The Division of Workers’ Compensation has posted the 2015 DWC Audit and Enforcement Unit annual report on its website. The annual report provides information on how claims administrators audited by the DWC performed and includes the Administrative Director’s ranking report for audits conducted in calendar year 2014.
The 2015 Audit and Enforcement Unit annual report details the results of audits conducted in 2014 and provides the name and location of each insurer, self-insured employer and third-party administrator audited during that time. This report to the Legislature summarizes audits conducted in accordance with Labor Code §§129 & 129.5 to assure that injured workers, and their dependents in the event of their death, are provided with all benefits due them in an expeditious manner. The audit findings, by law, must detail the number of files audited, the number and type of violations cited and the amount of an undisputed compensation found due and unpaid to the injured worker.
Performance of insurers, self-insured employers, and third party administrators subject to profile audit review and full compliance audit is rated in accordance with the performance standards set annually by the Administrative Director. The DWC Administrative Director’s 2015 Audit Ranking Report lists, in ascending order by performance rating, the administrators audited in calendar year 2014.
The DWC Audit Unit completed a total of 47 profile audit reviews (PAR audits). Of the PAR audits, 46 were routinely selected, and 1 was a target audit, which was conducted based upon failure of a prior audit. Forty audit subjects (85%) met or exceeded the PAR 2014 performance standard and therefore had no penalty citations assessed. Seven audit subjects (15%) failed to meet or exceed the PAR standard, and their audits expanded into a full compliance audit of indemnity claims (FCA stage 1). Three of these audit subjects (43% of those failing to meet or exceed the PAR standard) met or exceeded the FCA 2014 performance standard. The remaining four of the seven audit subjects (57% of those failing to meet or exceed the PAR standard) failed to meet or exceed the FCA 2014 performance standard, and their audits expanded into a full compliance audit of indemnity claims (FCA stage 2) and added a sample of denied claims to be audited.
The DWC Administrative Director’s 2014 Audit Ranking Report (Statewide Exhibit 4) is part of this annual report. The Ranking Report provides the performance ratings for the 47 audit subjects listed in order, from the best to worst performer ...
The 2015 Audit and Enforcement Unit annual report details the results of audits conducted in 2014 and provides the name and location of each insurer, self-insured employer and third-party administrator audited during that time. This report to the Legislature summarizes audits conducted in accordance with Labor Code §§129 & 129.5 to assure that injured workers, and their dependents in the event of their death, are provided with all benefits due them in an expeditious manner. The audit findings, by law, must detail the number of files audited, the number and type of violations cited and the amount of an undisputed compensation found due and unpaid to the injured worker.
Performance of insurers, self-insured employers, and third party administrators subject to profile audit review and full compliance audit is rated in accordance with the performance standards set annually by the Administrative Director. The DWC Administrative Director’s 2015 Audit Ranking Report lists, in ascending order by performance rating, the administrators audited in calendar year 2014.
The DWC Audit Unit completed a total of 47 profile audit reviews (PAR audits). Of the PAR audits, 46 were routinely selected, and 1 was a target audit, which was conducted based upon failure of a prior audit. Forty audit subjects (85%) met or exceeded the PAR 2014 performance standard and therefore had no penalty citations assessed. Seven audit subjects (15%) failed to meet or exceed the PAR standard, and their audits expanded into a full compliance audit of indemnity claims (FCA stage 1). Three of these audit subjects (43% of those failing to meet or exceed the PAR standard) met or exceeded the FCA 2014 performance standard. The remaining four of the seven audit subjects (57% of those failing to meet or exceed the PAR standard) failed to meet or exceed the FCA 2014 performance standard, and their audits expanded into a full compliance audit of indemnity claims (FCA stage 2) and added a sample of denied claims to be audited.
The DWC Administrative Director’s 2014 Audit Ranking Report (Statewide Exhibit 4) is part of this annual report. The Ranking Report provides the performance ratings for the 47 audit subjects listed in order, from the best to worst performer ...
Barry Frank Evans of Hancock Park, CA, passed away peacefully on January 25, 2016 at the young age of 90 years. As a "giant" in the workers compensation legal community, he practiced as a defense attorney representing industry, employers and insurance companies in the defense of industrial injury claims before the Workers Compensation Appeals Board for over 60 years. During his many years of legal practice, he represented large self-insured employers [like Bethlehem Steel, Northrup Corporation and Bank of America], national insurance companies [such as Liberty Mutual , Home Insurance , Homeland Insurance, Fireman’s Fund, Industrial Indemnity; Republic Insurance Company , Tokio Marine and many more] in the California state workers compensation system; shipping and marine-based companies in the defense of Longshore & Harbor Workers’ claims; and esoteric claims under the Defense Base Act arising out of civil activities on military installations throughout the world, especially in the Middle East. For the last ten years of practice, Barry switched sides of the practice, with the urging of his partner, Mark Malter, and represented injured workers in California, for whom he had great compassion.
With respect to advanced educational training, Barry attended Harvard University from 1944 to 1947 as an undergraduate, receiving an Associate Bachelor’s degree. As an involved student, he was a member of Hasty Pudding [the theatrical group at Harvard], and participated in numerous productions. His class and peer group at Harvard included Jack Lemmon, Charlie Chaplin, and Robert Kennedy. At the same time, he enlisted in the U.S. Navy in 1944 as an officer [Lieutenant JG] and served during World War II, remaining in the US Naval Reserves from 1946 through 1959. He attended Boston University School of Law from 1947 to 1949, graduating with an LLB in an accelerated law program. He was admitted to the Massachusetts Bar Association in 1949 and the California Bar in 1953.
His first major employment was with Employers' Group Insurance Company in 1951 handling insurance claims, and then he commenced the practice of law in January 1953 with the firm of Herlihy & Herlihy in Los Angeles practicing Workers' Compensation Defense. He later joined Willian T. Hays and John F. McLaughlin establishing a Workers' Compensation Defense Firm.
Barry was a leader amongst his peers, joining the ranks of historic law firms in the industry. From his original position as an associate with the old firm of Herlihy & Herlihy, he then created his own firms of Hays, Laughlin & Evans, which then morphed into Laughlin, Evans, Dalbey & Cumming and then Evans, Dalbey & Cumming. Barry Evans, Blair Dalbey and Ray Cumming were partners for over 25 years before they brought in some younger attorneys, at which point the law firm developed into Evans, Cumming & Malter, and eventually Evans & Malter. During the growth of Evans, Cumming & Malter, the firm had five offices statewide [from San Diego to San Jose], with 27 attorneys and 89 support staff. Barry Evans was president of the California Workers Compensation Defense Association, and was a frequent speaker for major industry groups, such as California Manufactures Association, California Self-Insureds Association, and the IAIABC [International Association of Industrials Accident Boards and Commissions]. From 1977 through 1986, he authored and recorded audio books for a lecture series on legal developments in workers compensation with Eugene Marias of Rose, Klein & Marias, Charles Lawrence Swezey, and Melvin Witt [founder of the California Worker’s Compensation Reporter (CWCR) for CEB [California’s Continuing Education of the Bar]. Throughout his career, he presented and argued numerous cases before the Workers Compensation Appeals Board, the California Court of Appeal, and the California Supreme Court. It was not uncommon for Barry to be invited by various industry leaders to author amicus [“friend of the court”] briefs on major issues presented to the Supreme Court including the cases of Wilkinson [which established the proper rating of disability for successive injuries]; Hegglin and the cases that challenged the constitutionality of Labor Code Section 5500.5.
However, the lasting impact that Barry Evans has left to this world and upon our memories is not the legal results of his litigation prowess, but rather the depth of human contact with such a loving and caring man. Barry was honored and revered by many, but he was deeply loved by a special few: his dedicated wife, his very special children and grandchildren that he adored; his partner to which he was like a father; his friends who will forever laugh at his jokes and remember his cherubic smile, and the many staff members for whom he cared and gave support. We know that Barry is in heaven looking down upon us all with a loving smile, and a chuckle under his breath.
He is survived by his loving wife of 67 years, Harriett Lillian Evans; children: Joan Mindy Fay and Neil C. Evans; his son David S. Evans predeceased him in 2001; and seven grandchildren: Elliott, Rachael, Andrew, Michael, Ashlyn, Brandon and Brooke. A memorial service will be held at 12:00 noon, Friday, January 29, 2016, at Hillside Memorial Park Cemetery located at 6001 West Centinela Avenue in Culver City, CA; and he shall be laid to rest next to his son, David Evans, and his daughter-in-law, Marsha Evans ...
With respect to advanced educational training, Barry attended Harvard University from 1944 to 1947 as an undergraduate, receiving an Associate Bachelor’s degree. As an involved student, he was a member of Hasty Pudding [the theatrical group at Harvard], and participated in numerous productions. His class and peer group at Harvard included Jack Lemmon, Charlie Chaplin, and Robert Kennedy. At the same time, he enlisted in the U.S. Navy in 1944 as an officer [Lieutenant JG] and served during World War II, remaining in the US Naval Reserves from 1946 through 1959. He attended Boston University School of Law from 1947 to 1949, graduating with an LLB in an accelerated law program. He was admitted to the Massachusetts Bar Association in 1949 and the California Bar in 1953.
His first major employment was with Employers' Group Insurance Company in 1951 handling insurance claims, and then he commenced the practice of law in January 1953 with the firm of Herlihy & Herlihy in Los Angeles practicing Workers' Compensation Defense. He later joined Willian T. Hays and John F. McLaughlin establishing a Workers' Compensation Defense Firm.
