The State of Medical Care in California’s Workers’ Compensation System

Katherine Roe

Todays' guest post is authored by Katie Roe*  of the California Bar and was originally published at rivercityattorneys.com/blog (Fraulob & Brown).

When you’re injured at work, you expect that your employer’s insurance carrier will dutifully provide you with proper medical treatment for your injury. After all, future medical care is one of the “benefits” injured workers are entitled to in California. Denial of medical treatment is the number one frustration we hear from our clients on a daily basis.

What injured workers quickly discover is that their medical treatment is strictly controlled by the insurance carrier and their medical fate is in the hands of a doctor who has never treated them and may not even have their complete medical records. This process is called Utilization Review (UR). Under UR an outside physician gets to decide whether or not the insurance company should authorize the medical treatment prescribed by your primary treating physician. This doctor doesn’t even have to be licensed in California.

If the medical treatment prescribed by your physician is denied, your only recourse is to appeal the decision to an Independent Medical Reviewed (IMR). In California, MAXIMUS is the company contracted to conduct IMR reviews. Like UR doctors, the IMR doctor deciding your fate, has never met you or treated you and does not need to be licensed in California. In fact, their identity is protected. If your medical treatment is denied by UR, your chances of IMR overturning the decision are not good. California Workers’ Compensation Institute, an insurance research group, found that 91% of IMR decisions uphold the UR denial. If the treatment is denied by IMR, absent a change in circumstances, the denial will be in effect for one year.

While an injured worker has the right to appeal an IMR determination to the Workers’ Compensation Appeals Board, the only legal bases on which to appeal are fraud, conflict of interest, or mistake of fact. However, even if your appeal is successful the WCAB still cannot overturn the IMR doctor’s decision. If an appeal is granted, the remedy is referral to a different IMR for another review. Yes, you read that right, your award is to go through the IMR process again!

Many injured workers end up seeking treatment for their work related injuries through private insurance, Medicare or Medi-Cal. A study by J. Paul Leigh, a health economist at the University of California, Davis, estimated that only 1/3 of necessary medical treatment and lost wages is being paid for by workers’ compensation insurers.

The lack of adequate medical care for injured workers today is the result of Senate Bill 863, which was passed on August 1, 2012 and signed into law by Governor Brown on September 18, 2012. This law was the result of lobbying by big businesses and insurance companies, who have influence over the State Legislature and the Governor of California. We remind our clients that you also have a political voice. We recommend you go to Voters Injured at Work (www.viaw.org) for information on how to become involved with fixing this broken system.

To read more about the dismal state of medical treatment for injured workers all over America I encourage you to read Insult to Injury by Michael Grabell athttps://www.propublica.org/article/the-demolition-of-workers-compensation.

*Katherine Roe is originally from the San Francisco Bay Area. She attended University of St. Thomas, Saint Paul Minnesota for her undergraduate degree in Sociology with a minor in Criminal Justice. She earned her Master in Public Administration from University of Notre Dame de Namur, Belmont, CA. Katie graduated from University of the Pacific McGeorge School of Law in Sacramento where she received the Witkin Award for Health Law and Elder Law Clinic. She is a practicing attorney in the areas of Workers’ Compensation Law, Social Security Disability and Elder Law, including estate planning with wills, trusts, deeds, powers of attorney and health care directives.
While in college, Katie tutored grade school and high school students in low-income neighborhoods in Saint Paul and Minneapolis, MN and interned with the Oakdale, MN Police Department.
During law school, Katie interned with Legal Aid Society of San Mateo County, Human Rights Fair Housing Commission and the California Department of Insurance. While at McGeorge, she worked in the Elder and Health Law Clinic where she handled Medicare appeals, elder abuse cases, restraining orders, wills, trusts, consumer protection, special needs trusts, and powers of attorney.
While the Clinical Fellow at McGeorge she received the Cohn Sisters’ Scholarship for Patient Advocacy.

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NY Worker's Compensation Board Proposes New Medical Treatment Guidelines

New York Worker’s Compensation Board’s proposed new medical treatment guidelines that will modify 2010 previously implemented.

1. Adopt the new carpal tunnel syndrome (CTS) medical treatment guidelines (MTG) as the standard of care for the treatment of injured workers with carpal tunnel syndrome;
2. Modify current MTGs to include new maintenance care recommendations; and
3. Implement consensus changes to simplify the process, reduce litigation and speed dispute resolution.

