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With the changing landscape of health care, outpatient spine surgery is being more commonly performed to reduce cost and to improve efficiency. Anterior cervical discectomy and fusion (ACDF) is one of the most common spine surgeries performed and demand is expected to increase with an aging population.

But a new study published in The Spine Journal claims that patients who get spinal surgery at outpatient centers may be more likely to have serious complications or require repeat operations than their counterparts who get these procedures in a hospital.

Researchers focused on an operation known as anterior cervical discectomy and fusion (ACDF), which involves removing a damaged disc in the neck to reduce pressure on the spinal cord or nerve root that can cause pain, numbness and weakness. Most of these surgeries are done in hospitals with a one or two night stay, but a growing number of people are going instead to outpatient centers that may have lower costs in part because they don’t keep patients overnight.

The study looked at outcomes for 1,215 patients who had outpatient ACDF and 10,964 people who had these operations in a hospital between 2011 and 2016. All of the patients in the study had insurance through Humana. In both the inpatient and outpatient groups, half of the patients were at least 65 to 69 years old. Overall, there were few complications, researchers report in The Spine Journal.

One year after surgery, 5.5 percent of the people who had outpatient surgery needed repeat operations, as did 4.1 percent in the inpatient group.

After accounting for individual patient characteristics like age, gender and other health problems, the researchers found that people who had outpatient ACDF were 79 percent more likely to require repeat operations within one year than patients who had operations in a hospital. Outpatients were also 25 percent more likely to experience postoperative kidney failure.

"We were surprised that the outpatient cohort had greater rates of postoperative renal failure since these patients are typically younger and healthier to undergo surgery in the outpatient setting," said senior study author Dr. Don Young Park of the David Geffen School of Medicine at the University of California, Los Angeles.

"Our study is the first to show that outpatient ACDF is associated with some increased risk, even in ideal surgical candidates," Park said by email reported as reported by Reuters Health.

But the study was not a controlled experiment designed to prove whether or how the location of surgery might influence the outcomes. Another limitation of the study is that it relied on insurance claims data and lacked detailed medical information on individual patients, the authors note. Researchers also didn’t have data on early complications such as emergency room visits or hospitalizations.

Individual patient factors missing from the insurance claims data might explain the slight differences in outcomes between inpatient and outpatient operations, said Dr. Matthew McGirt of Carolina Neurosurgery & Spine Associates in Charlotte, North Carolina, who wasn’t involved in the study.

Still, the findings add to the evidence that these operations can be done safely, but should be considered only after other treatments such as physical therapy, pain medication or steroid injections fail, doctors say.

"Surgery should be reserved for patients with severe pain despite an appropriate course of non-operative treatment or for those with neurologic deficits," said Dr. Frank Phillips, a researcher at Rush University Medical Center in Chicago who wasn’t involved in the study.

"In appropriately selected patients, the success rate for ACDF procedure in terms of improving symptoms is generally above 90 percent," Phillips said by email.
/ 2017 News, Daily News
The Centers for Medicare and Medicaid Services has released an updated Non-Group Health Plan (NGHP) User Guide version 5.3.

The primary change to the User Guide involves the details of the CMS transition with its Social Security Number Removal Initiative (SSNRI) and how this transition will impact MMSEA Section 111 Reporting.

The Medicare Access and CHIP Reauthorization Act (MACRA) requires CMS to remove Social Security Numbers (SSNs) from Medicare beneficiary ID cards and issue new cards with a new 11-byte Medicare Beneficiary Identifier (MBI) to beneficiaries by April 2019.

There will be a 15-month transition period beginning October 2018. During the transition per
iod, physicians and other providers may submit a Medicare claim using either the patient’s valid and active SSN or the MBI. Medicare will return both the SSN and the MBI on the remittance advice.

All Medicare claims submitted after January 2020 will be required to use the MBI. Those claims filed with the patient’s SSN will be rejected.

Regarding Section 111 reporting for health plans and workers' compensation administrators, the most current Medicare ID (HICN or MBI) will be returned in the Section 111 response files in the "Medicare ID" field. Further, if an RRE submits information with a HICN and the Medicare beneficiary has received their MBI, the MBI will be returned. Otherwise, the most current HICN will be returned.

Responsible Reporting Entities (RREs) may submit subsequent Section 111 information for the Medicare beneficiary using either the HICN or MBI.

Regarding conditional payment correspondence, the Benefits Coordination and Recovery Center (BCRC) and Commercial Repayment Center (CRC) correspondence will use the Medicare identifier that RREs most recently provided when creating or updating a Medicare Secondary Payer (MSP) record.

Therefore, if the most recent information that was received used a HICN, all subsequent issued correspondence will be generated with the HICN as the Medicare ID. If the most recent information received used an MBI, all subsequent issued correspondence will be generated with the MBI as the Medicare ID ...
/ 2017 News, Daily News
Mahmoud Alzayat, on behalf of the People of the State of California, filed a qui tam action against his employer, Sunline Transit Agency, and his supervisor, Gerald Hebb, alleging a violation of the Insurance Frauds Prevention Act (IFPA or the Act). (Ins. Code, § 1871 et seq.)

Sunline is a public entity that provides regional transportation services and oversight of other transportation entities such as taxi companies. Alzayat was employed by Sunline as a stops and zones technician, and in that capacity he maintained bus stop infrastructure. Hebb was Alzayat’s supervisor.

On the day of the injury, Alzayat was working on a bus stop. The only available bags of concrete mix weighed 90 pounds. Alzayat asked Hebb for permission to either break down a 90-pound bag into lighter ones or to have another employee help him. Hebb refused Alzayat’s requests, and the two argued for about two minutes. Hebb ultimately ordered Alzayat to lift the 90-pound bag by himself without breaking it down first. Alzayat complied and, immediately upon lifting the bag, felt intense pain in his lumbar spine, and he partially collapsed. Alzayat dropped the bag and its contents spilled out. When Hebb asked Alzayat why he had dropped the bag, Alzayat complained he had injured his back when lifting the bag.

In the report, Hebb wrote he did not witness Alzayat’s injury. Alzayat alleged Hebb made false statements in the incident report submitted in response to Alzayat’s claim for workers’ compensation, and Hebb repeated those false statements in a deposition taken during the investigation into Alzayat’s claim for compensation.

