and honor of Carrie Nevans, the acting administrative director, who passed away in 2011. "This award is about recognizing and acknowledging those extraordinary individuals whose efforts, often unsung, do so much to benefit the comp system for the betterment of employees and employers," said DIR Director Christine Baker. DWC is a division of DIR.
Nominations should be made for those individuals who have made a significant contribution to the betterment of the workers’ compensation community in the highest professional manner. DWC will honor the Southern California recipient in Los Angeles and the Northern California recipient in Oakland during an award ceremony at the educational conference luncheons.
To submit your nominations, please complete the DWC nomination form and send to Wendy So at wso@dir.ca.gov no later than January 5, 2015 ...
The awards, which began in 2010, were renamed in memory and honor of Carrie Nevans, the acting administrative director, who passed away in 2011. "This award is about recognizing and acknowledging those extraordinary individuals whose efforts, often unsung, do so much to benefit the comp system for the betterment of employees and employers," said DIR Director Christine Baker. DWC is a division of DIR.
Nominations should be made for those individuals who have made a significant contribution to the betterment of the workers’ compensation community in the highest professional manner. DWC will honor the Southern California recipient in Los Angeles and the Northern California recipient in Oakland during an award ceremony at the educational conference luncheons.
To submit your nominations, please complete the DWC nomination form and send to Wendy So at wso@dir.ca.gov no later than January 5, 2015 ...
The primary impact of the Ebola epidemic "crisis" on U.S. property and casualty insurers will be on companies writing workers compensation insurance, according to a new study by the Insurance Information Institute. In a paper written by Dr. Dr. Steven Weisbart, senior Institute vice president and chief economist, said the WC category will likely be most affected because health-care workers could be most directly exposed (as happened in Texas and in several African countries). Other possible effects might be on various liability insurance lines, such as general liability, directors and officers liability and medical malpractice liability, Weisbart said in his paper. Weisbart said that WC would be primarily impacted because it pays for the cost of medical care and lost income for people who become ill in the course of their work, and pays death benefits if they die from a work-related cause.
"As with life insurance, it is unlikely that many workers in the main affected African countries have workers compensation-type coverages," he said. Citing the latest Swiss Re report, Weisbart said that the level of premiums per capita for all non-life insurance coverages combined (not just WC) in the three most-affected countries "is so low as to not be listed."
In the United States, by contrast, Weisbart said, WC coverage is nearly universal, but the likelihood of claims is low, assuming that employers and their workers take CDC-recommended precautions. He also notes that, as with life insurance coverage, "reinsurance will help mitigate the financial effect of a surge in claims, which are likely to be very costly in the event of actual work-related infections." In his report, Weisbart said that, "at this stage," it is impossible to forecast the precise number of such claims or the amounts of damages that might be sought.
"That said, assuming the Center for Disease Control’s protocols are successfully followed, the number of Ebola cases should be small, thereby limiting the number and likelihood of tort actions that can impact various liability coverages," Weisbart concluded.
As for the total world impact, Weisbart said that as of Oct. 10, the Ebola virus has infected at least 8,399 people and killed 4,035, according to the World Health Organization. This includes 4,762 confirmed cases, 2,196 probable cases and 1,652 suspected cases. He said that as of Oct. 10, all but four of the cases were in four countries in Africa (Guinea, Liberia, Sierra Leone, and Nigeria). One was in Senegal, one in Spain, and (as of Oct. 12) two in the United States.
There are five known strains of the Ebola virus, Weisbart said in his study. The one causing the illness and deaths noted above is the Zaire strain, which was identified in 1976, he said.Weisbart also said that there is currently no cure and no vaccine for this virus. Treatment is isolation (to prevent spread) and focus on symptoms—mainly dialysis and fluids to prevent dehydration and reduce fever. He also said that the mortality rate of infected people to date is roughly 50 percent ...
"As with life insurance, it is unlikely that many workers in the main affected African countries have workers compensation-type coverages," he said. Citing the latest Swiss Re report, Weisbart said that the level of premiums per capita for all non-life insurance coverages combined (not just WC) in the three most-affected countries "is so low as to not be listed."
In the United States, by contrast, Weisbart said, WC coverage is nearly universal, but the likelihood of claims is low, assuming that employers and their workers take CDC-recommended precautions. He also notes that, as with life insurance coverage, "reinsurance will help mitigate the financial effect of a surge in claims, which are likely to be very costly in the event of actual work-related infections." In his report, Weisbart said that, "at this stage," it is impossible to forecast the precise number of such claims or the amounts of damages that might be sought.
"That said, assuming the Center for Disease Control’s protocols are successfully followed, the number of Ebola cases should be small, thereby limiting the number and likelihood of tort actions that can impact various liability coverages," Weisbart concluded.
As for the total world impact, Weisbart said that as of Oct. 10, the Ebola virus has infected at least 8,399 people and killed 4,035, according to the World Health Organization. This includes 4,762 confirmed cases, 2,196 probable cases and 1,652 suspected cases. He said that as of Oct. 10, all but four of the cases were in four countries in Africa (Guinea, Liberia, Sierra Leone, and Nigeria). One was in Senegal, one in Spain, and (as of Oct. 12) two in the United States.
There are five known strains of the Ebola virus, Weisbart said in his study. The one causing the illness and deaths noted above is the Zaire strain, which was identified in 1976, he said.Weisbart also said that there is currently no cure and no vaccine for this virus. Treatment is isolation (to prevent spread) and focus on symptoms—mainly dialysis and fluids to prevent dehydration and reduce fever. He also said that the mortality rate of infected people to date is roughly 50 percent ...
A Contra Costa County jail inmate added ten counts to a 50-charge indictment after he allegedly tried to order the killings of witnesses set to testify against him in a workers' compensation fraud case.
A grand jury voted to indict defendant Charles Waldo with nine counts of solicitation to commit murder and one count of conspiracy to commit murder. The indictment alleges that while serving time in custody at the Martinez Detention Facility, the defendant solicited and conspired with other inmates to arrange the killing of nine different witnesses that were set to testify against him at an upcoming trial. These ten new charges will be added to the fifty charges the defendant currently faces.
The investigation of Mr. Waldo began when the Auto Insurance Fraud Unit of the Contra Costa County District Attorney’s Office received information about a fraudulent auto insurance claim related to an automobile arson. With the assistance of the Contra Costa County Fire Protection District, the investigation expanded and soon involved multiple fraudulent insurance claims related to the arsons and vandalisms of five cars over a five year period. The loss from these fraudulent claims exceeds $100,000.
The investigation also uncovered a series of crimes that occurred at a local business. Mr. Waldo had worked at the business and eventually talked the owner into making him the manager. Once he was in charge of the business it is alleged that Mr. Waldo embezzled over $100,000 from the business and that he stole property from the business, including a $38,000 generator. As the manager, Waldo was able to force out other employees and replace them with his associates. He directed these associates to commit additional crimes while working for the company such as the theft of recyclable metals and the theft of an electrical transformer. He also had his associates help construct a 2000 square foot addition to his Pittsburg, CA home. This work occurred while his associates were being paid by, and supposed to be working for, the victim company.
Investigators from the California Department of Insurance established that Waldo was also committing Workers’ Compensation Insurance fraud and tax code violations. Investigators from the Employment Development Department discovered that Mr. Waldo claimed unemployment insurance benefits for a year after being fired from the victim business. Mr. Waldo claimed these benefits despite the fact that he had secured other employment.
The new allegations came to light when a witness was alerted that a "hit" had been put out on him. The District Attorney’s office promptly started an investigation which led to two witnesses and one document. The document was a hit list that included nine names, the order in which they were to be killed, and suggested methods by which the murders were to occur. The methods included staged car accidents, drug overdoses and robberies that had "gone bad".
The charges carry a maximum penalty of 25 years to life in jail ...
