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The Division of Workers’ Compensation (DWC) today posted the 2015 RAND study Home Health Care for California’s Injured Workers - Options for Implementing a Fee Schedule. California

The Medicare fee schedule for home health services covers only home health services provided when a homebound individual needs intermittent or part-time skilled care. To date, DWC has not implemented a Medicare-based fee schedule for home health services. Section 74 of Senate Bill 863 added Labor Code §5307.8, which requires that DWC adopt a fee schedule for home health services not covered by Medicare. This fee schedule must establish fees and service provider requirements based on the rules used by the In-Home Supportive Services (IHSS) program, a MediCal-funded program that provides supportive services necessary to enable elderly and disabled individuals to remain safely within their homes. The DWC asked RAND to provide technical assistance in developing the fee schedule and related coverage policies for home health services.

The 130 page RAND study found that neither the Medicare fee schedule nor the IHSS fee schedule would be sufficient to cover the full range of potential home care services provided to injured workers. Nonetheless the DWC, the fee schedule should build on existing fee schedules policies, coding system and payment amounts. This is the approach that has been taken with respect to other components of the OMFS. Given the SB 863 requirements, priority should be given to adapting the IHSS fee schedules as needed for the WC patient population. There should be standardized codes describing the type and volume of services provided to the injured worker. To the extent feasible, the codes should draw on existing code sets. The payment rates should be adequate to cover the estimated costs (including a fair return on investment) of providing the services efficiently, and the payment incentives should be structured to safeguard against the under- or over provision of care. One of the more controversial RAND recommendations might be their suggestion that "To balance worker choice with safety and cost considerations, family members should be allowed to provide attendant care services when they have the training to do so and there is appropriate financial accountability and oversight."

The DWC will hold a public meeting to discuss issues related to the home health services fee schedule on Tuesday, March 3, from 10:00 a.m. to Noon at the Elihu Harris State Office Building Auditorium located at 1515 Clay Street in Oakland. The purpose of the meeting is to hear input from the public regarding issues including assessing the need for home health services, service provider requirements, fee amounts, and billing codes ...
/ 2015 News, Daily News
Research scientists in Edinburgh have come up with a new 'solution' that could reduce the risk of osteoarthritis developing in tens of thousands of people who undergo orthopaedic surgery every year - sugar. According to the summary in Reuters Health, people who have surgery for joint problems are at increased risk of developing osteoarthritis because the operation can damage cartilage cells. But a team at the University of Edinburgh have found that by simply adding sugar to the saline solution used to wash out joints during orthopaedic surgery protects the cartilage from being damaged and may even improve cartilage repair.

Osteoarthritis, which affects more than eight million people in the UK, occurs when cartilage at the ends of bones wears away, leading to stiff, painful joints. There is no cure and treatment is limited to pain relief and joint replacement in severe cases.

The main risk factors for developing for the condition are ageing, obesity, and joint damage. People who undergo surgery or arthroscopic procedures to treat joint problems - often because of a sports injury or unexplained joint pain - are at an increased risk of developing osteoarthritis because surgery can damage the joint and tissue by destroying cartilage cells called chondrocytes.

But in experiments on rats, the team at Edinburgh University's Centre for Integrative Physiology found that by adding sugar to the saline solution used during surgery to wash out the joint they could protect the joints from this increased risk. Sugar raises the osmotic pressure of the saline, which protects the cells against injury during surgery. The researchers describe the solution as 'chondroprotective' because it protects the cartilage cells against injury.

The team have also shown that as well as protecting against cartilage damage there is better cartilage repair when the chondroprotective solution is used, compared to the usual saline currently used in orthopaedic surgery. Their research was funded by Arthritis Research UK and published in the journal Osteoarthritis and Cartilage.

Dr Andrew Hall, principal investigator and reader in cell physiology said: "Our findings could have major implications for tens of thousands of people who undergo arthroscopic surgery, such as footballers or other sportspeople who've damaged their cartilage. Or in fact anyone who's had exploratory surgery for a sore or painful knee. "There is a worry that all these people are at risk of developing osteoarthritis from their surgery. But if surgeons can be persuaded to use this chondroprotective solution as standard that risk could be substantially reduced. It's a cheap, simple solution that can protect the cartilage in the joint during arthroscopy and surgery."

Dr Stephen Simpson, director of research at Arthritis Research UK commented: "It's extraordinary that something as simple as a sugar solution can have such a beneficial, protective effect on the joints during surgery and can actually help repair cartilage damage. It seems a simple yet potentially valuable step that surgeons around the country could be persuaded to include in their procedures." ...
/ 2015 News, Daily News
An article in Risk and Insurance speculates that as more insurance distribution channels are being created, the potential disruption of the ordinary course of business for underwriters and brokers increases. One of those channels, although details are hazy, involves Overstock.com Inc., a Utah-based e-commerce site that survived the dot-com bust by selling dying Internet companies’ inventories.

Since April 2014, Overstock.com has sold insurance, including auto, property, liability and workers’ comp for businesses, through an exchange where consumers receive live quotes, pick which the coverage they like, and then have a policy bound for them. But who is really doing the the underwriting? Apparently, the underwriters’ names had been confidential, but when asked Dave Nielsen, Overstock.com’s senior vice president, said shared some of them: 21st Century, Progressive, Safeco and American Strategic (ASI). Overstock.com is "seeing good traffic" on the site, Nielsen said, and he’s expecting to "see [sales] continually increasing month over month" as the company adds more products. The logistics of claims and other policy-servicing depends on the carrier, Nielsen added. Overstock services some accounts in-house; others it transfers directly to carriers. But no matter what, policyholders contact Overstock first.