Carpal Tunnel Syndrome (CTS)
The new CTS MTG provide evidence based guidelines for the treatment of carpal tunnel syndrome, the most common occupational disease experienced in the workers’ compensation system. Like the other MTGs, the CTS MTG should improve the quality of care, speed access to the most beneficial treatment, and control the use of ineffective treatment.

Maintenance Care
The original four MTGs primarily address treatment for the acute and sub-acute phases of injury, with limited recommendations for the management of chronic conditions and chronic pain. As part of its effort to develop chronic pain guidelines, the MAC re-evaluated those recommendations that relate to maintenance care, recognizing that in certain situations maintenance care (chiropractic and occupational/physical therapy) should be available. The revised MTGs will authorize an ongoing maintenance program that can include up to 10 visits per year for those who have a previously observed and documented objective deterioration in functional status without the identified treatment. To be eligible for maintenance care, injured workers with chronic pain must have reached maximum medical improvement (MMI), have a permanent disability, and meet the requirements of the maintenance care program. No variance is allowed from the 10 visit annual maximum.

The new recommendations address a major concern of both providers and payers: the high number of variance requests. To date, more than three quarters of the variance requests are for maintenance care for those with chronic pain. Injured workers will now have access to important maintenance care while payers and providers will be relieved from the administrative burden of handling individual variance requests for this care. The remainder of the chronic pain guidelines is expected to be completed by early 2013.

Process Changes
The regulations also include several changes to simplify the process, reduce conflict, and speed dispute resolution. These consensus changes are the result of suggestions from stakeholders. The changes will achieve the following:

• enable parties to more easily choose resolution by the Medical Director’s Office, which provides faster and less costly dispute resolution;
• clarify and simplify transmission requirements that were resulting in rejection of thousands of variance requests for technical violations;
• allow carriers to partially grant variance requests, thereby expediting care and reducing litigation;
• eliminate submission of duplicate variance requests;
• reduce the number of procedures requiring C-4 Authorization, and
• authorize submission of variance requests through a web-based portal or other technology in the future, should it become available.
•  

In addition, several changes to the Forms C-4 AUTH, C-8.1, MG-1 and MG-2 forms that have been agreed upon with stakeholders will be implemented.  Comments on the draft forms may be sent to formsdepartment@wcb.ny.gov and will be considered if received by Monday, November 26, 2012. Final versions of the forms will be posted in early December. The parties will be expected to begin using the new forms after February 1, 2013. Old forms cannot be used to initiate new requests after March 15, 2013.

Complete copies of the proposed regulations, new and revised guidelines, complete description of the process changes, draft versions of the new forms, and other information are available on the Proposed Changes to New York Medical Treatment Guidelines page of the Board’s website. The regulations will be published in the November 21, 2012 State Register.

More about workers’ compensation medical treatment

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RICO Case Against Wal-Mart & CMI Settles for $8 Million
Nov 14, 2012
The claim, on behalf of 7,000 Colorado Wal-Mart workers charges conspiracy with: Claims Management Inc., American Home Assurance Co. and Concentra Health Services Inc., to control medical treatment, who may have .
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Penalties for Insurance Companies Who Fail to Pay Enough for Medical Care

The quality of medical care for workers' compensation beneficiaries has always been a major issue. Injured workers just don't want to go to an employer selected physician.They want to go to a doctor who provides good quality medical care and one they have confidence in. It makes good medical sense. While one concept to adjust the issue is to compel insurance carriers to pay for outcome driven results. If the doctor cures you, then the doctor should be paid in full for the reasonable value of his or her services. If the opposite, well then maybe the doctor should get paid less.

Another approach, enacted by the federal government is to compel insurance carriers to pay a certain percentage of premiums collected for medical care, instead of paying large sums for administration expenses. That could be applied to workers' compensation carriers. Instead of paying 80% of the premium to fight the claim, workers' compensation insurance companies should be compelled to pay 80% to cure the medical condition.

Read more about this concept:
HHS Unveils Medical Loss Ratio Rule (Kaiser Health Breaking News)

"The Department of Health and Human Services today released its final medical loss ratio rule. According to an HHS press release, the rule will ensure that health insurance companies spend at least 80 percent of consumers' health insurance premiums on medical care rather than on income, overhead and marketing expenses. "If your insurance company doesn't spend enough of your premium dollars on medical care or quality improvement this year, they'll have to give you rebates next year," said CMS Acting Administrator Marilyn Tavenner, in the release . "This will bring costs down and give insurance companies the incentive to focus on what matters for patients – high quality health care."

read more

...

For over 3 decades the Law Offices of Jon L. Gelman  1.973.696.7900  jon@gelmans.com have been representing injured workers and their families who have suffered occupational accidents and illnesses.

