After over a dozen acts of Congress and innumerable reams of debate and conjecture about its fate, it’s time to say goodbye to the Medicare Sustainable Growth Rate (SGR) formula.
From 1980-1990, Medicare payments to doctors were based on charges. During that period, spending under the program on physician services inflated rapidly, growing at an annual rate of 13.4 percent. Congress took note and reformed the system in two key ways: (1) rates paid for services would be determined by the resources, or inputs, necessary to perform them; and (2) annual increases for services would be restricted based on the total volume of services delivered.
The heralded budget deal struck in 1997 by then-President Clinton and the Republican-controlled Congress included a refinement to the aspect of Medicare physician payment rates linked to volume growth, newly labeled the Sustainable Growth Rate (SGR) formula. In very short terms, the SGR boosted payments when the growth rate of spending on physician services fell short of growth in the gross domestic product (GDP). Likewise, it cut payments when physician spending grew more rapidly than GDP. Prices, the number of Medicare beneficiaries, and changes in law were all accounted for, essentially leaving utilization rate as the only key factor driving the SGR algorithm.
The SGR seemed a nice little incentive for docs to rein in their prescribing pens and be more efficient, except that the incentive was spread across over a million physicians and related professionals, creating a classic collective action problem. No one much seemed to care, though, until 2002, when Medicare’s base payment rate for these services was cut by 4.8 percent. Suddenly, the flaws in the formula got everyone’s attention, including Congress’s. For 2003 (and ever since), Congress passed a law to block the cuts generated by the SGR formula.
Doctors were set to receive a 21% cut in payments on April 1 if Congress did not act (again). The current funding formula expired on April 1. However, the Centers for Medicare and Medicaid Services said that it takes a minimum of 14 days to pay claims from doctors, giving senators until midnight Tuesday to act before checks went out. Just in the nick of time, a bipartisan bill passed the Senate by 92-8. The House overwhelmingly passed the "doc fix" bill by a vote of 392-37 on March 26 before leaving town for a two-week recess. President Obama is expected to quickly sign the bill into law.
The bill would repeal the current Medicare payment formula for doctors and replace it with one that would increase payments to doctors by one-half of 1% every year through 2019. After that, doctors would receive bonuses or penalties depending on performance scores from the government. Their scores would be based on the value of the care they provide rather than on the volume of patients they see. This in effect becomes a "pay per performance" model of reimbursement. Medicare recipients with incomes of more than $85,000 a year would be required to pay higher Medicare Part B premiums starting in 2018. The legislation would end the annual scramble by lawmakers to pass a temporary patch to keep the payments from plummeting. Congress has been struggling with what both sides call a "flawed formula" since lawmakers enacted it in 1997.
The non-partisan Congressional Budget Office estimated that the bill would increase the deficit by $141 billion over 11 years. But the CBO also said the bill spends $900 million less than if Congress simply froze Medicare payment rates for doctors over that same period.
The formulaic approach to setting base payment rates is gone, replaced with automatic increases for all doctors from 2015 through 2019. For six years after that, no automatic increases will be provided and doctors’ respective rates will be altered based on their performance under a Merit-Based Payment Incentive System (MIPS). The MIPS is basically a consolidation of three pay-for-performance programs already underway and the addition of another. It is a process that combines existing Medicaid incentive programs and creates a composite performance score that will inform a provider’s reimbursement rates based on four performance categories: Quality, Resource use, Meaningful use, and Clinical practice improvement activities. A provider’s performance in these categories will be reflected in the Composite Performance Score, a 0-100 scale that informs the level of reimbursement. A threshold would be established annually that providers would have to meet or exceed in order to be eligible for enhanced rates. Those who fail to meet the threshold would be at risk of reduced rates. It is a zero sum game, and physicians who make more will be offset by physicians who make less.
This long awaited transformation of physician payment is expected to stimulate payment reform throughout the healthcare industry, including Workers' Compensation. It will of course take years for this to take place ...
From 1980-1990, Medicare payments to doctors were based on charges. During that period, spending under the program on physician services inflated rapidly, growing at an annual rate of 13.4 percent. Congress took note and reformed the system in two key ways: (1) rates paid for services would be determined by the resources, or inputs, necessary to perform them; and (2) annual increases for services would be restricted based on the total volume of services delivered.
The heralded budget deal struck in 1997 by then-President Clinton and the Republican-controlled Congress included a refinement to the aspect of Medicare physician payment rates linked to volume growth, newly labeled the Sustainable Growth Rate (SGR) formula. In very short terms, the SGR boosted payments when the growth rate of spending on physician services fell short of growth in the gross domestic product (GDP). Likewise, it cut payments when physician spending grew more rapidly than GDP. Prices, the number of Medicare beneficiaries, and changes in law were all accounted for, essentially leaving utilization rate as the only key factor driving the SGR algorithm.
The SGR seemed a nice little incentive for docs to rein in their prescribing pens and be more efficient, except that the incentive was spread across over a million physicians and related professionals, creating a classic collective action problem. No one much seemed to care, though, until 2002, when Medicare’s base payment rate for these services was cut by 4.8 percent. Suddenly, the flaws in the formula got everyone’s attention, including Congress’s. For 2003 (and ever since), Congress passed a law to block the cuts generated by the SGR formula.
Doctors were set to receive a 21% cut in payments on April 1 if Congress did not act (again). The current funding formula expired on April 1. However, the Centers for Medicare and Medicaid Services said that it takes a minimum of 14 days to pay claims from doctors, giving senators until midnight Tuesday to act before checks went out. Just in the nick of time, a bipartisan bill passed the Senate by 92-8. The House overwhelmingly passed the "doc fix" bill by a vote of 392-37 on March 26 before leaving town for a two-week recess. President Obama is expected to quickly sign the bill into law.
The bill would repeal the current Medicare payment formula for doctors and replace it with one that would increase payments to doctors by one-half of 1% every year through 2019. After that, doctors would receive bonuses or penalties depending on performance scores from the government. Their scores would be based on the value of the care they provide rather than on the volume of patients they see. This in effect becomes a "pay per performance" model of reimbursement. Medicare recipients with incomes of more than $85,000 a year would be required to pay higher Medicare Part B premiums starting in 2018. The legislation would end the annual scramble by lawmakers to pass a temporary patch to keep the payments from plummeting. Congress has been struggling with what both sides call a "flawed formula" since lawmakers enacted it in 1997.
The non-partisan Congressional Budget Office estimated that the bill would increase the deficit by $141 billion over 11 years. But the CBO also said the bill spends $900 million less than if Congress simply froze Medicare payment rates for doctors over that same period.
The formulaic approach to setting base payment rates is gone, replaced with automatic increases for all doctors from 2015 through 2019. For six years after that, no automatic increases will be provided and doctors’ respective rates will be altered based on their performance under a Merit-Based Payment Incentive System (MIPS). The MIPS is basically a consolidation of three pay-for-performance programs already underway and the addition of another. It is a process that combines existing Medicaid incentive programs and creates a composite performance score that will inform a provider’s reimbursement rates based on four performance categories: Quality, Resource use, Meaningful use, and Clinical practice improvement activities. A provider’s performance in these categories will be reflected in the Composite Performance Score, a 0-100 scale that informs the level of reimbursement. A threshold would be established annually that providers would have to meet or exceed in order to be eligible for enhanced rates. Those who fail to meet the threshold would be at risk of reduced rates. It is a zero sum game, and physicians who make more will be offset by physicians who make less.
This long awaited transformation of physician payment is expected to stimulate payment reform throughout the healthcare industry, including Workers' Compensation. It will of course take years for this to take place ...
The Office of Administrative Law (OAL) has approved the Division of Workers’ Compensation’s (DWC) final version of the Workers’ Compensation Information System (WCIS) regulations regarding Medical Billing Reporting.
The California legislature enacted sweeping reforms to California’s workers’ compensation system in 1993. The legislature directed the DWC to put together comprehensive information about workers’ compensation in California. The result is the WCIS. The WCIS has four components: the First Reports of Injury (FROI) reporting guidelines were implemented March 1, 2000. The Subsequent Reports of Injury (SROI) reporting guidelines were implemented July 1, 2000. Reporting of annual summary of benefits began January 31, 2001. Medical bill payment reporting regulations were adopted on March 22, 2006. The regulations require medical bill payment records for services with a date of service on or after September 22, 2006 and a date of injury on or after March 1, 2000.
California workers’ compensation medical bill payment records are processed by diverse organizations: large multi-state insurance companies, smaller specialty insurance carriers, self-insured employers or insurers, third-party administrators handling claims on behalf of self-insured employers, as well as bill review companies. The organizations have widely differing technological capabilities, so the WCIS is designed to be as flexible as possible in supporting EDI medical transmissions.
EDI is the computer-to-computer exchange of data or information in a standardized format. In California, workers’ compensation, medical EDI refers to the electronic transmission of detailed medical bill payment records information from trading partners, i.e., senders, to the California DWC. For collecting medical bill payment records data, the WCIS adopts the IAIABC Workers’ Compensation Medical Bill Data reporting Implementation Guide Release 2.0.
The regulations include release of California Electronic Data Interchange (EDI) Implementation Guide for Medical Bill Payment Records, Version 2.0, which brings California reporting requirements into compliance with IAIABC standards for medical bill payment reporting, as set forth in the IAIABC Workers’ Compensation Medical Bill Data Reporting Implementation Guide, Release 2.0 (February 1, 2014). The effective date of the new regulations, including the California EDI Guide for Medical Bill Payment Records, Version 2.0, is April 6, 2016.
The updated regulations will allow WCIS to collect more robust and useful data that will assist with research regarding workers’ compensation issues. The notice and text of the regulations can be found on the WCIS regulations page ...
The California legislature enacted sweeping reforms to California’s workers’ compensation system in 1993. The legislature directed the DWC to put together comprehensive information about workers’ compensation in California. The result is the WCIS. The WCIS has four components: the First Reports of Injury (FROI) reporting guidelines were implemented March 1, 2000. The Subsequent Reports of Injury (SROI) reporting guidelines were implemented July 1, 2000. Reporting of annual summary of benefits began January 31, 2001. Medical bill payment reporting regulations were adopted on March 22, 2006. The regulations require medical bill payment records for services with a date of service on or after September 22, 2006 and a date of injury on or after March 1, 2000.
California workers’ compensation medical bill payment records are processed by diverse organizations: large multi-state insurance companies, smaller specialty insurance carriers, self-insured employers or insurers, third-party administrators handling claims on behalf of self-insured employers, as well as bill review companies. The organizations have widely differing technological capabilities, so the WCIS is designed to be as flexible as possible in supporting EDI medical transmissions.
EDI is the computer-to-computer exchange of data or information in a standardized format. In California, workers’ compensation, medical EDI refers to the electronic transmission of detailed medical bill payment records information from trading partners, i.e., senders, to the California DWC. For collecting medical bill payment records data, the WCIS adopts the IAIABC Workers’ Compensation Medical Bill Data reporting Implementation Guide Release 2.0.
The regulations include release of California Electronic Data Interchange (EDI) Implementation Guide for Medical Bill Payment Records, Version 2.0, which brings California reporting requirements into compliance with IAIABC standards for medical bill payment reporting, as set forth in the IAIABC Workers’ Compensation Medical Bill Data Reporting Implementation Guide, Release 2.0 (February 1, 2014). The effective date of the new regulations, including the California EDI Guide for Medical Bill Payment Records, Version 2.0, is April 6, 2016.
The updated regulations will allow WCIS to collect more robust and useful data that will assist with research regarding workers’ compensation issues. The notice and text of the regulations can be found on the WCIS regulations page ...
Michael D. Drobot and his company Healthsmart Pacific, Inc. owner and operator of the Pacific Hospital of Long Beach has now filed a lawsuit against the 30 individuals who sued him, and their attorneys allegedly for falsely and maliciously claiming that Drobot and Healthsmart's former hospital, Pacific Hospital of Long Beach, harmed them by what it claims was a non-existent "counterfeit screw" conspiracy. This new lawsuit is filed by attorney Keith Fink in Los Angeles County Superior Court,, case BC578484. The lawsuit seeks at least $30 million in damages.
The lawsuit names three prominent law firms and the individuals they represented when they filed about 30 lawsuits last year. According to the near-identical complaints, each of these individuals alleged that Drobot and Healthsmart "conspired" with doctors to insert "counterfeit screws" into these persons' spines. Drobot's new lawsuit names law firms Kabateck, Brown Kellner, LLP, Cotchett, Pitre and McCarthy, LLP, and Knox Ricksen, LLP, the individual attorneys at each firm who prepared and litigated these claims, and the 30 "non-patients" who sued Drobot and Healthsmart for treatment they allegedly received elsewhere. The 30 plaintiffs, now defendants, are Golia, Bravo, Moses, Arroyo, Averhart, Cahill, Cichy, Coslett, Dail, Dixon, Duron, Epps, Espinoza, Fabila, Gonzales, Gutkowski, Heath, Lorton, Marciel, Mashtalier-Scott, McAlonan, Mejia, Perry, Philips, Plescia,Toppel, Vargas, Ventimiglia, Williams, Wilson, Kabateck, KBK, Hutchinson, CPM, KR, Pitre,Hamilton, LiCalsi, Danowitz, Sokolove, Barrett, Melidonian, DiCorrado, and Hakimfar.