Most of the insureds probably care little about the identify of the underwriters, said Denise Garth, partner and chief digital officer at consultancy Strategy Meets Action (SMA). As far as the insurance buyer goes, they’re a customer of Overstock.com. "[Overstock is] definitely the channel where it’s been sold, and it’s the channel where the customer is going to go to for service," Garth said.

And it’s just one channel of many it seems that are on the verge of disrupting well-tread insurance distribution networks. In particular, according to a report from London-based market risk and consulting firm Finaccord, as many as 281 retail brands around the world are selling insurance, up from 232 retailers in 2010. Global names like Walmart, Tesco, Marks and Spencer, and Carrefour are "leveraging" their brands and huge customer bases to sell mainstream insurance products, said Finaccord Director Alan Leach. "They can supplement the thin profit margin that they can earn from their core business by selling financial services," Leach said. They wield data they already collect on their customers to empower cross-selling. If they know which of their customers buy pet food, they know which of their customers to market pet insurance to.

At this point, however, this trend of retailers selling insurance is "not so much" in the United States, Leach said, and in many cases, they’re selling personal lines products to consumers. But retailers are just one group the traditional insurance world must confront. Some observers, like Garth, argue that this trend doesn’t just put the insurance distribution process at stake, but affects the industry’s business model as a whole. Some of the savviest, brawniest, data-driven companies in the world are coming. Alibaba, of the recent record-breaking IPO, launched an online insurance platform in 2013 called Leyebao, aimed at Alibaba’s online store owners and their employees. Google forayed into the insurance space in the U.K. in 2012, with a car insurance comparison tool. They’re coming because consumers apparently want them to.

"Competition in the insurance industry could quickly intensify as consumers become open to buying insurance not only from traditional competitors such as banks but also from Internet giants," said Michael Lyman, global managing director for management consulting within Accenture’s insurance industry practice, when he announced the Feb. 2014 research. The disruption will not be as black and white as an Alibaba launching an insurance company or Walmart taking jobs away from Main Street agents. The invaders seem to care less about the means than the end result. "They want to own a customer for a lifetime," Garth said.

Their success at that could leave insurers as mere "manufacturers" of insurance products, and agents and brokers as mere customer service representatives, for the companies that will own consumer loyalty and lifetime customer value ...
/ 2015 News, Daily News
The Los Angeles County District Attorney’s Office announced that a 69-year-old Encino physician was sentenced to two years in jail for prescribing various narcotic drugs without a legitimate medical need. Los Angeles Superior Court Judge Dennis Landin sentenced Dr. Yahya Hedvat to a total of seven years, but suspended five. He ordered the Encino physician, who operated a medical clinic called "Urgent Care," located at 18055 Ventura Blvd to surrender on Feb. 18 to begin serving his sentence.

In November, Hedvat pleaded no contest to all 11 counts contained in two cases, BA428107 and BA414896. He also admitted the allegation that he was out on bail when he continued criminal activity and a second case was filed in August. Hedvat was first charged in October 2013 with unlawfully prescribing controlled substances, including hydrocodone, suboxone and clonazepam, without a legitimate medical need in a 10-count Grand Jury indictment. After voluntarily surrendering his DEA license to prescribe controlled substances, Hedvat agreed to sell additional drugs, including Norco and Ativan, to an undercover agent with the California Medical Board on Aug. 8.

Deputy District Attorneys John Niedermann and Emily Street with the Major Narcotics Division prosecuted both cases.

Hedvat however continues to hold a California Physicians and Surgeons license although it is suspended by order of the Superior Court in the criminal cases pending against him. He is a 1972 graduate of Tabriz University located in Tabriz, East Azarbaijan Province, Iran. He was issued a license to practice in California in 2004. The only current disciplinary charges pending against him are unrelated to his convictions. The Accusation alleges "gross negligence" in the practice of medicine. Two patients are the subject of the Accusation which claims he was "was grossly negligent and incompetent in the care and treatment of a patient." The two cases allege that he misdiagnosed both of them after failing to perform a competent physical examination, failed to keep proper chart entries of symptoms and physical complaints, and failed to properly refer them to competent care ...
/ 2015 News, Daily News
Jesus Cordova was awarded 100% disability and future medical care as a result of his injury while employed by Graventa Enterprises who was insured by the State Fund. The current dispute involved the future medical care, and the UR process. The WCJ found that the defendant issued utilization review non-certification notices on June 28 and July 19,2013 and that neither denial was communicated timely to the applicant's primary treating physician or accompanied by the required Independent Medical Review form, thereby rendering the denials inadmissible. The WCJ awarded the contested medical treatment, penalties, and attorney's fees.

In a Petition for Reconsideration, the State Fund claimed in essence, that the WCJ erred in awarding the contested medical treatment, penalties, and attorneys fees, arguing that the Appeals Board lacks jurisdiction to decide a dispute over a utilization review decision which was communicated to the primary treating physician on or after July l, 2013 and in refusing to apply Labor Code section 4610(9)(6) to a request for treatment which issued within 12 months of a utilization review decision denying the same treatment. Defendant also contends that the WCJ is without power to award an attorney fee for enforcement of a medical award.

The WCAB panel in the case of Cordova v Graventa Enterprises that Labor Code section 4610.5, which provides for independent medical review of utilization review decisions, applies to "any dispute over a utilization review decision if the decision is communicated to the requesting physician on or after July l, 2013, regardless of the date of injury. However none of the disputed denials of treatment were communicated to a requesting physician on or after July 1.2013, thus none of the disputed utilization review decisions are subject to independent medical review.

