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The European Medicines Agency (EMA) reports that the agency has been subject to a cyber attack and that some documents relating to the regulatory submission for Pfizer and BioNTech’s COVID-19 vaccine candidate, BNT162b2, which has been stored on an EMA server, had been unlawfully accessed, BioNTech revealed in a statement published on its website.

The German biotechnology company, previously best-known for its work pioneering cancer immunotherapy research, stressed that "no BioNTech or Pfizer systems" were accessed during the breach, suggesting that it was the European Union regulator whose security failed.

They added that they were "unaware" of any of their study participants being identified as a result of the breach and that they are awaiting "further information about EMA’s investigation and will respond appropriately and in accordance with EU law."

"Our focus remains steadfast on working in close partnership with governments and regulators to bring our COVID-19 vaccine to people around the globe as safely and as efficiently as possible to help bring an end to this devastating pandemic," they concluded.

The British National Cyber Security Centre (NCSC) has indicated that the hack should not impact the BioNTech/Pfizer vaccine’s rapid and at-times troubled rollout in the United Kingdom.

The Medicines and Healthcare products Regulatory Agency (MHRA) has advised that the coronavirus prophylactic should not be administered to people with a "history of a significant reaction" to medicines, foods, or vaccines, after two National Health Service (NHS) workers showed symptoms of an "anaphylactoid reaction" shortly after being injected.

The regulator now advised that "resuscitation facilities" should be present at all vaccination sites, and vaccinations not carried out if they are now available.

On the hacks, the NCSC said that it was "working with international partners to understand the impact of this incident affecting the EU’s medicine regulator, but there is currently no evidence to suggest that the UK’s medicine regulator has been affected."

According to the BBC, it is "not clear" whether or not cyber-attackers also hacked the EMA’s documents on the Moderna vaccine at present.

China, Iran, and Russia have all been accused of using hackers against coronavirus vaccine research by Western governments ...
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/ 2020 News, Daily News
The Department of Industrial Relations (DIR) and its Division of Workers’ Compensation (DWC) posted a progress report on the Department’s Independent Medical Review (IMR) program.

IMR is the medical dispute resolution process for the state’s workers’ compensation system that resolves disputes about the medical treatment of injured workers. The report describes IMR program activity in 2019, the seventh year since the program was implemented.

The organization administering the program, Maximus Federal Services, Inc., received over 222,000 IMR applications, and issued almost 164,000 Final Determination Letters, each addressing one or more medical necessity disputes.

Some highlights of the report:

-- The monthly average length of time to issue an IMR determination after receipt of all medical records ranged from 7 to 8 days throughout 2019.
-- An average of 13,600 IMR decisions were issued each month. Overall there was a 12% decrease from 2018.
-- 93.5% of all unique IMR applications filings were deemed eligible for review.
-- 10.4% of the utilization review (UR) decisions that denied treatment requests made by physicians treating injured workers were overturned. This rate of overturn is similar to the previous year (10.3%).
-- As in previous years, substantially similar rates of overturned cases occurred in all geographic regions in which injured workers reside.
-- Treatment request denials were overturned at a rate of 10.4%, with specialist consultations, office visits and mental health services overturned most often.
-- Pharmaceuticals accounted for 36.7% of treatment requests sent for IMR with opioids comprising nearly one of every three pharmaceutical requests.
-- Guidelines contained in the Medical Treatment Utilization Schedule continue to be the primary resource for the determination of medical necessity.

The progress report is posted on the DIR website ...
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/ 2020 News, Daily News
34 year old Perry Adam Lieber, who lives in Santa Barbara and who was a former Ventura County firefighter, was charged earlier this year with three felonies in a case involving workers' compensation fraud.

Lieber allegedly made material misrepresentations about the nature and extent of an industrial injury as well as his true physical abilities, the DA's office said. Prosecutors also say he misrepresented his income while getting disability pay and lied under oath during a deposition.

Lieber, ultimately pled guilty this month to felony workers’ compensation fraud under Insurance Code section 1871.4(a), admitting a special allegation that the theft totaled more than $100,000 in losses to the victims.

During his guilty plea, Lieber admitted making false and material misrepresentations for the purpose of obtaining disability benefits to which he was not entitled during his workers’ compensation claim.

Victim agencies York Risk Services and the County of Ventura are alleged to have sustained losses of approximately $148,177.

Chief Mark Lorenzen of the Ventura County Fire Department said Lieber resigned from the agency in early March.

According to a report in the Ventura County Star at the time of his arrest, the Chief said the department was not surprised by the charges the DA's office has brought against Mr. Lieber. "We were aware of a number of irregularities during the last portion of his career. We brought those to the attention of the county risk management unit."

The maximum penalty for a violation of Insurance Code 1871.4(a) is five years in jail, as well as a fine of up to double the amount of fraud, or approximately $296,354.