Barry was a leader amongst his peers, joining the ranks of historic law firms in the industry. From his original position as an associate with the old firm of Herlihy & Herlihy, he then created his own firms of Hays, Laughlin & Evans, which then morphed into Laughlin, Evans, Dalbey & Cumming and then Evans, Dalbey & Cumming. Barry Evans, Blair Dalbey and Ray Cumming were partners for over 25 years before they brought in some younger attorneys, at which point the law firm developed into Evans, Cumming & Malter, and eventually Evans & Malter. During the growth of Evans, Cumming & Malter, the firm had five offices statewide [from San Diego to San Jose], with 27 attorneys and 89 support staff. Barry Evans was president of the California Workers Compensation Defense Association, and was a frequent speaker for major industry groups, such as California Manufactures Association, California Self-Insureds Association, and the IAIABC [International Association of Industrials Accident Boards and Commissions]. From 1977 through 1986, he authored and recorded audio books for a lecture series on legal developments in workers compensation with Eugene Marias of Rose, Klein & Marias, Charles Lawrence Swezey, and Melvin Witt [founder of the California Worker’s Compensation Reporter (CWCR) for CEB [California’s Continuing Education of the Bar]. Throughout his career, he presented and argued numerous cases before the Workers Compensation Appeals Board, the California Court of Appeal, and the California Supreme Court. It was not uncommon for Barry to be invited by various industry leaders to author amicus [“friend of the court”] briefs on major issues presented to the Supreme Court including the cases of Wilkinson [which established the proper rating of disability for successive injuries]; Hegglin and the cases that challenged the constitutionality of Labor Code Section 5500.5.
However, the lasting impact that Barry Evans has left to this world and upon our memories is not the legal results of his litigation prowess, but rather the depth of human contact with such a loving and caring man. Barry was honored and revered by many, but he was deeply loved by a special few: his dedicated wife, his very special children and grandchildren that he adored; his partner to which he was like a father; his friends who will forever laugh at his jokes and remember his cherubic smile, and the many staff members for whom he cared and gave support. We know that Barry is in heaven looking down upon us all with a loving smile, and a chuckle under his breath.
He is survived by his loving wife of 67 years, Harriett Lillian Evans; children: Joan Mindy Fay and Neil C. Evans; his son David S. Evans predeceased him in 2001; and seven grandchildren: Elliott, Rachael, Andrew, Michael, Ashlyn, Brandon and Brooke. A memorial service will be held at 12:00 noon, Friday, January 29, 2016, at Hillside Memorial Park Cemetery located at 6001 West Centinela Avenue in Culver City, CA; and he shall be laid to rest next to his son, David Evans, and his daughter-in-law, Marsha Evans ...
Novartis wants every puff of its emphysema drug Onbrez to go into the cloud. The Swiss drugmaker has teamed up with U.S. technology firm Qualcomm to develop an internet-connected inhaler that can send information about how often it is used to remote computer servers known as the cloud.
According to the report in Reuters Health, this kind of new medical technology is designed to allow patients to keep track of their drug usage on their smartphones or tablets and for their doctors to instantly access the data over the web to monitor their condition.
It also creates a host of "Big Data" opportunities for the companies involved - with huge amounts of information about a medical condition and the efficacy of a drug or device being wirelessly transmitted to a database from potentially thousands, even millions, of patients. The potential scale of the so-called "Medical Internet of Things" has not been lost on pharmaceutical and tech firms around the world, both big companies hunting growth and smaller ones looking to provide bespoke products and services.
It has created unlikely alliances. Novartis' domestic rival Roche has also teamed up with Qualcomm and Danish diabetes drugmaker Novo Nordisk has partnered with IBM on cloud-linked device projects, for example, while healthcare device maker Medtronic is working with a U.S. data-analytics firm Glooko. GlaxoSmithKline, meanwhile, is in talks with Qualcomm about a medical technology joint venture potentially worth up to $1 billion, according to people familiar with the matter.
However, with the opportunity comes risk. Security experts warn that hacked medical information can be worth more than credit card details on the black market as fraudsters can use it to fake IDs to buy medical equipment or drugs that can be resold, or file bogus insurance claims. The U.S. Centers for Disease Control and Prevention estimates there are 35 million U.S. hospital discharges a year, a billion doctor and hospital visits and even more prescriptions, much of which is stored in cloud databases.
Now the "Medical Internet of Things" is introducing more and more web-connected devices into the equation and pushing even more confidential patient data on to the cloud. This is creating potential new opportunities for thieves seeking to penetrate medical companies' security where they may target names, birth dates, policy numbers, billing data and the diagnosis codes needed to obtain drugs, say experts.
Novartis aims to have its inhaler for chronic lung disease, to be on the market by 2019. Other pharma-tech alliances include Aerocrine and Microsoft, which are working together on a cloud project to analyze data from allergy and asthma patients. Google is, meanwhile, working with French drugmaker Sanofi to collect and analyze information from diabetes sufferers. The U.S. tech giant also has a partnership with Novartis to develop a smart contact lens that can monitor diabetics' glucose levels.
All the companies involved in such projects say they are going to extreme lengths to protect patients' data from hackers ...
According to the report in Reuters Health, this kind of new medical technology is designed to allow patients to keep track of their drug usage on their smartphones or tablets and for their doctors to instantly access the data over the web to monitor their condition.
It also creates a host of "Big Data" opportunities for the companies involved - with huge amounts of information about a medical condition and the efficacy of a drug or device being wirelessly transmitted to a database from potentially thousands, even millions, of patients. The potential scale of the so-called "Medical Internet of Things" has not been lost on pharmaceutical and tech firms around the world, both big companies hunting growth and smaller ones looking to provide bespoke products and services.
It has created unlikely alliances. Novartis' domestic rival Roche has also teamed up with Qualcomm and Danish diabetes drugmaker Novo Nordisk has partnered with IBM on cloud-linked device projects, for example, while healthcare device maker Medtronic is working with a U.S. data-analytics firm Glooko. GlaxoSmithKline, meanwhile, is in talks with Qualcomm about a medical technology joint venture potentially worth up to $1 billion, according to people familiar with the matter.
However, with the opportunity comes risk. Security experts warn that hacked medical information can be worth more than credit card details on the black market as fraudsters can use it to fake IDs to buy medical equipment or drugs that can be resold, or file bogus insurance claims. The U.S. Centers for Disease Control and Prevention estimates there are 35 million U.S. hospital discharges a year, a billion doctor and hospital visits and even more prescriptions, much of which is stored in cloud databases.
Now the "Medical Internet of Things" is introducing more and more web-connected devices into the equation and pushing even more confidential patient data on to the cloud. This is creating potential new opportunities for thieves seeking to penetrate medical companies' security where they may target names, birth dates, policy numbers, billing data and the diagnosis codes needed to obtain drugs, say experts.
Novartis aims to have its inhaler for chronic lung disease, to be on the market by 2019. Other pharma-tech alliances include Aerocrine and Microsoft, which are working together on a cloud project to analyze data from allergy and asthma patients. Google is, meanwhile, working with French drugmaker Sanofi to collect and analyze information from diabetes sufferers. The U.S. tech giant also has a partnership with Novartis to develop a smart contact lens that can monitor diabetics' glucose levels.
All the companies involved in such projects say they are going to extreme lengths to protect patients' data from hackers ...
The Division of Workers’ Compensation sent a reminder email message urging parties to use the revised version of the QME Form 105 that became effective October 1, 2015.
The QME Form 105 is used to request a panel Qualified Medical Evaluator (QME) examination for an unrepresented injured worker. Claims administrators are required to send the current form to injured workers when the claim is disputed or when there is a dispute to the Primary Treating Physician’s report.
The QME Form 105 and instructions for its completion are posted on the DWC website. A Spanish-language version of the form and instructions are also available. The old forms have been removed from the website.
The approved regulations simplified the QME Form 105 for unrepresented injured workers, which must still be mailed to the DWC Medical Unit for processing ...
The QME Form 105 is used to request a panel Qualified Medical Evaluator (QME) examination for an unrepresented injured worker. Claims administrators are required to send the current form to injured workers when the claim is disputed or when there is a dispute to the Primary Treating Physician’s report.
The QME Form 105 and instructions for its completion are posted on the DWC website. A Spanish-language version of the form and instructions are also available. The old forms have been removed from the website.
The approved regulations simplified the QME Form 105 for unrepresented injured workers, which must still be mailed to the DWC Medical Unit for processing ...
An article published in Business Insurance says that a U.S. Food and Drug Administration committee's vote in favor of approving a long-acting, rod-shaped drug implant to combat opioid addiction could mean added costs for workers compensation payers.
In a 12-5 vote last week, the FDA's Psychopharmacologic Drugs Advisory Committee approved Probuphine. The implant, by South San Francisco, California-based Titan Pharmaceuticals Inc. and Princeton, New Jersey-based Braeburn Pharmaceuticals, which is surgically inserted under the skin of the arm, can help reduce opioid dependence by delivering a daily dose of buprenorphine for up to six months.
Probuphine is a version of buprenorphine, which federal law classifies as a Schedule III controlled substance. Buprenorphine is a "widely accepted tool to help people taper from opioids" that already is available in tablet and film formulations, Mark Pew, senior vice president at Duluth, Georgia-based medical management company PRIUM, said in an email. "In a perfect world, the buprenorphine is added to discontinue the opioids, and then the buprenorphine is itself discontinued," Mr. Pew said. "However, since we don't live in a perfect world, often the buprenorphine stays long-term."