A grand jury voted to indict defendant Charles Waldo with nine counts of solicitation to commit murder and one count of conspiracy to commit murder. The indictment alleges that while serving time in custody at the Martinez Detention Facility, the defendant solicited and conspired with other inmates to arrange the killing of nine different witnesses that were set to testify against him at an upcoming trial. These ten new charges will be added to the fifty charges the defendant currently faces.
The investigation of Mr. Waldo began when the Auto Insurance Fraud Unit of the Contra Costa County District Attorney’s Office received information about a fraudulent auto insurance claim related to an automobile arson. With the assistance of the Contra Costa County Fire Protection District, the investigation expanded and soon involved multiple fraudulent insurance claims related to the arsons and vandalisms of five cars over a five year period. The loss from these fraudulent claims exceeds $100,000.
The investigation also uncovered a series of crimes that occurred at a local business. Mr. Waldo had worked at the business and eventually talked the owner into making him the manager. Once he was in charge of the business it is alleged that Mr. Waldo embezzled over $100,000 from the business and that he stole property from the business, including a $38,000 generator. As the manager, Waldo was able to force out other employees and replace them with his associates. He directed these associates to commit additional crimes while working for the company such as the theft of recyclable metals and the theft of an electrical transformer. He also had his associates help construct a 2000 square foot addition to his Pittsburg, CA home. This work occurred while his associates were being paid by, and supposed to be working for, the victim company.
Investigators from the California Department of Insurance established that Waldo was also committing Workers’ Compensation Insurance fraud and tax code violations. Investigators from the Employment Development Department discovered that Mr. Waldo claimed unemployment insurance benefits for a year after being fired from the victim business. Mr. Waldo claimed these benefits despite the fact that he had secured other employment.
The new allegations came to light when a witness was alerted that a "hit" had been put out on him. The District Attorney’s office promptly started an investigation which led to two witnesses and one document. The document was a hit list that included nine names, the order in which they were to be killed, and suggested methods by which the murders were to occur. The methods included staged car accidents, drug overdoses and robberies that had "gone bad".
The charges carry a maximum penalty of 25 years to life in jail ...
In 2004, the State Fund issued a workers’ compensation policy to a construction company doing business as L and M Construction. In May 2005, it audited the employer to calculate the final premium due for the policy year resulting in a claim by the SCIF for $497,265.48 premium due under the 2004 policy. SCIF was unsuccessful in obtaining payment, thus it assigned the debt to a collection company that sued the employer to recover.
In July 2007, SCIF propounded its first discovery set, to the employer which included form interrogatories, requests for admission, and requests for production of documents. The interrogatories were form interrogatories approved for use in civil cases. The employer's response to each of these requests was the same: "Overbroad, overburdensome, vague and ambiguous, irrelevant, seeks information not reasonably calculated to lead to the discovery of admissible evidence." A meet and confer process resulted in supplemental responses in September 2007. Appellant denied several requests for admission, provided non-committal answers to the rest, and added objections to requests that required admitting dates or verifying documents. This was the beginning of a discovery war between the parties that became quite acrimonious. For example, during one deposition, the employer's attorney ridiculed the questions and then abruptly ended the deposition.
There were numerous motions by SCIF to enforce discovery. In August 2008, the court denied SCIF's motion for terminating sanctions, but awarded $3,000 in additional sanctions on the ground that the employer and its counsel willfully violated the court’s order by failing to attend the deposition and produce documents in a timely fashion, by "stonewalling," and walking out of the deposition. It ordered that all discovery matters be heard by the earlier-appointed discovery referee. Yet the employer "continued to evade identifying specific documents and potential witnesses in support of its denial that it owed any money." The SCIF again filed discovery motions and requests for terminating sanctions which the referee recommended. The referee found appellant’s discovery responses continued to be dilatory, evasive, lacking a factual basis, and thus violative of the prior order. The trial court granted terminating sanctions. The sanctions were affirmed in the unpublished case of State Compensation Fund v. Notis Enterprises.
Under the Civil Discovery Act (§ 2016.010 et seq.), courts may impose monetary, issue, evidence, terminating, and contempt sanctions for "misuse of the discovery process." Misuses of the discovery process include: (1) "[f]ailing to respond or to submit to an authorized method of discovery"; (2) "[m]aking, without substantial justification, an unmeritorious objection to discovery"; (3) "[m]aking an evasive response to discovery"; (4) "[d]isobeying a court order to provide discovery"; (5) "[m]aking or opposing, unsuccessfully and without substantial justification, a motion to compel or to limit discovery"; and (6) "[f]ailing to confer in person, by telephone, or by letter with an opposing party or attorney in a reasonable and good faith attempt to resolve informally any dispute concerning discovery . . . ." (§ 2023.010, subds.(d)-(i).) The trial court may impose terminating sanctions, such as striking a party’s pleadings and rendering a judgment by default against the party, for willful violations preceded by a history of abuse, where "the evidence shows that less severe sanctions would not produce compliance with the discovery rules . . . ."
"The record supports the referee’s finding that appellant and its counsel repeatedly violated section 2023.010 by failing to respond to discovery, making unmeritorious objections and evasive responses, disobeying court orders, opposing motions to compel without substantial justification, and failing to confer in good faith. The referee properly considered appellant’s ongoing failure to comply with discovery requests and court orders."
Although this case was in the Superior Court, the same rules apply before the WCAB. Labor Code section 5710 provides that the deposition of witnesses in workers' compensation cases are "to be taken in the manner prescribed by law for like depositions in civil actions in the superior courts of this state...." Thus this case is a good overview of the enforcement mechanisms available when a litigant unreasonable interferes with appropriate discovery ...
In July 2007, SCIF propounded its first discovery set, to the employer which included form interrogatories, requests for admission, and requests for production of documents. The interrogatories were form interrogatories approved for use in civil cases. The employer's response to each of these requests was the same: "Overbroad, overburdensome, vague and ambiguous, irrelevant, seeks information not reasonably calculated to lead to the discovery of admissible evidence." A meet and confer process resulted in supplemental responses in September 2007. Appellant denied several requests for admission, provided non-committal answers to the rest, and added objections to requests that required admitting dates or verifying documents. This was the beginning of a discovery war between the parties that became quite acrimonious. For example, during one deposition, the employer's attorney ridiculed the questions and then abruptly ended the deposition.
There were numerous motions by SCIF to enforce discovery. In August 2008, the court denied SCIF's motion for terminating sanctions, but awarded $3,000 in additional sanctions on the ground that the employer and its counsel willfully violated the court’s order by failing to attend the deposition and produce documents in a timely fashion, by "stonewalling," and walking out of the deposition. It ordered that all discovery matters be heard by the earlier-appointed discovery referee. Yet the employer "continued to evade identifying specific documents and potential witnesses in support of its denial that it owed any money." The SCIF again filed discovery motions and requests for terminating sanctions which the referee recommended. The referee found appellant’s discovery responses continued to be dilatory, evasive, lacking a factual basis, and thus violative of the prior order. The trial court granted terminating sanctions. The sanctions were affirmed in the unpublished case of State Compensation Fund v. Notis Enterprises.
Under the Civil Discovery Act (§ 2016.010 et seq.), courts may impose monetary, issue, evidence, terminating, and contempt sanctions for "misuse of the discovery process." Misuses of the discovery process include: (1) "[f]ailing to respond or to submit to an authorized method of discovery"; (2) "[m]aking, without substantial justification, an unmeritorious objection to discovery"; (3) "[m]aking an evasive response to discovery"; (4) "[d]isobeying a court order to provide discovery"; (5) "[m]aking or opposing, unsuccessfully and without substantial justification, a motion to compel or to limit discovery"; and (6) "[f]ailing to confer in person, by telephone, or by letter with an opposing party or attorney in a reasonable and good faith attempt to resolve informally any dispute concerning discovery . . . ." (§ 2023.010, subds.(d)-(i).) The trial court may impose terminating sanctions, such as striking a party’s pleadings and rendering a judgment by default against the party, for willful violations preceded by a history of abuse, where "the evidence shows that less severe sanctions would not produce compliance with the discovery rules . . . ."
