Menu Close

Tag: 2021 News

DWC Sets Hearing for Copy Service Fee Schedule Updates

The Division of Workers’ Compensation has issued a Notice of Public Hearing to amend the Copy Service Price Schedule. The Zoom public hearing is scheduled for Monday, August 30, 2021 at 10 a.m.

The proposed updates to the regulations include:

– – An increase of the flat rate for copy services from $180 to $225 for records up to 500 pages, and includes all associated services such as pagination, witness fees for delivery of records, and subpoena preparation.
– – Several provisions to address improper payments, such as a preclusion for medical providers to improperly charge for inspection of records, maximum witness fees from third party release of information services, and an increase for bills not paid within 30 days of billing.
– – A procedure to object to services provided within 30 days of a request by an injured worker to an employer, claims administrator or workers’ compensation insurer for copies of records in the employer’s possession that are relevant to the claim. It is not uncommon for an employee’s attorney to subpoena records even though they have been subpoenaed by defendant. The 30-day waiting period is triggered when the copy service advises the claims administrator of an intent to copy records from a specific location for a specific dispute. The parties would then have an opportunity to object within the waiting period. Once an objection is raised, the parties must meet and confer to resolve the objection.
– – DWC will also charge and collect retrieval costs for records requested under the Public Records Act.

The proposed amendments to the Copy Service Price Schedule are exempt from the rulemaking provisions of the Administrative Procedure Act. DWC is required to have a 30-day public comment period, hold a public hearing, respond to all the comments received during the public comment period, and publish the order adopting the regulations online. Members of the public may review and comment on the proposal until August 30, 2021.

Members of the public may attend the public meeting:

Access Information
– – Join from PC, Mac, Linux, iOS or Android:
– – Or Telephone:
– – Dial: USA 216 706 7005
– – USA 8664345269 (US Toll Free)
– – Conference code: 956474

Find local AT&T Numbers:

Mandatory Drug Monitoring Databases Reduced Opioid Use

A new study from the Workers Compensation Research Institute examines the effects of must-access prescription drug monitoring programs (PDMPs) and recent regulations limiting the duration of initial opioid prescriptions on various outcomes for workers with work-related injuries.

“The policies examined were part of an extensive effort by stakeholders at local, state, and national levels to address potential excessive opioid prescribing and opioid abuse,” said John Ruser, president and CEO of WCRI. “Must-access PDMPs reduced the amount of opioids prescribed to workers without changing the likelihood that workers had any opioid prescriptions.”

The study, Effects of Opioid-Related Policies on Opioid Utilization, Nature of Medical Care, and Duration of Disability, explores how policies limiting access to opioid prescriptions contributed to changes in opioid utilization and how they altered other medical care related to the management of pain. The study estimates the effects of state-level opioid policies by comparing outcomes in states that adopted the policies relative to states that did not, while accounting for other factors that could have influenced changes in opioid utilization and the other outcomes studied.

In California, the prescription drug monitoring program is called Controlled Substance Utilization Review and Evaluation System (CURES). CURES is a database of Schedule II, Schedule III, Schedule IV and Schedule V controlled substance prescriptions dispensed in California. Section 11165.4 of the Health and Safety Code, sets forth the requirements for mandatory consultation of CURES.

The following are among the study’s findings:

– – Must-access PDMPs reduced the amount of opioids prescribed by 12 percent in the first year.
– – Regulations limiting duration of initial opioid prescriptions resulted in a 19 percent decrease in the amount of opioids among claims with opioids.
– – For most injuries, there was little evidence that workers increased the use of other types of care due to must-access PDMPs. However, for neurologic spine pain cases, the policies resulted in an increase in the number of non-opioid pain medications and an increase in whether workers had interventional pain management services.
– – Must-access PDMPs and limits on initial prescriptions had little impact on the duration of temporary disability benefits captured within 12 months after an injury.

The analysis includes information for workers injured between October 1, 2009, and March 31, 2018, in 33 states: Alabama, Arizona, Arkansas, California, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nevada, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Wisconsin. These states represent 85 percent of benefits paid in 2017.

The authors of this study are David Neumark and Bogdan Savych. To learn more about this study or to download a copy, visit

No Jury Trial In Superior Court Comp Coverage Dispute

In June 2016, Kirk Hollingsworth was involved in a fatal accident while working for defendant Heavy Transport, Inc. (HT).

