The Division of Workers’ Compensation announced that medical providers who treat injured California workers can now have free online access to the State’s Medical Treatment Utilization Schedule (MTUS) guidelines.

“Medical providers in California should ensure that treatment decisions for injured workers are based on the best available evidence,” said George Parisotto, DWC Administrative Director. “By providing these guidelines free of charge, we are removing barriers that we expect will improve quality of care and reduce friction in the utilization review process.”

Licensed healthcare providers who treat California injured workers can use MDGuidelines: CA MTUS-ACOEM Edition to quickly search the latest evidence-based recommendations incorporated into the State’s MTUS. Providers who perform qualified medical evaluations, utilization review or independent medical review can also register to use the online tool free of charge.

The MTUS, a set of regulations based on the principles of evidence-based medicine, has adopted treatment guidelines developed by the American College of Occupational and Environmental Medicine (ACOEM). In most cases, medical treatment that is reasonable and necessary to cure or relieve an injured worker from the effects of injury means treatment that is based upon the ACOEM treatment guidelines. Providers must register in order to gain access to the site administered by the Reed Group. The site includes online training webinars and instructions. Users can email MTUS@reedgroup.com for more information.

The Division of Workers’ Compensation monitors the administration of workers’ compensation claims, and provides administrative and judicial services to assist in resolving disputes that arise in connection with claims for workers’ compensation benefits.

Decisions made by UR physicians are justified by evidence based medicine, which is derived from scientific medical studies.  A new study will help rule out compounded pain creams in most cases.

The new study reported by Reuters Health and published in the Annals of Internal Medicine suggests that compounded pain creams are no better for chronic pain than topical treatments that contain no medicine at all..The current study focused on pain creams made from medicines that are often prescribed for pain in pill form such as muscle relaxants, anticonvulsants and non-steroidal anti-inflammatory (NSAID) drugs.

In this study, researchers randomly assigned 399 patients with different types of chronic pain to receive either a compounded cream containing an analgesic or a placebo cream without any medicine.

After one month, 36 percent of patients who used pain creams and 28 percent who got placebo creams reported less pain than they had at the start, a difference that was too small to rule out the possibility that it was due to chance.

“We know from other studies that some of the agents (lidocaine, non-steroidal anti-inflammatory drugs) may be effective for certain types of acute and chronic pain, so it is surprising that the difference here did not reach statistical significance in any of the pain types,” said senior study author Dr. Steven Cohen, a pain researcher at Walter Reed National Military Medical Center in Bethesda, Maryland, and Johns Hopkins Medicine in Baltimore.

“This matters because compounded pain creams are much more expensive than prescribed (lidocaine, diclofenac) or over-the-counter (capsaicin) pain creams, but they didn’t provide meaningful benefit compared to placebo cream,” Cohen said by email.

All of the patients in the current study were treated at pain clinics at Walter Reed and had one of three types of pain syndromes. Within these three groups, patients were randomly chosen to receive either a compounded cream or a placebo cream.

One third of the patients had neuropathic pain, which happens due to nerve damage and includes phantom limb pain experienced by amputees. Patients in this group who got compounded creams received anticonvulsants.

Another third had so-called nociceptive pain, the most common kind that is often due to an injury or infection, not nerve damage. Patients in this group who got compounded creams received muscle relaxants and NSAIDs.

And one third had “mixed” pain caused by a variety of things; many of the compounded creams were similar to drugs provided for nerve damage or nociceptive pain.

When patients rated their pain levels on a 10-point scale, with 10 being the most painful, the average pain reductions reported by both compounded-cream users and the placebo group after a month were nearly identical. The difference between groups was 0.1 points for neuropathic pain and 0.3 points for both nociceptive and mixed pain.

Both the U.S. House of Representatives and the Senate have begun holding hearings this year on the rising costs of medicines. The government is intensifying its scrutiny of the pharmaceutical industry and rising prescription drug prices, a top voter concern and a priority of President Donald Trump’s administration.

U.S. Senator Bernie Sanders sent a letter to Catalyst Pharmaceuticals asking it to justify its decision to charge $375,000 annually for a medication that for years has been available to patients for free.

The drug, Firdapse, is used to treat Lambert-Eaton Myasthenic Syndrome (LEMS), a rare neuromuscular disorder, according to the letter, made available to Reuters by the senator’s office. The disorder affects about one in 100,000 people in the United States.

In the letter dated Feb. 4, Sanders asked Catalyst to lay out the financial and non-financial factors that led the company to set the list price at $375,000, and say how many patients would suffer or die as a result of the price and how much it was paying to purchase or produce the drug.

Catalyst declined to comment on Sanders’ letter.  Its shares fell nearly 8 percent to $2.31

For years, patients have been able to get the same drug for free from Jacobus Pharmaceuticals, a small New Jersey-based drug company, which offered it through a U.S. Food and Drug Administration (FDA) program called “compassionate use.”  The program allows patients with rare diseases and conditions access to experimental drugs outside of a clinical trial when there is no viable alternative.

Florida-based Catalyst received FDA approval of Firdapse in November, along with exclusive rights to market the medication for several years. The company, which bought rights to the drug from a company called BioMarin in 2012, develops and commercializes drugs for rare diseases.

BioMarin and FDA did not immediately respond to requests for comment.

In December, Catalyst announced it would price Firdapse at $375,000 a year.  “Catalyst’s decision to set the annual list price at $375,000 is not only a blatant fleecing of American taxpayers, but is also an immoral exploitation of patients who need this medication,” Sanders wrote in his letter.

Democratic Representative Elijah Cummings, chairman of the House Oversight Committee, in January wrote to 12 pharmaceutical firms asking for detailed information on how they set drug prices.