Labor code section 4610(9)(6) provides that "A utilization review decision to modify, delay, or deny a treatment recommendation shall remain effective for 12 months from the date of the decision without further action by the employer with regard to any further recommendation by the same physician for the same treatment unless the further recommendation is supported by a documented change in the facts material to the basis of the utilization review decision." The record had insufficient evidence to determine whether the utilization review decision or decisions were timely made and whether defendant relied on section 4610(e)(6) or submitted additional requests for that prescription to utilization review. Thus this issue was deferred with jurisdiction reserved at the trial level.

On the issue of penalties, defendant's delay of treatment that was authorized by a utilization review physician was unreasonable. However, with respect to the denied prescription for Nucynta, defendant could reasonably rely on the utilization review denial. Accordingly,the Findings and Award was amended to award a penalty and an attorneys fee on the delayed provision of Neurontin. Applicant's attorney is entitled to a fee pursuant to Labor Code section 5814.5 for successfully enforcing an award.

The WCAB also decided to "admonish defendant that applicant has an award of medical treatment and the utilization review cycle of denials and authorizations for applicant's prescription medications appears arbitrary. While defendant is entitled to submit every prescription request to utilization review, we suggest that defendant should consider whether doing so is cost effective and fulfills its obligation to provide applicant with medical treatment to cure or relieve him from the effects of his industrial injury." ...
/ 2015 News, Daily News
The U.S. Supreme Court on Tuesday vacated a lower court's ruling that had ended patent protection for Teva Pharmaceuticals' multiple sclerosis drug Copaxone. The decision could have broader implications for how courts decide future pharmaceutical patent disputes.

According to the summary in Modern Healthcare, the justices decided 7-2 to vacate a lower court's ruling that the Jerusalem-based pharmaceutical company's key patent on the drug was invalid. They ruled that the U.S. Court of Appeals for the Federal Circuit was wrong to evaluate the facts of the case independently rather than rely on the district court's previous finding of the facts.

The justices decided to send the case back to the U.S. Court of Appeals for the Federal Circuit, which handles patent issues, for further review in light of their ruling. The federal circuit court had ruled against Teva on a technical question having to do with whether Teva had adequately described the molecular weight of an active ingredient in Copaxone known as Copolymer 1 in its drug patents. More broadly, the justices' decision Tuesday will likely make it more difficult for the U.S. Court of Appeals for the Federal Circuit to overturn district court decisions in certain pharmaceutical patent cases moving forward, said Daryl Wiesen, an attorney for Teva with Goodwin Proctor.

Arti Rai, a professor at Duke University School of Law, also said that the ruling Tuesday might make appeals in certain patent cases less frequent. It might also make trial courts more willing to "engage in time-consuming" analysis when it comes to looking into claim construction, or what specific patents cover and prevent others from doing. "In the past, because trial courts knew they would be reviewed de novo in any event, they didn't want to do inquiries that were time consuming," Rai said. Rai co-authored a brief filed in the Teva case arguing for a result similar to the one reached by the Supreme Court. The brief was not in support of either side, however.

"We are encouraged by the U.S. Supreme Court's decision and look forward to the Federal Circuit's review," Erez Vigodman, Teva president and CEO, said in a statement. "We will continue to explore all available avenues to protect our intellectual property for COPAXONE 20mg/mL." In 2013, Teva sold $4.3 billion worth of the drug, according to a company financial statement.

Mylan Inc. CEO Heather Bresch said in a statement Tuesday that, "We continue to believe that the '808 patent is invalid as indefinite and we will address that issue with the Federal Circuit Court of Appeals." The pharmaceutical company, along with Sandoz, Momenta Pharmaceuticals and Natco Pharma were respondents in the Supreme Court case ...
/ 2015 News, Daily News
Portable X-ray services are becoming more popular as patients seek medical care in familiar surroundings.

According to the Report in Reuters Health, proponents say-home X-ray services help frail patients avoid difficult and potentially hazardous trips to hospitals. Other patients seek in-home providers out of convenience, as an ankle or chest X-ray can take less than 20 minutes. "We go to the patient and take the X-ray, rather than having the patient go to the doctor’s office," said Paul Fowler, founder of Specialty Portable X-Ray, Inc. in New York. "Usually, in about an hour after we take an X-ray we give these results directly to the doctor," he told Reuters Health. "With the digital X-rays, we are using probably less exposure than you would at the hospital."

Patients must have a doctor’s prescription for an x-ray, or for an ultrasound exam, which can also be done at home. Fowler’s company charges about $300 for a visit for patients without health insurance, he said. Some celebrities seek his services to avoid paparazzi and unwanted attention.

Jacob R. Wuerstle, president of Diagnostic X-ray Service, Inc. in Pennsylvania, said portable X-rays are also used in assisted living facilities and prisons. "We keep the patients in a setting that they’re familiar with, that they’re comfortable with," he told Reuters Health. The option for home X-rays is especially helpful for elderly patients in snowy parts of the country. His technicians scan more than 30,000 patients per year. Sessions cost about $200. "We use state-of-the-art equipment and we transmit right from the patient’s bedside to the radiologist," he said.

Dr. James C. Carr, a professor of radiology at Northwestern University’s Feinberg School of Medicine in Chicago, believes trained technicians using portable machines can provide quality scans for patients in rural areas or unable to move. "As long as the equipment is being regulated and the technologists are satisfactorily trained, concerns can be mitigated," he told Reuters Health.

But portable X-ray machines, while convenient, may be less accurate. Dr. David Levin, professor and chairman emeritus of the Department of Radiology at Thomas Jefferson University Hospital in Philadelphia said he would not recommend in-home X-rays for mobile patients. "The quality of those images is usually not very good. If you compare the quality of those kinds of studies with the quality of a study that was performed in a hospital in a radiology department or in a private radiology office, there is going to be no comparison," he told Reuters Health. "If a portable X-ray is absolutely necessary because of the patient’s clinical condition, then it’s justifiable."

