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Jaime Chavez Jr. claimed injury to his left leg, right shoulder, bilateral knees, cervical spine, psyche, vision and internal system on October I 3, 2017 while employed as a tree trimmer by Cut It Right Tree Service.

He was assigned to cut multiple mulberry trees and a camphor tree. He was given a harness that was missing the right thigh strap. His task was to strip the three mulberry trees, to clear and shape them, and to clear and shape the camphor tree.

He became concerned, however, with how the ground crew was handling the debris. The brush was being moved in a manner that tangled his rope. He spoke with both the members of the ground crew to "stop playing with his life." It appeared that they improved in their work.

But after lunch, approximately 3:00 p.m, he heard "an explosion." He thought that the chainsaw had blown or the wood chipper. But his harness had cinched up and he saw that his leg had been ripped off and was hanging. As he came to realize later, the rope had wrapped around his leg, pulled tight, and then noticed that the left pant leg was now hanging flat. He knew that his leg had been popped out of the socket. As he understood later, the rope auto-amputated his leg from the knee down.

Mr. Chavez stated he had 15 years working in the tree trimming business. Prior to what happened to him, he has not heard of anyone suffering a leg amputation.

The matter proceeded to trial on February 3, 2020. The parties stipulated to injury AOE/COE to the following parts: left leg (amputation), right shoulder, bilateral knees and cervical spine. One of the issues was "sudden and extraordinary event."

The WCJ commented in the Opinion on Decision "The defense contends that Applicant's injuries are, first, barred by the six month rule. However, from a plain reading of the facts of this case, it is clear that this was both a "violent act" (as defined under Labor Code § 4660.1) and a "sudden and extraordinary" event (as defined under Labor Code § 3208.3). Thereby, Applicant is entitled to benefits for his psychiatric injuries, including the possibility of impairment benefits.

Defendants petition for reconsideration of this finding was denied in the panel decision of Chavez v Cut it Right Tree Service, SCIF.

The legislative and judicial history of section 3208.3(d) show that a "sudden and extraordinary" employment condition means something that is not regular and routine, and is uncommon, unusual and unexpected. (See Matea v. Workers' Comp. Appeals Bd. (2006) 144 Cal.App.4th 1435, 1449 (71 Cal.Comp.Cases 1522].) The Court of Appeal in Matea acknowledged that "[g]as main explosions and workplace violence are certainly uncommon and usually totally unexpected events; thus, they may be sudden and extraordinary employment conditions."

"Applicant's unrebutted testimony reflects that the injury occurred so quickly that he did not initially realize what had happened until he saw his leg. Defendant's contentions that applicant had "notice" that the injury would occur because of his warnings to co-workers to be careful with his rope are unpersuasive. The injury was caused by a sudden employment condition." ...
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/ 2020 News, Daily News
The Division of Workers' Compensation (DWC) has posted an order adjusting the pathology and clinical laboratory section of the Official Medical Fee Schedule (OMFS) to conform to changes in the Medicare payment system, as required by Labor Code section 5307.1.

The update includes fee schedule changes identified in CMS Transmittal 10367, Change Request 11937, which may be accessed on the Medicare website. The pathology and clinical laboratory fee schedule update order adopts the following Medicare change:

-- CY 2020 Q4 Release: Revised for October 2020 (20CLABQ4)

The order adopting the updated OMFS pathology and clinical laboratory fee schedule can be found on the DWC fee schedule web page ...
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/ 2020 News, Daily News
Mallinckrodt filed for bankruptcy protection on Monday, saddled with lawsuits alleging it helped fuel the U.S. opioid epidemic. They are the third major durgmaker to seek bankruptcy protection.

The company had said in February it planned to have its generic drug business file for bankruptcy as part of a tentative $1.6 billion opioid settlement to resolve claims by state attorneys general and U.S. cities and counties.

Last March, the company also lost a court battle to avoid paying higher rebates to state Medicaid programs for its top-selling drug.

In September, Mallinckrodt hired restructuring advisers to help limit its liabilities regarding the opioid settlement and a potential restructuring. The opioid litigation had caused some concern at the company, including a suspension of its plans to spin off its generics business into a standalone entity due to the opioid litigation, as well as "market conditions."

Mallinckrodt said on Monday it had agreed to pay $1.6 billion over several years to settle opioid-related litigation. About $450 million would be paid as part of its settlement once the company emerged from chapter 11 bankruptcy.

The company would then pay $200 million in the first and second year after its emergence from the bankruptcy, and $150 million subsequently through the seventh year.

Mallinckrodt had agreed to pay $260 million over seven years to resolve disputes related to its multiple-sclerosis drug H.P. Acthar gel and pay out rebates to state Medicaid programs.

Mallinckrodt also plans to dismiss its appeal to a March ruling related to Acthar gel, whose price per-vial has risen from about $50 in 2001 to $38,892 in 2019.

During the bankruptcy protection, the company said it aims to resolve opioid-related claims and reduce its debt by about $1.3 billion, while surviving on cash on hand and cash generated from operations.

The company listed both assets and liabilities in the range of $1 billion to $10 billion in a filing with the U.S. Bankruptcy Court for the District Of Delaware.

Under terms of the settlement announced this morning, the court-supervised process will lead to the creation of a trust, which, as the company said, will "establish an abatement fund to offset the expense of helping to combat opioid addiction and providing support to communities impacted by opioid abuse." The court-supervised process is also expected to resolve all opioid-related claims against Mallinckrodt and its subsidiaries, the company said.

Mark Trudeau, president and chief executive officer of Mallinckrodt, said reaching the agreement and undergoing debt refinancing are important steps moving the company forward.