Hebb testified under oath that he had no conversation with Alzayat about the request to either break down the bag of concrete mix or to obtain help in lifting the bag. Hebb also denied having witnessed Alzayat injure himself when he lifted and then dropped the bag. Hebb’s false statements resulted in Alzayat’s claim being initially denied.

Alzayat filed a lawsuit alleging Hebb’s false statements in relation to Alzayat’s claim for workers’ compensation benefits constituted violations of Penal Code section 550, and formed predicate offenses for liability under the Insurance Frauds Prevention Act (IFPA). Alzayat prayed for a civil penalty against Hebb and Sunline of no less than $5,000 and no more than $10,000, an assessment of no more than three times the amount of his workers’ compensation claim, attorney fees, and costs.

The employer filed motions for judgment on the pleadings contending: (1) this lawsuit is based on allegedly false and fraudulent statements Hebb made in connection with a workers’ compensation proceeding and is, therefore, barred by the litigation privilege under Civil Code section 47, subdivision (b) and (2) Alzayat’s claim is barred by the workers’ compensation exclusivity rule.

The superior court concluded the workers’ compensation exclusivity rule is inapplicable, but ruled the litigation privilege bars Alzayat’s claim. Therefore, the court granted the motions without leave to amend and entered judgment dismissing the lawsuit.

Alzayat appealed from the judgment, contending the litigation privilege only applies to tort claims and not to statutory claims such as an action under the IFPA, and the IFPA is a specific statute that prevails over the general litigation privilege. The employer cross-appealed, arguing that, even if Alzayat’s lawsuit is not barred by the litigation privilege, the superior court erred by not granting judgment on the pleadings on the ground that Alzayat’s claim is barred by the workers’ compensation exclusivity rule.

The Court of Appeal agreed with Alzayat that his lawsuit is not barred by the litigation privilege nor by the workers’ compensation exclusivity rule in the published case of The People ex. rel. Mahmoud Alzayat v Gerald Hebb et. al.

The IFPA was in large measure designed to prevent workers’ compensation insurance fraud, and the Act includes a number of legislative findings and declarations that are relevant here. "Workers’ compensation fraud harms employers by contributing to the increasingly high cost of workers’ compensation insurance and self-insurance and harms employees by undermining the perceived legitimacy of all workers’ compensation claims."

The IFPA provides for civil liability for various forms of workers’ compensation insurance fraud. "Every person who violates any provision of this section or Section 549, 550, or 551 of the Penal Code shall be subject, in addition to any other penalties that may be prescribed by law, to a civil penalty of not less than five thousand dollars ($5,000) nor more than ten thousand dollars ($10,000), plus an assessment of not more than three times the amount of each claim for compensation, as defined in Section 3207 of the Labor Code..."

The litigation privilege, codified at Civil Code section 47, subdivision (b), provides that a ‘publication or broadcast’ made as part of a ‘judicial proceeding’ is privileged. This privilege is absolute in nature, applying "to all publications, irrespective of their maliciousness." The litigation privilege is broad, but it has its limits. Like any statute, Civil Code section 47(b) is subject to the rule of statutory construction that a particular provision prevails over a general one ...
/ 2017 News, Daily News
Ambulances are a vital part of emergency medical services. However, they come in single, homogeneous, high intervention form, which is at times unnecessary, resulting in excessive costs for patients and insurers. Many potential emergency room patients are too sick to drive themselves to a hospital. But an ambulance can cost hundreds or thousands of dollars without insurance.

So researchers from the University of Kansas asked whether UberX’s entry into a city caused substitution away from traditional ambulances for low risk patients, reducing overall volume. The study investigated ambulance rates in 766 U.S. cities from 43 different states.

They discovered that a popular ride-sharing app can step in, while also freeing up the ambulances for those who need them most.

The results showed at least a 7% decrease in the ambulance rate from Uber entry into a city. This decrease likely caused a reduction in wait time for the remaining ambulance volume. Given that even a reduction of a few minutes can drastically improve survival rates for serious conditions, this could be associated with a substantial welfare improvement.

Researchers often cite costly transportation as a significant barrier to receiving quality healthcare. A study by Samina T. Syed and Lisa K. Sharp, doctors at the Kalamazoo College, suggests that cost-efficient access to a vehicle is consistently associated with increased access to health care.

With demand for ambulances decreased by available Uber drivers, emergency personnel have been able reach critical patients faster while also applying necessary treatment on the way to the hospital, according to the economic study from the University of Kansas:

"Given that even a reduction of a few minutes can drastically improve survival rates for serious conditions, this could be associated with a substantial welfare improvement."

"In order to lower health care spending while improving health outcomes, people can use the least-skilled professional who is still qualified," said the paper's author, University of Kansas economist David Slusky. "It's the same in the provider space: you don't need a neurosurgeon to diagnose strep throat."

"We want to find every way possible," Slusky said, "to bend the medical cost curve." ...
/ 2017 News, Daily News
California’s top court on Thursday opened the door for consumers to sue Novartis AG and other makers of brand-name pharmaceutical products over injuries blamed on generic versions of the drugs manufactured by other companies.

The case is T.H. v. Novartis Pharmaceuticals Corporation, California Supreme Court, No. S233898.

The California Supreme Court’s ruling broke with decisions nationally to the contrary and created exposure for brand-name drugmakers who could be sued in the state for failing to warn users about the risks of cheaper, generic versions of their drugs.

Reuters Health reports that Leslie Brueckner, the plaintiffs’ lawyer, said the decision was the only one currently by a state’s top court to favor consumers of generic drugs, who legally cannot sue generic drugmakers for not warning about their products’ risks. "This is just a huge victory for public health and safety, and this victory will be felt nationwide," she said.

Novartis, whose appeal had the support of industry groups including the U.S. Chamber of Commerce, said it disagrees with the court’s decision to potentially hold it responsible for an injury caused by a different company’s product.

The decision came in a lawsuit centered on two twin children who were diagnosed with developmental delays and autism after their mother while pregnant took a generic version of Brethine to suppress premature labor.

Under a 2011 ruling by the U.S. Supreme Court, generic drug companies cannot be sued for failing to provide adequate label warnings about potential side effects because federal law requires them to use the brand-name versions’ labels.