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New Jersey Issues Workers Compensation Guidance on Evaluating Disputed Medical Provider Claims

A NJ Workers' Compensation Task Force report has been published that provides guidance to the parties in evaluating disputed medical provider claims. While declaring that, "certainly there are no overnight solutions," the report provides a manual type of suggestions for negotiation, litigation and resolution.

1. The new WCRI report, Benchmarks for Designing Workers’ Compensation Medical Fee Schedules. Fee schedules vary dramatically from state to state and based upon the type of payer;

2. The fees customarily paid for like services within the same community;

3. The fees paid to the same physician or medical provider by other payers for like treatment;

4. The fees billed and the accepted payments for such bills by a given provider. The Court may wish to consider the disparity in payments accepted from different sources (i.e. Medicare vs. PIP and commercial carriers);

5. A review of the Health Insurance Claim Forms (“HCFA”) submitted by the provider to the claim payer and the Explanations of Benefits (“EOB”) that that claim payer sends to the provider. The EOB provides the amount billed for a given procedure or service performed on a particular date of services. The EOB also provides the amount paid and, where applicable, identifies the reason why a disparity may exist in the amount billed and the amount paid. The use of certified professional coders may be employed to review the bill along with the medical records to be sure that it is consistent with CPT coding standards;

6. The HCFAs or EOBs from other medical providers in the same geographic area or community for the same medical treatment provided;

7. Using commercial and/or private databases such as Ingenix’s Prevailing Healthcare Charges System (“PHCS”); the Medical Data Resource (“MDR”) database, and; Wasserman’s Physician Fee Reference (“PFR”) database to name a few;

8. The type of facility where the procedure was performed. For example, was the services provided at a Level 1 trauma center versus a community hospital;

9. Consideration of whether there was a contract between a claim payer and the medical provider, such as a PPO network, in which case the contract would be controlling;

10. Consideration ofMedicare/Medicaid reimbursement rates;

11. Testimony from medical office personnel as to what services were billed for, the payments received and how the bill was formulated;

12. Consideration of state sanctioned PIP fee schedules;

13. Consideration of commercial carrier authorized payments.
.....
For over 3 decades the Law Offices of Jon L. Gelman 1.973.696.7900 jon@gelmans.com have been representing injured workers and their families who have suffered work related accident and injuries.

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State Acts to Restrict Medical Care

The State of NJ has proposed sweeping regulations to limit the payment of medical care under automobile insurance policies, and this action is seen as yet another signal that workers' compensation medical delivery may become even further restricted. In an effort to reduce insurance premiums, the NJ Department of Banking and Insurance, has proposed massive changes in the manner and method that doctors may bill for medical treatment and diagnostic procedures and has restructured the process for appealing a denied claim.

The State claims that medical delivery costs are soaring. It has been reported that for every premium dollar that insurance companies receive, they end up spending $1.23 on medical benefits. The regulations are designed to reduce medical services and produce a profitable insurance product.

Furthermore, the purpose of the regulations are to limit legal costs. The sate reported that in one instance a contested medical  resulted in the payment of $375 in medical benefits, but the legal costs awarded for that recovery were $3,380.

The regulations prohibit the use of innovative radiological diagnostic testing. "X-ray digitization or computer aided radiographic mensuration reported under CPT 76499 or any other code are not reimburseable under PIP."

The comment period for the new rules runs thorough early September 2011. The impact of the regulations is to reduce medical care and diagnostic procedures that will impact resulting workers' compensation benefits. Ironically providing the best medical benefits available would seemingly comply with the intent of the compensation act and ultimately economically benefit the employer by producing a healthy workforce, The process of cost cutting will only ultimately degrade the medical delivery component of workers' compensation even further.

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Who Calls The Shots, Your Employer-Selected Doctor Or The Insurance Company?

Insurance companies sometimes tell doctors that they will not pay for procedures that the doctor says are medically appropriate.

Today's post comes from guest author Nathan Reckman from Paul McAndrew Law Firm.

In Iowa, employers have the right to control an injured worker’s medical care. This means that if you are injured at work, your employer gets to send you to a doctor of their choosing. The doctors chosen by the employer are called “authorized treating physicians.” In theory, after an employer chooses their authorized treating physician, they are required to pay for any care that doctor believes is necessary to treat the work injury. In practice, the employer and their workers’ compensation insurance company often try to interfere with the care the injured worker is entitled to by refusing to pay for procedures or tests recommended by their handpicked doctor.