"Importantly, when finalized, we believe the proposed settlement and capital restructuring activities will provide us with a clear path forward to achieving our long term strategy, preserving value for our financial stakeholders and providing us with the flexibility to operate effectively," Trudeau said in a statement.

Trudeau continued but adding that, while the company has had some uncertainties, it has delivered strong earnings and has a strong pipeline that continues to "build momentum." Trudeau said the company anticipates seeking regulatory approval of terlipressin and StratGraft in the coming months, as well as the completion of key clinical study results and data readouts across the portfolio ...
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/ 2020 News, Daily News
Mitchell, announced the new Mitchell Provider Data Explorer solution, which provides a holistic view of medical provider behavior in the P&C industry. Using data visualization, Provider Data Explorer enables both auto casualty and workers' compensation claims organizations to analyze medical provider treatment and billing behaviors to identify irregular activities that may signal fraud, waste and abuse.

Fraud accounts for 5% to 10% of claims costs for U.S. and Canadian insurers, costing about $80 billion per year for all lines of insurance, according to the Coalition Against Insurance Fraud.

By providing visual depictions of claims data, the visualization tool compares medical provider behavior to that of their peers. Users can see provider peer-to-peer comparisons that can be used in a variety of ways, including easily pinpointing outliers in order to help identify potential fraudulent or abusive medical provider treatment or billing behaviors for investigation.

The new data visualization tool tracks a variety of metrics related to provider behavior, including but not limited to treatment duration, treatment frequency, billing and adjustment behaviors, and procedure codes that, if incorrect, may disproportionately drive up the charged amount.

In addition to helping to detect potential fraud, waste and abuse, Mitchell's customers have already reported success using Provider Data Explorer for a variety of purposes.

-- Validation: Provider Data Explorer allowed one large insurance carrier to validate the charges of a provider compared to its peers across multiple counties. "We were able to visually see just how much that provider was an outlier," the carrier said. "The ability to then see the actual claim-level detail and the specifics of the codes allowed us to hone in further and get some more detail around the provider's billing habits."
-- Identification: Another large insurance carrier used Provider Data Explorer to help a claimant find a local physician who was accepting auto insurance medical benefits. "One of our adjusters had a claimant that was injured in an accident but couldn't find a doctor that would accept auto insurance," the carrier said. "With just a few clicks, we were able to use Provider Data Explorer to identify multiple providers that had billed us for auto claims in the claimant's zip code and surrounding areas. The adjuster was then able to provide a list to the claimant of providers in his area willing to accept auto insurance."

Medical provider data quality is a chronic issue, with the healthcare industry spending $2.1 billion annually to maintain provider databases. Provider Data Explorer utilizes Mitchell's foundational provider data management capabilities, which work to resolve provider data quality issues, including duplicate records and inaccurate information.

Mitchell Provider Data Explorer is currently available to Mitchell DecisionPoint® bill review customers and will be rolled out to Mitchell SmartAdvisor® bill review customers in phases through the end of 2020.

Headquartered in San Diego, California, Mitchell International, Inc. delivers smart technology solutions that simplify and accelerate claims handling and repair processes, driving more accurate, consistent and cost-effective resolutions ...
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/ 2020 News, Daily News
Charles Lewis filed a claim for an injury against Horizon Christian Fellowship that occurred on May 11, 2015 and also filed a cumulative trauma, a lower back injury, that he alleged occurred from April 11, 2016 to April 11, 2017.

Horizon was insured by GuideOne Mutual Insurance From March 1, 2015 to June 1, 2017, and was insured by Brotherhood Mutual Insurance Company from February 28, 2013 to February 28, 2015. On August 30, 2018 GuideOne filed a Petition for Joinder of Brotherhood as an additional party under Labor Code section 5500.5.

GuideOne and Lewis entered a Joint Compromise and Release which the WCJ approved on September 17, 2018. Brotherhood was joined as a party on October 16, 2018.

On January 18, 2019, GuideOne filed a Declaration of Readiness to Proceed on the issues of "Joinder Order issued 10/16/2018," and that the complete file had been served on Brotherhood on 11/19/2018.

On January 31, 2019, Brotherhood filed an objection to the Declaration of Readiness to Proceed, stating it had not received the complete file and that it had subpoenaed additional records, which were needed before a hearing takes place on contribution issues.

on October 21, 2019, GuideOne filed another Declaration of Readiness for a Mandatory Settlement Conference (MSC) on the issue of Contribution/Arbitration and the conference was set for December 18, 2019. During the conference, Brotherhood "reserved its defense of untimely filing of the Petition for Contribution" as an issue for the arbitrator.

Brotherhood argued that GuideOne's claim for contribution was barred because it had not timely submitted a pleading titled "Petition for Contribution" by September 17, 2019, one year after the Compromise and Release was approved. GuideOne argued that its January 18, 2019 Declaration of Readiness was sufficient to initiate contribution proceedings.

The arbitrator issued an order rejecting Brotherhood's arguments, and noted in his decision that although a better practice is the filing of an actual petition for contribution that clears any confusion, he concluded that the Declaration of Readiness was sufficient to initiate the contribution proceeding.

The WCAB denied reconsideration. The fourth district Court of Appeal affirmed the arbitrator in its minute order of a Summary Denial in the case of Brotherhood Mutual Insurance Company v. WCAB, Guideone Mutual Insurance Company et al. Case Number D 077799.

In general the WCAB has inherent power to control its practice and procedure to prevent frustration, abuse, or disregard of its processes." (Crawford v. Workers' Comp. Appeals Bd. (1989) 213 Cal.App.3d 156, 164.) A review of a decision of the WCAB is limited to whether the WCAB acted without or in excess of its powers and whether the order, decision or award was unreasonable, not supported by substantial evidence or procured by fraud. (Lab. Code § 5952.)

