The "Insurance TPA Market by Service Type, by Service, and by End User - Global Opportunity Analysis and Industry Forecast, 2023-2030" reports that the insurance TPA Market size was valued at USD 307.79 billion in 2022, and is projected to reach USD 511.49 billion by 2030, at a CAGR of 5.5% during the forecast period, 2023-2030. Innovative startup companies are emerging and revolutionizing the operational landscape within the insurance third-party administrator (TPA) industry. This factor is expected to drive the growth of the insurance TPA market. These emerging startups are transforming the conventional TPA business model by focusing on process optimization through automation and expedited claims handling. Moreover, they prioritize delivering transparent and dependable customer service to ensure customer satisfaction, comprehensive care, and operational efficiency. Moreover, the increasing healthcare costs drive a higher demand for TPAs. As healthcare expenses continue to rise, there is a growing need for efficient management and cost-containment solutions. This has led to an increased reliance on TPAs, who specialize in streamlining administrative processes, negotiating with healthcare providers, and implementing strategies to control expenses. As a result, the demand for TPAs has significantly accelerated due to the rising healthcare expenses. The TPAs reduce costs without compromising the quality of healthcare, and have established themselves as vital assets to self-insuring programs. These factors accelerate the growth of the insurance TPA market. However, the rising concerns of security and privacy of consumers from third parties restrain the market growth. On the contrary, the technological advancements such as wearable technologies, blockchain, and artificial intelligence (AI) enable TPAs to manage claims and other processes. They guarantee efficient insurance services, offer exceptional service, and lower operational costs. This, in turn, creates ample growth opportunities for the key market players of the insurance TPA market in the coming years. The global insurance TPA market is segmented on the basis of type, services, end user, and geography. - - Based on type, the market is classified into health insurance, property and casualty insurance, workers' compensation insurance, disability insurance, travel insurance, and others. - - Based on services, the market is categorized into claims management and risk control management. - - Based on end user, the market is divided into healthcare, construction, real estate and hospitality, transportation, staffing, and others. - - Based on geography, the market is segmented into North America, Europe, Asia-Pacific, and Rest of the World (RoW). North America holds the largest share of the insurance TPA market. This dominance is driven by the increase in chronic diseases such as cancer, heart disease, and diabetes caused by unhealthy habits such as smoking, alcohol consumption, and poor diet. As a result, there is a surge in the number of insurance policies, leading to the outsourcing of services to insurance TPAs for efficient claims management. Additionally, the region's vulnerability to natural disasters such as floods, earthquakes, and storms encourages individuals to opt for property insurance plans to mitigate potential losses. The growing number of insurance policies is expected to further drive the growth of the insurance TPA market in this region. The key players in the global insurance TPA market include: - - Sedgwick Claims Management Services, Inc. - - United HealthCare Services (UMR), Inc. - - Crawford & Co. - - Gallagher Bassett Services, Inc. - - CorVel Corp. - - Meritain Health - - ESIS, Inc. - - Helmsman Management Services LLC - - Trustmark Health Benefits, Inc. - - Cannon Cochran Management Services Inc., dba CCMSI ...

United Behavioral Health ("UBH") is one of the nation’s largest managed healthcare organizations. It administers insurance benefits for mental health conditions and substance use disorders for various commercial health benefit plans. In this role, UBH processes coverage requests made by plan members to determine whether the treatment sought is covered under the respective plans. UBH retains discretion to make these coverage determinations "for specific treatment for specific members based on the coverage terms of the member’s plan." ERISA is a federal statute designed to regulate "employee benefit plan[s]." 29 U.S.C. § 1003(a). Congress enacted ERISA "to promote the interests of employees and their beneficiaries in employee benefit plans," 29 U.S.C. § 1132(a) sets forth a comprehensive civil enforcement scheme. The named Plaintiffs in this class action are all beneficiaries of ERISA-governed health benefit plans for which UBH was the claims administrator. Plaintiffs all submitted coverage requests, which UBH denied. Among the individually named Plaintiffs, there are ten different ERISA plans. Among the class members, there may be as many as 3,000 different plans. The Parties stipulated to a sample class of 106 members, from which they submitted a sample of health insurance plans. Plaintiffs alleged that the Plans required, as a condition of coverage, that treatment be consistent with generally accepted standards of care ("GASC") or were governed by state laws specifying certain criteria for making coverage or medical necessity determinations. UBH employed two different processes to determine whether a requested service was covered. First, where the requested service was subject to a Plan exclusion, UBH issued an administrative denial. Administrative denials did not involve clinical reviews and are not at issue in this appeal. Second, for those claims not administratively denied, UBH conducted a clinical review, by which UBH Peer Reviewers made clinical coverage determinations. To assist with these clinical coverage determinations, UBH developed internal guidelines used by UBH’s clinicians. The Guidelines applied across Plans and were not customized based on specific plan terms. For this reason, among others, Plaintiffs argue that the Guidelines implemented only the plan exclusion for coverage inconsistent with GASC, which appeared in all plans. UBH issued new Level of Care Guidelines each year, which contained several parts, some of which Plaintiffs challenge tas more restrictive than GASC,. The district court entered judgment in Plaintiffs’ favor, concluding that UBH breached its fiduciary duties and wrongfully denied benefits because the Guidelines impermissibly deviated from GASC and state-mandated criteria. The district court also found that financial incentives infected UBH’s Guideline development process, particularly where the Guidelines "were riddled with requirements that provided for narrower coverage than is consistent with" GASC. Based on these findings, the district court concluded that UBH breached its fiduciary duty to comply with Plan terms and breached its duties of loyalty and care "by adopting Guidelines that are unreasonable and do not reflect" GASC. It also held that UBH improperly denied Plaintiffs benefits by relying on its restrictive Guidelines that were inconsistent with the Plan terms and state law. The district court issued declaratory and injunctive relief, directed the implementation of court-determined claims processing guidelines, ordered "reprocessing" of all class members’ claims in accordance with the new guidelines, and appointed a special master to oversee compliance for ten years. UBH appealed and argued that Plaintiffs lacked Article III standing to bring their claims because: (1) Plaintiffs did not suffer concrete injuries; and (2) Plaintiffs did not show proof of benefits denied, and so they cannot show any damages traceable to UBH’s Guidelines. The 9th Circuit disagreed with this argument in the published case of Wit v United Behavioral Health -20-17363 (Aug 2023). However it did find error in other aspects of the trial court orders, and reversed in part. To establish standing under Article III, a plaintiff must show (i) that he suffered an injury in fact that is concrete, particularized, and actual or imminent; (ii) that the injury was likely caused by the defendant; and (iii) that the injury would likely be redressed by judicial relief. The 9th Circuit ruled that Plaintiffs met all three criteria. UBH also appealed from the district court’s class certification order. The district court’s class certification decision was reviewed for an abuse of discretion. As to Plaintiffs’ denial of benefits claim, the 9th Circuit agreed, and concluded that the district court erred in granting class certification here based on its determination that the class members were entitled to have their claims reprocessed regardless of the individual circumstances at issue in their claims. It ordered remand for claim reprocessing where a plaintiff has shown that his or her claim was denied based on the wrong standard and that he or she might be entitled to benefits under the proper standard. UBH further argues that the district court erred by concluding that the Guidelines improperly deviated from GASC, and by failing to apply an appropriate level of deference to UBH’s interpretation of the Plans. It was undisputed that the Plans in this case confer UBH with discretionary authority to interpret the Plan terms. But where "an administrator has a dual role as plan administrator and plan insurer, there is a structural conflict of interest ." However, the district court’s findings did not excuse it from applying the abuse of discretion standard. "Abuse of discretion review applies to a discretion-granting plan even if the administrator has a conflict of interest." In short, while the Plans mandated that a treatment be consistent with GASC, they did not compel UBH to cover all treatment that was consistent with GASC. Thus the 9th Circuit reversed the district court’s judgment that UBH wrongfully denied benefits to the named Plaintiffs to the extent the district court concluded the Plans require coverage for all care consistent with GASC ...

