The genetic-screening sales reps turn out at health fairs, houses of religion, parks and elder enclaves, offering seniors a chance to learn if they or their loved ones are at risk of developing cancer. All they need, the reps say, is a free cheek swab.
Reuters reports that, U.S. federal investigators say, some of the sales representatives are part of a burgeoning industry that threatens to become what multiple government investigators call the next big frontier in healthcare fraud: genetic testing, which is reaping millions of dollars from unnecessary tests that target senior citizens.
Shimon Richmond, assistant inspector general for investigations with the Office of Inspector General for the Department of Health and Human Services, said his office has seen a steady stream of complaints into genetic testing. In 2018, the inspector general’s office received about one or two complaints per week. Now, he said, the fraud hotline burns with as many as 50 calls weekly.
"We have investigations going on in this space across the country. It is not limited to one geographic region," Richmond said in an interview. "This is touching every corner."
In all, more than 300 federal investigations, conducted by multiple law enforcement agencies, are examining genetic testing fraud schemes, said a law enforcement official who spoke on condition of anonymity because the inquiries are not yet public. The investigative crush was sparked in part by unusual Medicare billing data patterns that started to emerge in 2015.
In the United States, genetic testing has skyrocketed. For Medicare, the public insurance program for elderly and disabled Americans, payouts for genetic tests jumped from $480 million in 2015 to $1.1 billion in 2018, a Reuters analysis found. Those figures do not include invoices for spending by state Medicaid programs, which serve the poor, or supplemental Medicare insurance programs offered by private insurers.
The investigations are examining billings submitted to federal health insurance programs. By law, all diagnostic lab tests must be ordered by a doctor treating a patient for a specific condition.
In the cases under review, investigators and patients told Reuters, marketers get elderly residents to turn over their Medicare or Medicaid information, along with their driver’s license and other identifying information, and tell them they will take a free cheek swab that can help them understand their risks of developing cancer or whether their genetics could unlock clues about how they will respond to drug treatments. They then get a doctor to sign off and approve the test and ship the swab off to a lab, which seeks Medicare payouts.
But many of the lab tests are not relevant to the patient’s history, and some of the doctors sign off on the results without conferring with the patient, said investigators familiar with the operations and patients interviewed by Reuters. Suspect companies pocket thousands, with a cut going to doctors, but the seniors get little, if any, benefit, investigators say.
Brian Benczkowski, the assistant attorney general for the U.S. Department of Justice’s Criminal Division, estimated that fraudulent billings submitted over the last few years are expected to total "north of $1 billion." He called genetic testing of the elderly "the next big frontier in federal healthcare fraud enforcement."
A little-explored world surrounds the marketing companies, laboratories and telemedicine companies involved in elder genetic testing. Among them is Spectrum. Another is Clio Laboratories, the Georgia-based lab that is part of an interconnected network of labs, medical billing operations, a telemedicine firm and other healthcare-related limited liability companies, company records show.
In a handful of cases, the patients who had DNA samples sent to Clio or Spectrum said they never spoke with a doctor about why the cancer or pharmacogenetic tests were medically necessary. Moreover, when test results were completed, they were mailed directly to patients’ homes. That is not the norm, say doctors and medical experts. Usually, the ordering physician receives results first, then reviews them with the patient.
In 2017, the most recent data available, Clio billed Medicare $8.6 million for genetic testing and was paid about $4.6 million.
Some of the doctors involved in the genetic testing wave also have checkered pasts. One California doctor was signing off on genetic tests for patients even as two states had disciplined him or were preparing to do so after he was criminally convicted in Los Angeles.
Orthopedic surgeon Dr. Mitchell G. Cohen pleaded guilty in November 2015 to filing a false tax return in connection with an illegal kickback scheme, cooperated with the government’s investigation, and later served more than eight months in a halfway house in central California through March 2019, court records show. Cohen was not charged with making an illegal kickback, but pleaded guilty to making a false tax return in a case federal authorities said involved kickbacks.
Cohen was approving genetic tests for Medicare patients during his stint in the halfway house and after his probation period ended. He approved the medical necessity of genetic tests handled by labs including BioConfirm in Georgia and Elite Medical Laboratories, lab records show. He signed off on the genetic test for Elite in September 2018, as he was serving his sentence in the halfway house, records show. He approved the medical necessity of tests sent to Bioconfirm on May 10, 2019 ...
Reuters reports that, U.S. federal investigators say, some of the sales representatives are part of a burgeoning industry that threatens to become what multiple government investigators call the next big frontier in healthcare fraud: genetic testing, which is reaping millions of dollars from unnecessary tests that target senior citizens.
Shimon Richmond, assistant inspector general for investigations with the Office of Inspector General for the Department of Health and Human Services, said his office has seen a steady stream of complaints into genetic testing. In 2018, the inspector general’s office received about one or two complaints per week. Now, he said, the fraud hotline burns with as many as 50 calls weekly.
"We have investigations going on in this space across the country. It is not limited to one geographic region," Richmond said in an interview. "This is touching every corner."
In all, more than 300 federal investigations, conducted by multiple law enforcement agencies, are examining genetic testing fraud schemes, said a law enforcement official who spoke on condition of anonymity because the inquiries are not yet public. The investigative crush was sparked in part by unusual Medicare billing data patterns that started to emerge in 2015.
In the United States, genetic testing has skyrocketed. For Medicare, the public insurance program for elderly and disabled Americans, payouts for genetic tests jumped from $480 million in 2015 to $1.1 billion in 2018, a Reuters analysis found. Those figures do not include invoices for spending by state Medicaid programs, which serve the poor, or supplemental Medicare insurance programs offered by private insurers.
The investigations are examining billings submitted to federal health insurance programs. By law, all diagnostic lab tests must be ordered by a doctor treating a patient for a specific condition.
In the cases under review, investigators and patients told Reuters, marketers get elderly residents to turn over their Medicare or Medicaid information, along with their driver’s license and other identifying information, and tell them they will take a free cheek swab that can help them understand their risks of developing cancer or whether their genetics could unlock clues about how they will respond to drug treatments. They then get a doctor to sign off and approve the test and ship the swab off to a lab, which seeks Medicare payouts.
But many of the lab tests are not relevant to the patient’s history, and some of the doctors sign off on the results without conferring with the patient, said investigators familiar with the operations and patients interviewed by Reuters. Suspect companies pocket thousands, with a cut going to doctors, but the seniors get little, if any, benefit, investigators say.
Brian Benczkowski, the assistant attorney general for the U.S. Department of Justice’s Criminal Division, estimated that fraudulent billings submitted over the last few years are expected to total "north of $1 billion." He called genetic testing of the elderly "the next big frontier in federal healthcare fraud enforcement."
A little-explored world surrounds the marketing companies, laboratories and telemedicine companies involved in elder genetic testing. Among them is Spectrum. Another is Clio Laboratories, the Georgia-based lab that is part of an interconnected network of labs, medical billing operations, a telemedicine firm and other healthcare-related limited liability companies, company records show.
In a handful of cases, the patients who had DNA samples sent to Clio or Spectrum said they never spoke with a doctor about why the cancer or pharmacogenetic tests were medically necessary. Moreover, when test results were completed, they were mailed directly to patients’ homes. That is not the norm, say doctors and medical experts. Usually, the ordering physician receives results first, then reviews them with the patient.
In 2017, the most recent data available, Clio billed Medicare $8.6 million for genetic testing and was paid about $4.6 million.
Some of the doctors involved in the genetic testing wave also have checkered pasts. One California doctor was signing off on genetic tests for patients even as two states had disciplined him or were preparing to do so after he was criminally convicted in Los Angeles.
Orthopedic surgeon Dr. Mitchell G. Cohen pleaded guilty in November 2015 to filing a false tax return in connection with an illegal kickback scheme, cooperated with the government’s investigation, and later served more than eight months in a halfway house in central California through March 2019, court records show. Cohen was not charged with making an illegal kickback, but pleaded guilty to making a false tax return in a case federal authorities said involved kickbacks.
Cohen was approving genetic tests for Medicare patients during his stint in the halfway house and after his probation period ended. He approved the medical necessity of genetic tests handled by labs including BioConfirm in Georgia and Elite Medical Laboratories, lab records show. He signed off on the genetic test for Elite in September 2018, as he was serving his sentence in the halfway house, records show. He approved the medical necessity of tests sent to Bioconfirm on May 10, 2019 ...
A Riverside County man pleaded guilty to two federal drug trafficking charges, one of which involves the theft of at least nine doctors’ DEA numbers and dates of birth that he used to obtain oxycodone and other prescription medications that he later sold on the darknet.
Christopher Lazenby, 29, of Homeland, pleaded guilty to a two-count criminal information charging him with possessing with intent to distribute methamphetamine and oxycodone.
According to his plea agreement, Lazenby perpetrated his scheme by stealing the identities of at least nine doctors and one physician’s assistant, which allowed him to use the Drug Enforcement Administration’s online registration system to change the addresses of eight doctors to mailboxes he had rented in South Los Angeles and Carson. Lazenby changed the address of a ninth doctor to show his medical office was a room at a Motel 6 in Inglewood, according to an affidavit filed with the criminal complaint in the case.
With official records showing new addresses for the doctors, Lazenby - who used the aliases "Jamey Neher," "Bryan Sheldon," and "Colin Bohlinger" - forged the doctors’ signatures on counterfeit prescriptions and ordered oxycodone, hydrocodone and Adderall to be sent to the addresses he controlled, the plea agreement states. Lazenby admitted that after he received the narcotics, he used the dark web and Craigslist to advertise the drugs for sale.
Lazenby was arrested on October 3, 2018 at his hotel room in Torrance, which he had rented using an alias, the plea agreement states. During searches of his hotel room and car, law enforcement seized narcotics including 196 grams of methamphetamine, oxycodone pills, prescription pads in the names of the identity theft victim doctors, rubber stamps in the names of ID theft victim doctors (which Lazenby used to fraudulently sign the counterfeit prescriptions), and computer equipment, according to the plea agreement.
United States District Judge Stephen V. Wilson scheduled a February 10, 2020 sentencing hearing, at which time Lazenby will face a statutory maximum sentence of life in federal prison and a mandatory minimum sentence of 10 years in federal prison ...
Christopher Lazenby, 29, of Homeland, pleaded guilty to a two-count criminal information charging him with possessing with intent to distribute methamphetamine and oxycodone.
According to his plea agreement, Lazenby perpetrated his scheme by stealing the identities of at least nine doctors and one physician’s assistant, which allowed him to use the Drug Enforcement Administration’s online registration system to change the addresses of eight doctors to mailboxes he had rented in South Los Angeles and Carson. Lazenby changed the address of a ninth doctor to show his medical office was a room at a Motel 6 in Inglewood, according to an affidavit filed with the criminal complaint in the case.