The father of the children, referred to in court papers as T.H. and C.H., instead sued Novartis, which made Brethine until 2001, and aaiPharma Inc, which bought the rights to it in 2007 while their mother was taking the generic version.

Novartis argued its duty to warn consumers did not cover those taking generics and that a contrary ruling would effectively make it the market’s insurer.

The court disagreed. Justice Mariano-Florentino Cuéllar wrote that brand-name manufacturers are the only entities with the ability to strengthen a warning label.

"So a duty of care on behalf of all those who consume the brand-name drug or its bioequivalent ensures that the brandname manufacturer has sufficient incentive to prevent a known or reasonably knowable harm," Cuéllar wrote.

The court also held 4-3 that Novartis could be sued despite divesting itself of Brethine because its failure to update the warning label before the sale could foreseeably cause the children harm ...
/ 2017 News, Daily News
A US drugmaker is charging almost $300 for a bottle of prescription vitamins that can be bought online for less than $5, in the latest attempt at price gouging in the world's largest healthcare market.

In the latest example of eye-watering price-gouging in the US’s lightly regulated pharmaceutical industry, records show Avondale Pharmaceuticals, a mysterious company registered in Alabama, raised the price of Niacor from $32.46 to $295.

Niacor is a prescription version of niacin, a type of vitamin B3 that is frequently used to treat high blood cholesterol. A wide range of generic versions of the vitamin are available; Walmart sells a jar of 100 tablets for $14.99 while other brands are available online for even less.

Yet some doctors still prefer to use the version approved by the US Food and Drug Administration to treat high cholesterol. The Financial Times said many doctors will be unaware the price of Niacor, for which 19,000 prescriptions were written last year, has so drastically increased because such announcements are not always made public or announced to the medial profession.

Avondale, a secretive Alabama-based company, put the price of Niacor up shortly after acquiring the rights to the medicine in a so-called "buy-and-raise" deal -- a strategy made famous by Martin Shkreli, the disgraced biotech entrepreneur.

Shkreli, became the so-called "most hated man in the US" after he bought the rights to a drug used to treat people with Aids and increased the price by almost 5,000 per cent.

Shkreli was convicted in August of two counts of fraud and one count of conspiracy for misleading investors in hedge funds he ran. He is currently in jail awaiting sentencing.

The Financial Times said Avondale Pharmaceuticals bought the rights to Niacor from Upsher Smith, a division of Japan’s Sawai Pharmaceutical, earlier this year. The company also bought the rights to a drug used to treat respiratory ailments, known as SSKI, and multiplied the price 25 times, raising the cost of a 30ml bottle from $11.48 to $295.

Avondale Pharmaceuticals does not have a website and lists its address as a business park in Mountain View, a suburb on Birmingham, Alabama. The registered agent for the company is Acrogen Pharmaceuticals, which was set up in 2016 by Mark Pugh.

When The Independent visited the registered address, the suite said to be the company’s office was empty. People working in neighbouring offices said the suite had been vacant for some time and that they were not aware of any pharmaceutical companies or of Mr Pugh.

Mr Pugh’s Linkedin page says he is currently the CEO of Acella Pharmaceuticals, which lists its address in Alpharetta, north of Atlanta, Georgia. Nobody at that company responded to calls or emails.

Michael Rea, chief executive of Rx Savings, which makes software to help people find cheaper medicine, told the newspaper: "This is the latest example of an inefficient US market where the consumer, payer and doctor don’t have all of the information available to make a financially sound choice."

He added: "They are caught in a web of inefficiency and are being taken advantage of." ...
/ 2017 News, Daily News
Though employers and workers’ compensation insurers have been utilizing telemedicine for quite some time, the Insurance Journal reports that there has been a recent uptick in interest surrounding virtual physical therapy, also known as telerehab.

Telerehab provides virtual access to physical therapy and is intended to be a replacement for an in-person visit to an outpatient facility. According to a recent white paper released by MedRisk, while not all treatment is translatable to telerehab, "online exercise demos, virtual workout supervision, and secure communication tools make it possible to supplement in-clinic physical therapy with valuable remote services including patient follow-ups, home treatment plans, questions and answers, and consultations with specialists."

Sean Sullivan, chief operating officer and vice president of Business Development for the national rehab and wellness provider Go2Care, said telerehab can include the whole spectrum of what is called "musculoskeletal care management."

According to Michelle Despres, vice president and national product leader at workers’ compensation firm One Call, telerehab is convenient because it can be done via a cell phone, tablet or a computer. The process can work via live or pre-recorded videos and mobile apps, said Despres. Remote patient monitoring can be achieved by using health and fitness trackers or through patient self-reporting.

"They would have access to one on one live treatment with a physical therapist (PT), the idea being that there’s a convenience factor. If someone would like to be treated, we offer hours between 6:00 AM and 10:00 PM. There’s a lot of flexibility. Most outpatient clinics are not open to those hours," added Despres. "There may be a possibility that someone could say at lunchtime, ‘I’m going to do my PT. I’m not going to leave my office. I’m going to do it right here.'" She added that injured workers could do it anywhere they have the privacy and the availability to perform their visit.

Highly adaptable, telerehab can begin with online videoconferencing and move toward live, face to face interaction, according to Sullivan of Go2Care.

"We’re also looking at telerehab being defined as a home exercise program support application. This is an apps based concept," said Despres. "It allows the treating therapist in the brick and mortar facility to offer their individual patients and injured workers the ability to log into an app, much like a fitness app, that many people use on their phones or their tablets and have the opportunity to have their home program delivered electronically."

While there’s been traction in both the group health and Medicare markets, there has been a slow adoption rate by the workers’ compensation industry, despite the fact the concept has been around for quite a while, said Sullivan.

"In workers’ compensation, to my knowledge no one yet has any deliverable data or outcomes information to be able to say that it’s being adopted at X rate in the work comp space," said Despres.

"There was a push, not from the carriers but from - the employers," said Sullivan. "I’m having a lot of carriers come to me saying, ‘We want to do it,’ but they don’t know where to start. When the carriers right now are talking to me, they’re saying, ‘Do we do the prevention? Do we do the treatment, or do we do the monitoring?'" He expects carriers will pilot one or all three aspects to determine the best fit.