Business Group on Health is a non-profit organization representing large employers’ perspectives on optimizing workforce strategy through innovative health, benefits and well-being solutions and on health policy issues. Business Group members include the majority of Fortune 100 companies as well as large public-sector employers, who collectively provide health and well-being programs for more than 60 million individuals in 200 countries. Mental health needs among workforces continued to climb this year, with 77% of large employers reporting an increase and another 16% anticipating one in the future, according to Business Group on Health’s 2024 Large Employer Health Care Strategy Survey. This represents a 33 percentage-point surge over last year, when 44% of employers saw an increase in employee mental health concerns. The Business Group survey also showed that cancer was still the top driver of large companies’ health care costs while rising prescription drug costs also proved to be a leading concern. Cancer overtook musculoskeletal conditions last year as the top driver of large companies’ health care costs and shows no sign of abating in the coming years. Yet as businesses respond to the increase in mental health needs, grapple with soaring health care costs and address issues of health equity and affordability, they will continue to invest strategically in diverse health and well-being offerings for the upcoming year, the survey also showed. "Our survey found that in 2024 and for the near future, employers will be acutely focused on addressing employees’ mental health needs while ensuring access and lowering cost barriers," said Ellen Kelsay, president and CEO of Business Group on Health. "Companies will need to creatively and deftly navigate these and other challenges in the coming year, especially as they remain committed to providing high-quality health and well-being offerings while managing overall costs." The survey gathered data on a range of critical topics related to employer-sponsored health care for the coming year. A total of 152 large employers across varied industries, who together cover more than 19 million people in the United States, completed the survey between June 1, 2023, and July 18, 2023. More details on employers’ top areas of concern, according to the survey: - - An increase in mental health challenges was cited as the most significant area of prolonged impact resulting from the pandemic. Last year, 44% of employers saw a rise in mental health concerns, while 77% of employers reported an increase this year, with another 16% anticipating one in the future. To address this trend in 2024, employers said they were acutely focused on access to mental health services by providing more options for support and lowering cost barriers to care. - - One in two employers said cancer was the No. 1 driver of health care costs, and 86% said it ranked among the top three, likely due to late-stage cancer diagnoses from the pandemic. Last year, cancer overtook musculoskeletal conditions as the top driver of large companies’ health care costs, for the first time. - - Pharmacy costs continue to affect trend and affordability. While 92% of employers are concerned about high-cost drugs in the pipeline, 91% reported concern about pharmacy cost trend overall. This comes as employers experienced an increase in the median percentage of health care dollars spent on pharmacy, from 21% in 2021 to 24% in 2022. For 2024, employers said they planned to deploy various pharmacy management strategies. - - After plan design changes, health care trend may reach a 6% increase in 2023 and 2024, which is higher than historical increases. Employers said they would continue to focus on plan and patient affordability, underscoring the demand for delivery system and payment transformation to focus more heavily on improvement in outcomes, lowered total cost of care, reduction in unnecessary services, and the prioritization of prevention and primary care. - - In 2024, employers plan to assess partnerships and vendors to ensure value and higher-quality, cost-effective services. The survey also showed that employers are holding vendors accountable for greater transparency in results, pricing and contractual terms. In addition, nearly half of employers plan to require vendors to report on health equity measures, while many seek to streamline partnerships and vendor offerings. - - Employers identified transparency as a potential tool to contain costs and improve quality, enabling employees to make more educated health care decisions (87%). Employers also expressed support for engagement platforms, which could aid employees in identifying and navigating appropriate health and well-being solutions. In addition, 73% of employers prioritized requirements for more transparency in PBM pricing and contracting, while 58% expressed an interest in additional reporting and better provider quality measurement standards. - - While employers continue to see virtual health as essential to their overall strategy, they are less inclined to see virtual health as transformative on its own. In 2021, 85% of employers said virtual health would impact overall delivery, compared with 74% in 2022 and 64% in 2023. Employers indicated concerns with virtual health, including a lack of integration among solutions. - - Employers’ health equity approaches continue to evolve, with a focus on specific communities and populations within the workforce. In 2024, many employers (86%) said they would collaborate with employee resource groups (ERGs) to promote benefits and well-being initiatives to specific groups, while 61% said they would require health plan and navigation partners to maintain directories of health care and mental health providers. In addition, 85% of employers plan to implement at least one strategy to support the health and well-being needs of LGBTQ+ employees ...

The Department of Justice just announced deferred prosecution agreements resolving criminal antitrust charges against Teva Pharmaceuticals USA, Inc. and Glenmark Pharmaceuticals Inc., USA. As part of those agreements, both companies will divest a key business line involved in the misconduct, and as an additional remedial measure, Teva will make a $50 million drug donation to humanitarian organizations. Teva will pay a $225 million criminal penalty - the largest to date for a domestic antitrust cartel - and Glenmark will pay a $30 million criminal penalty. Both companies will face prosecution if they violate the terms of the agreements, and if convicted, would likely face mandatory debarment from federal health care programs. The agreements each require the companies to undertake remedial measures, including the timely divestiture of their respective drug lines for pravastatin, a widely used cholesterol medicine that was a core part of the companies’ price-fixing conspiracy. This extraordinary remedy forces the companies to divest a business line that was central to the misconduct. Teva must also donate $50 million worth of clotrimazole and tobramycin, two additional drugs with prices affected by Teva’s criminal schemes, to humanitarian organizations that provide medication to Americans in need. Both Teva and Glenmark have agreed, among other things, to cooperate with the department in the ongoing criminal investigations and resulting prosecutions, report to the department on their compliance programs, and modify those compliance programs where necessary and appropriate. As part of the agreements, Teva admitted to participating in three antitrust conspiracies that affected essential medicines - including pravastatin, clotrimazole and tobramycin - and Glenmark admitted to participating in a conspiracy to fix the price of pravastatin. Pravastatin is a commonly prescribed cholesterol medication that lowers the risk of heart disease and stroke; clotrimazole is commonly prescribed to treat skin infections; and tobramycin is commonly prescribed to treat eye infections and cystic fibrosis. Also as part of the agreements, the parties filed joint motions, which are subject to approval by the Court, to defer prosecution and trial on the filed charges for the three-year terms of the agreements or until after the criminal penalties are paid, whichever occurs later. During the multi-year investigation, the Antitrust Division and its law enforcement partners uncovered price-fixing, bid-rigging and market-allocation schemes affecting many generic medicines, and charged seven generic pharmaceutical companies for their participation in the schemes. With these newest agreements, all seven companies have resolved their criminal charges and collectively agreed to pay more than $681 million in criminal penalties. In June 2020, Glenmark was charged with one count of price fixing for its role in a conspiracy affecting the prices of pravastatin and other generic drugs. A grand jury returned a superseding indictment against Glenmark and Teva in August 2020 for the same and similar conduct. Count one alleged that Teva conspired with Glenmark, Apotex Corp. and others to increase prices for pravastatin and other generic drugs. Apotex admitted its role in this conspiracy and agreed to pay a $24.1 million penalty in May 2020. Count two charged Teva for its role in a conspiracy with Taro Pharmaceuticals U.S.A. Inc., its former executive Ara Aprahamian and others to increase prices, rig bids and allocate customers of generic drugs, including clotrimazole, a medicine used to treat skin infections. Taro admitted to its role in this conspiracy and agreed to pay a $205.7 million penalty to resolve that charge in July 2020. Aprahamian was indicted in February 2020 and is awaiting trial. Count three charged Teva for its role in a conspiracy with Sandoz Inc. and others to increase prices, rig bids and allocate customers of generic medicines, including cystic fibrosis medicine tobramycin. A former Sandoz executive pleaded guilty for his participation in the conspiracy in February 2020. Sandoz admitted to its role in the conspiracy and agreed to pay a $195 million penalty in March 2020 ...

