Menu Close

Tag: 2013 News

DWC Says RBRVS Fee Schedule Takes Effect In 2014

WorkCompAcademy

The Division of Workers’ Compensation will begin using a resource-based relative value scale (RBRVS) based physician fee schedule in 2014. On September 24, the OAL filed the Physician Fee Schedule with the Secretary of State which will be published in the California Code of Regulations. The adopted Physician Fee Schedule regulations are effective January 1, 2014, and will be applicable for services rendered on or after January 1.

“These regulations will provide a more responsive framework for appropriate medical care and returning injured employees to work,” said Christine Baker, the director of the Department of Industrial Relations.

“Adopting a payment schedule based on the RBRVS will increase fairness in reimbursement across the spectrum of medical services, help to reduce disputes regarding the reasonable value of medical services, and improve injured workers’ access to the most needed medical services,” said Dr. Rupali Das, Executive Medical Director of DWC.

In the RBRVS-based system, relative value units interact with payment ground rules and the conversion factor to determine the maximum fee in light of the resources to provide the service. Senate Bill 863 directs DWC’s administrative director to adopt a physician fee schedule based upon the federal RBRVS used in the Medicare payment system.

The Physician Fee Schedule will be updated before January 1, 2014, by Administrative Director Order, in accordance with Labor Code §5307.1(g)(2), to reflect 2014 changes in procedure codes, relative weights, and the adjustment factors in subdivision (g) (the Medicare Economic Index and any relative value scale adjustment factor), to be applicable for services rendered on or after January 1, 2014. The Administrative Director Order will be issued as soon as possible after CMS adopts the 2014 Medicare Physician Fee Schedule final rule. CMS usually publishes the Physician Fee Schedule final rule approximately the first of November.

This RBRVS based Physician Fee Schedule will be applicable for services rendered on or after January 1, 2014, instead of the earlier OMFS physician fee schedule. The earlier OMFS physician fee schedule has not been updated with new codes and relative value units since 1999. This newly adopted physician fee schedule uses current procedure codes and relative values, and provides a mechanism for annual updates to reflect changes in coding, practice patterns, and inflation.

View More

Obamacare Opens to Crashing Websites and Grumbling Users

WorkCompAcademy

As tech launches go, Obamacare has been pretty bumpy, if not a downright Fail Whale-style debacle according to a report in Bloomberg Businessweek. The federally run website was unresponsive for much of Tuesday morning, and only four of 15 exchange websites being run by states and the District of Columbia were working from 9:30 a.m. to 10:30 a.m. In the days before the launch, meanwhile, insurers complained about errors in the premiums that shoppers would see online and certain functions had to be delayed because the software that determined eligibility remained a work-in-progress.

“Like every new law, there will be glitches we’ll fix,” President Obama said during a Rose Garden speech. “This morning the [federal] site has been running more slowly than it normally will. The reason is more than one million people visited healthcare.gov before 7 this morning. There were five times more users this morning than had ever been on healthcare.gov at one time.”

The San Jose Mercury News reported that the widely anticipated rollout of California’s online health insurance exchange witnessed sluggish access and spotty problems Tuesday, but that didn’t stop state officials from labeling it “a historic day” that will begin to allow millions of Californians to access quality health care for the first time. For many, the array of plans and prices offered under Obamacare proved to be a welcome surprise, but others experienced sticker shock from significantly higher costs.

On the first day of a six-month open enrollment period, the California website received one million page views in the first hour, followed by 800,000 page views every hour after, according to Covered California staff. The computer system that was designed to accommodate 2,000 concurrent users was getting 3,000, officials said, while the exchange’s two operative call centers in the state received nearly 9,000 calls by noon. But there were problems. Users reported “horrendously slow” response times, with Web pages sometimes never loading. Some of the problems mimicked those around the country, where a combination of high demand and technical glitches seemed to overwhelm other online systems early in the day. But California’s exchange didn’t crash.

Covered California officials estimate that during the initial open-enrollment period, which ends March 31, they will enroll 500,000 to 700,000 Californians who are eligible for subsidies to make their care more affordable.

New York officials said roughly two million people had visited their state-run site by mid-afternoon.

However, Washington state residents going to their state-run exchange were greeted with the words “Connection Refused.” Officials said the problems impacted only some visitors, but the site appeared down into Tuesday evening.

In Oregon, which has one of the country’s 16 state-based exchanges, ;glitches also materialized.Visitors were told: “Online enrollment is coming soon! Sign up to receive an email notification when it’s available.” Officials had warned earlier this week visitors would need an insurance agent or another third party to sign up in the first several weeks.

