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With the likelihood of workers' compensation COVID-19 claims on the horizon, and with presumptions supporting them, opportunities for apportionment of permanent disability may be more important than ever in claims management.

Researchers who just published a new study, report that a person's blood type may affect their risk for COVID-19, the disease caused by the new corona virus.

The findings appear on the website medRxiv, where health researchers publish studies before they undergo the peer review process required by journals.

Researchers used observational healthcare data on 1559 individuals tested for SARS-CoV-2 (682 COV+) with known blood type in the New York Presbyterian (NYP) hospital system to assess the association between ABO+Rh blood type and SARS-CoV-2 infection status, intubation, and death.

They found a higher proportion of blood group A and a lower proportion of blood group O among COV+ patients compared to COV-, though in both cases the result is significant only in Rh positive blood types.

The effect of blood type is not explained by risk factors they considered (age, sex, hypertension, diabetes mellitus, overweight status, and chronic cardiovascular and lung disorders).

In a meta-analysis of NYP data with previously-reported data from China, they found enrichment for A and B and depletion of O blood groups among COVID-19 patients compared to the general population. They also found new evidence of associations between B, AB, and Rh blood groups and COVID-19 and further evidence of recently-discovered associations between A and O blood groups and COVID-19.

The China study was limited because of its small size and it didn't offer an explanation for its findings, Gao Yingdai, a researcher from the State Key Laboratory of Experimental Hematology in Tianjin, told the South China Morning Post.

The finding that blood type may affect COVID-19 risk could be important for healthcare workers treating COVID-19 patients, because those with A blood types" "might need particularly strengthened personal protection to reduce the chance of infection."

Also, people with A blood types might require "more vigilant surveillance and aggressive treatment," and identifying a person's blood type as a routine part of treating COVID-19 and other coronavirus infections might be helpful, according to the researchers, Newsweek reported.
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/ 2020 News, Daily News
Daniel Brodie Howard suffered major injuries in an automobile accident while acting within the scope of his employment with Agra Tech, Inc. Hartford was Agra Tech, Inc.’s workers’ compensation carrier. He was hospitalized and in a coma. Thus the probate court appointed his brother, David Howard as conservator of his person and estate.

A civil tort action was filed against multiple parties to recover for the injuries. Hartford filed a complaint in intervention seeking to recover the workers’ compensation benefits it had paid as a result of conservatee’s accident.

In 2012, a WCJ found conservatee to be totally and permanently disabled and awarded permanent disability, medical care for life, and attorney fees.

On October 30, 2013, conservatee, Hartford, and Toyota, one of the tort defendants, signed a mediation agreement that called for Toyota to pay a specified sum to conservatee. In 2014, the probate court signed an order approving the compromise of the disputed claim against the other driver and Toyota and directed payments from the settlement proceeds for attorney fees and expenses, to Hartford (for medical and like expenses it had paid), and conservatee (for the balance of the settlement).

Numerous disputes arose between the parties over the distribution of funds, each of which were subsequently resolved.

Then, in 2016, conservatee filed a motion in the probate court to assess attorney fees, asking the probate court to order Hartford to "reimburse Conservatee $150,934.76 in costs and $179,605.48 in attorney’s fees as Hartford’s pro rata share of Conservatee’s costs and attorney’s fees in creating the Toyota settlement." Conservatee stated the authority for the motion was labor code sections 3856, subdivision (b), and 3860, subdivision (e), and the "common fund" doctrine.

The probate court concluded that it lacked jurisdiction to consider conservatee’s claims because the underlying civil case had been dismissed with prejudice upon conservatee’s request. The court of appeal agreed and affirmed the order in the unpublished case of Conservatorship of Howard.

Conservatee’s motion to assess attorney fees did not revive the civil action or overcome the effect of the voluntary dismissal of that action. Upon dismissal of the civil action, the probate court no longer had jurisdiction to enter any further order distributing the settlement proceeds from the civil action ...
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/ 2020 News, Daily News
Workers' Compensation has experienced a long-term decline in overall claim frequency. However, for motor vehicle claims, the story is quite different.

The National Council on Compensation Insurance (NCCI), just published an update to it's 2018 research brief titled "Motor Vehicle Accidents in Workers Compensation," which examined the frequency and severity of motor vehicle accidents (MVA) from 2000 to 2016.

The brief noted that frequency decreased for both MVAs and all claims from 2000 to 2011. However, a key finding was that from 2011 to 2016, while the frequency of all workers compensation claims continued to decrease, the frequency of MVAs increased in both WC and in the general population. It cited the rapid expansion of smartphone ownership during this period as a possible contributing factor. Some key findings of the new update show:

-- MVA frequency increased. From 2011 to 2018, the frequency of MVA lost-time claims increased, while the frequency of all lost-time claims decreased. Our previous research showed that the same was true for the period 2011 to 2016.
-- Smartphone ownership over 80%. Smartphone ownership skyrocketed after the introduction of the iPhone in 2007, but growth has tapered off in recent years. As of year-end 2018, the percentage of US adults who own a smartphone is estimated to be over 80%.
-- Safety evolves. State-of-the-art vehicle safety features, such as automatic emergency braking, will take time to penetrate the driving pool, as the average car age is just under 12 years.
-- MVA claim severity. MVA lost-time claims continue to cost over 80% more than the average lost-time claim, because MVA claims tend to involve severe injuries (e.g., head, neck, and spine).