As the portable X-ray market grows, state and federal regulations for radiation protection must be followed, said Dr. William Thorwarth, Jr., chief executive officer of the American College of Radiology in Virginia. "You want to be very certain that the technologist who’s acquiring the images is appropriately trained and qualified," he told Reuters Health. "There needs to be appropriate precautions so that other people in the house are not exposed." ...
/ 2015 News, Daily News
The Press Telegram reports that Lawyers have agreed to delay the public corruption trial of former state Sen. Ron Calderon and his brother until August,.

Prosecutors and defense lawyers filed a stipulation Wednesday in Los Angeles federal court to postpone the trial from May 19 to Aug. 11 because they need to review about 280,000 pages of evidence, including about 2,000 recorded phone calls.

The Montebello Democrat has pleaded not guilty to accepting $100,000 in cash bribes, trips and dinners in exchange for pushing workers’ compensation legislation and a film industry tax credit scheme that was actually an FBI sting. His term expired at the end of the year.

Thomas Calderon, 60, a former lawmaker-turned-lobbyist, has pleaded not guilty to laundering bribes through a tax-exempt group and consulting company he operates.

Ron Calderon, 57, was one of three Senate Democrats suspended last year because of felony charges, due in part to bribes he is accused of receiving from the former owner of Pacific Hospital in Long Beach. Michael Drobot, head of the now-defunct hospital, pleaded guilty last year to federal charges related to his role in a medical fraud scheme that authorities have said may be the largest of its kind in California history. Drobot has told federal officials that he also bribed Ron Calderon in order to keep on the books the labor code provisions that made it possible to seek inflated reimbursements for spinal hardware ...
/ 2015 News, Daily News
The California Department of Justice was one of five law enforcement agencies investigating a Los Angeles "Pill Mill" medical clinic that lead to the arrest of five suspects after a federal grand jury issued a 33-count indictment, Authorities allege this was a narcotics trafficking ring in which illegal prescriptions were sold for a flat rate of $500 at the now-closed Southfork Medical Clinic in Los Angeles and the drugs obtained with those prescriptions were shipped to Texas for sale on the black market. Prescriptions were allegedly sold for drugs that included oxycodone, hydrocodone, alprazolam (best known by the brand name Xanax), carisoprodol (a muscle relaxant) and promethazine with codeine (a cough syrup sold on the street as "purple drank" and "sizzurp").

Those arrested include Jagehauel Gillespie, 39, of Houston, the operator of Southfork, and alleged ringleader. Investigators seized nearly 10,000 pills from his home in January 2013 and 48 bottles of promethazine with codeine from a car driven across Texas by Gillespie and another suspect in July 2010. Gillespie is also charged with using fake identities and fraudulent driver’s licenses to fill prescriptions at Los Angeles-area pharmacies. Gillespie faces up to 149 years in federal prison if convicted.

Also arrested was Dr. Madhu Garg, 63, of Glendora, the medical doctor who wrote prescriptions at Southfork, allegedly without any medical necessity, before the Medical Board of California revoked her license in late 2013. Garg, issued more than 10,000 prescriptions - with nearly 80 percent of those for hydrocodone or alprazolam, most of which were at the maximum dosage - over a 15-month period, according to records maintained by the State of California. In addition to drug counts, Garg is charged with money laundering for allegedly wiring money obtained from the drug conspiracy to an account in Kuala Lumpur.

According to records at the California Medical Board, in 2011 Garg "was a partner with Southern California Permanente Medical Group and worked at Kaiser Baldwin Park Medical Center-West Covina Medical Offices, practicing family medicine. On or about October 24, 2011, she reported for work and was asked to undergo drug testing as she appeared to be "out of it." The results of that drug test were received on or about October 31, 2011, and were noted to be positive for amphetamines, methamphetamines, and hydrocodone. Respondent was placed off-work." Medical Board Records also reflect that she claims to have practiced "occupational medicine." These and other allegations led to the revocation of her medical license.

Diane Nunez, 24, of Long Beach who oversaw day-to-day operations at Southfork was also arrested along with Daniel Clay, 45, of Houston, who allegedly shipped controlled substances from Southern California to Texas. Ray Steven Benton, 56, of Baldwin Hills, was arrested and is allegedly, a "capper" who allegedly recruited patients to obtain prescriptions at Southfork. Benton is also charged with firearms offenses and with using fake identities and fraudulent driver’s licenses to fill prescriptions at Los Angeles-area pharmacies.

"Los Angeles is a major source of the deadly and addictive prescription drugs that are diverted to street sales across the Western United States," said Acting United States Attorney Stephanie Yonekura. "This case is the latest in a series of prosecutions clearly demonstrating that law enforcement is committed to stemming the tide of drugs being diverted to the black market, as well as putting an end to medical professionals who abuse their prescription pads and their ethical obligations."

The indictment describes multiple undercover operations conducted during the investigation. During an October 2013 meeting at Southfork, Gillespie allegedly agreed that Garg would prescribe oxycodone and promethazine with codeine for an undercover cooperator in exchange for the person returning to the clinic with bottles of the prescribed cough syrup. Later that day, Garg allegedly gave the undercover witness prescriptions for those drugs and agreed to issue more prescriptions later that week under a different patient name. Six days later, during another meeting at Southfork, Gillespie allegedly gave the undercover witness forged prescriptions for oxycodone and promethazine with codeine using another doctor’s name and medical license number.

Two other suspects named in the indictment are currently being sought by authorities. Those two fugitives are: Jessica Poe, 32, of Inglewood, California, Gillespie’s girlfriend, who allegedly forged a doctor’s signature on prescriptions; and Joseph Tyree Boyance, 35, whose whereabouts are presently unknown, an alleged "capper" who recruited patients to obtain prescriptions at Southfork.