The California Attorney General announced the sentencing of a Southern California doctor for an illegal prescription scheme that defrauded the state Medi-Cal program of over $20 million. Mohammed El-Nachef, M.D., was sentenced to five years in jail after entering a plea of guilty for prescribing medically unnecessary HIV medications, anti-psychotics, and opioids to over a thousand Medi-Cal beneficiaries in Los Angeles and Orange Counties. As part of his sentence, El-Nachef also paid $2.3 million in restitution and surrendered his medical license. The prosecution in this case was carried out by the California Department of Justice’s Division of Medical Fraud and Elder Abuse (DMFEA). El-Nachef served as the prescriber at two clinics - one in Anaheim and the other in Los Angeles - and carried out the prescription scheme from June 2014 to April 2016. In exchange for cash payments, he prescribed expensive medications to Medi-Cal beneficiaries who had no medical need for them. The medications were not kept or used by the beneficiaries, but were instead diverted to the illicit market for cash. He was accused of helping "two convicted felons, Steve Fleming and Oscar Abrons, in a scheme to obtain expensive pharmaceuticals that were sold on the illicit market," according to court papers filed by the state Attorney General’s Office. In September 2022, El-Nachef pled guilty in the Orange County Superior Court to one count of insurance fraud and one count of aiding and abetting the unauthorized practice of medicine. He will serve his five-year sentence split, with two years in the Orange County Jail and three years on mandatory supervision. DMFEA protects Californians by investigating and prosecuting those who defraud the Medi-Cal program as well as those who commit elder abuse. These settlements are made possible only through the coordination and collaboration of governmental agencies, as well as the critical help from whistleblowers who report incidences of abuse or Medi-Cal fraud at oag.ca.gov/dmfea/reporting ...

Kristina Raines and Darrick Figg, on behalf of themselves and a putative class, allege that they received offers of employment that were conditioned on successful completion of preemployment medical screenings to be conducted by defendant U.S. Healthworks Medical Group (USHW), who was acting as an agent of plaintiffs’ prospective employers. Raines received an offer from Front Porch Communities and Services (Front Porch) for a position as a food service aide, but the offer was conditioned on her passing the preemployment medical screening conducted by USHW. Raines alleges that she responded to most of the questions on the written questionnaire, but she declined to answer the question about the date of her last menstrual period. She alleges that the exam was then terminated, and Front Porch revoked its offer of employment. Figg received an offer from the San Ramon Valley Fire Protection District to serve as a member of the volunteer communication reserve, but his offer, too, was conditioned on his passing the preemployment medical screening conducted by USHW. Figg alleges that he answered all the questions, successfully passed the screening, and was hired for the position. Raines filed a state court action against Front Porch and USHW which the defendants removed to federal court. A second amended complaint added Figg as a named defendant, and dismissing Front Porch as a defendant (pursuant to a settlement) and adding other defendants. The third amended complaint, which is the operative complaint, alleges claims under the FEHA, the Unruh Civil Rights Act (Civ. Code, § 51 et seq.), unfair competition law (Bus. & Prof. Code, § 17200 et seq.), and the common law right of privacy. The named defendants were ultimately U.S. Healthworks Medical Group, a corporation; Select Medical Holdings Corporation, a corporation; Concentra Group Holdings LLC, a corporation; U.S. Healthworks, Inc., a corporation; Select Medical Corporation, a corporation; Concentra, Inc., a corporation; Concentra Primary Care of California, a medical corporation; and Occupational Health Centers of California, a medical corporation. Defendants moved to dismiss, and the district court granted the motion with prejudice as to all claims except plaintiffs’ unfair competition law claim. In dismissing plaintiffs’ FEHA claim, the district court concluded that the FEHA does not impose liability on the agents of a plaintiff’s employer. As to plaintiffs’ unfair competition law claim, the district court had granted dismissal without prejudice, but plaintiffs requested an order dismissing the claim with prejudice, and the district court granted their request. Plaintiffs then appealed the dismissal of their other claims. After holding oral argument, the United States Court of Appeals for the Ninth Circuit asked the California Supreme Court to answer the question "Does California’s Fair Employment and Housing Act, which defines ‘employer’ to include ‘any person acting as an agent of an employer,’ Cal. Gov’t Code § 12926(d), permit a business entity acting as an agent of an employer to be held directly liable for employment discrimination?" (Raines v. U.S. Healthworks Medical Group (9th Cir. 2022) 28 F.4th 968, 969.) The California Supreme Court concluded that "an employer’s business entity agents can be held directly liable under the FEHA for employment discrimination in appropriate circumstances when the business-entity agent has at least five employees and carries out FEHA-regulated activities on behalf of an employer." in the case of Raines v. U.S. Healthworks Medical Group -S273630 (August 2023). Section 12940 of the FEHA makes it an "unlawful employment practice" for "any employer" "to make any medical or psychological inquiry of an applicant" (§ 12940, subd. (e)(1)), and section 12926, subdivision (d) states that, for purposes of the FEHA, the term " ‘[e]mployer’ includes any person regularly employing five or more persons, or any person acting as an agent of an employer, directly or indirectly . . . ." "The most natural reading of this language is that a 'person acting as an agent of an employer' is itself an employer for purposes of the FEHA. Indeed, this interpretation accounts for and reasonably construes the word 'includes' (§ 12926, subd. (d)), a word that, in this context, can only be intended to broaden the scope of the term 'employer.' " And they went on to say "Of significance to our analysis, the FEPA’s 1959 definition of employer took its agent-inclusive language from the National Labor Relations Act (NLRA) (29 U.S.C. § 151 et seq.), a federal law that assures fair labor practices and workplace democracy. At that time, and still today, the NLRA provided that '[t]he term ‘employer’ includes any person acting as an agent of an employer, directly or indirectly.' " The California Supreme court therefore concluded that the "legislative intent leads us to conclude that the agent-inclusive language of section 12926, subdivision (d) permits a business-entity agent of an employer to be held directly liable for violation of the FEHA when it carries out FEHA-regulated activities on behalf of an employer." ...

For over 20 years Liberty Mutual has published the Workplace Safety Index (WSI). Liberty Mutual’s WSI estimates the top ten causes of the most serious workplace injuries - those causing an employee to miss more than five days of work - and ranks them by their direct costs of medical and lost-wage payments. The 2023 Liberty Mutual Workplace Safety Index (WSI) is based on information from Liberty Mutual, customized data from the U.S. Bureau of Labor Statistics Office of Safety, Health, and Working Conditions, and the National Academy of Social Insurance (NASI). U.S. industries spent $58.61 billion on the direct costs of worker injuries, and 82.2 percent of that cost ($48.15B) was for the top 10 causes of disabling injuries and illnesses. The 10 most costly causes of workplace injuries and illnesses are: 1) Overexertion involving outside sources - - Cost per year: $12.84B 2) Falls on same level - - Cost per year: $8.98B 3) Falls to lower level - - Cost per year: $6.09B 4) Struck by object or equipment - - Cost per year: $5.14B 5) Other exertions or bodily reactions - - Cost per year: $3.67B 6) Exposure to other harmful substances - - Cost per year: $3.35B 7) Roadway incidents involving motorized land vehicles - - Cost per year: $2.58B 8) Caught in or compressed by equipment or objects - - Cost per year: $1.98B 9) Slip or trip without fall - - Cost per year: $1.92B 10) Pedestrian vehicular incidents - - Cost per year: $1.61B One notable change is the presence of pedestrian vehicular incidents for the first time in the Index’s top 10. In addition to being a high-severity cause of loss, the BLS reported the highest number of these injuries in the previous 10 years, coupled with lower injury counts for most other causes of loss. Compared to last year’s WSI, total estimated industry cost reduced the most for Leisure & Hospitality (-16.8%; consistent with the economic contraction caused by COVID-19 in this sector), whereas Professional & Business Services and Healthcare & Social Assistance experienced an increase in total cost of 6.2% and 4.3%, respectively ...