At the time this case was filed, the Ventura County District Attorney’s Office Workers’ Compensation Fraud Unit obtained a temporary restraining order seizing Lieber’s bank accounts and other assets in connection with the fraud investigation.

As a condition of Lieber’s plea, a portion of these assets will be liquidated to pay victim restitution and criminal fines.

Lieber is scheduled to be sentenced on January 6, 2021, at 9:00 a.m. in courtroom 12 of the Ventura County Superior Court ...
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/ 2020 News, Daily News
On December 8, 53 year old David Burgmeier, who lives in Simi Valley California, pleaded guilty to four counts of felony insurance fraud and four counts of felony unemployment insurance fraud.

At the time of his pleas, Burgmeier paid $45,000 in partial restitution owed to the victims in this case, the State Compensation Insurance Fund (State Fund) and the State of California Unemployment and Disability Insurance Tax Program (EDD).

According to CSLB records, Burgmeier has been a licensed general building contractor since 1998. From March 2008 through March 2016, Burgmeier owned and operated Burgmeier Construction in Simi Valley.

During that time, Burgmeier misrepresented the number of his employees and the total amount of payroll to the victims in this case. His fraud resulted in the underpayment of insurance premiums totaling $176,265 to State Fund, and an underpayment of taxes totaling $39,608 to EDD. <br /

Burgmeier will be sentenced on January 7, 2021, at 9:00 a.m. in courtroom 47 of the Ventura County Superior Court.

Burgmeier faces a maximum sentence term of 10 years 8 months in prison.

His state contractors license expired on May 31, 2018 and he is no longer licensed in California ...
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/ 2020 News, Daily News
On November 20, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a final rule to modernize and clarify the regulations that interpret the Medicare physician self-referral law (often called the "Stark Law"), which has not been significantly updated since it was enacted in 1989. .

Under the Stark Law, a physician is prohibited from making referrals to an entity for healthcare services if the physician has a financial relationship with the entity. The regulations were intended to protect patients in a health care system that reimbursed providers on a fee-for-service basis. In this type of system, there is a motivation to provide more services.

The new final rule supports the CMS "Patients over Paperwork" initiative by reducing the unnecessary regulatory burdens on physicians and other healthcare providers while reinforcing the Stark Law’s goal of protecting patients from unnecessary services and being steered to less convenient, lower quality, or more expensive services because of a physician’s financial self-interest.

Through the Patients over Paperwork initiative, the final rule opens additional avenues for physicians and other healthcare providers to coordinate the care of the patients they serve - allowing providers across different healthcare settings to work together to ensure patients receive the highest quality of care.

In addition, as part of the Regulatory Sprint to Coordinated Care, CMS worked closely with the Department of Health and Human Services Office of Inspector General in finalizing policies that advance the transition to a value-based healthcare delivery and payment system that improves the coordination of care among physicians and other healthcare providers in both the federal and commercial sectors.

Healthcare Leadership Council President Mary Grealy said, "This should be recognized as one of the most important health policy achievements of recent years. We are moving toward an era in healthcare that recognizes the importance of care coordination and fully integrated care involving primary care providers, specialists, hospitals, pharmacies, drug and device manufacturers and more."

Grealy continued, "These laws, as written, discouraged innovative patient-focused multi-sector collaborations at a time in which we should be enthusiastically encouraging them. What these new rules recognize is that we can protect patients from fraud and abuse while still allowing the healthcare system to evolve in a way that benefits patients and achieves greater cost-efficiency."

It remains to be seen if regulators in California will follow this thinking in terms of regulating those involved in workers' compensation medical delivery systems ...
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/ 2020 News, Daily News
In the COVID-19 era, under relaxed federal emergency orders, licensed clinicians have been able to prescribe opioid analgesics for their patients even if they've only ever seen the patient via telehealth, rather than in person.

The Ryan Haight Online Pharmacy Consumer Protection Act, passed in 2008, included a prohibition on writing prescriptions for controlled substances such as opioids by means of the internet unless the clinician first conducted an in-person exam. It came with a number of exceptions and carve-outs, one of which is for public health emergencies such as the one declared by HHS Secretary Alex Azar, MD, on Jan. 31. It effectively put the Ryan Haight Act provision on hold for the duration of the emergency.

The Drug Enforcement Agency issued an exception allowing prescribing of controlled substances via telemedicine without a prior in-person visit during the pandemic, though it specifies that telephone-only communications are not part of that exception.

But what happens when the current COVID emergency order issued by the Department of Health and Human Services (HHS) expires? Palliative care doctors who have learned how to manage patients remotely via telemedicine may have to return to old ways -- including a requirement that they see a patient in person before prescribing opioids.

CMS has indicated that it will revisit guidelines around telehealth services generally at the time when the emergency order is phased out. However it is not known if it address the prescribing situation.

This question plays out in the context of the other, ongoing national epidemic of prescription opioid overdoses, with federal agencies trying to curb excessive opioid prescribing.