This case is the product of an investigation by the Drug Enforcement Administration’s Los Angeles and Houston field divisions, Internal Revenue Service-Criminal Investigation, the Los Angeles Police Department, the California Department of Justice, and the Texas Department of Public Safety ...
/ 2015 News, Daily News
Isidro Santillan, 54, of Pacoima, was sentenced to three years in state prison and agreed to pay more than $133,000 in restitution to multiple victims. For more than two years Santillan embezzled over $100,000 from clients, pocketed premium money and created phony documents leaving his clients at great financial risk Santillan pleaded no contest to two felony counts of grand theft and multiple acts of embezzlement.

The Department of Insurance launched an investigation in late 2012 after receiving complaints about Santillan's business practices regarding the sale of commercial auto, general liability, and worker's compensation insurance and bonds. Some of his victims discovered canceled checks that exceeded the cost of the insurance policy they had agreed to purchase.

Investigators said that Santillan, aka Art Sanchez, issued premium checks that did not require the payer's signature, and then instead of sending these premiums to his clients' insurers, he cashed the checks for his own personal use. Santillan did not forward premium payments to purchase policies for his clients, which left his victims at risk for uninsured losses. Santillan attempted to cover up his theft by providing both falsified and legitimate certificates of insurance and premium finance agreements. In some instances, he allegedly made partial premium payments but the policies were later canceled by insurers due to lack of full payment.

This case was prosecuted by the Los Angeles County District Attorney's Office-Consumer Protection Unit ...
/ 2015 News, Daily News
Medical treatment reimbursement schemes continue to evolve over time. Decades ago, health practitioners we paid for "procedures" no matter how well they worked. The more procedures one was able to accomplish over time resulted in more revenue. This was a disincentive for quality, and a huge incentive for simple quantity. Today the emphasis is moving in the direction of higher payment for better outcomes. A recent article in Property Casualty 360 predicts this evolution to continue into workers' compensation this year.

Larger employers are developing outcome-based networks, not only for workers’ compensation, but for their group health as well. They’re contracting directly with the healthcare networks to ensure that their workers receive the best medical care and tying compensation to outcomes. We’re seeing a shift from a focus on price to programs with an understanding that better outcomes lead to increased productivity and overall lower costs.

Employers also are recognizing the importance of mental health to wellness. We’re seeing a wellness revolution more focused on the patient as a whole person and the importance of managing health both physically and mentally.

The evolving health care model is tied directly to an evolving viewpoint on disability management. More employers are realizing the importance of managing all disability, not just that associated with workers’ compensation claims. This integrated disability management model is reportedly the future of claims administration. Employers who retain risk on the workers’ comp side usually do the same thing with non-occupational, short-term and long-term disability.

Coventry advertises the most recent addition to its suite of network offerings, an Outcomes-based Network program aimed at identifying workers’ compensation providers who have been statistically shown to contribute to effective patient outcomes and controlled claims costs. The Outcomes-based Network was developed in response to the market’s desire for smaller occupational health focused networks whereby clients can increase utilization with doctors who are associated with their most desirable outcomes. The Outcomes-based Network claims to differ from other focused network offerings as it addresses the importance of identifying providers based on total claims outcomes.

Sedgwick embarked on a mission to create a truly outcomes-based network solution with two main components. Deploy the network solution throughout the daily claims and medical management process. Measure how medical providers are doing across a broad spectrum of data points by creating scorecards. In a recent evaluation of 107,000 claims, using high-scoring providers resulted in: 40% faster claim resolution, 61% less incurred expense, 62% less incurred medical expense and 73% less lost time days. A company white paper provides details of its approach.

Liberty Mutual has Outcomes Based Networks in fifteen states including California. Provider selection was based on an in-depth analysis of medical and return to work outcomes for point of entry providers and orthopedic surgeons and extensive field knowledge of regional medical directors and claims and managed care professionals for all other providers.

Yet others are not convinced that this new payment model will deliver as promised. Aaron E. Carroll, a professor of pediatrics who writes a column for the New York Times, said after reviewing the medical literature in 2014 that pay for performance in the U.S. and U.K. has brought "disappointingly mixed results." Sometimes even large incentives don't change the way doctors practice medicine. Sometimes incentives do change practice, but even when they do, clinical outcomes don't improve. Critics say that pay for performance is a technique borrowed from corporate management, where the main outcome of concern is profit.

Responding to public backlash to managed care in the 1990s, California health care plans and physician groups developed a set of quality performance measures and public "report cards", emerging in 2001 as the California Pay for Performance Program, now the largest pay-for-performance program in the country. Financial incentives based on utilization management were changed to those based on quality measures. Provider participation is voluntary, and physician organizations are accountable through public scorecards, and provided financial incentives by participating health plans based on their performance ...
/ 2015 News, Daily News
A Los Angeles County probation officer has been arrested and charged with two counts of worker's compensation insurance fraud after allegedly altering medical documentation, authorities said Tuesday.

Raymond Milton, who is assigned to a juvenile detention camp as a deputy probation officer, is expected to face two counts of insurance fraud for allegedly altering medical documents to dupe the county Probation Department out of more than $2,300 in sick time pay, officials said.

Milton, 41, was arrested Saturday afternoon and posted bail the next day, according to Sheriff’s Department records.

The Probation Department has been cracking down on insurance fraud and employee misconduct.

"Within the last year, the department added a Special Projects Team comprised of four supervisory level investigators," said Senior Probation Director Jennifer Kaufman. "These investigators are specially trained to recognize the signs of workers compensation and medical fraud." ...
/ 2015 News, Daily News
Workers' Compensation Judge Pamela A Pulley has been appointed to the position of Presiding Judge at the Santa Ana district office of the Workers' Compensation Appeals Board. .