Typically, when an authorized doctor suggests an expensive course of care (like surgery) the first thing the doctor will do is check with the insurance company to make sure the surgery is going to be paid for. Instead of immediately scheduling the needed surgery, the doctor will wait until the insurance carrier agrees to pay for the procedure. Doctors do this so they don’t have to worry about how they are going to be paid. Asking for this unneeded authorization from the insurance company means the insurance company now has a say in determining what individual procedures are proper for the care of the work injury.

We often see injured workers whose injury was initially accepted by the employer until the doctor requests authorization for an expensive surgery. When faced with the additional cost of surgery, the insurance carrier denies the work injury hoping the injured worker will either forego surgery or try to pay for the surgery through other means, such as their personal health insurance.

This situation may also arise when the authorized doctor recommends expensive diagnostic procedures, like CT scans, or refers the injured worker to a specialist, for example a psychiatrist for depression related to the work injury.

To make sure your rights are protected, it’s often helpful to have an experienced workers’ compensation attorney on your side if you’re facing a situation where your employer is trying to interfere with the decisions of their handpicked doctor. Injured workers should get the care that their doctor, not an insurance company, determines is medically appropriate.

Read more about "medical treatment" and workers' compensation.

NY Worker's Compensation Board Proposes New Medical ...

Nov 16, 2012

New York Worker's Compensation Board's proposed new medical treatment guidelines that will modify 2010 previously implemented. Adopt the new carpal tunnel syndrome (CTS) medical treatment guidelines (MTG) as the ...

http://workers-compensation.blogspot.com/

Our Journey Forward on Occupational Medical Care - Workers ...

Nov 09, 2012

On Tuesday, the American people expressed its support for a unified medical care program that will embrace all aspects of life, including industrial accidents and diseases. They validated, as did the Supreme Court, the ...

http://workers-compensation.blogspot.com/

Workers' Compensation Jeopardy: Romney and Medical Costs

Nov 01, 2012

Planned changes by Mitt Romney to Medicare and Medicaid will have a dire effect on the regulations of the future cost of workers' compensation medical treatment. Proposed changes to the Federal program will indirectly ...

http://workers-compensation.blogspot.com/

Workers' Compensation: Out of State Medical Treatment Allowed By ...

Jan 22, 2011

The court held that the failure of the employer/insurance carrier to provide medical care for out-of-state treatment, even though requested by the employee, was deemed a refusal of the employer to provide adequate medical ...

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CA DWC Posts Proposed Changes to the Medical Treatment Utilization Schedule Regulations Online for Public Comment

Medical treatment guidelines are being proposed to providence evidential standards for the workers' compensation medical benefits. Today's post was shared by votersinjuredatwork and comes from www.workerscompensation.com

The Division of Workers’ Compensation (DWC) has posted proposed changes to the existing Medical Treatment Utilization Schedule (MTUS) regulations to the online forum where members of the public may review and comment on the proposals. “These changes to DWC’s evidence-based medical treatment guidelines provide a critically needed framework describing best practices for providing medical care for work-related illnesses and injuries,” said DWC Executive Medical Director Dr. Rupali Das. The proposed updates to the MTUS were developed in cooperation with the multidisciplinary Medical Evidence Evaluation Advisory Committee (MEEAC). The proposed amendments to the MTUS regulations modify regulatory definitions, which includes a definition for Evidenced Based Medicine, and adds new definitions for terms used in the strength of evidence methodologies. The regulations clarify the role of the MTUS in accordance with Labor Code section 4600 and set forth the process to determine if medical care is reasonable and necessary when the MTUS is inapplicable.

Defense Firm Prohibited From Seeking Unfettered Medical Discovery

A defense firm, that had a “custom” of seeking unlimited medical discovery in workers’ compensation claims, was barred from utilizing that litigation tactic. The NJ Appellate Division affirmed the trial level decision of The Honorable Emille R. Cox, Supervising Judge of Compensation that prohibited requests for unlimited medical data.

Published: 2011 Workers' Compensation Law Treatise

The 2011 Supplement to Gelman on Workers' Compensation Law has been published and is shipping. Now in its third edition, the 3 volume hard-bound series, provides a comprehensive analysis of workers' compensation law. Published by West Publishing, a business of Thomsom-Reuters, it is totally integrated into the West citation system and Westlaw® research system. The series and updates may be ordered in hardbound, CD-Rom and/or accessed thorough the Westlaw® research system.

What's New

The newly enacted statutory changes to the New Jersey Workers’ Compensation Act and promulgated Rules permitting Emergent Medical Care Motions, new registration requirements for insurers, and new judicial enforcement powers of Judges of Compensation, including sanctions and contempt powers, are contained in this supplemental material. The judicial decision imposing direct liability against an insurance carrier for delay and/or denial of medical treatment is discussed.