Titan Pharmaceuticals submitted a new drug application for Probuphine to the FDA in 2012, but the agency decided against approving the treatment since the dose provided was too low to be effective for patients new to buprenorphine treatment. This time around, the advisory committee expressed concerns about whether physicians would be sufficiently trained on surgically inserting the rod, saying "provider qualification and training should be better defined."
Mr. Pew said the implant could become a "long-term cost consideration" for workers comp payers. "If Probuphine becomes a long-term strategy for pain management, it could be a very expensive addition," Mr. Pew added. "If all other drugs were tapered appropriately, then the payer may be swapping one cost for another, and that may or may not be a cost-efficient swap."
The FDA, which is scheduled to make a decision by Feb. 27, isn't obligated to follow the committee's recommendation ...
In a 12-5 vote last week, the FDA's Psychopharmacologic Drugs Advisory Committee approved Probuphine. The implant, by South San Francisco, California-based Titan Pharmaceuticals Inc. and Princeton, New Jersey-based Braeburn Pharmaceuticals, which is surgically inserted under the skin of the arm, can help reduce opioid dependence by delivering a daily dose of buprenorphine for up to six months.
Probuphine is a version of buprenorphine, which federal law classifies as a Schedule III controlled substance. Buprenorphine is a "widely accepted tool to help people taper from opioids" that already is available in tablet and film formulations, Mark Pew, senior vice president at Duluth, Georgia-based medical management company PRIUM, said in an email. "In a perfect world, the buprenorphine is added to discontinue the opioids, and then the buprenorphine is itself discontinued," Mr. Pew said. "However, since we don't live in a perfect world, often the buprenorphine stays long-term."
Titan Pharmaceuticals submitted a new drug application for Probuphine to the FDA in 2012, but the agency decided against approving the treatment since the dose provided was too low to be effective for patients new to buprenorphine treatment. This time around, the advisory committee expressed concerns about whether physicians would be sufficiently trained on surgically inserting the rod, saying "provider qualification and training should be better defined."
Mr. Pew said the implant could become a "long-term cost consideration" for workers comp payers. "If Probuphine becomes a long-term strategy for pain management, it could be a very expensive addition," Mr. Pew added. "If all other drugs were tapered appropriately, then the payer may be swapping one cost for another, and that may or may not be a cost-efficient swap."
The FDA, which is scheduled to make a decision by Feb. 27, isn't obligated to follow the committee's recommendation ...
The Los Angeles County District Attorney’s Office announced that a 29-year-old man who portrayed a dancing hamster in car commercials pleaded no contest to insurance fraud.
Leroy Barnes, who was arrested in 2014, entered his no contest plea to one count each of insurance fraud and false statements regarding aid. Los Angeles County Superior Court Judge Norm Shapiro immediately sentenced Barnes to 90 days of electronic monitoring. Barnes also was ordered to perform 400 hours of community service and pay more than $24,000 in restitution.
Barnes, best known for playing one of the hip-hop hamsters in the popular Kia car commercials, received disability benefits between September 2010 and September 2011. During that time, Barnes claimed he was not employed but was actually working on the Kia commercials. He is also professionally known by the alternate names: Leroy 'Hypnosis' Barnes Jr.; Leroy Barnes Jr.; Leroy 'Hypnosis' Barnes; MoWii and the Rej3ctz
Barnes said he was struck and injured by a falling piece of ceiling in June 2010 while dancing for a theatrical production company, He then began receiving disability benefits from the Employment Development Department after seeing a doctor in July 2010. The doctor diagnosed Barnes with a sprain, strain and joint dysfunction of the thoracic spine and irritation to the eye. His disability claim was extended every few months because Barnes continued to say that he was hurt.
However Barnes began dancing intermittently in September 2010 and continued to dance until benefits ended in September 2011. In addition to the Kia commercial, he also worked as a backup dancer for pop stars Madonna, Kelly Rowland and Chris Brown, and a rap group called The Rej3ctz and assisted in recording the song Cat Daddy. During this same timeframe he collected $51,000 in workers' compensation benefits ...
Leroy Barnes, who was arrested in 2014, entered his no contest plea to one count each of insurance fraud and false statements regarding aid. Los Angeles County Superior Court Judge Norm Shapiro immediately sentenced Barnes to 90 days of electronic monitoring. Barnes also was ordered to perform 400 hours of community service and pay more than $24,000 in restitution.
Barnes, best known for playing one of the hip-hop hamsters in the popular Kia car commercials, received disability benefits between September 2010 and September 2011. During that time, Barnes claimed he was not employed but was actually working on the Kia commercials. He is also professionally known by the alternate names: Leroy 'Hypnosis' Barnes Jr.; Leroy Barnes Jr.; Leroy 'Hypnosis' Barnes; MoWii and the Rej3ctz
Barnes said he was struck and injured by a falling piece of ceiling in June 2010 while dancing for a theatrical production company, He then began receiving disability benefits from the Employment Development Department after seeing a doctor in July 2010. The doctor diagnosed Barnes with a sprain, strain and joint dysfunction of the thoracic spine and irritation to the eye. His disability claim was extended every few months because Barnes continued to say that he was hurt.
However Barnes began dancing intermittently in September 2010 and continued to dance until benefits ended in September 2011. In addition to the Kia commercial, he also worked as a backup dancer for pop stars Madonna, Kelly Rowland and Chris Brown, and a rap group called The Rej3ctz and assisted in recording the song Cat Daddy. During this same timeframe he collected $51,000 in workers' compensation benefits ...
Receiving Workers’ Compensation benefits has been associated with inferior outcomes after lumbar fusion. The purpose of this new study was to compare the outcomes of cervical disc arthroplasty between patients receiving and those not receiving Workers’ Compensation. The results were published in the Journal of Bone and Joint Surgery.
The researchers examined data on 189 patients who underwent cervical disc arthroplasty; 144 patients received workers' compensation while 45 did not. The researchers found:
1. The average patient-reported measures were significantly improved one year after surgery for both groups. Workers' compensation and non-workers compensation groups reported similar outcomes.
2. The rate of operations was similar between the two groups - 7.6 percent received workers' compensation compared with 13.3 percent of those who didn't receive workers compensation.
3. The complication rates were similar between the two groups - 2.8 percent for the workers compensation patients compared with 4.4 percent of the non-workers compensation patients.
4. The return to work rate was 77.7 percent for the workers compensation group and 79.4 percent for the non-workers compensation patients.
5. However, the patients receiving workers compensation reported significantly more days off - 145.2 days off - compared with the non-workers compensation patients who took off 61.9 days.
The researchers concluded that after cervical disc arthroplasty, patients receiving Workers’ Compensation had outcomes that were similar to those of patients not receiving Workers’ Compensation in terms of patient-reported outcomes, surgery-related complications, reoperations, and return-to-work status. But, patients receiving Workers’ Compensation remained off work for a longer interval than did patients not receiving Workers’ Compensation ...
The researchers examined data on 189 patients who underwent cervical disc arthroplasty; 144 patients received workers' compensation while 45 did not. The researchers found:
1. The average patient-reported measures were significantly improved one year after surgery for both groups. Workers' compensation and non-workers compensation groups reported similar outcomes.
2. The rate of operations was similar between the two groups - 7.6 percent received workers' compensation compared with 13.3 percent of those who didn't receive workers compensation.
3. The complication rates were similar between the two groups - 2.8 percent for the workers compensation patients compared with 4.4 percent of the non-workers compensation patients.
4. The return to work rate was 77.7 percent for the workers compensation group and 79.4 percent for the non-workers compensation patients.
5. However, the patients receiving workers compensation reported significantly more days off - 145.2 days off - compared with the non-workers compensation patients who took off 61.9 days.
The researchers concluded that after cervical disc arthroplasty, patients receiving Workers’ Compensation had outcomes that were similar to those of patients not receiving Workers’ Compensation in terms of patient-reported outcomes, surgery-related complications, reoperations, and return-to-work status. But, patients receiving Workers’ Compensation remained off work for a longer interval than did patients not receiving Workers’ Compensation ...
Armando Tavares had been employed by Luis Scattini & Sons for three to four years before his death. He worked as a tractor driver on a seasonal basis and drove a tractor approximately 10 hours a day. Tavares sometimes worked as many as 12 hours a day, and he was a dedicated and conscientious employee.
In 2011 while he was pressure washing the mud off the tractor and disc one morning while at work he told his foreman that he was having chest pain. He asked to use the restroom before he went to the doctor. He went into the portable toilet, but he did not come out. Co workers called 911 and first responders pronounced his death after resuscitation efforts failed. A pathology report indicated he died as a result of ischemic heart disease due to coronary artery atherosclerosis (heart attack due to hardening and narrowing of arteries which supply the heart muscle).
His widow and dependent children were awarded $320,000 in death benefits after a hearing that determined the death was AOE-COE. The WCJ based the finding on the opinion of two doctors who "agree that Mr. Tavares’[s] heart attack was caused by the physical strain he exerted while using the restroom facilities at work." Reconsideration was denied, and the award was affirmed by the court of appeal in the unpublished case of Star Insurance Company v WCAB and Maria Rosa Tavares.