There is a notable disparity in smartphone ownership between younger and older drivers. Nearly all drivers under age 30, but only half of drivers over age 65, own a smartphone. This suggests that smartphone ownership among employed drivers may creep further upward as younger individuals enter the workforce and older workers retire.

However, since the vast majority of drivers now own smartphones, we may not see the same MVA frequency increases that occurred during the period when smartphone ownership was significantly increasing.

Greater use of cell phone blocking technology would also be expected to make driving safer, if enabled by the driver. This technology, available through smartphone apps, prohibits calls or texts while the vehicle is in motion. Alternatively, Bluetooth technology allows for hands-free communication while driving.

Several factors that may put downward pressure on MVA claim frequency include (i) stricter state cell phone laws, and (ii) vehicle safety improvements.

The source of data for this study is Statistical Plan data for NCCI states. This database contains detailed policy information, which allows an analysis of frequency and severity by various claim characteristics ...
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/ 2020 News, Daily News
Yosemite Community College District hired contractors to complete a remodeling project at the campus that included roof repair and replacement on several buildings. Kitchell CEM was the general contractor or program manager for the project. This included developing and implementing a program-wide safety program. Western Single Ply-Nevada was the roofing subcontractor. The plaintiff Ramon Mora was its employee.

In 2015 a 2x4, without the typical accompanying 2x6, was anchored to the edge of the roof to use as scaffolding. While Mora was on the 2x4 anchor board without a safety harness, the board gave way and he fell over 20 feet off the unprotected roof edge.

Mora filed a civil action that alleged General Contractor owed him a duty of care and breached that duty by failing to develop and implement a safety program that included fall prevention and protection measures.

The trial court sustained the General Contractor's demurrer. The order stated (1) workers’ compensation was "the sole and exclusive remedy for employees who sustain injuries while performing work in the scope of their employment"; (2) General Contractor "did not have the requisite degree of control over the property to support a claim for Premises Liability"; and (3) the negligence allegations were insufficient to state a cause of action against General Contractor. The Court of Appeal reversed in the unpublished case of Mora v Kitchell CEM.

The Privette doctrine will bar causes of action by an independent contractor’s employee against a non-negligent hirer that did not affirmatively act. A hirer can be a landowner, general contractor, or any other entity that hires an independent contractor.

Plaintiff’s complaint alleges that Roofing Subcontractor "was a subcontractor hired to perform reroofing work at the SUBJECT PREMISES." The complaint does not state who hired Roofing Subcontractor "to perform reroofing work." Thus, on the face of the complaint, the hirer of Roofing Subcontractor is not clearly and affirmatively shown. Consequently, at the pleading stage, the Privette doctrine cannot be a bar to the complaint because the hirer is not identified.

It is worthy of note that this opinion will likely be of limited value to this plaintiff. The identical issues will be tested again after a motion for summary judgment. Such a motion can included undisputed facts that establish the defendant as the General Contractor, and thus protected by Privette. This appeal is the result of Mora's sixth amended complaint, and Mora has undoubtedly had difficulty establishing his case thus far ...
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/ 2020 News, Daily News
A Beverly Hills anesthesiologist and his girlfriend, the owner of a Los Alamitos-based laboratory, are behind bars on charges of stealing about $52 million in an alleged insurance fraud scheme.

Dr. Randy Rosen, who was involved in a civil federal lawsuit involving a health care fraud scheme at a Long Beach hospital that was settled in 2017, was being held on $52 million bail along with co-defendant Liza Vismanos, who are both scheduled to be arraigned when a judge will also consider lowering their bail.

Vismanos owns the Wellness Wave surgical center in Beverly Hills and the Lotus Labs medical laboratory in Los Alamitos, according to the bail motion.

"In approximately June 2017, Rosen/Vismanos entered into a fraud scheme specifically targeting patients from addiction recovery rehabs to bill their private medical insurance carriers primarily for two types of procedures; a non-FDA approved Naltrexone implant and Cortisone injections," according to the bail motion.

"Rosen put his patients under anesthesia for these procedures in order to bill insurance for a major medical surgery at an approximate cost of $80,000 per procedure," according to the bail motion.

"Per Rosen’s records he performed these procedures in as little as one-minute increments with as many as 72 procedures per day. Additionally, Rosen collected blood and urine from his patients, which was processed at Lotus Labs at a cost of approximately $4,000 per day after the procedure with no known medical necessity."

Investigators allege 18 insurance companies were billed from June 2017 to May 2019 $661,940,464 and the two received $51,060,523.

The two are also accused of using two "body-broker" groups that would "sell Rosen patients in exchange for a kickback of the insurance proceeds," the bail motion alleges.

The "marketers" would - often pay the patients (oftentimes $500 to $2,000 per procedure) to incentivize them into returning to Rosen for multiple procedures," the bail motion alleges.

Investigators also allege "at least 35 of Rosen’s patients involved in this scheme have passed away, many by overdose," according to the bail motion.