Drobot alleges that these 30 plaintiffs were from his point of view "non-patients" because the surgeries during which each alleged to have received counterfeit hardware did not take place at the Pacific Hospital of Long Beach. Thus, as "non-patients" he in essence alleges that whatever happened to them was not of his making. Instead he lists the facilities were each of the surgeries took place, These other facilities are identified as a "non-party" since these facilities are not defendants in the new suit. The non-party facilities include Parkview Community Hospital, Riverside Community Hospital, Rancho Specialty Hospital all in Riverside and Tri-City Regional Medical Center in Hawaiian Gardens. The suit alleges that "None of the aforementioned Non-Patient Defendants received any form of medical treatment whatsoever from Plaintiffs PHLB" and that "Drobot had no financial interest, no participation in, nor any involvement whatsoever in the aforementioned medical treatment received by the Non-Patient Defendants listed above."
Last February, Los Angeles Superior Court Judge Elihu M. Berle dismissed the cases filed by Golia, Bravo, and Moses against Drobot, Pacific Hospital of Long Beach and the other hospitals and physicians accused of using the alleged "counterfeit'' surgical screws. One of the difficulties in these cases was the inability of the plaintiffs to prove what hardware had been implanted since it had not been surgically removed and examined. In this regard Drobot alleges that the "Non-Patient Defendants (and implicitly Attorney Defendants who drafted their underlying complaints) themselves did not and could not know nor reasonably conclude that the medical parts surgically inserted into their bodies were deficient because these parts had not been removed from the Non-Patient Defendants’ bodies for examination and testing." Following dismissal of three of the cases most of the remaining 27 cases were voluntarily dismissed by the plaintiffs.
Drobot's new lawsuit alleges in the aftermath that "no reasonable person'' would have believed that Drobot and Healthsmart Pacific could be held liable for surgeries that occurred at other hospitals on the facts alleged. As his new lawsuit further alleges, the individuals' lawyers repeatedly disregarded multiple attempts to have these claims voluntarily dismissed from the outset.
Drobot's new lawsuit is the second filed by the former hospital executive against the trio of law firms that alleged the counterfeit screw conspiracy. In October 2014, Drobot and Healthsmart Pacific filed a $50 million defamation lawsuit, alleging that the attorneys defamed him and his company on television and radio. The prior action remains pending ...
The lawsuit names three prominent law firms and the individuals they represented when they filed about 30 lawsuits last year. According to the near-identical complaints, each of these individuals alleged that Drobot and Healthsmart "conspired" with doctors to insert "counterfeit screws" into these persons' spines. Drobot's new lawsuit names law firms Kabateck, Brown Kellner, LLP, Cotchett, Pitre and McCarthy, LLP, and Knox Ricksen, LLP, the individual attorneys at each firm who prepared and litigated these claims, and the 30 "non-patients" who sued Drobot and Healthsmart for treatment they allegedly received elsewhere. The 30 plaintiffs, now defendants, are Golia, Bravo, Moses, Arroyo, Averhart, Cahill, Cichy, Coslett, Dail, Dixon, Duron, Epps, Espinoza, Fabila, Gonzales, Gutkowski, Heath, Lorton, Marciel, Mashtalier-Scott, McAlonan, Mejia, Perry, Philips, Plescia,Toppel, Vargas, Ventimiglia, Williams, Wilson, Kabateck, KBK, Hutchinson, CPM, KR, Pitre,Hamilton, LiCalsi, Danowitz, Sokolove, Barrett, Melidonian, DiCorrado, and Hakimfar.
Drobot alleges that these 30 plaintiffs were from his point of view "non-patients" because the surgeries during which each alleged to have received counterfeit hardware did not take place at the Pacific Hospital of Long Beach. Thus, as "non-patients" he in essence alleges that whatever happened to them was not of his making. Instead he lists the facilities were each of the surgeries took place, These other facilities are identified as a "non-party" since these facilities are not defendants in the new suit. The non-party facilities include Parkview Community Hospital, Riverside Community Hospital, Rancho Specialty Hospital all in Riverside and Tri-City Regional Medical Center in Hawaiian Gardens. The suit alleges that "None of the aforementioned Non-Patient Defendants received any form of medical treatment whatsoever from Plaintiffs PHLB" and that "Drobot had no financial interest, no participation in, nor any involvement whatsoever in the aforementioned medical treatment received by the Non-Patient Defendants listed above."
Last February, Los Angeles Superior Court Judge Elihu M. Berle dismissed the cases filed by Golia, Bravo, and Moses against Drobot, Pacific Hospital of Long Beach and the other hospitals and physicians accused of using the alleged "counterfeit'' surgical screws. One of the difficulties in these cases was the inability of the plaintiffs to prove what hardware had been implanted since it had not been surgically removed and examined. In this regard Drobot alleges that the "Non-Patient Defendants (and implicitly Attorney Defendants who drafted their underlying complaints) themselves did not and could not know nor reasonably conclude that the medical parts surgically inserted into their bodies were deficient because these parts had not been removed from the Non-Patient Defendants’ bodies for examination and testing." Following dismissal of three of the cases most of the remaining 27 cases were voluntarily dismissed by the plaintiffs.
Drobot's new lawsuit alleges in the aftermath that "no reasonable person'' would have believed that Drobot and Healthsmart Pacific could be held liable for surgeries that occurred at other hospitals on the facts alleged. As his new lawsuit further alleges, the individuals' lawyers repeatedly disregarded multiple attempts to have these claims voluntarily dismissed from the outset.
Drobot's new lawsuit is the second filed by the former hospital executive against the trio of law firms that alleged the counterfeit screw conspiracy. In October 2014, Drobot and Healthsmart Pacific filed a $50 million defamation lawsuit, alleging that the attorneys defamed him and his company on television and radio. The prior action remains pending ...
An investigation by the U.S. Department of Labor's Occupational Safety and Health Administration has determined that management of the Union Pacific Railroad added insult to injury when it blamed a worker in Roseville who was hurt on-the-job and then retaliated against him for reporting his injury in February 2011. Investigators reported that Union Pacific violated the Federal Railroad Safety Act when the company retaliated against the employee for reporting to his supervisors that he was hurt while lifting materials and equipment. As a result, OSHA has ordered the railroad to pay the worker $100,000 in punitive and compensatory damages.
OSHA claims that this case follows a pattern of behavior by Union Pacific toward its injured employees. OSHA recently reported that the railroad has faced more than 200 whistleblower complaints nationwide since 2001. "Union Pacific has repeatedly retaliated against workers who report on-the-job injuries," said Barbara Goto, acting OSHA regional administrator in San Francisco. "That flies in the face of the protections that the FRSA affords."
After being hurt, the employee in Roseville reported his injury. Although evidence at an investigatory hearing proved otherwise, Union Pacific charged the employee with causing his own injury by not using proper ergonomic and safety techniques. The company suspended him without pay for five days. In November 2012, Union Pacific apparently changed course. The company expunged the employee's record and paid him for the day he attended the investigation hearing and the five days of his suspension. Since the company voluntarily corrected the retaliation, OSHA assessed $50,000 in punitive damages. Any of the parties in this case can file an appeal with the department's Office of Administrative Law Judges.
In the most recent case, OSHA investigators determined that Union Pacific disciplined a 35-year-employee after the locomotive freight engineer reported injuries sustained in a Dec. 22, 2013 collision and received medical attention. The company has been ordered to pay the engineer $350,000 in punitive and compensatory damages and reasonable attorney's fees, remove disciplinary information from the employee's personnel record and provide information about whistleblower rights to all its employees. Prior to this incident, the employee had never been disciplined. "Union Pacific strongly disagrees with OSHA's findings in this case. We will appeal," said a Union Pacific spokesperson.
More than 200 whistleblower complaints have been logged against the railroad since 2001.
Union Pacific is the principal operating company of Union Pacific Corp, which functions in 23 states across the western two-thirds of the United States. It has 47,000 employees and operates 8,000 locomotives over 32,000 route miles.
OSHA enforces the whistleblower provisions of the FRSA and 21 other statutes protecting employees who report violations of various airline, commercial motor carrier, consumer product, environmental, financial reform, food safety, health care reform, nuclear, pipeline, worker safety, public transportation agency, railroad, maritime and securities laws.
Employers are prohibited from retaliating against employees who raise various protected concerns or provide protected information to the employer or to the government. Employees who believe that they have been retaliated against for engaging in protected conduct may file a complaint with the secretary of labor to request an investigation by OSHA's Whistleblower Protection Program. Detailed information on employee whistleblower rights, including fact sheets, is available at http://www.whistleblowers.gov ...
OSHA claims that this case follows a pattern of behavior by Union Pacific toward its injured employees. OSHA recently reported that the railroad has faced more than 200 whistleblower complaints nationwide since 2001. "Union Pacific has repeatedly retaliated against workers who report on-the-job injuries," said Barbara Goto, acting OSHA regional administrator in San Francisco. "That flies in the face of the protections that the FRSA affords."
After being hurt, the employee in Roseville reported his injury. Although evidence at an investigatory hearing proved otherwise, Union Pacific charged the employee with causing his own injury by not using proper ergonomic and safety techniques. The company suspended him without pay for five days. In November 2012, Union Pacific apparently changed course. The company expunged the employee's record and paid him for the day he attended the investigation hearing and the five days of his suspension. Since the company voluntarily corrected the retaliation, OSHA assessed $50,000 in punitive damages. Any of the parties in this case can file an appeal with the department's Office of Administrative Law Judges.
In the most recent case, OSHA investigators determined that Union Pacific disciplined a 35-year-employee after the locomotive freight engineer reported injuries sustained in a Dec. 22, 2013 collision and received medical attention. The company has been ordered to pay the engineer $350,000 in punitive and compensatory damages and reasonable attorney's fees, remove disciplinary information from the employee's personnel record and provide information about whistleblower rights to all its employees. Prior to this incident, the employee had never been disciplined. "Union Pacific strongly disagrees with OSHA's findings in this case. We will appeal," said a Union Pacific spokesperson.
More than 200 whistleblower complaints have been logged against the railroad since 2001.
Union Pacific is the principal operating company of Union Pacific Corp, which functions in 23 states across the western two-thirds of the United States. It has 47,000 employees and operates 8,000 locomotives over 32,000 route miles.
OSHA enforces the whistleblower provisions of the FRSA and 21 other statutes protecting employees who report violations of various airline, commercial motor carrier, consumer product, environmental, financial reform, food safety, health care reform, nuclear, pipeline, worker safety, public transportation agency, railroad, maritime and securities laws.
Employers are prohibited from retaliating against employees who raise various protected concerns or provide protected information to the employer or to the government. Employees who believe that they have been retaliated against for engaging in protected conduct may file a complaint with the secretary of labor to request an investigation by OSHA's Whistleblower Protection Program. Detailed information on employee whistleblower rights, including fact sheets, is available at http://www.whistleblowers.gov ...
The Department of Industrial Relations has now launched the Return-to-Work Supplement Program for injured workers. This fund - which will get an additional $5,000 to each eligible injured worker who has a disproportionate loss of earnings - is an important component of the workers’ compensation reforms in Senate Bill 863. This program is based on findings of studies done by RAND concerning permanent disability and in particular the study entitled Identifying Permanently Disabled Workers with Disproportionate Earnings Losses for Supplemental Payments.
"This program is another example of the benefits that SB 863 brought about for injured workers," said DIR Director Christine Baker. "Many workers face economic hardship when they suffer disabling work injuries and this supplement will help them regain some of those lost earnings."
DIR inaugurated the new program with an online portal as well as kiosks that connect to the portal in its Division of Workers’ Compensation (DWC) offices across the state, allowing injured workers to easily file the application in five steps. Section 17305 of the new regulations state "An application must be submitted by electronic means through the Department of Industrial Relations web site. The Department will make access to this web site available at each Division of Workers’ Compensation Information and Assistance Office location in the state."
To be eligible for the Return-to-Work Supplement, the individual must have received the Supplemental Job Displacement Benefit (SJDB) Voucher for an injury occurring on or after January 1, 2013. All completed applications will be reviewed for eligibility within 60 days from the date of filing. Payment to workers will be made within 25 days of the eligibility determination.
Regulations for the Return-to-Work Supplement Program were approved by the Office of Administrative Law (OAL) and filed with the Secretary of State on April 6, 2015. These regulations will be implemented on April 13 and are authorized by Labor Code section 139.48.
Commencing 30 days after the effective date of these regulations, and continuing until the Administrative Director of the Division of Workers’ Compensation amends Form DWC-AD 10133.32 to include notice of the Return-to-Work Supplement application process, all Vouchers issued shall be accompanied by a cover sheet, prepared by the claims administrator, containing the following notice: "Because you have received this Voucher and are unable to return to your usual employment you may be eligible for a Return-to-Work Supplement. You must apply within one year from the date this Voucher was served on you. You should make a copy of the Voucher which you will need to apply for the Return-to-Work Supplement. Details about the Return-to-Work supplement program are available from the Department of Industrial Relations on its web site, www.dir.ca.gov, or by calling 510-286-0787."
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 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 based on further studies conducted by the Director in accordance with Labor Code section 139.48.
An individual dissatisfied with any final decision of the Director on his or her application for the Return-to-Work Supplement may, file an appeal at the Workers’ Compensation Appeals Board (WCAB) District Office ...
"This program is another example of the benefits that SB 863 brought about for injured workers," said DIR Director Christine Baker. "Many workers face economic hardship when they suffer disabling work injuries and this supplement will help them regain some of those lost earnings."
DIR inaugurated the new program with an online portal as well as kiosks that connect to the portal in its Division of Workers’ Compensation (DWC) offices across the state, allowing injured workers to easily file the application in five steps. Section 17305 of the new regulations state "An application must be submitted by electronic means through the Department of Industrial Relations web site. The Department will make access to this web site available at each Division of Workers’ Compensation Information and Assistance Office location in the state."