"The record supports the referee’s finding that appellant and its counsel repeatedly violated section 2023.010 by failing to respond to discovery, making unmeritorious objections and evasive responses, disobeying court orders, opposing motions to compel without substantial justification, and failing to confer in good faith. The referee properly considered appellant’s ongoing failure to comply with discovery requests and court orders."
Although this case was in the Superior Court, the same rules apply before the WCAB. Labor Code section 5710 provides that the deposition of witnesses in workers' compensation cases are "to be taken in the manner prescribed by law for like depositions in civil actions in the superior courts of this state...." Thus this case is a good overview of the enforcement mechanisms available when a litigant unreasonable interferes with appropriate discovery ...
Federal authorities are ramping up efforts to crack down on healthcare fraud, announcing plans to prosecute top executives at hospitals and other organizations involved with fraud - and target other fraudsters as well.
Leslie Caldwell, assistant attorney general for the criminal division at the Department of Justice, said in a recent presentation: "We are stepping up our prosecutions of corporations involved in healthcare fraud. Corporate healthcare fraud cases are a natural fit for us in light of our healthcare fraud expertise and our prosecutions of corporate cases in the financial fraud and foreign bribery arenas. We have numerous ongoing corporate healthcare fraud investigations, and we are determined to bring more."
Healthcare attorney Peter Zeindenberg, a partner in the Washington officer of the law firm Arent Fox, says that the Justice Department's warning is aimed at top executives at hospitals and other healthcare organizations where fraudulent activities, ranging from false Medicare billing to illegal kick-backs, are taking place.
For the most part, fraud-related cases against healthcare organizations have often ended up with restitution or settlements, not criminal prosecutions of executives that involve prison time, he says. "Companies have been able to resolve these cases by entering into non-prosecution or deferred prosecution agreements and leave individual executives untouched," he says. In large part due to public pushback on corporate executives too often getting passes, the Justice Department is sending out signals that it "wants to serve up executives on a silver platter," for misconduct that includes healthcare fraud, Zeidenberg says. But the attorney says he's "somewhat dubious" that will actually happen. OIG Crack Down
In addition to the Justice Department's efforts, the Department of Health and Human Services' Office of Inspector General is also stepping up its fraud crackdown activities. OIG often gets involved in criminal cases against owners of small medical companies or clinics - or individual physicians - where false billing and identity fraud is alleged, says Scott Lampert, assistant special agent in charge of the HHS OIG's New York Regional Office, Office of Investigations. "Cases involving identity theft are a growing problem," he tells Information Security Media Group. "Medical ID numbers are an ATM card to fraudsters."
One of the largest "and most blatant" such cases to date was the prosecution and conviction of the owner of a Long Island, N.Y., medical supply company who posed as a clinician when visiting nursing homes. Helene Michel entered nursing homes pretending she was a clinician and stole information from patient charts, submitting more than $7 million in fraudulent Medicare billing using those records, Lampert says. In April 2013, Michel was convicted on charges of healthcare fraud and wrongful disclosure of individually identifiable health information. She was sentenced to 12 years federal prison time and ordered to pay more than $4.4 million in restitution. Her husband and co-conspirator, Etienne Allonce, for the second year in a row tops the HHS OIG's "most wanted" fugitive list. Joseph Giambalvo, special agent with the HHS OIG's New York regional office, tells ISMG that Allonce is believed to be in Haiti. "We have an arrest warrant out for him," he says. The fraud case involving Allonce and Michel "is one of the largest medical identity theft cases we've had, and the first prosecution in the Northeast of a HIPAA case for the misuse of personal health information for profit," Lampert says ...
Leslie Caldwell, assistant attorney general for the criminal division at the Department of Justice, said in a recent presentation: "We are stepping up our prosecutions of corporations involved in healthcare fraud. Corporate healthcare fraud cases are a natural fit for us in light of our healthcare fraud expertise and our prosecutions of corporate cases in the financial fraud and foreign bribery arenas. We have numerous ongoing corporate healthcare fraud investigations, and we are determined to bring more."
Healthcare attorney Peter Zeindenberg, a partner in the Washington officer of the law firm Arent Fox, says that the Justice Department's warning is aimed at top executives at hospitals and other healthcare organizations where fraudulent activities, ranging from false Medicare billing to illegal kick-backs, are taking place.
For the most part, fraud-related cases against healthcare organizations have often ended up with restitution or settlements, not criminal prosecutions of executives that involve prison time, he says. "Companies have been able to resolve these cases by entering into non-prosecution or deferred prosecution agreements and leave individual executives untouched," he says. In large part due to public pushback on corporate executives too often getting passes, the Justice Department is sending out signals that it "wants to serve up executives on a silver platter," for misconduct that includes healthcare fraud, Zeidenberg says. But the attorney says he's "somewhat dubious" that will actually happen. OIG Crack Down
In addition to the Justice Department's efforts, the Department of Health and Human Services' Office of Inspector General is also stepping up its fraud crackdown activities. OIG often gets involved in criminal cases against owners of small medical companies or clinics - or individual physicians - where false billing and identity fraud is alleged, says Scott Lampert, assistant special agent in charge of the HHS OIG's New York Regional Office, Office of Investigations. "Cases involving identity theft are a growing problem," he tells Information Security Media Group. "Medical ID numbers are an ATM card to fraudsters."
One of the largest "and most blatant" such cases to date was the prosecution and conviction of the owner of a Long Island, N.Y., medical supply company who posed as a clinician when visiting nursing homes. Helene Michel entered nursing homes pretending she was a clinician and stole information from patient charts, submitting more than $7 million in fraudulent Medicare billing using those records, Lampert says. In April 2013, Michel was convicted on charges of healthcare fraud and wrongful disclosure of individually identifiable health information. She was sentenced to 12 years federal prison time and ordered to pay more than $4.4 million in restitution. Her husband and co-conspirator, Etienne Allonce, for the second year in a row tops the HHS OIG's "most wanted" fugitive list. Joseph Giambalvo, special agent with the HHS OIG's New York regional office, tells ISMG that Allonce is believed to be in Haiti. "We have an arrest warrant out for him," he says. The fraud case involving Allonce and Michel "is one of the largest medical identity theft cases we've had, and the first prosecution in the Northeast of a HIPAA case for the misuse of personal health information for profit," Lampert says ...
More than two dozen lawsuits were filed in Los Angeles Superior Court against a former hospital executive and a collection of his business partners that allege the group was behind counterfeit screws and hardware used in spinal surgeries at various Southern California hospitals.The lawsuits claim that unknowing patients underwent spinal surgeries with doctors who benefited financially for using certain hardware - allegedly made at an auto shop in Temecula - and for performing surgery at certain hospitals. The former hospital executive, Michael Drobot, was indicted in February for his role in bribing a state senator to protect the $500 million insurance fraud scheme he was using to bilk the state’s workers compensation fund. Drobot agreed to a plea deal and is cooperating with federal law enforcement.
Also named in the lawsuit are Pacific Hospital of Long Beach, Riverside Community Hospital, Spinal Solutions, Orthopedic Alliance, Crowder Machine and Tool Shop and doctors Jack Akmakjian, Sunny Uppal and Khalid Ahmed. Attorneys told KPCC they have received hundreds of calls from people concerned they may have the fake parts, adding that they are going through each case to figure out if those former patients may have been impacted by the scheme. Drobot’s operation included bribes for doctors and others who referred patients to Drobot’s hospital, used hardware distributed by his partners, and inflated prices for medical hardware. The lawsuits say the victims are "among thousands of spinal fusion surgery patients in Southern California and elsewhere who [have] such counterfeit, non-FDA approved medical devices implanted into their bodies as a consequence of the systematic pattern of fraud and deceit." According to the lawsuits, Spinal Solutions, a distributor out of Murrieta, was behind the manufacture of the fake screws provided to hospitals and doctors who were also part of the scheme.