With official records showing new addresses for the doctors, Lazenby - who used the aliases "Jamey Neher," "Bryan Sheldon," and "Colin Bohlinger" - forged the doctors’ signatures on counterfeit prescriptions and ordered oxycodone, hydrocodone and Adderall to be sent to the addresses he controlled, the plea agreement states. Lazenby admitted that after he received the narcotics, he used the dark web and Craigslist to advertise the drugs for sale.
Lazenby was arrested on October 3, 2018 at his hotel room in Torrance, which he had rented using an alias, the plea agreement states. During searches of his hotel room and car, law enforcement seized narcotics including 196 grams of methamphetamine, oxycodone pills, prescription pads in the names of the identity theft victim doctors, rubber stamps in the names of ID theft victim doctors (which Lazenby used to fraudulently sign the counterfeit prescriptions), and computer equipment, according to the plea agreement.
United States District Judge Stephen V. Wilson scheduled a February 10, 2020 sentencing hearing, at which time Lazenby will face a statutory maximum sentence of life in federal prison and a mandatory minimum sentence of 10 years in federal prison ...
Studies continue to show that artificial intelligence is on a par with human experts when it comes to making medical diagnoses based on images.
The potential for artificial intelligence in healthcare has caused excitement, with advocates saying it will ease the strain on resources, free up time for doctor-patient interactions and even aid the development of tailored treatment. Last month the UK announced £250m of funding for a new NHS artificial intelligence laboratory.
However, experts have warned the latest findings are based on a small number of studies, since the field is littered with poor-quality research.
One burgeoning application is the use of AI in interpreting medical images - a field that relies on deep learning, a sophisticated form of machine learning in which a series of labelled images are fed into algorithms that pick out features within them and learn how to classify similar images. This approach has shown promise in diagnosis of diseases from cancers to eye conditions.
However questions remain about how such deep learning systems measure up to human skills. Now researchers say they have conducted the first comprehensive review of published studies on the issue, and found humans and machines are on a par.
Prof Alastair Denniston, at the University Hospitals Birmingham NHS foundation trust and a co-author of the study, said the results were encouraging but the study was a reality check for some of the hype about AI.
Dr Xiaoxuan Liu, the lead author of the study and from the same NHS trust, agreed. 'There are a lot of headlines about AI outperforming humans, but our message is that it can at best be equivalent,' she said.
Writing in the Lancet Digital Health, Denniston, Liu and colleagues reported how they focused on research papers published since 2012 - a pivotal year for deep learning.
An initial search turned up more than 20,000 relevant studies. However, only 14 studies - all based on human disease - reported good quality data, tested the deep learning system with images from a separate dataset to the one used to train it, and showed the same images to human experts.
The team pooled the most promising results from within each of the 14 studies to reveal that deep learning systems correctly detected a disease state 87% of the time - compared with 86% for healthcare professionals - and correctly gave the all-clear 93% of the time, compared with 91% for human experts.
However, the healthcare professionals in these scenarios were not given additional patient information they would have in the real world which could steer their diagnosis.
Prof David Spiegelhalter, the chair of the Winton centre for risk and evidence communication at the University of Cambridge, said the field was awash with poor research.
"This excellent review demonstrates that the massive hype over AI in medicine obscures the lamentable quality of almost all evaluation studies," he said. "Deep learning can be a powerful and impressive technique, but clinicians and commissioners should be asking the crucial question: what does it actually add to clinical practice?"
However, Denniston remained optimistic about the potential of AI in healthcare, saying such deep learning systems could act as a diagnostic tool and help tackle the backlog of scans and images. What’s more, said Liu, they could prove useful in places which lack experts to interpret images.
Liu said it would be important to use deep learning systems in clinical trials to assess whether patient outcomes improved compared with current practices ...
The potential for artificial intelligence in healthcare has caused excitement, with advocates saying it will ease the strain on resources, free up time for doctor-patient interactions and even aid the development of tailored treatment. Last month the UK announced £250m of funding for a new NHS artificial intelligence laboratory.
However, experts have warned the latest findings are based on a small number of studies, since the field is littered with poor-quality research.
One burgeoning application is the use of AI in interpreting medical images - a field that relies on deep learning, a sophisticated form of machine learning in which a series of labelled images are fed into algorithms that pick out features within them and learn how to classify similar images. This approach has shown promise in diagnosis of diseases from cancers to eye conditions.
However questions remain about how such deep learning systems measure up to human skills. Now researchers say they have conducted the first comprehensive review of published studies on the issue, and found humans and machines are on a par.
Prof Alastair Denniston, at the University Hospitals Birmingham NHS foundation trust and a co-author of the study, said the results were encouraging but the study was a reality check for some of the hype about AI.
Dr Xiaoxuan Liu, the lead author of the study and from the same NHS trust, agreed. 'There are a lot of headlines about AI outperforming humans, but our message is that it can at best be equivalent,' she said.
Writing in the Lancet Digital Health, Denniston, Liu and colleagues reported how they focused on research papers published since 2012 - a pivotal year for deep learning.
An initial search turned up more than 20,000 relevant studies. However, only 14 studies - all based on human disease - reported good quality data, tested the deep learning system with images from a separate dataset to the one used to train it, and showed the same images to human experts.
The team pooled the most promising results from within each of the 14 studies to reveal that deep learning systems correctly detected a disease state 87% of the time - compared with 86% for healthcare professionals - and correctly gave the all-clear 93% of the time, compared with 91% for human experts.
However, the healthcare professionals in these scenarios were not given additional patient information they would have in the real world which could steer their diagnosis.
Prof David Spiegelhalter, the chair of the Winton centre for risk and evidence communication at the University of Cambridge, said the field was awash with poor research.
"This excellent review demonstrates that the massive hype over AI in medicine obscures the lamentable quality of almost all evaluation studies," he said. "Deep learning can be a powerful and impressive technique, but clinicians and commissioners should be asking the crucial question: what does it actually add to clinical practice?"
However, Denniston remained optimistic about the potential of AI in healthcare, saying such deep learning systems could act as a diagnostic tool and help tackle the backlog of scans and images. What’s more, said Liu, they could prove useful in places which lack experts to interpret images.
Liu said it would be important to use deep learning systems in clinical trials to assess whether patient outcomes improved compared with current practices ...
Pursuant to Labor Code section 5307.1, subdivision (g)(2), the Administrative Director of the Division of Workers’ Compensation ordered that the Durable Medical Equipment, Prosthetics, Orthotics, Supplies portion of the Official Medical Fee Schedule contained in title 8, California Code of Regulations, section 9789.60, is adjusted to conform to changes to the Medicare payment system that were adopted by the Centers for Medicare & Medicaid Services (CMS) in the October 2019 Quarter 4 DMEPOS Fee Schedule update.
Effective for services rendered on or after October 1, 2019, the maximum reasonable fees for Durable Medical Equipment, Prosthetics, Orthotics, Supplies shall not exceed 120% of the applicable California fees set forth in the Medicare calendar year 2019 "Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) Fee Schedule" revised effective October 2019, contained in the electronic file "DME19-D [ZIP, 4MB]" which is adopted and incorporated by reference, excluding the "Former CBA Fee Schedule File", "Former CBA National Mail-Order DTS Fee Schedule File", and "Former CBA Zip Code File".
The fee schedule data file (DMEPOS_OCT) sets forth two columns for California labelled: "CA (NR)" [California Non-Rural] and "CA (R)" [California Rural]. For the services on or after October 1, 2019, payment shall not exceed 120% of the fee set forth for the HCPCS code in the CA (NR) column, except the fee shall not exceed 120% of the fee set forth in the CA (R) column if the injured worker’s residence zip code appears on the DMERuralzip_Q42019 file. Where column CA (NR) sets forth a fee for a code, but CA (R) for the code is listed as "0.00" the fee shall not exceed 120% of the CA (NR) fee, regardless of whether the injured worker’s address zip code is rural or non-rural.
DME19-D [ZIP, 4MB] includes the following documents which are incorporated by reference:
-- DMEBACK 2019
-- DMEPOS_OCT
-- DMEREAD 2019 rev 6-1-19
-- DMERuralzip_Q42019
Excluding:
-- Former CBA Fee Schedule File
-- Former CBA National Mail-Order DTS Fee Schedule File
-- Former CBA Zip Code File
The CMS Manual System, Pub 100-4 Medicare Claims Processing, Transmittal 4386, Change Request 11433, August 30, 2019 sets forth the fourth quarter changes and is relied upon in adopting this update Order.
CMS has not made second, third or fourth quarter updates to the 2019 Parenteral and Enteral Nutrition fee schedule (PEN) file. Therefore, the Administrative Director Order dated December 21, 2018 continues to be effective for Parenteral and Enteral Nutrition fees, and the DMEPEN_JAN file contained in the DME19-A remains effective for services rendered on or after October 1, 2019.
The Medicare October 2019 fourth quarter DMEPOS fee schedule revision is available on the Centers for Medicare & Medicaid Services’ DMEPOS Fee Schedule quarterly file webpage ...
Effective for services rendered on or after October 1, 2019, the maximum reasonable fees for Durable Medical Equipment, Prosthetics, Orthotics, Supplies shall not exceed 120% of the applicable California fees set forth in the Medicare calendar year 2019 "Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) Fee Schedule" revised effective October 2019, contained in the electronic file "DME19-D [ZIP, 4MB]" which is adopted and incorporated by reference, excluding the "Former CBA Fee Schedule File", "Former CBA National Mail-Order DTS Fee Schedule File", and "Former CBA Zip Code File".
The fee schedule data file (DMEPOS_OCT) sets forth two columns for California labelled: "CA (NR)" [California Non-Rural] and "CA (R)" [California Rural]. For the services on or after October 1, 2019, payment shall not exceed 120% of the fee set forth for the HCPCS code in the CA (NR) column, except the fee shall not exceed 120% of the fee set forth in the CA (R) column if the injured worker’s residence zip code appears on the DMERuralzip_Q42019 file. Where column CA (NR) sets forth a fee for a code, but CA (R) for the code is listed as "0.00" the fee shall not exceed 120% of the CA (NR) fee, regardless of whether the injured worker’s address zip code is rural or non-rural.
