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The Travelers Companies, Inc. announced the results of the Travelers Mental Wellness Checkup, a national survey of 2,000 employed adults across more than 10 industries. Most respondents reported experiencing some type of negative effect on their mental health since the pandemic began last year: 59% have worried about losing a loved one, 50% have suffered from loneliness and 37% said their level of personal stress has worsened.

However, respondents have remained resilient, as most reported that their mental state appears to be recovering, with 73% describing their current mental health as excellent or good – up from 67% in the early months of the pandemic.

"Understanding an employee’s mental health plays an important role in managing workplace injuries," said Dr. Marcos Iglesias, Vice President and Chief Medical Director at Travelers. "The pandemic has likely affected the many psychosocial factors that can complicate the healing process and delay the time it takes to recover from a physical injury. It’s encouraging to see workers’ mental health trending back toward pre-pandemic levels because when employees are in a good mental state, they are safer, more productive and can often recuperate quicker if they do get hurt."

Positivity and the use of coping mechanisms are likely contributing to the improving outlooks. When asked to name any "silver lining" they’ve experienced during the pandemic, most employed adults (84%) identified at least one of the following, including:

- - Having a job (41%).
- - Saving money (34%).
- - Working remotely (29%).
- - Ability to multitask between personal and professional responsibilities (24%).
- - Picking up a new hobby (20%).
- - Not commuting (19%).
- - Connecting with others virtually (15%).

Exercise and spending time with family were the top ways that respondents described managing loneliness and stress over the last year, followed by using social media, spending time with pets and reaching out to friends or co-workers. Coping strategies varied somewhat by age group: baby boomers were more likely to keep in touch with others, while millennials were more likely to turn to social media or a new hobby.

The survey also found a correlation between employer-provided resources and workers’ mental health. Thirty percent of respondents who believe their employer has provided ample mental health resources also reported that their ability to manage stress improved during the pandemic, and one-third (33%) noted that loyalty to their employer increased. Meanwhile, 42% of workers who feel their employer has not provided enough mental health support said their ability to manage stress worsened during the pandemic, and 29% said loyalty to their employer decreased.

Dr. Iglesias added, "It’s important to note that employers can positively affect the overall well-being of their employees by taking a more holistic view of their health beyond just physical safety."

To download the report and learn more about the findings, including generation- and industry-specific differences, please visit Travelers.com/mentalhealth ...
/ 2021 News, Daily News
See’s Candies secured a victory when the California Court of Appeals rejected a proposed statewide employment class action based on alleged meal and rest period violations.

The lead plaintiff, Debbie Salazar, alleged claims for unpaid overtime, unpaid minimum wages, failure to provide rest and meal periods, failure to provide wage statements and to maintain payroll records, failure to timely pay wages on termination, and unfair and unlawful business practices under Business and Professions Code section 17200.

Salazar sought certification of two classes: a "single staffing class" and a "meal break class." With respect to the meal break class,

Salazar acknowledges that See’s official meal break policy complies with California law. Salazar’s theory is that, despite that policy, See’s consistent practice was to deny second meal periods when shifts exceeded 10 hours. Salazar claims that she can prove this consistent practice, and therefore establish liability, through common proof.

In opposition to the motion, See’s argued that See’s did not rely only on the Scheduling Form to provide second meal breaks, but also provided employees with training on its policies and required its shop managers to implement those policies.

In support of its opposition, See’s submitted declarations from 55 employees, including both managers and shop employees. The managers testified generally about See’s policy of providing a second meal break for shifts over 10 hours. Most of the employee declarants testified that they were aware of this policy. More than half of the employee declarants had worked shifts longer than 10 hours, and almost all of these testified that they took second meal breaks during such shifts at least some of the time. Four employees testified that they occasionally chose not to take a second meal break so that they could leave work earlier or get overtime pay.

The trial court denied certification of the meal break class on two grounds. First, the court found that Salazar had failed to show that she could prove through common evidence that See’s had a consistent practice to deny second meal breaks. Second, the trial court found that Salazar’s proposed trial plan was inadequate to manage these individual issues.

The court of appeal affirmed denial of class certification in the published case of Salazar v Sees Candy.

Class actions are authorized "when the question is one of a common or general interest, of many persons, or when the parties are numerous, and it is impracticable to bring them all before the court." (Code Civ. Proc., § 382.) To certify a class, "[t]he party advocating class treatment must demonstrate the existence of an ascertainable and sufficiently numerous class, a well-defined community of interest, and substantial benefits from certification that render proceeding as a class superior to the alternatives."

The community of interest factor in turn has three requirements: (1) common questions of fact or law that predominate over individual issues; (2) class representatives with claims or defenses typical of the class; and (3) class representatives who can adequately represent the class.

Class certification is generally inappropriate if liability can be established only through individual proof. When common issues predominate over individual issues, a class should not be certified if there is no way to manage the remaining individual issues "fairly and efficiently."

Under the substantial evidence standard, the court of appeal must credit the trial court’s reasonable inferences, even if a competing inference could be drawn ...
/ 2021 News, Daily News
The Division of Workers’ Compensation has issued a notice of conference call public hearing for a proposed evidence-based update to the Medical Treatment Utilization Schedule (MTUS), which can be found at California Code of Regulations, title 8, section 9792.23.8.