Star Insurance asserted that this case presents an opportunity for the court to clarify whether workers’ compensation cases are exempt from the higher evidentiary standards set forth in the federal case of Daubert v. Merrell Dow Pharmaceuticals, Inc. (1993) 509 U.S. 579 (Daubert). Petitioner argues that the Daubert standard should be applied generally to workers’ compensation matters and particularly to the medical evidence in this case. The Daubert standard provides a rule of evidence regarding the admissibility of expert witnesses' testimony during United States federal legal proceedings. The Daubert standard is now the law in federal court and over half of the states. However the much lower Frye standard remains the law in some jurisdictions including California, Illinois, Maryland, New Jersey, Pennsylvania, and Washington.
After noting that the petitioner did not raise this evidentiary issue in its petition for reconsideration, and that Section 5904 provides: "The petitioner for reconsideration shall be deemed to have finally waived all objections, irregularities, and illegalities concerning the matter upon which the reconsideration is sought other than those set forth in the petition for reconsideration." Accordingly, petitioner may not raise the issue for the first time on in its petition for writ of review. (See Nicky Blair’s Restaurant v. Workers’ Comp. Appeals Bd. (1980) 109 Cal.App.3d 941, 959.)" The court went on to reject this contention on the merits.
"All hearings and investigations before the appeals board or a workers’ compensation judge are governed by [Division 4 of the Labor Code] and by the rules of practice and procedures adopted by the appeals board." (§ 5708.) The Board and workers’ compensation judges are not "bound by the common law or statutory rules of evidence and procedure . . . ." (Ibid.) Section 5709 provides: "No informality in any proceeding or in the manner of taking testimony shall invalidate any order, decision, award, or rule made and filed as specified in this division. No order, decision, award, or rule shall be invalidated because of the admission into the record, and use as proof of any fact in dispute, of any evidence not admissible under the common law or statutory rules of evidence and procedure." It is simply not the province of this court to establish evidentiary rules for workers’ compensation proceedings. (Cf. South Coast Framing, supra, 61 Cal.4th at p. 307.) ...
In 2011 while he was pressure washing the mud off the tractor and disc one morning while at work he told his foreman that he was having chest pain. He asked to use the restroom before he went to the doctor. He went into the portable toilet, but he did not come out. Co workers called 911 and first responders pronounced his death after resuscitation efforts failed. A pathology report indicated he died as a result of ischemic heart disease due to coronary artery atherosclerosis (heart attack due to hardening and narrowing of arteries which supply the heart muscle).
His widow and dependent children were awarded $320,000 in death benefits after a hearing that determined the death was AOE-COE. The WCJ based the finding on the opinion of two doctors who "agree that Mr. Tavares’[s] heart attack was caused by the physical strain he exerted while using the restroom facilities at work." Reconsideration was denied, and the award was affirmed by the court of appeal in the unpublished case of Star Insurance Company v WCAB and Maria Rosa Tavares.
Star Insurance asserted that this case presents an opportunity for the court to clarify whether workers’ compensation cases are exempt from the higher evidentiary standards set forth in the federal case of Daubert v. Merrell Dow Pharmaceuticals, Inc. (1993) 509 U.S. 579 (Daubert). Petitioner argues that the Daubert standard should be applied generally to workers’ compensation matters and particularly to the medical evidence in this case. The Daubert standard provides a rule of evidence regarding the admissibility of expert witnesses' testimony during United States federal legal proceedings. The Daubert standard is now the law in federal court and over half of the states. However the much lower Frye standard remains the law in some jurisdictions including California, Illinois, Maryland, New Jersey, Pennsylvania, and Washington.
After noting that the petitioner did not raise this evidentiary issue in its petition for reconsideration, and that Section 5904 provides: "The petitioner for reconsideration shall be deemed to have finally waived all objections, irregularities, and illegalities concerning the matter upon which the reconsideration is sought other than those set forth in the petition for reconsideration." Accordingly, petitioner may not raise the issue for the first time on in its petition for writ of review. (See Nicky Blair’s Restaurant v. Workers’ Comp. Appeals Bd. (1980) 109 Cal.App.3d 941, 959.)" The court went on to reject this contention on the merits.
"All hearings and investigations before the appeals board or a workers’ compensation judge are governed by [Division 4 of the Labor Code] and by the rules of practice and procedures adopted by the appeals board." (§ 5708.) The Board and workers’ compensation judges are not "bound by the common law or statutory rules of evidence and procedure . . . ." (Ibid.) Section 5709 provides: "No informality in any proceeding or in the manner of taking testimony shall invalidate any order, decision, award, or rule made and filed as specified in this division. No order, decision, award, or rule shall be invalidated because of the admission into the record, and use as proof of any fact in dispute, of any evidence not admissible under the common law or statutory rules of evidence and procedure." It is simply not the province of this court to establish evidentiary rules for workers’ compensation proceedings. (Cf. South Coast Framing, supra, 61 Cal.4th at p. 307.) ...
The former owner and operator of three medical clinics located in Los Angeles was sentenced to 78 months in prison for his role in a scheme that submitted more than $4.5 million in fraudulent claims to Medicare.
Hovik Simitian, 48, of Los Angeles, pleaded guilty to one count of conspiracy to commit health care fraud on Aug. 18, 2015, and was sentenced this month by U.S. District Court Judge Beverly Reid O’Connell of the Central District of California, who also ordered Simitian to pay $1,668,559 in restitution to Medicare.
Simitian owned and operated Columbia Medical Group Inc., Life Care Medical Clinic and Safe Health Medical Clinic, three medical clinics in Los Angeles. In connection with his guilty plea, Simitian admitted that from approximately February 2010 through June 2014, he and his co-conspirators paid illegal cash kickbacks to patient recruiters who brought Medicare beneficiaries to the clinics. Simitian also admitted that he and his co-conspirators then billed Medicare for lab tests and other services that were not medically necessary or were not actually provided to the Medicare beneficiaries, which they supported with false documentation they created. Simitian admitted that he submitted a total of $4,526,791 in false and fraudulent claims to Medicare and Medicare paid $1,668,559 on those claims.
The FBI and HHS-OIG investigated the case, which was brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office of the Central District of California. Trial Attorneys Blanca Quintero and Alexander F. Porter of the Criminal Division’s Fraud Section are prosecuting the case.
Assistant Attorney General Leslie R. Caldwell of the Justice Department’s Criminal Division, U.S. Attorney Eileen M. Decker of the Central District of California, Assistant Director in Charge David Bowdich of the FBI’s Los Angeles Division and Special Agent in Charge Chris Schrank of the U.S. Department of Health and Human Services Office of the Inspector General (HHS-OIG) Los Angeles Region made the announcement ...
Hovik Simitian, 48, of Los Angeles, pleaded guilty to one count of conspiracy to commit health care fraud on Aug. 18, 2015, and was sentenced this month by U.S. District Court Judge Beverly Reid O’Connell of the Central District of California, who also ordered Simitian to pay $1,668,559 in restitution to Medicare.
Simitian owned and operated Columbia Medical Group Inc., Life Care Medical Clinic and Safe Health Medical Clinic, three medical clinics in Los Angeles. In connection with his guilty plea, Simitian admitted that from approximately February 2010 through June 2014, he and his co-conspirators paid illegal cash kickbacks to patient recruiters who brought Medicare beneficiaries to the clinics. Simitian also admitted that he and his co-conspirators then billed Medicare for lab tests and other services that were not medically necessary or were not actually provided to the Medicare beneficiaries, which they supported with false documentation they created. Simitian admitted that he submitted a total of $4,526,791 in false and fraudulent claims to Medicare and Medicare paid $1,668,559 on those claims.
The FBI and HHS-OIG investigated the case, which was brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office of the Central District of California. Trial Attorneys Blanca Quintero and Alexander F. Porter of the Criminal Division’s Fraud Section are prosecuting the case.
Assistant Attorney General Leslie R. Caldwell of the Justice Department’s Criminal Division, U.S. Attorney Eileen M. Decker of the Central District of California, Assistant Director in Charge David Bowdich of the FBI’s Los Angeles Division and Special Agent in Charge Chris Schrank of the U.S. Department of Health and Human Services Office of the Inspector General (HHS-OIG) Los Angeles Region made the announcement ...
The Division of Workers’ Compensation has posted an order adjusting the Official Medical Fee Schedule (OMFS) to conform to changes in the Medicare payment system as required by Labor Code section 5307.1.
The CMS Medicare National Physician Fee Schedule Relative Value File that was initially released for the January 2016 update, and which was adopted by the Administrative Director’s order of November 30, 2015, has been revised by CMS to correct technical errors. The Administrative Director has adopted the revised RVU file for services rendered on or after January 1, 2016.
The Administrative Director has also adopted and posted the monthly Medi-Cal rates file update for physician-administered drugs, biologicals, vaccines or blood products, effective for services rendered on or after January 15, 2016.
The order adopting the updates, the text of regulations, and the Medi-Cal rates file can be found on the DWC website ...
The CMS Medicare National Physician Fee Schedule Relative Value File that was initially released for the January 2016 update, and which was adopted by the Administrative Director’s order of November 30, 2015, has been revised by CMS to correct technical errors. The Administrative Director has adopted the revised RVU file for services rendered on or after January 1, 2016.
The Administrative Director has also adopted and posted the monthly Medi-Cal rates file update for physician-administered drugs, biologicals, vaccines or blood products, effective for services rendered on or after January 15, 2016.
The order adopting the updates, the text of regulations, and the Medi-Cal rates file can be found on the DWC website ...