View More

CAAA Announces New Officers For Coming Year

WorkCompAcademy

The California Applicants’ Attorneys Association (CAAA) announced that it has installed a new president and team of officers for the coming year. Incoming CAAA President Jim Butler of ButlerViadro, a Bay Area firm specializing in fighting for the rights of California’s injured workers, said his priorities would include “bringing out-of-control Utilization Review (UR) to heel, building strategic alliances with like-minded organizations to address workplace injuries, improving CAAA’s communication with our members and the outside world, and strengthening the rules of professional conduct as applicable to workers’ compensation advocates. CAAA is urging stronger standards for all parties to the workers’ compensation system, and strengthening penalties for unreasonable delay and denial of recommended medical treatment and approved disability compensation.”

Mr. Butler was born in Compton, California, the son of an attorney who represented plaintiffs in pharmaceutical malpractice and product liability cases. He lived in Central America for several years, and is fluent in Spanish.

Mr. Butler earned his law degree at the University of San Francisco. While in law school, he received awards for best brief and oral argument for the school’s Moot Court Competition. He has also received the American Jurisprudence Award in Professional Responsibility. He graduated with a Bachelor of Arts in rhetoric from the University of California at Berkeley. Butler is the author of the Injured Worker Survival Guide (1987 – 1995).

“CAAA has built a powerful digital platform over the past three years, and we will focus its power on improving our internal and external communications, and to distribute our education programs. As the premier workers’ compensation education provider, we want to make our expertise available to all interested parties to improve the treatment of injured workers,” said Butler. “We invite visitors to caaa.org, and we will be making some of our programs available there for free; For example, right now the public will find a free podcast on Independent Medical Review.”

CAAA’s leaders for 2013-2014 also include Larry Stern of Mallery and Stern as Legislative Chair, Bernardo De La Torre of the Law Office of Bernardo De La Torre, Bert Arnold of Boxer and Gerson as Treasurer and, Christel Schoenfelder of Rose, Klein and Marias as Secretary.

View More

DWC Proposes New UR/IMR Regulations

WorkCompAcademy

The Division of Workers’ Compensation (DWC) has posted a 15-day notice of modification to the proposed utilization review (UR) and independent medical review (IMR) regulations to the DWC website. Members of the public are invited to present written comments regarding the proposed modifications to dwcrules@dir.ca.gov until 5 p.m. on October 11. The number of proposed changes are extensive. The following are some examples.

The new proposed rules set forth a revised Request for Authorization form (DWC Form RFA), emphasizing that it must be signed by the employee’s treating physician. There is a statement on the DWC Form RFA that it is not a separately reimbursable report under the Official Medical Fee Schedule.

One of the proposed changes that may be of concern to claim administrators is Section 9792.9.1(c)(2), Under this proposed language, a non-conforming request for authorization (i.e., an incomplete Form RFA or request that does not use the form) must be returned to the requesting physician within three business days or else be considered as complete and subject to all applicable timeframes and requirements. This provisions would seem to place a substantial burden on claim administrators. It would seem that a Request for Authorization buried in any document forwarded by a treating physician would have to be identified (by reading carefully every single word in the document) and then this obscure language would rise to the level of an official Request for Authorization unless the administrator objected in three days. It is difficult to see how a claim department could meet this burden.

Section 9792.10.4 of the proposed changes allow the independent review organization delegated the responsibility by the Administrative Director to conduct independent medical review pursuant to Labor Code section 139.5 (IMRO) may consolidate two or more eligible applications for independent medical review by a single employee for resolution in a single determination if the applications involve the same requesting physician and the same date of injury.

The new proposed regulations implement new procedures to impose sanctions. Section 9792.10.6(j) provides that upon receipt of credible information that the claims administrator has failed to has failed to comply with its obligations under the independent medical review requirements the Administrative Director shall, concurrent or subsequent to the issuance of the final determination issued by the independent review organization, issue an order to show cause for the assessment of administrative penalties against the claims administrator under new section 9792.12(c). Section Section 9792.10.7 provides that upon receipt of credible information that the claims administrator has failed to implement the final determination, the Administrative Director shall issue an order to show cause for the assessment of administrative penalties against the claims administrator under new section 9792.12(c).

Section 9792.12(c) is a new subdivision to provide for Independent Medical Review Administrative Penalties. The subdivision lists specific violations and the amount to be assessed as an administrative penalty for each.

The notice, text of the regulations, and forms can be found on the proposed regulations page.