Blue Shield of California announced a new pharmacy care model that is designed to fix problems in what it calls "today’s broken prescription drug system." The nonprofit health plan is transforming how medications are purchased and supplied to its 4.8 million members by selecting organizations that share Blue Shield’s vision for more affordable and transparent pharmacy services. Today’s announcement is a major milestone in Blue Shield’s Pharmacy Care Reimagined initiative, which will help provide its members with convenient, transparent access to medications while lowering costs. Once Blue Shield’s multi-year strategy is fully implemented, the health plan expects to save up to $500 million in annual drug costs. Most American adults take at least one prescription drug annually, with more than a third of adults taking at least three medications per year. Already a significant cost, total prescription drug spend in the United States is consistently rising. In 2021, the American healthcare system spent more than $600 billion on prescription drugs - about $1,500 per person, per year. The current pharmacy care system rewards some stakeholders for selling more drugs at higher costs. Blue Shield is seeking to transform the system into a value-based model that provides members with the medications they need at a more affordable cost. "The current pharmacy system is extremely expensive, enormously complex, completely opaque, and designed to maximize the profit of participants instead of the quality, convenience and cost-effectiveness for consumers," said Paul Markovich, president and CEO of Blue Shield of California. "That is why we are working with like-minded partners to create a completely new, more transparent system that gets the right drugs to the right people at the right time at a substantially lower cost." In today’s current pharmacy supply chain, there can be up to a dozen companies involved in the process from when a drug is made to when a member receives it. Some can add complexity and cost without adding value or providing transparency into the rationale for their pricing. To simplify the system and cut unnecessary costs, Blue Shield has selected five companies with like-minded philosophical and technology standards to build a new, innovative model following regulatory approval. Together, Blue Shield will offer an integrated, coordinated, and holistic pharmacy experience to its members. - - Amazon Pharmacy will provide fast and free delivery of prescription medications, complete with status updates, as well as upfront pricing and 24/7 access to pharmacists. - - Mark Cuban Cost Plus Drug Company will establish a simple, transparent, and more affordable pricing model, reducing surprise drug costs at the pharmacy pick-up counter. - - Abarca will pay prescription drug claims quickly and accurately while continuing to evolve its technology platform, Darwin, to support new, simplified payment models. - - Prime Therapeutics will work with Blue Shield to negotiate savings with drug manufacturers to move toward a value-based model that aligns drug prices to patient efficacy and health outcomes. - - CVS Caremark will provide specialty pharmacy services for members with complex conditions, including education and high-touch patient support. "Amazon Pharmacy is thrilled to join Blue Shield of California in their effort to help members get the medications they need, when they need them, at a price they can afford," said John Love, vice president of Amazon Pharmacy. "With the help of Amazon’s upfront pricing, on-time delivery, and round-the-clock access to clinical care, we can provide a customer-centric pharmacy experience that supports better health outcomes." "Our company was built on a commitment to deliver transparent and affordable prescription drugs to everyone, and we are excited to collaborate with Blue Shield of California to change this part of the healthcare system in such an impactful and meaningful way," said Alex Oshmyansky, founder and CEO of Mark Cuban Cost Plus Drug Company. "We hope others will follow in the effort to fix this convoluted and inefficient prescription drug supply chain." ...

The Labor Commissioner’s Office has cited Flying Food Group more than $1.2 million for failing to timely rehire 21 employees who had been laid off during the COVID-19 pandemic once the caterer increased its business operations, and began hiring staff, as required by law. The impacted employees included 18 employees at Flying Food Group’s Los Angeles International Airport site and three employees at its San Francisco International Airport site who had been employed as station attendants, dishwashers, drivers, porters, equipment liquor set-up attendants, cooks and cook helpers. The Labor Commissioner’s Office started its investigation into the Inglewood-based airport catering company in November 2022 after receiving Reports of Labor Law Violation from Unite Here Local 11 on behalf of laid-off workers. The workers’ complaint stated they were not offered an opportunity to return to their jobs based on seniority when the catering group increased business operations in 2021. The investigation included interviews with workers, depositions from Flying Food Group’s Human Resources managers, and an audit of payroll records from April 16, 2021 to April 20, 2023. The investigation determined that Flying Food Group LLC DBA Flying Food Group had violated the Right to Recall law and the Labor Commissioner’s Office cited the catering company $1,190,500 in liquidated damages, $2,100 in civil penalties, and $27,730 in assessed interest for a total of $1,220,330. Liquidated damages and assessed interest will be paid to the workers upon collection. Civil penalties go to the State’s general fund. The law is specified in Labor Code 2810.8, and entitles each worker whose rights are violated liquidated damages of $500 per day until the violation is cured, as well as civil penalties against the employer of $100 for each employee whose rights are violated. Any employee suffering unlawful retaliation for asserting recall rights may also be awarded back pay, front pay benefits and reinstatement. The Right to Recall law went into effect on April 16, 2021, and runs through December 31, 2024. Covered workers include employees at hotels or private clubs with 50 or more guest rooms, airports, airport service providers and event centers. Also included are laid-off employees engaged in building services such as janitorial, maintenance and security services at retail and commercial buildings. The Department of Industrial Relations’ Division of Labor Standards Enforcement (California Labor Commissioner’s Office) combats wage theft and unfair competition by investigating allegations of illegal and unfair business practices. The Labor Commissioner’s Office in 2020 launched an interdisciplinary outreach campaign, "Reaching Every Californian." The campaign amplifies basic protections and builds pathways to affected populations, so workers and employers understand legal protections and obligations, as well as the Labor Commissioner’s enforcement procedures. Californians can follow the Labor Commissioner on Facebook and Twitter ...

Juan Lopez claimed injury to his cervical, thoracic, and lumbar spine, to his shoulders and arms, to his heart and lungs, and in the form of hypertension, HIV, and GERD , while employed by Barrett Business Services as a laborer during the period from December 23, 2009, through December 23, 2010 (ADJ7745966). He also claimed injury to his heart and blood system, and in the form of HIV and GERD while employed by the same Barrett on September 13, 2010 (ADJ7909061). By December 2014, the case had already been remanded by the Board on the issue of AOE/COE and assigned to a new WCJ after the prior WCJ had retired. The on-going litigation of this matter from December 2014 to the present included a number of additional times when the matter was continued or ordered off calendar for development of the record. The the case was submitted and the new WCJ issued an Opinion, and a Petition for Reconsideration was denied. At an MSC in September 2016 the defendant asked that the case be set for trial on all issues, and applicant asked for a continuance, which was granted, and at the next MSC in November 2016 defendant asked that discovery be closed and the case set for trial, but the WCJ to the matter off calendar for a PQME appointment. After a DOR was filed, a trial scheduled for February 6, 2018, but the applicant did not appear, and the case was continued. On April 24, 2018, the parties appeared, the matter was pending submission to allow post-trial briefs and submitted on May 14, 2018. On June 15, 2018, the WCJ vacated submission in part because the internal PQME deferred to an expert in infectious disease. At the second status conference after the submission was vacated the court issued an order for a panel qualified medical examiner in Infectious Disease. On February 7, 2019, the parties appeared for a status conference and no PQME panel had been issued because applicant's hearing representative "guessed" his office did not send the paperwork. The court continued the status conference. At the next status conference on May 2, 2019, the parties agreed to submit on the existing record. but the WCJ found that the record needed further development, At a continued MSC on August 19, 2021, the parties supplemented the existing record with the report of Dr. Vyas and the matter was submitted. On October 6, 2021, the court realizing the report submitted was not the internal medicine report the court had been waiting for and vacated the submission. Finally on May 10, 2023, the matter was tried and submitted. On May 22, 2023, the WCJ issued a Finding and Award which found applicant failed to meet his burden to show industrial injury on the disputed body parts. Applicant filed a Petition for Reconsideration in case number ADJ7745966, where the WCJ found that applicant did not sustain injury AOE/COE to his lungs or in the form of HIV (human immunodeficiency virus). And in case number ADJ7909061wherein the WCJ found that applicant did not sustain injury AOE/COE, to his heart and blood system nor in the form of HIV or GERD. Applicant contends the record should be further developed regarding applicant’s HIV injury claim. Reconsideration was denied in the panel decision of Lopez v Barrett Business Services -ADJ7909061-ADJ7745966 (August 2023). The WCJ and the Appeals Board have a duty to further develop the record where there is insufficient evidence on an issue. (McClune v. Workers’ Comp. Appeals Bd. (1998) 62 Cal.App.4th 1117, 1121-1122 [63 Cal.Comp.Cases 261]; see also Tyler v. Workers’ Comp. Appeals Bd. (1997) 56 Cal.App.4th 389, 394 [62 Cal.Comp.Cases 924].) However, if a party fails to meet its burden of proof by obtaining and introducing competent evidence, it is not the job of the Appeals Board to rescue that party by ordering the record to be developed. (Lab. Code, § 5502; San Bernardino Community Hospital v. Workers' Comp. Appeals Bd. (McKernan) (1999) 74 Cal.App.4th 928 [64 Cal.Comp.Cases 986]; Telles Transport Inc. v. Workers' Comp. Appeals Bd. (2001) 92 Cal.App.4th 1159 [66 Cal.Comp.Cases 1290].) The duty to develop the record must be balanced with the parties’ obligation to exercise due diligence to complete necessary discovery. (San Bernardino Community Hosp. v. Workers’ Comp. Appeals Bd. (McKernan), supra.) "In this case, the parties have submitted the case for decision three times and the WCJ has vacated submission three times.The medical record has not been developed as directed by the WCJ despite ample opportunity to do so." "Our review of the entire record (for the period from January 2011, to the present) clearly indicates that applicant was repeatedly given the opportunity to develop the record in support of his injury claims. As noted above, it is not our responsibility to rescue a party by ordering the record to be developed when that party has previously been provided ample opportunity to further develop the record." "Thus, applicant has not shown good cause, under the circumstances of this matter, to yet again, delay final resolution of applicant’s injury claims through further development of the record. Therefore, we will not disturb the WCJ’s F&A." ...