DME19-D [ZIP, 4MB] includes the following documents which are incorporated by reference:
-- DMEBACK 2019
-- DMEPOS_OCT
-- DMEREAD 2019 rev 6-1-19
-- DMERuralzip_Q42019
Excluding:
-- Former CBA Fee Schedule File
-- Former CBA National Mail-Order DTS Fee Schedule File
-- Former CBA Zip Code File
The CMS Manual System, Pub 100-4 Medicare Claims Processing, Transmittal 4386, Change Request 11433, August 30, 2019 sets forth the fourth quarter changes and is relied upon in adopting this update Order.
CMS has not made second, third or fourth quarter updates to the 2019 Parenteral and Enteral Nutrition fee schedule (PEN) file. Therefore, the Administrative Director Order dated December 21, 2018 continues to be effective for Parenteral and Enteral Nutrition fees, and the DMEPEN_JAN file contained in the DME19-A remains effective for services rendered on or after October 1, 2019.
The Medicare October 2019 fourth quarter DMEPOS fee schedule revision is available on the Centers for Medicare & Medicaid Services’ DMEPOS Fee Schedule quarterly file webpage ...
A Huntington Beach doctor with a history of legal and disciplinary problems is one of the 25 people accused of participating in a Medicare fraud scheme that netted about $150 million through fraudulent insurance claims, according to federal prosecutors.
74 year old Nagesh Shetty, was just indicted in connection with the scheme, which involved "medically unnecessary" cardiac treatments and testing through an Inglewood healthcare provider, Global Cardio Care.
Shetty was first licensed by the California Medical Board in 1979 and has operated practices in Costa Mesa, West Covina and the West Hills neighborhood of Los Angeles, according to documents and online records.
In 1994, Shetty was indicted in federal court on 28 counts of mail fraud on allegations of defrauding a Minnesota-based insurance company through nonexistent, medically unnecessary or excessive medical treatment."That case was later transferred to a California district court and charges were eventually dropped, court records show.
In 1996, Shetty was sentenced to 21 months in federal prison and fined $40,000 for filing false income tax returns and failing to report more than $400,000 in income over a three-year period in the 1980s, court documents show. At the time of the crimes, Shetty was owner and attending physician of Harbor Newport Medical Clinic in Costa Mesa.
While in prison, Shetty was indicted in 1998 on federal charges alleging that he defrauded military and private health insurance programs.
In 2000, a jury convicted Shetty of 26 felony counts of mail fraud and he was sentenced to two years in prison and three years’ supervised release, court records show. He also was ordered to pay restitution, including more than $28,000 to the U.S. Treasury and more than $19,000 to Blue Cross Blue Shield, court records show.
The California Medical Board revoked Shetty’s license in 2000, according to board records. His license to practice medicine also was revoked in New York in 1999 and Washington state in 2001, records show.
In 2005, Shetty petitioned the California board to reinstate his medical certificate. At the time, Shetty was bagging groceries and stocking shelves at a store and said his inability to practice his profession had caused emotional and financial strain for his wife and four children.
He was granted a probationary license, according to a decision by an administrative law judge, with the conditions that he complete an ethics course and a clinical training program, undergo monitoring and be barred from practicing solo, supervising physician assistants and handling any billing matters.
In 2009, Shetty completed his probation and the board reinstated his license.
In a disciplinary order effective April 26 2019, the board issued Shetty a public reprimand stemming from a case in which he was accused of repeated negligence and failure to maintain adequate and accurate records involving a patient in 2016, according to California Department of Consumer Affairs records.
And now he faces charges for his 2019 arrest! ...
74 year old Nagesh Shetty, was just indicted in connection with the scheme, which involved "medically unnecessary" cardiac treatments and testing through an Inglewood healthcare provider, Global Cardio Care.
Shetty was first licensed by the California Medical Board in 1979 and has operated practices in Costa Mesa, West Covina and the West Hills neighborhood of Los Angeles, according to documents and online records.
In 1994, Shetty was indicted in federal court on 28 counts of mail fraud on allegations of defrauding a Minnesota-based insurance company through nonexistent, medically unnecessary or excessive medical treatment."That case was later transferred to a California district court and charges were eventually dropped, court records show.
In 1996, Shetty was sentenced to 21 months in federal prison and fined $40,000 for filing false income tax returns and failing to report more than $400,000 in income over a three-year period in the 1980s, court documents show. At the time of the crimes, Shetty was owner and attending physician of Harbor Newport Medical Clinic in Costa Mesa.
While in prison, Shetty was indicted in 1998 on federal charges alleging that he defrauded military and private health insurance programs.
In 2000, a jury convicted Shetty of 26 felony counts of mail fraud and he was sentenced to two years in prison and three years’ supervised release, court records show. He also was ordered to pay restitution, including more than $28,000 to the U.S. Treasury and more than $19,000 to Blue Cross Blue Shield, court records show.
The California Medical Board revoked Shetty’s license in 2000, according to board records. His license to practice medicine also was revoked in New York in 1999 and Washington state in 2001, records show.
In 2005, Shetty petitioned the California board to reinstate his medical certificate. At the time, Shetty was bagging groceries and stocking shelves at a store and said his inability to practice his profession had caused emotional and financial strain for his wife and four children.
He was granted a probationary license, according to a decision by an administrative law judge, with the conditions that he complete an ethics course and a clinical training program, undergo monitoring and be barred from practicing solo, supervising physician assistants and handling any billing matters.
In 2009, Shetty completed his probation and the board reinstated his license.
In a disciplinary order effective April 26 2019, the board issued Shetty a public reprimand stemming from a case in which he was accused of repeated negligence and failure to maintain adequate and accurate records involving a patient in 2016, according to California Department of Consumer Affairs records.
And now he faces charges for his 2019 arrest! ...
Former licensed public adjuster John Schoon, 54, of Huntington Beach, was sentenced to 180 days in county jail and five years of felony probation after pleading guilty to three felony counts of embezzlement and one felony count of forgery. Schoon stole over $132,000 in claims proceeds for clients by forging signatures and guarantee stamps.
Schoon has already paid $12,000 in restitution and was ordered to pay an additional $52,311 as a condition of his probation. Additionally, Schoon is not to have any contact with his victims and is forbidden from engaging in insurance related activities.
"The Department’s investigation revealed this adjuster went to great lengths to defraud his clients," said Insurance Commissioner Ricardo Lara.
An investigation by the California Department of Insurance (CDI) revealed that Schoon, acting as World Wide Public Adjusters, negotiated checks by forging the signature of at least one of his clients and also forged endorsement guarantee stamps on behalf of that client’s mortgage company.
On January 17, 2015, CDI revoked Schoon's licensing rights and privileges; however, Schoon continued to act as a public adjuster under the license of his wife, Andrea Schoon, which she obtained one month later on February 20, 2015. Interviews with several insureds that were represented by World Wide Public Adjusters, Inc. revealed they entered into contracts with Mr. Schoon and not his wife, although the contracts listed her public adjuster license number.
On September 12, 2016, his wife's public adjuster licensing rights were revoked. Mr. Schoon continued to act as a public adjuster and on at least one occasion, used the public adjuster license number that belonged to a former colleague.
He failed to provide clients with the claim proceeds they were owed on multiple occasions. Mr. Schoon lied to clients about the status of their payments and wrote fraudulent checks with no intention of providing them with their funds, while using those claims proceeds for personal expenses or to pay other clients. In some cases, it appears that the clients were not even aware of some of the payments issued with regards to their insurance claims. Mr. Schoon did not provide clients with their claim proceeds and/or outstanding balances until they filed claims against his or his wife’s bonds or threatened legal action. This case was prosecuted by the Orange County District Attorney’s office ...
Schoon has already paid $12,000 in restitution and was ordered to pay an additional $52,311 as a condition of his probation. Additionally, Schoon is not to have any contact with his victims and is forbidden from engaging in insurance related activities.
"The Department’s investigation revealed this adjuster went to great lengths to defraud his clients," said Insurance Commissioner Ricardo Lara.
An investigation by the California Department of Insurance (CDI) revealed that Schoon, acting as World Wide Public Adjusters, negotiated checks by forging the signature of at least one of his clients and also forged endorsement guarantee stamps on behalf of that client’s mortgage company.
On January 17, 2015, CDI revoked Schoon's licensing rights and privileges; however, Schoon continued to act as a public adjuster under the license of his wife, Andrea Schoon, which she obtained one month later on February 20, 2015. Interviews with several insureds that were represented by World Wide Public Adjusters, Inc. revealed they entered into contracts with Mr. Schoon and not his wife, although the contracts listed her public adjuster license number.
On September 12, 2016, his wife's public adjuster licensing rights were revoked. Mr. Schoon continued to act as a public adjuster and on at least one occasion, used the public adjuster license number that belonged to a former colleague.
He failed to provide clients with the claim proceeds they were owed on multiple occasions. Mr. Schoon lied to clients about the status of their payments and wrote fraudulent checks with no intention of providing them with their funds, while using those claims proceeds for personal expenses or to pay other clients. In some cases, it appears that the clients were not even aware of some of the payments issued with regards to their insurance claims. Mr. Schoon did not provide clients with their claim proceeds and/or outstanding balances until they filed claims against his or his wife’s bonds or threatened legal action. This case was prosecuted by the Orange County District Attorney’s office ...
The court of appeal ruled on a case between CIGA and the Travelers that upheld the endorsement on the Travelers policy limiting its coverage for special employees in a general special employment situation.
In the unpublished case of Travelers v WCAB, and CIGA, two employers agreed that the general employer, StaffChex, vwould obtain workers’ compensation insurance for employees it leased to the special employer Jessie Lord Bakery. Relying on this agreement, the special employer obtained workers’ compensation insurance from Travelers for its own employees with a "limiting endorsement" excluding coverage for special employees.
These agreements were in place for several years when a special employee, Jose Luis Mastache, was injured on the job while assigned to the special employer. The general employer’s insurer, Ullico Casualty Company, thereafter became insolvent and California Insurance Guarantee Association (CIGA) took over the administration of the claim.
Although there was a written endorsement attached to the Traveler's policy excluding coverage for special employees, and the special employee’s carrier was informed the general employee had obtained the required workers’ compensation insurance, the Workers’ Compensation Appeals Board invalidated the Travelers limiting endorsement because the limiting endorsement had not been signed by the special employer. The written affirmation was required under WCAB Rules, section 2259(e) in effect at the time the Travelers policy was written.
Thus, Travelers, the insurer for the special employer was ordered to bear all liability for compensation to the injured worker when the general employer’s insurer became insolvent. This obligated Travelers to pay the entire claim since CIGA had shown there was "other" insurance in effect. Travelers appealed and the court of appeal reversed the WCAB in the unpublished case.
The question of whether Travelers is "other insurance," relieving CIGA of liability, turns on whether the endorsement in the Travelers policy is valid.