Rule 10510 states, "After jurisdiction of the Workers' Compensation Appeals Board is invoked pursuant to rule 10450, a request for action by the Workers' Compensation Appeals Board, other than a rule 10500 form pleading, shall be made by petition."

The WCAB has previously concluded a Declaration of Readiness is sufficient under that statutory provision and rule 10510 to initiate proceedings. (See Old Republic Ins. Co. v. Workers' Comp. Appeals Bd. (Bennett) (2010) 75 Cal.Comp.Cases 168, 169 (Bennett).) As the WCAB found in Bennett, neither section 5500.5, subdivision (e) or rule 10510 specify that a petition is required in this circumstance. Section 5500.5, subdivision (e) does not specify what document must be used to initiate a contribution proceeding and rule 10510 contains an explicit exception for the use of a Declaration of Readiness ...
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/ 2020 News, Daily News
Liberty Mutual Fire Insurance issued workers’ compensation and general liability insurance policies to Shea Homes (Shea) since 2010.

Shea, a residential real estate developer, maintains an owner-controlled insurance program called the Shea Homes Partnership Insurance Program (SHPIP). Under the SHPIP, Shea purchases workers’ compensation insurance coverage for contractors enrolled in the program. Enrollment in the SHPIP is mandatory for all contractors working at Shea projects.

Falcon Framing Company, Inc. was an approved Shea trade partner and had been continuously enrolled in the SHPIP since at least 2009. On March 1, 2012, Falcon and Shea entered into a construction contract for the Shea Seaside project in Encinitas, California.

On April 5, 2012, Falcon formed a new corporate entity named FFC, Inc. (FFC). It conducted the same business, at the same office, with the same customers, suppliers, and equipment as Falcon. FFC acquired Falcon’s assets for no consideration and Falcon was dissolved on August 13, 2012.

Falcon did not notify Shea, Orion, or Liberty that they had dissolved Falcon and were continuing their business operations through FFC until August 20, 2012, when Marc Corbitt, an FFC employee suffered catastrophic injuries while working at the Shea Seaside project. At the time of the accident, Falcon had been paid in full for the Seaside project and had paid all of the premiums for the Liberty policy issued to Falcon.

FFC tendered the claim to Liberty and to Zenith, who had issued a worker’s compensation policy to Falcon for work on projects other than Shea jobsites. Liberty denied coverage for the claim. Zenith paid $3,239,003.86, subject to a reservation of rights, to resolve the claim. It then filed an action against Liberty and was awarded the full amount from Liberty. In a prior appeal, the judgment was reversed and remanded.

After remand, the trial court ruled that the Liberty policy did not provide coverage to FFC for Corbett’s injuries and that Liberty had no obligation to indemnify or reimburse Zenith for sums paid on FFC’s worker’s compensation claim. The Court of Appeal affirmed in the unpublished case of Zenith v. Liberty Mutual Fire Insurance.

FFC is not an insured under the Liberty policy terms. Zenith provides no legal support for its contention that the successor corporation of a named insured employer in a worker’s compensation policy acquires the named insured’s rights under the policy.

Falcon’s failure to notify Liberty of its dissolution and the formation of FFC after the date of the policy’s inception did not extend coverage to FFC. The plain language of the Liberty policy does not provide coverage to FFC ...
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/ 2020 News, Daily News
Federal officials announced a historic nationwide enforcement action involving 345 charged defendants across 51 federal districts, including more than 100 doctors, nurses and other licensed medical professionals.

These defendants have been charged with submitting more than $6 billion in false and fraudulent claims to federal health care programs and private insurers, including more than $4.5 billion connected to telemedicine, more than $845 million connected to substance abuse treatment facilities, or "sober homes," and more than $806 million connected to other health care fraud and illegal opioid distribution schemes across the country.

"This nationwide enforcement operation is historic in both its size and scope, alleging billions of dollars in healthcare fraud across the country," said Acting Assistant Attorney General Brian C. Rabbitt.

The largest amount of alleged fraud loss charged in connection with the cases - $4.5 billion in allegedly false and fraudulent claims submitted by more than 86 criminal defendants in 19 judicial districts - relates to schemes involving telemedicine: the use of telecommunications technology to provide health care services remotely.

According to court documents, certain defendant telemedicine executives allegedly paid doctors and nurse practitioners to order unnecessary durable medical equipment, genetic and other diagnostic testing, and pain medications, either without any patient interaction or with only a brief telephonic conversation with patients they had never met or seen.

Durable medical equipment companies, genetic testing laboratories, and pharmacies then purchased those orders in exchange for illegal kickbacks and bribes and submitted false and fraudulent claims to Medicare and other government insurers.

The continued focus on prosecuting health care fraud schemes involving telemedicine builds on the efforts and impact of the 2019 "Operation Brace Yourself" Telemedicine and Durable Medical Equipment Takedown, which resulted in an estimated cost avoidance of more than $1.5 billion in the amount paid by Medicare for orthotic braces in the 17 months following that takedown.

The "sober homes" cases include charges against more than a dozen criminal defendants in connection with more than $845 million of allegedly false and fraudulent claims for tests and treatments for vulnerable patients seeking treatment for drug and/or alcohol addiction. The subjects of the charges include physicians, owners and operators of substance abuse treatment facilities, as well as patient recruiters (referred to in the industry as "body brokers").

The cases involving the illegal prescription and/or distribution of opioids or that fall into more traditional categories of health care fraud include charges and guilty pleas involving more than 240 defendants who allegedly participated in schemes to submit more than $800 million in false and fraudulent claims to Medicare, Medicaid, TRICARE, and private insurance companies for treatments that were medically unnecessary and often never provided.