Frank Diaz claimed injury to his head, neck, back, shoulders, chest, ribs, hips, and buttocks, while employed by Pacific Coast Framers as a construction worker on April 16, 2020. On August 22, 2023, treating physician Dr. Miller issued an RFA wherein he requested a re-evaluation with neurologist, Dr. Nudleman, a re-evaluation with Dr. Salkinder, an ENG/VNG [electronystagmogrophy/videonystagmography] examination, six sessions of vestibular rehabilitation, a nurse evaluation for home care needs, and a request for 30-day inpatient at Casa Colina with physiatrist Dr. Patterson and neuropsychological evaluation with Dr. Elizabeth Cisneros. Regarding the 30-day Casa Colina inpatient request, Dr. Miller stated, "This is an expedited request." The August 31, 2022, UR recommendation, stated that the request was first received by State Compensation Insurance Fund on August 26, 2022, and was received by Genex (UR) on August 30, 3022. The UR recommendation certified/authorized the requested treatment except for the 30-day Casa Colina inpatient request that was non-certified. It also stated that Dr. Miller’s request for expedited review was not "accompanied by evidence reasonably establishing that the injured worker faces an imminent and serious threat to his ... health; or that the timeframe for utilization review under 8CCR 9792.9.1(c)(3) would be detrimental to the injured workers’ condition." The parties went to trial raising as one of the issues whether the UR denial, dated August 31st, 2022, in regard to PTP Dr. Lawrence Miller's RFA, dated August 22nd, 2022, was untimely inasmuch as applicant contends the RFA called for expedited review. The WCJ found that the August 31, 2022 Utilization Review [UR] was timely so the Appeals Board does not have jurisdiction to determine whether the medical treatment and services requested by Lawrence Miller, M.D., pertaining to the Casa Colina referral, is reasonably required to cure or relieve applicant from the effects of his industrial injury. Applicant's Petition for Reconsideration was denied in the panel decision of Diaz v Pacific Coast Framers -ADJ14244911 (August 2023). The Labor Code section 4610-time limits within which a UR decision must be made are mandatory. The Appeals Board has jurisdiction to determine whether a UR decision is timely. However, the Appeals Board does not have jurisdiction to address whether treatment requested in a timely UR decision is reasonably required. The "IMR process is the exclusive mechanism for review of a utilization review decision." (King v. CompPartners, Inc. (2018) 5 Cal.5th 1039, 1048 [83 Cal.Comp.Cases 1523]; Dubon v. World Restoration, Inc. (2014) 79 Cal.Comp.Cases 1298 (Appeals Board en banc).) Here, as explained by the WCJ: "Dr. Miller was required to document at the time of submission of the RFA, that the applicant is facing an imminent or serious threat to his health or safety or that the normal UR timelines would be detrimental to the applicant’s life or health and the reasons, therefore. Dr. Miller did not do so." "In total, between the two trials conducted in this case, applicant offered, and this Court admitted 22 separate exhibits. Of those exhibits, Applicant’s Exhibits 1 through 17 pre-date Dr. Miller’s report and RFA dated August 22, 2022. Despite Petitioner’s representation to the contrary, not one of those medical reports document that applicant is facing an imminent or serious threat to his health or safety or that applicant presented a danger to himself and to those around him. Further, none document that applicant required in-patient care at Casa Colina." Having reviewed the trial record, the WCAB Panel agreed with the WCJ that none of the reports from Dr. Miller constitute evidence that applicant’s condition was an imminent and serious threat to his health that would warrant the 72-hour expedited review delineated in AD rule 9792.9.1(c)(4) ...

In 2020, Allstate Insurance Company and several of its affiliates filed two qui tam actions alleging insurance fraud in violation of the California Insurance Frauds Prevention Act (IFPA) (Ins. Code, § 1871 et seq.) and the Unfair Competition Law (UCL) (Bus. & Prof. Code, § 17000 et seq.) against three medical corporations, a medical management company and its parent company, four physicians, and Sattar Mir, an individual. The first action was filed against Discovery Radiology Physicians, P.C., a professional medical corporation; Mir; and radiologists Drs. Safvi and Feske. The second action was filed against Mir; OneSource Medical Diagnostics, LLC, a medical management company owned by Mir; 1st Source Capital, LLC, OneSource’s parent company; Safvi Medical Corporation and Expert MRI, P.C., professional medical corporations; and radiologists Drs. Safvi, Mazhar, and Khan. The complaints alleged that the three medical corporations - Discovery Radiology, Expert MRI, and Safvi Medical - were formed and controlled by Mir, who is not a physician, to broker radiology services. The medical corporations solicited patients, referred the patients to MRI facilities and radiologists with whom Mir had contracted, and then billed Allstate for the MRIs. The bills represented that the MRIs had been performed by the defendant medical corporations, but the MRIs actually were performed at MRI facilities whose identities were not disclosed, and were read by radiologists under contract with the medical corporations. The resulting bills falsely identified the technical and professional services as having been provided by one of the three defendant medical corporations and grossly inflated the fees for the services provided. Demurrers were filed to amended complaints by the defendants in both actions. The trial court sustained the demurrers without leave to amend. It found, first, that Allstate did not comply with the court’s prior order because it did not identify the dates of each allegedly false bill, the persons or entities who prepared the bills, the persons or entities who transmitted the bills to Allstate, or which defendants made each alleged false statement. Second, the court found the complaints "woefully lacking in the required specificity." The trial court also said it was insufficient for Allstate to "invoke the mantra of 'structural fraud.' Importantly, Allstate makes no claim here that: (1) MRIs were not administered; (2) MRIs were not medically necessary; or (3) qualified radiologists did not read the MRIs. . . . [¶] . . . [Instead, Allstate argues] that this case involves the unlawful corporate practice of medicine and that ‘Mir engaged in the unlawful practice of medicine." The Court of Appeal reversed in the Published case of P. ex rel. Allstate Ins. Co. v. Discovery Radiology etc. -B315264 (August 2023). This appeal presents four basic issues: (1) Are the business models alleged in the amended complaints unlawful? (2) If the alleged business models are unlawful, do they give rise to causes of action under the IFPA and the UCL? (3) Do the amended complaints plead fraud with sufficient particularity? (4) Does the Discovery action adequately allege delayed discovery to survive demurrer on statute of limitations grounds? The answer to each of these questions was "yes." First, the operative complaints allege the unlicensed practice of medicine in violation of the Medical Practice Act (§ 2000 et seq.) and related statutes. Second, claims submitted to an insurer for medical services rendered in violation of the Medical Practice Act may give rise to causes of action under the IFPA and the UCL. Third, Allstate’s claims are pled with adequate specificity. Finally, as alleged, the claims asserted in the Discovery action are not time-barred as a matter of law. Defendants asserted , that the business practices alleged in the complaints were lawful because Mir and OneSource allegedly provided only managerial and/or administrative services, not medical care, and thus did not engage in the unlicensed practice of medicine. The Court of Appeal was not aware of any appellate decisions that have discussed the unlicensed practice of medicine in the specific context of referrals for radiology services. However, the Attorney General has twice opined that selecting a radiology provider involves the practice of medicine. In an opinion issued in 2000, the Attorney General stated that a management services organization may not, for a fee, select, schedule, secure, and pay for radiology diagnostic services ordered by a physician because that would constitute the unlicensed practice of medicine. Subsequently, in a 2009 opinion the Attorney General "reiterate[d] [its] view that professional radiology services - specifically including the selection of a suitable radiologist, and the selection of a suitable radiology facility with appropriate equipment and personnel, as well as preparing and interpreting radiological images - involve the exercise of professional judgment as part of the practice of medicine." (92 Ops.Cal.Atty.Gen. 56 (2009).) "The amended complaints state claims against each defendant for engaging in or assisting in the unlicensed practice of medicine because they allege an unlawful degree of control by non-physicians over the medical corporations’ provision of diagnostic radiology services." ...