The court of appeals made the observation that it was addressing a commercial relationship between two relatively sophisticated parties and a third sophisticated insurance company who embarked on a course of dealing that had been in place for a number of years before Mastache was injured.This entire structure was set aside by the appeals board, ostensibly over the absence of a signature by Jessie Lord on the endorsement to the contract with Travelers, even though this contractual structure had been functioning for three years when Mastache was injured.
The parties complied with the applicable regulatory requirements and it is undisputed that they complied with their contractual commitments to one another. They performed these contractual commitments for several years. The court of appeals concluded that the appeal board’s decision was thus unreasonable and inequitable.
"Nullifying a three-sided, sophisticated contractual structure, under which all three parties performed their obligations in good faith over the absence of a signature on an endorsement to a contract disregards reality and is inequitable." ...
In the unpublished case of Travelers v WCAB, and CIGA, two employers agreed that the general employer, StaffChex, vwould obtain workers’ compensation insurance for employees it leased to the special employer Jessie Lord Bakery. Relying on this agreement, the special employer obtained workers’ compensation insurance from Travelers for its own employees with a "limiting endorsement" excluding coverage for special employees.
These agreements were in place for several years when a special employee, Jose Luis Mastache, was injured on the job while assigned to the special employer. The general employer’s insurer, Ullico Casualty Company, thereafter became insolvent and California Insurance Guarantee Association (CIGA) took over the administration of the claim.
Although there was a written endorsement attached to the Traveler's policy excluding coverage for special employees, and the special employee’s carrier was informed the general employee had obtained the required workers’ compensation insurance, the Workers’ Compensation Appeals Board invalidated the Travelers limiting endorsement because the limiting endorsement had not been signed by the special employer. The written affirmation was required under WCAB Rules, section 2259(e) in effect at the time the Travelers policy was written.
Thus, Travelers, the insurer for the special employer was ordered to bear all liability for compensation to the injured worker when the general employer’s insurer became insolvent. This obligated Travelers to pay the entire claim since CIGA had shown there was "other" insurance in effect. Travelers appealed and the court of appeal reversed the WCAB in the unpublished case.
The question of whether Travelers is "other insurance," relieving CIGA of liability, turns on whether the endorsement in the Travelers policy is valid.
The court of appeals made the observation that it was addressing a commercial relationship between two relatively sophisticated parties and a third sophisticated insurance company who embarked on a course of dealing that had been in place for a number of years before Mastache was injured.This entire structure was set aside by the appeals board, ostensibly over the absence of a signature by Jessie Lord on the endorsement to the contract with Travelers, even though this contractual structure had been functioning for three years when Mastache was injured.
The parties complied with the applicable regulatory requirements and it is undisputed that they complied with their contractual commitments to one another. They performed these contractual commitments for several years. The court of appeals concluded that the appeal board’s decision was thus unreasonable and inequitable.
"Nullifying a three-sided, sophisticated contractual structure, under which all three parties performed their obligations in good faith over the absence of a signature on an endorsement to a contract disregards reality and is inequitable." ...
On September 5, 2019, the California Insurance Commissioner approved changes to the California Workers’ Compensation Uniform Statistical Reporting Plan - 1995 (USRP), California Workers’ Compensation Experience Rating Plan - 1995 (ERP) and Miscellaneous Regulations for the Recording and Reporting of Data - 1995 (Miscellaneous Regulations). These changes are effective January 1, 2020.
The 2020 versions of these publications, along with the advisory California Basic Underwriting Manual, are now available in the Filings and Plans section of the Workers’ Compensation Insurance Rating Bureau of California (WCIRB) website and at the links below.
California Workers' Compensation Uniform Statistical Reporting Plan - 1995.
California Workers' Compensation Experience Rating Plan - 1995.
Miscellaneous Regulations for the Recording and Reporting of Data - 1995.
California Basic Underwriting Manual.
The Classification Search tool on wcirb.com has also been updated to reflect new and revised classifications effective January 1, 2020. Users can search classifications by keyword or classification code and view current classification phraseologies, footnotes and related USRP rules. The Classification Search also provides the prior year’s phraseology for comparison, which is at the bottom of each classification’s Detail Record page in the Prior Phraseology and Footnote section.
Enter a search term or classification code using the tool to begin your search. Narrow your search by choosing an industry group or related classifications from the "Filter By" pulldown menu. Refer to the Insurance Commissioner's rules regarding the Standard Classification System in Part 3, Standard Classification System, of the California Workers' Compensation Uniform Statistical Reporting Plan - 1995 (USRP) ...
The 2020 versions of these publications, along with the advisory California Basic Underwriting Manual, are now available in the Filings and Plans section of the Workers’ Compensation Insurance Rating Bureau of California (WCIRB) website and at the links below.
California Workers' Compensation Uniform Statistical Reporting Plan - 1995.
California Workers' Compensation Experience Rating Plan - 1995.
Miscellaneous Regulations for the Recording and Reporting of Data - 1995.
California Basic Underwriting Manual.
The Classification Search tool on wcirb.com has also been updated to reflect new and revised classifications effective January 1, 2020. Users can search classifications by keyword or classification code and view current classification phraseologies, footnotes and related USRP rules. The Classification Search also provides the prior year’s phraseology for comparison, which is at the bottom of each classification’s Detail Record page in the Prior Phraseology and Footnote section.
Enter a search term or classification code using the tool to begin your search. Narrow your search by choosing an industry group or related classifications from the "Filter By" pulldown menu. Refer to the Insurance Commissioner's rules regarding the Standard Classification System in Part 3, Standard Classification System, of the California Workers' Compensation Uniform Statistical Reporting Plan - 1995 (USRP) ...
A local health care fraud enforcement action has resulted in federal charges against of 25 Southern California defendants for their alleged involvement in healthcare fraud schemes that fraudulently sought over $150 million from the Medicare and Medicaid programs, as well as private insurers and union health benefit plans. Fourteen of those charged in federal court in Los Angeles and Santa Ana are doctors or medical professionals.
A total of 10 cases have been announced. Those charged are:
Dr. Ronald Weaver, 70, of Pacific Palisades; Sara Soulati, 49, of Santa Monica; Dr. John Weaver, 75, of Alhambra; Dr. Ronald Carlish, 78, of Pacific Palisades; Dr. Howard Elkin, 68, of Whittier; Dr. Wolfgang Scheele, 79, of Los Angeles; and Dr. Nagesh Shetty, 74 of Huntington Beach, who were charged for their alleged participation in an approximately $135 million scheme to defraud Medicare through medically unnecessary cardiac treatments and testing through Global Cardio Care of Inglewood.
Navid Vahedi, 40, of Los Angeles; Vahedi’s pharmacy, Fusion Rx Compounding Pharmacy; and Joseph S. Kieffer, 39, a marketer, of Los Angeles, who were charged in a fraud and kickback scheme. Vahedi and Kieffer, allegedly paid commissions to marketers and some patients to obtain medically unnecessary compounded drugs to allow Fusion Rx to bill health care providers for those compounded drugs, many of which were reimbursed at rates much higher than average medications.
Hilda Haroutunian, 59, of Sun Valley; Dr. Keyvan Amirikhorheh, 60, of Seal Beach; Lorraine Watson, 56, a physician’s assistant, of Valley Village; Noem Sarkisyan, 63, of North Hollywood; and Edmond Sarkisyan, 40, a medical assistant, of North Hollywood, who were charged for their alleged participation in an approximately $10 million scheme to defraud the Family Planning, Access, Care and Treatment (Family PACT) program administered by Medi-Cal, the California Medicaid program, through fraudulent claims for family planning services, testing and prescriptions for non-existent patients submitted through Los Angeles Community Clinic and associated diagnostic testing laboratories and pharmacies.
Amir Friedman, 54, an anesthesiologist, of Calabasas, who is charged for his alleged participation in a conspiracy to commit honest services mail and wire fraud and Travel Act violations involving approximately $800,000 in kickbacks for compounded pharmaceutical drugs involving New Age Pharmaceuticals, Inc., in Beverly Hills.
Susan H. Poon, 54, a chiropractor who resides in Dana Point, who was arrested after a federal grand jury charged her in an approximately $2 million scheme to defraud Anthem, Aetna, and other Blue Cross Blue Shield Association affiliates, including the Teamsters Western Region and Local 177 health care plans.
Antonio Olivera, 78, of Downey; Emelita Cephass, 57, of Downey; and Martin Canter, 70, of Rancho Palos Verdes, who were charged for their alleged participation in a hospice kickback scheme.
Mahyar David Yadidi, 37, a chiropractor who resides in Los Angeles, who was charged with conspiracy to commit health care fraud for operating a scheme to defraud the International Longshore and Warehouse Union - Pacific Maritime Association health care benefit plan.
Darren Hines, 49, a chiropractor who lives in the Harbor City neighborhood of Los Angeles, who was charged with health care fraud for operating a scheme to defraud the International Longshore and Warehouse Union - Pacific Maritime Association health care benefit plan ...
A total of 10 cases have been announced. Those charged are:
Dr. Ronald Weaver, 70, of Pacific Palisades; Sara Soulati, 49, of Santa Monica; Dr. John Weaver, 75, of Alhambra; Dr. Ronald Carlish, 78, of Pacific Palisades; Dr. Howard Elkin, 68, of Whittier; Dr. Wolfgang Scheele, 79, of Los Angeles; and Dr. Nagesh Shetty, 74 of Huntington Beach, who were charged for their alleged participation in an approximately $135 million scheme to defraud Medicare through medically unnecessary cardiac treatments and testing through Global Cardio Care of Inglewood.
Navid Vahedi, 40, of Los Angeles; Vahedi’s pharmacy, Fusion Rx Compounding Pharmacy; and Joseph S. Kieffer, 39, a marketer, of Los Angeles, who were charged in a fraud and kickback scheme. Vahedi and Kieffer, allegedly paid commissions to marketers and some patients to obtain medically unnecessary compounded drugs to allow Fusion Rx to bill health care providers for those compounded drugs, many of which were reimbursed at rates much higher than average medications.
Hilda Haroutunian, 59, of Sun Valley; Dr. Keyvan Amirikhorheh, 60, of Seal Beach; Lorraine Watson, 56, a physician’s assistant, of Valley Village; Noem Sarkisyan, 63, of North Hollywood; and Edmond Sarkisyan, 40, a medical assistant, of North Hollywood, who were charged for their alleged participation in an approximately $10 million scheme to defraud the Family Planning, Access, Care and Treatment (Family PACT) program administered by Medi-Cal, the California Medicaid program, through fraudulent claims for family planning services, testing and prescriptions for non-existent patients submitted through Los Angeles Community Clinic and associated diagnostic testing laboratories and pharmacies.