Judge Pully received her undergraduate degree from Northwestern University from 1983 to 1987 and then her law degree from the University of Connecticut School of Law between 1987 and 1990.

She began her law career as an Associate Attorney with the Cantrell, Green, firm in Long Beach for ten years between 1991 and 2001 in Long Beach. She was then an Associate Attorney with Prindle, Decker and Amaro for four years between 2001and 2005

She has been a Workers' Compensation Administrative Law Judge February 2005 until her current appointment as the Presiding Workers' Compensation Judge ...
/ 2015 News, Daily News
Santa Barbara County District Attorney Joyce E. Dudley announced the arrest of local business owner Alberto "Al" Rodriguez, his wife Maria Rodriguez, and Byron Duran. Rodriguez and his wife own United Seal Coating, also known as United Sealcoating and Slurry Seal, Inc., United Paving, and Santa Barbara Paving. Duran is a long-time employee of the company.

The complaint filed by the District Attorney's Office alleges 42 felony counts which include violations of the California Unemployment Insurance Code, Workers' Compensation Premium Fraud, Fraudulent Denial of Workers' Compensation Benefits, and Wage Theft. All three suspects are scheduled to appear for an arraignment in Department 8 of the Santa Barbara Superior Court on January 30, 2015.

The three suspects were arrested by detectives from the California Department of Insurance along with members of local law enforcement on January 14, 2015. The arrest of the three suspects was the result of an investigation by the California Department of Insurance Fraud Division, the Santa Barbara County District Attorney's Office, the Franchise Tax Board, the Employment Development Department, and the Division of Labor Standards Enforcement ...
/ 2015 News, Daily News
The WCIRB has released an update to its Analysis of Changes in Indemnity Claim Frequency report which was originally published in 2012 and last updated in December 2013. In prior reports, WCIRB researchers explored potential causes for the increases in claim frequency in California that have persisted since 2010 and that differ from the claim frequency experience of other states. Prior frequency reports have identified a number of factors influencing claim frequency including increases in cumulative injury claims, increases in smaller non-cumulative injury claims that may have been reported as medical-only in the past, increases in the proportion of indemnity claims relative to total claims, and increases in late-reported indemnity claims and the proportion of medical-only claims that later transition to indemnity.

In this latest update, WCIRB researchers studied the influencing factors driving recent claim frequency based on the most up-to-date data available. The WCIRB’s principal findings include:

1) Unlike in most other states over the last several years, California indemnity claim frequency has continued to increase as WCIRB data currently indicates increases of 3.2%, 3.9% and 0.9% in 2012, 2013, and 2014, respectively.
2) The number of late reported indemnity claims continues to increase, whereas the percentage of medical only claims reported after 18 months has generally remained stable since 2007.
3) The level of cumulative injury claims has continued to increase. Approximately 13% of indemnity claims are estimated to involve a cumulative injury in 2013 compared to approximately 8% in the 2005 to 2007 period.
4) The growth in cumulative injury claims beginning in 2009 has been concentrated in claims involving more serious injuries and multiple injured body parts. Both the proportion of cumulative injury claims involving indemnity benefits and the proportion involving injuries to multiple body parts have increased significantly since 2010.
5) Based on WCIRB surveys of cumulative injury claims, both the proportion of cumulative injury claims involving multiple insurers and the proportion involving attorney representation has increased in recent years. In addition, approximately two-thirds of surveyed claims were initially denied in part or in whole by the insurer and approximately 40% of claims, despite long-standing statutory limitation on the compensability of post-termination claims, were reported post-termination.
6) Shifts to a less hazardous composition of industries in California ("industrial mix") have historically driven claim frequency downward. The recent economic recovery in higher hazard industries such as construction and manufacturing has had the opposite impact. In 2013, rather than dampening claim frequency, shifting industrial mix is increasing claim frequency by approximately 1%.
7) The 2010 increase in frequency was greatest in industries that were most impacted by the recession (e.g. construction and real estate). Since 2010, relativities for higher-frequency industries such as agriculture, construction, and entertainment have increased while those for the lower-frequency industries such as real estate, professional services, and finance have declined.
8) The 2010 indemnity claim frequency increase was generally experienced across all California regions. Since that time, the increases have been concentrated in the Los Angeles area. Indemnity claim frequency increased an estimated 9% in the Los Angeles Basin region from 2010 to 2013 while, similar to the pattern shown in many other states, other California regions showed modest declines. By comparison, indemnity claim frequency in the Bay Area declined by 7% over the same period. The Los Angeles area also has experienced significantly higher numbers of cumulative injury claims and claims involving multiple body parts than other regions of California.
9) As the economy recovers, newer workers enter the system and are often more likely to be injured on the job than more experienced workers. The proportion of injured workers with less than 2 years of experience at their current job has grown by 8% from 2010 to 2014, suggesting the economic recovery is a significant driver of recent claim frequency increases.

The full Analysis of Changes in Indemnity Claim Frequency - January 2015 Update Report is available in the Research and Analysis section of the WCIRB website ...
/ 2015 News, Daily News
After 18 states enacted reforms to limit the prices paid to doctors for prescriptions they write and dispense, this WCRI study finds that physician-dispensers in Illinois and California discovered a new way to continue charging and to get paid two to three times the price of a drug when compared with pharmacies. The study identifies the mechanism that allows doctors in Illinois and California to dispense drugs from their offices at much higher prices when compared with pharmacies. Although this study uses data from two large states, it raises questions for all states where physician-dispensing prices are regulated.