The conference call public hearing is scheduled for Friday, June 11, at 10 a.m. and members of the public may attend by calling 866-390-1828 and using access code 5497535#. Members of the public may review and comment on the proposed updates. Written comments must be submitted no later than June 11.

Please see the proposed regulation page for direction for submitting written comments.

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

- - Workplace Mental Health Guideline - Anxiety Disorders (ACOEM April 30, 2021)

The proposed evidence-based update to the MTUS regulations are exempt from Labor Code sections 5307.3 and 5307.4 and the rulemaking provisions of the Administrative Procedure Act. However, DWC is required under Labor Code section 5307.27 to have a 30-day public comment period, hold a public hearing, respond to all the comments received during the public comment period and publish the order adopting the update online ...
/ 2021 News, Daily News
The injured worker was employed by Applied Materials from 1996 until 2008. During that time, she claimed three industrial injuries: a specific injury to her neck and right upper extremity in 2001, a specific injury to her neck and both upper extremities in 2005, and a cumulative trauma injury to her neck, both upper extremities, and psyche ending on her last day worked in January 2008.

The worker later claimed that in 2013, she was sexually exploited by Dr. John Massey, (an anesthesiologist/pain specialist), the physician primarily responsible for the treatment of her industrial injuries after 2007. At the time, Massey was a member of the Bay Area Pain and Wellness Clinic (BAPWC). His license has since been revoked for his sexual misconduct by the California Medical Board.

She claimed that he touched her inappropriately on multiple occasions at his clinic and had sexual intercourse with her five times in her home. As a result of the doctor’s alleged misconduct, she claimed that she suffered a further injury to her psyche and was diagnosed with posttraumatic stress disorder (PTSD). Worker claimed her PTSD was industrial as a compensable consequence of the medical treatment her employer provided for all three of her industrial injuries.

Arrowood Indemnity Company was the workers’ compensation carrier for the 2001 specific injury claim. XL Specialty Insurance Company, as administered by Corvel Corporation was the workers’ compensation carrier for both the 2005 specific injury and the 2008 cumulative trauma injury claims.

Both insurers contended that Worker’s psychiatric injury resulting from her claimed sexual exploitation by Dr. Massey was not industrial because it was the result of a consensual sexual relationship and occurred at her home.

The case went to trial before a workers’ compensation judge in 2017. The WCJ found that all of Worker’s injury claims - including her depression, anxiety, and PTSD - were industrial, and awarded 100 percent permanent disability based on her PTSD alone retroactive to October 2010; found no apportionment; and concluded that the insurers were jointly and severally liable for the PD award since Dr. Massey treated all three of her industrial injuries.

In its June 2019 decision, the WCAB amended the amount of the weekly TD and PD rates as recommended by the WCJ, made an order regarding attorney fees that is not at issue here, and otherwise affirmed the WCJ’s findings and award.

The Court of Appeal affirmed the finding of psychiatric injury resulting from the sexual exploitation by Dr. Massey, but rejected the finding of total disability in the unpublished case of Applied Materials v. Workers’ Comp Appeals Board.

On the issue of industrial causation, the Court of Appeal concluded that the Worker met her burden of proving that her PTSD was a compensable consequence injury. It rejected Petitioners’ contention that the sexual conduct here was consensual, since as a matter of law a patient cannot consent to sexual contact with his or her physician (Bus. & Prof. Code, § 729, subd. (b)), as well as their contention that the PTSD is not compensable under the rules governing industrial injuries arising out of assaults by third parties.

It concluded that the 100 percent PD award must be annulled because: (a) the psychiatric reports that the WCAB relied on do not constitute substantial evidence since Dr. Sidle relied on an incorrect legal theory, the alternative path theory, that was rejected in Fitzpatrick, supra, 27 Cal.App.5th 607; and (b) Worker’s evidence was otherwise insufficient to rebut the scheduled rating for her psychiatric disability ...
/ 2021 News, Daily News
The Workers Compensation Research Institute (WCRI) released a new study, Hospital Outpatient Payment Index: Interstate Variations and Policy Analysis, 10th Edition, which compares hospital payments for a group of common outpatient surgeries in workers’ compensation across 36 states from 2005 to 2019.

"Rising hospital outpatient costs have been a focus for public policymakers and system stakeholders in recent policy debates in many states," said Ramona Tanabe, WCRI’s executive vice president and counsel. "The study provides meaningful comparisons of hospital outpatient payments across states, as well as hospital payment trends in relation to reforms of hospital outpatient fee regulations."

The following is a sample of the study’s findings:

- - Hospital payments per outpatient surgical episode in states with percent-of-charge-based fee regulations were 73 to 209 percent higher than the median of the study states with fixed-amount fee schedules in 2019. In states with no fee schedules, they were 61 to 130 percent higher.
- - Growth in hospital outpatient payments per episode among non-fee schedule states ranged from 25 percent in Iowa to 54 percent in Missouri, while the payments in the median fixed-amount fee schedule state without substantial changes in regulations increased about 4 percent from 2011 to 2019.
- - Variation between average workers’ compensation payments and Medicare rates for a common group of procedures across states ranged from a low of 38 percent (or $2,294) below Medicare in Nevada to a high of 502 percent (or $24,758) above Medicare in Alabama.