Drobot’s attorney, Terree Bowers, said the lawsuits are "scare tactics" and that they are "reprehensible." He further denies any counterfeit parts were used at Drobot’s hospital. "There is absolutely no indication or evidence that Spinal Solutions ... screws were ever used at Pacific Hospital," he said. "It is false and patients who went to that facility do not have to be alarmed." Bowers said the federal indictment does not include any accusations regarding fake screws, and he said his own investigation into hospital records do not indicate counterfeit screws were used there. "They are creating fear in patients that have absolutely no reason to afraid," he said.
Last summer, the State Insurance Commission Fund filed a lawsuit against Drobot and his son under the state’s racketeering laws. It alleges the Drobots created shell companies that supposedly made spinal hardware and billed for it at much higher rates than what it costs ...
Also named in the lawsuit are Pacific Hospital of Long Beach, Riverside Community Hospital, Spinal Solutions, Orthopedic Alliance, Crowder Machine and Tool Shop and doctors Jack Akmakjian, Sunny Uppal and Khalid Ahmed. Attorneys told KPCC they have received hundreds of calls from people concerned they may have the fake parts, adding that they are going through each case to figure out if those former patients may have been impacted by the scheme. Drobot’s operation included bribes for doctors and others who referred patients to Drobot’s hospital, used hardware distributed by his partners, and inflated prices for medical hardware. The lawsuits say the victims are "among thousands of spinal fusion surgery patients in Southern California and elsewhere who [have] such counterfeit, non-FDA approved medical devices implanted into their bodies as a consequence of the systematic pattern of fraud and deceit." According to the lawsuits, Spinal Solutions, a distributor out of Murrieta, was behind the manufacture of the fake screws provided to hospitals and doctors who were also part of the scheme.
Drobot’s attorney, Terree Bowers, said the lawsuits are "scare tactics" and that they are "reprehensible." He further denies any counterfeit parts were used at Drobot’s hospital. "There is absolutely no indication or evidence that Spinal Solutions ... screws were ever used at Pacific Hospital," he said. "It is false and patients who went to that facility do not have to be alarmed." Bowers said the federal indictment does not include any accusations regarding fake screws, and he said his own investigation into hospital records do not indicate counterfeit screws were used there. "They are creating fear in patients that have absolutely no reason to afraid," he said.
Last summer, the State Insurance Commission Fund filed a lawsuit against Drobot and his son under the state’s racketeering laws. It alleges the Drobots created shell companies that supposedly made spinal hardware and billed for it at much higher rates than what it costs ...
Physical therapy after total hip (THR) or total knee replacement (TKR) surgery is standard care for all patients. Now, a new study, appearing in the Journal of Bone and Joint Surgery (JBJS), also found that physical therapy before joint replacement surgery, or "prehabilitation," can diminish the need for postoperative care by nearly 30 percent, saving an average of $1,215 per patient in skilled nursing facility, home health agency or other postoperative care.
Approximately 50 million U.S. adults have physician-diagnosed arthritis. As the condition progresses, arthritis patients often require THR and/or TKR to maintain mobility and life quality. The number of THRs is expected to grow by 174 percent (572,000 patients) between 2005 and 2030, and TKRs by 673 percent (3.48 million). In recent years, the length of hospital stay following surgeries has decreased from an average of 9.1 days in 1990 to 3.7 days in 2008, while the cost of post-acute care, primarily in skilled nursing facilities and home health agencies, has "skyrocketed."
Health-care costs following acute hospital care have been identified as a major contributor to regional variation in Medicare spending. This study investigated the associations of preoperative physical therapy and post-acute care resource use and its effect on the total cost of care during primary hip or knee arthroplasty. Utilizing Medicare claims data, researchers were able to identify both preoperative physical therapy and postoperative care usage patterns for 4,733 THR and TKR patients. Postoperative, or "post-acute" care, was defined as the use of a skilled nursing facility, home health agency or inpatient rehabilitation center within 90 days after hospital discharge. Home health agency services included skilled nursing care, home health aides, physical therapy, speech therapy, occupational therapy and medical social services.
Approximately 77 percent of patients utilized care services following surgery. After adjusting for demographic characteristics and comorbidities (other conditions), patients receiving preoperative physical therapy showed a 29 percent reduction in postoperative care use. In addition:
1) 54.2 percent of the preoperative physical therapy group required postoperative care services, compared to 79.7 percent of the patients who did not have preoperative therapy.
2) The decline in postoperative care services resulted in an adjusted cost reduction of $1,215 per patient, due largely to lower costs for skilled nursing facility and home health agency care.
3) Preoperative physical therapy cost an average of $100 per patient, and was generally limited to one or two sessions.
"This study demonstrated an important opportunity to pre-empt postoperative outcome variances by implementing preoperative physical therapy along with management of comorbidities before and during surgery," said orthopaedic surgeon Ray Wasielewski, MD, co-author of the study ...
Approximately 50 million U.S. adults have physician-diagnosed arthritis. As the condition progresses, arthritis patients often require THR and/or TKR to maintain mobility and life quality. The number of THRs is expected to grow by 174 percent (572,000 patients) between 2005 and 2030, and TKRs by 673 percent (3.48 million). In recent years, the length of hospital stay following surgeries has decreased from an average of 9.1 days in 1990 to 3.7 days in 2008, while the cost of post-acute care, primarily in skilled nursing facilities and home health agencies, has "skyrocketed."
Health-care costs following acute hospital care have been identified as a major contributor to regional variation in Medicare spending. This study investigated the associations of preoperative physical therapy and post-acute care resource use and its effect on the total cost of care during primary hip or knee arthroplasty. Utilizing Medicare claims data, researchers were able to identify both preoperative physical therapy and postoperative care usage patterns for 4,733 THR and TKR patients. Postoperative, or "post-acute" care, was defined as the use of a skilled nursing facility, home health agency or inpatient rehabilitation center within 90 days after hospital discharge. Home health agency services included skilled nursing care, home health aides, physical therapy, speech therapy, occupational therapy and medical social services.
Approximately 77 percent of patients utilized care services following surgery. After adjusting for demographic characteristics and comorbidities (other conditions), patients receiving preoperative physical therapy showed a 29 percent reduction in postoperative care use. In addition:
1) 54.2 percent of the preoperative physical therapy group required postoperative care services, compared to 79.7 percent of the patients who did not have preoperative therapy.
2) The decline in postoperative care services resulted in an adjusted cost reduction of $1,215 per patient, due largely to lower costs for skilled nursing facility and home health agency care.
3) Preoperative physical therapy cost an average of $100 per patient, and was generally limited to one or two sessions.
"This study demonstrated an important opportunity to pre-empt postoperative outcome variances by implementing preoperative physical therapy along with management of comorbidities before and during surgery," said orthopaedic surgeon Ray Wasielewski, MD, co-author of the study ...
A longtime Travis Unified School District employee pleaded guilty to workers' compensation fraud last week, according to officials with the Solano County District Attorney's Office.
Damon Fraticelli, a 27-year employee of Travis Unified School District, pleaded guilty to one felony count of workers' compensation fraud last Friday, officials said. Fraticelli had alleged an on the job injury which prevented him from doing any of his duties as a janitor or participating in physical activities. According to officials at the Solano County District Attorney's Office, Fraticelli told an occupational health physician in April 2013 that pain in his right shoulder was so severe he could only wipe and clean tables with his left hand.
The following day, Fraticelli was filmed bowling with his right arm for approximately 40 minutes. Also, at about this time, Fraticelli's name appeared in newspapers as achieving top bowling scores, officials said. An investigation by the North Bay Schools Insurance Authority and the Solano County District Attorney's Office Fraud Unit revealed several examples of misrepresentations, according to officials.