Not much is needed for telerehab to work, said Sullivan and Despres. "They don’t require anything except the injured worker has to have their own Wi-Fi or their own device a cell phone, a smartphone or a tablet, or a computer," said Despres. The employer doesn’t have to set up anything, though they might choose to offer a private room that employees could use at lunchtime or at their own discretion.

"It can be done from anywhere. We’re servicing a manufacturing site in rural America. There’s not a whole lot around it, but there are 600 employees," Sullivan said. "We just set up a kiosk at the location. The employee has the freedom to elect to conduct that visit in the comfort of their home, should they choose. But they’re not choosing that, at least, to date." ...
/ 2017 News, Daily News
The Department of Industrial Relations (DIR) reports that 376 Californians died on the job in 2016, down slightly from the 388 deaths in 2015.

"Even one workplace fatality is too many, and our thoughts are with the families of those that died on the job last year," said Christine Baker, DIR Director. "The fatality data released today is a reminder that we must all continue our efforts to reduce workplace safety and health hazards in order to prevent worker deaths."

A review of the past twelve years indicates that workplace fatalities in California remain below the average rate of fatalities prior to 2008, when the last recession began, and remained flat over the past two years at 2.2 deaths per 100,000 workers. On the national level, the rate of fatalities jumped from 3.4 to 3.6 per 100,000 workers.

There were 376 fatal injuries on the job in California in 2016, compared to 388 in 2015, 344 in 2014, and 396 in 2013. Data comes from the Census of Fatal Occupational Injuries (CFOI), which is conducted annually in conjunction with the U.S. Bureau of Labor Statistics (BLS). Figures for 2016 are the latest numbers available.

Key findings from the latest census in California include:

- One in five (20%) of all California workplace deaths identified in 2016 were attributed to violence and other injuries by persons or animals. The incidence of workplace homicides in 2016 accounts for 12% of all workplace deaths in the state.
- Nearly two of every five (38%) California workplace deaths identified in 2016 occurred in transportation incidents.
- One in six (17%) of all California workplace deaths identified in 2016 were attributed to trips, slips and falls; with 90% of those deaths involving falls to a lower level.
- Nearly two of every five (39%) California workplace deaths in 2016 were Latinos. This fatality rate has fluctuated over the past ten years from 37% to 49%.

The percentage of Latino deaths in the workplace continues to be an area the department is tracking closely. DIR over the past eight years has increased workplace safety outreach and education to Spanish-speaking workers, with a focus on high-hazard work.

Tables reflecting final data for 2016 (and prior years’ final data) for California are posted online, as well as a report reflecting four years’ of fatal occupational injuries in California.

DIR conducts the California Census annually in conjunction with the U.S. Bureau of Labor Statistics. CFOI produces comprehensive, accurate and timely counts of fatal work injuries. This Federal-State cooperative program was implemented in all 50 states and the District of Columbia in 1992 ...
/ 2017 News, Daily News
The number of U.S. deaths at work from unintentional drug and alcohol overdoses jumped more than 30% in 2016, according to new government data, showing that the nation’s struggle with a deadly opioid epidemic is migrating to the workplace.

The Bureau of Labor Statistics’ National Census of Fatal Occupational Injuries said that 217 workers died on the job last year as a result of an unintentional overdose from the nonmedical use of drugs or alcohol, up from 165 in 2015. The number of accidental overdose deaths at work has nearly tripled since the BLS began compiling the data in 2011.

And an article in the Wall Street Journal reports that the statistic is part of a bigger problem.

"The surge in deaths, the abuse and the way in which this has turned into a crisis which encompasses so many elements, it’s not at all surprising this crisis has migrated" into the workplace, said John Deskins, an economist at West Virginia University.

The Department of Labor will respond by working "with public and private stakeholders to help eradicate the opioid crisis as a deadly and growing workplace issue," said Loren Sweatt, the Occupational Safety and Health Administration’s deputy assistant secretary.

Earlier this year, OSHA limited its reporting of fatalities in the U.S., as part of a series of moves by the agency cutting back the amount of information about workplace accidents made available to the public.

Other causes of workplace death still dominated in 2016, a year during which the economy added 2.24 million new jobs.

Total fatal work injuries rose 7% to 5,190 in 2016, according to the report. Deaths due to workplace violence increased 23% last year from the year before, making that the second most common cause of death on the job in 2016 after transportation incidents. The number of workplace suicides rose 27% in 2016 from the year before, to 291, the highest number since the census began recording the number of suicides at work in 1992.

Drug abuse is taking a toll on the U.S. economy. The burden of prescription opioid abuse from crime, lost work productivity through absenteeism or poor job performance and health care costs is an estimated $78.5 billion a year, according to a 2013 study by the CDC.

The Federal Reserve’s Beige Book - a survey based on anecdotes collected from the central bank’s 12 regional banks - reported in July that manufacturers in the St. Louis region cited candidates’ inability to pass drug tests or to consistently report to work as a difficulty in hiring workers.

In a 2015 paper, Princeton University economists Anne Case and Angus Deaton termed the rise in mortality from suicide, drugs and alcohol since the late 1990s among middle-aged white Americans "deaths of despair." ...
/ 2017 News, Daily News
The WCIRB has completed its review and analysis of September 30, 2017 experience submitted by insurers. This report is based on data reported to the WCIRB by insurers who wrote almost 100% of the statewide market.

Overall, 2017 is expected to be a comparatively good year for California workers' compensation insurance carriers.

First the bad news. Written premium will decrease slightly. California written premium (gross of deductible credits) for 2016 is approximately $18.1 billion, which is 3% above the written premium reported for 2015. Written premium for the first nine months of 2017 is $13.5 billion, which is 4% below the written premium reported for the first nine months of 2016.

The projected industry average charged rate (rates charged by insurers that reflect all rating plan adjustments except deductible credits, retrospective rating plan adjustments, terrorism charges, and policyholder dividends) per $100 of payroll for policies incepting in the first nine months of 2017 is $2.47. This is 10% below the average rate charged in 2016 and 17% below the average rate charged in 2015. The approved January 1, 2018 advisory pure premium rates are on average approximately 30% below the January 1, 2015 advisory pure premium rates.

The reduction in overall premium dollars for the year is not unexpected in light of the success of recent system reform efforts.