Because every state is different, both for opioids and telehealth, providers need to take a close look at existing state law.

Attorney Sarah Churchill Llamas, chair of the healthcare industry group at the law firm Winstead PC in Austin said "At the end of the day, even if doctors do everything they're supposed to, they could still get reviewed by their state medical board. Now that you're overlaying telemedicine on top of opioid prescribing, I could see where a physician might say: 'I just don't feel comfortable going out on a limb with this."

"My advice, do what's best for your patients' care, but plan for the future. You have to know that the relaxation of regulations due to the emergency orders is going to end, and that may be tough for your patients." ...
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/ 2020 News, Daily News
Last year, Governor Gavin Newsom signed AB 51, which effectively outlawed mandatory arbitration agreements with employees - a new version of a bill that prior Governor Jerry Brown had vetoed repeatedly while he was in office.

The law allows workers to pursue damages and attorneys’ fees and open criminal cases against employers who discriminate and retaliate against them for declining arbitration contracts.

The analysis of the Senate Rules Committee demonstrated that the legislature was well aware that a bill prohibiting arbitration agreements could be challenged as being preempted by the Federal Arbitration Act ("FAA").

As the bill’s author stated, "The Supreme Court has never ruled that the FAA applies in the absence of a valid agreement. AB 51 regulates employer behavior prior to an agreement being reached. Further, understanding the Courts’ hostile precedence toward policies that outright ban or invalidate arbitration agreements, AB 51 does neither. Both pre-dispute and post dispute agreements remain allowable and the bill takes no steps to invalidate any arbitration agreement that would otherwise be enforceable under the FAA. The steps help ensure this bill falls outside the purview of the FAA."

Courthouse News reports that this past January, U.S. District Judge Kimberly Mueller blocked state officials from enforcing key provisions of the bill that regulate agreements governed by the Federal Arbitration Act. The Obama appointee agreed with a coalition of business groups led by the U.S. Chamber of Commerce that AB 51 unfairly regulated or singled out arbitration agreements in comparison to other contracts.

The ruling was appealed to the 9th Circuit Court of Appeals, and the matter was set for oral argument this December.

Arguing employers could retaliate against workers, a California Justice Department attorney told a Ninth Circuit panel Monday it should overturn a judge’s ruling that federal law preempts the state’s pro-worker bill barring arbitration requirements as conditions of employment.

Proponents of the bill say it protects workers in food service, hospitality and retail who are increasingly being forced to sign away their rights to sue in exchange for being hired.

The chamber argued the bill would unfairly expose California businesses to civil and criminal penalties and force them to both alter hiring practices and spend more on dispute resolution.

California Deputy Attorney General Chad Stegeman told the Ninth Circuit AB 51 was crafted to complement the Federal Arbitration Act - referred to during oral arguments as the FAA - and that it doesn’t undermine arbitration but rather targets employers’ "discriminatory intent" toward workers.

"It’s a matter of consent. An employer can’t fire an employee because of their refusal to arbitrate," Stegeman said, adding Mueller’s ruling exposes workers to unfair contracts. "The court created a new substantive right to force arbitration. But there’s no such right derived from the FAA."

Andrew Pincus of Mayer Brown, an attorney for the chamber, told the panel the Federal Arbitration Act clearly preempts state laws that block formation and enforcement of arbitration agreements.

Supreme Court precedent directly applies in situations described in AB 51 where workers must weigh the benefits of nonnegotiable employment contracts even if they don’t have the same bargaining power, Pincus said.

The panel took the matter under submission and did not indicate when it would rule ...
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/ 2020 News, Daily News
A retired British shop clerk received the first shot in the country’s Covid-19 vaccination program Tuesday, the start of an unprecedented global immunization effort intended to offer a route out of a pandemic that has killed 1.5 million.

The Associated Press reports that Margaret Keenan, who turns 91 next week, got the shot at 6:31 a.m. on what public health officials have dubbed "V-Day." She was first in line at University Hospital Coventry, one of several hospitals around the country that are handling the initial phase of the United Kingdom’s program. As luck would have it, the second injection went to a man named William Shakespeare, an 81-year-old who hails from Warwickshire, the county where the bard was born.

The U.K. is the first Western country to start a mass vaccination program after British regulators last week authorized the use of a Covid-19 shot developed by U.S. drugmaker Pfizer and Germany’s BioNTech. U.S. and European Union regulators may approve the vaccine in the coming days or weeks, fueling a global immunization effort.

Britain’s program is likely to provide lessons for other countries as they prepare for the unprecedented task of vaccinating billions of people. U.K. health officials have been working for months to adapt a system geared toward vaccinating groups of people like school children and pregnant women into one that can rapidly reach much of the nation’s population.

Amid the fanfare that greeted Britain’s first shot, authorities warned that the vaccination campaign would take many months, meaning painful restrictions that have disrupted daily life and punished the economy are likely to continue until spring.