Fraticelli was sentenced to five years of probation and a required to perform community service in addition to being ordered to pay $10,000 in restitution ...
Damon Fraticelli, a 27-year employee of Travis Unified School District, pleaded guilty to one felony count of workers' compensation fraud last Friday, officials said. Fraticelli had alleged an on the job injury which prevented him from doing any of his duties as a janitor or participating in physical activities. According to officials at the Solano County District Attorney's Office, Fraticelli told an occupational health physician in April 2013 that pain in his right shoulder was so severe he could only wipe and clean tables with his left hand.
The following day, Fraticelli was filmed bowling with his right arm for approximately 40 minutes. Also, at about this time, Fraticelli's name appeared in newspapers as achieving top bowling scores, officials said. An investigation by the North Bay Schools Insurance Authority and the Solano County District Attorney's Office Fraud Unit revealed several examples of misrepresentations, according to officials.
Fraticelli was sentenced to five years of probation and a required to perform community service in addition to being ordered to pay $10,000 in restitution ...
A national medical billing company has agreed to pay $1.95 million for allegedly defrauding the Medicare and Medicaid systems. Thus it seems that culpability can now be placed on non-medical administrative perpetrators that are involved in nothing more than the paperwork end of a medical practice.
The United States Attorney’s Office announced that it has reached a settlement with Medical Business Service, Inc. (MBS), which agreed to pay $1.95 million to settle claims that it violated the False Claims Act by fraudulently changing diagnosis codes on claims to Medicare and Medicaid, in order to get the rejected claims paid on behalf of radiologists. MBS was located in Florida, with an office in Duluth, Ga.
The civil settlement resolves the United States’ investigation into MBS’s billing practices. The United States alleges that MBS improperly coded and billed claims by radiologists that were submitted to the Medicare and Medicaid programs. Medicare and Medicaid issue guidance stating that they will not pay for certain procedures given to patients with specific diagnoses. Medicare and Medicaid will reject claims for payment that combine those procedures and diagnoses. MBS allegedly changed the diagnosis codes on previously rejected claims to avoid those restrictions in order to have the claims paid. The settlement covers a three year period, 2008-2010, during which the conduct allegedly occurred.
"Billing companies provide a key check-point to combat medical billing fraud. Consequently, they will be examined with the same scrutiny as healthcare providers," said United States Attorney Sally Quillian Yates.
"The health care providers who contracted with MBS placed their trust in the company to correctly process claims and not submit fraudulent information to the Medicare and Medicaid programs," said Derrick L. Jackson, Special Agent in Charge of the U.S. Department of Health and Human Services, Office of Inspector General in Atlanta. "The lack of compliance and oversight by MBS placed all these providers at risk. Billing services such as MBS have no less of a duty to ensure truthful information on claims than do the providers who use these services."
This civil settlement resolves a lawsuit filed by Katlisa N. Vaughn under the qui tam, or whistleblower, provisions of the False Claims Act, which allow private citizens to bring civil actions on behalf of the United States and share in any recovery obtained. The case, pending in the Northern District of Georgia, is filed under United States of America, State of Florida, State of Georgia, State of New York, State of Tennessee, and State of Texas ex rel. Katlisa N. Vaughn v. Medical Business Service, Inc., Civ. No. 1:10-CV-2953. The Federal government will receive $1.917 million from the settlement, while Florida, Georgia, New York, and Texas will split the remainder of the settlement. Ms. Vaughn will receive a share of the settlement payment that resolves the qui tam suit that she filed. The claims settled in the civil settlement are allegations only, and there has been no determination of liability.
This resolution is part of the government’s emphasis on combating health care fraud under the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced by Attorney General Eric Holder and Kathleen Sebelius, Secretary of the Department of Health and Human Services, in May 2009. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover more than $14 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department’s total recoveries in False Claims Act cases since January 2009 are over $20 billion ...
The United States Attorney’s Office announced that it has reached a settlement with Medical Business Service, Inc. (MBS), which agreed to pay $1.95 million to settle claims that it violated the False Claims Act by fraudulently changing diagnosis codes on claims to Medicare and Medicaid, in order to get the rejected claims paid on behalf of radiologists. MBS was located in Florida, with an office in Duluth, Ga.
The civil settlement resolves the United States’ investigation into MBS’s billing practices. The United States alleges that MBS improperly coded and billed claims by radiologists that were submitted to the Medicare and Medicaid programs. Medicare and Medicaid issue guidance stating that they will not pay for certain procedures given to patients with specific diagnoses. Medicare and Medicaid will reject claims for payment that combine those procedures and diagnoses. MBS allegedly changed the diagnosis codes on previously rejected claims to avoid those restrictions in order to have the claims paid. The settlement covers a three year period, 2008-2010, during which the conduct allegedly occurred.
"Billing companies provide a key check-point to combat medical billing fraud. Consequently, they will be examined with the same scrutiny as healthcare providers," said United States Attorney Sally Quillian Yates.
"The health care providers who contracted with MBS placed their trust in the company to correctly process claims and not submit fraudulent information to the Medicare and Medicaid programs," said Derrick L. Jackson, Special Agent in Charge of the U.S. Department of Health and Human Services, Office of Inspector General in Atlanta. "The lack of compliance and oversight by MBS placed all these providers at risk. Billing services such as MBS have no less of a duty to ensure truthful information on claims than do the providers who use these services."
This civil settlement resolves a lawsuit filed by Katlisa N. Vaughn under the qui tam, or whistleblower, provisions of the False Claims Act, which allow private citizens to bring civil actions on behalf of the United States and share in any recovery obtained. The case, pending in the Northern District of Georgia, is filed under United States of America, State of Florida, State of Georgia, State of New York, State of Tennessee, and State of Texas ex rel. Katlisa N. Vaughn v. Medical Business Service, Inc., Civ. No. 1:10-CV-2953. The Federal government will receive $1.917 million from the settlement, while Florida, Georgia, New York, and Texas will split the remainder of the settlement. Ms. Vaughn will receive a share of the settlement payment that resolves the qui tam suit that she filed. The claims settled in the civil settlement are allegations only, and there has been no determination of liability.
This resolution is part of the government’s emphasis on combating health care fraud under the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced by Attorney General Eric Holder and Kathleen Sebelius, Secretary of the Department of Health and Human Services, in May 2009. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover more than $14 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department’s total recoveries in False Claims Act cases since January 2009 are over $20 billion ...
For decades, it's been the conventional wisdom that U.S. healthcare costs are high because doctors order expensive tests to protect themselves from malpractice lawsuits, but new evidence says that assumption is wrong. The study from the RAND Corporation found that in three states where the laws were rewritten to make it virtually impossible to sue a doctor for mistakes, the cost of care did not go down in hospital emergency departments.
"If your goal is cost savings, if you believe there is a lot of pure waste going on, then malpractice reform is a blind alley," Dr. Daniel Waxman, chief author of the study, told Reuters Health by phone.
According to the story in Reuters Health, the idea that defensive medicine is responsible for higher health costs "has come up over and over and over again," said Waxman, of Rand HEALTH in Santa Monica, California. "It distracts people from looking for other avenues" that might bring costs down more effectively. A 2010 study even pegged the cost of needless care motivated by fear of malpractice lawsuits at $210 billion a year.
The new study in the New England Journal of Medicine looked at costs before and after Georgia, Texas and South Carolina changed their laws to only allow emergency department doctors to be sued for gross negligence, in which the doctor knows that a treatment will likely cause serious injury, yet does it anyway. "People say the letter of that law is an almost-impossible threshold to meet," although such decisions are ultimately left up to the courts, said Waxman, who is an emergency department physician.