The good news is that despite the reduction in total premium dollars, the underwriting profits have dramatically improved as a result of claim cost containment.

The combined ratio is a measure of profitability used by an insurance company to indicate how well it is performing in its daily operations. The ratio is typically expressed as a percentage. A ratio below 100% indicates that the company is making underwriting profit while a ratio above 100% means that it is paying out more money in claims that it is receiving from premiums.

The WCIRB projects an ultimate accident year combined loss and expense ratio of 90% for 2016. Of this ratio, 54% is attributable to the indemnity and medical loss ratio, 18% is attributable to the loss adjustment expense ratio, and 18% is attributable to the other expense ratio. This projection is generally consistent with the ratios for the prior two accident years, which represent the lowest combined ratios since the 2004 through 2006 period.

It is important to remember that the combined loss and expense ratio was projected at 131 in the year 2000. A projection now that is under 100 is a remarkable improvement in underwriting profit results.

The WCIRB projects indemnity claim frequency for accident year 2016 to be approximately 1% below the frequency for 2015 but 10% above the frequency for 2009. The frequency increases experienced in 2010 through 2014 are largely attributed to increases in cumulative injury claims, late reported indemnity claims, claims involving injuries to multiple body parts, and claims from the Los Angeles Basin area. 2015 and 2016 represent the first consecutive years of projected indemnity claim frequency decline since before the Great Recession. The projected indemnity claim frequency for the first nine months of 2017 is approximately 1% higher than that for 2016.

The WCIRB projects the average cost (or "severity") of a 2016 indemnity claim to be approximately $78,000, which is 2% higher than the projected severity for 2015. Total claim severity growth over the last several years has been relatively modest as increases in average indemnity and ALAE costs have been in part offset by declines in average medical costs through 2016.
/ 2017 News, Daily News
Physicians who practiced at the Campbell Medical Group, Dr. Vilasini Ganesh a family practitioner and Dr. Gregory Belcher an orthopedic surgeon, were convicted of health care fraud by a federal jury after an eight-week jury trial.

The jury found Ganesh, 47, of Saratoga, guilty of five counts of health care fraud and five counts of making false statements relating to claims fraudulently submitted to health care benefit programs. Belcher, 56, also of Saratoga, was found guilty of one count of making a false statement relating to a health care benefit program. The defendants were acquitted of conspiracy and money laundering counts, and Belcher was also acquitted of four other health care fraud counts and one other count of making a false statement relating to a health care benefit program.

Evidence at trial showed that Ganesh submitted false and fraudulent claims to several health care benefit programs for services that she knew were not properly payable, by including claims for days when the patient had not been seen by the provider, and claims that the patients had been seen by another physician provider who was no longer affiliated with her practice.

Evidence at trial further demonstrated that Belcher had on at least one occasion submitted a false claim in connection with a billing matter related to his physical therapy practice.

On July 13, 2017, a federal grand jury indicted the defendants, charging them with one count of conspiracy to commit health care fraud, in violation of 18 U.S.C. § 1349; one count of conspiracy to commit money laundering, in violation of 18 U.S.C. § 1956(h); and multiple counts health care fraud, in violation of 18 U.S.C. § 1347, and 2 and false statement relating to health care matters, in violation of 18 U.S.C. § 1035.

The indictment alleged that Ganesh would misrepresent, conceal and hide her wrongdoings or direct her subordinates to do as such. When she was approached by representatives from the insurance companies or the patients themselves, for example, to provide documentation or additional information to substantiate the submitted claims, she’d either forbid her office staff from speaking to anyone about the claims or she would just resubmit the false information, according to the DOJ.

She was accused of working with Belcher to submit hundreds of claims for reimbursement from the insurance companies for days that were weekends when their practice was closed, days on which the patients denied they were seen and days when the patients could not have been seen by Ganesh or her staff because either the patient or the doctor was not physically present.

The doctors were suspected of using billing codes that indicated either one of them had spent more than 24 hours in a single day seeing patients. The pair allegedly maintained multiple bank accounts through which they tried to hide their illegally obtained money.

The defendants are currently out of custody, on a $350,000 bond as to Ganesh and a $250,000 bond as to Belcher. Judge Koh scheduled the defendants’ sentencing hearing for April 4, 2018.

Assistant U.S. Attorneys Patrick Delahunty and Jeff Nedrow are prosecuting the case with the assistance of Susan Kreider and Nina Burney Williams. The prosecution is the result of a two-year investigation by the Federal Bureau of Investigation ...
/ 2017 News, Daily News
California is "the wild, wild west right now," said Kansas Cafferty, a commissioner with the National Certification Commission for Addiction Professionals.

In a state with about 1,800 licensed recovery centers and an unknown number of unlicensed sober living homes and testing labs, According to the story in the Orange County Register, Cafferty is among many who believe California needs to get better at rehab regulation. "There (are) a lot of places committing crimes that authorities are trying to enforce, but they can’t keep up with it."

Marlies Perez, chief of the California Department of Health Care Services’ Substance Use Disorder Compliance Division, which licenses rehab treatment centers, said her agency can only do what the state Legislature allows.

She would not say whether her department needs more authority, or if it is doing a good job protecting consumers.

"We’re not going to quantify our functions," Perez said. "Our role is to provide oversight. That is, once again, exercise the authority that we have" and work with other regulatory agencies when appropriate.

Carol Sloan, the health department’s spokesperson, said state codes list specific causes for denying a treatment center license. Reasons include prior revocation of a license and failure to comply with fire codes. Other than that, applications from would-be operators and counselors generally aren’t screened by the state.

Drug counselors in California are certified by industry-related agencies to work in recovery programs. And once certified, they’re governed by a code of conduct written by the certifying agency that could make them subject to discipline for such things as sexual misconduct or drug abuse.

But officials and critics say neither the third-party certification organizations, nor the state health services agency, are routinely notified by law enforcement or state officials when treatment center operators or their workers are convicted of crimes or disciplined for license violations.

It’s not a new problem, and California legislators have fought about it for years. Still, they’ve made only halting progress in beefing up licensing standards and rehab monitoring. That’s partly because of industry lobbying, and because of fears that tighter rules will raise treatment costs or limit the number of rehab beds just when the nation’s opioid crisis is cranking up demand.