Payments for services provided and billed by hospitals are captured in this study. Professional services billed by nonhospital medical providers (e.g., physicians, physical therapists, and chiropractors), transactions for durable medical equipment and pharmaceuticals billed by providers other than hospitals, and payments made to ambulatory surgery centers are excluded. The study also provides an analysis of major policy changes in states with recent fee schedule reforms.

The study covers 36 large states that represent 88 percent of the workers’ compensation benefits paid in the United States. These states are Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, West Virginia, and Wisconsin.

For more information about this report or to download a copy, visit the WCRI website. The report was authored by Olesya Fomenko and Rebecca Yang ...
/ 2021 News, Daily News
41 year old Carolyn Plaza, who lives in Fresno, self-surrendered after a warrant for her arrest was issued on six felony counts of insurance fraud.

A criminal complaint filed on April 16 , alleges Plaza underreported more than $3 million in employee payroll in order to fraudulently reduce her company’s workers’ compensation insurance premium by nearly $1 million.

Plaza is the co-owner of Absolute Urethane, Inc., a construction contracting business serving the Fresno and surrounding Central Valley areas since 2006.

The California Department of Insurance began an investigation after receiving a tip from the State Compensation Insurance Fund alleging Plaza had manipulated payroll reports to avoid paying higher insurance premiums.

The Department of Insurance investigation uncovered that Plaza had provided false payroll records to State Fund for multiple policy years.

After comparing those payroll records to the records she reported to the Employment Development Department, the investigation discovered that Plaza underreported $3,146,863 in employee payroll over five years. Plaza’s underreporting resulted in a $985,091 loss in premium to State Fund.

Employers are required to maintain workers’ compensation insurance to cover their employees in the event of an accidental on-the-job injury. To ensure proper coverage, employers are required to accurately report the number of employees, job classifications, and the amount of payroll expended.

One of the common ways in which employers avoid paying insurance premiums is to underreport a business’s payroll by providing false payroll reports to their insurance company.

In this case, Plaza’s underreporting significantly lowered the premiums owed. Businesses that fraudulently lower their premiums benefit from an unfair market advantage, giving them the ability to charge less in labor costs, and thereby underbid businesses who pay the appropriate premiums.

Arraignment is scheduled for June 28, 2021, in the Fresno County Superior Court. The Fresno County District Attorney’s Office is prosecuting this case ...
/ 2021 News, Daily News
After years of firing employees when they requested medical treatment for work-related injuries, 71 year old Man Tat Szeto, the owner of MT Szeto Construction, admitted to committing felony workers’ compensation insurance fraud.

Worker’s compensation premium fraud occurs when an employer makes material misrepresentations to an insurance carrier about its claims history, payroll or risk classification of its workers, in order to obtain insurance coverage at less than the proper rate.

The construction company handles commercial, multi-family and residential construction projects throughout the greater San Francisco Bay Area.

California Contractors State License Board brought this case to the attention of the Santa Clara County District Attorney’s Office as a result of suspicious activity that occurred at a new residential construction project in San Jose.

In late 2018, multiple former employees reported that they had been fired after requesting medical treatment for injuries they had sustained while at work. When an employee injured himself, rather than file an appropriate claim with the employee's insurance company and risk an increase in premium, Szeto simply handed them cash and terminated them.

The employees who frequently worked upwards of 70 hours would be paid for only 40 hours, which is wage theft.

He avoided approximately $86,000 in premium payments to his insurer by underreporting employees and injuries.

To further his scheme, Szeto used the banking system to launder $165,000 to pay employees "off the books." Szeto was also charged with unemployment insurance tax fraud and money laundering.

Szeto’s plea agreement requires that he be placed on five years formal probation, serve nine months in county jail, and make restitution of approximately $250,000.

The Santa Clara County District Attorney’s Office, in coordination with the California Department of Insurance and the Department of Industrial Relations, investigated Szeto for nearly two years.
...
/ 2021 News, Daily News
58 year old Katherine Zalewski, who lives in of Richmond, has been reappointed to the Workers’ Compensation Appeals Board, where she has served since 2014 when she was appointed by Governor Brown, and as Chair since 2017.

Zalewski was Chief Counsel at the California Department of Industrial Relations from 2012 to 2014, where she was a Workers’ Compensation Administrative Law Judge and Advisor to the Division of Workers’ Compensation from 2009 to 2011.

Prior to her appointment as a Workers’ Compensation Judge in 2009, Ms. Zalewski represented insurers and self-insured employers in workers’ compensation matters throughout Northern California.

She was Senior Associate at Schmit Law Office from 2000 to 2009 and Manager and an Attorney at Pacific Coast Services from 1998 to 2000 and at Express Network and Direct Legal Support Services from 1993 to 1998. She was an Attorney at Kinder and Wuerfel from 1990 to 1993, at Finnegan and Marks from 1988 to 1990 and at Foreman and Brasso from 1986 to 1988.