The team's analysis of more than 3.8 million Medicare records from 1,166 hospitals also included neighboring states where the standard of malpractice remained ordinary negligence, which is a failure to exercise reasonable care. "If you ask physicians, 'Do you practice defensively?' They overwhelmingly say, 'Yes we do.' They say they order more CT scans and MRIs. They admit people to the hospital. That certainly is a long-standing belief among physicians and lay people at this point," said Dr. Waxman.
But when the team examined emergency room bills and the likelihood that the patients would be admitted to the hospital or receive a CT or MRI scan, Waxman and his colleagues found no difference in nearly every measure before and after the three states changed their laws. Only in Georgia did they see any shift - a 3.6 percent drop in the average emergency room charge compared to neighboring states after the Peach State revised its law in 2005.
"Although there was a small reduction in charges in one of the three states (Georgia), our results in aggregate suggest that these strongly protective laws caused little (if any) change in practice intensity among physicians caring for Medicare patients in emergency departments," the researchers conclude in the report. The new laws may not have changed how doctors practice, but in Texas the 2003 reforms cut the number of malpractice lawsuits by 60 percent and the total of malpractice payments by 70 percent.
"This certainly runs counter to most people's expectation," Waxman said. "Basically, there are a whole bunch of things going on. No doctor wants to be sued. But doctors also don't want to make mistakes. They don't want to cause harm. They don't want to say no to patients. So everything favors doing more. There are reasons to be faulted for not doing more, and very little pushback if you don't."
"It's easy to blame something that's out of your control," he said, "and the legal system is a convenient scapegoat." ...
"If your goal is cost savings, if you believe there is a lot of pure waste going on, then malpractice reform is a blind alley," Dr. Daniel Waxman, chief author of the study, told Reuters Health by phone.
According to the story in Reuters Health, the idea that defensive medicine is responsible for higher health costs "has come up over and over and over again," said Waxman, of Rand HEALTH in Santa Monica, California. "It distracts people from looking for other avenues" that might bring costs down more effectively. A 2010 study even pegged the cost of needless care motivated by fear of malpractice lawsuits at $210 billion a year.
The new study in the New England Journal of Medicine looked at costs before and after Georgia, Texas and South Carolina changed their laws to only allow emergency department doctors to be sued for gross negligence, in which the doctor knows that a treatment will likely cause serious injury, yet does it anyway. "People say the letter of that law is an almost-impossible threshold to meet," although such decisions are ultimately left up to the courts, said Waxman, who is an emergency department physician.
The team's analysis of more than 3.8 million Medicare records from 1,166 hospitals also included neighboring states where the standard of malpractice remained ordinary negligence, which is a failure to exercise reasonable care. "If you ask physicians, 'Do you practice defensively?' They overwhelmingly say, 'Yes we do.' They say they order more CT scans and MRIs. They admit people to the hospital. That certainly is a long-standing belief among physicians and lay people at this point," said Dr. Waxman.
But when the team examined emergency room bills and the likelihood that the patients would be admitted to the hospital or receive a CT or MRI scan, Waxman and his colleagues found no difference in nearly every measure before and after the three states changed their laws. Only in Georgia did they see any shift - a 3.6 percent drop in the average emergency room charge compared to neighboring states after the Peach State revised its law in 2005.
"Although there was a small reduction in charges in one of the three states (Georgia), our results in aggregate suggest that these strongly protective laws caused little (if any) change in practice intensity among physicians caring for Medicare patients in emergency departments," the researchers conclude in the report. The new laws may not have changed how doctors practice, but in Texas the 2003 reforms cut the number of malpractice lawsuits by 60 percent and the total of malpractice payments by 70 percent.
"This certainly runs counter to most people's expectation," Waxman said. "Basically, there are a whole bunch of things going on. No doctor wants to be sued. But doctors also don't want to make mistakes. They don't want to cause harm. They don't want to say no to patients. So everything favors doing more. There are reasons to be faulted for not doing more, and very little pushback if you don't."
"It's easy to blame something that's out of your control," he said, "and the legal system is a convenient scapegoat." ...
The Division of Workers’ Compensation (DWC) has issued a notice of public hearing to revise various provisions of the Official Medical Fee Schedule (OMFS). The public hearing has been scheduled for 10 a.m., November 14, 2014, in the Auditorium of the Elihu Harris Building, 1515 Clay Street, Oakland, CA 94612. Members of the public may also submit written comment on the regulations until 5 p.m. that day. The proposed amendments are as follows:
1) Amend the fee schedules provisions in Article 5.3 and section 9790 in Article 5.5, to reiterate the applicable dates of fee schedule provisions. The Division has become aware of the misapplication of the effective dates of various fee schedule provisions.
2) Amend the inpatient hospital fee schedule provisions that address the operating disproportionate share hospital (DSH) adjustments. The proposed amendments are necessary as a result of changes made by Medicare to their operating DSH adjustment methodology.
3) Amend the inpatient hospital fee schedule provisions that address the outlier payments for eligible transfer cases. The Division has become aware of the need to clarify that hospitals transferring an inpatient to another hospital or post-acute care provider are eligible to receive an outlier payment for qualifying cases. The proposed amendments provide the methodology for determining whether a case is eligible for an outlier payment, and if so, how the payment amount would be calculated. The proposed methodology conforms to Medicare’s payment methodology.
4) Minor amendments that are required to conform to the proposed changes, to update, or to clarify various sections of the Official Medical Fee Schedule.
The notice, initial statement of reasons, and text of the regulations can be found on the proposed regulations webpage ...
1) Amend the fee schedules provisions in Article 5.3 and section 9790 in Article 5.5, to reiterate the applicable dates of fee schedule provisions. The Division has become aware of the misapplication of the effective dates of various fee schedule provisions.
2) Amend the inpatient hospital fee schedule provisions that address the operating disproportionate share hospital (DSH) adjustments. The proposed amendments are necessary as a result of changes made by Medicare to their operating DSH adjustment methodology.
3) Amend the inpatient hospital fee schedule provisions that address the outlier payments for eligible transfer cases. The Division has become aware of the need to clarify that hospitals transferring an inpatient to another hospital or post-acute care provider are eligible to receive an outlier payment for qualifying cases. The proposed amendments provide the methodology for determining whether a case is eligible for an outlier payment, and if so, how the payment amount would be calculated. The proposed methodology conforms to Medicare’s payment methodology.
4) Minor amendments that are required to conform to the proposed changes, to update, or to clarify various sections of the Official Medical Fee Schedule.
The notice, initial statement of reasons, and text of the regulations can be found on the proposed regulations webpage ...
A shooting at the State of Nevada Department of Administrative Hearings Division building in Las Vegas on Monday stemmed from a workers' compensation claim 11 years earlier, an arrest report reveals. Michael Kogler, who was shot, previously worked with the accused shooter, 73-year-old Leonard Sullivan, at MGM Resorts. Kogler worked as a claims adjuster for MGM at the time.
According to the arrest report, Sullivan, who was dressed in a suit, wore a hat, and carried a cane, was seen by multiple people before the shooting, including a maintenance employee who asked if he needed help finding his way. He reportedly told the man, "no." "The male walked slowly across the landing outside the office as if waiting for someone," the arrest report said.
Moments later, Kogler passed Sullivan on the walkway, when the 73-year-old yelled out Kogler's name. "Kogler turned around and said, 'yes' and the suspect shot him," according to the arrest report. Sullivan reportedly uttered Kogler had been "missing over him for 10 years" after he shot him. Kogler was shot in the upper chest. He was taken to University Medical Center and is expected to be OK.
Police said Sullivan was subdued by security officers and arrested when police arrived at the office building on Rancho Drive near Sahara Avenue. A security guard reported that after being detained, Sullivan told him he planned to put the gun into his mouth, according to the report. Sullivan faces one charge of attempted murder with weapon. Police received a call the day before the shooting from from an acquaintance who said Sullivan had made suicidal remarks, the report said.