Investigators also said the alleged scheme was the subject of a CBS report in July 2018 that "focused on the death of a patient," but "despite this attention Rosen/Vismanos continued with their fraud scheme, continued paying kickbacks and patients continued to die." ...
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/ 2020 News, Daily News
Telemedicine has grown more popular over the past few months as physicians utilized new methods to connect with and diagnose their patients in the wake of the COVID-19 shutdowns. However, even before these changes became necessary, a report by Property Casualty 360 says that many employers and medical offices found that virtual appointments delivered another alternative to providing care for some patients.

"When an injured employee suffers a serious or complex injury, nurses can be a valuable resource to promote recovery and return to work," says Jennifer Cogbill, vice president, GBCARE at Gallagher Bassett.

There are a wide range of medical services that can be provided remotely from kiosks in airports and pharmacies that allow individuals to check their pulse, blood pressure, temperature and other vitals to triaging care through telehealth visits. In these cases, nurses usually serve as the gatekeepers who determine what level of care is required for a patient, from a bandage to something more serious.

Dave Lupinsky, vice president of medical review services at CorVel Corporation, which provides health care management services for employers, third-party administrators, insurers and government entities, finds that care management starts by assessing which level of care is required: self-care that patients can provide to themselves with guidance from a nurse or other service provider, telecare provided remotely or care in a traditional brick and mortar location such as an emergency room or occupational clinic for more serious situations.

For most patients, the visits are conducted either over a desktop computer or some sort of mobile device (e.g., cell phone or tablet).

Despite the convenience tele-visits provide, some very real limitations must be considered. Some patients may not be technology savvy and have trouble accessing the patient portal or getting their computer to operate correctly (i.e., turning on the camera or microphone). Telemedicine also is not applicable for all injury and treatment types due to the limitations with the exam and other services needed.

As telemedicine moves from a niche service to more mainstream use, the value in terms of insurance and workers’ compensation claims will grow exponentially. James Quiggle, senior director of communications for the Coalition Against Insurance Fraud, anticipates that a new surge of tele-scams could well become America’s next large surge of medical fraud.

"Workers’ comp, auto and health insurers could find themselves confronting surges of false telemedicine claims. Insurers in each line have a unique vulnerability due to the large volume of medical claims," he asserts. "

Scams focus on exams, tests and treatments that don’t require physical contact " often abusing telemed codes. Many scams will be familiar, only using telemed as the fraud delivery vehicle. Providers might do dozens of perfunctory, two-minute, tele-consults to see if a patient is injured and needs physical therapy. Doctors bill insurers for one-hour sessions and receive kickbacks for referring patients to the physical therapist."

"Large crime rings will profit mightily from telemedicine. Telemarketing firms can hire phone boiler rooms to tele-recruit hundreds of bogus patients. The patients are referred to colluding providers for bogus tele-consults and treatment," he says, outlining how the fraud process will develop.

While not a panacea, telemedicine does provide another tool for medical professionals to connect with patients, particularly in a time when social distancing seems prudent. However, like every aspect of new technology, it needs to be implemented wisely ...
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/ 2020 News, Daily News
Misael Mendoza-Hernandez suffered a "non-catastrophic" injury in 2007 while working for his employer, Colosseum Athletics. State Fund was Colosseum’s workers’ compensation insurer.

In November 2008, a physician designated by State Fund injured Mendoza-Hernandez’s spine while giving him an epidural, rendering Mendoza-Hernandez "effectively quadriplegic." As a result, he needs catheterization every four to six hours. He cannot use his hands to do this, so he needs skilled nursing care for the catheterization. He also needs rectal suppositories to be able to defecate and must rely on another person to insert the suppositories.

Mendoza-Hernandez and State Fund entered into a written stipulation that State Fund would pay for home health care for eight hours per day, seven days per week, "until such time" as the parties’ agreed medical examiner reviewed certain documents and issued a supplemental report on Mendoza-Hernandez’s home health care needs. State Fund was to "then abide by those recommendations." State Fund was also to "restart rehab gym payments and authorizations until an AME report to [the] contrary."

The AME his report, which recommended 24 hour home health care. State Fund did not abide by the AME recommendation, and did not pay for 24 hour home care or for the rehabilitative gym membership. Mendoza-Hernandez to engage in further litigation before the WCAB to enforce the order.

In 2014, the parties stipulated to 100 percent disability. The parties subsequently agreed on the amounts of attorney fees, penalties, and sanctions that State Fund should pay for its refusal to pay the prior order.

Mendoza-Hernandez’s filed a civil action against State Fund for a single cause of action for intentional infliction of emotional distress. State Fund demurred to the Complaint. The trial court sustained the demurrer without leave to amend. The Court of appeal affirmed the dismissal in the unpublished case of Misael Mendoza-Hernandez v State Compensation Insurance Fund.

In Unruh v. Truck Insurance Exchange (1972) 7 Cal.3d 616 (Unruh), our Supreme Court created an exception to exclusive jurisdiction "where an employer’s insurance carrier intentionally commits outrageous and extreme conduct totally unnecessary to and far beyond the bounds of normal investigation and defense of a worker’s claim."

The trial court concluded that this exception did not apply to the facts that Mendoza-Hernandez alleged. The court cited Everfield v. State Compensation Insurance Fund (1981) 115 Cal.App.3d 15 (Everfield) for the proposition that an insurer’s "mere denial of payment, even if intentional, is still within the jurisdictional purview of the workers’ compensation scheme."