Amir Friedman, 54, an anesthesiologist, of Calabasas, who is charged for his alleged participation in a conspiracy to commit honest services mail and wire fraud and Travel Act violations involving approximately $800,000 in kickbacks for compounded pharmaceutical drugs involving New Age Pharmaceuticals, Inc., in Beverly Hills.
Susan H. Poon, 54, a chiropractor who resides in Dana Point, who was arrested after a federal grand jury charged her in an approximately $2 million scheme to defraud Anthem, Aetna, and other Blue Cross Blue Shield Association affiliates, including the Teamsters Western Region and Local 177 health care plans.
Antonio Olivera, 78, of Downey; Emelita Cephass, 57, of Downey; and Martin Canter, 70, of Rancho Palos Verdes, who were charged for their alleged participation in a hospice kickback scheme.
Mahyar David Yadidi, 37, a chiropractor who resides in Los Angeles, who was charged with conspiracy to commit health care fraud for operating a scheme to defraud the International Longshore and Warehouse Union - Pacific Maritime Association health care benefit plan.
Darren Hines, 49, a chiropractor who lives in the Harbor City neighborhood of Los Angeles, who was charged with health care fraud for operating a scheme to defraud the International Longshore and Warehouse Union - Pacific Maritime Association health care benefit plan ...
The Los Angeles City Attorney has filed criminal charges against eight individuals for allegedly importing over 100,000 foreign pharmaceuticals and selling them on street corners, in parks, in front of grocery stores, travel agencies and beauty salons, primarily to Latino customers.
Gloria Garcia, 65; Teresa Cruz, 64, Martha Bueno, 62; Bryan Pineda, 28; Maria Vences-Tinoco, 50; Maria Rosa Portillo, 74; Martha Siguenza, 74; and Helen Portillo, 40, were each charged with selling prescription medications without a license. Each was allegedly selling the illegally imported drugs out of attractive candy-colored displays throughout Los Angeles. Each defendant faces up to one year in jail. Additionally, first time offenders can be fined $5,000 and second time offenders face a $10,000 maximum fine. None of the defendants are licensed or trained medical providers.
Investigations into the suspects for dispensing illegal and dangerous pharmaceuticals led to the seizure of over 100,000 pills, compounds, and injectable medications that could have caused serious harm or death to consumers. The drugs seized included injectable drugs - typically used to treat back pain or bone infections - which cannot be purchased over the counter, require a prescription, and should only be injected by a licensed medical provider.
Also seized were antibiotics - the unsupervised use of which can increase resistance and lower effectiveness - pain medication, injectable contraception, lidocaine, and other potentially dangerous compounds. These foreign-made pharmaceuticals have not been approved for consumption by the general public in the United States.
L.A. County formed the Health Authority Law Enforcement Task Force (HALT) in 1999, after two Latino infants died from taking illegal medications. HALT is the group that made the August arrests. So far this year, it has arrested 34 people in 54 cases, 48 of them involving illegal pharmaceuticals sold to immigrants, said Erick Aguilar, one of the investigators.
Illegal pharmaceuticals are being sold to immigrants in "every rural swap meet you can find," and the sellers are becoming more sophisticated, Aguilar said. "They’re better at hiding it," and "they’re more careful who they sell to."
Many were sheer counterfeits. Others, though legal south of the border, were not approved for sale in the United States. Some had expired. Still others would have been legal if sold by people licensed to do so - but none of the sellers held pharmacist licenses or any other medical credential.
"Counterfeit medicines may contain the wrong ingredients, contain too little, too much or no active ingredient at all - or contain other, potentially life-threatening hidden ingredients," said Jeremy Kahn, an FDA spokesman.
Between October 2017 and July 2018, FDA officials confiscated nearly 22,000 packages containing illegal pharmaceuticals from international mail facilities, Kahn said. He said authorities routinely impound various opioids as well as dietary supplements laced with erectile dysfunction drugs and other dubious products. They come from India, China and across Europe - "just about everywhere," Kahn said ...
Gloria Garcia, 65; Teresa Cruz, 64, Martha Bueno, 62; Bryan Pineda, 28; Maria Vences-Tinoco, 50; Maria Rosa Portillo, 74; Martha Siguenza, 74; and Helen Portillo, 40, were each charged with selling prescription medications without a license. Each was allegedly selling the illegally imported drugs out of attractive candy-colored displays throughout Los Angeles. Each defendant faces up to one year in jail. Additionally, first time offenders can be fined $5,000 and second time offenders face a $10,000 maximum fine. None of the defendants are licensed or trained medical providers.
Investigations into the suspects for dispensing illegal and dangerous pharmaceuticals led to the seizure of over 100,000 pills, compounds, and injectable medications that could have caused serious harm or death to consumers. The drugs seized included injectable drugs - typically used to treat back pain or bone infections - which cannot be purchased over the counter, require a prescription, and should only be injected by a licensed medical provider.
Also seized were antibiotics - the unsupervised use of which can increase resistance and lower effectiveness - pain medication, injectable contraception, lidocaine, and other potentially dangerous compounds. These foreign-made pharmaceuticals have not been approved for consumption by the general public in the United States.
L.A. County formed the Health Authority Law Enforcement Task Force (HALT) in 1999, after two Latino infants died from taking illegal medications. HALT is the group that made the August arrests. So far this year, it has arrested 34 people in 54 cases, 48 of them involving illegal pharmaceuticals sold to immigrants, said Erick Aguilar, one of the investigators.
Illegal pharmaceuticals are being sold to immigrants in "every rural swap meet you can find," and the sellers are becoming more sophisticated, Aguilar said. "They’re better at hiding it," and "they’re more careful who they sell to."
Many were sheer counterfeits. Others, though legal south of the border, were not approved for sale in the United States. Some had expired. Still others would have been legal if sold by people licensed to do so - but none of the sellers held pharmacist licenses or any other medical credential.
"Counterfeit medicines may contain the wrong ingredients, contain too little, too much or no active ingredient at all - or contain other, potentially life-threatening hidden ingredients," said Jeremy Kahn, an FDA spokesman.
Between October 2017 and July 2018, FDA officials confiscated nearly 22,000 packages containing illegal pharmaceuticals from international mail facilities, Kahn said. He said authorities routinely impound various opioids as well as dietary supplements laced with erectile dysfunction drugs and other dubious products. They come from India, China and across Europe - "just about everywhere," Kahn said ...
Gov. Newsom signed AB 5 - what he called a landmark bill for workers.
AB 5 will codify a state Supreme Court Dynamax ruling last year that simplified the test for when a worker should be classified as an employee and therefore be entitled to a minimum wage, health benefits and other protections. The contentious legislation is expected to affect ride-hailing giants Uber and Lyft, plus a host of other companies that use independent contractors.
"The hollowing out of our middle class has been 40 years in the making, and the need to create lasting economic security for our workforce demands action," said Newsom, who had previously voiced support for the bill, in his signing letter. "Assembly Bill 5 is an important step."
A defiant Uber said last week that it is "no stranger to legal battles" and believes it can pass the test imposed by the courts and AB 5: that a worker is an independent contractor when he or she is free from control by a company; when the worker’s duties are outside the usual course of the company’s business; and when the worker is "customarily engaged in an independently established trade, occupation, or business of the same nature as the work performed."
Uber said it does not plan to classify its drivers as employees when the bill becomes law in January. The San Francisco ride-hailing company, which has offered concessions short of classifying drivers as employees and has been negotiating with labor leaders and the governor, said through a spokesman Wednesday that "California is missing a real opportunity to lead the nation by improving the quality, security and dignity of independent work."
But the bill’s author, Assemblywoman Lorena Gonzalez, D-San Diego, said in an interview, "If Uber thinks they’re so strong and powerful that they’re just going to ignore the law, that’s the reason we put the local enforcement clause in the bill." AB 5 includes a provision empowering cities with populations over 750,000 to prosecute companies that continue to misclassify their workers.
Uber, Lyft and food delivery startup DoorDash have put $90 million into a fund for a campaign that would bring the issue to voters.
Representatives for Lyft and DoorDash said Wednesday they were encouraged Newsom indicated he would keep talking with business and labor in an effort to "preserve flexibility and innovation."
But both companies also mentioned the possibility of putting the issue on the ballot. In addition, Lyft has warned that it wouldn’t need as many drivers and pointed to a recent study that says hundreds of thousands of drivers in the state could lose their ability to drive for the company if it is forced to classify them as employees.
The Orange County Register points out that one professor thinks ride-hailing drivers might see a smaller paycheck.
"This is yet to be seen but it is a possible argument because the incentives and reward system will be restructured to account for employee status," said Orly Lobel, director of the Program on Employment and Labor Law at the University of San Diego.
Other workers, such as doctors, hairdressers and real estate agents, have secured exemptions from the bill. Newspaper publishers who use contract delivery workers got a one-year delay for compliance. But those in the trucking and music industries, among others, have also complained about the bill ...
AB 5 will codify a state Supreme Court Dynamax ruling last year that simplified the test for when a worker should be classified as an employee and therefore be entitled to a minimum wage, health benefits and other protections. The contentious legislation is expected to affect ride-hailing giants Uber and Lyft, plus a host of other companies that use independent contractors.
"The hollowing out of our middle class has been 40 years in the making, and the need to create lasting economic security for our workforce demands action," said Newsom, who had previously voiced support for the bill, in his signing letter. "Assembly Bill 5 is an important step."
A defiant Uber said last week that it is "no stranger to legal battles" and believes it can pass the test imposed by the courts and AB 5: that a worker is an independent contractor when he or she is free from control by a company; when the worker’s duties are outside the usual course of the company’s business; and when the worker is "customarily engaged in an independently established trade, occupation, or business of the same nature as the work performed."
Uber said it does not plan to classify its drivers as employees when the bill becomes law in January. The San Francisco ride-hailing company, which has offered concessions short of classifying drivers as employees and has been negotiating with labor leaders and the governor, said through a spokesman Wednesday that "California is missing a real opportunity to lead the nation by improving the quality, security and dignity of independent work."
But the bill’s author, Assemblywoman Lorena Gonzalez, D-San Diego, said in an interview, "If Uber thinks they’re so strong and powerful that they’re just going to ignore the law, that’s the reason we put the local enforcement clause in the bill." AB 5 includes a provision empowering cities with populations over 750,000 to prosecute companies that continue to misclassify their workers.
Uber, Lyft and food delivery startup DoorDash have put $90 million into a fund for a campaign that would bring the issue to voters.
Representatives for Lyft and DoorDash said Wednesday they were encouraged Newsom indicated he would keep talking with business and labor in an effort to "preserve flexibility and innovation."