To be eligible for the Return-to-Work Supplement, the individual must have received the Supplemental Job Displacement Benefit (SJDB) Voucher for an injury occurring on or after January 1, 2013. All completed applications will be reviewed for eligibility within 60 days from the date of filing. Payment to workers will be made within 25 days of the eligibility determination.
Regulations for the Return-to-Work Supplement Program were approved by the Office of Administrative Law (OAL) and filed with the Secretary of State on April 6, 2015. These regulations will be implemented on April 13 and are authorized by Labor Code section 139.48.
Commencing 30 days after the effective date of these regulations, and continuing until the Administrative Director of the Division of Workers’ Compensation amends Form DWC-AD 10133.32 to include notice of the Return-to-Work Supplement application process, all Vouchers issued shall be accompanied by a cover sheet, prepared by the claims administrator, containing the following notice: "Because you have received this Voucher and are unable to return to your usual employment you may be eligible for a Return-to-Work Supplement. You must apply within one year from the date this Voucher was served on you. You should make a copy of the Voucher which you will need to apply for the Return-to-Work Supplement. Details about the Return-to-Work supplement program are available from the Department of Industrial Relations on its web site, www.dir.ca.gov, or by calling 510-286-0787."
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 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 based on further studies conducted by the Director in accordance with Labor Code section 139.48.
An individual dissatisfied with any final decision of the Director on his or her application for the Return-to-Work Supplement may, file an appeal at the Workers’ Compensation Appeals Board (WCAB) District Office ...
San Francisco District Attorney George Gascón announced that Catherine Gregoire, age 52, of Hercules, CA, and Adela Delores Belfrey, age 52, of Oakland, CA were arrested on April 9, 2015 and charged with conspiracy to commit insurance fraud, false and fraudulent claims, claims adjuster fraud, grand theft by false pretenses, forgery, and money laundering. In addition, Belfrey is charged with two counts of identity theft. Belfrey was arrested at her work in Pleasanton by investigators with the San Francisco District Attorney’s office, while Gregoire was simultaneously arrested by officers with the Alameda County Sheriff’s Department on a plane arriving at the Oakland Airport from Los Angeles.
Gregoire, an ex-employee of Amtrust North America, is alleged to have created several shell companies under which she submitted a hundred and thirty-seven fraudulent invoices which Belfrey, a senior claims adjuster at AmTrust North America, is alleged to have secretly approved. Over an eight month period, Gregoire and Belfrey executed a scheme which resulted in over $528,058 of company funds being deposited into bank accounts controlled by Gregoire. According to court records, Gregoire paid $134,776 in cash for a 2014 Mercedes G 550 with funds that are alleged to have been fraudulently received from Amtrust North America. The vehicle was seized during the execution of the search warrant by District Attorney Investigators.
Belfrey remains in-custody on $325,000 bail and is charged with fifteen felonies including conspiracy to defraud another, false and fraudulent claims, claims adjuster fraud, insurance fraud, grand theft of personal property by false pretenses, forgery, money laundering, and identity theft. Gregoire is charged with thirteen felonies, including conspiracy to defraud another, false and fraudulent claim, claims adjuster fraud, insurance fraud, grand theft of personal property by false pretenses, forgery, and money laundering.
The arrest of Gregoire and Belfrey is the result of an extensive investigation by Senior Investigator William Jespersen of the San Francisco District Attorney’s Office Bureau of Investigations. Assistant District Attorney Dennis Chow is prosecuting the case ...
Gregoire, an ex-employee of Amtrust North America, is alleged to have created several shell companies under which she submitted a hundred and thirty-seven fraudulent invoices which Belfrey, a senior claims adjuster at AmTrust North America, is alleged to have secretly approved. Over an eight month period, Gregoire and Belfrey executed a scheme which resulted in over $528,058 of company funds being deposited into bank accounts controlled by Gregoire. According to court records, Gregoire paid $134,776 in cash for a 2014 Mercedes G 550 with funds that are alleged to have been fraudulently received from Amtrust North America. The vehicle was seized during the execution of the search warrant by District Attorney Investigators.
Belfrey remains in-custody on $325,000 bail and is charged with fifteen felonies including conspiracy to defraud another, false and fraudulent claims, claims adjuster fraud, insurance fraud, grand theft of personal property by false pretenses, forgery, money laundering, and identity theft. Gregoire is charged with thirteen felonies, including conspiracy to defraud another, false and fraudulent claim, claims adjuster fraud, insurance fraud, grand theft of personal property by false pretenses, forgery, and money laundering.
The arrest of Gregoire and Belfrey is the result of an extensive investigation by Senior Investigator William Jespersen of the San Francisco District Attorney’s Office Bureau of Investigations. Assistant District Attorney Dennis Chow is prosecuting the case ...
Former State Senator Ron Calderon, a Democrat from Montebello, was indicted in February 2014 on 24 felony charges including bribery, money laundering and tax fraud. They include accepting $88,000 in bribes in exchange for official actions involving bills affecting the film industry and workers’ compensation benefits. He has pleaded not guilty and his trial is now set for August 11. These charges carry a maximum sentence of 400 years in prison.
Capitol sources confirmed the Los Angeles Times report that federal prosecutors have served subpoenas on about 10 staff members in the California Legislature who may be called as witnesses in the trial, It does not appear that any of the subpoenas issued so far are for senators, although Assemblyman Adam Gray's office confirmed he has been subpoenaed based on his work as a former aide to Calderon. Gray was Sen. Calderon’s legislative director from 2008 to 2011, advising him on bills coming up for votes.
Some elected officials are expected to be called as witnesses, according to Assistant U.S. Atty. Mack E. Jenkins. "We are subpoenaing public officials for the Aug. 11 trial date," Jenkins said. "They are potentially witnesses. It doesn’t necessarily mean they will testify, but it means they may potentially testify, so we want to make sure they are available during the trial." Jenkins would not say how many subpoenas have been issued, but Capitol sources who spoke on condition of anonymity because they are not authorized to comment on the case said about 10 had been delivered.
Another former Calderon staffer who has been contacted in the past by federal prosecutors is Assemblyman Adam Gray (D-Merced). A spokesman for Gray said Friday that Gray has been subpoenaed as a former staffer.
Senate President Pro Tem Kevin de León’s office refused to clarify whether the Los Angeles Democrat had been subpoenaed, but in a statement, spokeswoman Claire Conlon said, "Senator de León has been asked to assist the prosecution as a witness in the Calderon trial and, as has been the case from the very beginning of this process, he will readily and fully participate. Since the senator’s been cooperating in this matter for nearly two years, he expected to be called and he’s prepared to serve as needed." De León’s name is mentioned 56 times in the affidavit laying out the federal government’s allegations that Calderon accepted $88,000 in bribes from an undercover agent and a hospital executive. According to the affidavit, Calderon sought de León’s support for legislation to maintain workers’ compensation rules that aided hospital executive Michael D. Drobot, as well as a bill to give tax credits to low-budget independent films. An undercover federal agent posing as a movie producer gave a $5,000 campaign contribution to de León, which the senator later returned.
The former senator has denied any wrongdoing. A year after his indictment on federal corruption charges, Calderon awaits his day in court, working as an acquisitions manager at Red Hill Real Estate Solutions at 652 Mesa Dr., in Corona. The company specializes in buying distressed properties. "He is doing very well," said his attorney, Mark Geragos. "He's working and he's got enormous support from his friends and family." The attorney said Calderon is helping with the 330,000 pages of discovery documents provided by the U.S. attorney's office, including tapes and transcripts for 2,200 recorded telephone calls and meetings.
Geragos called the case "the definition of entrapment," saying, "Most of these so-called offenses were completely manufactured by the government at the cost of millions of dollars to the taxpayer." Assistant U.S. Atty. Mack E. Jenkins said his side is ready with a counter-argument. "The legal standard for entrapment is that there must be no predisposition toward bribery" by the defendant, Jenkins said. "We believe we can meet the legal standard that there was predisposition."
Geragos, who has represented pop star Michael Jackson, actress Wynona Ryder and singer Chris Brown, has also represented other political figures, including former Rep. Gary Condit, former Los Angeles City Councilman Nate Holden and Whitewater figure Susan McDougal, a former business partner of then-President Clinton. Geragos said Calderon would not be the only state lawmaker called to testify at the trial, which is set for Aug. 11. "I think it's without question that there will be lawmakers called as witnesses, and not necessarily just by the defense." ...
Capitol sources confirmed the Los Angeles Times report that federal prosecutors have served subpoenas on about 10 staff members in the California Legislature who may be called as witnesses in the trial, It does not appear that any of the subpoenas issued so far are for senators, although Assemblyman Adam Gray's office confirmed he has been subpoenaed based on his work as a former aide to Calderon. Gray was Sen. Calderon’s legislative director from 2008 to 2011, advising him on bills coming up for votes.
Some elected officials are expected to be called as witnesses, according to Assistant U.S. Atty. Mack E. Jenkins. "We are subpoenaing public officials for the Aug. 11 trial date," Jenkins said. "They are potentially witnesses. It doesn’t necessarily mean they will testify, but it means they may potentially testify, so we want to make sure they are available during the trial." Jenkins would not say how many subpoenas have been issued, but Capitol sources who spoke on condition of anonymity because they are not authorized to comment on the case said about 10 had been delivered.
Another former Calderon staffer who has been contacted in the past by federal prosecutors is Assemblyman Adam Gray (D-Merced). A spokesman for Gray said Friday that Gray has been subpoenaed as a former staffer.
Senate President Pro Tem Kevin de León’s office refused to clarify whether the Los Angeles Democrat had been subpoenaed, but in a statement, spokeswoman Claire Conlon said, "Senator de León has been asked to assist the prosecution as a witness in the Calderon trial and, as has been the case from the very beginning of this process, he will readily and fully participate. Since the senator’s been cooperating in this matter for nearly two years, he expected to be called and he’s prepared to serve as needed." De León’s name is mentioned 56 times in the affidavit laying out the federal government’s allegations that Calderon accepted $88,000 in bribes from an undercover agent and a hospital executive. According to the affidavit, Calderon sought de León’s support for legislation to maintain workers’ compensation rules that aided hospital executive Michael D. Drobot, as well as a bill to give tax credits to low-budget independent films. An undercover federal agent posing as a movie producer gave a $5,000 campaign contribution to de León, which the senator later returned.
The former senator has denied any wrongdoing. A year after his indictment on federal corruption charges, Calderon awaits his day in court, working as an acquisitions manager at Red Hill Real Estate Solutions at 652 Mesa Dr., in Corona. The company specializes in buying distressed properties. "He is doing very well," said his attorney, Mark Geragos. "He's working and he's got enormous support from his friends and family." The attorney said Calderon is helping with the 330,000 pages of discovery documents provided by the U.S. attorney's office, including tapes and transcripts for 2,200 recorded telephone calls and meetings.
Geragos called the case "the definition of entrapment," saying, "Most of these so-called offenses were completely manufactured by the government at the cost of millions of dollars to the taxpayer." Assistant U.S. Atty. Mack E. Jenkins said his side is ready with a counter-argument. "The legal standard for entrapment is that there must be no predisposition toward bribery" by the defendant, Jenkins said. "We believe we can meet the legal standard that there was predisposition."
Geragos, who has represented pop star Michael Jackson, actress Wynona Ryder and singer Chris Brown, has also represented other political figures, including former Rep. Gary Condit, former Los Angeles City Councilman Nate Holden and Whitewater figure Susan McDougal, a former business partner of then-President Clinton. Geragos said Calderon would not be the only state lawmaker called to testify at the trial, which is set for Aug. 11. "I think it's without question that there will be lawmakers called as witnesses, and not necessarily just by the defense." ...
An article in Business Insurance reports that higher pricing and improved underwriting are credited for workers compensation insurers' better financial performance in 2014, after years of struggle. The industry's financial turn-around from the lean years of 2010 and 2011 has translated into declining workers comp advisory rates in many states throughout the country. "This year's been very favorable for employers," said Peter Burton, Wayne, Pennsylvania-based senior division executive of state relations at the National Council on Compensation Insurance Inc.
Four of the five largest workers comp insurers had lower loss ratios in 2014 compared to 2013, according to market share data the Washington-based National Association of Insurance Commissioners released in March. Travelers Cos. Inc., the largest workers comp insurer by premiums written, saw its loss ratio decline last year as did Hartford Financial Services Group Inc., American International Group Inc. and Liberty Mutual Holding Co. Inc., which fell to the No. 4 comp insurer after cutting back on its workers comp business. Zurich Insurance Group Ltd., the fifth-largest workers comp insurer, saw its loss ratio increase nearly 5 percentage points.
"Advances in data analytics in our underwriting, claims and risk engineering are leading to better outcomes for injured workers and our customers,'' Joseph Wells, Hartford, Connecticut-based vice president of workers compensation underwriting and product operations at Hartford, said in a statement. "As a result of these advances, we have seen reductions in lost-time frequency, as well as improved return-to-work outcomes."
While most of the largest comp insurers only saw small decreases in their loss ratios, "it does reflect stronger underwriting on their parts," according to the NAIC. In the case of Liberty Mutual, cutting back on risky workers comp accounts likely also helped improve its results. "They're getting rid of any business that's caused them problems and retaining higher quality insureds," the NAIC said.