Hollingsworth’s wife and son, plaintiffs Leanne and Mark Hollingsworth, filed a wrongful death complaint in superior court against HT and Bragg Investment Company, Inc.

Plaintiffs alleged that HT lacked the required workers’ compensation insurance at the time of the incident, and therefore plaintiffs were entitled to sue Bragg/HT under Labor Code section 3706, which states, “If any employer fails to secure the payment of compensation, any injured employee or his dependents may bring an action at law against such employer for damages . . . .”

Bragg/HT then filed an application for adjudication of claim with the Workers’ Compensation Appeals Board. Only one of these tribunals could have exclusive jurisdiction over plaintiffs’ claims, and in a previous court of appeal opinion, Hollingsworth v. Superior Court (2019) 37 Cal.App.5th 927 (Hollingsworth I), the court held that the superior court, which had exercised jurisdiction first, should resolve the questions that would determine which tribunal had exclusive jurisdiction over plaintiffs’ claims.

Following remand, plaintiffs asserted they were entitled to a jury trial on the factual issues that would determine jurisdiction. The superior court denied plaintiffs’ request and held a hearing in which it received evidence and heard testimony regarding HT’s insurance status. The superior court determined that HT was insured by a workers’ compensation policy at the time of Hollingsworth’s death, and therefore the WCAB had exclusive jurisdiction over the matter. Plaintiffs appealed. The court of appeal affirmed the trial court in the published case of Hollingsworth v. Heavy Transport, Inc.

Plaintiffs assert on appeal, that they were entitled to a jury trial on the fact issues that would determine jurisdiction. The appellate court disagreed.

Although a jury may determine questions relevant to workers’ compensation exclusivity when the issue is raised as an affirmative defense to common law claims, jurisdiction under Labor Code section 3706 is an issue of law for the court to decide.

Citing numerous decisions, the court said that it is the general rule that “[i]n a civil case . . . personal and subject matter jurisdiction ordinarily are issues for the court, not the jury.”

Because plaintiffs asserted jurisdiction under Labor Code section 3706, it was appropriate for the court, not a jury, to determine the questions relevant to jurisdiction. Plaintiffs did not have a right to a jury trial on these facts.

Pfizer Legal Battle Over Anti Kickback Law Heats Up

Three years ago, pharma giant Pfizer paid $24 million to settle federal allegations that it was paying kickbacks and inflating sales by reimbursing Medicare patients for out-of-pocket medication costs.

By making prohibitively expensive medicine essentially free for patients, the company induced them to use Pfizer drugs even as the price of one of those medicines, covered by Medicare and Medicaid, soared 44% to $225,000 a year, the Justice Department alleged.

Now, Kaiser Health News reports that Pfizer is suing the federal authorities to legalize essentially the same practice it was accused of three years ago – a fighting response to a federal crackdown that has resulted in a dozen drug companies being accused of similar practices.

A Pfizer win could cost taxpayers billions of dollars and erase an important control on pharma marketing after decades of regulatory erosion and soaring drug prices, say health policy analysts. A federal judge’s ruling is expected any day.

“If this is legal for Pfizer, Pfizer will not be the only pharmaceutical company to use this, and there will effectively be a gold rush,” government lawyer Jacob Lillywhite said in oral arguments last month.

Pfizer’s legal argument “is aggressive,” said Chris Robertson, a professor of health law at Boston University. “But I think they’ve got such a political tailwind behind them” because of pocketbook pain over prescription medicine – even though it’s caused by pharma manufacturers. Pfizer’s message, “‘We’re just trying to help people afford their drugs,’ is pretty attractive,” he said.

That’s not all that’s working in Pfizer’s favor. Courts and regulations have been moving pharma’s way since the Food and Drug Administration allowed limited TV drug ads in the 1980s. Other companies of all kinds also have gained free speech rights allowing aggressive marketing and political influence that would have been unthinkable decades ago, legal scholars say.

Among other court arguments, Pfizer initially claimed that current regulation violates its speech protections under the First Amendment, essentially saying it should be allowed to communicate freely with third-party charities to direct patient assistance.

“It’s infuriating to realize that, as outlandish as they seem, these types of claims are finding a good deal of traction before many courts,” said Michelle Mello, a professor of law and medicine at Stanford University. “Drug companies are surely aware that the judicial trend has been toward more expansive recognition of commercial speech rights.”