Ms. Zalewski received her B.A. from the University of California, Berkeley in 1983 and her J.D. from Hastings College of the Law in 1986.

This position requires Senate confirmation and the compensation is $164,122.

Zalewski is registered without party preference ...
/ 2021 News, Daily News
Former Santa Ana Police Officer Jonathan Ridge was fired from the Santa Ana Police Department after admitting to worker compensation fraud.

Ridge pled guilty to several charges: one count of making a false statement to obtain compensation, and three counts of filing a fraudulent insurance benefit claim.

"Mr. Ridge’s criminal conduct is intolerable, erodes the public trust and violates the very oath he took to serve as a peace officer by the City of Santa Ana," Santa Ana Police Department, Chief of Police David Valentin said in a statement via Twitter. "This conduct does not represent the ethical, principled, and hard-working employees of the Santa Ana Police Department."

Ridge sustained an injury while on duty in pursuit of a suspect who was driving a stolen vehicle on Oct. 5, 2017. He then went on disability due to the injuries he had sustained.

While on leave in May 2018, Ridge had surgery to repair his injured wrist and his doctor recommended he stay out of work for up to six months. Ridge was cleared by his doctor to return to work in November 2018.

Ridge returned to work with several medical restrictions. However, the City of Santa Ana was unable to accommodate his restrictions despite having an extensive return-to-work program for injured employees. They continued paying Ridge’s disability payments, which comprised the full amount of working pay.

The Santa Ana Police Department began doing surveillance on Ridge in March 2019 after observing little to no improvement to his injury after 18 months off the job.

The investigation revealed that Ridge was engaged in activities beyond what his doctor imposed, including attending college classes weeks after his wrist surgery, taking a road trip to Utah, going to the beach and even riding a motorcycle.

Ridge received his full-time pay for over a year while not working despite being fully capable of returning to work.

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

The former SAPD officer was sentenced to six months in jail and two years of probation ...
/ 2021 News, Daily News
Underwriting profitability remained relatively stable in the U.S. workers' compensation market in 2020 as the COVID-19 pandemic raged and premium volumes fell. But while the pandemic may be ebbing in the U.S. in 2021, the workers' comp space cannot yet say it was unscathed.

The top 3 workers' compensation players held their positions in 2020 despite seeing sharp falls in premium volume, S&P Global Market Intelligence data shows. The Travelers Cos. Inc. continued to rule the roost with control of 7.3% of the U.S. market, even though its direct premiums written fell 11.3% to $3.74 billion.

Changes further down the ranks were confined to one-position moves. Chubb Ltd. took fourth place from Liberty Mutual Group Inc., AF Group nudged State Insurance Fund Workers' Compensation Fund out of the eighth spot and Old Republic International Corp. knocked American International Group Inc. out of the top 10.

Premium volume was down across the board as the pandemic kept workers at home or saw them furloughed or laid off. Direct written premiums were down 10.5% year over year to $31.41 billion for the top 20 and 9.2% to $51.06 billion for the industry.

However, underwriting profitability looks to have held up despite concerns about a flurry of losses from the introduction of rebuttable presumptions for pandemic-related workers' compensation claims in several states, which shifts the burden of proof to the employer from the employee.

The workers' compensation industry's collective direct incurred loss ratio, prior to consideration of reinsurance, increased year over year, but only by 1.3 percentage points to 47.4%.

The combined ratio is likely to have seen a similar trend. Dan Aronson, U.S. casualty leader at insurance broker Marsh LLC, said during an April webinar that the industrywide private carrier combined ratio was estimated to be 86% for 2020, compared with 85% for 2019.

Workers' compensation underwriting profitability has been "pretty solid" in recent years because of falling claims frequency, Sid Ghosh, vice president at Moody's, said in an interview. The pandemic, which halted many business activities, has helped workers' compensation claims frequency "tremendously," he said.

There are signs that claims costs from workers catching COVID-19 will not be as high as feared. Dennis Tierney, Marsh's director of workers' compensation claims, on the webinar said one surprise was that the average COVID-19 claim cost less than $5,000, compared with around $20,000 for the typical workers' compensation claim.

That said, the workers' compensation market may not be done with the pandemic yet. Tierney said the potential for long-term health effects of COVID-19 is not yet fully known. As time goes on, the overall picture of the pandemic's impact may change, he said.

Ghosh said another unknown is how working from home for a prolonged period of time may affect workers' health in the long run. "We don't know how that is going to evolve," he said. He also noted that the claims frequency reductions were "a temporary benefit to the industry" that would be reversed as people return to work.

The introduction of new presumption rules in several states is "a worry for the workers' comp industry," Ghosh said, although Moody's not aware of a material number of claims resulting from these changes so far. He added that some states were considering whether to expand the rules from essential workers to a wider group ...
/ 2021 News, Daily News
A pharmaceutical company headquartered in Delaware has agreed to pay $12.6 million to resolve allegations that it violated the False Claims Act by paying kickbacks.