The total of all costs related to County of Los Angeles liability and workers' compensation claims increased by $45.0 million to $577.5 million, which represents an 8.4 percent increase over FY 2013-14. Hilda Solis, chair of the Los Angeles County Board of Supervisors, said in a statement that the increase is "an urgent call for introspection and action." She added that she was "particularly concerned" with the costs of defending the Sheriff’s Department in excessive-force and officer-involved shooting cases.
The County's Self-insured Workers’ Compensation Claim Administration Program is the largest local governmental program in the State of California. It is responsible for administering over 27,500 open workers’ compensation claims with approximately 11,000 new workers’ compensation claims reported annually. The Risk Manager's Message stated "as the largest risk cost driver for the County, the Workers’ Compensation system continues to be the main focus for this fiscal year.
The cost of county workers’ compensation claims rose from $342.2 million in 2014 to $359.3 million last year despite the decrease in claims by 395 to 10,550, which represents a 3.6 percent decrease over FY 2013-14. The increased cost of claims is attributed to the statutory increase in weekly permanent disability rates since medical expenses and temporary disability benefits showed modest decreases.
The Sheriff’s Department made up the largest share of those payouts, with $123.7 million in 2015, up from $110.6 million the year before. If that were not bad enough, the cost of lawsuits against the Los Angeles County Sheriff’s Department jumped 50% from 2014 to 2015 - an increase driven largely by multimillion-dollar payouts in excessive-force and jail death cases.
Medical expenses are the largest single component of the workers’ compensation program cost. During FY 2014-15, the Program received over 409,000 bills from medical service providers. Back in FY 2011-12, a PBM was established to improve the evaluation of drug therapies prescribed to County injured workers. Evaluating the final quarter of FY 2014-15 against program inception baseline data demonstrates the increased utilization of generic drugs to 78.7% (an increase of 18.4% over the baseline). Increased home delivery to 14.2% (an increase of 75.3% over the baseline). And increased PBM Network penetration to 92.5% (an increase of 35.2% over the baseline).
In FY 2012-13, pharmacists from the PBM identified significant use of costly compound medications on the workers’ compensation program. CEO staff utilized data mining capabilities provided by the PBM to identify questionable compound medication prescription patterns. In FY 2014-15, efforts continued to reduce the use and costs of unwarranted compound medication by focused utilization review protocols.
Employment Practices Liability (non-Workers’ Compensation) claims increased by 35 to 193, which represents a 22.1 percent increase over FY 2013-14. The cost of claims and lawsuits increased by $7.1 million to $21.1 million, which represents a 50.5 percent increase over FY 2013-14. Six claims had expenses greater than $500,000 and represented 35 percent of this total ($7.5 million). These allegations include wrongful termination, whistleblower, sexual harassment, and failure to promote ...
The County's Self-insured Workers’ Compensation Claim Administration Program is the largest local governmental program in the State of California. It is responsible for administering over 27,500 open workers’ compensation claims with approximately 11,000 new workers’ compensation claims reported annually. The Risk Manager's Message stated "as the largest risk cost driver for the County, the Workers’ Compensation system continues to be the main focus for this fiscal year.
The cost of county workers’ compensation claims rose from $342.2 million in 2014 to $359.3 million last year despite the decrease in claims by 395 to 10,550, which represents a 3.6 percent decrease over FY 2013-14. The increased cost of claims is attributed to the statutory increase in weekly permanent disability rates since medical expenses and temporary disability benefits showed modest decreases.
The Sheriff’s Department made up the largest share of those payouts, with $123.7 million in 2015, up from $110.6 million the year before. If that were not bad enough, the cost of lawsuits against the Los Angeles County Sheriff’s Department jumped 50% from 2014 to 2015 - an increase driven largely by multimillion-dollar payouts in excessive-force and jail death cases.
Medical expenses are the largest single component of the workers’ compensation program cost. During FY 2014-15, the Program received over 409,000 bills from medical service providers. Back in FY 2011-12, a PBM was established to improve the evaluation of drug therapies prescribed to County injured workers. Evaluating the final quarter of FY 2014-15 against program inception baseline data demonstrates the increased utilization of generic drugs to 78.7% (an increase of 18.4% over the baseline). Increased home delivery to 14.2% (an increase of 75.3% over the baseline). And increased PBM Network penetration to 92.5% (an increase of 35.2% over the baseline).
In FY 2012-13, pharmacists from the PBM identified significant use of costly compound medications on the workers’ compensation program. CEO staff utilized data mining capabilities provided by the PBM to identify questionable compound medication prescription patterns. In FY 2014-15, efforts continued to reduce the use and costs of unwarranted compound medication by focused utilization review protocols.
Employment Practices Liability (non-Workers’ Compensation) claims increased by 35 to 193, which represents a 22.1 percent increase over FY 2013-14. The cost of claims and lawsuits increased by $7.1 million to $21.1 million, which represents a 50.5 percent increase over FY 2013-14. Six claims had expenses greater than $500,000 and represented 35 percent of this total ($7.5 million). These allegations include wrongful termination, whistleblower, sexual harassment, and failure to promote ...
With a backlash brewing over the price of medicines in the United States, drugmakers are pushing back with a new message: Most people don't pay retail. Top executives from Eli Lilly, Merck and Biogen said in interviews with Reuters this week that the media focus on retail, or "list prices," for branded medications is misplaced. They stressed that the actual prices paid by prescription benefit managers, insurers and other large purchasers are reduced through negotiated discounts.
A couple of dramatic price hikes in 2015 exposed the whole industry to ongoing scrutiny in Congress and on Wall Street. Turing Pharmaceuticals raised the price of a generic anti-infective drug called Daraprim by 5,000 percent, and the larger Valeant Pharmaceuticals International raised the price on a heart drug Isuprel by more than 200 percent.
The largest drugmakers quickly portrayed those cases as outliers. But the industry practice of raising prices each year for treatments used by millions of people is attracting new attention.
Adam Schechter, Merck's president of Global Human Health, said the industry needs to better explain the value of drugs and how they can prevent healthcare costs down the line. "We have to explain the difference between the list price and the net price," he said in an interview.Toward that end, two drugmakers at the JP Morgan Healthcare Conference in San Francisco this week shared with Reuters some limited information on actual pricing.
Eli Lilly said the actual average price increase on Humalog, its injectable insulin used to treat diabetes, has been a modest 1 to 2 percent annually over the last five years. The company declined to provide a list price. Horizon Pharma plc, a small drugmaker, raised list prices across its business about 7 percent for this year, Chief Executive Tim Walbert said in an interview. But he said he expects the company's actual price increases to be 4 percent or less.
More recently, Pfizer, one of the world's largest drugmakers, raised U.S. list prices on more than 100 drugs as of Jan. 1, according to data from information services company Wolters Kluwer that was published last week by UBS Securities. The list included a 9.4 percent rise for pain drug Lyrica and a nearly 13 percent increase for erectile dysfunction drug Viagra. Pfizer said in an email the prices don't reflect "considerable discounts" to many payers, but did not provide examples of net prices.
Drugmakers keep actual pricing details close to guard their position in negotiations with commercial insurers and government health plans like Medicaid. There is no centralized catalog of U.S. list prices or rebates for medicines. That drug executives at the San Francisco conference allowed even a glimpse into their actual pricing strategies reflects the intensity of the new attention being paid to their practices.
The candor of some individual pharmaceutical executives follows earlier messaging by industry advocates. In a November blog post, the industry's main lobbying group PhRMA, reported that list prices grew 13 percent in 2014, but actual prices increased only 5 percent.
U.S. health insurers say that, even accounting for discounts, drug prices are rising at an unsustainable rate, and they are pressuring drugmakers for cuts. "Whether it's a gross number, or a net number, it is still astronomical," said Daniel Hilferty, chief executive of Independence Blue Cross, which operates in Pennsylvania and New Jersey ...
A couple of dramatic price hikes in 2015 exposed the whole industry to ongoing scrutiny in Congress and on Wall Street. Turing Pharmaceuticals raised the price of a generic anti-infective drug called Daraprim by 5,000 percent, and the larger Valeant Pharmaceuticals International raised the price on a heart drug Isuprel by more than 200 percent.
The largest drugmakers quickly portrayed those cases as outliers. But the industry practice of raising prices each year for treatments used by millions of people is attracting new attention.
Adam Schechter, Merck's president of Global Human Health, said the industry needs to better explain the value of drugs and how they can prevent healthcare costs down the line. "We have to explain the difference between the list price and the net price," he said in an interview.Toward that end, two drugmakers at the JP Morgan Healthcare Conference in San Francisco this week shared with Reuters some limited information on actual pricing.
Eli Lilly said the actual average price increase on Humalog, its injectable insulin used to treat diabetes, has been a modest 1 to 2 percent annually over the last five years. The company declined to provide a list price. Horizon Pharma plc, a small drugmaker, raised list prices across its business about 7 percent for this year, Chief Executive Tim Walbert said in an interview. But he said he expects the company's actual price increases to be 4 percent or less.
More recently, Pfizer, one of the world's largest drugmakers, raised U.S. list prices on more than 100 drugs as of Jan. 1, according to data from information services company Wolters Kluwer that was published last week by UBS Securities. The list included a 9.4 percent rise for pain drug Lyrica and a nearly 13 percent increase for erectile dysfunction drug Viagra. Pfizer said in an email the prices don't reflect "considerable discounts" to many payers, but did not provide examples of net prices.