Kogler said he worked with Sullivan 10 years ago for MGM Mirage, where Kogler was a claims adjuster, according to the police report.. At the time, Sullivan said he tripped over a luggage cart at a Las Vegas hotel. Sullivan has filed numerous claims and had been to the hearing office on "several occasions" before Monday's shooting, police said ...
According to the arrest report, Sullivan, who was dressed in a suit, wore a hat, and carried a cane, was seen by multiple people before the shooting, including a maintenance employee who asked if he needed help finding his way. He reportedly told the man, "no." "The male walked slowly across the landing outside the office as if waiting for someone," the arrest report said.
Moments later, Kogler passed Sullivan on the walkway, when the 73-year-old yelled out Kogler's name. "Kogler turned around and said, 'yes' and the suspect shot him," according to the arrest report. Sullivan reportedly uttered Kogler had been "missing over him for 10 years" after he shot him. Kogler was shot in the upper chest. He was taken to University Medical Center and is expected to be OK.
Police said Sullivan was subdued by security officers and arrested when police arrived at the office building on Rancho Drive near Sahara Avenue. A security guard reported that after being detained, Sullivan told him he planned to put the gun into his mouth, according to the report. Sullivan faces one charge of attempted murder with weapon. Police received a call the day before the shooting from from an acquaintance who said Sullivan had made suicidal remarks, the report said.
Kogler said he worked with Sullivan 10 years ago for MGM Mirage, where Kogler was a claims adjuster, according to the police report.. At the time, Sullivan said he tripped over a luggage cart at a Las Vegas hotel. Sullivan has filed numerous claims and had been to the hearing office on "several occasions" before Monday's shooting, police said ...
The Insurance Journal reports that California’s Department of Industrial Relations Director is taking a bit of umbrage with a study released last week that showed the state was ranked as the most expensive in the nation for workers’ compensation. Despite major workers’ comp reforms signed into law in 2012 California topped the 2014 Oregon Workers’ Compensation Premium Rate Ranking Summary, a list of average premiums paid by employers that the Oregon Department of Consumer and Business Services puts out every two years. Premium rates in the report ranged from a low of 88 cents in North Dakota to $3.48 in California. Premiums paid were 61 cents lower in Connecticut, the next state with a wide margin behind California. Oregon ranked 43rd, reportedly its best performance since the report was first put out in 1988.
The report was seized on by the Workers’ Compensation Action Network as an example of how tough it is to be an employer in California. "Try as we might to reform California’s workers’ compensation system, employers here continue to bear the heaviest cost burden in the nation - by a wide margin," WCAN spokesman Jerry Azevedo said the day the report was issued.
But on Monday DIR Director Christine Baker called out some issues she had with the study. "It’s good for Oregon, but it isn’t fair to California," Baker said. A detailed reply to the study put out by DIR notes the Oregon study has "inconsistencies and methodologies that skew the ranking." Baker said the report compares different occupational classes, and it fails to include adjustments resulting from the application of deductible plans or the return of policyholder dividends. "It is such a completely different distribution," she said, adding that the industrial mix and the size of California’s employment ranks are not comparable to other states in the study. "It’s a good study for Oregon," Baker added. "It makes Oregon look really good, but it’s apples-to-oranges for California. It’s just not comparable."
According to Jay Dotter, who put together the Oregon study, anyway you slice it the report doesn’t bode well for California’s workers’ comp system. The report takes 50 business classes and compares losses over a three-year period. "That’s going to vary a little bit state by state," Dotter acknowledged. "But you can look at top 10 by payroll and you’re going to see the same top 10 (in terms of premium ranking) probably in every state." He added: "What that’s saying is the industry mix really doesn’t have that big of an effect on it."
Also not taken into account in the report are the reforms to California’s workers’ comp system ushered in by Senate Bill 863 in 2012, many of which have yet to take effect, Baker said. Projections indicate that without SB 863, workers’ compensation costs would have spiked more sharply in 2013 and 2014, and that insurance prices had already begun to rise in 2012. SB 863, which initiated an independent medical review and a utilization review process, has already had a positive impact on workers’ comp, according to DIR. Medical expenses appear to be under better control, according to preliminary data from the Workers’ Compensation Insurance Rating Bureau of California. The data indicates that the estimated ultimate medical loss per lost-time claim is down 1.3 percent from accident year 2012 to 2013.
SB 863 also reduced ambulatory surgery center facility fees from 120 percent to 80 percent of Medicare’s hospital outpatient fee schedule, according to DIR, which stated the average amount paid per ASC episode in the first six months after the change in fee schedules was 26 percent lower than in the year before the change took effect.
Yet another aspect of SB 863 repealed the separate reimbursement for spinal hardware, after which the average amount paid per episode of the spinal surgery involving implantable hardware fell by 56 percent, according to DIR.
Finally, perhaps the biggest SB 863 change was a lien filing fee. During the first year the filing fee was in effect, 213,092 liens were filed, down from 469,190 in 2011, a greater than 50 percent reduction, according to DIR, which estimates the lien filing fee is saving California employers and insurers $270 million per year in litigation and settlement costs. "I think there are a lot of things happening at the same time," Baker said of the ongoing SB 863 reforms. "We’re hearing from the judges that cases are settling a lot quicker. It will take time to balance all of this out. It will take another two to three years I think."
Dotter acknowledged that the report, which looks at data up to Jan. 1, 2014, does not reflect SB 863 reforms. But, he added, "We’ll have some idea of that when we do the 2016 study." ...
The report was seized on by the Workers’ Compensation Action Network as an example of how tough it is to be an employer in California. "Try as we might to reform California’s workers’ compensation system, employers here continue to bear the heaviest cost burden in the nation - by a wide margin," WCAN spokesman Jerry Azevedo said the day the report was issued.
But on Monday DIR Director Christine Baker called out some issues she had with the study. "It’s good for Oregon, but it isn’t fair to California," Baker said. A detailed reply to the study put out by DIR notes the Oregon study has "inconsistencies and methodologies that skew the ranking." Baker said the report compares different occupational classes, and it fails to include adjustments resulting from the application of deductible plans or the return of policyholder dividends. "It is such a completely different distribution," she said, adding that the industrial mix and the size of California’s employment ranks are not comparable to other states in the study. "It’s a good study for Oregon," Baker added. "It makes Oregon look really good, but it’s apples-to-oranges for California. It’s just not comparable."
According to Jay Dotter, who put together the Oregon study, anyway you slice it the report doesn’t bode well for California’s workers’ comp system. The report takes 50 business classes and compares losses over a three-year period. "That’s going to vary a little bit state by state," Dotter acknowledged. "But you can look at top 10 by payroll and you’re going to see the same top 10 (in terms of premium ranking) probably in every state." He added: "What that’s saying is the industry mix really doesn’t have that big of an effect on it."
Also not taken into account in the report are the reforms to California’s workers’ comp system ushered in by Senate Bill 863 in 2012, many of which have yet to take effect, Baker said. Projections indicate that without SB 863, workers’ compensation costs would have spiked more sharply in 2013 and 2014, and that insurance prices had already begun to rise in 2012. SB 863, which initiated an independent medical review and a utilization review process, has already had a positive impact on workers’ comp, according to DIR. Medical expenses appear to be under better control, according to preliminary data from the Workers’ Compensation Insurance Rating Bureau of California. The data indicates that the estimated ultimate medical loss per lost-time claim is down 1.3 percent from accident year 2012 to 2013.
SB 863 also reduced ambulatory surgery center facility fees from 120 percent to 80 percent of Medicare’s hospital outpatient fee schedule, according to DIR, which stated the average amount paid per ASC episode in the first six months after the change in fee schedules was 26 percent lower than in the year before the change took effect.
Yet another aspect of SB 863 repealed the separate reimbursement for spinal hardware, after which the average amount paid per episode of the spinal surgery involving implantable hardware fell by 56 percent, according to DIR.