Other vaccines are also being reviewed by regulators around the world, including a collaboration between Oxford University and drugmaker AstraZeneca and one developed by U.S. biotechnology company Moderna.

Britain has received 800,000 doses of the Pfizer vaccine, enough to vaccinate 400,000 people. The first shots will go to people over 80 who are either hospitalized or already have outpatient appointments scheduled, along with nursing home workers and vaccination staff. Others will have to wait their turn.

Britain is the first country to deliver a broadly tested and independently reviewed vaccine to the general public. On Saturday, Russia began vaccinating thousands of doctors, teachers and others at dozens of centers in Moscow with its Sputnik V vaccine.

China has also begun giving its own domestically made shots to its citizens and selling them abroad. But those products are being viewed differently because neither countries’ vaccines have finished the late-stage trials scientists consider essential for proving that a vaccine is safe and effective.
...
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/ 2020 News, Daily News
Applicant attorney, Moses Luna, 73, of Newport Beach, was arrested on 20 felony counts of insurance fraud after allegedly billing 20 separate insurance companies for translation and interpreting services to collect over $310,000 in undeserved workers’ compensation fees.

An investigation by the Department of Insurance and the Orange County District Attorney’s Office found Luna, a workers’ compensation attorney, created Adelante Interpreting, Inc., a translation and interpreting company, and then fraudulently billed 20 separate insurance carriers for translation and interpreting services.

Luna exclusively referred his own workers’ compensation clients to Adelante Interpreters to fraudulently collect over $311,220 in workers’ compensation fees.

The fees Luna received were for translation and interpreting services rendered to workers’ compensation claimants during depositions and medical appointments. Insurance companies paid the fees, due to Luna’s referrals, since the services were necessary for processing the claims.

Luna failed to disclose his financial interest in the company, as required by law, and used his daughter’s name, Deborah Luna, on corporate paperwork to hide his ownership of the company.

Although his daughter’s name was used for the paperwork, Luna controlled all aspects of Adelante Interpreters including, but not limited to: administrative protocols, employee protocols, independent contractor protocols, as well as billing and collection protocols.

The victim insurance companies include: ACM, AIG, Amtrust, BHHC, CompWest, Employers, ESIS, Farmers, Hartford, ICW, Liberty Mutual, Markel, Matrix, Midwest, Sedgwick, SCIF, Sentry, Travelers, York and Zurich.

Luna is scheduled to return to court on January 19, 2021. This case is being prosecuted by the Orange County District Attorney’s Office ...
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/ 2020 News, Daily News
Cal/OSHA’s emergency regulations requiring employers to protect workers from hazards related to COVID-19 are now in effect, following their approval by the Office of Administrative Law. The emergency standards apply to most workers in California

"These are strong but achievable standards to protect workers. They also clarify what employers have to do to prevent workplace exposure to COVID-19 and stop outbreaks," said Cal/OSHA Chief Doug Parker.

Some Non-California employers are required to meet Federal OSHA standards. OSHA has markedly stepped up its enforcement of safety measures related to coronavirus.

Since the start of the coronavirus pandemic through Nov. 5, 2020, the U.S. Department of Labor's Occupational Safety and Health Administration (OSHA) has issued 203 citations arising from inspections for violations relating to coronavirus, resulting in proposed penalties totaling $2,851,533.

OSHA inspections have resulted in the agency citing employers for violations, including failures to:

-- Implement a written respiratory protection program;
-- Provide a medical evaluation, respirator fit test, training on the proper use of a respirator and personal protective equipment;
-- Report an injury, illness or fatality;
-- Record an injury or illness on OSHA recordkeeping forms; and
-- Comply with the General Duty Clause of the Occupational Safety and Health Act of 1970

OSHA has already announced citations relating to the coronavirus arising out of 178 inspections, which can be found at dol.gov/newsroom.

Eleven of the most recent citations, issued between Nov. 20 and Nov. 26 and made public Friday, have resulted in coronavirus-related fines totaling $101,207, according to the statement. All 11 employers cited are either health care facilities or senior care living facilities, with recent fines up to $25,061, according to data released by OSHA.

OSHA provides more information about individual citations at its Establishment Search website, which it updates periodically ...
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/ 2020 News, Daily News
The California Attorney General announced the arraignment and surrender of Dr. Po Long Lew for unlawfully prescribing sedatives and muscle relaxants to his patients without a medical purpose.

Dr. Lew allegedly prescribed benzodiazepines such as Xanax, and carisoprodols such as Soma without first completing a legitimate physical exam of his patients and without his patients demonstrating a medical need.

He was arraigned in Los Angeles Superior Court. Dr. Lew is charged with ten counts of Unlawful Prescribing Without Medical Purpose, in violation of Health & Safety Code Section 11153.