View More

Researchers Find Little “Rhyme or Reason” Behind Physician Reimbursement

WorkCompAcademy

Private insurance companies across the U.S. pay doctors dramatically different amounts for the same routine office visits and services, according to a new study reported by Reuters Health. Physicians at the high end of the reimbursement spectrum get more than twice as much as those at the low end for the same service, with little apparent reason for the difference, researchers say.

“We figured that if we looked at fairly similar office services across clinics, the amount received by doctors might not vary much,” said Laurence Baker, co-author of the study and chief of health services research at Stanford University in California. “But that was not true.”

In the push to contain healthcare costs, focusing on how much care patients use won’t solve the problem unless the market forces determining what doctors charge and what insurers pay are better understood, Baker and his colleagues write in the journal Health Affairs. Unlike other health care cost studies, theirs looks at actual reimbursement amounts to physicians, and not the amount billed.

The researchers analyzed more than 40 million claims filed in 2007 for nearly a dozen types of service ranging from five-minute check-ups to comprehensive exams. The most common claim filed was for a “problem-focused” exam lasting about 15 minutes with a patient the physician already knew. The lowest-paid 5 percent of doctors received $47 or less for the visit while the highest-paid 5 percent received $86 or more. The average reimbursement amount was $63. For more complex, yet identical, office visits lasting longer and involving a new patient, the reimbursements ranged from $103 or less to $257 or more.

The price differences couldn’t be explained by the patients’ age or sex, the physicians’ specialty, the patients’ insurance plan type – preferred provider organizations (PPO) or point of service (POS) – or whether the physician was in the plan’s network. Geographic location accounted for some of the price variation, but only about one-third of it. Even with location taken into account, researchers could not pinpoint differences among specific cities because Truven Health Analytics, the company that provided the data, did not allow precise location information to be published in the study. “The point is that (there is) very little that can explain these price differences, no matter what information you put into the model,” Dr. Renee Hsia, professor of emergency medicine at the University of California at San Francisco, told Reuters Health. “There is not much rhyme or reason as to why the prices are what they are,” Hsia, who was not involved in the research, said.

Baker suggested that some variables, such as the quality of service provided by physicians, or the market power of insurance companies, could influence payments, but these were not analyzed in the study. “The take-away message is to get a quote before you go to the doctor’s office and consider shopping around,” said Chapin White, a senior health researcher at Center for Studying Health System Change in Washington, D.C.

Comparison shopping on cost isn’t easy for consumers, however, because the information is not readily available. Companies trying to bring price information to the public include the San Francisco-based startup Castlight and FAIR Health in New York City. “We think it is important to push future analyses further to include information we were not able to look at here,” Baker told Reuters Health. For example, the team did not know the size of the physicians’ practices. Larger practices may be able to command higher reimbursements, he said.

View More

Medical Identity Theft Increased by 19%

WorkCompAcademy

A new study reported in SC Magazine says that as the number of individuals impacted by medical identity theft continues to climb, so does the number of victims fooled by spurious emails and websites designed to purloin their sensitive information.

According to the “2013 Survey on Medical Identity Theft,” the number of people who’ve fallen victim to this type of fraud has increased by 19 percent since last year, accounting for more than 1.8 million victims in 2013. More than 300,000 new medical identity theft cases cropped up during the one-year period, the study found. The survey was conducted by the Ponemon Institute and sponsored by the Medical Identity Fraud Alliance (MIFA) and data breach prevention firm ID Experts.

The study, in its fourth year, surveyed nearly 800 adults in the U.S. who self-reported that they, or their close family members, were victims of medical identity theft.  Along with the rise in medical identity fraud, experts also saw a significant uptick in dubious websites being erected by saboteurs and spam emails being sent – all with the intent of tricking individuals into giving up their medical information.

Between 2012 and 2013, the percentage of medical identity theft victims reporting spoofed websites and phishing emails as the likely cause of their troubles doubled. This year, eight percent of respondents cited the cyber schemes as the cause of their issues, while only four percent of victims reported the same in 2012.

In the report, medical identity theft was defined as a person using an individual’s name or personal identity “to fraudulently receive medical service, prescription drugs and goods, including attempts to commit fraudulent billing.”

Larry Ponemon, chairman and founder of the Ponemon Institute, told SCMagazine.com earlier this week that in this study, and in other Ponemon studies, the frequency of spear phishing targeting medical identity theft victims has gone up. Furthermore, spear phishing, attempts to infiltrate an individual’s network or steal their data by crafting a targeted ruse they are likely to open via email, is likely under-reported among medical identity theft victims, Ponemon added.

“A lot of people aren’t even aware that they have fallen for a phishing scam because they were so sophisticated,” he said. “The ability to record it is difficult because people aren’t even aware that it’s happened to them.”