An analysis of the newly adopted procedures for the reimbursement of conditional payments established by Medicare and the protocols to co-ordinate workers’ compensation claims with the Centers for Medicare and Medicaid Services is contained in this supplement. The materials also provide the authorizations required to obtain conditional payment information from the Coordinator of Benefits. Debt collection referral to the Department of the Treasury is also reviewed.

The new Community and Worker Right to Know material has been incorporated into this supplement. The current hazardous substance lists and the substances that have been deemed extremely dangerous are provided.

The supplement reviews new case law concerning electronic cancellation of coverage as well as the standard for claims to be considered casually related to the employment.

The judicial interpretation of the Exclusivity Doctrine is discussion in light of the dual capacity status of a household contact / bystander and also former employee. The evidential requirements in latent occupational claims is reviewed.

The mandatory reporting requirements of the SCHIP Extension Act of 2007 are described as well as the appeal procedure under the reimbursement provision of the Medicare Secondary Payer Act.

These pocket parts provide information concerning the requirements for medical monitoring in workers’ compensation claims. It discusses. the Asbestos Fund, which has been established for those entities where workers’ compensation coverage cannot be established. The newly designed forms that need to be utilized in filing for benefits are included. Also, the recently modified Motion for Temporary and Medical Benefits, including a form Certification, is provided and discussed.

The newly revised Judgments for Total and Permanent Disability are provided in this pocket part. The Judgments include new refinements in offsets for pensions and Social Security disability benefits. Reviewed also is the “intentional wrong exception” to the Exclusivity Bar which has been the subject of new workers’ compensation insurance policy language and regulation.

The recently promulgated administrative rules governing the disposition of Temporary Disability Benefits are discussed. The non-duplication of benefits provisions are reviewed including the multiple agency adjudication process. An expansion of benefits available to Federal public safety officers is reviewed in this supplement.

Collateral medical benefit issues are discussed in light of the recent Supreme Court decision concerning this matter. The pocket parts include a Motion to Join the Collateral Health Carrier and provide sample Certifications to be used in support of the application. New pleadings issued by the Division of Workers’ Compensation in the area of medical payment and reimbursement claims are provided and commented upon in these materials.

Additionally, these pocket parts provide information concerning the new Rules of the Division of Workers’ Compensation embodying electronic filing requirements and new procedures involving both formal and informal proceedings, motion practice, post judgment process, and judicial performance. The expanded Medicare secondary reporting requirements and the mandatory coordination of benefits are reviewed in this supplement. The recovery aspects of Medicare conditional payments as well as future medical provisions are updated and discussed. The new Child Support Lien distribution forms, computation worksheets and judgments are provided and explained in depth. The NJ Supreme’ Court ruling and the legislative enactments are discussed concerning same sex couples and the availability of workers’ compensation benefits.

This supplement reviews the newly promulgated Rules concerning the Uninsured Employers’ Fund and audio and video coverage of workers’ compensation proceedings. The horrific tragedy of September 11th, 2001 and the impact it has upon the Workers’ Compensation system is discussed. This supplement reviews the newly enacted Smallpox Emergency Protection Act as well as recent court decisions concerning acts of terrorism. The subsequent legislative changes enacted in response to potential terrorist threats are reviewed, including the Public Safety Officers’ Benefit Act as well as the liberalized legislative enactments involving rescue workers and medical personnel.

The far-reaching ramifications of the newly enacted healthcare reform legislation are reviewed. The new prototype occupational medical care program, encompassing potential occupational exposure claims, is presented in this supplement.

The impact of the newly promulgated Federal rules and regulations concerning medical record privacy and compliance with the Health Insurance Portability and Accountability Act (HIPPA) medical authorization requirements are reviewed in this supplement and model forms are furnished. The recently enacted statutory workers' compensation coverage options available to proprietors and partners are discussed. The supplement reviews the recent court decisions expanding the responsibility of the Second Injury Fund for pre-existing medical conditions in cases in which latent diseases become manifest during retirement. The statutory enactments concerning State Temporary Disability Benefits are reviewed. The recently amended Energy Employees Occupational Illness Compensation Act is explained in detail and forms are furnished and discussed.

The new administration and management of claims arising from insolvent workers’ compensation insurance is covered in this pocket part.