Finally, perhaps the biggest SB 863 change was a lien filing fee. During the first year the filing fee was in effect, 213,092 liens were filed, down from 469,190 in 2011, a greater than 50 percent reduction, according to DIR, which estimates the lien filing fee is saving California employers and insurers $270 million per year in litigation and settlement costs. "I think there are a lot of things happening at the same time," Baker said of the ongoing SB 863 reforms. "We’re hearing from the judges that cases are settling a lot quicker. It will take time to balance all of this out. It will take another two to three years I think."
Dotter acknowledged that the report, which looks at data up to Jan. 1, 2014, does not reflect SB 863 reforms. But, he added, "We’ll have some idea of that when we do the 2016 study." ...
The California Division of Workers’ Compensation announced that registration for its 22nd annual educational conference is now open. This is the largest workers' compensation educational event in the state. It is held in February in both Northern and Southern California. Speakers from the Division of Workers’ Compensation and the private sector will address the most current topics and issues confronting claims administrators, medical providers, attorneys, rehabilitation counselors and others involved in workers’ compensation.The conference will take place February 9-10, 2015 at the Los Angeles Airport Marriott and February 19-20, 2015 at the Oakland Marriott City Center Hotel.
Attendee, exhibitor, and sponsor registration forms may be downloaded from the conference website.
Conference registration flyers were recently mailed to the more than 8,000 names on our mailing list. Registration forms are also available at the conference website and the front counters of the DWC district offices in the state.
This annual event is the largest workers’ compensation training in the state and allows claims administrators, attorneys, medical providers, return to work specialists, employers and others to learn firsthand about the most recent developments in the system. Attendees will be interested in how DWC continues to implement the provisions of SB 863 with new regulations, forms, and procedures.
DWC has applied for continuing educational credits by attorney, claims adjuster, rehabilitation counselor, case manager, disability management, and qualified medical examiner certifying organizations. Organizations who would like to become sponsors of the DWC conference can do so by going to the website.
In 2014 more than 1,800 attendees and 135 exhibitors signed up, so DWC encourages early registration ...
Attendee, exhibitor, and sponsor registration forms may be downloaded from the conference website.
Conference registration flyers were recently mailed to the more than 8,000 names on our mailing list. Registration forms are also available at the conference website and the front counters of the DWC district offices in the state.
This annual event is the largest workers’ compensation training in the state and allows claims administrators, attorneys, medical providers, return to work specialists, employers and others to learn firsthand about the most recent developments in the system. Attendees will be interested in how DWC continues to implement the provisions of SB 863 with new regulations, forms, and procedures.
DWC has applied for continuing educational credits by attorney, claims adjuster, rehabilitation counselor, case manager, disability management, and qualified medical examiner certifying organizations. Organizations who would like to become sponsors of the DWC conference can do so by going to the website.
In 2014 more than 1,800 attendees and 135 exhibitors signed up, so DWC encourages early registration ...
Workers compensation experts explained how to control workers comp costs related to opioid management and the aging workforce during Business Insurance's fifth annual Workers Comp and Safety Virtual Conference.
In his keynote speech, William Zachry, vice president of risk management for Safeway Inc., talked about the top 10 cost drivers for workers comp claims. Mr. Zachry's recommendations included connecting utilization review and bill review processes for comp claims, using pre-employment screenings to avoid placing workers in jobs that they are physically unfit to perform, and reducing litigation in comp cases by showing an interest in injured workers. "Calls from the supervisor or owner of the company asking if the injured worker understands his or her benefits, if the benefit notices were confusing or if the medical care is good, and if there is anything that the employer can do the for the employee (can have) a massive effect on reducing litigation," Mr. Zachry said.
In another presentation, Kimberly George, senior vice president and senior health care advisor for Sedgwick Claims Management Services Inc., talked about the challenges and opportunities that go hand-in-hand with the Patient Protection Affordable Care Act.
In a presentation on controlling the use of opioids in workers comp, speakers discussed guidelines for prescribing such medications and the use of prescription formularies to prevent overprescribing. Dr. Steven Feinberg, chief medical officer for Feinberg Medical Group in Palo Alto, California, said the use of opioids may be appropriate for some patients, but it's best to avoid long-term use of such drugs.
Alex Swedlow, president of the Oakland, California-based California Workers' Compensation Institute, and Vennela Thumula, policy analyst with the Cambridge, Massachusetts-based Workers Compensation Research Institute, presented evidence that closed prescription drug formularies, which have been successful in reducing workers comp medical costs in Texas and Washington state, could help reduce workers comp medical costs in other states.
While older workers are less likely to be injured on the job, those who are hurt often take longer to return to work at full capacity, presenters said in another session. David Barry, senior vice president and national technical director for casualty risk control for Willis North America Inc., said older workers made up 26% of all fatal accidents in 2005, yet they represented only 16% of the workforce at the time. During the session, Debbie Villegas, human resources manager for Jordan Foster Construction L.L.C., said it's difficult to replace knowledgeable older workers, so some employees who have retired from the company have actually returned to manage projects as consultants.
Lance Perry, senior ergonomist and professional engineer for Zurich Services Corp., said ergonomics is key to keeping older workers safe and healthy. He added that safety managers, productivity managers and quality managers have to work together to identify solutions that will accommodate the physical, physiological and psychosocial changes of an aging workforce.
Nearly 900 risk managers, safety managers, human resources and benefit managers, brokers and third-party administrators, among other attendees, registered for the free online event. You can view the event on demand online at BusinessInsurance.com/CompCosts ...
In his keynote speech, William Zachry, vice president of risk management for Safeway Inc., talked about the top 10 cost drivers for workers comp claims. Mr. Zachry's recommendations included connecting utilization review and bill review processes for comp claims, using pre-employment screenings to avoid placing workers in jobs that they are physically unfit to perform, and reducing litigation in comp cases by showing an interest in injured workers. "Calls from the supervisor or owner of the company asking if the injured worker understands his or her benefits, if the benefit notices were confusing or if the medical care is good, and if there is anything that the employer can do the for the employee (can have) a massive effect on reducing litigation," Mr. Zachry said.
In another presentation, Kimberly George, senior vice president and senior health care advisor for Sedgwick Claims Management Services Inc., talked about the challenges and opportunities that go hand-in-hand with the Patient Protection Affordable Care Act.
In a presentation on controlling the use of opioids in workers comp, speakers discussed guidelines for prescribing such medications and the use of prescription formularies to prevent overprescribing. Dr. Steven Feinberg, chief medical officer for Feinberg Medical Group in Palo Alto, California, said the use of opioids may be appropriate for some patients, but it's best to avoid long-term use of such drugs.
Alex Swedlow, president of the Oakland, California-based California Workers' Compensation Institute, and Vennela Thumula, policy analyst with the Cambridge, Massachusetts-based Workers Compensation Research Institute, presented evidence that closed prescription drug formularies, which have been successful in reducing workers comp medical costs in Texas and Washington state, could help reduce workers comp medical costs in other states.
While older workers are less likely to be injured on the job, those who are hurt often take longer to return to work at full capacity, presenters said in another session. David Barry, senior vice president and national technical director for casualty risk control for Willis North America Inc., said older workers made up 26% of all fatal accidents in 2005, yet they represented only 16% of the workforce at the time. During the session, Debbie Villegas, human resources manager for Jordan Foster Construction L.L.C., said it's difficult to replace knowledgeable older workers, so some employees who have retired from the company have actually returned to manage projects as consultants.
Lance Perry, senior ergonomist and professional engineer for Zurich Services Corp., said ergonomics is key to keeping older workers safe and healthy. He added that safety managers, productivity managers and quality managers have to work together to identify solutions that will accommodate the physical, physiological and psychosocial changes of an aging workforce.
Nearly 900 risk managers, safety managers, human resources and benefit managers, brokers and third-party administrators, among other attendees, registered for the free online event. You can view the event on demand online at BusinessInsurance.com/CompCosts ...