But both companies also mentioned the possibility of putting the issue on the ballot. In addition, Lyft has warned that it wouldn’t need as many drivers and pointed to a recent study that says hundreds of thousands of drivers in the state could lose their ability to drive for the company if it is forced to classify them as employees.
The Orange County Register points out that one professor thinks ride-hailing drivers might see a smaller paycheck.
"This is yet to be seen but it is a possible argument because the incentives and reward system will be restructured to account for employee status," said Orly Lobel, director of the Program on Employment and Labor Law at the University of San Diego.
Other workers, such as doctors, hairdressers and real estate agents, have secured exemptions from the bill. Newspaper publishers who use contract delivery workers got a one-year delay for compliance. But those in the trucking and music industries, among others, have also complained about the bill ...
A former vocational nurse working at the California Institution for Men in Chino has been sentenced in a workers’ compensation fraud case in which he falsely claimed an inmate attacked him with a needle, and later collected tens of thousands of dollars in workers’ compensation benefits.
On June 7, 2019, a jury trial was held at the Riverside County Superior Court in Banning, California. Ndiawar Diop, DOB: 7-15-77, was convicted of six felonies - one count each of making a false workers’ compensation claim and attempted perjury as well as four counts of making a false statement in order to receive an insurance benefit.
On Sept. 13, 2019, Diop was sentenced by a Riverside County judge to six years, six months in county jail, five years of which are on mandatory supervision.
The judge also ordered Diop to pay restitution in the amount of $97,164.
In June 2013, Diop, who worked as a vocational nurse for the California Department of Corrections and Rehabilitation, reported that he accidentally poked himself with a needle while at work.
However, over time, Diop’s description of what happened changed.
Diop later said he thought it was an intentional act by the inmate to stick him with the needle and, on a later date, changed his story to say it happened when the inmate tried to stab in him the neck with the needle, resulting in the injury to his hand as he tried to shield himself from the attack.
However, that statement was proven false by the evidence presented at the trial.
The case, RIF1705383, was prosecuted by Deputy District Attorney Blaine Hopp of the DA’s Insurance Fraud Team and was investigated by the California Department of Corrections and Rehabilitation ...
On June 7, 2019, a jury trial was held at the Riverside County Superior Court in Banning, California. Ndiawar Diop, DOB: 7-15-77, was convicted of six felonies - one count each of making a false workers’ compensation claim and attempted perjury as well as four counts of making a false statement in order to receive an insurance benefit.
On Sept. 13, 2019, Diop was sentenced by a Riverside County judge to six years, six months in county jail, five years of which are on mandatory supervision.
The judge also ordered Diop to pay restitution in the amount of $97,164.
In June 2013, Diop, who worked as a vocational nurse for the California Department of Corrections and Rehabilitation, reported that he accidentally poked himself with a needle while at work.
However, over time, Diop’s description of what happened changed.
Diop later said he thought it was an intentional act by the inmate to stick him with the needle and, on a later date, changed his story to say it happened when the inmate tried to stab in him the neck with the needle, resulting in the injury to his hand as he tried to shield himself from the attack.
However, that statement was proven false by the evidence presented at the trial.
The case, RIF1705383, was prosecuted by Deputy District Attorney Blaine Hopp of the DA’s Insurance Fraud Team and was investigated by the California Department of Corrections and Rehabilitation ...
The Workers’ Compensation Insurance Rating Bureau of California has released its quarterly update on California statewide insurer experience valued as of June 30, 2019.
Highlights of the report include:
-- California written premium through the second calendar quarter of 2019 is 7 percent below the same period for 2018, suggesting that the 2019 premium decrease will also be significant. This is the third consecutive year of premium decreases.
-- The average charged rate for the first six months of 2019 is 10 percent below that for 2018 and 32 percent below the peak in 2014. The WCIRB recently proposed a further 5% decrease in advisory pure premium rates for January 1, 2020.
-- The WCIRB projects the ultimate accident year loss ratio for 2018 to be four points above that for accident year 2017, driven by higher claim severities for 2018 and lower premium rates.
-- The 90 percent combined loss and expense ratio projected for accident year 2018 represents the sixth consecutive year of combined ratios below 100 percent. Combined ratios below 100 percent are one indicator of a healthy workers’ compensation system.
-- The ratio for the percent of open indemnity claims closed in the next year increased in each of the last six years and in 2019 is the highest ratio since 1999.
-- Cumulative trauma (CT) claim rates continue to increase in accident year 2017, and the ratio of CT claims to all indemnity claims has increased by more than 80 percent since accident year 2005.
-- The projected total loss and allocated loss adjustment expense claim severity for accident year 2018 is 5 percent higher than that for accident year 2017, following several years of modest declines in claim severities.
-- Medical service costs per claim decreased 17% from 2012 to 2015, primarily driven by a 23% decrease in the number of transactions per claim. Overall medical cost levels have been relatively flat since 2015.
-- Pharmaceutical costs per claim decreased 80% from 2012 to 2018. These reductions have been driven by SB 863’s independent medical review and independent bill review, reduced utilization of opioids, changes to Medi-Cal reimbursement rates and the new drug formulary.
-- The number of liens filed in the first two quarters of 2019 are more than 60% below pre-SB 1160 and AB 1244 levels.
The full report is available in the Research section of the WCIRB website and linked below: ...
Highlights of the report include:
-- California written premium through the second calendar quarter of 2019 is 7 percent below the same period for 2018, suggesting that the 2019 premium decrease will also be significant. This is the third consecutive year of premium decreases.
-- The average charged rate for the first six months of 2019 is 10 percent below that for 2018 and 32 percent below the peak in 2014. The WCIRB recently proposed a further 5% decrease in advisory pure premium rates for January 1, 2020.
-- The WCIRB projects the ultimate accident year loss ratio for 2018 to be four points above that for accident year 2017, driven by higher claim severities for 2018 and lower premium rates.
-- The 90 percent combined loss and expense ratio projected for accident year 2018 represents the sixth consecutive year of combined ratios below 100 percent. Combined ratios below 100 percent are one indicator of a healthy workers’ compensation system.
-- The ratio for the percent of open indemnity claims closed in the next year increased in each of the last six years and in 2019 is the highest ratio since 1999.
-- Cumulative trauma (CT) claim rates continue to increase in accident year 2017, and the ratio of CT claims to all indemnity claims has increased by more than 80 percent since accident year 2005.
-- The projected total loss and allocated loss adjustment expense claim severity for accident year 2018 is 5 percent higher than that for accident year 2017, following several years of modest declines in claim severities.
-- Medical service costs per claim decreased 17% from 2012 to 2015, primarily driven by a 23% decrease in the number of transactions per claim. Overall medical cost levels have been relatively flat since 2015.
-- Pharmaceutical costs per claim decreased 80% from 2012 to 2018. These reductions have been driven by SB 863’s independent medical review and independent bill review, reduced utilization of opioids, changes to Medi-Cal reimbursement rates and the new drug formulary.
-- The number of liens filed in the first two quarters of 2019 are more than 60% below pre-SB 1160 and AB 1244 levels.
The full report is available in the Research section of the WCIRB website and linked below: ...
The Division of Workers’ Compensation just launched an updated free online education course for physicians treating patients in the California workers’ compensation system.
"Caring for California’s Injured Workers: Using California’s Medical Treatment Utilization Schedule (MTUS) 2019" is one of a series of education modules developed for medical doctors, chiropractors and nurses. The course is also available to anyone else wishing to learn about the MTUS, and a completion certificate is available.
The MTUS is the primary source of guidance for treating physicians and physician reviewers for the evaluation and treatment of injured workers. It incorporates evidence-based treatment guidelines of the American College of Occupational and Environmental Medicine (ACOEM), which are published by the ReedGroup.
"All medical providers who treat injured California workers should understand and follow the MTUS. The online course is a convenient tool for providers to learn how to use the treatment guidelines and formulary that are designed to improve medical outcomes for injured workers," said DWC Executive Medical Director Dr. Raymond Meister.
Medical doctors, chiropractors and nurses who take the course will receive up to one and a half hours of free CME credit. Qualified medical evaluators (QMEs) may report up to one and one half hours of credit for QME reappointment. The course is also available to anyone else wishing to learn about the MTUS, and a completion certificate is available.
The education module covers:
-- What the MTUS is, how to use it, and how you may be able to obtain free online access to the MTUS-ACOEM treatment guidelines
-- How to navigate the MTUS-ACOEM treatment guidelines and apply recommendations for patient care
-- The MTUS Drug Formulary
-- When to consider recommendations outside of the MTUS guidelines for the care of your patient
-- The role of utilization review (UR) and independent medical review (IMR) physicians
Access to the physician education module can be found on the DWC website ...
"Caring for California’s Injured Workers: Using California’s Medical Treatment Utilization Schedule (MTUS) 2019" is one of a series of education modules developed for medical doctors, chiropractors and nurses. The course is also available to anyone else wishing to learn about the MTUS, and a completion certificate is available.
The MTUS is the primary source of guidance for treating physicians and physician reviewers for the evaluation and treatment of injured workers. It incorporates evidence-based treatment guidelines of the American College of Occupational and Environmental Medicine (ACOEM), which are published by the ReedGroup.
"All medical providers who treat injured California workers should understand and follow the MTUS. The online course is a convenient tool for providers to learn how to use the treatment guidelines and formulary that are designed to improve medical outcomes for injured workers," said DWC Executive Medical Director Dr. Raymond Meister.
Medical doctors, chiropractors and nurses who take the course will receive up to one and a half hours of free CME credit. Qualified medical evaluators (QMEs) may report up to one and one half hours of credit for QME reappointment. The course is also available to anyone else wishing to learn about the MTUS, and a completion certificate is available.
The education module covers:
-- What the MTUS is, how to use it, and how you may be able to obtain free online access to the MTUS-ACOEM treatment guidelines
-- How to navigate the MTUS-ACOEM treatment guidelines and apply recommendations for patient care
-- The MTUS Drug Formulary
-- When to consider recommendations outside of the MTUS guidelines for the care of your patient
-- The role of utilization review (UR) and independent medical review (IMR) physicians
Access to the physician education module can be found on the DWC website ...
San Diego City Attorney Mara Elliott has filed a lawsuit against grocery delivery company Instacart, alleging the tech giant has misclassified its employees as independent contractors.
The suit comes three days after new legislation, called Assembly Bill 5, cleared the California Legislature, spurring panic among gig economy giants such as Uber and Lyft. The bill is now on its way to the desk of Gov. Gavin Newsom, who has previously pledged his support. Should the bill be signed into law, it would prevent many companies from classifying their workers as independent contractors rather than employees.