This year, State Sen. Pat Bates, R-Laguna Niguel, introduced a bill to reform the system, but it stalled in committee. Today, she describes the state’s oversight of rehab operators, sober living homes and counselors as "troubling."
Senator Pat Bates speaks during a drug overdose awareness memorial at Crown Valley Park in Laguna Niguel earlier this year. (Photo by Drew A. Kelley, Contributing Photographer)

"There is significant resistance - to looking at a (rehab operator’s) background," Bates said. "There’s a culture about giving these people a second chance."

Still, she insists that background checks and tougher licensing requirements for counselors, employees and rehab operators are vital. "It’s something we need to pursue." ...
/ 2017 News, Daily News
Michelle Janet Lias was a food services worker with the Corona/Norco Unified School District. She claimed she sustained an injury to the lower right side of her back on June 11, 2013, when she picked up a box of frozen burritos.

She received total workers’ compensation benefits of $4,450.43 between June 17 and November 12, 2013. An additional $13,740.60 was also paid out for her medical expenses during that period.

On October 12, 18, and 20, 2013, an insurance investigator recorded three clandestine videos of defendant. In those videos, defendant spent an extended amount of time in a car driving, she went to a pumpkin patch event, she bent down and tied her shoes, she walked without a limp, she carried a package to her car, and she sat in a casino gambling.

On November 12, 2013, the defendant’s treating physician changed his opinion after viewing the videos. The physician said defendant was "milking it." On the same date, he issued a supplemental orthopedic report in which he wrote that defendant was not disabled and should return to work.

Lias pled guilty to fraudulently making a material statement and representation for the purpose of obtaining compensation. (Ins. Code, § 187.14, subd. (a)(4); count 1.) The People filed a request for restitution in an aggregate amount of $45,747.23, itemized as follows: salary payments of $9,902.69, medical expenses of $15,116.60, clandestine investigation in the amount of $7,651.60, photocopying in the amount of $3,050.80, bill review expenses of $1,312.14, defense fees of $5,859.21, and deposition expenses of $2,854.19.

The court granted defendant three years of summary probation and later imposed victim restitution in the amount of $35,525.08. The court denied restitution for photocopying, bill review, and defense fees. On appeal, defendant contends the court abused its discretion in awarding that amount of restitution. The Court of Appeal affirmed the restitution order in the unpublished case of People v Lias.

Generally speaking, restitution awards are vested in the trial court’s discretion and will be disturbed on appeal only when the appellant has shown an abuse of discretion. Even though the trial court has broad discretion in making a restitution award, that discretion is not unlimited. While it is not required to make an order in keeping with the exact amount of loss, the trial court must use a rational method that could reasonably be said to make the victim whole, and may not make an order which is arbitrary or capricious. When there is a factual and rational basis for the amount of restitution ordered by the trial court, no abuse of discretion will be found by the reviewing court.

"Here, the court acted well within its discretion by implicitly determining that defendant had never suffered an injury; thus, its restitutionary award of all wages and medical expenses incurred as a result of defendant’s faked injury is supported by the record. This is regardless of the date reflected in the complaint and in defendant’s plea. Indeed, the clandestine videos showed that defendant had been capable of performing tasks as early as October 12, 2013, that she was reporting to her physician she could not do." ...
/ 2017 News, Daily News
The Internal Revenue Service has announced that the standard mileage rate for business miles will increase 1.0 cents per mile to 54.5 cents per mile as of January 1, 2018.

The California Workers’ Compensation Institute (CWCI) notes that this means the mileage rate that California workers’ compensation claims administrators pay injured workers for travel related to medical treatment or evaluation of their injuries will need to be adjusted to the new IRS rate for travel on or after January 1, 2018, regardless of the date of injury, though the current rate of 53.5 cents per mile rate should be paid for all 2017 travel.

California Labor Code §4600 (e)(2), working in conjunction with Government Code §19820 and Department of Personnel Administration regulations, requires claims administrators to reimburse injured workers for such expenses at the rate adopted by the Director of the Department of Personnel Administration for non-represented (excluded) state employees, which is tied to the IRS published mileage rate.

In a news wire issued December 14, the IRS announced that as of January 1, 2018, the standard mileage rate will increase to 54.5 cents per business mile driven. The IRS bases the standard mileage rate on an annual study of the fixed and variable costs of operating an automobile.

There have been multiple mileage rate changes over the past decade, so the California Division of Workers’ Compensation has posted downloadable mileage-expense forms on the forms section of its website which show applicable rates based on travel date.

A new form with the 2018 rate is expected to be posted shortly but it should not be used until reimbursements are being made for 2018 travel.

In the meantime, claims organizations should alert their staff and programmers that the rate will increase to 54.5 cents per mile for travel on or after January 1, 2018 ...
/ 2017 News, Daily News
Beverly Hills Radiologist Ronald Grusd and two of his corporations, California Imaging Network Medical Group and Willows Consulting Company, were convicted by a federal jury this week of fraud and bribery charges in connection with a massive health care-fraud scheme involving the State of California’s Workers’ Compensation program.

After a seven-day trial, the jury found Dr. Grusd and his companies guilty on all charges facing them, including Conspiracy, Honest Services Mail and Wire Fraud, Health Care Fraud, and Travel Act violations, based on their years-long bribery and fraud scheme.

According to evidence presented at trial, Dr. Grusd and his companies paid kickbacks for patient referrals from multiple clinics in San Diego and Imperial counties in order to fraudulently bill insurance companies over $25 million for medical services. Dr. Grusd negotiated with various individuals, including a primary treating physician, the payment of kickbacks for the referral of workers’ compensation patients for various medical services, including MRIs, ultrasounds, Shockwave treatments, toxicology testing and prescription pain medications.

After the patients were referred for the treatment or service, one of Dr. Grusd’s companies, California Imaging Network Medical Group, would fraudulently bill insurance companies for the procedures, concealing from both the patients and the insurers that substantial kickbacks had been paid in violation of California law. Another of Dr. Grusd’s companies, Willows Consulting Company, funneled the kickback payments to those directing the referral of the patients from the various clinics. Records presented at trial showed that Dr. Grusd paid over one hundred thousand dollars in bribes to secure the billings for hundreds of patients, with bribes paid on a per-patient or per-body-part formula.