The recent Supreme Court decisions concerning the high judicial threshold for evaluation of scientific evidence are analyzed. The requirements for proof of scientific evidence in complex workers’ compensation cases are discussed including the admissibility of testimony from non-physicians experts. Furthermore, the evolving and expanding issues concerning medical monitoring are reviewed.

This pocket part also discusses recent changes in the application for counsel fees. The supplement includes the newly promulgated administrative directive embodying those changes.

To Order

The series and updates may be ordered in hardbound, CD-Rom and/or accessed thorough the Westlaw® research system.

More Information
Table of Contents Supp. 2011
Index, Supp. 2011
Summary of Contents

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California Workers' Compensation $25 Million Medical Fraud: US Attorney Charges Providers

San Diego Nov 10 2015: Eight medical professionals and associates are charged in federal grand jury indictments with buying and selling patients in a bribery scheme involving $25 million in improper claims for medical services and devices which were then billed to California Workers’ Compensation insurance companies.

FBI agents along with investigators from the California Department of Insurance and the San Diego County District Attorney’s Office served five search warrants and three seizure warrants today at locations in San Diego, Chula Vista, National City, Murietta and Los Angeles. Authorities arrested five people, including a radiologist, a chiropractor, a medical equipment provider, a medical clinic administrator and a so-called medical marketer. An attorney and a medical service provider were summoned to appear in federal court on Thursday.  One indicted defendant, Gonzalo Paredes, remains a fugitive and a warrant has been issued for his arrest.

These defendants, plus six corporations, are charged in three federal grand jury indictments unsealed today with conspiracy and honest services mail fraud. The indictments allege that these players either paid or received tens of thousands of dollars to buy or sell hundreds of patients, without the patients’ knowledge - therefore depriving those patients of their right to their doctors’ honest services.

“Today’s indictments are only the first wave of charges in what we believe is rampant corruption on the part of some physicians and chiropractors in their dealings with the health care system in general, and California’s Workers’ Compensation System in particular,” said U.S. Attorney Laura Duffy. “A patient puts his trust, and his very life, into the hands of his physician. A doctor’s decisions should never, under any circumstances, be influenced by anything other than the patient’s best interest.”

“Today's indictments show how the defendants in this case allowed greed and corruption to influence their patient care decisions and treated their patients as a commodity to be bought and sold,” said FBI Special Agent in Charge Eric S. Birnbaum. “The FBI will continue to use our intelligence and investigative expertise to identify, disrupt and dismantle sophisticated criminal conspiracies that unlawfully enrich individuals at the expense of patient care. The FBI and our law enforcement partners are committed to rooting out corruption in our health care system.”

“This criminal network bought and sold patients like cattle,” said District Attorney Bonnie Dumanis. “They cashed in on people who trusted them with their health and they conspired to illegally game the system on a level that we’ve not seen before. But, the game is over.”

“Our detectives from the California Department of Insurance worked closely with the FBI, United States Attorney's Office and San Diego District Attorney's office to investigate and arrest these medical providers for insurance fraud, which adds crippling costs to California's workers compensation system,” said Department of Insurance Commissioner Dave Jones. “These are not victimless crimes. When medical providers defraud insurers, those costs are passed on to California businesses and consumers, who already are struggling to make ends meet.”

This is how the schemes worked:

Patients who said they were injured on the job filed a workers’ compensation claim with the state of California and sought treatment for their injury. In this round of indictments, the workers sought help from a chiropractor.

The chiropractors were the gateway to a wide-array of health care fraud. In these cases alone they prescribed medical equipment, referred the patients for MRIs and X-Rays, and ordered specialized treatments such as Shockwave therapy.

As alleged in one of the indictments, Los Angeles radiologist Ronald Grusd paid bribes to a San Diego chiropractor in exchange for patient referrals. The bribes were funneled to the chiropractor via Grusd’s corporation, Willows Consulting, a shell company. The checks were labeled “professional services,” but this was a sham.

In order to further hide the illegal kickbacks, checks were issued to intermediaries - defendants Alexander Martinez and his father, Ruben - through their front companies, “Line of Sight” and “Desert Blue Moon.” The Martinezes took their “cut” and then, in turn, paid off the chiropractor.
Grusd’s practice, California Imaging Network Medical Group, has clinics in San Diego, Los Angeles, Beverly Hills, Fresno, Rialto, Santa Ana, Studio City, Bakersfield, Calexico, East Los Angeles, Lancaster, Victorville and Visalia.