The NLRB issued a decision in Stericycle Inc., adopting a new legal standard for evaluating employer work rules challenged as facially unlawful under Section 8(a)(1) of the National Labor Relations Act. The decision overrules Boeing Co. (2017), which was later refined in LA Specialty Produce Co. (2019). The new standard builds on and revises the Lutheran Heritage Village-Livonia (2004) standard. The Board had previously invited parties and amici to submit briefs addressing whether the Board should reconsider the Boeing standard. The former "Boeing Standard" established a new test: when evaluating a facially neutral policy, rule or handbook provision that, when reasonably interpreted, would potentially interfere with the exercise of NLRA rights, the Board will evaluate two things: (i) the nature and extent of the potential impact on NLRA rights, and (ii) legitimate justifications associated with the rule. Applying the new standard, the Board concluded that Boeing lawfully maintained a no-camera rule that prohibited employees from using camera-enabled devices to capture images or video without a valid business need and an approved camera permit. The Board majority reasoned that the rule potentially affected the exercise of NLRA rights, but that the impact was comparatively slight and outweighed by important justifications, including national security concerns. And pursuant to Boeing, the Board also announced that, prospectively, three categories of rules will be delineated to provide greater clarity and certainty to employees, employers, and unions. In Stericycle, Board explained that the primary problem with the Boeing and LA Specialty Produce standard was that it permitted employers to adopt overbroad work rules that chill employees’ exercise of their rights under Section 7 of the Act. Under that standard, an employer was not required to narrowly tailor its rules to promote its legitimate and substantial business interests without unnecessarily burdening employee rights. The Board also rejected Boeing’s categorical approach to work rules, under which certain types of rules were held to be always lawful, regardless of how they were drafted or what interests a particular employer cited in defense of the rule. Under the new standard adopted in Stericycle, the General Counsel must prove that a challenged rule has a reasonable tendency to chill employees from exercising their rights. If the General Counsel does so, then the rule is presumptively unlawful. However, the employer may rebut the presumption by proving that the rule advances a legitimate and substantial business interest and that the employer is unable to advance that interest with a more narrowly tailored rule. If the employer proves its defense, then the work rule will be found lawful to maintain. In line with this framework, the Board rejected the categorical approach of Boeing in favor of case-specific consideration of work rules. "Boeing gave too little consideration to the chilling effect that work rules can have on workers’ Section 7 rights. Under the new standard, the Board will carefully consider both the potential impact of work rules on employees and the interests that employers articulate in support of their rules. By requiring employers to narrowly tailor their rules to serve those interests, the Board will better support the policies of the National Labor Relations Act," said Chairman Lauren McFerran. Members Wilcox and Prouty joined Chairman McFerran in issuing the decision. Member Kaplan dissented. The NLRB's latest decision regarding workplace rules affects both unionized and non-unionized workplaces. The new standard will be applied retroactively, thus a workplace rule created under the Boeing Standard is likely unlawful. In his dissent, Member Kaplan, among other issues, argued that the "Board must not apply a new rule of decision retroactively - meaning in all pending cases in whatever stage - if doing so would work a manifest injustice. SNE Enterprises, 344 NLRB 673, 673 (2005). To determine whether retroactive application would cause manifest injustice, the Board considers 'the reliance of the parties on preexisting law, the effect of retroactivity on accomplishment of the purposes of the Act, and any particular injustice arising from retroactive application.' Id. Each of these considerations militates against retroactive application." Kaplan also lamented that "the full breadth of my colleagues' decision cannot be understood until the Board addresses the question of safe harbor language in future cases." ...

In August 2002, Michael Ayala was severely injured in a preplanned attack by inmates while at his job as a correctional officer at the Lancaster State Prison He filed a workers’ compensation claim and alleged that the injury was caused by the serious and willful misconduct of his employer, California Department of Corrections and Rehabilitation (CDCR). Labor Code section 4553 provides that '[t]he amount of compensation otherwise recoverable shall be increased one-half . . . where the employee is injured by reason of serious and willful misconduct" by the employer. Ayala and CDCR agreed that the injury caused Ayala 85 percent permanent disability, but they could not agree whether CDCR engaged in serious and willful misconduct. A WJC found that CDCR did not engage in serious and willful misconduct. However, on reconsideration, the Workers’ Compensation Appeals Board (the Board) rescinded the decision and reversed, finding that CDCR had engaged in serious and willful misconduct. Over a dissent, a Board majority found that CDCR "failed to act on a credible threat of inmate violence that was specifically reported to be planned for the day of the attack and took the facility off lockdown despite this threat even though it possessed additional information . . . that this had long been planned." The Board’s determination established Ayala’s entitlement to an additional 50 percent of "compensation otherwise recoverable" per section 4553. Ayala and CDCR disagreed, however, about what constituted the "amount of compensation otherwise recoverable" under that section. While he was temporarily totally disabled Ayala was paid his full salary because he was on industrial disability leave and enhanced industrial disability leave. However the WCJ found that the compensation upon which the penalty applies was what Ayala would have been paid in temporary disability. But on reconsideration, the Board again rescinded and reversed the workers’ compensation judge’s decision, this time finding that the base compensation was what Ayala was paid on industrial disability leave and enhanced industrial disability leave. The Court of Appeal reversed in the published case of Cal. Dept. Corrections & Rehabilitation v. Workers' Comp. App. Bd. -E079076 (August 2023). The Court of Appeal first noted Labor Code Section 3207, entitled "Compensation," which states that "‘[c]ompensation’ means compensation under this division and includes every benefit or payment conferred by this division upon an injured employee, or in the event of his or her death, upon his or her dependents, without regard to negligence." However it stated that the definition is "is as capacious as it is circular." "Equally unambiguous, though, is that industrial disability leave benefits are not 'compensation,' as such benefits are not provided by Division 4 of the Labor Code. They in fact are provided outside of the Labor Code altogether. Supplied by section 19871 of the Government Code, industrial disability leave is an alternative to temporary disability and is available to certain state officers and employees, such as those who are members of the Public Employees’ Retirement System (Gov. Code, § 19869)." Industrial disability leave provides an employee his or her full salary (net of certain taxes), but only for 22 days; after 22 days, the pay becomes two-thirds of full pay. (Gov. Code, § 19871, subd. (a).) However, a subset of eligible workers, defined in the Government Code as "excluded employees," are entitled to receive enhanced industrial disability leave. (Gov. Code, §§ 19871.2, 3527, subd. (b); Cal. Code Regs., tit. 2, § 599.769.) Enhanced industrial disability leave extends the period of full pay from 22 days to one year. (Gov. Code, § 19871.2.) If a worker continues to be temporarily disabled after industrial disability leave and enhanced industrial disability leave benefits terminate, then temporary disability payments begin. (Gov. Code, § 19874, subd. (a).) There is no ambiguity here. "Compensation," as the term is used in section 4553, includes only items provided by Division 4 of the Labor Code, but industrial disability leave is provided by the Government Code. Accordingly, the "amount of compensation otherwise recoverable" under section 4553 does not include industrial disability leave. However, the Board concluded that section 4553 base compensation includes industrial disability leave, mainly relying on Brooks v. Workers’ Comp. Appeals Bd. (2008) 161 Cal.App.4th 1522 . When the Court of Appeal decided Brooks it took the view that industrial disability leave equated to leave provided by the Labor Code. However in doing so Brooks construed a different statute, Labor Code section 4656, subdivision (c)(1), than does Ayala in this case. In Brooks the issue was whether the year of industrial disability leave payments the worker received counted toward the statute’s two-year limitation or whether the limitation period started only when industrial disability leave stopped and temporary disability payments began. To the extent that Brooks could be read as support for the proposition that any features of or limitations on temporary disability necessarily must apply to industrial disability leave because of the way industrial disability leave is defined "we respectfully disagree." "Compensation" under section 3207 "still requires that it be provided by Division 4 of the Labor Code, just as it always has." ...