In the study, the groups also found that seven percent of medical identity theft victims believed a data breach suffered by their health care provider, insurer or related organizations, was the cause of fraud. Last year, six percent of respondents cited those reasons as the cause.

View More

Fed Panels Agree on Drug Compounding Bill

WorkCompAcademy

House of Representatives and Senate committees have agreed on legislation that would give the Food and Drug Administration greater authority to regulate companies that compound sterile drugs and ship them across state lines. The legislation would also create a national set of standards to track pharmaceuticals through the distribution chain to help thwart the introduction of fake medication into the drug supply.

Reuters Health reports that the bill, called the Drug Quality and Security Act, comes in response to a deadly outbreak last year of fungal meningitis that killed more than 50 people and was traced to a tainted steroid sold by the New England Compounding Center in Framingham, Massachusetts.

The legislation is expect to pass smoothly and quickly through the full House and Senate.

Traditionally, pharmacists who compound medication mix tailored doses for individual patients in response to specific prescriptions. Over the last decade the practice has mushroomed, with some pharmacies selling thousands of doses of regularly used mixtures without prescriptions for physicians to keep for future use. The legislation would draw a distinction between traditional compounding pharmacies and those such as NECC which ship sterile products across state lines. These larger organizations, to be known as “outsourcing facilities,” would be regulated by the FDA but be exempt from the full spectrum of regulations that apply to traditional pharmaceutical companies. Traditional compounding pharmacies would continue to be regulated by state boards of pharmacy.

Previous attempts to create national standards to track and trace drugs have foundered amid complaints from companies that they would be too costly to implement. But concerns over counterfeit drugs have been growing. Last year, fake vials of Roche Holding AG’s cancer drug Avastin appeared in the United States from Britain where it was purchased from a Turkish wholesaler.

The World Health Organization estimates that less than 1 percent of medicines available in the developed world are likely to be counterfeit. Globally, that number is around 10 percent.

In the United States, dozens of states have some type of regulation designed to track a drug’s pedigree, but the rules are inconsistent. The bill is designed to resolve the current patchwork of federal regulation by applying a uniform standard nationwide.

View More

Sexual Conviction Restricts L.A. Orthopedic AME/QME Medical License

WorkCompAcademy

Fred F. Hafezi, M.D. is currently listed on the DWC QME database as a spine specialist with offices in Azusa and Ontario California. The Medical Board of California reflects that he holds Physicians and Surgeons certificate G19337 originally issued in October 1970. The Board records reflect that he is certified in Orthopedic Surgery.

Medical Board records also reflect that on June 25, 2013 the office of the Attorney General of California filed an Accusation against Dr. Hafezi asking that the Board revoke or suspend his Physician and Surgeon’s Certificate,

In support of this request, the Accusation alleged that “on April 25, 2013, in the case of The People of the State of California v. Farhad Fred Hafezi, Los Angeles County Superior Court case number KA090841, Respondent (Hafezi) was ordered, as part of his sentence, to register as a sex offender pursuant to the provisions of Penal Code section 290. As a result of his being ordered to register as a sex offender, Respondent’s Physician’s and Surgeons’ Certificate No. 019337 is subject to mandatory revocation pursuant to the provisions of Business and Professions Code Section 2232.”

The Accusation continues to allege the circumstances of the criminal prosecution. “Respondent was charged with several counts of oral copulation, contact with a minor with intent to commit a sexual offense, unlawful sexual intercourse with a person under the age of 18, all violations of the Penal Code. On April 1, 2011, Respondent did an “open plea” and pled nolo contendere to all 4 counts. Then on May 26, 2011, Respondent withdrew his plea of guilty. On April 5, 2013, the court denied Respondent’s motion to withdraw his guilty plea. As a result of his plea, he now stands convicted of several counts of oral copulation and a count of unlawful sexual intercourse with a person under 18. Respondent was sentenced on May 23, 2013. Imposition of sentence was suspended, and Respondent was placed on formal probation for 36 months, ordered to serve 180 days in the Los Angeles County Jail and required to register as a sex offender pursuant to Penal Code section 290. Respondent is currently out of jail as he was given credit for time served for his county jail sentence.”

On August 6, 2013, while being represented in the Matter of the Accusation by the Law Offices of Richard A. Moss, Hafezi and his attorney signed a Stipulation for Restricted Practice. The purpose of the Stipulation was to restrict his Physicians and Surgeons certificate pursuant to Government Code section 11529.

Pursuant to the Stipulation, on August 16, Hafezi was ordered to “cease performing any activity for which a license as a physician is required in the State o! California with the sole and singular exception he may complete reports on patients seen as workers compensation referrals who were referred to him prior to the date of endorsement of this Stipulation by the administrative law judge.”