Drugmakers keep actual pricing details close to guard their position in negotiations with commercial insurers and government health plans like Medicaid. There is no centralized catalog of U.S. list prices or rebates for medicines. That drug executives at the San Francisco conference allowed even a glimpse into their actual pricing strategies reflects the intensity of the new attention being paid to their practices.
The candor of some individual pharmaceutical executives follows earlier messaging by industry advocates. In a November blog post, the industry's main lobbying group PhRMA, reported that list prices grew 13 percent in 2014, but actual prices increased only 5 percent.
U.S. health insurers say that, even accounting for discounts, drug prices are rising at an unsustainable rate, and they are pressuring drugmakers for cuts. "Whether it's a gross number, or a net number, it is still astronomical," said Daniel Hilferty, chief executive of Independence Blue Cross, which operates in Pennsylvania and New Jersey ...
The U.S. Court of Appeals for the 9th Circuit affirmed an $8.6 million judgment in favor of Allstate Insurance Company against former Las Vegas chiropractor Obteen N. Nassiri.
Nassiri began defrauding Allstate in 2003 by exaggerating clinical findings, submitting improbable diagnoses, billing for services not rendered, providing unnecessary and excessive treatment, misrepresenting billing, making inappropriate referrals and exhibiting a general pattern of illegal and fraudulent conduct, according to the Allstate lawsuit, originally filed in 2008 in the U.S. District Court of Nevada.
The Chiropractic Physicians' Board of Nevada revoked Nassiri's license in 2010.
"Medical fraud drives up costs for everyone -- and in this case it was egregious fraud," said Melinda Wilson, an Allstate spokesperson. "This is a notice to every fraudster out there: Allstate is going to battle fraud wherever we find it to protect our policyholders and all consumers. We're gratified the courts in this case continue to help us fight that battle."
In June 2013, following a 10-day trial, the jury awarded $1.1 million in damages against Obteen N. Nassiri, Advanced Accident Chiropractic Care, ONN Management, Digital Imaging, and Digital X-Ray Services, LLC. Following the trial, the District Court trebled the damages under Federal and Nevada State RICO laws, increasing the award of damages to $3.5 million, and added pre-judgment interest of $1 million. Punitive damages, attorney fees, costs and additional pre-judgment interest were added to the award, increasing the total amount of the judgment to $8.6 million.
Nassiri was the only defendant who appealed the 2013 decision, arguing the District Court erred in admitting the testimony of Allstate's damages and in denying his motion for summary judgment. The appellate court rejected his contentions and upheld the jury's decision. The court concluded "Where the tort itself is of such a nature as to preclude the ascertainment of the amount of damages with certainty . . . it will be enough if the evidence show the extent of the damages as a matter of just and reasonable inference, although the result be only approximate." ...
Nassiri began defrauding Allstate in 2003 by exaggerating clinical findings, submitting improbable diagnoses, billing for services not rendered, providing unnecessary and excessive treatment, misrepresenting billing, making inappropriate referrals and exhibiting a general pattern of illegal and fraudulent conduct, according to the Allstate lawsuit, originally filed in 2008 in the U.S. District Court of Nevada.
The Chiropractic Physicians' Board of Nevada revoked Nassiri's license in 2010.
"Medical fraud drives up costs for everyone -- and in this case it was egregious fraud," said Melinda Wilson, an Allstate spokesperson. "This is a notice to every fraudster out there: Allstate is going to battle fraud wherever we find it to protect our policyholders and all consumers. We're gratified the courts in this case continue to help us fight that battle."
In June 2013, following a 10-day trial, the jury awarded $1.1 million in damages against Obteen N. Nassiri, Advanced Accident Chiropractic Care, ONN Management, Digital Imaging, and Digital X-Ray Services, LLC. Following the trial, the District Court trebled the damages under Federal and Nevada State RICO laws, increasing the award of damages to $3.5 million, and added pre-judgment interest of $1 million. Punitive damages, attorney fees, costs and additional pre-judgment interest were added to the award, increasing the total amount of the judgment to $8.6 million.
Nassiri was the only defendant who appealed the 2013 decision, arguing the District Court erred in admitting the testimony of Allstate's damages and in denying his motion for summary judgment. The appellate court rejected his contentions and upheld the jury's decision. The court concluded "Where the tort itself is of such a nature as to preclude the ascertainment of the amount of damages with certainty . . . it will be enough if the evidence show the extent of the damages as a matter of just and reasonable inference, although the result be only approximate." ...
A former El Dorado Hills man has pleaded guilty in federal court to using business funds for personal expenses.
Gregory J. Chmielewski, 46, of West Bend, Wisc., operated a business in Roseville and later Sacramento called Management Resources Group California LLC, which also went by the name Independent Management Resources.
The company was supposed to sell and manage workers' compensation insurance for companies, eventually paying money for valid claims. But Chmielewski spent funds that were supposed to be reserved for claims, and the company couldn’t cover claims. On Friday he pleaded guilty in Sacramento to two counts of mail fraud for transferring business funds to his own personal use.
According to the plea agreement, California workers' compensation insurance rates rose quickly in early 2003. Some entrepreneurs negotiated agreements with California Indian tribes to collaborate on business ventures to sell alternative insurance plans not subject to the state's insurance regulations because the ventures operated under the sovereign domestic nation status of the tribe. That’s what Chmielewski did.
Prosecutors say Chmielewski in 2003 set up Management Resources Group California LLC to sell workers' compensation insurance. Chmielewski then worked with Fort Independence Community of Paiute Indians near Death Valley to create a professional employer organization called Independent Staffing Solutions, managed by his Management Resources Group.
From 2004 through 2007, more than $225 million passed through Independent Staffing Solutions accounts. As part of managing Independent Staffing Solutions, Chmielewski promised to maintain a financial reserve to pay valid claims. But Chmielewski used $7.3 million of the money in reserve accounts for his own personal real estate investments.
Independent Management Resources went out of business in 2010 through a Chapter 7 bankruptcy liquidation, leaving about 117 injured workers with approximately $1.8 million in unpaid claims.
Chmielewski is scheduled to be sentenced on April 1, by U.S. District Judge Garland E. Burrell Jr. Chmielewski faces a maximum statutory penalty of 20 years in prison and a $250,000 fine or up to twice the gain or loss from the offense.
This case was investigated by the U.S. Postal Inspection Service, the IRS and the California Department of Insurance. Assistant U.S. Attorneys Heiko Coppola and Andre Espinosa were prosecutors ...
Gregory J. Chmielewski, 46, of West Bend, Wisc., operated a business in Roseville and later Sacramento called Management Resources Group California LLC, which also went by the name Independent Management Resources.
The company was supposed to sell and manage workers' compensation insurance for companies, eventually paying money for valid claims. But Chmielewski spent funds that were supposed to be reserved for claims, and the company couldn’t cover claims. On Friday he pleaded guilty in Sacramento to two counts of mail fraud for transferring business funds to his own personal use.
According to the plea agreement, California workers' compensation insurance rates rose quickly in early 2003. Some entrepreneurs negotiated agreements with California Indian tribes to collaborate on business ventures to sell alternative insurance plans not subject to the state's insurance regulations because the ventures operated under the sovereign domestic nation status of the tribe. That’s what Chmielewski did.
Prosecutors say Chmielewski in 2003 set up Management Resources Group California LLC to sell workers' compensation insurance. Chmielewski then worked with Fort Independence Community of Paiute Indians near Death Valley to create a professional employer organization called Independent Staffing Solutions, managed by his Management Resources Group.
From 2004 through 2007, more than $225 million passed through Independent Staffing Solutions accounts. As part of managing Independent Staffing Solutions, Chmielewski promised to maintain a financial reserve to pay valid claims. But Chmielewski used $7.3 million of the money in reserve accounts for his own personal real estate investments.
Independent Management Resources went out of business in 2010 through a Chapter 7 bankruptcy liquidation, leaving about 117 injured workers with approximately $1.8 million in unpaid claims.
Chmielewski is scheduled to be sentenced on April 1, by U.S. District Judge Garland E. Burrell Jr. Chmielewski faces a maximum statutory penalty of 20 years in prison and a $250,000 fine or up to twice the gain or loss from the offense.
This case was investigated by the U.S. Postal Inspection Service, the IRS and the California Department of Insurance. Assistant U.S. Attorneys Heiko Coppola and Andre Espinosa were prosecutors ...
An advance-fee scam is a type of fraud and one of the most common types of confidence trick. The scam typically involves promising the victim a significant share of a large sum of money, which the fraudster requires a small up-front payment to obtain. If a victim makes the payment, the fraudster either invents a series of further fees for the victim, or simply disappears.
There are many variations on this type of scam, including 419 scam, Fifo's fraud, Spanish Prisoner scam, the black money scam and the Detroit-Buffalo scam. The scam has been used with fax and traditional mail, and is now prevalent in online communications like emails.
Online versions of the scam originate primarily in the United States, the United Kingdom and Nigeria, with Ivory Coast, Togo, South Africa, the Netherlands, and Spain also having high incidences of such fraud. The scam messages often claim to originate in Nigeria, but usually this is not true. The number "419" refers to the section of the Nigerian Criminal Code dealing with fraud, the charges and penalties for offenders. Generally a victim will receive an email from someone in a foreign country who claims to have a stash of cash and needs your help to get the money out of the country into your bank account. In exchange for your help, you are to keep part of the money, which never arrives.