In another indictment, a second San Diego chiropractor, Dr. George Reese, with offices on El Cajon Boulevard, referred patients to a Los Angeles area medical service provider (controlled by attorney Lee Mathis and Fernando Valdes, president of Foremost Shockwave Solutions ) in return for bribes. The bribes were set by the conspirators at $100 per patient and paid through an intermediary. After taking a cut amounting to $25 per patient, the intermediary would pay the remaining $75 per patient to Reese.

Although disguised as “office rent” payments, the illegal bribes were paid in cash during clandestine exchanges in restaurants and parking lots. For example, $6,000 in cash was delivered to Reese in the parking lot of the Jolly Roger in Oceanside, hidden in a gift bag. Other times, it was passed in envelopes or stashed inside newspapers.

According to the indictment, Reese and his codefendants generated and submitted bills to insurers totaling in the tens of millions of dollars. Most of these treatments involved the providing of “Shockwave therapy,” which uses low energy sound waves to initiate tissue repair. Proceeds from the insurance claims generated through this scheme were paid to Mathis and Valdes.

In the final indictment, a San Diego chiropractor referred patients to a licensed provider of durable medical equipment, Julian Garcia. In return Garcia paid the chiropractor $50 for each patient – in cash, to disguise the kickbacks. Garcia then improperly billed Workers Comp insurers millions for hot and cold packs for patients who had been secured by bribes.

Top NJ Workers' Compensation Decisions of 2019

It has been an active 2019 for workers’ compensation decisions in New Jersey. There have been two NJ Supreme Court opinions and three reported Appellate Court opinions that are noteworthy. From a review of the pending docket the NJ Supreme Court will be reviewing at least 3 very significant issues in 2020 invoking workers’ compensation issues.

Hospitals May Soon Be Reaching For The Stars

Should injured workers have the opportunity to select the "best rated" medical provider? The Federal government is looking forward to providing outcome base rating information. The workers' compensation system should utilize that information and allow injured workers to be able make an educated choice in seeking medical care. Today's post was shared by Kaiser Health News and comes from www.kaiserhealthnews.org

Star wars may be coming to a hospital near you.

Medicare is considering assigning stars or some other easily understood symbol to hospitals so patients can more easily compare the quality of care at various institutions. The ratings would appear on Medicare’s Hospital Compare website and be based on many of the 100 quality measures the agency already publishes.

The proposal comes as Medicare confronts a paradox: Although the number of ways to measure hospital performance is increasing, those factors are becoming harder for patients to digest. Hospital Compare publishes a wide variety of details about medical centers, including death rates, patient views about how well doctors communicated, infection rates for colon surgery and hysterectomies, emergency room efficiency and overuse of CT scans.

In its proposed rules for hospitals in the fiscal year starting Oct. 1, the Centers for Medicare & Medicaid Services asked for ideas about "how we may better display this information on the Hospital Compare Web site. One option we have considered is aggregating measures in a graphical display, such as star ratings."

Private groups such as Consumer Reports, the Leapfrog Group and US News and World Report already issue hospital guides that boil down the disparate Medicare scores -- along with their own proprietary formulas -- to come up with numeric scores, letter grades or rankings.

But even before it's formally proposed, the possibility of the government rating...

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For over 3 decades the Law Offices of Jon L. Gelman  1.973.696.7900  jon@gelmans.com have been representing injured workers and their families who have suffered occupational accidents and illnesses.

Read more about "medical treatment" and workers' compensation:

Workers' Compensation: What Medical Expenses Are Covered In A ...

Apr 15, 2013

The main difference is in Nebraska, as long as the worker elects a prior treating doctor to treat their injury (for example, the worker's family doctor), that doctor can dictate the medical care and refer them to others for treatment.

http://workers-compensation.blogspot.com/

NJ Bayonne Medical Center - Highest Priced Medicine in the Nation

May 18, 2013

While workers' compensation insurance carriers may set approved fees or contract with providers, hospitals have huge disparities in the cost for medical care provided. Additionally, there appears to be no difference in the ...

http://workers-compensation.blogspot.com/

NY Worker's Compensation Board Proposes New Medical - Workers ...