It is further stipulated and agreed that the Stipulation would be posted on the Boards website as a public document. The Stipulation is to remain in effect until completion of the administrative proceedings against him, and the issuance of a final decision of the Medical Board thereon.

A Medical Board “Action Report” dated July 1997 reflects prior discipline for Dr. Hafezi based upon Business and Professions Code §2234(b)(c)(d) “Negligent and incompetent treatment of a patient with a back injury.”

View More

FSK Employment Law Conference Set for November 7

WorkCompAcademy

Floyd, Skeren and Kelly LLP is pleased to announce its Northern California Annual Employment Law Conference, which will feature keynote speakers Christine Baker, Director of the Department of Industrial Relations and Phyllis W. Cheng, Director of the California Department of Fair Employment and Housing (DFEH).

The conference will be held on November 7, at the South San Francisco Conference Center.

This is an all-day event, designed for employers, managers, claims adjusters, risk managers, attorneys, and any other professionals associated with human resources and employment law. The conference will provide helpful guidance related to numerous workplace topics, including: the new California disability regulations (which impact an employer’s policies on reasonable accommodation, the interactive process and leaves of absence); the new comprehensive pregnancy disability regulations; a workers’ compensation update, focusing in on the latest developments related to SB 863; an overview of important OSHA workplace requirements and procedures; a review of 6 critical steps an employer can take to avoid costly employment related lawsuits; and, an update on the evolving role of social media in the workplace.

Ms. Cheng will discuss the important new disability and pregnancy regulations in effect as of January 2013. The new disability regulations significantly expand the protections for disabled workers and set forth new employer obligations and requirements related to disability discrimination, reasonable accommodation, the interactive process, job descriptions, and medical certifications. The new pregnancy disability regulations greatly expand the protections afforded to employees disabled by pregnancy including new notice requirements and an expanded list of conditions that constitute a pregnancy disability. Ms. Cheng will review key provisions of the new regulations, what is new for employers, the DFEH’s enforcement perspective, and employer best practices for ensuring compliance.

Ms. Baker will co-present with David W. O’Brien, Esq., Retired Workers’ Compensation Administrative Law Judge. They will provide a workers’ compensation update focusing in on the latest developments pertaining to SB 863 and new case law.

Visit www.fskhrtraining.com for more information and online registration.

View More

LexisNexis Data Compromised by Identity Theft Hackers

WorkCompAcademy

An identity theft service that sells Social Security numbers, birth records, credit and background reports on millions of Americans has infiltrated computers at some of America’s largest consumer and business data aggregators, according to a seven-month investigation by KrebsOnSecurity.

Two of the hacked servers were inside the networks of Atlanta, Ga.-based LexisNexis Inc., a company that maintains the world’s largest electronic database for legal and public-records related information. LexisNexis is also widely used by members of the workers’ compensation community for legal research.

Contacted about the findings, LexisNexis confirmed that the two systems listed in the botnet interface were public-facing LexisNexis Web servers that had been compromised.

A tiny unauthorized program called “nbc.exe” was placed on the servers as far back as April 10, 2013, suggesting the intruders have had access to the company’s internal networks for at least the past five months. The program was designed to open an encrypted channel of communications from within LexisNexis’s internal systems to the botnet controller on the public Internet.

An initial analysis of the malicious bot program installed on the hacked servers reveals that it was carefully engineered to avoid detection by antivirus tools. A review of the bot malware in early September using Virustotal.com – which scrutinizes submitted files for signs of malicious behavior by scanning them with antivirus software from nearly four dozen security firms simultaneously – gave it a clean bill of health: none of the 46 top anti-malware tools on the market today detected it as malicious.

All three victim companies said they are working with federal authorities and third-party forensics firms in the early stages of determining how far the breaches extend, and whether indeed any sensitive information was accessed and exfiltrated from their networks.

For its part, LexisNexis confirmed that the compromises appear to have begun in April of this year, but said it found “no evidence that customer or consumer data were reached or retrieved,” via the hacked systems. The company indicated that it was still in the process of investigating whether other systems on its network may have been compromised by the intrusion.

“Immediately upon becoming aware of this matter, we contacted the FBI and initiated a comprehensive investigation working with a leading third party forensic investigation firm,” said Aurobindo Sundaram, vice president of information assurance and data protection at Reed Elsevier, the parent company of LexisNexis. “In that investigation, we have identified an intrusion targeting our data but to date have found no evidence that customer or consumer data were reached or retrieved. Because this matter is actively being investigated by law enforcement, I can’t provide further information at this time.”

View More