The settlement resolves allegations that Incyte Corporation purportedly used an independent foundation as a conduit to pay the copays of certain federal beneficiaries taking Incyte’s drug Jakafi, which was approved to treat myleofibrosis in 2011.

Specifically, Incyte was the sole donor to a fund that was opened in November 2011 to assist only myleofibrosis patients. After the fund opened, the government alleges that Incyte used the fund to pay the copays of federal beneficiaries taking Jakafi who were ineligible for assistance from the fund because they did not have myleofibrosis.

Incyte managers pressured the foundation, through phone calls and emails, to provide economic assistance to these ineligible patients, and Incyte’s contractor helped ineligible patients to complete applications submitted to the fund for assistance. The government alleges that through this conduct, Incyte caused false claims for Jakafi to be submitted to Medicare and TRICARE.

When a beneficiary obtains a prescription drug covered by Medicare or TRICARE, the beneficiary may be required to make a partial payment, which may take the form of a copayment, coinsurance or a deductible. Congress included copay requirements in these federal programs, in part, to serve as a check on health care costs, including the prices that pharmaceutical manufacturers can demand for their drugs.

Under the Anti-Kickback Statute, a pharmaceutical company is prohibited from offering or paying, directly or indirectly, any remuneration - which includes money or any other thing of value - to induce federal beneficiaries to purchase the company’s drugs. This prohibition extends to the payment of patients’ copay obligations.

The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by Justin Dillon, a former compliance executive at Incyte. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. The qui tam case is captioned U.S. ex rel. Dillon v. Incyte Corp., No. 2:18 -cv-2642 (E.D. Pa.).

Dillon will receive approximately $3.59 million of the recovery ...
/ 2021 News, Daily News
The days of waiting some time for a pharmacist to fill a prescription made by your doctor may soon be behind us.

Pharmacies, doctors’ offices and other medical institutions could one day offer individual patients medications that are customized to their needs using 3D printing technology.

Courthouse News reports that the new technology has been developed in recent years under an expanding field of pharmaceutical research aiming to understand how to shape the effect medication has on patients.

The 3D-printed pill model could spark a wave of personalized pharmacological interventions tailored to meet the unique needs of all patients, according to lead researcher of the study Sheng Qi.

Qi, a professor at the United Kingdom’s University of East Anglia, said in a statement released with the study that the current pharmacological landscape currently takes the opposite approach, manufacturing one form of medication meant to satisfy all patients.

"Personalized medicine uses new manufacturing technology to produce pills that have the accurate dose and drug combinations tailored to individual patients. This would allow the patients to get maximal drug benefit with minimal side effects," Qi said. "Such treatment approaches can particularly benefit elderly patients who often have to take many different types of medicines per day, and patients with complicated conditions such as cancer, mental illness and inflammatory bowel disease."

The study’s findings could one day shape an element of personalized medicine that can create a tailored pharmacological regimen at the site where patients are being treated, Qi said.

Most 3D-printed products and objects use a device that heats filament material and places tiny fragments of the filament into a custom pattern.

The personalized pills are created using a newly developed 3D printing method that can shape a pill containing the medication without the use of filaments.

The research team led by Qi has developed the ability to print pills that feature more porous structures allowing for faster or slower release of medicine when taken orally.

The findings show that the speed of medicine dispersing within the body can be regulated by pill structures created using the new technology, according to the study published Monday in the International Journal of Pharmaceutics.

The study said future research is needed to make the technology produce pills that can regulate dosing frequency.

If the technology is improved, people on complex medical regimens requiring multiple medications taken each day could one day be able to take one pill that slowly releases a day’s worth of doses.

Researchers Andy Gleadall and Richard Bibb of England’s Loughborough University also contributed to the study.

Members of the study team did not immediately respond to a request for further comment on the report ...
/ 2021 News, Daily News
Brooke Gomez, 29, of Maxwell, was convicted and sentenced on one misdemeanor count of workers’ compensation insurance fraud after she claimed to be too injured to work in order to collect workers’ compensation benefits while working for another employer.

Gomez pleaded no contest to the misdemeanor charge and was sentenced in Colusa County Superior Court on April 26, 2021. She was placed on 12 months summary probation and ordered to pay $6,000 in restitution and $630 in fines.

On August 14, 2019, while working as a rice grader, Gomez sustained an abdominal injury while lifting bags of rice. Following her injury, a workers’ compensation claim was filed with her employer’s insurance company and Gomez began receiving workers’ compensation payments.

Gomez told her employer she had been offered several part-time jobs, but declined the offers due to her work injury. However, other mill workers reported to their employer that they witnessed Gomez working as a bartender at a local bar.

An investigation by the California Department of Insurance found Gomez misrepresented her symptoms to medical professionals and those handling her claim. Undercover surveillance showed Gomez interacting with customers, serving drinks, completing cash transactions with patrons and wiping down tables - all functions she claimed not to be able to do as a result of her injury.

The surveillance also discovered Gomez discussing her workers’ compensation claim with bar patrons and discussing her hopes of not getting caught working at the bar while receiving workers’ compensation benefits.