Nov 16, 2012

New York Worker's Compensation Board's proposed new medical treatment guidelines that will modify 2010 previously implemented. Adopt the new carpal tunnel syndrome (CTS) medical treatment guidelines (MTG) as the ...

http://workers-compensation.blogspot.com/

Obama Administration Delays and Simplifies Rules on Health Care

Jul 03, 2013

Read more about The Affordable Health Care Act: Workers' Compensation: Protecting Healthcare Workers. May 06, 2013. Kerri A. Thom, MD, MS, Assistant Professor of Medicine at the University of Maryland School of ...

http://workers-compensation.blogspot.com/

Related articles

• NJ Workers Compensation Companies Pay More for Hospital Fees
• Proposed Medicare Payment Reductions Will Impact Workers' Compensation Costs
• CMS Consolidates Web Portals for Coordination of Benefits & Recovery
• Privacy: Workers' Compensation Health Data Heading for Electronic Storage
• Infectious Disease: Cyclospora Infection Becomes More Widespread

Florida medical marijuana and the 2016 Election Cycle

The medical marijuana initiative may have a major effect n the future of not only the nation'a presidential outcome but also of the fate of workers' compensation in the State of Florida. As goes Florida in the 2016 election cycle so probably will the nation, because of the mechanics of the National count of electoral college votes. 

The medical marijuana ballot question lost last off-year cycle because the liberal turnout was so low. The initiative could spur more voters to the poles and impact not only the Florida presidential count but also the local and state candidates. 

Ironically, a large voter turnout will result in the election of more liberals into office in Florida will ultimately liberalize the state leadership and its present negative thoughts on benefits. The upcoming election may ultimately impact the pending judicial cases involving the constitutionality of Florida's workers' compensation act.

Today's post is shared from reuters.com/

TALLAHASSEE, Fla. (Reuters) - The push to legalize medical marijuana in Florida continues with a two-pronged campaign, supporters said on Friday, sharing plans to mount another ballot drive in 2016 as a way to pressure state lawmakers to consider legislation permitting prescription pot. A constitutional amendment to legalize medical marijuana in Florida last year fell just short of the 60 percent approval needed to pass in the state. Morgan, who spent about $4 million on his United for Care campaign last year, said he has revised the ballot language to...

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Read more about medical marijuana and workers' compensation:

Workers' Compensation: Florida: Legalizing Marijuana Fails ...
Nov 05, 2014
Copyright. (c) 2014 Jon L Gelman, All Rights Reserved. Wednesday, November 5, 2014. Florida: Legalizing Marijuana Fails to Pass. Amendment 2. Amend Constitution to legalize medical marijuana? ANSWER, VOTES, PCT.
http://workers-compensation.blogspot.com/

For Marijuana, a Second Wave of Votes to Legalize
Oct 29, 2014
As the libertarian movement in the Republican Party has gained force, with leaders like Senator Rand Paul, Republican of Kentucky, supporting decriminalization of marijuana and others going even further, an anchor of the ...
http://workers-compensation.blogspot.com/

Workers' Compensation: Marijuana and Workers' Comp
Sep 08, 2014
There are some who believe medical marijuana and the workplace are a potent mix just waiting to be stirred as increasingly more states approve the herb and its derivatives for medicinal use. Not only are states approving the ...
http://workers-compensation.blogspot.com/

Court Rules Workers Comp Must Cover Medical Marijuana
Sep 22, 2014
"Indeed, medical marijuana is a controlled substance and is a drug,” the court wrote. “Instead of a written order from a health care provider, it requires the functional equivalent of a prescription - certification to the program.
http://workers-compensation.blogspot.com/

Found on

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Jobs, Growth & Universal Healthcare

Robert Reich, in a 3 minute video, states the reasons why jobs, growth and universal healthcare are needed to expand the US economy. 

This is reflective of the issues plaguing the nation's workers' compensation system, especially soaring medical delivery costs (administrative, clinical and pharmaceutical).  

Read more about "universal healthcare" and workers' compensation:

Universal Medical and Workers' Compensation: It's Not

Feb 01, 2013

Medical care afforded by workers' compensation delivery systems will ultimately be merged into a universal national program, despite all the opposition along the way. My friend, and cycling inspiration, who keeps me trying to ...

http://workers-compensation.blogspot.com/

Our Journey Forward on Occupational Medical Care - Workers ...

Nov 09, 2012

Going forward it is imperative that a universal medical program be established to provide medical treatment for all work-related occupational injuries and exposures. The delay and denial of medical benefits to those who suffer ...

http://workers-compensation.blogspot.com/

Path to Federalization: A National Workers Compensation System

Jul 05, 2012

Those efforts demonstrate a commitment to bring the nation ever closer to a universal care medical program incorporating the entire patchwork of workers' compensation medical delivery systems. The US Supreme Court has ...

http://workers-compensation.blogspot.com/

Workers' Compensation: Vermont Universal Health Care to Embrace ...

Mar 05, 2011

Vermont Universal Health Care to Embrace Workers Compensation. A two-stage bill in Vermont is geared to establishing a single-payer medical health care system that would include medical for workers' compensation ...

http://workers-compensation.blogspot.com/