Last month the Centers for Medicare and Medicaid Services (CMS) updated the Self-Administration Toolkit for Workers’ Compensation Medicare Set-Aside Arrangements (Toolkit) to version 1.4. If a Medicare beneficiary decided to self-administer their WCMSA, they should review the Self-Administration Toolkit for WCMSAs. This Toolkit describes the process and guidelines for beneficiaries managing their WCMSA account and walks them through the set-up of their WCMSA through its depletion (exhaustion). Also available are copies of the Account Expenditure for Lump Sum Account (Attestation Letter), Account Expenditure for Structured Annuity (Attestation Letter) and a Transaction Record Sample. Medicare beneficiaries can use the Transaction Record Sample (or a similar document) to keep track of all deposits to and withdrawals from their WCMSA account. The account expenditure letters are blank and can be used to submit the required annual attestation that the Medicare beneficiary correctly used the funds in the WCMSA account. This Toolkit: - - Describes the self-administration process and guidelines, from when you first set up the WCMSA bank account until all of its funds have been used. - - Explains who you will work with to manage your WCMSA account. - - Discusses the two types of WMCSA accounts, lump sum and structured. The lump-sum account is discussed first, and the Toolkit includes a section on Topics Unique to Structured WCMSA Accounts later on. - - Covers special circumstances, such as when your Medicare beneficiary status changes. A WCMSA may be funded in one of two ways. A lump sum, in which the beneficiary receives one check or deposit for the entire WCMSA, from their settlement. Or a structured settlement, in which the beneficiary receives an initial deposit and smaller annual payments in following years. Once a WCMSA account is set up, it can only be use it to pay for medical treatment or prescription drugs related to the beneficiary's WC claim, and only if the expense is for a treatment or prescription Medicare would cover. This is true even if the beneficiary is not yet a Medicare beneficiary (not yet enrolled in Medicare). If an item or service is not covered by Medicare, the beneficiary will have to pay for it themselves or with other insurance. WCMSA funds may not be used for services that Medicare does not cover. The WCMSA account may also be used to pay for the following costs when they are directly related to the account: - - Cost of copying documents - - Mailing fees/postage - - Any banking fees related to the account - - Income tax on interest income from the account Beneficiaries will need to keep clear and accurate records of everything they do with the WCMSA account. Medicare will use these records to determine if the account funds were spent properly ...

Freelance workers in the City of Los Angeles received more protections with the Los Angeles City Council’s adoption on February 24, 2023 of Ordinance 187782 which is intended to protect the Freelance industry. The new law became effective on July 1, 2023 and employers must now comply with the provisions of this ordinance. The Ordinance defines a Freelance Worker as "an individual natural person, or an entity whose legal and beneficial interests are held entirely and whose work is performed entirely by no more than one individual natural person, hired or engaged as a bona fide independent contractor to perform services for a Hiring Entity in exchange for compensation" with some exceptions to this definition. And a Hiring Entity is defined as "means an entity regularly engaged in business or commercial activity. A hiring entity is regularly engaged in business or commercial activity if the hiring entity owns or operates any trade or business, including a not for profit business, or represents itself as engaging in any trade, or business. A "Hiring Entity" does not include an entity that hires app-based transportation and delivery drivers to provide prearranged services." And the provisions of this new Ordinance apply to "a written or oral contract between a Freelance Worker and a Hiring Entity entered into on or after July 1,2023; and to work performed within the City by a Freelance Worker that is entitled to payment of $600 or more in a calendar year for the same Hiring Entity. If the Freelance Worker and the Hiring Entity fall under the provisions of this Ordinance, they must have a written agreement that includes, at a minimum, all of the following information: - - The name, mailing address, phone number, and, if available, email address of both the Hiring Entity and the Freelance Worker; - - An itemization of all services to be provided by the Freelance Worker, the value of the services to be provided pursuant to the contract, and the rate and method of compensation; and - - The date by which the hiring entity must pay the contracted compensation or the manner by which such date will be determined. A Hiring Entity must provide full payment to the Freelance Worker on or before the date specified in the written contract or, if the written contract does not specify a due date or if there is no written contract, no later than 30 calendar days after services are rendered. A Hiring Entity and Freelance Worker shall each retain written records related to this article for no less than four years, including contracts, payment records, and any other written or electronic records to demonstrate compliance. A waiver by a Freelance Worker of any provision in this article shall be deemed contrary to public policy and shall be void and unenforceable. A Freelance Worker may either file a civil action for violations under this Ordinance, or file a complaint with the Office of Wage Standards of the Bureau of Contract Administration within the Department of Public Works is the "Designated Administrative Agency" or "DAA." If a Hiring Entity fails to respond to the DAA’s request for information and/or documents within 20 calendar days, the Freelance Worker shall be entitled to a procedural rebuttable presumption in any subsequent civil action that the Hiring Entity committed the violations alleged in the corresponding complaint filed with the DAA. If the Freelance Worker prevails in a civil action, in addition to damages provided in the Ordinance, they are entitled to recover all reasonable attorney’s fees and costs, injunctive relief, and other remedies as deemed appropriate by a court. Employers should carefully read the entire Ordinance, and it would be wise to consult with legal counsel if you are unclear about the requirements of this Ordinance ...

The California Attorney General's office announced the arrest of and filing of charges against Dr. Arash Malian Padidar, a Santa Clara County physician with an office located at 105 N Bascom Ave Ste 104 San Jose, CA 95128. He is accused of illegally prescribing opioids to patients. The arrest and charges are the result of an investigation into an alleged two-years-long illegal prescription scheme by the California Department of Justice (DOJ). Padidar was arrested by DOJ agents and booked into the Santa Clara County Jail. DOJ investigators found that Padidar’s illegal prescription scheme was carried out between October 2018 and October 2020 and involved the highly addictive pain medication Norco. He is facing charges on seven felony counts, including for obtaining opioids by fraud, deceit and misrepresentation, issuing prescriptions without a legitimate medical purpose, forging the name of another physician who's name he allegedly obtained, and issuing a prescription, unlawful use of personal information and conspiracy to commit a crime. According to the allegations on the criminal complaint, Padidar wrote prescriptions that were given to an unnamed conspirator, who filled the prescriptions at several Wallgreen and other pharmacies, and then the unnamed coconspirator gave the pills back to Padidar. Padidar's alleged activity was uncovered when an employee who had helped with the scheme came forward a month or two after being fired by the doctor in July 2019, according to a criminal complaint filed with Santa Clara County Superior Court. The investigation and arrest were conducted by DOJ’s Division of Medi-Cal Fraud & Elder Abuse (DMFEA), which was alerted to the alleged crimes by the DEA. DMFEA protects Californians by investigating and prosecuting those who defraud the Medi-Cal program as well as those who commit elder abuse. These investigations are made possible only through the coordination and collaboration of governmental agencies, as well as the critical help from whistleblowers who report incidences of abuse or Medi-Cal fraud at oag.ca.gov/dmfea/reporting. DMFEA receives 75% of its funding from HHS under a grant award totaling $53,792,132 for federal fiscal year 2022-2023. The remaining 25% is funded by the State of California. The federal fiscal year is defined as through September 30, 2023. "Doctors are trusted with the immense responsibility of protecting our health and our lives," said Attorney General Bonta. "When a bad actor exploits their position for personal gain, they not only shatter our trust, they harm vulnerable patients. Let today’s arrest serve as a warning: The California Department of Justice will not tolerate abuses of power and will hold perpetrators accountable." "This investigation focused on a trusted member of the medical community who allegedly utilized forgery and fraud to obtain highly addictive opioids for his own personal benefit,” said Drug Enforcement Administration (DEA) Special Agent in Charge Brian M. Clark. "Healthcare professionals have a duty to prescribe controlled substances in a manner that ensures the well-being of the public. DEA will continue to keep communities safe and healthy by holding those accountable who put them in harm’s way. I want to thank CA DOJ Division of Medi-Cal Fraud and Elder Abuse and DEA Diversion for their exceptional work in this investigation." ...