According to court documents, in many cases, patient recruiters, beneficiaries and other co-conspirators were allegedly paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could then submit fraudulent bills to Medicare. Also included are charges against medical professionals and others involved in the distribution of more than 30 million doses of opioids and other prescription narcotics.

The Department of Justice also announced the creation of the National Rapid Response Strike Force of the Health Care Fraud Unit of the Criminal Division’s Fraud Section. The National Rapid Response Strike Force’s mission is to investigate and prosecute fraud cases involving major health care providers that operate in multiple jurisdictions, including major regional health care providers operating in the Criminal-Division-led Health Care Fraud Strike Forces throughout the United States.

Prior to the charges announced as part of this historical nationwide enforcement action and since its inception in March 2007, the Health Care Fraud Strike Force program had charged more than 4,200 defendants who have collectively billed the Medicare program for approximately $19 billion.

Further information:
-- Graphics, Images and Resources.
-- Case Descriptions.
-- Court Documents ...
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/ 2020 News, Daily News
Sedgwick, has added a solution to its technology suite of services that streamlines the submission process for California employers who are required under new legislation to report and determine COVID-19 workplace outbreaks.

On Sept. 17, 2020, California Gov. Gavin Newsom signed into law CA SB 1159, which expands workers' compensation injury claims to include illness or death from COVID-19 within specific dates of infection. The law also establishes a rebuttable presumption of injury within certain limitations, shortens the period to accept or deny claims to either 30 or 45 days from the filing, and requires exhaustion of COVID-related paid sick leave prior to compensation. SB1159 requires employers to calculate outbreaks using specific criteria and report all positive tests to their administrator.

This action codified Newsom's executive order from March 19, 2020, and expanded rebuttable presumptions to more professions and employees if and when an "outbreak" is determined for injuries from July 6, 2020, through Jan. 1, 2023. The law took effect immediately and includes added responsibility for employers and administrators.

Employers are now required to report to their claims administrator within 30 business days of the effective date of CA SB 1159 when and how many employees in California tested positive for COVID-19 between July 6 and Sept. 17, 2020. From Sept. 18 onward, employers must report positive tests within three business days, as well as the largest number of employees who have worked at the infected location in the 45 days preceding the last day the positive employee was in the place of employment.

To ease the process for California employers, Sedgwick has launched a COVID-19 intake portal for reporting positive test results. Sedgwick's award-winning global intake platform provides an innovative, easy-to-use and secure cloud-based system to initiate the process of recording positive tests and exposure events tied to COVID-19 in the workplace.

"With any new legislation, Sedgwick's objective is to provide an appropriate, effective and efficient means to help our clients meet their compliance requirements," said Max Koonce, Sedgwick's chief claims officer. "Our global intake platform simplifies the COVID-19 reporting process for California employers so they can follow the state's guidelines, protect their employees and customers, and keep their workplaces operating safely during the pandemic."

"Sedgwick's quick response with this advanced intake and reporting solution will help clients easily report information under CA SB 1159, giving them more time to focus on their day-to-day operations," said Leah Cooper, Sedgwick managing director of global consumer technology ...
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/ 2020 News, Daily News
The Workers’ Compensation Insurance Rating Bureau of California has published its report on insurer loss and premium experience valued as of June 30, 2020. This Quarterly Experience Report contains charts illustrating current cost drivers in the system. Highlights of the findings include the following.

Written premium for the first two quarters of 2020 is 11% below that for the first two quarters of 2019. The impact of the COVID-19 crisis on the California economy is expected to significantly reduce employer payroll and insurer premium for the remainder of 2020. The large decrease in premium for the second quarter of 2020 is driven by the sudden and sharp slowdown in the economy.

The average charged rate for the first two quarters of 2020 is 8% below that for 2019 and 40% below the peak in 2014. The January 1, 2020 approved advisory pure premium rates are on average 47% below those for January 1, 2015. Absent COVID-19, the indicated average advisory pure premium rate for January 1, 2021 was slightly below the 2020 level. However, when including the COVID-19 claim impact, the WCIRB proposed a 2.6% increase in average advisory pure premium rates.

The projected combined ratio for 2019 is 8 points higher than 2018 and 16 points higher than the low point in 2016 as premium levels have lowered while claim costs increased moderately. Despite the recent increase, combined ratios for 2013 through 2019 are below 100% and are the lowest since the 2003 through 2007 period.

Claim activity in the second quarter of 2020 was significantly slower due to the pandemic and shelter-in-place period and may not be indicative of future claim activity.

Indemnity claims have settled quicker over the last several years, largely driven by SB 863 and SB 1160 reforms. Average claim closing rates declined sharply in the second quarter of 2020 as a result of the pandemic and shelter-in-place period.

Incremental reported claims have generally increased through 2019. Reported indemnity claims in the second quarter of 2020 were 10% lower than the second quarter of 2019, while medical-only claims were one-third lower. The recent lower claim counts are likely due to the slowdown of economic activity, less work being done outside the home, and delays in reporting of claims during the shelter-in-place period.

The number of liens filed in 2019 and 2020 are more than 60% below pre-SB 1160 and AB 1244 levels. Lien filings decreased in the first two quarters of 2020, though some of the decrease is likely due to the pandemic ...
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/ 2020 News, Daily News
Several cervical artificial disc technologies have been developed to replace degenerated intervertebral discs in the cervical spine. While no artificial disc can perfectly replace a natural disc’s ability to cushion and transfer loads in the neck, an artificial disc may maintain more of the cervical spine’s natural range of motion compared to fusion surgery.

Artificial discs are available in various sizes, shapes, and heights in order to achieve these goals and provide good surgical outcomes. Several types of discs have been fabricated using different materials, designs, and techniques.