Kai Pan, an insurance analyst at Morgan Stanley in New York, said improved losses can be attributed in part to workers comp insurers pushing for price increases during the past several years. "Workers comp, in particular, has shown some meaningful pricing improvements, so that helped improve the underwriting margin,". Additionally he said that larger workers comp insurers may have more resources to invest in predictive modeling and other underwriting tools to help stave off losses that smaller insurers could not avoid "You would imagine ... a large company would have better resources to use, so they're probably better off than some of their smaller peers," Mr. Pan said.
Workers comp insurers also have benefited from using claims management strategies to help reduce the severity and frequency of comp claims, Debbie Michel, Chicago-based president of Liberty Mutual's third-party administrator Helmsman Management Services L.L.C., said in a statement. That includes use of outcomes-based medical providers for treating workers and efforts to control the use of narcotic prescriptions in comp claims, according to Ms. Michel's statement.
The NAIC's data aligns with projections from NCCI, which found comp insurer performance stabilizing following a peak in unprofitability in 2010 and 2011. NCCI's Mr. Burton said that has translated to lower advisory rates for employers across the nation. In the 38 states where Boca Raton, Florida-based NCCI provides ratemaking services, the agency requested 30 workers comp rate decreases for the 2014-15 policy year and only six rate increases. "The filings speak to the balanced environment we have in workers comp today," Mr. Burton said.
Meanwhile, loss ratios for the top 25 workers comp insurers as a whole remained relatively flat at about 60.8% in 2014, up from 60.1% in 2013, according to NAIC data. Smaller insurers were most likely to see an uptick in their loss ratio. Though it's unclear why some insurers' loss ratios increased last year, it could be that claim exposures caused by a growing labor force in recent years have contributed, Mr. Dwelle said. "There's usually a little bit of uptick in loss exposure associated with an improving jobs market," Mr. Dwelle said. "Sometimes, that shows itself first in smaller-account business, then in the large business." ...
Four of the five largest workers comp insurers had lower loss ratios in 2014 compared to 2013, according to market share data the Washington-based National Association of Insurance Commissioners released in March. Travelers Cos. Inc., the largest workers comp insurer by premiums written, saw its loss ratio decline last year as did Hartford Financial Services Group Inc., American International Group Inc. and Liberty Mutual Holding Co. Inc., which fell to the No. 4 comp insurer after cutting back on its workers comp business. Zurich Insurance Group Ltd., the fifth-largest workers comp insurer, saw its loss ratio increase nearly 5 percentage points.
"Advances in data analytics in our underwriting, claims and risk engineering are leading to better outcomes for injured workers and our customers,'' Joseph Wells, Hartford, Connecticut-based vice president of workers compensation underwriting and product operations at Hartford, said in a statement. "As a result of these advances, we have seen reductions in lost-time frequency, as well as improved return-to-work outcomes."
While most of the largest comp insurers only saw small decreases in their loss ratios, "it does reflect stronger underwriting on their parts," according to the NAIC. In the case of Liberty Mutual, cutting back on risky workers comp accounts likely also helped improve its results. "They're getting rid of any business that's caused them problems and retaining higher quality insureds," the NAIC said.
Kai Pan, an insurance analyst at Morgan Stanley in New York, said improved losses can be attributed in part to workers comp insurers pushing for price increases during the past several years. "Workers comp, in particular, has shown some meaningful pricing improvements, so that helped improve the underwriting margin,". Additionally he said that larger workers comp insurers may have more resources to invest in predictive modeling and other underwriting tools to help stave off losses that smaller insurers could not avoid "You would imagine ... a large company would have better resources to use, so they're probably better off than some of their smaller peers," Mr. Pan said.
Workers comp insurers also have benefited from using claims management strategies to help reduce the severity and frequency of comp claims, Debbie Michel, Chicago-based president of Liberty Mutual's third-party administrator Helmsman Management Services L.L.C., said in a statement. That includes use of outcomes-based medical providers for treating workers and efforts to control the use of narcotic prescriptions in comp claims, according to Ms. Michel's statement.
The NAIC's data aligns with projections from NCCI, which found comp insurer performance stabilizing following a peak in unprofitability in 2010 and 2011. NCCI's Mr. Burton said that has translated to lower advisory rates for employers across the nation. In the 38 states where Boca Raton, Florida-based NCCI provides ratemaking services, the agency requested 30 workers comp rate decreases for the 2014-15 policy year and only six rate increases. "The filings speak to the balanced environment we have in workers comp today," Mr. Burton said.
Meanwhile, loss ratios for the top 25 workers comp insurers as a whole remained relatively flat at about 60.8% in 2014, up from 60.1% in 2013, according to NAIC data. Smaller insurers were most likely to see an uptick in their loss ratio. Though it's unclear why some insurers' loss ratios increased last year, it could be that claim exposures caused by a growing labor force in recent years have contributed, Mr. Dwelle said. "There's usually a little bit of uptick in loss exposure associated with an improving jobs market," Mr. Dwelle said. "Sometimes, that shows itself first in smaller-account business, then in the large business." ...
City Attorney Mike Feuer announced that a Los Angeles city crackdown has prompted more than 500 medical marijuana shops to close down in less than two years, According to the report in the Los Angeles Times, that represents a jump from a year ago, when Feuer reported that about a hundred pot shops had been shuttered. The city attorney has also targeted other ways medical marijuana has been distributed, securing court injunctions against a Boyle Heights pot farmers market and a smartphone app used to arrange pot deliveries."There are a whole bunch of different vehicles that we pursued to close them," including civil and criminal cases and warning letters, Feuer said. "We've made tremendous progress."
Still, the city doesn't know how many marijuana businesses continue to operate, raising concerns from critics that the crackdown may amount to a game of whack-a-mole.Under Proposition D, approved by voters two years ago, pot shops and the landlords that lease them space can be prosecuted if the businesses don't meet a number of requirements. Those include being registered under past L.A. ordinances and operating a specified distance from public parks, schools and other facilities.
When the restrictions were approved, city officials estimated that fewer than 140 medical marijuana dispensaries would be eligible to remain open and avoid prosecution. At the time, police officials said they believed roughly 700 pot shops were operating, although some estimates put the figure more than twice as high. Feuer said neighborhood complaints about the city failing to tackle illegal shops, which he routinely heard when he was first elected two years ago, are now much less frequent. "We are shutting down unlawful dispensaries at a rapidly increasing pace," he said. That "momentum" will make new, unlawful shops reluctant to open in Los Angeles, he said.
Last year, more than 450 medical marijuana shops filed tax renewals to report their gross receipts, according to the Office of Finance. The number appears to have fallen slightly this year, with 415 businesses renewing around the March deadline. But it isn't clear if the tax numbers account for all shops. Hundreds more marijuana businesses - more than 1,100 dispensaries - are still registered on the books to pay business taxes, though city officials say many of those may have closed without telling the finance office.
Another estimate by UCLA researchers, who canvassed addresses they found online and through city registrations, found 418 marijuana businesses operating in L.A. last year - more than three times the number supposedly allowed. That was only a slight decrease from two years earlier, when a similar survey found 476 shops. The UCLA Medical Marijuana Research team also found that marijuana shops have been shifting from the San Fernando Valley and East L.A. to South L.A. and San Pedro. Principal investigator Bridget Freisthler said it's unclear why. It "might be in response to community efforts to close some dispensaries," she said.
San Diego reports a similar struggle to control the number of shops. In four years, more than 200 of the dispensaries have been shut down, with 40 more awaiting enforcement, according to the city attorney's office. All opened during the time when the city had no zoning that would permit marijuana dispensaries. The San Diego City Council in July adopted a medical marijuana ordinance allowing no more than four dispensaries in each of the nine council districts. A dozen applications are being reviewed. "Our aggressive enforcement of city zoning regulations is necessary to protect neighborhood standards and safety," said San Diego City Attorney Jan Goldsmith.
Medical marijuana is an $18 million dollar tax boon for the City of San Jose, but two of the South Bay’s largest dispensaries are now in a conflict with city leaders. In February, the Investigative Unit revealed that some San Jose pot shops owe millions in unpaid marijuana taxes. In that story, San Jose Mayor Sam Liccardo sent a message to the owners of Medimarts in East San Jose and All American Cannabis Club in West San Jose, "Pack up, it’s time to move on and pay up on your way out," said Liccardo. Dave Armstrong, President and CEO of Medimarts, said the Mayor’s tough talk creates puts him between a rock and a hard place. "The city wants us to do something, but on the other hand it’s illegal," said Armstrong.
Armstrong argues that by paying the city’s Marijuana Business Tax, he’s also admitting to selling a federally banned substance. "So which of is the worse of the two?" he said. "Breaking federal law or breaking a municipality ordinance?....It’s where we’ve been for three years." The All American Cannabis Club (A2C2) in San Jose makes the same argument" Founder Dave Hodges said the city is using back door tactics to shut him down.
Many cities have banned cannabis dispensaries, while others tax and regulate collectives operating out of retail storefronts as well as cultivation. The federal government has a history of threatening California city council members, county supervisors, and government staffers with drug trafficking charges if they seek to regulate medical cannabis cultivation or distribution. Federal prosecutors have shut down cultivation regulation programs in Humboldt County and Oakland ...
Still, the city doesn't know how many marijuana businesses continue to operate, raising concerns from critics that the crackdown may amount to a game of whack-a-mole.Under Proposition D, approved by voters two years ago, pot shops and the landlords that lease them space can be prosecuted if the businesses don't meet a number of requirements. Those include being registered under past L.A. ordinances and operating a specified distance from public parks, schools and other facilities.
When the restrictions were approved, city officials estimated that fewer than 140 medical marijuana dispensaries would be eligible to remain open and avoid prosecution. At the time, police officials said they believed roughly 700 pot shops were operating, although some estimates put the figure more than twice as high. Feuer said neighborhood complaints about the city failing to tackle illegal shops, which he routinely heard when he was first elected two years ago, are now much less frequent. "We are shutting down unlawful dispensaries at a rapidly increasing pace," he said. That "momentum" will make new, unlawful shops reluctant to open in Los Angeles, he said.
Last year, more than 450 medical marijuana shops filed tax renewals to report their gross receipts, according to the Office of Finance. The number appears to have fallen slightly this year, with 415 businesses renewing around the March deadline. But it isn't clear if the tax numbers account for all shops. Hundreds more marijuana businesses - more than 1,100 dispensaries - are still registered on the books to pay business taxes, though city officials say many of those may have closed without telling the finance office.
Another estimate by UCLA researchers, who canvassed addresses they found online and through city registrations, found 418 marijuana businesses operating in L.A. last year - more than three times the number supposedly allowed. That was only a slight decrease from two years earlier, when a similar survey found 476 shops. The UCLA Medical Marijuana Research team also found that marijuana shops have been shifting from the San Fernando Valley and East L.A. to South L.A. and San Pedro. Principal investigator Bridget Freisthler said it's unclear why. It "might be in response to community efforts to close some dispensaries," she said.
San Diego reports a similar struggle to control the number of shops. In four years, more than 200 of the dispensaries have been shut down, with 40 more awaiting enforcement, according to the city attorney's office. All opened during the time when the city had no zoning that would permit marijuana dispensaries. The San Diego City Council in July adopted a medical marijuana ordinance allowing no more than four dispensaries in each of the nine council districts. A dozen applications are being reviewed. "Our aggressive enforcement of city zoning regulations is necessary to protect neighborhood standards and safety," said San Diego City Attorney Jan Goldsmith.
Medical marijuana is an $18 million dollar tax boon for the City of San Jose, but two of the South Bay’s largest dispensaries are now in a conflict with city leaders. In February, the Investigative Unit revealed that some San Jose pot shops owe millions in unpaid marijuana taxes. In that story, San Jose Mayor Sam Liccardo sent a message to the owners of Medimarts in East San Jose and All American Cannabis Club in West San Jose, "Pack up, it’s time to move on and pay up on your way out," said Liccardo. Dave Armstrong, President and CEO of Medimarts, said the Mayor’s tough talk creates puts him between a rock and a hard place. "The city wants us to do something, but on the other hand it’s illegal," said Armstrong.
Armstrong argues that by paying the city’s Marijuana Business Tax, he’s also admitting to selling a federally banned substance. "So which of is the worse of the two?" he said. "Breaking federal law or breaking a municipality ordinance?....It’s where we’ve been for three years." The All American Cannabis Club (A2C2) in San Jose makes the same argument" Founder Dave Hodges said the city is using back door tactics to shut him down.
Many cities have banned cannabis dispensaries, while others tax and regulate collectives operating out of retail storefronts as well as cultivation. The federal government has a history of threatening California city council members, county supervisors, and government staffers with drug trafficking charges if they seek to regulate medical cannabis cultivation or distribution. Federal prosecutors have shut down cultivation regulation programs in Humboldt County and Oakland ...
A lab worker, a housekeeper at a local mall and a roofer have each recently been charged with felony insurance fraud in separate cases in which they allegedly falsely claimed that their workplace injuries had prevented them from returning to work.
Cosme Cortes-Alva, 39, of San Jose, Nancy Benitez, 28, of San Jose, Ajitender Singh Chadha, 53, of Union City, could be sentenced to prison time, if convicted, and will be ordered to pay full restitution. They have all been arraigned, are out of custody, and await preliminary hearings.
The three cases share allegations that the defendants claimed debilitating injuries and were later seen to be doing physical activities beyond their stated limitations while collecting thousands in insurance benefits.