Pfizer’s lawsuit, in the Southern District of New York, seeks a judge’s permission to directly reimburse patient expenses for two of its heart-failure drugs each costing $225,000 a year. An outside administrator would use Pfizer contributions to cover Medicare copays, deductibles and coinsurance for those drugs, which otherwise would cost patients about $13,000 a year.

Letting pharma companies put money directly into patients’ pockets to pay for their own expensive medicines “does induce people to get a specific product” instead of shopping for a cheaper or more effective alternative, said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University. “It’s kind of the definition of a kickback.”

Government rule-makers have warned against such payments since the launch of Medicare’s Part D drug benefit in 2006. Drug companies routinely help privately insured patients with cost sharing through coupons and other means, but private carriers can negotiate the overall price.

Because Congress gave Medicare no control over prescription drug prices, having patients share at least part of the cost is the only economic force guarding against unlimited price hikes and industry profits at taxpayer expense.

At the same time, however, regulators have allowed the industry to help patients with copays by routing money through outside charities – but only as long as the charities are “bona fide, independent” organizations that don’t match drugmaker money with specific drugs.

Several charities have blatantly violated that rule in recent years by colluding with pharma companies to subsidize particular drugs, the Justice Department has alleged. A dozen companies have paid more than $1 billion to settle allegations of kickback violations.

WCIRB Report Shows First Combined Ratio Over 100% Since 2012

The WCIRB just published its 2021 State of the System report. Highlights of the report show the recent changes in premium revenue, claims, and costs.

The sharp and sudden employment drops in 2020 significantly impacted workers’ compensation exposure, the number of claim filings and claims activity. Premium levels dropped sharply in 2020 due to continued insurer rate decreases and the pandemic-related economic slowdown. Premiums are forecast to increase modestly in 2021 with economic recovery and the impact of insurer rate decreases moderating.

The insurance market remains stable and non-concentrated. Insurer charged rates continue to decrease and are now at a 50-year low. Average indemnity claim costs are rising, while average medical claim costs remain relatively flat. The impact of the pandemic on average claim costs in the long-term remains uncertain.

Average insurer rates charged for the first quarter of 2021 are only 2% below the rates charged in 2020, possibly signaling a sign of moderating insurer rate decreases and potential future hardening of the insurance market. Total written premium is forecast to increase modestly in 2021 with the economic recovery and moderation of the impact of declining premium rates, but would still be well below the level from 2014 to 2019.

California had the highest rates in the country until 2018, when rate declines moved it from the top spot. It is now the fourth highest, behind New Jersey, New York, and Vermont.

Almost 150,000 COVID-19 claims have been filed in the California workers’ compensation system. The impact of the filing of so many COVID-19 claims in 2020 on claim frequency was in part offset by a reduction in the number of non-COVID-19 claims filed. Over one-half of the almost 150,000 COVID-19 claims filed in the California workers’ comp system as of June 1, 2021 were within the insured system.

Over time, the ratio of COVID-19 claims relative to statewide infections declined as the COVID- 19 workers’ compensation presumption created by Senate Bill (SB) No. 1159 was more restrictive than the Governor’s Executive Order issued in spring 2020.

The winter surge resulted in over 2 million infections statewide and the largest volume of COVID-19 workers’ compensation claims filed during the pandemic. COVID-19 claims as a percent of all indemnity claims peaked in December 2020 during the winter surge of infections. As vaccines rolled out in spring 2021, the proportion of COVID-19 claims has been very modest. A much higher than projected share of COVID-19 claims has been filed by younger workers. Younger individuals are more likely to have mild COVID-19 symptoms.

Currently projected costs of COVID-19 claims in the insured system for accident years 2020 and 2021 are over $1 billion in total.

Preliminary estimates suggest the CT claim share of indemnity claims for accident years 2020 and 2021 are significantly below the 2018 and 2019 levels. The vast majority of increases in CT claims since 2012 came from the Los Angeles Basin and San Diego areas.

Following the implementation of reforms related to lien filings of SB 863 (in 2013) and SB 1160 and Assembly Bill (AB) 1244 (in 2017), the number of lien filings dropped significantly. The number of liens filed in 2020 is over 70% below the pre- SB 1160 and AB 1244 level.