The Court of Appeal agreed with this reasoning, adding "California courts have invariably barred statutory and tort claims alleging that an insurer unreasonably avoided or delayed payment of benefits even though the insurer committed fraud and other misdeeds in the course of doing so." ...
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/ 2020 News, Daily News
The Workers’ Compensation Insurance Rating Bureau has prepared its annual report containing estimated California workers’ compensation costs for 2019. The report in general terms explains how much money came into the system in premiums, and then discusses how it was spent. The report does not include self-insured costs and expenses.

Insurer Losses, Expenses and Profits - Calendar year 2019 earned premium totaled $16.1 billion (as compared to the $17.4 billion of premium earned in 2018). Total insurer paid losses in 2019 were $8.3 billion, or 51% of calendar year earned premium. California insurers incurred $5.4 billion in expenses in 2019, or 34% of 2019 earned premium. (For comparison purposes, in 2018, total incurred expenses were 34% of earned premium).

So how was the remaining 66% of the earned premium spent?

Physician and Medical-Legal Costs - In 2019, $4.6 billion, or 55% of total loss payments, were for medical services.

Indemnity Benefits - In 2019, $3.8 billion, or 45% of total loss payments, were for indemnity benefits (including vocational rehabilitation benefits).

Vocational Rehabilitation Benefits - About $73 million in vocational rehabilitation-related benefits were paid in calendar year 2019. This was 1.9% of all indemnity payments in 2019, of which 97% was for non-transferable education vouchers. (For comparison purposes, in 2018, vocational rehabilitation benefits paid was $87 million or 2.3% of all indemnity payments, of which 97% was for non-transferable education vouchers).

In total, incurred losses and expenses in calendar year 2019 were $13.2 billion, or 82% of earned premium. Based on insurer statutory Annual Statement information, the WCIRB estimates policyholder dividends incurred in 2019 to be 0.2% of 2019 earned premium, resulting in an underwriting profit of $2.9 billion, or 18% of premium. (For 2018, the underwriting profit was 23% of earned premium, or $4.1 billion.)

Fees Paid to Applicant Attorneys - Although generally part of incurred indemnity losses rather than expenses, the amount paid in 2019 to applicant attorneys was derived from the WCIRB’s Annual Expense Call. In 2019, applicant attorneys were paid $446 million. (In 2018, applicant attorneys were paid $386 million.) ...
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/ 2020 News, Daily News
The Commission on Health and Safety and Workers’ Compensation (CHSWC), which was established in 1994, examines the health and safety and workers’ compensation systems in California and makes recommendations to improve their operation. The 324 page 2019 Annual Report is now available on the CHSWC website.

Here are some highlights of the latest Report:

The California workers’ compensation system covers an estimated 16,775,000 employees working for over 1,019,255 employers in the state. These employees and employers generated a gross domestic product of $2,968,118,000,000 ($3.0 trillion) in 2018. A total of 682,160 occupational injuries and illnesses were reported for 2018, ranging from minor medical treatment cases to catastrophic injuries and deaths. The total paid cost to employers for workers’ compensation in 2018 was an estimated $23.5 billion.

The advisory pure premium rates approved January 1, 2019, are on average 41 percent below those as of January 1, 2015. The charged rate rose on average by 21 percent from the first period of 2012 to its peak in 2015 and then decreased by 33 percent from the first period of 2015 to the first period of 2019. According to the WCIRB this decrease is largely due to the significant savings from SB 863.

Another significant accomplishment was the development and implementation of a streamlined process for California employers who wish to become self-insured to accomplish this process in a "speed-of-business" manner. In 2011, the total time required to complete the private self-insured application process and be issued a certificate of authority to self-insure was nearly nine months. In 2012, this was shortened to four to six months, with additional reductions during 2013 to less than 30 days. In 2014, OSIP successfully worked with private employers and completed this process consistently in less than 14 days.

Research on the impact of the 2012 workers’ compensation reforms on earnings losses suggests that SB 863 is likely to meet its primary objective of restoring adequate wage replacement rates, although some inequities still exist in these rates across impairments.

Operators in the underground economy create an unfair advantage over their law-abiding competitors and cost the state an estimated $8.5 billion to $10 billion in uncollected tax revenues each year. CSHWC suggest continued research into ways to identify the underground economy and ensure compliance with workers’ compensation and health and safety laws.

In recent years, criminal indictments and prosecutions have highlighted the extent of medical provider fraud in the workers’ compensation system. Estimates of the cost of this fraud to participants in the workers’ compensation system are as high as $1 billion per year ...
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/ 2020 News, Daily News
As U.S. opioid prescriptions continue to trend downwards, skeletal muscle relaxer scripts are on the rise, according to an analysis of the CDC's National Ambulatory Medical Care Survey (NAMCS).

Between 2005 and 2016, the number of office visits in which muscle relaxers were prescribed, most commonly for back pain and musculoskeletal conditions, doubled from 15.5 million to 30.7 million, reported Charles E. Leonard, PharmD, MSCE, of the University of Pennsylvania in Philadelphia, and colleagues.

While office visits resulting in new skeletal muscle relaxer prescriptions during this period remained relatively stable at about six million per year, visits for continued therapy tripled from 8.5 million to 24.7 million, the researchers wrote in JAMA Network Open.