Democratic Representatives Frank Pallone and Diana DeGette wrote to the heads of Eli Lilly and Co, Novo Nordisk and Sanofi SA, the long-time leading manufacturers of insulin, requesting information on why the drug’s price has skyrocketed in recent years.

A Ventura County man has been sentenced to 168 months in federal prison for participating in a massive fraud scheme that used dozens of nonexistent companies to collect nearly $5 million in unemployment benefits for phony employees who never performed any work at the fake entities.

Jack Benjamin Hessiani, a.k.a. “Jack Herrera,” 40, of Camarillo, was sentenced today by United States District Judge John A. Kronstadt. Hessiani pleaded guilty in August 2018 to one count of mail fraud.

According to court documents, Hessiani created numerous fictitious businesses for the sole purpose of defrauding the Employment Development Department (EDD), the state agency that administers the federal unemployment insurance program in California.

After he and his co-schemers filed documents with EDD that showed made-up earnings for the fictitious workers, Hessiani and the co-schemers submitted claims for unemployment insurance benefits for laid-off “employees.” In fact, many of the “employees” were people who had agreed to provide their personal identifying information in exchange for a portion of the unemployment insurance benefits. Some of the benefit portions would go to drug users who likely used the funds to enable future drug purchases, while others were poor students who later faced criminal exposure as a result of the actions of Hessiani and his co-schemers, court papers state.

The unemployment benefits were sent in the form of checks and debit cards to “mail drops” that Hessiani and the co-schemers established in the names of other individuals, according to court documents. After EDD began issuing unemployment benefits, Hessiani ensured that documents were filed that falsely stated that the laid-off “workers” were still unemployed, and he later sought “extended benefits” to obtain unemployment insurance benefits for the sham workers beyond the normal six-month period. These extended benefits were ultimately funded by the United States Treasury.

According to court documents, Hessiani and his co-schemers submitted approximately 725 unemployment insurance claims – including 521 original claims and 204 claims for extended benefits – in the names of 384 “employees.” The investigation identified 43 fictitious companies based in Ventura County that were used to further the scheme, which caused EDD to suffer actual losses of $3.96 million and the United States Treasury to suffer actual losses of approximately $900,000. Hessiani enlarged his scheme by inducing the people whose names were already being used to obtain fraudulent benefits to “recruit” others who would be identified as additional false employees at the fictitious companies, and he paid referral fees for each new fake worker brought into the scheme.

Three other defendants in the case have pleaded guilty to criminal charges and are pending sentencing. They are Hessiani’s brother, James Manuel Herrera, 30, of Camarillo; Eduardo Josue Garcia, 27, of Camarillo; and Daniel Ayala-Mora, 29, formerly of Camarillo.

The Division of Workers’ Compensation has posted the 2018 DWC Audit Unit annual report on its website. The annual report provides information on how claims administrators audited by the DWC performed and includes the Administrative Director’s ranking report for audits conducted in calendar year 2017.

The 2018 Audit Unit annual report details the results of audits conducted in 2017 and provides the name and location of each insurer, self-insured employer, and third-party administrator audited during that time.

The DWC Audit & Enforcement Unit completed 41 profile audit reviews (PAR audits). Of the PAR audits, 40 were routinely selected and there was 1 target audit, which would have been conducted based upon failure of a prior audit. The total number of PAR audit subjects included 5 insurance companies, 11 self-administered / self-insured employers, 21 third-party administrators (TPA), and 4 insurance companies / third-party administrators combined claims adjustinglocations.

Thirty-seven audit subjects (90%) met or exceeded the PAR 2017 performance standard and therefore had no penalty citations assessed in accordance with Labor Code section 129.5(c) and CCR, Title 8, Section 10107.1(c)(4). These audit subjects were, however, ordered to pay all unpaid compensation.

Four audit subjects (10%) failed to meet or exceed the PAR standard and their audits expanded into a full compliance audit of indemnity claims (FCA stage 1). One of these audit subjects (25% of those failing to meet or exceed the PAR standard) met or exceeded the FCA 2017 performance standard and therefore had penalty citations assessed for unpaid and late payment of indemnity in accordance pursuant to Labor Code section 129.5(c)(2) and CCR, Title 8, Sections 10107.1(d).

The remaining three of the four audit subjects (75% of those failing to meet or exceed the PAR standard) failed to meet or exceed the FCA 2017 performance standard and their audits expanded into full compliance audit of indemnity claims (FCA stage 2) and added a sample of denied claims to be audited. These audit subjects were assessed administrative penalties for all penalty citations in accordance with Labor Code section 129.5(c) and CCR, Title 8, Section 10107.1(d) and 10107.1(e).

The audit findings, by law, must detail the number of files audited, the number and type of violations cited, and the amount of an undisputed compensation found due and unpaid to the injured worker. The audit findings presented in this report are statistical and do not identify any individual injured worker. The Labor Code provides that contents of the claim files and the Audit Unit working papers are confidential.

The DWC Administrative Director’s 2017 Audit Ranking Report is part of this annual report. The Ranking Report provides the performance ratings for the 41 audit subjects listed in order, from the best to worst performer.

Congratulations to Zenith Insurance Company – Pleasanton for having the best score in the Ranking Report.  The ranking of the remaining 40 organizations are listed by name on the Ranking Report.

Performance of insurers, self-insured employers, and third party administrators subject to profile audit review and full compliance audit is rated in accordance with the performance standards set annually by the Administrative Director. The DWC Administrative Director’s 2018 Audit Ranking Report lists, in ascending order by performance rating, the administrators audited in calendar year 2017.