Working out of his medical practice in Rosemead, the complaint alleges that between December 2018 and October 2019, Dr. Lew prescribed the muscle relaxant Soma, and two sedatives, Xanax and Ativan to patients individually or in combinations of two of the three medications. Benzodiazepines (sedatives) and carisoprodols (muscle relaxants) are known to cause a dangerous drug interaction when taken with opioids.

They are especially dangerous because each of the medications depress the central nervous system and a person’s ability to breathe. The three medications together are known to those addicted to prescription medication as the "Holy Trinity," and are highly sought out on the street.

The case stems from an investigation conducted by the California Department of Justice’s Division of Medi-Cal Fraud and Elder Abuse (DMFEA). Through the DMFEA, the Attorney General’s office works to protect Californians by investigating and prosecuting those who perpetuate fraud on the Medi-Cal program.

DMFEA also investigates and prosecutes those responsible for abuse, neglect, and fraud committed against elderly and dependent adults in the state. DMFEA regularly works with whistleblowers, the California Department of Health Care Services, and law enforcement agencies to investigate and prosecute.

It is important to note that a criminal complaint contains charges that are only allegations against a person. Every defendant is presumed innocent until proven guilty ...
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/ 2020 News, Daily News
In 2013, Latonja Johnson worked at two different jobs. She worked at Goodwill as an e-commerce book handler, sorting books that had been donated. She also worked for a company called Advantage Sales and Marketing (ASM) as an events specialist. Her job was to hand out food samples at Sam’s Club.

Johnson filed a worker’s compensation claim with Goodwill claiming she injured her back on July 12, 2013, while lifting books out of a book bin.

She filed a second worker’s compensation claim with ASM on July 31, 2013, claiming she injured her back on July 11, 2013, while lifting a small oven used to heat food.

She proceeded to be treated by two sets of doctors under both claims.

On May 29, 2015, Latonja Johnson was interviewed by investigators from the Workers’ Compensation Fraud Unit of the San Bernardino County District Attorney’s Office for filing two claims with two separate employers while working for both at the same time.

She said she was employed by Goodwill, and she had filed a claim for her back injury from July 12, 2013, and was treated by company doctors. Defendant said she did not work for another employer while employed with Goodwill. She said she was hired by ASM but only trained with them and did not officially work for them. Defendant said she told her supervisor at Sam’s Club that she was hurt but that she was not injured at Sam’s Club. She claimed her supervisor forced her to file paperwork with ASM anyway.

A jury found Johnson guilty of two counts of knowingly presenting a fraudulent claim. The court of appeal affirmed in the unpublished case of People v Johnson.

Her appeal argued two issues. Whether her conviction for presenting a fraudulent insurance claim in count 3 was part of an indivisible course of conduct, such that the court should have stayed the sentence rather than imposing one year consecutive. And whether the trial court abused its discretion in denying defendant probation.

After the court's independent review of the record it found no arguable issues ...
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/ 2020 News, Daily News
On August 30, 2014, Isaul Alvarado, an employee of Ventura Coastal, sustained a serious leg injury when he stepped into an uncovered screw conveyor (also known as an auger) located below ground level on Ventura’s premises.

The Division of Occupational Safety and Health conducted an inspection of Ventura’s facility and issued a citation to Ventura under the California Occupational Safety and Health Act for a serious violation of a regulation requiring screw conveyors at or below floor level to be guarded by railings or substantial covers or gratings.

Ventura appealed the citation to the Board, arguing that it did not violate the safety order or, if there was a violation, it was misclassified as serious. The ALJ upheld the citation, finding Ventura committed the violation alleged, and it was properly classified as a serious violation. The ALJ did, however, reduce the proposed penalty.

The Board, on its own motion, ordered reconsideration of the ALJ’s decision regarding the penalty. Ventura also filed a petition for reconsideration by the Board, asserting as grounds for reconsideration that the evidence did not justify the findings of fact, and the findings of fact did not support the decision.

On September 22, 2017, the Board issued its decision after reconsideration, upholding the decision of the ALJ.

On October 20, 2017, Ventura filed a second petition for reconsideration with the Board. It asserted three of the Board’s factual findings were not supported by the evidence, so the decision exceeded the Board’s authority. Alternatively, at a minimum, the violation should be reclassified from serious to general.

On December 15, 2017, Ventura filed a petition for a writ of mandate in the superior court, seeking review of the Board’s September 22, 2017 decision. The Board filed a motion to dismiss or for judgment on the pleadings, asserting the writ petition was statutorily required to be filed within 30 days after the Board’s decision was issued. The trial court granted the Board’s motion and entered a judgment of dismissal.

The Court of Appeal reversed and remand with directions in the published decision of Ventura Coastal LLC, v Occupational Safety and Health Appeals Board.

Ventura’s second petition for reconsideration was not properly filed and had no effect on the timeliness of its petition for writ of mandate. The Board’s decision after reconsideration was filed on September 22, 2017, and Ventura’s time for filing a petition for writ of mandate for review of that decision expired 31 days thereafter, on October 23, 2017 (because October 22 fell on a Sunday). Its petition for writ of mandate was not filed until December 15, 2017.