In one case, a man was videotaped for two hours clambering up and down from a roof despite claiming that he was too hurt to work and terrified of ladders. Alva, who fell off of a roof and badly injured his back in 2013, falsely testified at a deposition that he had not worked at all since his injury
Benitez, who was hurt doing housekeeping for a store at Valley Fair Mall in 2011, told the insurance company that she could not walk or drive without extreme pain. She was later seen driving to a mall, shopping and caring for a small child.
Chadha said that he was hurt during a 2011 accident at the lab where he worked, could not work, and was reliant upon his wife’s income. An investigation found that he was actually the owner and operator of a gas station, and that he was concealing his income.
"The Workers’ Compensation system is set up to quickly compensate injured workers while they recuperate from their injuries," Deputy District Attorney David Soares said. "When an injured worker lies about the extent of their injury or their physical abilities as they recover, they are adding unnecessary costs that potentially cheat every worker and every employer in California." ...
Cosme Cortes-Alva, 39, of San Jose, Nancy Benitez, 28, of San Jose, Ajitender Singh Chadha, 53, of Union City, could be sentenced to prison time, if convicted, and will be ordered to pay full restitution. They have all been arraigned, are out of custody, and await preliminary hearings.
The three cases share allegations that the defendants claimed debilitating injuries and were later seen to be doing physical activities beyond their stated limitations while collecting thousands in insurance benefits.
In one case, a man was videotaped for two hours clambering up and down from a roof despite claiming that he was too hurt to work and terrified of ladders. Alva, who fell off of a roof and badly injured his back in 2013, falsely testified at a deposition that he had not worked at all since his injury
Benitez, who was hurt doing housekeeping for a store at Valley Fair Mall in 2011, told the insurance company that she could not walk or drive without extreme pain. She was later seen driving to a mall, shopping and caring for a small child.
Chadha said that he was hurt during a 2011 accident at the lab where he worked, could not work, and was reliant upon his wife’s income. An investigation found that he was actually the owner and operator of a gas station, and that he was concealing his income.
"The Workers’ Compensation system is set up to quickly compensate injured workers while they recuperate from their injuries," Deputy District Attorney David Soares said. "When an injured worker lies about the extent of their injury or their physical abilities as they recover, they are adding unnecessary costs that potentially cheat every worker and every employer in California." ...
North Hollywood resident Gevorg "George" Kupelian was sentenced to 30 months in custody for his role in a $1 million fraud scheme and was ordered to repay $964,011 in restitution.
According to court documents, Gevorg Kupelian and others operated the El Centro Clinic, located at 485 Broadway Street, Suites C and D, in El Centro, California, as a Medicare-billing mill. Kupelian admitted that he set up the clinic and found a doctor to act as the official physician of record. But, as Kupelian acknowledged, the doctor served primarily as a "front" so that Kupelian could use his Medicare billing number to submit Medicare claims.
Kupelian has further admitted that he recruited and paid "cappers," individuals whose sole task was to find senior citizens in El Centro and convince them to go to the Clinic. In exchange for providing their Medicare beneficiary numbers, the senior citizens received a free pair of shoes and/or a free buffet lunch. Once they arrived at the Clinic, the beneficiaries were subject to a pre-determined gauntlet of tests, which were not based on the patient’s medical needs and were provided without proper supervision by a physician. In some cases, the clinic billed Medicare despite the fact that the tests were not provided at all.
Kupelian also arranged for a so-called Physician Assistant ("PA") to see patients (in lieu of the "front" doctor, who was often absent), write progress notes, and order tests. As detailed in today’s court proceedings, the so-called PA hired by Kupelian was, in fact, unlicensed to practice medicine in any capacity in California.
Many of the tests that the Clinic claimed to have administered to beneficiaries required either that a physician administer the test or that a physician be within the Clinic during testing. On over 800 occasions, the Clinic billed Medicare for these tests despite cell phone location records showing that the doctor was not in Imperial County at all during the times these tests were allegedly administered. The Clinic also submitted reimbursement from Medicare for allergy tests despite evidence showing that these tests were never performed in the Clinic by a doctor or anyone else.
The co-conspirators operated the El Centro Clinic in a manner designed to maximize Medicare reimbursements without regard to the medical needs of its patients. For example, they staffed the clinic, either by being personally present or arranging for others to be, in order to give the impression to the recruited Medicare beneficiaries and outside observers that the beneficiaries were being seen by qualified medical professionals. In fact, oftentimes the recruited beneficiaries would never see a doctor or other qualified medical professional during a particular visit to the El Centro Clinic. They also caused tests to be performed on recruited Medicare beneficiaries without regard to their medical necessity, including breathing tests, bladder tests, EKGs, and ultrasounds, for the primary purpose of generating billings to Medicare.
Kupelian also admitted creating "sample" lab sheets and billing forms with certain tests and diagnoses checked. He instructed the clinic’s employees to duplicate the checked boxes from the sample forms on patients’ actual forms, without regard to the patients’ actual medical conditions or what tests they actually needed or received. Moreover, Kupelian instructed the clinic’s employees that all patients were to undergo all of the tests offered by the clinic, without regard to the patients’ actual diagnoses or what tests they actually needed. After the unnecessary tests were conducted, Kupelian inserted false test results into patient files to make it appear that tests had been done and results were appropriately generated, when in fact they had not.
Using these tactics, the El Centro Clinic generated over $2.7 million in claims to Medicare, which resulted in payments of approximately $1.3 million to the doctor, 75% of which the doctor immediately transferred into Kupelian’s bank account. Out of his proceeds, Kupelian paid the other co-conspirators, including the cappers and the fake PA.
Kupelian was ordered to surrender on July 8, 2015 ...
According to court documents, Gevorg Kupelian and others operated the El Centro Clinic, located at 485 Broadway Street, Suites C and D, in El Centro, California, as a Medicare-billing mill. Kupelian admitted that he set up the clinic and found a doctor to act as the official physician of record. But, as Kupelian acknowledged, the doctor served primarily as a "front" so that Kupelian could use his Medicare billing number to submit Medicare claims.
Kupelian has further admitted that he recruited and paid "cappers," individuals whose sole task was to find senior citizens in El Centro and convince them to go to the Clinic. In exchange for providing their Medicare beneficiary numbers, the senior citizens received a free pair of shoes and/or a free buffet lunch. Once they arrived at the Clinic, the beneficiaries were subject to a pre-determined gauntlet of tests, which were not based on the patient’s medical needs and were provided without proper supervision by a physician. In some cases, the clinic billed Medicare despite the fact that the tests were not provided at all.
Kupelian also arranged for a so-called Physician Assistant ("PA") to see patients (in lieu of the "front" doctor, who was often absent), write progress notes, and order tests. As detailed in today’s court proceedings, the so-called PA hired by Kupelian was, in fact, unlicensed to practice medicine in any capacity in California.
Many of the tests that the Clinic claimed to have administered to beneficiaries required either that a physician administer the test or that a physician be within the Clinic during testing. On over 800 occasions, the Clinic billed Medicare for these tests despite cell phone location records showing that the doctor was not in Imperial County at all during the times these tests were allegedly administered. The Clinic also submitted reimbursement from Medicare for allergy tests despite evidence showing that these tests were never performed in the Clinic by a doctor or anyone else.
The co-conspirators operated the El Centro Clinic in a manner designed to maximize Medicare reimbursements without regard to the medical needs of its patients. For example, they staffed the clinic, either by being personally present or arranging for others to be, in order to give the impression to the recruited Medicare beneficiaries and outside observers that the beneficiaries were being seen by qualified medical professionals. In fact, oftentimes the recruited beneficiaries would never see a doctor or other qualified medical professional during a particular visit to the El Centro Clinic. They also caused tests to be performed on recruited Medicare beneficiaries without regard to their medical necessity, including breathing tests, bladder tests, EKGs, and ultrasounds, for the primary purpose of generating billings to Medicare.
Kupelian also admitted creating "sample" lab sheets and billing forms with certain tests and diagnoses checked. He instructed the clinic’s employees to duplicate the checked boxes from the sample forms on patients’ actual forms, without regard to the patients’ actual medical conditions or what tests they actually needed or received. Moreover, Kupelian instructed the clinic’s employees that all patients were to undergo all of the tests offered by the clinic, without regard to the patients’ actual diagnoses or what tests they actually needed. After the unnecessary tests were conducted, Kupelian inserted false test results into patient files to make it appear that tests had been done and results were appropriately generated, when in fact they had not.
Using these tactics, the El Centro Clinic generated over $2.7 million in claims to Medicare, which resulted in payments of approximately $1.3 million to the doctor, 75% of which the doctor immediately transferred into Kupelian’s bank account. Out of his proceeds, Kupelian paid the other co-conspirators, including the cappers and the fake PA.
Kupelian was ordered to surrender on July 8, 2015 ...
A federal grand jury indicted the general manager of a La Puente garment factory on charges of offering to pay bribes to an investigator with the United States Department of Labor in exchange for the investigator closing an investigation into wage violations. Howard Quoc Trinh, 41, of Arcadia, the manager of Seven-Bros Enterprises, is accused in the indictment of bribery of a public official.
The indictment charges Trinh with offering to pay $10,000 in bribes to a Department of Labor Wage and Hour investigator. The indictment also alleges that Trinh offered the bribe last month to secure the release of a hold known as a "Hot Goods" objection that had been placed on a shipment by the investigator. As part of the bribery scheme, Trinh actually paid the investigator $3,000, according to a criminal complaint previously filed in this case.
According to the affidavit in support of that complaint, the investigator was investigating Seven-Bros for violating the Fair Labor Standards Act (FLSA), which sets standards for minimum wage and overtime pay. The Labor Department Wage and Hour investigator led a team that conducted an unannounced visit to Seven-Bros on March 10. The investigation into wage violations covered a period from May 2012 through March 10, 2015, and found that Seven-Bros owed approximately $100,000 to compensate employees for FLSA violations over that period. According to the affidavit, the investigator returned to Seven-Bros on March 18, at which time Trinh said he did not owe his employees any back wages and that he wanted to "take care" of the investigator.
In response to Trinh’s statements, the Labor Department’s Office of Investigator General (OIG) initiated an investigation and outfitted the investigator with recording equipment. On the evening of March 18, during a recorded meeting, Trinh allegedly offered the investigator $10,000 to close out the investigation without finding any violations and to life the Hot Goods objection. The next day, during another recorded meeting, Trinh gave the investigator an initial payment of $3,000 in a manila envelope, according to the affidavit.
The criminal complaint was filed and Trinh was arrested by OIG special agents. At his initial court appearance, Trinh was ordered released on a $200,000 bond and was ordered to appear for an arraignment on April 17. If he is convicted of the bribery count in the indictment, Trinh would face a statutory maximum sentence of 15 years in federal prison.
The investigation in this case was conducted by the United States Department of Labor, Office of Investigator General, Office of Labor Racketeering and Fraud Investigations ...
The indictment charges Trinh with offering to pay $10,000 in bribes to a Department of Labor Wage and Hour investigator. The indictment also alleges that Trinh offered the bribe last month to secure the release of a hold known as a "Hot Goods" objection that had been placed on a shipment by the investigator. As part of the bribery scheme, Trinh actually paid the investigator $3,000, according to a criminal complaint previously filed in this case.
According to the affidavit in support of that complaint, the investigator was investigating Seven-Bros for violating the Fair Labor Standards Act (FLSA), which sets standards for minimum wage and overtime pay. The Labor Department Wage and Hour investigator led a team that conducted an unannounced visit to Seven-Bros on March 10. The investigation into wage violations covered a period from May 2012 through March 10, 2015, and found that Seven-Bros owed approximately $100,000 to compensate employees for FLSA violations over that period. According to the affidavit, the investigator returned to Seven-Bros on March 18, at which time Trinh said he did not owe his employees any back wages and that he wanted to "take care" of the investigator.
In response to Trinh’s statements, the Labor Department’s Office of Investigator General (OIG) initiated an investigation and outfitted the investigator with recording equipment. On the evening of March 18, during a recorded meeting, Trinh allegedly offered the investigator $10,000 to close out the investigation without finding any violations and to life the Hot Goods objection. The next day, during another recorded meeting, Trinh gave the investigator an initial payment of $3,000 in a manila envelope, according to the affidavit.
The criminal complaint was filed and Trinh was arrested by OIG special agents. At his initial court appearance, Trinh was ordered released on a $200,000 bond and was ordered to appear for an arraignment on April 17. If he is convicted of the bribery count in the indictment, Trinh would face a statutory maximum sentence of 15 years in federal prison.
The investigation in this case was conducted by the United States Department of Labor, Office of Investigator General, Office of Labor Racketeering and Fraud Investigations ...
Physical therapy may work as well as surgery for easing symptoms of lumbar spinal stenosis, a common cause of nerve damage and lower back pain among older people, according to a new study summarized by Reuters Health. Lumbar spinal stenosis, a compression of open spaces in the lower spinal column, can lead to pinched nerves, tingling, weakness and numbness in the back and the lower extremities. The condition becomes more common with age, and an estimated 2.4 million Americans may have it by 2021, according to the American Academy of Orthopedic Surgeons.
"Surgery is a riskier procedure, with about a 15 percent complication rate, and half of those are life-threatening," said Dr. Anthony Delitto, chair of physical therapy at the School of Health and Rehabilitation Sciences at the University of Pittsburgh. "It isn't a life-risking procedure to do physical therapy." Delitto and colleagues set out to see if they could show that physical therapy, long known to be safer than surgery, could work as well as at easing symptoms. Between 2000 and 2005, they asked 481 patients who consented to surgery if they would be willing to join a study where they would be randomly chosen to proceed with the operation or receive physical therapy. Most declined, to avoid being assigned to the non surgical group, but 169 patients agreed to participate in the experiment. Ultimately, 87 patients had surgery and 82 were assigned physical therapy.