Combined ratios in California have historically been volatile. Recent industry ratios have been fairly stable, with seven consecutive years of combined ratios below 100% from 2012 to 2019. Combined ratios since 2016 have been increasing primarily due to lower premium levels driven by lower insurer rates and higher expense ratios. The combined ratio for 2020 is the first above 100% since 2012. Excluding the impact of COVID-19 claims, the 2020 combined ratio would be 96%.

Grocery Chain Cited for $115K in COVID Sick Pay Violations

The Labor Commissioner’s Office cited three El Super grocery stores in Southern California for failing to provide or delaying supplemental paid sick leave (SPSL) or other benefits to 95 workers impacted by COVID-19. Some of the workers were forced to work while sick, others were told to apply for unemployment while quarantining or in isolation, while others waited months to be paid.

The citations were issued to Bodega Latina Corporation, a Delaware corporation doing business as El Super with 52 stores in California. The following locations in Los Angeles and San Bernardino counties were cited:

– – 1100 W Slauson Avenue, Los Angeles 90044
– – 10721 Atlantic Avenue, Lynwood 90262
– – 14590 Bear Valley Road # 28, Victorville 92395

The 2021 SPSL, which went into effect on March 29 and is retroactive to January 1, 2021, requires that California workers are provided up to two weeks of supplemental paid sick leave if they are affected by COVID-19. Among the key updates in the legislation, leave time also applies to attending a COVID-19 vaccine appointment and recovering from symptoms related to the vaccine.

The law is in effect until September 30, 2021. Small businesses employing 25 or fewer workers are exempt from the law but may offer supplemental paid sick leave and receive a federal tax credit, if eligible.

The Labor Commissioner’s Office opened an investigation on September 9, 2020 after receiving complaints from workers and a referral from the United Food and Commercial Workers International Union representing grocery store workers.

The investigators determined the employer did not consistently inform workers of their rights to SPSL if impacted by COVID-19. In some instances, sick workers were told to come to work until they received their test results even when they had COVID-19 symptoms. To cover isolation time, workers were in some cases told to apply for unemployment or disability. Moreover, many were denied time off to isolate, even though members of their household had tested positive. Some workers were never paid for their time off due to COVID-19.

The citations include $114,741.67 in wages, damages and interest for failing to provide leave under 2020 COVID-19 SPSL for food sector workers (Labor Code § 248), and $14,894.66 in wages, damages and interest for failing to provide leave under 2021 COVID-19 SPSL for employers with 26 or more employees (Labor Code § 248.2). In addition, $318,200 was assessed in penalties for nonpayment or late payment of SPSL (Labor Code § 246(n)).

Anyone who currently works or has worked at El Super who believes their employer refused to provide paid sick leave or COVID-19 supplemental paid sick leave as required by law is encouraged to call the Labor Commissioner’s Office confidential Paid Sick Leave Hotline at (855-526-7775) and leave their contact information. All workers can also call the Labor Commissioner’s Office to ask questions or get more information on how to file a wage claim for paid sick leave at 833-LCO-INFO (833-526-4636).

Organized International Crime Behind Fraudulent UI Claims

A Bronx man allegedly received $1.5 million in just ten months. A California real estate broker raked in more than $500,000 within half a year. A Nigerian government official is accused of pocketing over $350,000 in less than six weeks.

What they all had in common, according to federal prosecutors, was participation in what may turn out to be the biggest fraud wave in U.S. history: filing bogus claims for unemployment insurance benefits during the COVID-19 pandemic. (The broker has pleaded guilty, while the Bronx man and Nigerian official have pleaded not guilty.)

One person, according to the U.S. Department of Labor, used a single Social Security number to file unemployment insurance claims in 40 states. Twenty-nine states paid up, sending $222,532.

But the problem extends far beyond a plague of solo scammers. Bots filing bogus applications in bulk, teams of fraudsters in foreign countries making phony claims, online forums peddling how-to advice on identity theft – all inside the infrastructure of perhaps the largest fraud wave in history.

A ProPublica investigation reveals that much of the fraud has been organized – both in the U.S. and abroad. Fraudsters have used bots to file online claims in bulk. And others, located as far away as China and West Africa, have organized low-wage teams to file phony claims.

The fraud has been enabled by a burgeoning online infrastructure, whose existence has not previously been reported in the mainstream press. Much of it is geared toward exploiting aging or obsolete state unemployment systems whose weaknesses have drawn warnings for decades.