Due to Gomez’s misrepresentations, she received $6,893 in undeserved workers’ compensation payments and her employers’ insurance company lost an additional $8,992 in legal and investigation costs.
...
/ 2021 News, Daily News
The current issue of the National Council on Compensation Insurance, Quarterly Economics Briefing - Q1 2021, surveys recent developments related to employment and wages and considers the risk to the emerging economic recovery from a possible fourth COVID surge.

The two-month fall in coronavirus case rates, coincident with the appearance of new vaccines, has kindled optimism. The expectation that new vaccines will bring the coronavirus pandemic under control by year-end, if not sooner, is itself a powerful driver for rapid recovery of spending and jobs in the United States - if that expectation is borne out in coming months.

After stagnating during the nationwide coronavirus (COVID-19) surge last winter, the pace of job recovery picked up in February and March. The rollout of new vaccines and a fall in coronavirus case rates are creating an expectation that the COVID recession may be over by year-end, if not sooner. This is also boosting discretionary consumption and new hiring.

However, an uptick in case rates beginning in late March casts a shadow on the prevailing mood of optimism.

Key Themes and Takeaways

- - Strong employment growth in February and March, plus declining coronavirus case rates and increasing vaccinations, point to an accelerating pace of economic recovery in 2021.
- - The March national employment gap is down to -=5.4%, a shortfall of 7 million jobs relative to seasonally expected employment levels. Lost jobs remain concentrated in service sectors, especially Leisure and Hospitality. Construction and Manufacturing are recovering strongly, but both sectors face material shortages and supply chain bottlenecks.
- - Unadjusted average weekly wages rose by more than 7% in 2020, in large measure because COVID-related job losses are concentrated among low-wage workers. Adjusting for the effect of COVID-related job losses on the wage distribution, average weekly wages rose by 3% in 2020 among workers who remained employed.
- - Economic impact payments from two new federal stimulus programs enacted in December and March were distributed to households during the first quarter. Transfer payments have kept national household disposable income and savings above pre-pandemic 2019 levels. Strong household balance sheets provide wherewithal to drive a rapid rebound in discretionary consumption spending in 2021.
- - About 30% of the United States population received at least one vaccine dose by the end of March, and vaccination rates are currently on the order of 3 million people per day. New coronavirus cases in March were down to about one-third of January’s rate. However, several states reported increases in cases and hospitalizations in late March attributed to a new and more contagious variant of the coronavirus.
- - Job losses from a new COVID surge, if it develops, may be modest - like those during last winter’s surge, but much lower than in two previous virus surges in spring and summer 2020.

Read the full Quarterly Economics Briefing for an in-depth look at the economy and how it is impacting workers compensation ...
/ 2021 News, Daily News
Cannabis use more than doubled over the past decade among Americans 50 and over, with nearly one in 10 now reporting usage over the past year, an analysis of the National Survey on Drug Use and Health (NSDUH) found.

Of the 8.9% who reported using cannabis in the past year; roughly one in five (18.5%) reported using it for medical purposes such as treatment of chronic pain or depression, or for diseases like arthritis, reported Namkee Choi, PhD, and Diana DiNitto, PhD, both from University of Texas at Austin.

Compared to recreational users, those using cannabis for medical purposes were more likely to discuss drug use with a healthcare professional (adjusted OR 4.18, 95% CI 2.53-6.89), to purchase from a medical cannabis dispensary (aOR 4.38, 95% CI 2.47-7.76), and to report more frequent use (aOR 2.56, 95% CI 1.35-4.86), according to the research in the American Journal of Drug and Alcohol Abuse.

"The findings suggest that some medical users may be self-treating without healthcare professional consultation," Choi said. "As part of routine care, healthcare professionals should screen for cannabis and other substance use, and for mental health problems, and recommend treatment when necessary."

For their study, the researchers examined 2018 and 2019 NSDUH data involving 17,685 individuals ages 50 and up, 55% of whom were women. Of self-described medical cannabis users -- which by NSDUH definition implies physician-recommended use – less than 40% reported discussing cannabis use with a healthcare provider, which the authors noted suggests that some reported medical use without a doctor's recommendation, possibly because they believed it to be necessary for relieving their symptoms.

Indeed, Choi and DiNitto cited another large survey performed in the U.S. in 2017 that found the most common medical reasons for marijuana use were anxiety (49%), insomnia (47%), chronic pain (42%), and depression (39%). Among those using marijuana for medical purposes, 21% did not have a doctor. Among those with doctors, 33% did not inform them, 28% reported their doctor was neutral on their use, 32% reported their doctor was supportive, and 8% reported their doctor was not supportive.

In the current study, while medical users reported using cannabis more frequently, with 40% using it roughly 4 to 7 days per week, they were less likely to have alcohol use disorder compared with nonmedical cannabis users (aOR 0.39, 95% CI 0.20-0.76). Otherwise, medical and nonmedical users did not differ on physical and most behavioral health indicators, although cannabis users in general had significantly higher rates of alcohol use disorder, nicotine dependence, other illicit drug use, and mental illness compared with nonusers.

Most were experienced users rather than new to cannabis use; most obtained cannabis from private/informal sources, reportedly with little difficulty. Of self-reported medical users, 71% reported exclusive medical use; the rest reported both medical and nonmedical use.