Now the advance-fee scam has a Workers' Compensation variant. A Chico woman has been arrested on suspicion of grand theft and elder abuse after accepting nearly $29,000 from an Illinois woman in a workers’ compensation scam. The woman, Sandra Freeman, 53, was arrested after Chico police detectives served a search warrant at her residence in the 2500 block of The Esplanade, according to a press release published in the Chicoer.
Detectives were said to have found evidence that Freeman had been accepting money orders, Western Union transactions and cash deliveries for more than year, according to the release. She would then allegedly wire the money to multiple locations in Nigeria.
The arrest stemmed from a report Chico police received Jan. 5 from the Danville Police Department in Illinois. The report outlined how a 72-year-old Danville woman had been the victim of an Internet scam. The woman, whose name was not given, received a private Facebook message from a person who was disguised as one of the woman’s friends. The message relayed that the woman was eligible to receive a $150,000 workers’ compensation settlement.
The woman was given a phone number spoke with an "attorney" who explained that to receive the settlement she would need to make payments to cover things like an "application, delivery fee, taxes, insurance and attorney’s fees," according to the release.
The woman, who felt comfortable talking to the unknown "attorney" because the information was provided by a person she thought was her Facebook friend, then sent five cash transactions to an address in Chico over the course of a month. The transactions totaled $28,700. The woman was told by the unknown person over the phone to mail the money to a Sandra Freeman. Chico police detectives then confirmed with the U.S. Postal Service that five envelopes were delivered to Freeman’s address on The Esplanade.
Following a search of Freeman’s home, she was booked at the Chico Police Department and taken to Butte County Jail ...
There are many variations on this type of scam, including 419 scam, Fifo's fraud, Spanish Prisoner scam, the black money scam and the Detroit-Buffalo scam. The scam has been used with fax and traditional mail, and is now prevalent in online communications like emails.
Online versions of the scam originate primarily in the United States, the United Kingdom and Nigeria, with Ivory Coast, Togo, South Africa, the Netherlands, and Spain also having high incidences of such fraud. The scam messages often claim to originate in Nigeria, but usually this is not true. The number "419" refers to the section of the Nigerian Criminal Code dealing with fraud, the charges and penalties for offenders. Generally a victim will receive an email from someone in a foreign country who claims to have a stash of cash and needs your help to get the money out of the country into your bank account. In exchange for your help, you are to keep part of the money, which never arrives.
Now the advance-fee scam has a Workers' Compensation variant. A Chico woman has been arrested on suspicion of grand theft and elder abuse after accepting nearly $29,000 from an Illinois woman in a workers’ compensation scam. The woman, Sandra Freeman, 53, was arrested after Chico police detectives served a search warrant at her residence in the 2500 block of The Esplanade, according to a press release published in the Chicoer.
Detectives were said to have found evidence that Freeman had been accepting money orders, Western Union transactions and cash deliveries for more than year, according to the release. She would then allegedly wire the money to multiple locations in Nigeria.
The arrest stemmed from a report Chico police received Jan. 5 from the Danville Police Department in Illinois. The report outlined how a 72-year-old Danville woman had been the victim of an Internet scam. The woman, whose name was not given, received a private Facebook message from a person who was disguised as one of the woman’s friends. The message relayed that the woman was eligible to receive a $150,000 workers’ compensation settlement.
The woman was given a phone number spoke with an "attorney" who explained that to receive the settlement she would need to make payments to cover things like an "application, delivery fee, taxes, insurance and attorney’s fees," according to the release.
The woman, who felt comfortable talking to the unknown "attorney" because the information was provided by a person she thought was her Facebook friend, then sent five cash transactions to an address in Chico over the course of a month. The transactions totaled $28,700. The woman was told by the unknown person over the phone to mail the money to a Sandra Freeman. Chico police detectives then confirmed with the U.S. Postal Service that five envelopes were delivered to Freeman’s address on The Esplanade.
Following a search of Freeman’s home, she was booked at the Chico Police Department and taken to Butte County Jail ...
A new study summarized in Reuters Health says that U.S. emergency rooms are increasingly running short on medications, including many that are needed for life-threatening conditions. Since 2008, the number of shortages has risen by more than 400 percent, researchers found. Half of all emergency room shortages were for life-saving drugs, and for one in 10 there were no available substitutes, they report in Academic Emergency Medicine. And a bad result in an emergency room can easily result in a higher workers' compensation claim cost in the long run.
Half of the individual shortage incidents had no explanation, the authors found. The rest had a variety of systemic causes that add up to a U.S. drug supply too low to meet public demand.
"Drug shortages are of particular concern in emergency care settings where providers must rapidly treat ill and injured patients," said lead author Kristy Hawley of the George Washington University School of Medicine and Health Sciences in Washington, D.C. "For most medications, substitutes exist but may not be as effective and may have more side effects, or providers may not have as much experience with them," she told Reuters Health by email.
The researchers looked at U.S. data on drug shortages between 2001 and 2014. The information came from hospital doctors' reports, and it's possible there were additional unreported shortages, the authors note. The number of shortages declined steadily between 2001 and 2007 but began a sharp, continual rise in 2008. Of the 1,798 shortages reported over the 13-year period, 610, or about one third, were for drugs used in emergency medicine. Over half of these were shortages of drugs used as lifesaving interventions or for high-risk conditions. The average shortage duration for emergency drugs was nine months.
Drugs for treating infections were the most common ones to run low, with 148 shortages. Painkillers and drugs for treating overdoses and poisonings were also among the most common shortages. Hawley noted that a particularly problematic shortage was for nalaxone, the only injectable treatment for opiate overdose.
In nearly half of shortage incidents, the manufacturer did not give a reason for the shortage when contacted. For shortages with a known reason, about a quarter were due to manufacturing problems or delays, around 15 percent were caused by market supply and demand issues and about 4 percent were from problems with raw materials.
In 2013, the U.S. Food and Drug Administration released a plan to combat drug shortages. Last spring, the agency also released a mobile app for doctors and pharmacists to search for information about drug shortages ...
Half of the individual shortage incidents had no explanation, the authors found. The rest had a variety of systemic causes that add up to a U.S. drug supply too low to meet public demand.
"Drug shortages are of particular concern in emergency care settings where providers must rapidly treat ill and injured patients," said lead author Kristy Hawley of the George Washington University School of Medicine and Health Sciences in Washington, D.C. "For most medications, substitutes exist but may not be as effective and may have more side effects, or providers may not have as much experience with them," she told Reuters Health by email.
The researchers looked at U.S. data on drug shortages between 2001 and 2014. The information came from hospital doctors' reports, and it's possible there were additional unreported shortages, the authors note. The number of shortages declined steadily between 2001 and 2007 but began a sharp, continual rise in 2008. Of the 1,798 shortages reported over the 13-year period, 610, or about one third, were for drugs used in emergency medicine. Over half of these were shortages of drugs used as lifesaving interventions or for high-risk conditions. The average shortage duration for emergency drugs was nine months.
Drugs for treating infections were the most common ones to run low, with 148 shortages. Painkillers and drugs for treating overdoses and poisonings were also among the most common shortages. Hawley noted that a particularly problematic shortage was for nalaxone, the only injectable treatment for opiate overdose.
In nearly half of shortage incidents, the manufacturer did not give a reason for the shortage when contacted. For shortages with a known reason, about a quarter were due to manufacturing problems or delays, around 15 percent were caused by market supply and demand issues and about 4 percent were from problems with raw materials.
In 2013, the U.S. Food and Drug Administration released a plan to combat drug shortages. Last spring, the agency also released a mobile app for doctors and pharmacists to search for information about drug shortages ...
Reuters Health reports that branded drug companies hammered out far fewer deals with generic drug makers to delay sales of cheaper medicines in the year after the Supreme Court ruled the Federal Trade Commission could legally pursue such agreements as potentially illegal.The FTC, which has fought the practice for years, said that pharmaceutical companies reached 21 of the "pay-for-delay" deals in fiscal 2014, compared with 29 in 2013 and a record 40 in 2012.
The Supreme Court ruling (Federal Trade Commission v. Actavis, 12-416) said in June 2013 that the deals could potentially be a violation of antitrust law but refused the FTC's request to declare them to be presumed to be illegal.
An FTC study concluded in 2010 that pay-to-delay costs consumers $3.5 billion a year in higher drug prices. Over the last decade, generic drugs have saved consumers more than $1 trillion. That figure could be a lot higher if pay-to-delay were banned. The FTC says 40 such deals were struck in fiscal 2012 alone.
In a typical pay-for-delay deal, a branded drug company will give a generic firm money or some other consideration in exchange for the generic firm's agreement to delay bringing out a cheaper version of the medicine.
The FTC said it was pleased with the drop in the number of the deals. "Although it is too soon to know if these are lasting trends, it is encouraging to see a significant decline in the number of reverse payment settlements," said Debbie Feinstein, director of the FTC’s Bureau of Competition, in a statement.
The FTC did not say which drug makers were involved in the 21 deals but did say that the 2014 agreements involved 20 different branded drugs with combined U.S. sales of about $6.2 billion.
Ten involved a cash payment, six involved compensation via a related business arrangement and five involved an agreement by the branded manufacturer to refrain from marketing a competing "authorized" generic for a certain period of time, the FTC said.
An FTC table said that there were three potential pay-for-delay deals in fiscal 2005, 14 the following two years and then a steady increase until 2012, when the number of deals hit 40 in fiscal 2012.