Dr. Grusd was ordered to return to federal court on March 12, 2018, for a sentencing hearing for himself as well as both corporations. Since 2009, Dr. Grusd and his various companies have filed tens of thousands of liens in the California Workers Compensation System, seeking reimbursement for hundreds of millions of dollars from multiple insurers. To date, any outstanding liens have been stayed and will be sent to lien consolidation for dismissal proceedings as a result of the convictions.

The jury could not reach a unanimous verdict as to Dr. Grusd’s administrator, Gonzalo Paredes, who was ordered back to court on January 4, 2018, for a hearing regarding a retrial.

Dr. Grusd, Paredes, and the corporations were originally indicted by a federal grand jury in November 2015, when the U.S. Attorney’s Office and the San Diego District Attorney’s Office, working in conjunction with the Federal Bureau of Investigation and the California Department of Insurance, announced multiple arrests arising from "Operation Back Lash" - a long-term, proactive health care fraud investigation targeting corruption and fraud in the California Workers’ Compensation system that is continuing.

Since then, nearly 40 individuals and corporations have been charged with federal and/or state crimes, including doctors, attorneys, marketers and providers of medical services and devices. The four other defendants charged with Dr. Grusd and Paredes - who were alleged to have received bribes in exchange for patient referrals - have pleaded guilty and are cooperating with the continuing investigation while awaiting sentencing. The charges on which Dr. Grusd went to trial were brought in July 2017, when a grand jury returned a Superseding Indictment against him and his companies.

Grusd’s practice, California Imaging Network Medical Group, operated clinics throughout California in San Diego, Los Angeles, Beverly Hills, Fresno, Rialto, Santa Ana, Studio City, Bakersfield, Calexico, East Los Angeles, Lancaster, Victorville and Visalia ...
/ 2017 News, Daily News
Cal/OSHA has cited three contractors $147,315 for safety violations after investigating the collapse of a temporary mold (formwork) and vertical shoring at an Oakland construction site that sent 13 workers to the hospital.

On May 26, workers at 3039 Broadway, a 435-unit mixed-use project, were pouring concrete into elevated formwork when the shoring system supporting the formwork collapsed. The workers fell some 20 feet along with freshly poured concrete, reinforcing steel, timber framework, and tools and equipment.

Some were able to get to safety on their own and others were assisted by firefighters. When emergency crews arrived, workers were using shovels to dig their colleagues out of the wet concrete.

Oakland Fire Battalion Fire Chief Ian McWhorter, who was still cleaning wet cement off his boots almost four hours later, said earlier the on-site workers "did an excellent job of extricating" their fellow workers before firefighters arrived and took over.

McWhorter said the cement was "kind of like quicksand" and rescuers used plywood and planks to reach trapped workers so they would not sink.

The injured were taken to hospitals for cuts, bruises and strains, but no fatalities or major injuries were reported. One worker’s injuries required surgery.

Cal/OSHA Chief Juliann Sum said that "significant safety lapses caused injuries that could have been much worse if the workers hadn’t landed in freshly poured concrete. Employers must identify, evaluate and correct unsafe working conditions and follow all requirements to prevent employee injuries and illnesses."

Cal/OSHA’s investigation found that the formwork and vertical shoring system that collapsed were not properly designed, installed or inspected. The agency issued serious and serious accident-related citations to subcontractors Largo Concrete, Inc. and N.M.N. Construction, Inc. for $73,365 and $70,320, respectively, for failure to ensure that the formwork and vertical shoring were designed to safely withstand all intended loads, failure to have calculations and drawings approved by a California registered civil engineer as required for vertical shoring over 14 feet tall, and failure to ensure the shoring supports were erected on a level and stable base. General citations were issued to general contractor Johnstone Moyer, Inc. for $3,630 in proposed penalties.

Cal/OSHA addresses safety requirements for concrete construction and vertical shoring in its Cal/OSHA Pocket Guide for the Construction Industry ...
/ 2017 News, Daily News
Joung Hyen Lee, Hyen Uk Lee, and Esther Lee are former employees of The Christian Herald, Inc., a corporation they allege is solely owned and was managed by their former boss, Jun Yang.

Joung Hyen Lee was a reporter, while Hyen Uk Lee and Esther Lee were administrative assistants. These three plaintiffs filed suit against Yang and the Herald asserting five wage-and-hour claims. Hyen Uk Lee asserted three additional causes of action (assault and battery and intentional infliction of emotional distress against Yang, and premises liability against the Herald) arising out of alleged physical confrontations with Yang.

As to these claims, Hyen Uk Lee alleged that on two occasions in September 2012, Yang physically attacked her. Specifically, on September 13, 2012, Yang threw a cellular phone at her and grabbed her, causing injury to her arm and body. In addition, on September 20, 2012, Yang pushed Hyen Uk Lee against a door, causing her to hit her head on the corner of the door and lose consciousness. As to the tort claims against Yang, Hyen Uk Lee sought compensatory as well as punitive damages.

Yang argued the tort causes of action, assault and battery, and intentional infliction of emotional distress, failed to state a claim because workers’ compensation is the exclusive remedy for injury sustained in the workplace.

As to the two tort claims, the trial court noted Hyen Uk Lee alleged both incidents occurred in the workplace and concluded "the alleged facts do not fall outside of the scope of the exclusive remedy of the workers’ compensation statute. Nor is there an allegation of lack of workers’ compensation insurance as to these causes of action."

Plaintiffs appeal from the judgment entered in favor of Yang after the trial court sustained his demurrer to the first amended complaint without leave to amend. The Court of Appeal reversed the judgment in part in the unpublished case of Lee v. Yang.

The Court of Appeal reasoned that "the Labor Code provides an employee may sue his or her employer, notwithstanding the exclusive remedy provision of workers’ compensation, '[w]here the employee’s injury - is proximately caused by a willful physical assault by the employer." (§ 3602, subd. (b)(1); see also Soares v. City of Oakland (1992) 9 Cal.App.4th 1822, 1828 - 1829"

"Here, Hyen Uk Lee alleges that on September 13, 2012, Yang threw a cellular phone at her and grabbed her, causing injury to her arm and body. Hyen Uk Lee further alleges that on September 20, 2012, Yang pushed her against a door, causing her to hit her head on the corner of the door and to then lose consciousness. These allegations are sufficient to survive a demurrer on the cause of action for assault and battery." ...
/ 2017 News, Daily News
The use of cell phones has increased dramatically in recent years, including among children and young adults. These phones put out radio frequency (RF) energy. Some scientists and public health officials believe RF energy may affect human health.