At the start of the study, patients were at least 50 years old. They had to be able to walk at least a quarter mile without difficulty and have no underlying medical conditions such as dementia, severe vascular disease, cancer, or a prior heart attack. Most of them were sedentary or only mildly active, and they were typically obese. Patients in the surgery group were slightly younger, about 67 on average, compared with an average age of about 70 for patients receiving physical therapy.
The physical therapy regimen consisted of twice-weekly rehabilitation sessions for six weeks. Participants were allowed to opt out of this regimen in favor of surgery at any point during the study, and over an average two years of follow-up 47 of them, or 57 percent, did just that.
No matter what group they started in, participants achieved similar reduction of pain and other symptoms at two years. "The study demonstrates that both surgery and physical therapy are reasonable choices; the person who goes down either path ends up in the same place a year or two later," said Dr. Jeffrey Katz, director of the Orthopedic and Arthritis Center for Outcomes Research at Brigham and Women's Hospital in Boston. Katz, who wrote an editorial accompanying the study in Annals of Internal Medicine, noted that there's still a role for surgery in treating lumbar spinal stenosis. But there's no harm in trying physical therapy first, he said.
Because so many eligible patients opted not to participate in the study, and so many randomly selected for physical therapy abandoned it to get surgery, more research may still be needed in a larger group of patients to get a complete picture of the relative benefits of each option, said Dr. James Weinstein, chief executive of Dartmouth-Hitchcock health system, who wasn't involved in the study. Still, "surgery should be the last option," said Weinstein, lead author of a 2008 paper in the New England Journal of Medicine that found surgery more effective at curbing symptoms than non surgical alternatives.
Despite the small size of the current study and the number of patients who stopped physical therapy early, it still makes sense to try it before surgery, said Dr. Richard Deyo, a researcher in back pain at Oregon Health and Science University, in email to Reuters Health. "If they elect to have surgery at a later time, the results appear to be as good as for patients who choose earlier surgery," said Deyo, who wasn't involved in the study. "Some patients are inclined toward surgery because the high tech approach seems more definitive, attractive, and quicker. However, patients should realize they are likely to need physical therapy even after successful surgery, and recovery can be slow." ...
"Surgery is a riskier procedure, with about a 15 percent complication rate, and half of those are life-threatening," said Dr. Anthony Delitto, chair of physical therapy at the School of Health and Rehabilitation Sciences at the University of Pittsburgh. "It isn't a life-risking procedure to do physical therapy." Delitto and colleagues set out to see if they could show that physical therapy, long known to be safer than surgery, could work as well as at easing symptoms. Between 2000 and 2005, they asked 481 patients who consented to surgery if they would be willing to join a study where they would be randomly chosen to proceed with the operation or receive physical therapy. Most declined, to avoid being assigned to the non surgical group, but 169 patients agreed to participate in the experiment. Ultimately, 87 patients had surgery and 82 were assigned physical therapy.
At the start of the study, patients were at least 50 years old. They had to be able to walk at least a quarter mile without difficulty and have no underlying medical conditions such as dementia, severe vascular disease, cancer, or a prior heart attack. Most of them were sedentary or only mildly active, and they were typically obese. Patients in the surgery group were slightly younger, about 67 on average, compared with an average age of about 70 for patients receiving physical therapy.
The physical therapy regimen consisted of twice-weekly rehabilitation sessions for six weeks. Participants were allowed to opt out of this regimen in favor of surgery at any point during the study, and over an average two years of follow-up 47 of them, or 57 percent, did just that.
No matter what group they started in, participants achieved similar reduction of pain and other symptoms at two years. "The study demonstrates that both surgery and physical therapy are reasonable choices; the person who goes down either path ends up in the same place a year or two later," said Dr. Jeffrey Katz, director of the Orthopedic and Arthritis Center for Outcomes Research at Brigham and Women's Hospital in Boston. Katz, who wrote an editorial accompanying the study in Annals of Internal Medicine, noted that there's still a role for surgery in treating lumbar spinal stenosis. But there's no harm in trying physical therapy first, he said.
Because so many eligible patients opted not to participate in the study, and so many randomly selected for physical therapy abandoned it to get surgery, more research may still be needed in a larger group of patients to get a complete picture of the relative benefits of each option, said Dr. James Weinstein, chief executive of Dartmouth-Hitchcock health system, who wasn't involved in the study. Still, "surgery should be the last option," said Weinstein, lead author of a 2008 paper in the New England Journal of Medicine that found surgery more effective at curbing symptoms than non surgical alternatives.
Despite the small size of the current study and the number of patients who stopped physical therapy early, it still makes sense to try it before surgery, said Dr. Richard Deyo, a researcher in back pain at Oregon Health and Science University, in email to Reuters Health. "If they elect to have surgery at a later time, the results appear to be as good as for patients who choose earlier surgery," said Deyo, who wasn't involved in the study. "Some patients are inclined toward surgery because the high tech approach seems more definitive, attractive, and quicker. However, patients should realize they are likely to need physical therapy even after successful surgery, and recovery can be slow." ...
Christine Baker, Director of the Department of Industrial Relations has submitted a legislatively-mandated status report on DIR and Cal/OSHA’s Process Safety Management (PSM) Regulatory Oversight. The report is required pursuant to the Budget Act of 2014 (Provisions 1 and 2 of item 7350-001-3121, Chapter 25, Statutes of 2014).
"This report gives a description of appropriate funding allotted to our PSM Unit, which has allowed us to design and implement a new approach for regulating the petroleum refining industry," said Christine Baker, DIR Director.
In 2014, DIR convened or participated in over 20 stakeholder meetings with the petroleum refining industry, refinery workers, community-based organizations, and the public. At each of these meetings, DIR presented the findings and recommendations of the Governor's report and described DIR's proposed revisions to the PSM standard for refineries for discussion and feedback. Three of these meetings consisted of DIR's PSM Advisory Committee, made up of representatives of labor and industry. All twenty meetings were open to members of the public.
All of these meetings served as an important vehicle for accessing the technical expertise of refinery managers and workers, representatives of labor unions and community-based organizations, members of professional associations, and members of the public. Many of the recommendations generated in these meetings were incorporated into the PSM revisions organized into seven elements. Currently refineries in California are complying, to varying degrees, with six of the seven elements. The exception is Hierarchy of Hazard Controls Analysis which is a relatively new concept, with which only refineries in Contra Costa County are fully familiar.
The Status Report outlines some of the next steps. In 2015, DIR is coordinating an Interagency Enforcement Working Group to discuss the coordination of enforcement activities, including cross-referrals, cross-training, and joint or coordinated inspections and auditing. The working group will also identify the refineries to be targeted for inspection. Lastly, the group will discuss the facilitation and development of an electronic information and data sharing system among federal, state, and local agencies. This system will include information about inspections, compliance, and enforcement activity, as well as the means to collect information identified in reports and a process for timely flow of information between regulatory agencies.Cal/OSHA’s PSM Unit is responsible for inspecting refineries and chemical plants that handle large quantities of toxic and flammable materials. Health and safety standards enforced by the PSM Unit, including adequate employee training, are intended to prevent catastrophic explosions, fires, and releases of dangerous chemicals ...
"This report gives a description of appropriate funding allotted to our PSM Unit, which has allowed us to design and implement a new approach for regulating the petroleum refining industry," said Christine Baker, DIR Director.
In 2014, DIR convened or participated in over 20 stakeholder meetings with the petroleum refining industry, refinery workers, community-based organizations, and the public. At each of these meetings, DIR presented the findings and recommendations of the Governor's report and described DIR's proposed revisions to the PSM standard for refineries for discussion and feedback. Three of these meetings consisted of DIR's PSM Advisory Committee, made up of representatives of labor and industry. All twenty meetings were open to members of the public.
All of these meetings served as an important vehicle for accessing the technical expertise of refinery managers and workers, representatives of labor unions and community-based organizations, members of professional associations, and members of the public. Many of the recommendations generated in these meetings were incorporated into the PSM revisions organized into seven elements. Currently refineries in California are complying, to varying degrees, with six of the seven elements. The exception is Hierarchy of Hazard Controls Analysis which is a relatively new concept, with which only refineries in Contra Costa County are fully familiar.
The Status Report outlines some of the next steps. In 2015, DIR is coordinating an Interagency Enforcement Working Group to discuss the coordination of enforcement activities, including cross-referrals, cross-training, and joint or coordinated inspections and auditing. The working group will also identify the refineries to be targeted for inspection. Lastly, the group will discuss the facilitation and development of an electronic information and data sharing system among federal, state, and local agencies. This system will include information about inspections, compliance, and enforcement activity, as well as the means to collect information identified in reports and a process for timely flow of information between regulatory agencies.Cal/OSHA’s PSM Unit is responsible for inspecting refineries and chemical plants that handle large quantities of toxic and flammable materials. Health and safety standards enforced by the PSM Unit, including adequate employee training, are intended to prevent catastrophic explosions, fires, and releases of dangerous chemicals ...
Janak K. Mehtani M.D. is listed as a QME in psychiatry with an office on Fulton Avenue in Sacramento. He practices psychiatry under the business name Fair Oaks Psychiatric Associates. Recently the California Medical Board filed an Accusation against him complaining about his treatment of industrially injured patients and patients with chronic pain, anxiety, sleep disturbance and other problems.
The First Cause for Discipline alleges that his treatment was "grossly negligent." The Second Cause alleges that he "he committed repeated negligent acts in his care and treatment" of the Patients described in the Accusation. In the Third Cause that he "prescribed controlled substances and dangerous drugs" to these patients without an appropriate medical examination or medical indication. In the Fourth Cause that he "failed to maintain adequate and accurate medical records in the care and treatment" of these patients. And in the Fifth Cause for Discipline "that he has engaged in conduct which breaches the rules or ethical code of the medical profession, or conduct which is unbecoming a member in good standing of the medical profession, and which demonstrates an unfitness to practice medicine.
These charges are allegations only, and should not be considered to be true or accurate until there has been a trial on the merits and Dr. Mehtani be afforded an opportunity to be heard and present evidence on his behalf.
However the Accusation does set forth what the California Medical Board considers to be the standard of care for industrially injured patients in a psychiatric setting. The standards set forth in this Accusation should be read and understood by claims administrators and other workers' compensation professionals since this document sets forth standards that are seldom articulated in one document, with illustrative examples. This document should serve as a benchmark or checklist by which quality of treatment should be evaluated. Here are examples of the standards set forth in this Accusation by the California Medical Board.
First and foremost the Accusation reiterates the requirement that medical records clearly document medical findings, histories, complaints, and rationale for treatment decisions. Often this is not seen when reviewing subpoenaed records of treating physicians. For example, one of the patients complained of weight gain, yet the Accusation alleges that "there has been no documentation of Respondent's discussion of her weight gain. There was no documentation of her diet, exercise, weight or anything that addresses the risk of weight gain associated with psychotropic medications." Another concern was "Respondent failed to document the reason for prescribing Abilify, Ambien, and Cymbalta. Respondent failed to document and/or identify any concern about the risks of chronic use of a benzodiazepine Xanax and Ambien, which are not recommended for use greater than 60 days." The Accusation goes on to say "Respondent's charting is vague and suggests that the dose of Abilify was increased because the patient was having thoughts about cutting. Respondent failed to document what is being treated other than reducing anxiety and his concern about cutting. There is no description or identification of target symptoms, no identified measurable signs or symptoms to assess the progress or lack of progress in treatment. Respondent's clinical descriptions are vague and difficult to interpret." Later the Accusation states "Respondent also documented a global statement without providing any clinical justification or explanation. Respondent noted that "She remains disabled from gainful employment" without explaining and documenting exactly what was Patient GC's disability, how the disability affects her life and what are the barriers for progress".
The Accusation summarizes another case where the Respondent allegedly did not respond to letters sent by the State Compensation Insurance Fund, and "Respondent failed to document treatment goals and target symptoms so that the progress of treatment could be objectively evaluated. Respondent failed to document clinical reasons when there is a change in treatment,including change of medication as well as the dose." These factors among others are according to the Board allegedly "gross negligence" and reason to bring disciplinary action against the QME.
The Accusation alleges concern about the lack of an interpreter. The Board alleges that a "medical assistant" was at times used as an interpreter, and during one follow up visit the "interpreter was not notified of the appointment so she was seen without one." The Accusation alleges that "Respondent failed to provide an interpreter in order for Patient GC to freely share her feelings and be open to psychotherapeutic interventions." This patient was seen for about 40 visits of "Medical Psychoanalysis."
While these allegations may or may not be proven against this particular psychiatrist, they nonetheless set forth examples of what the California Medical Board considers to be appropriate care for industrially injured workers with psychiatric complaints, and what the Medical Board consider to be "gross negligence." This Accusation should serve as a guideline for appropriate record keeping, and care. All too often this is not the case reflected in typical subpoenaed records that are reviewed ...
The First Cause for Discipline alleges that his treatment was "grossly negligent." The Second Cause alleges that he "he committed repeated negligent acts in his care and treatment" of the Patients described in the Accusation. In the Third Cause that he "prescribed controlled substances and dangerous drugs" to these patients without an appropriate medical examination or medical indication. In the Fourth Cause that he "failed to maintain adequate and accurate medical records in the care and treatment" of these patients. And in the Fifth Cause for Discipline "that he has engaged in conduct which breaches the rules or ethical code of the medical profession, or conduct which is unbecoming a member in good standing of the medical profession, and which demonstrates an unfitness to practice medicine.