And now a California company has just obtained FDA approval for another promising product.

Simplify® Disc is a motion-preserving cervical artificial disc designed to allow for advanced imaging capability of MRI, to better match patients’ anatomies, and for physiologic movement. The three-piece disc, with a semi-constrained mobile core, is designed to mimic/replicate the natural biomechanical motion of a healthy disc. Implantation of the Simplify Disc is accomplished in a straightforward, three-step procedure.

Simplify Medical, a privately-held company, headquartered in Sunnyvale California, focused on cervical spinal disc arthroplasty and developer of the Simplify® cervical artificial disc, announced U.S. Food and Drug Administration (FDA) Approval for the Simplify Disc Pre-Market Application (PMA) for 1-level indications. Simplify Disc achieved superiority to the fusion control on the composite primary endpoint.

The prospective trial enrolled 166 Simplify Disc patients at 16 clinical sites across the United States, and results were compared with a historical fusion control. Simplify Disc was used for 1-level cervical implantation between the C3 to C7 vertebrae.

The study results demonstrated that Simplify Disc achieved superiority in overall success compared to anterior cervical discectomy and fusion (ACDF). At 24 months:

-- The Simplify Disc overall success rate of 93.0% was statistically superior to the ACDF overall success rate of 73.6% (p<.001).
-- 97.9% of Simplify Disc patients achieved a significantly higher rate of meaningful (15 point) improvement in Neck Disability Index (NDI) compared to ACDF at 88.0% (p=.009).
-- Simplify Disc mean NDI improved from 63.3 at baseline to 13.6 at 24 months, and was superior to ACDF at all follow-up timepoints.
-- Simplify Disc patients had a higher rate of improvement in neurological function at 79.9% compared to ACDF at 54.7%.
-- Simplify Disc mean VAS (Neck/Arm Pain) of 15.6 was superior to ACDF at 23.3 (p<.001).
-- Significantly fewer Simplify Disc patients, 10.8%, were taking narcotic pain medication compared to ACDF patients at 36.8% (p<.001).
-- Time to recovery (defined as 15 points of NDI improvement) was faster for Simplify Disc patients compared to ACDF patients. At 6 weeks, 87.0% of Simplify Disc patients and 76.8% of ACDF patients had achieved this threshold. At 3 months, 95.9% of Simplify Disc patients and 81.1% of ACDF patients had achieved recovery.
-- Simplify Disc patients had less adjacent level degeneration compared to ACDF patients. At the disc level above the treatment level, 82% of Simplify Disc patients and 52% of ACDF patients had no progression in degeneration. At the disc level below the treatment level, 72% of Simplify Disc patients and 34% of ACDF patients had no progression in degeneration.

The Simplify Disc is also being evaluated in a separate IDE study in the U.S. for 2-level indications. The enrollment for the 2-level trial was completed in November 2018. Simplify Disc is limited to investigational use for this indication ...
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/ 2020 News, Daily News
San Diego-based Phamatech, Inc. and its CEO and founder, Tuan Pham, have agreed to pay $3,043,484 to resolve allegations that they violated the False Claims Act by submitting false claims to Medicare for laboratory drug-testing services.

Phamatech is a medical technology company that manufactures diagnostic devices and provides laboratory testing including for drugs and alcohol.

The United States alleged that Phamatech improperly paid a medical clinic to induce it to refer orders for laboratory drug-testing to Phamatech and consequently received government reimbursement for those tests in violation of the federal Anti-Kickback Statute and the False Claims Act.

Specifically, the United States alleged that Phamatech paid kickbacks to Imperial Valley Wellness ("IVW"), a medical practice group, to induce IVW to order laboratory testing for its patients enrolled in Medicare. Phamatech allegedly paid IVW a per-specimen fee in exchange for IVW’s referral of urine samples from Medicare beneficiaries.

The government further alleged that many of the samples that IVW referred to Phamatech for testing under this arrangement were not medically necessary and therefore not lawfully eligible for Medicare reimbursement.

The False Claims Act allegations being resolved were originally brought in a lawsuit filed by a former employee of Phamatech, John Polanco, under the qui tam, or whistleblower, provisions of the False Claims Act, which allow private citizens with knowledge of fraud against the government to bring suit on behalf of the government and to share in any recovery.

Mr. Polanco will receive $517,392 from the settlement proceeds.

The investigation was conducted by the U.S. Attorney’s Office for the Southern District of California, the Department of Health and Human Services Office of Inspector General, and the Federal Bureau of Investigation.

This case is captioned United States, et al., ex rel. John Polanco v. Phamatech, Inc. and Tuan Pham, 16CV1835-L-NLS, and the matter was handled by Assistant U.S. Attorney Paul Starita of the Affirmative Civil Enforcement Unit of the U.S. Attorney’s Office ...
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/ 2020 News, Daily News
Palo Alto based Next Insurance announced the availability of its Workers' Compensation offering to 24 additional states across the nation, including Alabama, Iowa, Louisiana and Virginia.

This expansion increases the company's overall Workers' Compensation coverage in the US to more than 50% now equipping small business owners in 30 states with what it says is affordable, hassle-free policies.

Offering coverage that starts at just $14 per month, Next Insurance is helping to solve an often stressful and costly insurance requirement by giving business owners a seamless way to obtain an instant quote and explore their coverage options - all online. Small business owners can obtain General Liability, Professional Liability, Commercial Auto and Workers' Compensation coverage all under one roof.

"By expanding Workers' Compensation to more than half of the country, Next Insurance is taking another important step in our journey to become the one-stop-shop for all small businesses," said Sofya Pogreb, COO of Next Insurance.