Cal/OSHA announced it will be increasing its physical presence in Fresno, Santa Barbara and Riverside counties - allowing Cal/OSHA field inspectors to respond more efficiently in the Central Valley, Inland Empire and Central Coast areas, while providing services and resources to workers, employers and community-based organizations in these areas. The Division is setting up temporary satellite offices and is in the process of establishing permanent office locations in: - - Regional Office in Fresno - - High Hazard Office in Fresno - - District Office in Santa Barbara - - District Office in Riverside "While Cal/OSHA has been performing outreach and enforcement work in these regions, this planned expansion ensures a more permanent presence in these communities to serve as a resource for workers and employers," said Department of Industrial Relations Director Katie Hagen. "These new offices will represent an important step in continuing to scale our efforts to meet workers where they are and ensure their health, safety and rights are safeguarded." The additional office locations are prompted by operational needs and increased demand for responses to complaints, accidents and proactive high-heat inspections at workplaces in these areas, especially in high-hazard industries. Updates on these new offices will be posted on Cal/OSHA’s Enforcement Office location webpage. "We are working to secure office space and hiring is already underway," said Cal/OSHA Chief Jeff Killip. "We invite those who want to make a significant impact on workplace safety in California to join our dynamic team at Cal/OSHA. Our team is dedicated to ensuring that employees know their rights and that employers in our state provide safe work environments. If you want to make a difference, come join our team!" Cal/OSHA has openings for district managers, senior safety engineers, and associate safety engineers in the new Fresno, Santa Barbara and Riverside offices. Additionally, openings for industrial hygienists, public health professionals, attorneys, health and safety analysts and more will be posted soon. Those with biology, chemistry, toxicology or environmental science degrees are also encouraged to visit the Work at Cal/OSHA webpage and apply ...

Hospital acquisitions have consolidated care into fewer and larger health systems. From 2000 to 2020, the share of hospital beds that are part of health systems has risen from 58 percent to 81 percent nationally. A quarter of hospital markets no longer had any independent hospitals by 2020. A new study published by Elevance Health describes how prices, costs, and quality change when previously independent hospitals are acquired by systems. Hospital care is the largest segment in the $4.3 trillion U.S. healthcare sector, with $1.3 trillion in annual spending. Despite a decline in inpatient volume over the last decade, hospital spending as a share of the sector increased from 30 to 31 percent over this time. Most prior studies did not have access to negotiated prices between plans and hospitals, and therefore had to rely on average prices inferred from accounting data reported to the federal government. However, recent work has shown that these imputed prices are only weakly correlated with true prices. As a result, the new study draws conclusions about efficiency gains of the hospitals. Prior studies have not comprehensively evaluated the impact of efficiency gains for independent hospitals after acquisition. Hospitals experienced large cost efficiencies and higher revenues after system acquisition. - - Operating expenses declined by 6 percent, above market trend, at the acquired hospital following system ownership, without any offsetting increase in costs at the acquirer system. - - Reductions in personnel spending accounted for about 60 percent of the total decline in operating costs. - - Independent hospital acquisitions by hospital systems increased average inpatient prices for commercially insured patients by 5 percent above market trend, holding procedure intensity constant. - - Across the top seven Major Diagnostic Categories by volume, prices increased 5-8 percent, with digestive, infectious diseases, labor & delivery, respiratory, and the circulatory system experiencing the largest price increases. - - The size of the acquiring system size did not seem to matter with respect to price increases at the acquired hospital, suggesting that price increases were uniform at acquired independent hospitals. Hospital quality declined following acquisition, leading to worse outcomes for patients. - - For Elevance Health’s affiliated members receiving cardiac care, readmission rates increased by 10-12 percent and remained elevated for three years after the acquisition. - - Readmission rates for Medicare patients admitted with acute, non-deferrable conditions conservatively increased by 2-3 percent. - - Acquired hospitals that experienced greater staff reductions experienced greater readmission rate increases, suggesting the reduction in personnel may be a contributing factor. Access to care was generally reduced for patients at acquired hospitals. - - The study observed the closure of maternity wards, which were concentrated in rural hospitals. - - Given aforementioned price increases and staff reductions, one could expect a decrease in hospital patient volume, however the study did not detect a change. - - Access to medical technology did not change after acquisition. The Study Authors conclude by saying "This brief highlights that independent hospital mergers have negative consequences for insurers, employers, and consumers. Specifically, payers and patients are exposed to higher prices without a commensurate increase in quality of hospital care." "Further, access to care does not improve, with acquired systems no more likely to expand access to medical technology or services. Instead, patients are likely to experience a reduction in access to maternity wards and reduction in staff. As hospital mergers continue to occur at a high rate, it is important that stakeholders understand their implications." ...

The Fair Chance Act, which went into effect on January 1, 2018, is a California law that generally prohibits employers with five or more employees from asking about a job applicant's conviction history before making a job offer. California enacted the Fair Chance Act to reduce barriers to employment for individuals with conviction histories. The Fair Chance Act is part of California’s employment anti- discrimination statute called the Fair Employment and Housing Act (FEHA), which is enforced by the Civil Rights Department (CRD). The Fair Chance Act is codified at Government Code section 12952. For employers who are unfamiliar with this law, the the Civil Rights Council of the California Civil Rights Department has published an FAQ on its website. On July 24, 2023, the California Office of Administrative Law approved the California Civil Rights Council’s modifications to regulations which implement the California’s Fair Chance Act. The new regulations take effect on October 1, 2023, and employers are encouraged to understand and implement these changes before the deadline. Among the many changes to the regulations, is the requirement that if after a conditional offer of employment is made, and subsequently decides to deny the applicant the employment position " based solely or in part on the applicant’s conviction history," the employer must have made a reasoned, - and this must now under the new regulations be an "evidence-based determination" - of whether the applicant’s conviction history has a direct and adverse relationship with the specific duties of the job that justify denying the applicant the position. The new regulations then continue to provide detail on what may be taken into consideration in assessing the factors to determine whether the applicant’s conviction history has a direct and adverse relationship with the specific duties of the job that justify denying the applicant the position. Many of the new regulations help clarify employers obligations, and some new ones are added. These include expanded definitions which apply only to § 11017.1 "Consideration of Criminal History in Employment Decisions" such as: - - (1) "Applicant" includes, in addition to the individuals within the scope of the general definition in section 11008(a) of these regulations, individuals who have been conditionally offered employment, even if they have commenced employment when the employer undertakes a post-conditional offer review and consideration of criminal history; existing employees who have applied or indicated a specific desire to be considered for a different position with their current employer; and an existing employee who is subjected to a review and consideration of criminal history because of a change in ownership, management, policy, or practice. An employer cannot evade the requirements of Government Code section 12952 or this regulation by having an individual lose their status as an "applicant" by working before undertaking a post-conditional offer review of the individual’s criminal history. - - (2) "Employer" includes a labor contractor and a client employer; any direct and joint employer; any entity that evaluates the applicant’s conviction history on behalf of an employer, or acts as an agent of an employer, directly or indirectly; any staffing agency; and any entity that selects, obtains, or is provided workers from a pool or availability list. Employers are prohibited from including statements in job advertisements, postings, applications, or other materials that no persons with criminal history will be considered for hire, such as "No Felons" or "Most Have Clean Record." The new regulation also adds a description of evidence of rehabilitation or mitigating circumstances that an applicant voluntarily may provide to the employer. And in the event they do voluntarily provide such evidence, the new regulations added a provision prohibiting the employer from refusing "to accept additional evidence voluntarily provided by an applicant, or by another party at the applicant’s request, at any stage of the hiring process (including prior to making a preliminary decision to rescind the applicant’s job offer)" ...