These charges are allegations only, and should not be considered to be true or accurate until there has been a trial on the merits and Dr. Mehtani be afforded an opportunity to be heard and present evidence on his behalf.
However the Accusation does set forth what the California Medical Board considers to be the standard of care for industrially injured patients in a psychiatric setting. The standards set forth in this Accusation should be read and understood by claims administrators and other workers' compensation professionals since this document sets forth standards that are seldom articulated in one document, with illustrative examples. This document should serve as a benchmark or checklist by which quality of treatment should be evaluated. Here are examples of the standards set forth in this Accusation by the California Medical Board.
First and foremost the Accusation reiterates the requirement that medical records clearly document medical findings, histories, complaints, and rationale for treatment decisions. Often this is not seen when reviewing subpoenaed records of treating physicians. For example, one of the patients complained of weight gain, yet the Accusation alleges that "there has been no documentation of Respondent's discussion of her weight gain. There was no documentation of her diet, exercise, weight or anything that addresses the risk of weight gain associated with psychotropic medications." Another concern was "Respondent failed to document the reason for prescribing Abilify, Ambien, and Cymbalta. Respondent failed to document and/or identify any concern about the risks of chronic use of a benzodiazepine Xanax and Ambien, which are not recommended for use greater than 60 days." The Accusation goes on to say "Respondent's charting is vague and suggests that the dose of Abilify was increased because the patient was having thoughts about cutting. Respondent failed to document what is being treated other than reducing anxiety and his concern about cutting. There is no description or identification of target symptoms, no identified measurable signs or symptoms to assess the progress or lack of progress in treatment. Respondent's clinical descriptions are vague and difficult to interpret." Later the Accusation states "Respondent also documented a global statement without providing any clinical justification or explanation. Respondent noted that "She remains disabled from gainful employment" without explaining and documenting exactly what was Patient GC's disability, how the disability affects her life and what are the barriers for progress".
The Accusation summarizes another case where the Respondent allegedly did not respond to letters sent by the State Compensation Insurance Fund, and "Respondent failed to document treatment goals and target symptoms so that the progress of treatment could be objectively evaluated. Respondent failed to document clinical reasons when there is a change in treatment,including change of medication as well as the dose." These factors among others are according to the Board allegedly "gross negligence" and reason to bring disciplinary action against the QME.
The Accusation alleges concern about the lack of an interpreter. The Board alleges that a "medical assistant" was at times used as an interpreter, and during one follow up visit the "interpreter was not notified of the appointment so she was seen without one." The Accusation alleges that "Respondent failed to provide an interpreter in order for Patient GC to freely share her feelings and be open to psychotherapeutic interventions." This patient was seen for about 40 visits of "Medical Psychoanalysis."
While these allegations may or may not be proven against this particular psychiatrist, they nonetheless set forth examples of what the California Medical Board considers to be appropriate care for industrially injured workers with psychiatric complaints, and what the Medical Board consider to be "gross negligence." This Accusation should serve as a guideline for appropriate record keeping, and care. All too often this is not the case reflected in typical subpoenaed records that are reviewed ...
The Division of Workers’ Compensation has issued a notice of public hearing on proposed changes to the Qualified Medical Evaluator regulations. The proposed rulemaking is to amend existing regulations and forms to implement an online panel process for represented initial panel requests.
A public hearing on the proposed regulations has been scheduled at 10 a.m., Friday, May 22, 2015, 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 QME regulations amend existing regulations to require parties in a represented case to submit initial QME panel requests online and immediately receive a QME panel. The requesting party will then serve the panel request form, any required documentation, and the QME panel on all parties with a proof of service. The proposed rulemaking will also simplify QME Form 105 for unrepresented injured workers. The proposed regulations also makes non-substantive changes to the QME appointment from, reappointment form, and the QME unavailability form.
DWC will consider all public comments, and may modify the proposed regulations for consideration during an additional 15-day public comment period. The notices of rulemaking, text of the regulations, and the initial statements of reasons can be found at on the DWC rulemaking page. More information ...
A public hearing on the proposed regulations has been scheduled at 10 a.m., Friday, May 22, 2015, 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 QME regulations amend existing regulations to require parties in a represented case to submit initial QME panel requests online and immediately receive a QME panel. The requesting party will then serve the panel request form, any required documentation, and the QME panel on all parties with a proof of service. The proposed rulemaking will also simplify QME Form 105 for unrepresented injured workers. The proposed regulations also makes non-substantive changes to the QME appointment from, reappointment form, and the QME unavailability form.
DWC will consider all public comments, and may modify the proposed regulations for consideration during an additional 15-day public comment period. The notices of rulemaking, text of the regulations, and the initial statements of reasons can be found at on the DWC rulemaking page. More information ...
Transportation Network Companies (TNCs) provide for pre-arranged transportation services for compensation through online-enabled applications or platforms (such as smart phone apps) that connect passengers with drivers who provide the services in their personal vehicles. The three most widely used TNCs are UberX (available in 53 countries and more than 140 U.S. cities), Lyft (available in at least 60 locations) and Sidecar (available in Boston; Charlotte, NC; Chicago; Long Beach, Los Angeles, Oakland, Marin and other San Francisco Bay Area cities; San Diego; Seattle; and Washington, DC).
Regulation of TNCs is in its infancy. The first step in regulating TNCs is to determine which state or local entity has authority over TNCs. Regulatory authority varies from state to state. California was the first state to regulate this new industry. Legislation is now pending in at least 35 other states. In California, TNCs are regulated on a statewide level by the California Public Utilities Commission (CPUC), while taxis are regulated by municipalities. The CPUC asserted jurisdiction over TNCs by classifying them as charter-party carriers, or transportation providers that provide pre-arranged services for a fee and are subject to regulation by the CPUC. Limousines and many shuttle services are examples of charter-party carriers. State law delegates authority for regulation of taxis to cities or counties since taxis are not classified as charter-party carriers since their services can be pre-arranged or on demand such as hailing a cab on the street.
The insurance issues associated with TNC activities arise because TNC drivers use personal cars for that commercial activity but do not have commercial auto insurance. The California Department of Insurance held an investigatory hearing March 21, 2014, relating to insurance issues for TNCs. As a result of the hearing, Insurance Commissioner Dave Jones recommended TNCs provide $1 million in primary liability insurance that begins the moment the driver switches on the app. The issue of Worker's Compensation benefits and insurance has yet to be considered by regulatory bodies.
So now the issue of workers' compensation coverage must be resolved in the courts. According to an article in Business Insurance, drivers for ride-sharing services Uber Technologies Inc. and Lyft Inc.,argue in two cases that they are employees and not independent contractors. This could put the tech upstarts on the hook for workers compensation costs if court challenges succeed. In separate lawsuits filed in U.S. District Court in San Francisco, plaintiffs seeking to represent Uber and Lyft drivers nationwide base their allegations on California's labor law, since both Uber and Lyft reference the state's law in their driver contracts, said Shannon Liss-Riordan, a plaintiff attorney in both cases and a partner at Lichten and Liss-Riordan P.C. in Boston. Judges in both cases have limited the potential classes to drivers in California, but Ms. Liss-Riordan said those decisions likely will be appealed.
If Uber and Lyft drivers are deemed employees, the companies would need to evaluate providing workers comp coverage, said officials at the National Council on Compensation Insurance Inc. Court transcripts are sealed, but, according to wire service reports, in a January hearing in the Lyft case, U.S. District Judge Vince Chhabria said rulings in other California cases typically have found that "people who do the kinds of things that Lyft drivers do here are employees." U.S. District Judge Edward Chen reportedly said "I don't find that a very persuasive argument,"in a separate January hearing in the Uber case, in which the company argues it is a software platform, not an employer. Final rulings have not yet been made in either suit, both of which have been pending since 2013
The insurance industry is watching the cases closely. For example, NCCI identified ride-sharing services as one of the top emerging comp issues for 2015. The National Association of Insurance Commissioners (NAIC) adopted a white paper addressing the insurance coverage gaps associated with ridesharing services offered by Transportation Network Companies. The white paper was issued to assist state insurance regulators and state legislators throughout the United States who are considering how best to address insurance coverage gaps associated with TNCs and ridesharing. The paper recommends a range of potential state based regulatory solutions. Issues including insurance coverage gaps, coverage amounts and types of coverage are discussed, as well as the need for consumer outreach and education regarding these new transportation services ...
Regulation of TNCs is in its infancy. The first step in regulating TNCs is to determine which state or local entity has authority over TNCs. Regulatory authority varies from state to state. California was the first state to regulate this new industry. Legislation is now pending in at least 35 other states. In California, TNCs are regulated on a statewide level by the California Public Utilities Commission (CPUC), while taxis are regulated by municipalities. The CPUC asserted jurisdiction over TNCs by classifying them as charter-party carriers, or transportation providers that provide pre-arranged services for a fee and are subject to regulation by the CPUC. Limousines and many shuttle services are examples of charter-party carriers. State law delegates authority for regulation of taxis to cities or counties since taxis are not classified as charter-party carriers since their services can be pre-arranged or on demand such as hailing a cab on the street.
The insurance issues associated with TNC activities arise because TNC drivers use personal cars for that commercial activity but do not have commercial auto insurance. The California Department of Insurance held an investigatory hearing March 21, 2014, relating to insurance issues for TNCs. As a result of the hearing, Insurance Commissioner Dave Jones recommended TNCs provide $1 million in primary liability insurance that begins the moment the driver switches on the app. The issue of Worker's Compensation benefits and insurance has yet to be considered by regulatory bodies.
So now the issue of workers' compensation coverage must be resolved in the courts. According to an article in Business Insurance, drivers for ride-sharing services Uber Technologies Inc. and Lyft Inc.,argue in two cases that they are employees and not independent contractors. This could put the tech upstarts on the hook for workers compensation costs if court challenges succeed. In separate lawsuits filed in U.S. District Court in San Francisco, plaintiffs seeking to represent Uber and Lyft drivers nationwide base their allegations on California's labor law, since both Uber and Lyft reference the state's law in their driver contracts, said Shannon Liss-Riordan, a plaintiff attorney in both cases and a partner at Lichten and Liss-Riordan P.C. in Boston. Judges in both cases have limited the potential classes to drivers in California, but Ms. Liss-Riordan said those decisions likely will be appealed.
If Uber and Lyft drivers are deemed employees, the companies would need to evaluate providing workers comp coverage, said officials at the National Council on Compensation Insurance Inc. Court transcripts are sealed, but, according to wire service reports, in a January hearing in the Lyft case, U.S. District Judge Vince Chhabria said rulings in other California cases typically have found that "people who do the kinds of things that Lyft drivers do here are employees." U.S. District Judge Edward Chen reportedly said "I don't find that a very persuasive argument,"in a separate January hearing in the Uber case, in which the company argues it is a software platform, not an employer. Final rulings have not yet been made in either suit, both of which have been pending since 2013
The insurance industry is watching the cases closely. For example, NCCI identified ride-sharing services as one of the top emerging comp issues for 2015. The National Association of Insurance Commissioners (NAIC) adopted a white paper addressing the insurance coverage gaps associated with ridesharing services offered by Transportation Network Companies. The white paper was issued to assist state insurance regulators and state legislators throughout the United States who are considering how best to address insurance coverage gaps associated with TNCs and ridesharing. The paper recommends a range of potential state based regulatory solutions. Issues including insurance coverage gaps, coverage amounts and types of coverage are discussed, as well as the need for consumer outreach and education regarding these new transportation services ...
New research presented at the 2015 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) identifies nicotine dependence, obesity, alcohol abuse and depressive disorders as risk factors for low back pain, a common condition causing disability, missed work, high medical costs and diminished life quality.
Researchers reviewed electronic records of more than 26 million patients from 13 health care systems across the U.S., including 1.2 million patients diagnosed with low back pain (approximately 4.54 percent of the patient records). The review found that 19.3 percent of the patients diagnosed with a depressive disorder reported lower back pain, as did 16.75 percent of patients diagnosed as obese (a body mass index, or BMI, greater than 30kg/m²), 16.53 percent of the patients diagnosed with nicotine dependence, and 14.66 percent with reported alcohol abuse. Patients with nicotine dependence, obesity, depressive disorders, and alcohol abuse were had "statistically significant" relative risks of 4.489, 6.007, 5.511 and 3.326 for low back pain, respectively, when compared to other patients
"This study used an electronic health care database to identify modifiable risk factors - obesity, depressive disorders, alcohol and tobacco use - in patients with low back pain," said lead study author and orthopaedic surgeon Scott Shemory, MD. "The findings will allow physicians to better counsel and more closely follow their high-risk patients."
According to the U.S. Centers for Disease Control and Prevention's (CDC) 2012 National Health Survey, nearly one-third of U.S. adults reported that they had suffered from low back pain during the previous three months. For many adults, low back pain is debilitating and chronic. Determining modifiable risk factors for low back pain could help avoid or diminish the financial and emotional costs of this condition.
Apportionment of permanent disability in California workers' compensation can be based upon causation. Perhaps this study, and other similar investigations may provide more opportunities to obtain apportionment in low back injury cases ...