It is important that patients be made aware of the risks of obtaining cannabis and cannabis products from unregulated sources, the authors noted. "Given the increase in THC [tetrahydrocannabinol] potency, healthcare professionals should educate older cannabis users, especially high-frequency users, on potential safety issues and adverse effects."

In addition to urging doctors to do more to screen and educate their patients, the study authors say the NSDUH needs updating to "reflect changing cannabis product commercialization," with cannabidiol, topical solutions, and edibles often available now.

In fact, there has been a push in recent years to help familiarize healthcare providers with the health effects of cannabis: Last year, citing a 2015 survey of healthcare providers, Nora Volkow, MD, director of the National Institute on Drug Abuse, concluded that providers "perceive a knowledge gap related to cannabis dosing, treatment plans, and different areas related to cannabis products, so providers themselves realize the need for research and expertise to be developed in this area."

In the face of increasing patient requests, new guidelines have been issued on medical cannabis for chronic pain; and last fall, MedPage Today reported on the publication of Medical Marijuana: A Clinical Handbook.

Researchers noted that limitations of their study included the relatively small number of medical users and the fact some respondents may have under-reported their cannabis and other substance use ...
/ 2021 News, Daily News
The Division of Workers’ Compensation has posted proposed amendments to the Qualified Medical Evaluator (QME) regulations to its online forum where members of the public may review and comment on the proposals.

The proposed changes are necessary to bring existing regulations into compliance with amendments to the Labor Code and to clarify the Administrative Director’s authority with respect to the processes related to appointment and reappointment of Qualified Medical Evaluators, which is granted by relevant statutory authority.

The draft regulations include:

- - Clarification of regard to definitions to conform to changes made by Senate Bill 863
- - Provisions prohibiting providing false information on the application or reapplication for appointment
- - Provisions to conform amended regulations with proper gender pronouns
- - Provisions for electronic service of medical-legal reports and use of electronic signatures in the QME program
- - Revision of the number of hours necessary for initial qualification of physicians as QMEs
- - Revision of continuing education requirements including hourly requirements and the addition of anti-bias training for QMEs
- - Provisions that require a QME to comply with all Administrative Director’s regulations in order to be reappointed as a QME.
- - There is also a new regulation that provides a specific implementation of existing discretionary authority of the Administrative Director pursuant to Labor Code § 139.2
- - Clarification of the use of probation as a disciplinary sanction and allowing the Administrative Director to designate hearing officers for adjudication of disputes regarding appointment and reappointment applications
- - Clerical changes to the regulation on QME unavailability
- - Provisions allowing QME reappointment hearings to be heard by other tribunals in addition to the Office of Administrative Hearings
- - Regulations that are consolidated into new subdivisions are repealed.

The forum can be found on the DWC forums webpage under "current forums." Comments can be submitted to DWCrules@dir.ca.gov and will be accepted until 5 p.m. on Friday, May 14, 2021 ...
/ 2021 News, Daily News
The Department of Industrial Relations (DIR) and its Division of Workers’ Compensation (DWC) have posted an annual 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 2020, the eighth year since the program was implemented.

The Independent Medical Review Organization (IMRO) administering the program, Maximus Federal Services, Inc., received 184,100 IMR applications, and issued 136,740 Final Determination Letters, each addressing one or more medical necessity disputes.

In the first half of 2020, IMR program activity slowed with the emergence of the pandemic, but rebounded in the second half. Throughout the year, the IMRO issued decisions, on average, eight to 12 days after receipt of all medical records.

Some highlights of the report:

- - Nearly 94% of all unique IMR filings were deemed eligible for review, the highest annual percentage since IMR began.
- - Pharmaceutical requests accounted for 34% of all treatment requests sent for IMR, a smaller proportion of total service requests than in previous years.
- - Opioids comprised three out of 10 pharmaceutical requests.
- - Treatment request denials were overturned at a rate of 9.5%. Specialist consultants, office visits and mental health services were overturned most often.
- - Guidelines contained in the Medical Treatment Utilization Schedule continue to serve as the primary resource for the determination of medical necessity.

The progress report is posted on the DIR website ...
/ 2021 News, Daily News
The Ninth Circuit Court of Appeals ruled that Assembly Bill 5 was not preempted by federal laws governing the trucking industry, and reversed a lower court ruling, as it ordered freight carriers to begin complying with the California employment law.

Before 2018, the California Supreme Court’s framework for classifying workers as either employees or independent contractors was set forth in S.G. Borello & Sons, Inc. v. Department of Industrial Relations, 48 Cal. 3d 341 (1989).

Almost thirty years after Borello, the California Supreme Court revisited the framework for classifying workers as employees or independent contractors for purposes of California’s Industrial Welfare Commission (IWC) Wage Orders.2 See Dynamex Operations W. v. Superior Ct., 4 Cal. 5th 903, 912, 957 (2018). Dynamex adopted a standard commonly referred to as the "ABC" test.

In September 2019, the California legislature enacted AB- 5, which codified the ABC test and expanded its applicability. See Cal. Lab. Code § 2775.