And now Division of Environmental and Occupational Disease Control of the California Department of Public Health has published a guidance document that lists some of the potential health concerns, and provides guidance on how people can reduce their exposure. And certainly this may be an issue in future workers' compensation claims based upon the effects of cell phone use.

The scientific community has not reached a consensus on the risks of cell phone use, but the California health department said research suggests long-term, extensive use may affect health. Although the science is still evolving, some laboratory experiments and human health studies have suggested the possibility that long-term, high use of cell phones may be linked to certain types of cancer and other health effects, including:

- brain cancer and tumors of the acoustic nerve (needed for hearing and maintaining balance) and salivary glands
- lower sperm counts and inactive or less mobile sperm
- headaches and effects on learning and memory, hearing, behavior, and sleep

The Guidance Document concludes that "These studies do not establish the link definitely, however, and scientists disagree about whether cell phones cause these health problems and how great the risks might be. This document is intended to provide guidance for those people who want to reduce their own and their families’ exposures to RF energy from cell phones, despite this uncertainty."

"We know that simple steps, such as not keeping your phone in your pocket and moving it away from your bed at night, can help reduce exposure for both children and adults," said Dr. Karen Smith, state public health officer. Smart phones emit radio frequency energy when they send signals to and receive them from cell towers.

About 95 percent of Americans own a cell phone, and 12 percent rely on their smart phones for everyday Internet access, the health department said. In addition, the average age when children get their first phone is now just 10, and a majority of young people keep their phones on or near them most of the day and while they sleep. "Children’s brains develop through the teenage years and may be more affected by cell phone use," Smith said. "Parents should consider reducing the time their children use cell phones and encourage them to turn the devices off at night."

Other tips for reducing exposure to radio frequency energy from cell phones: Keeping the phone away from the body, reducing cell phone use when the signal is weak, reducing the use of cell phones to stream audio or video or to download or upload large files, keeping the phone away from the bed at night, removing headsets when not on a call, and avoiding products that claim to block radio frequency energy because they may actually increase your exposure.
/ 2017 News, Daily News
A new report published by Research and Markets says that the healthcare analytics market is expected to reach $29.84 billion by 2022 up from $8.92 billion in 2017, producing a compound annual growth rate (CAGR) of 27.3%.

Increasing government initiatives to increase EHR adoption, growing pressure to curb healthcare costs, availability of big data in healthcare, increasing venture capital investments, rising focus on improving patient outcomes, and technological advancements are driving the growth of the healthcare analytics market.

On the other hand, factors like the lack of skilled analysts (that limits the use of healthcare solutions), the high cost of these solutions, and operational gaps between payers and providers, are expected to limit the growth of this market to a certain extent.

The healthcare analytics market is segmented into descriptive, predictive, and prescriptive analytics by type.

The prescriptive analytics segment is expected grow at a highest CAGR during the forecast period. The high growth of this segment is attributed to the ability of prescriptive analytics to ensure the synergistic integration of predictions and prescriptions.

Based on application, the healthcare analytics market is segmented into clinical analytics, financial analytics, operational and administrative analytics, and population health analytics.

Financial analytics market is segmented into revenue cycle management; claims processing; payment integrity and fraud, waste, & abuse (FWA); and risk adjustment and risk assessment. Due to the rising focus of payers on the early detection of fraud and reducing preventable costs, the market for fraud analytics is expected to register a significant growth during the forecast period, therefore driving the market for financial analytics.

Based on the component, the healthcare analytics market is segmented into services, software, and hardware.

The services segment accounted for the largest share of the healthcare analytics market in 2016. With the increasing need for business analytics services and the introduction of technologically advanced healthcare analytics software, which requires extensive training to use as well as regular upgrades, the services segment is expected to grow at the highest CAGR during the forecast period.

In 2017, North America is expected to account for the largest share of the market followed by Europe. Factors such as growing federal healthcare mandates to curb rising healthcare costs and provide quality care; increasing regulatory requirements; growing EHR adoption; and rising government initiatives focusing on personalized medicine, population health management, and value-based reimbursements are expected to drive market growth in North America.

The report provides an overview of the healthcare analytics market. It aims at estimating the market size and future growth potential of this market across different segments such as type, application, component, delivery model, end user, and region.

The report also includes an in-depth competitive analysis of the key players in the market along with their company profiles, recent developments, and key market strategies ...
/ 2017 News, Daily News
According to a new A.M. Best Co. Inc. special report,the U.S. workers compensation industry experienced more financial impairments during a 17-year period from 2000-2016 than any other property/casualty line of business.

Best defines impairments as being situations in which a company has been placed, via court order, into conservation, rehabilitation and/or insolvent liquidation.

Overall, 354 property/casualty insurers became impaired during the study period.

Supervisory actions undertaken by insurance department regulators without court order were not considered impairments for this study unless delays or limitations were placed on policyholder payments, Best said in a statement.

According to the study, the workers compensation sector accounted for 26% of the impairments; commercial lines insurers represented 22% of the impairments, split between other liability/commercial multi-peril at 15% and commercial auto at 7%; and 23% of impairments were split among specialty lines. The remaining sectors accounted for personal lines.

Specific causal factors were identified for 91 of the impairments, with fraud or alleged fraud the leading cause and present in 23 of the impairments, while 21 impairments related primarily to affiliate problems.

Catastrophe losses, largely in Florida and Texas, were responsible for 18 impairments, while 16 companies suffered impairment after experiencing rapid growth, the according to the statement.

Of the 354 impaired companies during the period, 45% were rated by Best at some point during the period between the date of impairment and three prior year-ends.

The study concludes that there has been a significant decline in the number of impairments that Best has been involved in rating in recent years. From 2007-2016, there were 174 U. S. property/casualty impairments, of which 21% were rated by Best at a point during the period between date of impairment and three prior year-ends, compared with 45% for the 2000-2016 period, according to the statement ...
/ 2017 News, Daily News