In light of the recent Supreme Court decision in Saint Francis Memorial Hospital v. State Dept. of Public Health (2020) 9 Cal.5th 710, the time limitation for filing the writ petition is subject to equitable tolling, and the employer should have been allowed to amend its petition to allege facts supporting application of that doctrine.

The requirements for its application present questions of fact that have not yet been addressed by the trial court. This includes questions regarding whether the conduct of Ventura, the reason for its delay in filing the petition, and the length of the delay were reasonable and in good faith. Additionally, if tolling is appropriate, the trial court must determine the length of the tolling period and whether the petition was timely filed, in light of any tolling period that is allowed. The trial court must also address the issues of notice and prejudice to the Board ...
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/ 2020 News, Daily News
Judy Hein, 71, of Oxnard, was arraigned on five felony counts of insurance fraud after allegedly under reporting payroll for her Simi Valley roofing business by over $4 million, resulting in more than a $2 million loss to the State Compensation Insurance Fund.

On December 19, 2018, the Department of Insurance received a referral from State Fund alleging that Hein's business, Cal Roofing, Inc., was under reporting payroll in order to receive a reduced rate for its workers' compensation insurance.

An investigation discovered internet searches that indicated the number of roofing projects and business revenue was not in line with Cal Roofing's stated number of employees or estimated annual premium. When wage information from the Employment Development Department for Cal Roofing was compared to wage information in corresponding State Fund policy audits large discrepancies were revealed.

The investigation determined Hein was responsible for filing the fraudulent payroll reports with State Fund. She also signed EDD documents, which revealed the under reported payroll to State Fund, which she correctly reported to EDD.

The audit findings and payroll reports filed with State Fund show a payroll of $831,788 from 2013 through 2018. The payroll reports filed with EDD and bank records show a payroll of $4,948,114 for the same policy periods. Hein underreported Cal Roofing's payroll by $4,116,326 in order to obtain workers' compensation insurance at a reduced rate. The suspected fraud resulted in an estimated loss of $2,171,330 to State Fund in the form of unpaid insurance premiums.

Hein was arraigned on November 17, 2020, at the Ventura Superior Court. This case is being prosecuted by the Ventura County District Attorney's Office.

"Illegally under reporting payroll to your insurance company to save on business expenses is a crime," said Insurance Commissioner Ricardo Lara. "The fraudulent actions of this business owner led to artificially inflated costs to insurance companies, businesses and consumers. Insurance fraud is not a victimless crime. We all pay a cost for these illegal actions." ...
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/ 2020 News, Daily News
A list of pending COVID-19 litigation filed by employees against their employers maintained by NCCI, reports two that have been filed against California employers.

Norma Zuniga, the surviving spouse of Pedro Zuniga, an employee, who died on April 13, 2020, after contracting COVID-19, sued the employer, Safeway and Albertsons on May 13, 2020 in California Superior Court.

For approximately 22 years, decedent Pedro Zuniga was employed by Safeway as a material handler in the produce department at the Safeway Northern California Distribution Center in Tracy, California.

Plaintiff alleges that in March 2020, workers at the Distribution Center began to fall ill with COVID-19. These employees were mandated to continue working not only regular shifts, but also additional shifts (6 days per week, rather than 4 or 5) with longer hours (16 hours per day).

By mid-March 2020, employees at the Distribution Center, including Decedent, began complaining to their supervisors about the dangerous working conditions and their fears associated with the same. These complaints were met by superiors with threats of retaliatory disciplinary action, including the potential for accruing ‘points’ which could lead to termination.

On April 1, 2020, after experiencing a fever and other symptoms, Decedent received a COVID-19 test, which came back positive a few days later. On April 13, 2020, Decedent died in the Intensive Care Unit at Memorial Medical Center in Modesto, California, of cardiopulmonary arrest and hypoxic respiratory failure allegedly caused by COVID-19. I

Plaintiff’s Complaint filed in Alameda County Superior Court in May, asserts six causes of action for: (1) Negligence, (2) Gross Negligence, (3) Violations of Federal Occupational Safety and Health Act of 1970 (29 U.S. Code § 654); (4) Violations of the California Occupational Safety and Health Act of 1973 (Title 8, California Code of Regulations § 3203 and California Labor Code § 6400 et seq.); Fraudulent Concealment of Injury (California Labor Code § 3602(b)(2)); and (6) Wrongful Death.

In July, Safeway removed the case to the United States Federal District Court for the Northern District of California, and filed a 33 page Motion to Dismiss the complaint asserting that the California Workers’ Compensation Act provides the sole and exclusive remedy for the injuries suffered by the employee.