The proportion of older adults receiving muscle relaxant prescriptions increased three-fold across the study period such that by 2016, adults over 65 accounted for 22.2% of visits in which a muscle relaxant was prescribed, the team added. Also, 67.2% of continued muscle relaxant visits in 2016 were completed while the patient was on concomitant opioids.

"For a number of years now, the American Geriatrics Society has warned providers of prescribing skeletal muscle relaxers for older adults, and the long-term treatment with skeletal muscle relaxers was particularly concerning to us because most of the available data really only support short-term use of these drugs," Leonard told MedPage Today, adding that in some cases, especially among younger people, the drugs may be considered.

Nationally, opioid prescriptions decreased by about 20% between 2006 and 2017, in part due to the CDC's 2016 guidelines on opioid prescribing. Between 2015 and 2018, close to 11% of adults reported being on at least one pain medication prescription, and 6% said they were on opioids, per CDC data.

"The take-home message here is that muscle relaxers are being overprescribed and we need to be aware they are not really innocent medication," one researcher added ...
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/ 2020 News, Daily News
Attorney General Maura Healey announced a $11 million settlement with a mail-order pharmacy resolving allegations that it failed to implement adequate safeguards against unlawful and dangerous dispensing, resulting in the shipment of thousands of potentially illegitimate controlled substance prescriptions across the country.

In the complaint, filed along with a proposed consent judgment in Suffolk Superior Court, the AG’s Office alleges Injured Workers Pharmacy (IWP) violated Massachusetts consumer protection law by failing to implement effective policies and procedures for reviewing prescriptions to determine whether they were legitimate and by engaging in unlawful marketing practices to drive sales, including paying law firms for patient referrals.

"Injured Workers Pharmacy created an illegal operation that put dispensing speed and volume over patient and public safety," AG Healey said. "They dispensed thousands of prescriptions for dangerous drugs, including opioids like fentanyl, with a shocking lack of regard for whether those prescriptions were legitimate. Combatting the opioid epidemic remains a top priority of my office and we will aggressively pursue those who break our laws to profit from this crisis."

The AG’s Office began investigating IWP, which serves thousands of workers’ compensation patients nationwide, after learning that the pharmacy dispensed a high volume of controlled substances primarily to workers who had been injured on the job.

The AG’s complaint alleges that IWP pressured pharmacists to dispense prescriptions faster and implemented programs that prioritized dispensing speed and volume over protecting its patients and preventing diversion. The complaint further alleges that IWP’s dispensing and sales practices effectively precluded it from complying with statutory mandates and meeting its responsibility to fill only legitimate prescriptions issued in the usual course of professional treatment.

According to the AG’s complaint, IWP also used unlawful tactics to drive sales, including entering into illegal agreements to buy patient referrals and encouraging sales staff to engage in their own misconduct and ignore red flags by paying them based on dispensing volume.

As a result of these unfair dispensing and sales practices, the complaint alleges IWP filled and shipped:

-- Thousands of prescriptions written by problem prescribers who were ultimately disciplined, indicted or convicted for improper opioid prescribing. IWP did not stop dispensing their prescriptions until long after their behaviors were or should have been apparent to pharmacy and sales staff.
-- Thousands of dangerous, high-dose prescriptions, including for fentanyl formulations known to be especially dangerous.
-- Thousands of prescriptions for dangerous drug combinations known to be indicators of drug misuse and potential overdose, including the so-called "holy trinity" - a combination of an opioid, a benzodiazepine, and a muscle relaxant.

The proposed consent judgment, which remains subject to court approval, would require IWP to undertake significant changes to its operations and business practices ...
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/ 2020 News, Daily News
More than a half a million individuals are transported via air ambulance services each year, according to the Association of Air Medical Services. The majority of these transports are via helicopter in emergency situations; the remainder are fixed-wing transports for longer distances.

While fees charged by traditional medical transport services in California workers' compensation claims are regulated under the Official Medical Fee Schedule, air ambulance providers argue that they fall under the jurisdiction of the Airline Deregulation Act (ADA) of 1978, which prevents states from enacting or enforcing laws or regulations related to the price, route or service of an air transportation carrier.

In California workers' compensation, the WCAB issued an en banc decision in 2013 ( Luis Enriquez (deceased) v Couto Dairy and Zenith Insurance Company ) conceding the preemption of federal law over Official Medial Fee Schedule limits if the air ambulance provider could establish that they were an "air carrier" that provides air transportation within the meaning of the Airline Deregulation Act.

Yet the litigation debate over the preemption issue continues to rage in other jurisdictions. The Texas Supreme Court just ruled that preemption does not apply in Texas.

Excessive helicopter transport bills were the crux of the lawsuit in PHI Air Medical, LLC v. Texas Mutual Insurance Company, et al. A trial court rendered judgment in favor of eight plaintiff insurers, which included Texas Mutual Insurance Company and Hartford Underwriters Insurance Company, who disagreed with PHI’s per-trip charge for medically transporting injured workers.

The Texas trial court held the insurers could not be asked to pay more than 125 percent of the Medicare amount for air ambulance transport. On Jan. 31, 2018, however, the Texas Court of Appeals remanded the case, holding that any rate provisions for air ambulance transports are preempted by the ADA.