The Workers' Compensation state expansion announcement includes: Alaska, Arizona, Arkansas, Connecticut, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Mexico, Rhode Island, South Carolina, Tennessee, Utah, Vermont, Virginia, and West Virginia.

These states join previous coverage availability in: Colorado, Florida, Georgia, Illinois, Nevada and Texas.

Next Insurance said it will steadily expand Workers' Compensation in additional states into 2021.

With Next Insurance, insureds have access to USA- based licensed insurance advisors, tools and services like 24/7 access to certificates of insurance from a mobile device or computer and in-house claims filings where a decision is typically made within 48 hours.

Founded in 2016, the company is headquartered in Palo Alto, has received a total of $631 million in venture capital funding and has been recognized by Forbes Fintech 50, JMP Securities InsurTech 50 and Forbes Best StartUp Employers.

For more information visit Stay up to date on the latest with Next Insurance on Twitter, LinkedIn, Facebook and our blog ...
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/ 2020 News, Daily News
Last Wednesday was the deadline for Gov. Newsom to act on bills lawmakers passed this year. It capped a tumultuous legislative session that was delayed three times because of the pandemic.

In a normal year, more than 1,000 bills would have made it to Newsom's desk for his consideration. This year, it was just a few hundred.

Labor unions were disappointed to see him veto two of their biggest issues: A bill that would that sought to guarantee laid-off hospitality workers would be first in line to get their jobs back once those industries start rehiring and another that would have extended health and safety protections to domestic workers.

In a victory for business groups, Newsom vetoed Assembly Bill 3216, a proposed law that would have required that employers in certain industries - hotels, private clubs, airports or who provide building services to commercial buildings - would have rehire laid-off workers when they decided it was time to increase their workforces once again.

Newsom said in his veto message "I recognize the real problem this bill is trying to fix-to ensure that workers who have been laid off due to the COVID 19 pandemic have certainty about their rehiring and job security."

"But, as drafted, its prescriptive provisions would take effect during any state of emergency for all layoffs, including those that may be unrelated to such emergency. Tying the bill's provisions to a state of emergency will create a confusing patchwork of requirements in different counties at different times.The bill also risks the sharing of too much personal information of hired employees."

Nonetheless, many of California's largest cities - including Los Angeles, Long Beach, San Francisco and Oakland - have enacted their own rehiring ordinances in response to the pandemic. And California law already had worker retention laws for the janitorial industry and the grocery industry.

Newsom also vetoed SB 1257, a bill that would have included about 11 million California homes and apartments under Cal/OSHA’s jurisdiction.

His veto message proclaimed that "New laws in this area must recognize that the places where people live cannot be treated in the exact same manner as a traditional workplace or worksite from a regulatory perspective."

He went on to say that "SB 1257 would extend many employer obligations to private homeowners and renters, including the duty to create an injury prevention plan and requirement to conduct outdoor heat trainings. Many individuals to whom this law would apply to lack the expertise to comply with these regulations. The bill would also put into statute a potentially onerous and protracted "investigation by letter" procedure between Cal-OSHA and private tenants and homeowners. In short, a blanket extension of all employer obligations to private homeowners and renters is unworkable and raises significant policy concerns."
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/ 2020 News, Daily News
Uber Technologies and Lyft together are spending nearly $100 million on Proposition 22, a November California ballot initiative to overturn a state law, AB-5, that would compel them to classify drivers as employees.

The two ride-hailing companies would each face more than $392 million in annual payroll taxes and workers' compensation costs even if they drastically cut the number of drivers on their platforms, a Reuters calculation showed.

Using a recently published Cornell University driver pay study in Seattle as a basis, Reuters calculated that each full-time driver would cost the company, on average, an additional $7,700. That includes roughly $4,560 in annual employer-based California and federal payroll taxes and some $3,140 in annual workers' compensation insurance, which is mandated in California.

The companies say they would need to significantly hike prices to offset at least some of those additional costs, which in turn would likely cause a decrease in consumer demand, but cushion the blow of the added costs to the bottom line.

Yahoo News reports that Uber and Lyft have also said they could abandon the California market - an economy that would rank fifth in the world if the state were a sovereign nation. Other U.S. states have said they plan to follow California's lead and pass similar laws.

A "yes" vote on California's Proposition 22 gives Uber and Lyft what they seek, which is to overturn the state's gig worker law, known as AB5, which took effect in January. Uber and Lyft have insisted the law does not apply to them, sparking a legal battle.

Under the company-sponsored ballot measure, gig workers would receive some benefits, including minimum pay, healthcare subsidies and accident insurance, but remain independent contractors not entitled to more substantial employee benefits.

The question of whether so-called gig workers should be treated as employees has become a national issue in U.S. politics.

U.S. Democratic presidential candidate Joe Biden and his running mate, Senator Kamala Harris, have both voiced their strong support for California's labor law and directly called on voters to reject the companies' ballot proposal that would weaken it.

President Trump has not directly weighed in on the ballot measure, but the administration's Labor Department in September published proposed rules that would standardize legal definitions across the country and provide more room for companies to maintain independent contractors. U.S. Labor Secretary Eugene Scalia criticized AB5 in an opinion piece published on Sept. 22.

California represents 9% - or roughly $1.63 billion in all of 2019 - of Uber's global rides and food delivery gross bookings. However, California generates a negligible amount of adjusted earnings before interest, taxes, depreciation and amortization, Uber said in November.

Lyft, which operates only in the United States and does not have a food delivery business, in August said California makes up some 16% of the company's total rides. Lyft does not break out ride-hailing revenue, but California contributed $576 million as a share of total 2019 revenue ...
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An administrative law judge has dismissed liens valued at $18 million filed by convicted medical provider Michael E. Barri, bringing to a close one of the earliest cases aimed at combatting fraud in California’s workers’ compensation system.