In their motion, Safeway argues that "The rule of workers compensation exclusivity is not any different for the contraction of Coronavirus in the workplace and any resulting harm. To wit, the State of California has established that COVID injuries and death are to be processed via workers compensation. See Executive Order N-62-20."

Subsequently, the parties completed a private mediation on August 11, 2020, but were unable to resolve the action. Thus, the stay of proceedings in federal court was lifted, and the matter was allowed to proceed.

On November 20, Safeway filed a Motion to Change Venue to the Eastern District. And plaintiff Norma Zuniga filed a Motion to Remand the case back to the state courts. Both motions are scheduled for December 29, 2020.

The Plaintiffs remand motion is based in part on her First Amended Complaint which removed the federal cause of action and any federal law relied upon in her initial complaint, thus rendering Defendants Notice of Removal moot.

The second case reported on the NCCI list, Brooks v. Corecivic of Tennessee the Federal Court granted the employer's Motion tp Dismiss as to Plaintiff's claims for negligent supervision and intentional infliction of emotional distress, and denied the motion as to Plaintiff's wrongful constructive termination claims ...
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/ 2020 News, Daily News
Cal/OSHA’s emergency regulations requiring employers to protect workers from hazards related to COVID-19 are now in effect, following their approval yesterday by the Office of Administrative Law.

"These are strong but achievable standards to protect workers. They also clarify what employers have to do to prevent workplace exposure to COVID-19 and stop outbreaks," said Cal/OSHA Chief Doug Parker.

The emergency standards apply to most workers in California not covered by Cal/OSHA’s Aerosol Transmissible Diseases standard. The regulations require that employers implement a site-specific written COVID-19 prevention program to address COVID-19 health hazards, correct unsafe or unhealthy conditions and provide face coverings. When there are multiple COVID-19 infections or outbreaks at the worksite, employers must provide COVID-19 testing and notify public health departments.

The regulations also require accurate recordkeeping and reporting of COVID-19 cases.

As emergency standards, these regulations become effective immediately.

"We understand the need to educate and assist employers as they implement the new provisions of the emergency standards,” Parker noted. “For employers who need time to fully implement the regulations, enforcement investigators will take their good faith efforts to implement the emergency standards into consideration. However, aspects such as eliminating hazards and implementing testing requirements during an outbreak are essential."

Cal/OSHA has posted FAQs and a one-page fact sheet on the regulation, as well as a model COVID-19 prevention program. Employers are invited to participate in training webinars held by Cal/OSHA’s Consultation Services branch.

Cal/OSHA will convene a stakeholder meeting in December that will include industry and labor representatives to review the requirements of the emergency regulation and solicit feedback and recommend updates ...
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/ 2020 News, Daily News
39 year old Robert Zermeno Delara, of Fillmore, was arrested and charged with insurance fraud for allegedly denying his injured employees health and disability benefits to which they were entitled, and failing to notify his insurance carriers of industrial injuries sustained by his employees.

Delara is the owner-operator of two farm-labor contracting businesses located in Ventura County, Pacific Coast Farm Labor and B&R Farm Labor.

Through these businesses, Delara provides farm-labor and harvesting services to local agricultural producers who rely upon him to provide a skilled workforce while adhering to the safety and workplace injury reporting requirements of California law.

Delara is charged with three felony counts of violating Insurance Code section1871.4 for making false or fraudulent statements to discourage injured employees from seeking medical care.

He is charged with four additional felony counts of violating Penal Code section550(b)(3) for concealing or failing to disclose information that would impact his injured employees’ entitlement to benefits.

It is alleged that Delara’s failure to report workplace injuries resulted in premium losses to his workers’ compensation carriers of approximately $555,326, as well as additional costs related to the denial of benefits.

Delara faces a maximum possible sentence of 11years.

His arraignment is scheduled on November 30, 2020,at 9:00 a.m. in courtroom 12 of the Ventura County Superior Court ...
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/ 2020 News, Daily News
Paradigm Catastrophic Care Management announced the findings from an independent study commissioned with Boston Strategic Partners, Inc. (BSP), which determined Paradigm Specialty Networks’ cost reduction performance on implants exceeds the industry standard.

Boston Strategic Partners affirmed that "Fusion by Paradigm, reduces implant costs by 25 percentage points more than the typical industry outcomes.

Boston Strategic Partners, Inc. is a global health care analytics firm focused on health economics and outcomes research. The BSP study sourced 137 million lines of claim data from industry sources, including the Fusion by Paradigm reference price database, concluding that Paradigm Specialty Networks achieves the highest cost savings across the industry.