In Split June 26, 2020 Opinion, the Supreme Court of Texas Rejected Preemption Argument in Worker's Compensation Disputes. The Court held that the Airline Deregulation Act did not preempt state law pertaining to worker's compensation insurance benefit payments because the law does not expressly refer to air ambulance providers, and the standard for establishing the amount of reimbursement also was not preempted.

Thus the workers' compensation industry has not seen the final word on this issue ...
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/ 2020 News, Daily News
San Gorgonio Pass CHP Commander Captain Mike Alvarez announced.that a Banning California Highway Patrol officer was arrested Wednesday on suspicion of workers compensation insurance fraud.

Kathleen Beardsley, 46, was arrested by CHP investigators without incident at the Banning Police Department and was booked into Larry D. Smith Correctional Facility on suspicion of three felony charges tied to fraud as well as a felony grand theft charge, jail records show.

Her bail was set at $10,500. A court date has not been set, according to jail records.

The arrest was the culmination of a seven-month long investigation by the CHP's Workers Compensation Fraud Investigations Unit based at the agency's Sacramento headquarters, according to Alvarez.

The investigation began after Beardsley filed a workers compensation insurance claim on February 14, 2019 for unspecified injuries.

In October, a tip was received by the investigations unit about possible illicit activities by Beardsley. Surveillance was used on her by investigators, and she was observed "engaging in activities inconsistent with the limitations outlined in her claim," according to Alvarez's announcement.

Beardsley, who has been a CHP officer for 25 years, was summoned for questioning at the Banning Police Department, then arrested.

Beardsley, a 25-year veteran of the CHP, had been assigned to the San Gorgonio Pass Area since 2016. As a result of her arrest, she has been placed on administrative leave and her peace officer powers removed, according to Alvarez.

In addition to the criminal investigation, the CHP is also conducting an internal administrative investigation, according to Alvarez, although details were not released ...
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/ 2020 News, Daily News
The Division of Workers’ Compensation (DWC) has posted proposed amendments to the Medical-Legal Fee Schedule to its online forum where members of the public may review and comment on the proposals.

The draft regulations include:

-- A 25% increase in the multiplier for setting fees for evaluations.
-- Standardization of the fee that can be charged for a missed appointment.
-- Flat fees for comprehensive, follow-up, and supplemental medical-legal evaluations.
-- Rates for review of medical records based upon the amount of pages reviewed.
-- Elimination of complexity factors from the Medical-Legal Fee Schedule.
-- An increase in the hourly fee for medical-legal testimony.

The implementation of a predominantly fixed fee for all procedure billing codes is anticipated to reduce frictional costs. Moving to a flat-fee-based schedule and removing complexity factors is contemplated to reduce the incidence of disputes over billing.

The fee schedule was formulated after numerous stakeholder meetings where carriers, employers, physicians, and medical management companies were amply represented. The meetings took place over the course of approximately three months.

The forum can be found on the DWC forums web page under "current forums." Comments will be accepted on the forum until 5 p.m. on Friday, July 10, 2020 ...
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/ 2020 News, Daily News
A 39-year old Santa Ana police officer has been charged with committing workers’ compensation insurance fraud for continuing to accept his full pay without working even though he was physically capable of returning to work.

On October 5, 2017, Jonathon Ridge was injured on duty while in pursuit of a suspect driving a stolen vehicle. On that day, October 5, 2017, Ridge went out on disability leave due to his injuries. On May 2, 2018, while still on leave, Ridge had surgery on his left wrist, and his doctor continued to keep him off work while he was recovering from the surgery.

In November 2018, Ridge was released by a doctor to return to work with restrictions. The work restrictions were too severe for the City of Santa to accommodate, despite the City of Santa Ana having an extensive return-to-work program for injured employees. This resulted in the City of Santa Ana being required to continue to pay Ridge Total Temporary Disability and for Ridge to receive disability payments through an insurance policy, resulting in Ridge receiving 100% of his pay without working.

From March 2019 to May 2019 the City of Santa Ana authorized surveillance on Ridge because he did not seem to improve despite having had surgery on his wrist in May 2018 for injuries sustained in the on-duty collision 18 months earlier.

The surveillance and subsequent investigation found that Ridge was engaging in activities well beyond what the doctor had imposed. Ridge began attending college classes nearly full-time beginning in June 2018 - just weeks after his surgery. Additionally, he packed up his car and drove to Utah, went to the beach, and drove his motorcycle.

Ridge failed to disclose to his doctor or to the City of Santa Ana what he was actually capable of doing. This deprived the doctor of the opportunity to impose realistic work restrictions that the City of Santa Ana could accommodate. Instead, Ridge continued to receive 100% of his pay without working even though he was capable of returning to work in a modified position.

Ridge has been charged with four felony counts of insurance fraud. He faces a maximum sentence of eight years in state prison if convicted on all counts.

"Workers’ compensation fraud costs honest, hardworking businesses and government entities more than $30 billion a year," said Orange County District Attorney Todd Spitzer. "We cannot allow those who commit workers’ compensation fraud to go unpunished because the financial cost to government and private business makes the cost of doing business more and more difficult."