"The anti-fraud statutes that took effect in January 2017 were designed to prevent convicted medical providers from continuing to file lien claims and profiting from fraud," said Division of Workers’ Compensation (DWC) Administrative Director George Parisotto. "The dismissal of millions of dollars’ worth of liens shows the strategy to fight those schemes works."

DWC suspended Barri from participating in California’s workers’ compensation system after he pled guilty in 2016 to federal conspiracy charges and admitted receiving $206,506 in illegal kickbacks for referring dozens of patients for spinal surgeries and other medical services to Pacific Hospital of Long Beach and related entities.

The San Clemente chiropractor challenged his suspension in court and pursued collection of $18,161,362 in liens he had filed in 944 individual workers’ compensation cases through the entities he controlled.

An Appeals Court denied Barri’s writ in 2018 and upheld the anti-fraud legislation that led to his suspension, sending the matter of the liens back to the Workers’ Compensation Appeals Board (WCAB).

Administrative Law Judge Alan Skelly held several hearings in Anaheim in which the lien claimants, insurance carriers and members of the Department of Industrial Relations’ Anti-Fraud Unit were represented by counsel. Barri contested discovery related to his 944 liens, then filed a Notice of Withdrawal with Prejudice of liens of Tristar Medical Group, Jojaso Management, Inc., Michael E. Barri Chiropractic Corporation and Michael E. Barri, D.C. Judge Skelly accepted the notice and issued the order dismissing the liens.

Barri was one of many chiropractors, physicians and others who received lucrative kickbacks for each lumbar surgery and cervical fusion surgery referred to Pacific Hospital. During the last eight years of the scheme, the hospital submitted more than $580 million in fraudulent bills. Because of his referrals, Pacific Hospital billed insurance carriers approximately $3.9 million for spinal surgeries and other medical services.

Worker’s compensation reforms that went into effect in January 2017 required DWC to suspend certain medical providers from participating in the workers’ compensation system, including those who are convicted of a felony or misdemeanor involving fraud or abuse of any patient, the Medi-Cal or Medicare programs, or the workers’ compensation system itself. Labor Code section 139.21 provides for a hearing process regarding the suspension and a special lien adjudication procedure to address pending liens of those providers suspended based upon a criminal conviction.

The Department of Industrial Relation’s (DIR’s) fraud prevention efforts are posted online, including information on lien consolidations and the Special Adjudication Unit, frequently updated lists for physicians, practitioners, and providers who have been issued notices of suspension and those who have been suspended pursuant to Labor Code §139.21(a)(1) ...
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The Division of Workers’ Compensation has issued an order updating the Medical Treatment Utilization Schedule Drug List effective November 1, 2020.

The update order adopts changes to the MTUS Drug List, based on the American College of Occupational and Environmental Medicine (ACOEM) Practice Guidelines, which provide new drug recommendations addressed in the Depressive Disorders Guideline. The updated MTUS Drug List v.7 and the Administrative Director Order can be accessed on the DWC MTUS drug formulary webpage.
A drug listed as "Exempt" indicates the drug may be prescribed/dispensed without seeking authorization through Prospective Review if in accordance with MTUS. Examples of depressive disorder medications that are now exempt include the following brand names.

-- Elavil.
-- Wellbutrin, WellbutrinXL, WellbutrinSR.
-- Anafranil.
-- Pristiq.
-- Sinequan.
-- Cymbalta.
-- Lexapro.
-- Luvox.
-- Tofranil.
-- Marplan.
-- Fetzima.
-- Latuda.
-- Ludiomil.
-- Savella.
-- Pamelor.
-- Zyprexa.
-- Symbyax.
-- Paxil.
-- Pexeva.
-- Seroquel.
-- Risperdal.
-- Emsam.
-- Parnate.
-- Desyrel, Oleptro.
-- Trintellix.
-- Geodon.

DWC welcomes comment on the formulary drug list at ...
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Some of the sweeping changes just made to the California Superior Court system will apply to depositions in worker's compensation litigation, and will permanently allow remote depositions without consent of all parties.

The superior court system and the Appeals Board have distinct and separate rules of practice and procedures. Most of the new law will therefore not apply to worker's compensation litigation.

But, both systems share the discovery statutes. Depositions in workers' compensation are allowed by Labor Code section 5710 provides that "the deposition of witnesses residing within or without the state to be taken in the manner prescribed by law for like depositions in civil actions in the superior courts of this state under Title 4 (commencing with Section 2016.010) of Part 4 of the Code of Civil Procedure."

Governor Newsom just signed Senate Bill No. 1146, a new law that makes substantial changes to litigation in superior courts. However, since some of these changes pertain to how depositions are taken in superior courts, Labor Code 5710 would make those changes applicable to discovery in worker's compensation as well.

The new law amends Section 2025.310 of the Code of Civil Procedure, which is also specifically applicable to workers' compensation depositions. The following are the key new provisions of the deposition process.

" A deponent is not required to be physically present with the deposition officer when being sworn in at the time of the deposition."

"Subject to Section 2025.420, any party or attorney of record may, but is not required to, be physically present at the deposition at the location of the deponent."

In essence, these provisions eliminate the requirement that consent is required to conduct a deposition by remote methods. Although workers' compensation depositions have been conducted remotely since the beginning of the pandemic as a result of temporary workers' compensation rules, the remote deposition process is now a permanent part of the litigation landscape in both civil and workers' compensation proceedings.

Senate Bill 1146 was declared an "urgency statute" and thus takes effect immediately ...
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Cal/OSHA has cited five grocery stores in Southern California for failing to protect their employees from COVID-19. The retailers were cited for various health and safety violations including some classified as serious, with proposed penalties ranging from $13,500 to $25,560.