According to the report in the San Diego Tribune, Elliott’s lawsuit is asking for Instacart’s workers to receive compensation retroactively, including payment for things like minimum wage, overtime pay, meal breaks and expense reimbursement. The suit also alleges Instacart evaded paying workers compensation and unemployment insurance, along with state and federal payroll taxes.
Instacart did not respond to a request for comment by publication time.
San Francisco-based Instacart is a grocery delivery service that operates nationally and has a presence in San Diego. Its app allows customers to place grocery orders online, which are then purchased and delivered by a "shopper" who drives the order directly to their home.
The suit alleges that Instacart shoppers do not qualify as independent contractors under a 2018 California Supreme Court decision (Dynamex Operations West, Inc. v. Superior Court). It’s the Dynamex case that spurred AB 5 to move its way through the state legislature this year, sponsored by San Diego Democrat Lorena Gonzalez.
Procopio law partner Tyler Paetkau, who practices employment law, said AB 5 would change the game entirely for companies hiring contract workers. Employers used to have a lot of wiggle room to classify workers as independent contractors. This new bill now tightens the definition of an independent contractor. The most notable difference is that employers cannot use contractors unless the person’s work is “outside the normal business activities” of the hiring company.
Elliott’s suit alleges Instacart does not meet the criteria outlined in Dynamex, which AB 5 mirrors.
"Shoppers perform work that is directly within the course of Instacart’s business model, including ‘groceries delivered in as little as one hour,’" stated a City Attorney’s Office news release. "Shoppers are essential to providing the core service the company offers."
Proponents of AB 5 say the legislation will improve labor conditions for gig economy workers, forcing companies to offer benefits and protections that a normal employee would be granted - such as minimum wage, paid sick days and health insurance benefits. Opponents say the bill invokes outdated views of “employment,” hampering the millions of Californians who want flexible work.
Lawsuits seeking retroactive restitution could be a major challenge for companies throughout the state, Paetkau said, especially small businesses that have adopted the gig economy model popularized by Uber and Lyft.
"A lot of these companies are startups," Paetkau said. "They have some funding but limited resources. The worst thing that can happen to them is a lawsuit or claim. Especially involving multiple workers. This could wipe them out." ...
The suit comes three days after new legislation, called Assembly Bill 5, cleared the California Legislature, spurring panic among gig economy giants such as Uber and Lyft. The bill is now on its way to the desk of Gov. Gavin Newsom, who has previously pledged his support. Should the bill be signed into law, it would prevent many companies from classifying their workers as independent contractors rather than employees.
According to the report in the San Diego Tribune, Elliott’s lawsuit is asking for Instacart’s workers to receive compensation retroactively, including payment for things like minimum wage, overtime pay, meal breaks and expense reimbursement. The suit also alleges Instacart evaded paying workers compensation and unemployment insurance, along with state and federal payroll taxes.
Instacart did not respond to a request for comment by publication time.
San Francisco-based Instacart is a grocery delivery service that operates nationally and has a presence in San Diego. Its app allows customers to place grocery orders online, which are then purchased and delivered by a "shopper" who drives the order directly to their home.
The suit alleges that Instacart shoppers do not qualify as independent contractors under a 2018 California Supreme Court decision (Dynamex Operations West, Inc. v. Superior Court). It’s the Dynamex case that spurred AB 5 to move its way through the state legislature this year, sponsored by San Diego Democrat Lorena Gonzalez.
Procopio law partner Tyler Paetkau, who practices employment law, said AB 5 would change the game entirely for companies hiring contract workers. Employers used to have a lot of wiggle room to classify workers as independent contractors. This new bill now tightens the definition of an independent contractor. The most notable difference is that employers cannot use contractors unless the person’s work is “outside the normal business activities” of the hiring company.
Elliott’s suit alleges Instacart does not meet the criteria outlined in Dynamex, which AB 5 mirrors.
"Shoppers perform work that is directly within the course of Instacart’s business model, including ‘groceries delivered in as little as one hour,’" stated a City Attorney’s Office news release. "Shoppers are essential to providing the core service the company offers."
Proponents of AB 5 say the legislation will improve labor conditions for gig economy workers, forcing companies to offer benefits and protections that a normal employee would be granted - such as minimum wage, paid sick days and health insurance benefits. Opponents say the bill invokes outdated views of “employment,” hampering the millions of Californians who want flexible work.
Lawsuits seeking retroactive restitution could be a major challenge for companies throughout the state, Paetkau said, especially small businesses that have adopted the gig economy model popularized by Uber and Lyft.
"A lot of these companies are startups," Paetkau said. "They have some funding but limited resources. The worst thing that can happen to them is a lawsuit or claim. Especially involving multiple workers. This could wipe them out." ...
Lawyers for cities and counties suing drug companies over the opioid epidemic on Monday objected to a bid by pharmaceutical distributors and pharmacies to disqualify the federal judge overseeing the cases, saying it had no basis and came too late.
The plaintiffs’ lawyers moved swiftly to fight the request companies including AmerisourceBergen Corp (ABC.N), Cardinal Health Inc (CAH.N) and McKesson Corp (MCK.N) had made on Saturday for U.S. District Judge Dan Polster in Cleveland, Ohio, to step aside from the litigation.
In Monday’s brief, lawyers for the plaintiffs said the defendants had waived their ability to seek Polster’s recusal, noting they were relying on statements he made more than a year ago to belatedly seek his disqualification.
"If these Defendants really thought recusal was necessary, they were required to raise the issue sooner - much sooner," the plaintiffs’ lawyers wrote.
The companies had argued in Saturday’s motion that Polster, who has long pushed for a settlement that could "do something meaningful to abate this crisis," had made a series of public statements since 2018 that could cause a reasonable person to question his impartiality.
They said those statements, made in court hearings and media interviews, raised the prospect that he had improperly prejudged their liability ahead of the first trial on Oct. 21 involving two Ohio counties seeking $8 billion.
In Monday’s brief, the plaintiffs’ lawyers said the companies did not take action when Polster made those comments and actively participated in court-overseen settlement talks without objection.
Polster "has at no time expressed improper or biased views about the liability of any defendant, much less views based on extra-judicial sources," the lawyers wrote.
The companies who joined Saturday’s motion also include CVS Health Corp (CVS.N) and Walmart Inc (WMT.N). The defendants did not respond to requests for comment.
OxyContin maker Purdue Pharma, one of the lead defendants, filed for bankruptcy protection on Monday after reaching a tentative deal to resolve claims in the federal litigation and by 24 U.S. states ...
The plaintiffs’ lawyers moved swiftly to fight the request companies including AmerisourceBergen Corp (ABC.N), Cardinal Health Inc (CAH.N) and McKesson Corp (MCK.N) had made on Saturday for U.S. District Judge Dan Polster in Cleveland, Ohio, to step aside from the litigation.
In Monday’s brief, lawyers for the plaintiffs said the defendants had waived their ability to seek Polster’s recusal, noting they were relying on statements he made more than a year ago to belatedly seek his disqualification.
"If these Defendants really thought recusal was necessary, they were required to raise the issue sooner - much sooner," the plaintiffs’ lawyers wrote.
The companies had argued in Saturday’s motion that Polster, who has long pushed for a settlement that could "do something meaningful to abate this crisis," had made a series of public statements since 2018 that could cause a reasonable person to question his impartiality.
They said those statements, made in court hearings and media interviews, raised the prospect that he had improperly prejudged their liability ahead of the first trial on Oct. 21 involving two Ohio counties seeking $8 billion.
In Monday’s brief, the plaintiffs’ lawyers said the companies did not take action when Polster made those comments and actively participated in court-overseen settlement talks without objection.
Polster "has at no time expressed improper or biased views about the liability of any defendant, much less views based on extra-judicial sources," the lawyers wrote.
The companies who joined Saturday’s motion also include CVS Health Corp (CVS.N) and Walmart Inc (WMT.N). The defendants did not respond to requests for comment.
OxyContin maker Purdue Pharma, one of the lead defendants, filed for bankruptcy protection on Monday after reaching a tentative deal to resolve claims in the federal litigation and by 24 U.S. states ...
The Orange County Register reports that county officials say they will stand behind their sheriff’s deputies who are injured while trying to help others, even when they’re off duty and out of state. County supervisors voted Sept. 10, to extend workers compensation benefits to sworn employees who were hurt during the 2017 mass shooting at the Route 91 Harvest Festival in Las Vegas, and to county law enforcement caught up in future domestic terrorism events who use their training to protect civilians or assist local first responders.
Off-duty officers from several Southern California communities were attending the Las Vegas concert when a gunman fired on the crowd. Some were shot or received other injuries while leading people to safety, helping secure the area and providing others aid.
Orange County rejected workers comp claims filed by four of its deputies who were hurt, because California law at the time specifically referred to peace-keeping activities "anywhere in this state," but did not mention actions outside the state’s boundaries.
A bill from Assemblyman Tom Daly, D-Anaheim, that passed in 2018 clarified the law so that California peace officers injured off duty while responding to out-of-state crimes and life-threatening emergencies can collect public injury benefits. Now, Orange County has enshrined in its own policies that officers in good standing hurt in the Las Vegas shooting or such future incidents are eligible for workers compensation.
The new policy’s cost to county taxpayers is unknown because it will depend on how many claims are filed and what benefits are awarded.
Deputy Mark Seamans, hit by gunfire, was among the Orange County deputies whose claims were initially rejected. As Seamans told a reporter shortly after the incident, he never stopped to worry about his own safety while pulling people out of harm’s way. "The switch turned on, and it became everything we train for," he said at the time.
The county’s new policy doesn’t guarantee off-duty deputies’ claims will be paid, only that they’ll be considered even if the incident takes place in another state. The policy would not apply to claims of psychological injury or events outside the U.S. On Wednesday, a county spokeswoman said two claims by officers who were shot in Las Vegas are due to be approved.
Since Daly’s bill passed last year, San Bernardino County accepted a claim from one deputy injured at the Route 91 festival, county spokeswoman Felisa Cardona said. California Peace Officers Association spokesman Shaun Rundle said he wasn’t aware of other agencies making policy changes as Orange County did ...
Off-duty officers from several Southern California communities were attending the Las Vegas concert when a gunman fired on the crowd. Some were shot or received other injuries while leading people to safety, helping secure the area and providing others aid.
Orange County rejected workers comp claims filed by four of its deputies who were hurt, because California law at the time specifically referred to peace-keeping activities "anywhere in this state," but did not mention actions outside the state’s boundaries.