The agency noted that while the number of pay-for-delay deals declined in 2014, the absolute number of settlements actually settlements between branded and generic companies actually increased to a record 160 ...
The Supreme Court ruling (Federal Trade Commission v. Actavis, 12-416) said in June 2013 that the deals could potentially be a violation of antitrust law but refused the FTC's request to declare them to be presumed to be illegal.
An FTC study concluded in 2010 that pay-to-delay costs consumers $3.5 billion a year in higher drug prices. Over the last decade, generic drugs have saved consumers more than $1 trillion. That figure could be a lot higher if pay-to-delay were banned. The FTC says 40 such deals were struck in fiscal 2012 alone.
In a typical pay-for-delay deal, a branded drug company will give a generic firm money or some other consideration in exchange for the generic firm's agreement to delay bringing out a cheaper version of the medicine.
The FTC said it was pleased with the drop in the number of the deals. "Although it is too soon to know if these are lasting trends, it is encouraging to see a significant decline in the number of reverse payment settlements," said Debbie Feinstein, director of the FTC’s Bureau of Competition, in a statement.
The FTC did not say which drug makers were involved in the 21 deals but did say that the 2014 agreements involved 20 different branded drugs with combined U.S. sales of about $6.2 billion.
Ten involved a cash payment, six involved compensation via a related business arrangement and five involved an agreement by the branded manufacturer to refrain from marketing a competing "authorized" generic for a certain period of time, the FTC said.
An FTC table said that there were three potential pay-for-delay deals in fiscal 2005, 14 the following two years and then a steady increase until 2012, when the number of deals hit 40 in fiscal 2012.
The agency noted that while the number of pay-for-delay deals declined in 2014, the absolute number of settlements actually settlements between branded and generic companies actually increased to a record 160 ...
U.S. HealthWorks, one of the largest operators of occupational health and urgent care centers in the United States, announced it has acquired Muir/Diablo Occupational Medicine, an affiliate of John Muir Health, effective January 9, 2016. Muir/Diablo Occupational Medicine operates three occupational care centers in the East Bay region of the San Francisco Bay Area.
U.S. HealthWorks currently has 11 centers throughout the San Francisco Bay Area, including two in the East Bay (Oakland and Berkeley). The acquisition of these three centers allows U.S. HealthWorks to better serve the large population in the region and brings the total number of U.S. HealthWorks medical and onsite clinics to 227 nationwide in 20 states.
The acquired centers are located at: 2231 Galaxy Court , Concord, CA 94520, 1981 N. Broadway, Suite 190, Walnut Creek, CA 94596 and 2400 Balfour Road, Suite 230, Brentwood, CA 94513. The facilities will continue to offer a wide range of occupational health services, including injury management, physical exams, corporate medical services and physical rehabilitation.
“The physicians at Muir/Diablo have proven expertise in managing workplace injuries and reducing workplace risk,” said Joseph Mallas, President and Chief Executive Officer of U.S. HealthWorks. “We are pleased to bring these centers into the U.S. HealthWorks family and look forward to the opportunity to expand our service to clients and patients in this key California region.”
“We appreciate the opportunity to become part of the U.S. HealthWorks team in this region,” said John Gunderson, MD, President of Muir/Diablo Occupational Medicine. “U.S. HealthWorks is a leader in the field of occupational care, and with greater resources and an expanded team of experts, we look forward to continuing to provide exceptional patient care.”
The terms of the transactions were not disclosed.
U.S. HealthWorks, a subsidiary of Dignity Health, is one of the country’s largest operators of occupational healthcare centers with 227 medical and worksite clinics in 20 states and more than 3,600 employees, including about 800 medical providers. Its centers collectively serve more than 13,000 patients each day ...
U.S. HealthWorks currently has 11 centers throughout the San Francisco Bay Area, including two in the East Bay (Oakland and Berkeley). The acquisition of these three centers allows U.S. HealthWorks to better serve the large population in the region and brings the total number of U.S. HealthWorks medical and onsite clinics to 227 nationwide in 20 states.
The acquired centers are located at: 2231 Galaxy Court , Concord, CA 94520, 1981 N. Broadway, Suite 190, Walnut Creek, CA 94596 and 2400 Balfour Road, Suite 230, Brentwood, CA 94513. The facilities will continue to offer a wide range of occupational health services, including injury management, physical exams, corporate medical services and physical rehabilitation.
“The physicians at Muir/Diablo have proven expertise in managing workplace injuries and reducing workplace risk,” said Joseph Mallas, President and Chief Executive Officer of U.S. HealthWorks. “We are pleased to bring these centers into the U.S. HealthWorks family and look forward to the opportunity to expand our service to clients and patients in this key California region.”
“We appreciate the opportunity to become part of the U.S. HealthWorks team in this region,” said John Gunderson, MD, President of Muir/Diablo Occupational Medicine. “U.S. HealthWorks is a leader in the field of occupational care, and with greater resources and an expanded team of experts, we look forward to continuing to provide exceptional patient care.”
The terms of the transactions were not disclosed.
U.S. HealthWorks, a subsidiary of Dignity Health, is one of the country’s largest operators of occupational healthcare centers with 227 medical and worksite clinics in 20 states and more than 3,600 employees, including about 800 medical providers. Its centers collectively serve more than 13,000 patients each day ...
The Division of Workers’ Compensation ended its collection of lien activation fees at midnight on December 31, 2015. Any liens not activated by that time were dismissed by operation of law.
New liens are still required to pay a filing fee.
Lien fees are one of the components of Senate Bill 863’s workers’ compensation reforms. SB 863 requires a provider to pay a $150 filing fee for filing any new lien on or after January 1, 2013. For liens filed prior to January 1, 2013, prior to filing a Declaration of Readiness to Proceed (DOR) to request a lien conference or prior to appearing at a lien conference on or before January 1, 2014 were required to pay a lien activation fee. In addition any lien not activated by January 1, 2014 was to be dismissed by operation of law.
Litigation enjoined lien activation fees for two years until the U.S. Court of Appeals upheld the constitutionality of the fees. DWC resumed collection of the lien activation fees on November 9, 2015 before ending December 31, 2015.
One court provision stated that if between November 9, 2015 and December 31, 2015, the lien activation payment system became non-operational for six or more hours in a 24-hour period, the deadline would be extended by one calendar day for each day of non-operation. However, this was not necessary as the system remained operational. During this period more than 254,000 liens were activated. A total of 461,650 lien activation fees were filed between January 2013 and December 31, 2015. A total of 536,945 new liens were filed during the same time period ...
New liens are still required to pay a filing fee.
Lien fees are one of the components of Senate Bill 863’s workers’ compensation reforms. SB 863 requires a provider to pay a $150 filing fee for filing any new lien on or after January 1, 2013. For liens filed prior to January 1, 2013, prior to filing a Declaration of Readiness to Proceed (DOR) to request a lien conference or prior to appearing at a lien conference on or before January 1, 2014 were required to pay a lien activation fee. In addition any lien not activated by January 1, 2014 was to be dismissed by operation of law.
Litigation enjoined lien activation fees for two years until the U.S. Court of Appeals upheld the constitutionality of the fees. DWC resumed collection of the lien activation fees on November 9, 2015 before ending December 31, 2015.
One court provision stated that if between November 9, 2015 and December 31, 2015, the lien activation payment system became non-operational for six or more hours in a 24-hour period, the deadline would be extended by one calendar day for each day of non-operation. However, this was not necessary as the system remained operational. During this period more than 254,000 liens were activated. A total of 461,650 lien activation fees were filed between January 2013 and December 31, 2015. A total of 536,945 new liens were filed during the same time period ...
The Division of Workers’ Compensation administrative director has adopted an order incorporating the Centers for Medicare and Medicaid Services (CMS) revised ambulance fee schedule rates, ZIP code files and inflation factor for services rendered on or after January 15, 2016.
This order adjusting the ambulance services section of the Official Medical Fee Schedule (OMFS) conforms to changes in the Medicare payment system as required by Labor Code section 5307.1.
Effective for services rendered on or after January 15, 2016, the maximum reasonable fees for Ambulance Fee Schedule shall not exceed 120% of the applicable California fees set forth in the calendar year 2016 ambulance services, contained in the electronic Public Use file.
The Administrative Director incorporates by reference the following CMS files from the CMS website:
1) The CY 2016 Public Use File, as revised December 22, 2015
2) The CMS Zip Code Files as revised November 17, 2015
The adjustment incorporates the 2016 ambulance inflation factor which has been announced by CMS. The ambulance inflation factor for calendar year 2016 is negative 0.40 percent (-0.40%).
The Ambulance Fee Schedule may be accessed on the DWC website ...
This order adjusting the ambulance services section of the Official Medical Fee Schedule (OMFS) conforms to changes in the Medicare payment system as required by Labor Code section 5307.1.
Effective for services rendered on or after January 15, 2016, the maximum reasonable fees for Ambulance Fee Schedule shall not exceed 120% of the applicable California fees set forth in the calendar year 2016 ambulance services, contained in the electronic Public Use file.
The Administrative Director incorporates by reference the following CMS files from the CMS website:
1) The CY 2016 Public Use File, as revised December 22, 2015
2) The CMS Zip Code Files as revised November 17, 2015
The adjustment incorporates the 2016 ambulance inflation factor which has been announced by CMS. The ambulance inflation factor for calendar year 2016 is negative 0.40 percent (-0.40%).
The Ambulance Fee Schedule may be accessed on the DWC website ...