The data used for this report came from payors that represented 46 and 51 percent of all medical claims, respectively, for California and Illinois. The detailed prescription transaction data were organized by calendar quarter so that for each quarter, all prescriptions filled for claims with dates of injury within 24 months of the observation quarter were included. On average for each of the quarters reported, WCRI included 219,572 prescriptions paid for 60,448 claims in California. The same figures were 43,034 prescriptions paid for 12,714 claims in Illinois. The detailed prescription data cover calendar quarters from the first quarter of 2010 though the first quarter of 2013 ...
/ 2015 News, Daily News
The world's biggest drugmakers face a new reality when it comes to U.S. pricing for their products as insurers use aggressive tactics to extract steep price discounts, even for the newest medications says an article in Reuters Health. Big Pharma executives acknowledged the depth of change this week during public presentations and interviews with Reuters at the J.P. Morgan Healthcare conference in San Francisco. Drugmakers have long relied on their ability to charge whatever they deemed appropriate in the U.S., the world’s most expensive healthcare system.

Industry advocates have defended those U.S. prices in the past as a way to recoup the billions of dollars spent on experimental drugs that fail and to offset discounts offered overseas. "There has definitely been increased price competition ... if a product is viewed as a commodity," Derica Rice, chief financial officer at Eli Lilly and Co, said in an interview. "Our goal is clinical differentiation."

Pascal Soriot, chief executive of AstraZeneca Plc warned investors that the pressure exerted by health insurers has expanded from medicines used to treat common maladies to the specialized fields, like cancer, where drugmakers have been able to charge their highest prices. "Payers will try to leverage their strengths to try and get pricing concessions because those agents are very expensive," Soriot said.

Many say the tide shifted with a campaign by insurers and pharmacy benefits companies against Gilead Sciences Inc's $84,000 hepatitis C treatment Sovaldi. The drug represented the first effective cure for hepatitis C and quickly raked in billions of dollars in sales within its first few months on the market in 2014. Sovaldi's cost is based on a 12-week treatment regime and amounts to $1,000 a pill. By contrast, the treatment costs about $57,000 in the U.K As soon as U.S. regulators approved Sovaldi's competitor, a treatment from AbbVie Inc last month, the country's largest pharmacy benefits manager Express Scripts Co dropped reimbursement for the Gilead drug. Express Scripts said it had received a substantial discount from AbbVie, a departure from industry practice of pricing new competing drugs close to the incumbent for as long as possible. It didn't say how much the discount was. Express Scripts said this week it sought similar opportunities for discounts in new cancer medications, and was looking closely at a new class of cholesterol-fighting drugs aimed at millions of patients who can't tolerate or get enough benefit from widely-used statins. Amgen Inc and Regeneron Pharmaceuticals Inc are two of the companies racing to bring the new cholesterol treatments, which target a protein called PCSK9, to market. "It's not a worry. It's a reality that we will deal with," Regeneron CEO Len Schleifer said of Express Scripts' goals. "I think there will be fair pricing and healthy competition in the marketplace."

When pressed on how they could counter the growing pressure from insurers, large drugmakers say they are relying on strategies long employed in the marketplace, focusing research on diseases that don't have adequate treatments and finding ways to differentiate their products from competitors in terms of effectiveness and convenience. But some industry experts believe they will have to become far more selective even when entering a new treatment area. The hepatitis C example shows how insurers have been able to play just two competitors off one another to wrest a discount.

Gilead Chief Operating Officer John Milligan said that in recent weeks, more health plans are asking the company to drop its hepatitis C drug price more in line with AbbVie in order to keep both drugs on their reimbursement lists. "Payers are starting to move beyond hand-wringing to real action," said Glen Giovannetti, head of global life sciences at Ernst & Young. "We are starting to see (pharmaceutical) companies deciding which therapeutic options they want to compete in."

Nils Behnke, a partner with Bain and Co's global healthcare and strategy practices, noted that even for the most new promising classes of medications, there are often three or four companies pursuing similar development programs. "Companies that were heavily into specialty indications thought they were immune, but it is now clear that they are not," he said

Merck and Co CEO Kenneth Frazier acknowledged that U.S. prices for diabetes drugs remain under pressure. "We need to identify a value proposition ... show that over time we can reduce costs," he said in an interview.

Smaller biotech Isis Pharmaceuticals Inc said it is already taking into account potential competition when deciding which research programs to pursue. CEO Stanley Crooke said the company abandoned its PCSK9 program when it became clear the drug would reach the market only after several others. "We are working on diseases for which there are no real treatments -- Parkinson's, Alzheimer's, ALS," said George Scangos, CEO at Biogen-Idec. "In the future, we will see more correlation between value that drugs deliver and the way they are reimbursed." ...
/ 2015 News, Daily News
A three-month investigation ended this week with the arrests of a doctor’s office manager, a pharmacy technician and two other suspects in connection with a prescription drug ring that authorities say put more than 50,000 prescription narcotic pills on the streets of Modesto in the past year. According to the report in the Modesto Bee, blank prescription pads were being stolen from a pain management clinic, forged by members of the ring and filled at a Modesto CVS Pharmacy, said Chris Adams, an officer with the Modesto Police Department Narcotics Enforcement Team. The pills, most of them highly addictive, opiate-based drugs such as oxycodone and hydrocodone, were then sold on the street, police say. "Hydrocodone has a street value of $3 to $5 (per pill), and oxycodone can sell for up to $40 for an 80 mg pill," Adams said.

After an anonymous tip in November, investigators learned that nearly 300 fraudulent prescriptions had been filled in the past year using six fictitious names and eight real names. Tuesday, MNET officers, with the assistance of the police Street Gang Unit, detectives and agents of the federal Drug Enforcement Administration, served search warrants at the CVS Pharmacy in McHenry Village, Central Valley Pain Management on Mable Avenue, and three homes in Modesto and one in Hughson. During the searches, officers seized more than 2,800 prescription pills, two loaded firearms, a high-capacity magazine, $1,000 in cash and several fraudulent and blank prescription pads, Adams said.