A bill from Assemblyman Tom Daly, D-Anaheim, that passed in 2018 clarified the law so that California peace officers injured off duty while responding to out-of-state crimes and life-threatening emergencies can collect public injury benefits. Now, Orange County has enshrined in its own policies that officers in good standing hurt in the Las Vegas shooting or such future incidents are eligible for workers compensation.
The new policy’s cost to county taxpayers is unknown because it will depend on how many claims are filed and what benefits are awarded.
Deputy Mark Seamans, hit by gunfire, was among the Orange County deputies whose claims were initially rejected. As Seamans told a reporter shortly after the incident, he never stopped to worry about his own safety while pulling people out of harm’s way. "The switch turned on, and it became everything we train for," he said at the time.
The county’s new policy doesn’t guarantee off-duty deputies’ claims will be paid, only that they’ll be considered even if the incident takes place in another state. The policy would not apply to claims of psychological injury or events outside the U.S. On Wednesday, a county spokeswoman said two claims by officers who were shot in Las Vegas are due to be approved.
Since Daly’s bill passed last year, San Bernardino County accepted a claim from one deputy injured at the Route 91 festival, county spokeswoman Felisa Cardona said. California Peace Officers Association spokesman Shaun Rundle said he wasn’t aware of other agencies making policy changes as Orange County did ...
The Division of Workers’ Compensation (DWC) announces that the 2020 minimum and maximum temporary total disability (TTD) rates will increase on January 1, 2020. The minimum TTD rate will increase from $187.71 to $194.91 and the maximum TTD rate will increase from $1,251.38 to $1,299.43 per week.
Labor Code section 4453(a) (10) requires the rate for TTD be increased by an amount equal to percentage increase in the State Average Weekly Wage (SAWW) as compared to the prior year. The SAWW is defined as the average weekly wage paid to employees covered by unemployment insurance as reported by the U.S. Department of Labor for California for the 12 months ending March 31 in the year preceding the injury. In the 12 months ending March 31, 2019, the SAWW increased from $1,290 to $1,325 - an increase of 3.84013 percent.
Under Labor Code section 4659(c), workers with a date of injury on or after January 1, 2003 who are receiving life pension (LP) or permanent total disability (PTD) benefits are also entitled to have their weekly LP or PTD rate adjusted based on the SAWW.
SAWW figures may be verified using the U.S. Department of Labor’s Unemployment Insurance Data Base. # ...
Labor Code section 4453(a) (10) requires the rate for TTD be increased by an amount equal to percentage increase in the State Average Weekly Wage (SAWW) as compared to the prior year. The SAWW is defined as the average weekly wage paid to employees covered by unemployment insurance as reported by the U.S. Department of Labor for California for the 12 months ending March 31 in the year preceding the injury. In the 12 months ending March 31, 2019, the SAWW increased from $1,290 to $1,325 - an increase of 3.84013 percent.
Under Labor Code section 4659(c), workers with a date of injury on or after January 1, 2003 who are receiving life pension (LP) or permanent total disability (PTD) benefits are also entitled to have their weekly LP or PTD rate adjusted based on the SAWW.
SAWW figures may be verified using the U.S. Department of Labor’s Unemployment Insurance Data Base. # ...
Puni Pa'u suffered an admitted injury while working for the Department of Forestry. His PTP requested authorization for radio frequency ablation, a type of medical treatment, for an accepted injury to his back. The RFA was was received by EK Health on March 12, 2018, a Monday. EK Health denied the request for treatment on March 19, 2018, also a Monday.
Applicant made a second request for the same treatment; this request was received on April 16, 2018, a Monday, and denied on April 23, 2018, also a Monday.
Applicant filed a Declaration of Readiness to Proceed, alleging that both UR denials were late, and therefore that the WCAB had jurisdiction to award him the medical care he sought.
The core of the parties’ dispute was over whether defendant had complied with the requirement to render a decision within "five working days," as mandated by Labor Code section 4610. The WCJ found in pertinent part that defendant timely denied applicant’s requests for treatment via Utilization Review (UR). The WCJ concluded that the UR denials were timely because Saturdays and Sundays are not working days under the meaning of the Labor Code section 4610.
Applicant contends on reconsideration that the UR denials were untimely because Saturday is a working day for purposes of Labor Code section 4610, and therefore that the Workers’ Compensation Appeals Board (WCAB) has jurisdiction over the dispute and that the WCJ should have awarded applicant the requested treatment.
The WCAB affirmed the conclusion of the WCJ in the Significant Panel Decision of Puni Pa'u v Department of Forestry.
"Although Saturday is a business day under Civil Code section 9, it is not a working day under Labor Code section 4610, because Labor Code section 4610 does not incorporate the definition of business day found in Civil Code section 9. Applying the principles of statutory interpretation, we determine that the phrase "working day" found in Labor Code section 4610 does not include Saturdays based upon its standard modern usage, as reflected in dictionary definitions, statutory and regulatory enactments, and judicial decisions. Moreover, even if Saturday were a working day, the UR decisions in this case would still be timely based upon Code of Civil Procedure section 12a, which extends the deadline for performance of acts that fall due on a Saturday." ...
Applicant made a second request for the same treatment; this request was received on April 16, 2018, a Monday, and denied on April 23, 2018, also a Monday.
Applicant filed a Declaration of Readiness to Proceed, alleging that both UR denials were late, and therefore that the WCAB had jurisdiction to award him the medical care he sought.
The core of the parties’ dispute was over whether defendant had complied with the requirement to render a decision within "five working days," as mandated by Labor Code section 4610. The WCJ found in pertinent part that defendant timely denied applicant’s requests for treatment via Utilization Review (UR). The WCJ concluded that the UR denials were timely because Saturdays and Sundays are not working days under the meaning of the Labor Code section 4610.
Applicant contends on reconsideration that the UR denials were untimely because Saturday is a working day for purposes of Labor Code section 4610, and therefore that the Workers’ Compensation Appeals Board (WCAB) has jurisdiction over the dispute and that the WCJ should have awarded applicant the requested treatment.
The WCAB affirmed the conclusion of the WCJ in the Significant Panel Decision of Puni Pa'u v Department of Forestry.
"Although Saturday is a business day under Civil Code section 9, it is not a working day under Labor Code section 4610, because Labor Code section 4610 does not incorporate the definition of business day found in Civil Code section 9. Applying the principles of statutory interpretation, we determine that the phrase "working day" found in Labor Code section 4610 does not include Saturdays based upon its standard modern usage, as reflected in dictionary definitions, statutory and regulatory enactments, and judicial decisions. Moreover, even if Saturday were a working day, the UR decisions in this case would still be timely based upon Code of Civil Procedure section 12a, which extends the deadline for performance of acts that fall due on a Saturday." ...
This year the California Legislature again introduced legislation poised to limit apportionment in several ways with SB 731. The proposed law adds a sentence to LC 4663 (c) "The approximate percentage of the permanent disability caused by other factors shall not include consideration of race, religious creed, color, national origin, age, gender, marital status, sex, sexual identity, sexual orientation, or genetic characteristics."
The proposed law was likely a response to a few recent decisions that have enhanced the ability of employers to obtain apportionment of permanent disability. However the court successes may be short lived as a new proposed law is rapidly gaining momentum in the California Legislature to limit or water down apportionment law adopted in 2004 by S.B. 899.
In April 2017, the Court of Appeal published its decision in the City of Jackson v WCAB (Rice) which confirmed apportionment to genetic factors. Christopher Rice was a police officer who suffered a spine injury. A PQME found that genetic factors were significant factors in his permanent impairment. The Court of Appeal reversed the WCAB which refused to allow apportionment to genetics.
In December 2018, the Court of Appeal published its decision in City of Petaluma v WCAB and Aaron Lindh. In that case a PQME concluded that 85 percent of his disability was due to a previously asymptomatic, underlying condition. The ALJ, however, rejected apportionment and reconsideration was denied by the WCAB. The Court of Appeal reversed, and granted apportionment finding that the requirement that the asymptomatic preexisting condition will, in and of itself, naturally progress to disable the claimant. was “the law prior to 2004” and is no longer a requirement for apportionment to an underlying condition.
SB 731 has been passed by the California Senate on 5/19/2019, and sent to the State Assembly as of 5/22/2019. On 5/30/2019 the bill was sent to the Insurance Committee, and as of the end of the legislative session this year, has not had a finding by that Committee. Thus SB 731 will not be passed this year.
Similar bills were passed by the legislature and then vetoed by Governors Arnold Schwarzenegger and Jerry Brown for many years. It is likely that SB 731 will be passed by the legislature the next legislative session. It is not clear what response Governor Gavin Newsom will have if it is passed. However, the bill is not yet an urgency bill, so the effective date would be no earlier than January 1, 2021 if passed and signed next year. Employers who have cases in litigation involving apportionment issues would have more than one year to bring those cases to a conclusion ...
The proposed law was likely a response to a few recent decisions that have enhanced the ability of employers to obtain apportionment of permanent disability. However the court successes may be short lived as a new proposed law is rapidly gaining momentum in the California Legislature to limit or water down apportionment law adopted in 2004 by S.B. 899.
In April 2017, the Court of Appeal published its decision in the City of Jackson v WCAB (Rice) which confirmed apportionment to genetic factors. Christopher Rice was a police officer who suffered a spine injury. A PQME found that genetic factors were significant factors in his permanent impairment. The Court of Appeal reversed the WCAB which refused to allow apportionment to genetics.
In December 2018, the Court of Appeal published its decision in City of Petaluma v WCAB and Aaron Lindh. In that case a PQME concluded that 85 percent of his disability was due to a previously asymptomatic, underlying condition. The ALJ, however, rejected apportionment and reconsideration was denied by the WCAB. The Court of Appeal reversed, and granted apportionment finding that the requirement that the asymptomatic preexisting condition will, in and of itself, naturally progress to disable the claimant. was “the law prior to 2004” and is no longer a requirement for apportionment to an underlying condition.
SB 731 has been passed by the California Senate on 5/19/2019, and sent to the State Assembly as of 5/22/2019. On 5/30/2019 the bill was sent to the Insurance Committee, and as of the end of the legislative session this year, has not had a finding by that Committee. Thus SB 731 will not be passed this year.
Similar bills were passed by the legislature and then vetoed by Governors Arnold Schwarzenegger and Jerry Brown for many years. It is likely that SB 731 will be passed by the legislature the next legislative session. It is not clear what response Governor Gavin Newsom will have if it is passed. However, the bill is not yet an urgency bill, so the effective date would be no earlier than January 1, 2021 if passed and signed next year. Employers who have cases in litigation involving apportionment issues would have more than one year to bring those cases to a conclusion ...