The California Trucking Association, a trade association representing motor carriers that hire independent contractors who own their own trucks, and two independent owner-operators filed suit, seeking to enjoin enforcement of AB-5. It viewed the new rule statutorily classifying a worker as an employee as effectively precluding the business model employed by CTA’s members.

In October 2018, after Dynamex was decided, CTA, along with two independent owner-operators, filed this lawsuit against Xavier Becerra, the Attorney General of California, and others, seeking a declaration that the federal law, the Federal Aviation Administration Authorization Act of 1994 (FAAAA), preempted the ABC test as applied to motor carriers.The district court allowed the International Brotherhood of Teamsters, a labor union that represents owneroperators classified as employees, to intervene.

The federal district court held that CTA was likely to succeed on the merits of its claim. It therefore enjoined the state from enforcing AB-5 against any motor carrier doing business in California. The 9th Circuit Court of Appeals reversed in the published case of California Trucking Association v Bonita.

The Supremacy Clause of the United States Constitution provides that federal law "shall be the supreme Law of the Land; and the Judges in every State shall be bound thereby, anything in the Constitution or Laws of any State to the Contrary notwithstanding."

In Dilts v. Penske Logistics, LLC, 769 F.3d 637, 647 (9th Cir. 2014), the 9th Circuit determined that California’s meal and rest break laws, as applied to motor carriers, are not preempted by the FAAAA. See also Ridgeway, 946 F.3d at 1083-86 (holding that the FAAAA does not preempt a California minimum-wage law that would require Walmart to pay long-haul-truck-drivers minimum wages for layovers in California.

Four years after Dilts, the 9th Circuit concluded that the FAAAA does not preempt the test for classifying California workers as either employees or independent contractors. AB-5 is not significantly related to rates, routes, or services. Therefore, it concluded that the F4A does not preempt AB-5 as applied to motor carriers ...
/ 2021 News, Daily News
The DWC has posted the new Medical-Legal Fee Schedule (MLFS) on its website . The documents include the final text of amendments to the Medical-Legal Fee Schedule regulations, as well as forum comments and the DWC response, and action to the comments.

Some of the changes include:

- - Clarification of the Physician’s obligation when records are received without an attestation.
- - Clarification on billing for records previously reviewed under ML202.
- - Deletion tf the billing code ML206 related to the unreimbursed supplemental report.
- - Addition of the ability of physicians who are certified as Qualified Medical Evaluators in the specialty of Internal Medicine or who are board certified in Internal Medicine to use modifiers 97 & 98 for toxicology and oncology evaluations.

The industry in general reacted with some consternation about the new MLFS, and had questions about implementation of the Schedule.

Apparently in response, the DWC has posted the recordings of the Question and Answer Meetings held by Zoom on April 13 and April 20 regarding the new Medical-Legal Fee Schedule for the workers’ compensation system.

The links to the recorded sessions, which answered questions from stakeholders regarding the implementation of the fee schedule, can be found on the DWC website.

The Medical-Legal Fee Schedule, which became effective on April 1, 2021, is set forth at California Code of Regulations, title 8, sections 9793-9795 ...
/ 2021 News, Daily News
Liana Karapetyan, 41, of El Dorado Hills, pleaded guilty to one count of conspiracy to commit health care fraud and one count of conspiracy to pay and receive health care kickbacks.

According to court documents, Karapetyan and another individual owned and controlled home health care and hospice agencies in the greater Sacramento area: ANG Health Care Inc., Excel Home Healthcare Inc., and Excel Hospice Inc.

Karapetyan and another individual paid and directed others to pay kickbacks to multiple individuals for beneficiary referrals, including employees of health care facilities, as well as employees’ spouses.

The kickback recipients included John Eby, a registered nurse who worked for a hospital in Sacramento; Anita Vijay, the director of social services at a skilled nursing and assisted living facility in Sacramento; Jai Vijay, Anita Vijay’s husband; and Mariela Panganiban, the director of social services at a skilled nursing facility in Roseville.

In total, Karapetyan and others caused the agencies to submit over 8,000 claims to Medicare for the cost of home health care and hospice services. Based on those claims, Medicare paid the agencies approximately $31 million. Of that amount, Medicare paid the agencies at least over $2 million for services purportedly provided to beneficiaries referred in exchange for kickbacks paid to, among others, Eby, Anita Vijay, Jai Vijay, and Panganiban.

Because the agencies obtained the beneficiary referrals by paying kickbacks, the agencies should not have received any Medicare reimbursement.

This case is a product of an investigation by the Federal Bureau of Investigation and the Department of Health and Human Services’ Office of Inspector General. Assistant U.S. Attorney Matthew Thuesen is prosecuting the case.

Karapetyan will be sentenced on on Aug. 26. She faces maximum statutory penalties of 10 years in prison for the health care fraud conspiracy charge and five years in prison for the kickback conspiracy charge. She also faces a maximum fine of $250,000 or twice the gross gain or loss for each charge.

In separate cases, Eby, Jai Vijay, Anita Vijay, and Panganiban pleaded guilty for their roles in the kickback scheme. They await sentencing ...
/ 2021 News, Daily News