Arrested were Christina Martinez, 27; Lance Wilson, 30; and Mona Chavarin, 43, all of Modesto; and Lenele Nunez, 31, of Hughson. All are out of custody on bail. Chavarin is a licensed pharmacy technician, according to public records from the Department of Consumer Affairs, Board of Pharmacy.

Dr. Patrick Rhoades, owner of Central Valley Pain Management, said Wednesday that he is "in shock" over the arrest of his office manager, Nunez. "I had complete and total trust in her," he said. "I thought she would never be the type of person who would do that. This is just beyond me." Nunez had worked at Central Valley Pain Management for a number of years, starting out analyzing drug tests, advancing to become Rhoades’ medical assistant, then being promoted to office manager several years ago. "She had gained my trust greatly," Rhoades said. "In the last few years, she was performing admirably, many things in our office were running smoother than ever before." He said Nunez came to work in the morning Tuesday but then said she had to leave to address an issue with her children. She never returned.

Sgt. Kelly Rea, who supervises MNET, said prescription medication abuse and theft are on the rise. "We are seeing more and more of these cases come through our office," he said. "It’s alarming how many people are becoming addicted to these pills, and moving right into other highly addictive drugs, such as heroin."

Mike DeAngelis, a spokesman for CVS Pharmacy, responded by email to The Bee’s request for comment. "Prescription fraud is a serious criminal offense that we work hard to prevent," he wrote. "We have been and continue to fully cooperate with the authorities in the investigation of our employee’s alleged activities. As this is an ongoing investigation, we cannot comment further on the allegations and defer to the Modesto Police Department for any additional comments."

All of the suspects were arrested on 286 counts of forged prescriptions, 286 counts of prescription fraud, 286 counts of fraud, 286 counts of commercial burglary, 181 counts of identity theft and conspiracy, authorities said. Martinez also was arrested on suspicion of possession of a controlled substance for sale, transportation of a controlled substance, being armed in the commission of felony, and felony child endangerment because one of the guns seized was accessible to a child. Wilson also was arrested on suspicion of possession of a controlled substance for sale, being armed in the commission of felony, being a felon in possession of a firearm and possession of high capacity magazine ...
/ 2015 News, Daily News
Floyd, Skeren and Kelly is pleased to announce our 2015 Northern California Employment Law Conference, set for January 30, 2015 at the Hilton Garden Inn, 1800 Powell Street Emeryville. We will feature as our Keynote Speaker Dale Brodsky, Esq., Councilmember of the California Fair Employment and Housing Council.

The Conference will cover important workplace topics related to the Interactive Process, Disability Leave, Pregnancy Leave, the Affordable Care Act, Workers’ Compensation and the crossover issues related to the Fair Employment Act, and much more. Some of the topics covered are:

1) Understanding the Numerous, and Often Overlapping, California Leave Laws
2) An Overview of Proposed Regulatory Changes to the California Family Rights Act
3) Guidance on Preventing a Straightforward Workers’ Compensation Case from Turning Into a FEHA Nightmare
4) Mastering the Complexities of Pregnancy Leave: How Much Time is Required by Law and Why it Could be More Than 7 Months
5) An Affordable Care Act Update for Employers: What Changed as of January 1, 2015, Employer Responsibilities
6) Overview of New California Employment Laws in Effect as of January 2015
7) Reduce Work Comp Costs: Avoid Seven Common Mistakes

This conference will include helpful information for employers, supervisors, managers, claims adjusters, risk managers, attorneys and any other professional associated with human resources and employment law. For more information and to register visit us at: FSK HR TRAINING.

This program, has been approved for 7 (HR (General)) recertification credit hours toward PHR, SPHR and GPHR recertification through the HR Certification Institute. We will release the program number the day of the training in your materials, please be sure to note the program ID number on your recertification application form. For more information about certification or recertification, please visit the HR Certification Institute website at www.hrci.org ...
/ 2015 News, Daily News
Workers compensation claim frequency for health care workers declined by about 1% in 2014, but comp claim severity among medical workers increased 2% last year as health systems say they struggle with safety procedures that can reduce worker injuries, Aon Risk Solutions said in a report released Tuesday.

The findings were published in Aon’s annual Health Care Workers Compensation Barometer report, which surveyed 44 health care systems representing 1,150 medical facilities nationwide.

Among health care employers surveyed by Aon, 42% said their largest workplace safety concern is patient management, which includes lifting and handling of patients. About 74% of respondents said they have a safe patient handling program in place to help protect patients and employees from accidents, while 26% said they have no such program. Home Health Care Aide occupation has the highest average indemnity cost among workers compensation claims. This is potentially due to patient management.

"Health care systems with successful safe patient handling programs have found they can significantly reduce the number of employee injuries and lost work days from injuries," the report said. "Safe patient handling has been associated with not only fewer injuries but also a decrease in the severity of injuries."

Among health care employers that have safe handling programs, 88% said they are satisfied with the program but are concerned about the sustainability of such initiatives, Aon said. Twelve percent of respondents said they’re not satisfied with their safe patient handling programs.

"Many safe patient or resident mobility programs stall because they fail to realize the importance of following a continuous improvement platform and drive greater results for all aspects of the program," the report said. "Any program should follow a defined process and strive to continually improve."

Among the eleven states profiled within the report, California ($2.18) has the highest projected loss rate for 2015; Tennessee ($0.48) has the lowest projected loss rate for 2015. For the 2015 accident year, Aon projects that health care facilities will experience an annual loss rate of $0.75 per $100 of payroll. This projection applies at the countrywide level and is made assuming a $500,000 per occurrence limit ...
/ 2015 News, Daily News