Deputy District Attorney Pamela Leitao of the Insurance Fraud Unit is prosecuting this case ...
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/ 2020 News, Daily News
Kyle Adams, Daniel Castro and Jeremy Syto pleaded guilty in federal court, admitting their roles in a San Diego based fraud scheme that bilked the military healthcare program known as TRICARE out of more than $65 million.

At the same time, the alleged ringleaders of this scheme were charged with additional crimes. Jimmy and Ashley Collins, a civilian married couple living in Cleveland, Tennessee, were originally charged in January 2018. They were charged on June 9, 2020 with additional crimes related to their operation of the scheme.

The defendants admitted they illegallly recruited TRICARE patients to receive extraordinarily expensive and largely unnecessary prescription compounded drugs - which cost TRICARE an average of more than $14,500 per medication per month. They induced the patients to sign up by offering monthly payments to participate in a bogus "medical evaluation," when, in fact, no medical evaluation was taking place.

Although compounded drugs are not approved by the Food and Drug Administration (FDA), they are properly prescribed when a physician determines that an FDA-approved medication does not meet the health needs of a particular patient, such as if a patient requires a particular dosage or application or is allergic to a dye or other ingredient.

The three worked as recruiters for Jimmy and Ashley Collins. At the Collins’ direction, the defendants recruited TRICARE beneficiaries by promising to pay them to evaluate the medications as part of an ongoing medical study, when in reality, no study was taking place.

Once a recruiter convinced a TRICARE beneficiary to sign up to receive the compounded medications, the straw beneficiary’s information was sent to Choice MD, a Tennessee medical clinic co-owned and operated by Jimmy and Ashley Collins.

Doctors and medical professionals employed at Choice MD, including Dr. Susan Vergot, Dr. Carl Lindblad, and Candace Craven, then wrote prescriptions for the TRICARE beneficiaries, despite never conducting a medical review or examination of the patients in person.

Once signed by the doctors, these prescriptions were not given to the straw beneficiaries, but sent directly to The Medicine Shoppe, a pharmacy in Bountiful, Utah, which filled the prescriptions and received massive reimbursement from TRICARE.

The owners of The Medicine Shoppe then paid kickbacks to the Collinses based on a percentage of the TRICARE reimbursement paid for the prescriptions referred by the Collinses’ recruiter network. These kickback payments to the Collinses totaled at least $45.7 million dollars. The Collinses, in turn, paid kickbacks to the recruiters working as part of their network, including Adams, Castro, and Syto, among others.

In addition to guilty pleas from Adams, Castro, and Syto, both Dr. Vergot and Dr. Lindblad as well as Candace Craven, a nurse practitioner at Choice MD, have previously pleaded guilty for their roles in the conspiracy to commit healthcare fraud. CFK, Inc., the corporate owner of the Medicine Shoppe, has also pleaded guilty and paid a fine as part of this investigation ...
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/ 2020 News, Daily News
Richard Todd, a former police officer, sustained a cumulative trauma injury arising out of and in the course of his employment with the City of Los Angeles to his kidneys, heart, psyche, and in the form of hypertension during the period from January 1, 1990 through November 25, 2009.

A Findings and Award issued on March 6, 2012 against the employer of 64% permanent disability as a result of applicant’s injury to his kidneys, heart, and in the form of hypertension. After filing a petition to reopen, the parties stipulated to 68% permanent disability, In addition, there had been five prior stipulated awards in unrelated cases. Together, Todd made an argument for a 100% permanent disability award against the Subsequent Injuries Benefits Trust Fund.

The WCJ found that the sum of applicant’s successive disabilities entitled applicant to permanent and total disability.

The sole issue presented by the SIBTF Petition for Reconsideration was whether the WCJ correctly combined applicant’s prior and subsequent permanent disabilities under section 4751 by adding them to find that applicant is permanently and totally disabled. The WCJ findings were affirmed in the en banc decision of Todd v Subsequent Injuries Benefits Trust Fund.

SIBTF is a state fund that provides benefits to employees with preexisting permanent disability who sustain subsequent industrial disability. The preexisting disability may be congenital, developmental, pathological, or due to either an industrial or nonindustrial accident. It must be "independently capable of supporting an award" of permanent disability, "as distinguished from [a] condition rendered disabling only as the result of ‘lighting up’ by the second injury." There is no specific statute of limitations with respect to the filing of an application against SIBTF.

Once the threshold requirements are met, section L.C. 4751 provides that applicant "shall be paid in addition to the compensation due under this code for the permanent partial disability caused by the last injury compensation for the remainder of the combined permanent disability existing after the last injury . . . ."

The Court of Appeal’s decision in Bookout v. Workers’ Comp. Appeals Bd. (1976) 62 Cal.App.3d 214 [41 Cal.Comp.Cases 595], addressed the issue of how to determine the "combined permanent disability" as specified in section 4751.

The use of the MDT or CVC to combine multiple impairments or permanent disabilities with respect to the rating of single injuries, but not to combine successive permanent disabilities related to prior and subsequent injuries under section 4751. Under section 4751, non-overlapping successive permanent disabilities are to be added.

SIBTF is liable, under section 4751, for the total amount of the "combined permanent disability," less the amount due to applicant from the subsequent injury and less credits allowable under section 4753 ...
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/ 2020 News, Daily News
The WCIRB collects and validates classification data for all California employers. This data is critical to ensuring that policyholders engaged in common industries are similarly classified. It is also key to the publication of accurate experience modifications and the use of the data for ratemaking.