Communities have sprouted on messaging apps such as Telegram, where fraudsters trade tips on how to cash in. Hustlers advertise their techniques – or “sauces” (apparently short for “secret sauce”) – for filing bogus claims, along with state-specific instructions on how to get around security checks, according to a ProPublica review of messages on more than 25 such chat forums.

Some of the forums have thousands of participants and regularly offer stolen identities for sale, alongside tech tips, screenshots that ostensibly prove the methods work and advice on which states are easiest to game and which are “lit” – that is, still paying out fake claims. Users have created two Telegram channels in which they trade tips for filing claims in Maryland, whose labor department recently said it detected some 508,000 potentially fraudulent jobless claims between the start of May and mid-June. Participants in those forums have been talking about turning their efforts to Pennsylvania, where officials recently said they have “noticed an uptick” in fraudulent claims.

“From my experience, when this is all said and done, we are going to be counting in the hundreds of billions of dollars, not the tens of billions,” said Jon Coss, who heads a unit within Thomson Reuters that is helping states detect fake unemployment insurance claims.

Coss bases that assessment on the widespread fraudulent activity he’s seen. He said one U.S. state, which he declined to name, received fake claims – all purportedly from state residents – that originated from IP addresses in nearly 170 countries. They included countries historically linked to fraud, such as China, Nigeria and Russia, as well as more surprising ones, such as Cuba, Eritrea, Fiji and Monaco.

Overall, Coss said, between 40% and 50% of the claims his group has analyzed seem highly suspect. He added, “It’s mind-boggling the level of fraud that we’re seeing.

California Restrictions Tighten as New COVID Wave Spikes

The Centers for Disease Control and Prevention (CDC) is set on Tuesday to recommend masks for vaccinated people indoors under certain circumstances.

“Federal officials met on Sunday night to review new evidence that may have prompted the reversal,” the report continued. “The new guidance would mark a sharp turnabout from the agency’s position since May that vaccinated people do not need to wear masks in most indoor spaces.

New cases of COVID-19 are popping up in San Francisco and elsewhere in the Bay Area in what local media is callingclearly a fourth wave of the pandemic”, and everyone is clearly anxious and exhausted.

The latest surge in new cases arrived swiftly over the last two weeks, with the numbers in San Francisco still fairly low in the first days of July. The city was averaging 12.6 new cases per day in the month of June, and that rose to an average of 39 per day in the week after the July Fourth holiday. Now, SF’s seven-day average, as of Sunday (with a couple of days of delay in the health department’s reporting of numbers), was 147 new cases per day. 218 new infections were tallied in SF on Sunday alone, with 196 the previous day, which compares to days in mid-January when we were in the midst of the winter surge. July 20 also saw 215 new cases.

There has not been a day with over 200 new cases in San Francisco since the first week of February.

The number of hospitalized COVID patients has also risen sharply in SF in the last two weeks, rising from 24 on July 1 to 61 as of Saturday, according to state data.

UCSF’s Dr. Bob Wachter tweeted a lengthy thread Sunday about the current surge and the precautions he plans to take. He notes that everything they are seeing at UCSF points to the ongoing efficacy of the vaccines, but now 77% of cases they are seeing through routine testing of many patients are among the vaccinated, the chances of encountering the virus in public are much higher in SF now than a month ago. Based on internal data about asymptomatic cases, Wachter says you now have a 1 in 50 chance of encountering an asymptomatic COVID infection while out in the city, compared to about 1 in 1000 back in June.

California Gov. Gavin Newsom announced Monday that his state will be the first in the nation to impose a vaccine mandate on state employees and healthcare workers, requiring they show proof of vaccination or submit to regular tests.

California will also be requiring health care settings to verify that workers are fully vaccinated or tested regularly. Unvaccinated workers will be subject to at least weekly COVID-19 testing and will be required to wear appropriate PPE. This requirement also applies to high-risk congregate settings like adult and senior residential facilities, homeless shelters and jails.

The new policy for state workers will take effect August 2 and testing will be phased in over the next few weeks. The new policy for health care workers and congregate facilities will take effect on August 9, and health care facilities will have until August 23 to come into full compliance.

Correctional Officer’s Off-Duty Weight lifting Not AOE-COE

In 2006, Daniel Desimone began working for the County of Santa Barbara as a corrections officer.

In October 2007, he injured his lower back. The incident occurred at a private gym inside an apartment complex on a weekend when Desimone was not working and no other County employees were present. Desimone was attempting to lift 350 pounds without a fitness trainer. The injury resulted in permanent damage to his spine. He said that he was lifting weights in hopes of being promoted to Deputy Sheriff.