The grocery stores owned and operated by Cincinnati-based Kroger Company, were cited for failing to protect workers from exposure to COVID-19 because they did not update their workplace safety plans to properly address hazards related to the virus.

The Food 4 Less in Los Angeles and Ralphs grocery stores in Studio City, Sherman Oaks and West Hollywood put their workers at risk for serious illness by allowing too many customers in the store, which prevented workers from maintaining at least 6 feet of physical distance.

The Studio City location exposed workers in the cheese department to hazards related to COVID-19 as they did not install physical barriers between employees and customers. Plexiglas or other required barriers were not installed at registers 1-8 at the West Hollywood location.

Cal/OSHA inspectors determined that both the Culver City and West Hollywood locations failed to provide effective training for their employees, including instruction on how the virus is spread, measures to avoid infection, signs and symptoms of infection, and how to safely use cleaners and disinfectants.

The Culver City and Sherman Oaks grocery stores failed to report a worker’s fatal COVID-19 illness at each location. Cal/OSHA learned of the fatality seven days after the worker’s death in Culver City, and six days after the fatality in Sherman Oaks.

"Grocery retail workers are on the front lines and face a higher risk of exposure to COVID-19," said Cal/OSHA Chief Doug Parker. "Employers in this industry must investigate possible causes of employee illness and put in place the necessary measures to protect their staff."

Cal/OSHA has created guidance for many industries in multiple languages including videos, daily checklists and detailed guidelines on how to protect workers from the virus. This guidance provides a roadmap for employers on their existing obligations to protect workers from COVID-19.

Cal/OSHA reminds all employers and workers that any suspected cases of COVID-19 must be promptly reported to the local public health department. California employers must also report to Cal/OSHA any serious illness, serious injury or death of an employee that occurred at work or in connection with work within eight hours of when they knew or should have known of the illness.
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Arthur J. Gallagher disclosed that it was hit with a ransomware attack, prompting the world’s fourth-largest insurance broker by revenue to take its computer systems offline.

The Rolling Meadows, Illinois-based broker said in a securities filing late Monday that it is in "the process of restarting most of our business systems" after discovering the threat a few days ago. The incident affected Gallagher and Gallagher Bassett Services units.

"We promptly took all of our global systems offline as a precautionary measure, initiated response protocols, launched an investigation, engaged the services of external cybersecurity and forensics professionals, and implemented our business continuity plans to minimize disruption to our customers," the broker said in the disclosure.

Gallagher said it is still in the early stages of assessing the incident, which it does not expect to have "a material impact on our business, operations or financial conditions." Gallagher Bassett’s website remained offline and inaccessible amid a "system outage" as of Tuesday afternoon.

According to the report by, the attack highlights increasing risk financial firms face from hackers. Ransomware, a malicious software used to export payment by blocking a company or individual’s access to their data, is one of the most common types of cyberattacks and has grown in both size and scope in recent years.

While the frequency of new attacks have slowed by 18% in the first half of 2020, more hackers are finding success with their attacks and are making larger demands, according to a recent report by cyber insurance and security firm Coalition.

The company found that the average demand among its policyholders has doubled from 2019 through the first quarter of 2020 and increased 47% in the second quarter to more than $338,000, resulting in higher cyber losses for insurers.

Worsening the trend is the emergence of dangerous new strains of ransomware such as DoppelPaymer. The average size of ransom demands also vary sharply by malware strain.

Financial firms such as insurance carriers and brokers face a double threat, experts say. Not only do they write or sell cyber insurance, but they themselves are a popular target of hackers due to the large volume of personal information they handle.

Chubb, one of the largest carriers of cyber insurance as part of a policy package, was hit with a Maze ransomware attack in late March. Unlike other malware, Maze infects every computer in its path and not just an organization’s network, TechCrunch reported. A year earlier, Target sued Chubb for $74 million, alleging that the carrier did not properly compensate the retailer after a massive data breach in 2013.

At least financial institutions worldwide including were targeted in ransomware attacks this year, according to the Carnegie Endowment for International Peace ...
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Fernando Torres Garcia, 46, self-surrendered and was arraigned at the Kern County Superior Court on nearly a dozen felony counts of insurance fraud after allegedly misrepresenting an injury in order to receive undeserved workers’ compensation insurance benefits.

On July 16, 2018, Garcia reported to his employer that he injured his lower back and hip after he slipped while working in a trench to repair a water line. Garcia was diagnosed with a lumbar strain and was placed on modified duty, to which his employer accommodated.

Garcia continued to see his doctor as he claimed he was not improving and continued to suffer from pain. Garcia then amended his original workers’ compensation claim to include his entire back, right hip, right thigh, right leg, right elbow, both knees and cumulative trauma.

An investigation by the California Department of Insurance revealed Garcia had numerous doctor visits between August 2018 and March 2019. During this time, surveillance was conducted on Garcia, and revealed he was able to lift heavy objects multiple times. However, since Garcia continuously claimed he was not improving he was referred for an orthopedic evaluation and given a rating of five percent impairment for his lumbar spine.

On June 21, 2019, Garcia underwent a Panel Qualified Medical Evaluation. After the evaluator reviewed Garcia’s medical reports, the surveillance footage, and Garcia’s physical examination and abilities, he determined Garcia did not meet the requirements for any permanent disability or ratable impairment. It was his opinion that Garcia misrepresented his complaints during his examination.

Garcia’s material misrepresentations caused deposition and surveillance expenses totaling $5,873.50.

The Kern County District Attorney’s Office is prosecuting this case. Garcia is scheduled to return to court on November 20, 2020 ...
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