According to BSP, the lack of manufacturer implant pricing transparency often leads to insurer overpayment, potentially up to two times the cost to the hospital. In BSP’s independent analysis of industry practices and outcomes, Fusion by Paradigm outperformed the industry in delivering cost savings across key procedural categories, including the following:

-- Orthopedic procedures represent a significant number of surgeries paid for by workers’ compensation payers. The study revealed Fusion by Paradigm reduces fixation procedure costs by an average of 25 percentage points over the industry standard.
-- Spinal procedures, including cervical fusions and neurostimulator implantations, are often associated with high implant costs. Fusion by Paradigm generates cost reductions that are on average 18 percentage points higher than typical industry savings across these procedures.
-- Neurological and cranial procedures achieve significant cost savings with Fusion by Paradigm, with implant cost reductions surpassing the industry average by an additional 16 and 14 percentage points, respectively.

Paradigm added Fusion to its suite of services in 2017 through its acquisition of ForeSight Medical, a surgical management pioneer in the workers’ compensation industry. Fusion reports a 10-year track record of success.

Fusion uses a four-phase adjudication process that generates consistent, data-driven allowances for workers’ compensation payers. In addition to forensic assessment and the determination of objective allowances, Fusion incorporates real-time data to ensure the most up-to-date implant costs are factored into the review process. Paradigm Specialty Networks provides a thorough explanation of review to the provider with each adjudicated case and stands by its allowances with full defense.
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/ 2020 News, Daily News
Edward Marquez worked for the County of Los Angeles for approximately 20 years as an officer for the Los Angeles County Office of Public Safety. When that agency merged into the Los Angeles County Sheriff’s Department, Marquez was conditionally offered the position of deputy sheriff, provided he could establish that he was qualified for the position by passing a background check, medical examination, psychological examination, and polygraph examination.

Marquez failed the psychological examination and the Sheriff’s Department subsequently demoted him to the position of custody assistant. He was placed in a temporary assignment. He only worked in that position for a few months before he took a medical leave, and applied to the Los Angeles County Employees Retirement Association for a service-connected disability retirement under Government Code section 31720.

The Association granted Marquez’s application for a disability retirement, it found that his disability was not service connected because it related to a personnel decision, not the performance of his job duties.

Marquez challenged that decision by filing a petition for a writ of administrative mandamus. The trial court found that Marquez’s psychological incapacity was service connected because the psychological examination was required by the Sheriff’s Department as a condition of Marquez’s employment.

The Court of Appeal concluded that the court erred in its legal analysis. It reversed the judgment and remand for further proceedings.in the unpublished case of Marquez v. Los Angeles County Employees.

The only questions are whether Marquez’s psychological disability arose "out of" and "in the course of" employment, and whether his employment "substantially contributed" to his disability, as required under section 31270.

Section 31720 requires that a disability applicant’s employment "must contribute substantially to, or be a real and measurable part of, the employee’s permanent disability," in order to qualify the employee for a disability retirement.

Although he submitted to the fitness-for-duty test required for the position of deputy sheriff, he was not injured during the psychological examination. He was not injured by the examination. And he was not required to take any action as a consequence of the examination.

Marquez suffered psychological distress as a result of the Sheriff’s Department’s decision not to promote him to the position of deputy sheriff. That decision, and Marquez’s reaction to it, did not occur in connection with Marquez’s performance of his job duties ...
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/ 2020 News, Daily News
The California Insurance Commissioner has adopted and issued a revised average advisory pure premium rate, lowering the benchmark to $1.45 per $100 of payroll for workers’ compensation insurance, effective January 1, 2021.

This marks the tenth consecutive reduction to the average advisory pure premium rate benchmark since January 2015.

He did not order an additional adjustment for COVID-19 at this time, citing the need for additional data and review by the Department of Insurance and the Workers’ Compensation Insurance Rating Bureau.

Instead, he directed workers’ compensation insurance companies to clearly identify any COVID-19 adjustments in rate filings subsequently submitted to the Department of Insurance, and directed the WCIRB to collect data on aggregate premium charged for the COVID-19 adjustment on an ongoing basis.

"With the pandemic continuing to create uncertainty for the near future, we need to continue to review the data along with the impact of both vaccine distribution and additional and necessary public health measures to bend the curve," said Commissioner Lara. "Now is not the time to put an extra burden on front-line employers in health care, agriculture and other industries who are keeping our fragile economy afloat. While insurance companies can set appropriate rates, I urge them to be cautious and driven by the data."

The indicated average advisory pure premium rate level of $1.45 approved by the Commissioner is about 19.4 percent lower than the industry-filed average pure premium rate of $1.80 as of July 1, 2020.

Commissioner Lara’s decision results in an average advisory pure premium rate that is below the $1.56 average rate recommended by the WCIRB in its filing, which includes an add-on of $.06 for projected COVID-19 claims costs. The WCIRB’s recommended average pure premium rate would have been $1.50 without the projected COVID-19 claims costs, which compares to the Commissioner’s just-approved rate of $1.45. Commissioner Lara issued the advisory rate after a public hearing on October 5, 2020 and careful review of the testimony and evidence submitted by stakeholders.

The pure premium rate is only advisory, as the Legislature has not given the Commissioner rate authority over workers’ compensation rates.
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/ 2020 News, Daily News