Desimone continued working as a custody deputy until March 2016. In 2017, he filed an application for disability retirement benefits. Two reporting physicians agreed he was permanently incapacitated, but they disagreed on whether his disability was service connected. Dr. Conwisar opined that it was “within reasonable medical probability” that Desimone’s work activities contributed to the injury. Dr. Ganjianpour opined that Desimone’s disc herniation resulted from the 2007 weight-lifting incident and that his work duties did not “significantly and measurably contribute” to his incapacity.

The Board referred the question of whether the disability was service connected to a referee. The referee found that Desimone’s weight-lifting injury was not work related. A trial court affirmed the Board, and the Court of Appeal affirmed in the unpublished case of Desimone v the Retirement Board of Santa Barbara County.

Desimone argued that pursuant to Ezzy v. Workers’ Comp. Appeals Bd. (1983) 146 Cal.App.3d 252 (Ezzy), that he was entitled to service-connected disability benefits because (1) he believed that his weight-lifting activity was expected by his employer and (2) his belief was objectively reasonable.

In Ezzy, the court of appeal held that a worker’s compensation claimant injured during a company-sponsored softball game was participating in an activity in the course of her employment.

Ezzy, is not controlling authority because it involved a worker’s compensation claim under the Labor Code, and not, as here, a claim for service connected disability retirement benefits under the CERL (Gov. Code, § 31720). The trial court was therefore not required to apply the Ezzy test to determine whether Desimone’s injury was service connected.

But, even under the Ezzy test, Desimone did not prove that his injury was sustained in the course of his employment. He argues that his subjective belief that the County expected him to participate in heavy weight lifting was objectively reasonable.

The specific activity must have a substantial nexus between an employer’s expectations or requirement, or else the scope of coverage becomes virtually limitless. Accordingly, general assertions that it would benefit the employer for, or even that the employer expects, an employee to stay in good physical condition are not sufficient.

11 Skilled Nursing Facilities Resolve Fraud Claims for $2M

Interface Rehab, headquartered and operating in Orange County, has agreed to pay $2 million to resolve allegations that it violated the False Claims Act by causing the submission of claims to Medicare for rehabilitation therapy services that were not reasonable or necessary.

The settlement resolves allegations that, from January 1, 2006, through October 10, 2014, the Placentia-based Interface knowingly submitted or caused the submission of false claims for medically unreasonable and unnecessary “Ultra High” levels of rehabilitation therapy for Medicare Part A residents at 11 Skilled Nursing Facilities.

These facilities include Colonial Care Center, Covina Rehabilitation Center, Crenshaw Nursing Home, Green Acres Lodge, Imperial Care Center, Laurel Convalescent Hospital, Live Oak Rehabilitation Center, Longwood Manor Convalescent Hospital, Monterey Care Center, San Gabriel Convalescent Center, and Whittier Pacific Care Center.

In July 2020, the Department of Justice announced that Longwood Management Corporation and 27 affiliated skilled nursing facilities agreed to pay $16.7 million to the United States to resolve allegations that they violated the False Claims Act by submitting false claims to Medicare for rehabilitation therapy services that were not reasonable or necessary.

This newly announced  settlement resolves Interface’s role in that alleged conduct.

During the relevant time period, Medicare reimbursed skilled nursing facilities at a daily rate that reflected the skilled therapy and nursing needs of qualifying patients. The greater the patient’s needs, the higher the level of Medicare reimbursement. The highest level of Medicare reimbursement for skilled nursing facilities was for “Ultra High” therapy patients, who required a minimum of 720 minutes of skilled therapy from two therapy disciplines (e.g., physical, occupational, or speech therapy), one of which had to be provided five days a week.

The United States contends that Interface pressured therapists to increase the amount of therapy provided to patients in order to meet pre-planned targets for Medicare revenue. These alleged targets could only be achieved by billing for a high percentage of patients at the “Ultra High” level without regard to patients’ individualized needs.

This civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by Keith Pennetti, a former Director of Rehab at Interface. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. Mr. Pennetti, will receive $360,000 of the settlement proceeds. The qui tam case is captioned United States ex rel. Pennetti v. Interface Rehab, et al., No. CV-14-4133 (C.D. Cal.).

The claims resolved by the settlement are allegations only and there has been no determination of liability.