Researchers reviewed electronic records of more than 26 million patients from 13 health care systems across the U.S., including 1.2 million patients diagnosed with low back pain (approximately 4.54 percent of the patient records). The review found that 19.3 percent of the patients diagnosed with a depressive disorder reported lower back pain, as did 16.75 percent of patients diagnosed as obese (a body mass index, or BMI, greater than 30kg/m²), 16.53 percent of the patients diagnosed with nicotine dependence, and 14.66 percent with reported alcohol abuse. Patients with nicotine dependence, obesity, depressive disorders, and alcohol abuse were had "statistically significant" relative risks of 4.489, 6.007, 5.511 and 3.326 for low back pain, respectively, when compared to other patients
"This study used an electronic health care database to identify modifiable risk factors - obesity, depressive disorders, alcohol and tobacco use - in patients with low back pain," said lead study author and orthopaedic surgeon Scott Shemory, MD. "The findings will allow physicians to better counsel and more closely follow their high-risk patients."
According to the U.S. Centers for Disease Control and Prevention's (CDC) 2012 National Health Survey, nearly one-third of U.S. adults reported that they had suffered from low back pain during the previous three months. For many adults, low back pain is debilitating and chronic. Determining modifiable risk factors for low back pain could help avoid or diminish the financial and emotional costs of this condition.
Apportionment of permanent disability in California workers' compensation can be based upon causation. Perhaps this study, and other similar investigations may provide more opportunities to obtain apportionment in low back injury cases ...
Citing lower medical loss development, as well as indemnity and medical severities that continue to emerge below expectations, the insurer and public members of the WCIRB Governing Committee voted this week to authorize the WCIRB to submit a mid-year pure premium rate filing to the California Department of Insurance (CDI). The filing will propose a July 1, 2015 advisory pure premium rate of $2.46 per $100 of payroll which is 5.0% lower than the corresponding industry average filed pure premium rate of $2.59 as of January 1, 2015 and 10.2% less than the approved average January 1, 2015 advisory pure premium rate of $2.74.
The Governing Committee’s decision was based on the WCIRB Actuarial Committee’s analysis of insurer loss and loss adjustment experience as of December 31, 2014, which was reviewed at public meetings of the Actuarial Committee held on March 18, 2015 and March 30, 2015. While loss adjustment expenses continue to emerge at levels higher than expected, those higher costs are more than offset by better than projected loss experience. The primary drivers of the indicated reduction in advisory pure premium rates are:
1) Significant improvement in medical loss development since the WCIRB’s amended January 1, 2015 Pure Premium Rate Filing, which decreases the estimates of ultimate historical accident year loss ratios and the resultant future year medical cost projections.
2) Continued decline in the average cost of indemnity and medical on indemnity claims—particularly in the 2014 accident year. For the second consecutive year following the implementation of SB 863, medical severities declined by more than 4%.
3) Significant improvement in accident year 2014 experience, in large part driven by lower than expected severity growth.
The WCIRB anticipates submitting its filing to the CDI by April 6, 2015. The filing and all related documents will be available in the Publication and Filings section of the WCIRB website and the WCIRB will issue a Wire Story once the filing has been submitted. Documents related to the Governing Committee meeting, including the agenda and materials displayed or distributed at the meeting, are available on the Governing Committee page of the WCIRB website.
California joins other states that are announcing rate reductions this month. North Carolina Governor Pat McCrory announced that an average decrease in workers’ compensation insurance premium rates paid by North Carolina businesses will take effect in April 2015. The North Carolina Department of Insurance estimates that 95 percent of the state’s employers will see an average decrease of 3.4 percent in their 2015 premium rate. The remaining 5 percent, which constitutes businesses that purchase coverage through an "assigned risk pool," will see an average decrease of 4.5 percent. These significant decreases are a welcome change from 2014 premium rates which were 4.2 percent higher than what most employers paid in 2013.
Workers compensation advisory rates will decrease 5.99% for Pennsylvania employers this month, according to Pennsylvania Gov. Tom Wolf. This is the fourth year in a row that Pennsylvania workers comp advisory rates have decreased, according to the governor's statement.
Private employers in Ohio will see a 10.8% workers compensation rate decrease as of July 1, the Ohio Bureau of Workers' Compensation said. The 10.8% rate cut, approved by the Ohio Bureau of Workers' Compensation's board of directors is expected to yield a $153 million decrease in projected annual premium, the bureau said in a statement ...
The Governing Committee’s decision was based on the WCIRB Actuarial Committee’s analysis of insurer loss and loss adjustment experience as of December 31, 2014, which was reviewed at public meetings of the Actuarial Committee held on March 18, 2015 and March 30, 2015. While loss adjustment expenses continue to emerge at levels higher than expected, those higher costs are more than offset by better than projected loss experience. The primary drivers of the indicated reduction in advisory pure premium rates are:
1) Significant improvement in medical loss development since the WCIRB’s amended January 1, 2015 Pure Premium Rate Filing, which decreases the estimates of ultimate historical accident year loss ratios and the resultant future year medical cost projections.
2) Continued decline in the average cost of indemnity and medical on indemnity claims—particularly in the 2014 accident year. For the second consecutive year following the implementation of SB 863, medical severities declined by more than 4%.
3) Significant improvement in accident year 2014 experience, in large part driven by lower than expected severity growth.
The WCIRB anticipates submitting its filing to the CDI by April 6, 2015. The filing and all related documents will be available in the Publication and Filings section of the WCIRB website and the WCIRB will issue a Wire Story once the filing has been submitted. Documents related to the Governing Committee meeting, including the agenda and materials displayed or distributed at the meeting, are available on the Governing Committee page of the WCIRB website.
California joins other states that are announcing rate reductions this month. North Carolina Governor Pat McCrory announced that an average decrease in workers’ compensation insurance premium rates paid by North Carolina businesses will take effect in April 2015. The North Carolina Department of Insurance estimates that 95 percent of the state’s employers will see an average decrease of 3.4 percent in their 2015 premium rate. The remaining 5 percent, which constitutes businesses that purchase coverage through an "assigned risk pool," will see an average decrease of 4.5 percent. These significant decreases are a welcome change from 2014 premium rates which were 4.2 percent higher than what most employers paid in 2013.
Workers compensation advisory rates will decrease 5.99% for Pennsylvania employers this month, according to Pennsylvania Gov. Tom Wolf. This is the fourth year in a row that Pennsylvania workers comp advisory rates have decreased, according to the governor's statement.
Private employers in Ohio will see a 10.8% workers compensation rate decrease as of July 1, the Ohio Bureau of Workers' Compensation said. The 10.8% rate cut, approved by the Ohio Bureau of Workers' Compensation's board of directors is expected to yield a $153 million decrease in projected annual premium, the bureau said in a statement ...
The dominant model for payment of medical services has been a "payment for procedure" model which financially encourages vendors to provide as many medical procedures as possible without a financial incentive for a good outcome. Escalating costs have triggered experiments with other payment models that focus on value. Earlier this decade, "pay for performance" took center stage as a tactic for realigning payment with value. Another model known as "bundled payments" is being studied at the state and national level. One or combinations of these newer models may at some point determine payment under California workers' compensation.
Bundled payment is a single payment to providers or health care facilities (or jointly to both) for all services to treat a given condition or provide a given treatment. Bundled payment asks providers to assume financial risk for the cost of services for a particular treatment or condition, as well as costs associated with preventable complications. Just 1.6 percent of payments currently flowed through bundled payment models. However, use of bundled payments is growing in both the public and private sectors. The Centers for Medicare and Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI) Initiative will pilot bundled payments in almost 100 settings (ranging from hospitals to nursing homes) over the next three years, and the program is expanding further. Both Tennessee and Arkansas are working to implement multi-stakeholder episode-based payment initiatives.
Traditionally, Medicare makes separate payments to providers for each service they perform (pay for procedure model) for beneficiaries during a single illness or course of treatment. This approach can result in fragmented care with minimal coordination across providers and health care settings. It also rewards the quantity of services offered by providers rather than the quality of care furnished. Research has shown that bundled payments can align incentives for providers - hospitals, post-acute care providers, physicians, and other practitioners - allowing them to work closely together across all specialties and settings. The Bundled Payments for Care Improvement initiative was developed by the Center for Medicare and Medicaid Innovation (Innovation Center). The Innovation Center was created by the Affordable Care Act to test innovative payment and service delivery models that have the potential to reduce Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) expenditures while preserving or enhancing the quality of care for beneficiaries.
The Bundled Payment model has now caused researchers to focus on the cause of costly "bad" medical and surgical outcomes, research that is desperately needed. A new study from researchers at NYU Langone's Hospital for Joint Diseases identifies common causes of hospital readmissions following total hip and knee arthoplasty procedures. By finding these common causes, researchers believe quality can be increased and hospital costs decreased. The study was presented at the American Academy of Orthopaedic Surgeons Annual Meeting in Las Vegas.
The patients were part of the Bundled Payment for Care Initiative from the Centers for Medicare and Medicaid Services (CMS), a government pilot program where hospitals are paid for quality of procedures rather than quantity. One way to measure quality is by examining hospital readmission rates. Researchers studied 721 patients admitted to NYU Langone's Hospital for Joint Diseases between January and December 2013 for a total hip arthoplasty (THA) or total knee arthoplasty (TKA). Of those cases, 80 patients, or 11 percent, had to be re-admitted within 90 days.
THA and TKA readmissions due to surgical complications accounted for 54% and 44% of the indications for readmissions, respectively. Surgical complications included infection (11), wound complications (8) bleeding (7), periprosthetic fracture (5), dislocations (4), and post-surgical pain (4). The average cost of readmission for surgical complications was $36,038 for THA and $61,049 for TKA. Medical complications included gastrointestinal disease (11), pulmonary disease (8), genitourinary/renal complications (6), hematologic (6), cardiovascular (3), endocrine disorders (2) syncope (2), rheumatologic (1), lumbago (1), and an open ankle wound (1). The average cost of medical complications was $22,775 for THA and $10,283 for TKA patients, respectively.
"While some complications are unavoidable, we are proud of our low readmission rates at the Hospital for Joint Diseases and by identifying the causes for readmission, we hope to reduce our rates even further," says study co-author Joseph Bosco, MD, associate professor and Vice Chair for Clinical Affairs in the Department of Orthopaedic Surgery at NYU Langone. "As bundled payment programs are implemented more widely nationwide, other U.S. hospitals will follow our example and implement strategies to boost quality and reduce medical costs." ...
Bundled payment is a single payment to providers or health care facilities (or jointly to both) for all services to treat a given condition or provide a given treatment. Bundled payment asks providers to assume financial risk for the cost of services for a particular treatment or condition, as well as costs associated with preventable complications. Just 1.6 percent of payments currently flowed through bundled payment models. However, use of bundled payments is growing in both the public and private sectors. The Centers for Medicare and Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI) Initiative will pilot bundled payments in almost 100 settings (ranging from hospitals to nursing homes) over the next three years, and the program is expanding further. Both Tennessee and Arkansas are working to implement multi-stakeholder episode-based payment initiatives.
Traditionally, Medicare makes separate payments to providers for each service they perform (pay for procedure model) for beneficiaries during a single illness or course of treatment. This approach can result in fragmented care with minimal coordination across providers and health care settings. It also rewards the quantity of services offered by providers rather than the quality of care furnished. Research has shown that bundled payments can align incentives for providers - hospitals, post-acute care providers, physicians, and other practitioners - allowing them to work closely together across all specialties and settings. The Bundled Payments for Care Improvement initiative was developed by the Center for Medicare and Medicaid Innovation (Innovation Center). The Innovation Center was created by the Affordable Care Act to test innovative payment and service delivery models that have the potential to reduce Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) expenditures while preserving or enhancing the quality of care for beneficiaries.
The Bundled Payment model has now caused researchers to focus on the cause of costly "bad" medical and surgical outcomes, research that is desperately needed. A new study from researchers at NYU Langone's Hospital for Joint Diseases identifies common causes of hospital readmissions following total hip and knee arthoplasty procedures. By finding these common causes, researchers believe quality can be increased and hospital costs decreased. The study was presented at the American Academy of Orthopaedic Surgeons Annual Meeting in Las Vegas.
The patients were part of the Bundled Payment for Care Initiative from the Centers for Medicare and Medicaid Services (CMS), a government pilot program where hospitals are paid for quality of procedures rather than quantity. One way to measure quality is by examining hospital readmission rates. Researchers studied 721 patients admitted to NYU Langone's Hospital for Joint Diseases between January and December 2013 for a total hip arthoplasty (THA) or total knee arthoplasty (TKA). Of those cases, 80 patients, or 11 percent, had to be re-admitted within 90 days.
THA and TKA readmissions due to surgical complications accounted for 54% and 44% of the indications for readmissions, respectively. Surgical complications included infection (11), wound complications (8) bleeding (7), periprosthetic fracture (5), dislocations (4), and post-surgical pain (4). The average cost of readmission for surgical complications was $36,038 for THA and $61,049 for TKA. Medical complications included gastrointestinal disease (11), pulmonary disease (8), genitourinary/renal complications (6), hematologic (6), cardiovascular (3), endocrine disorders (2) syncope (2), rheumatologic (1), lumbago (1), and an open ankle wound (1). The average cost of medical complications was $22,775 for THA and $10,283 for TKA patients, respectively.
"While some complications are unavoidable, we are proud of our low readmission rates at the Hospital for Joint Diseases and by identifying the causes for readmission, we hope to reduce our rates even further," says study co-author Joseph Bosco, MD, associate professor and Vice Chair for Clinical Affairs in the Department of Orthopaedic Surgery at NYU Langone. "As bundled payment programs are implemented more widely nationwide, other U.S. hospitals will follow our example and implement strategies to boost quality and reduce medical costs." ...