As part of this effort, the WCIRB’s team of Field Representatives conducts on-site reviews at policyholders’ business locations to gather a detailed description of the operations and to verify the classifications that apply to their business. Based on this review, the Field Representative prepares a Classification Inspection Report that is sent to the both policyholder and their current insurer.

Effective July 1, 2020, the WCIRB is expanding its Special Inspection Report program to allow agents and brokers to request a WCIRB physical inspection of their clients’ California business operations. This new service is in response to frequent inquiries from agents and brokers for the WCIRB to conduct a physical inspection in order to affirm the standard classification applicable to an employer’s business. Prior to July 1, 2020, only the insurer of record could make a request of the WCIRB to conduct one of these Special Inspections.

The fee for conducting a Special Inspection is $200 per location inspected. The WCIRB will invoice the requesting insurer, agent or broker, once all location inspections are completed and the reports pub-lished. The WCIRB typically completes and publishes Special Inspections within 30 days of the request.

To request a Special Inspection, an agent or broker must complete the Agents/Brokers Request for WCIRB Inspection of Insured - Form 501a (available via WCIRB Connect®) and submit it electronically to the WCIRB Contact Center. For agent and broker requests, the Contact Center will initiate a digital authorization from the policyholder to ensure that the policyholder approves of the request.

For more information about this service, please contact the WCIRB Contact Center at customerservice@wcirb.com or 888.229.2472. A detailed overview of the WCIRB Classification Inspection Report can be found in the Learning Center on the WCIRB website at wcirb.com ...
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/ 2020 News, Daily News
What role have pharmaceutical companies played in fueling America’s epidemic of opioid addiction, and how have they and their stockholders profited?

This question has been answered by a new PBS documentary, Opioids Inc., documenting how one drug company bribed doctors, committed insurance fraud and made millions for Wall Street investors pushing a highly addictive opioid painkiller - and how it then became the first pharmaceutical company to have its CEO sentenced to prison time in federal court in connection with the opioid crisis.

The company was Insys Therapeutics, the CEO was John Kapoor, and the drug was Subsys, a fast-acting fentanyl-based spray that is 50 to 100 times stronger than heroin. Approved for treating cancer pain, it was prescribed much more generally, helping the company’s sales reach more than $300 million at their peak and stock prices on Wall Street surging.

Opioids, Inc. examines how federal prosecutors prepared the case against Insys by pursuing a novel strategy, using anti-racketeering laws designed to fight organized crime and working their way up the company’s ranks - and how they ultimately arrived at a "smoking gun": a spreadsheet ordered by Kapoor that showed how Insys tracked the money that went to doctors, and what the company got in return.

The documentary tells the inside story of the corruption behind Insys’ spectacular rise - a scheme that federal prosecutors said went all the way to the top, and that involved paying doctors to prescribe extreme doses of Subsys to their patients - and how investors looked the other way.

A former sales representatives from Kapoor’s company describe a culture of unbridled greed, detailing how they targeted high-prescribing doctors and nurse practitioners known as "whales."

"It wasn’t about cancer patients. It was about getting as many people as you could on the drug," says former sales representative April Moore, adding, "Low doses aren’t that much money. Higher dose, more money."

The company even held contests for the sales team: the higher the doses they got doctors to write, the larger the cash prize - despite the dangers to patients.

At the same time, the company was misleading insurers to approve prescriptions of the drug: "None of what we were saying was truthful," a former prior authorization specialist says. "We’re just pocketing the money off of a prescription that should’ve never been approved anyway. That’s insurance fraud."

Opioids, Inc. will be available to watch in full at pbs.org/frontline, on YouTube, and in the PBS Video App. An in-depth Financial Times story will publish at FT.com and at pbs.org/frontline ...
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/ 2020 News, Daily News
The Division of Workers’ Compensation has issued a notice of conference call public hearing for proposed evidence-based updates to the Medical Treatment Utilization Schedule (MTUS), which can be found at California Code of Regulations, title 8, section 9792.23.

The conference call public hearing is scheduled for Thursday, July 23 at 10 a.m. and members of the public may attend by calling 866-390-1828 and using access code 5497535#. Members of the public may review and comment on the proposed updates no later than July 23.


The proposed evidence-based updates to the MTUS incorporate by reference the latest published guidelines from American College of Occupational and Environmental Medicine (ACOEM) for the following:

-- Occupational Interstitial Lung Disease Guideline (ACOEM November 8, 2019)
-- Knee Disorders Guideline (ACOEM December 3, 2019)
-- Workplace Mental Health Guideline: Depressive Disorders (ACOEM February 13, 2020).
-- Occupational/Work-Related Asthma Guideline (ACOEM June 5, 2020)

The proposed evidence-based updates to the MTUS regulations are exempt from Labor Code sections 5307.3 and 5307.4 and the rulemaking provisions of the Administrative Procedure Act. However, DWC is required under Labor Code section 5307.27 to have a 30-day public comment period, hold a public hearing, respond to all the comments received during the public comment period and publish the order adopting the updates online ...
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/ 2020 News, Daily News