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Eight Medical Providers Suspended for Fraud by Division of Workers’ Compensation

The California DIR’s Department of Workers’ Compensation (DWC) has suspended an additional 8 medical providers who were found guilty of fraud. Orders of Suspension from California’s workers’ compensation system were filed against the following medical providers: Abraham Khorshad – This Beverly Hills investor in Aspen Medical Resources was also a co-conspirator with providers Jeffrey Campau and … Continued

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400 QMEs File Lawsuit Claiming License Terminated by DIR Without Hearings

Three former qualified medical evaluators (QMEs) who were denied re-appointment are suing the Department of Industrial Relations (DIR) and its director Christine Baker for using “underground regulations” to deny them re-appointment.

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Medicaid Systems Able to Pursue Full Settlement Amounts on Oct. 1

As the result of a federal law effective October 1, state Medicaid systems will likely intensify their efforts to collect money they’re owed from workers’ compensation settlements. 

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California DWC Posts Searchable Database of Liens Dismissed by Operation of Law

The California DIR’s Department of Workers’ Compensation (DWC) has posted a searchable database of liens dismissed by operation of law.

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10 Attorneys and 6 Cappers Charged in Massive Workers’ Compensation Insurance Referral Scheme

Charges have been filed against 10 attorneys and six cappers in a multi-million dollar workers’ compensation insurance referral scheme in Orange County.

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Apportionment and Genetic Factors of Disability

The Court of Appeal, Third Appellate District, in City of Jackson v. WCAB (Rice) (4/26/17), has issued a decision that will provide substantial assistance in achieving the Legislature’s directive in Labor Code Section 4663 with respect to apportionment.

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State Charges 26 in $40 Million SoCal Kickback Scheme

Orange County prosecutors recently charged 26 business owners, pharmacists, and doctors in a $40 million kickback scheme in Southern California.

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Aguilera v. Collins Chiropractic Group

In a recent decision, the Workers’ Comp Appeals Board affirmed its prior decision in Aguilera v. Collins Chiropractic Group which said that a plaintiff’s industrial injury caused only 88% permanent disability rather than the 100% determined by the Workers’ Comp Judge.

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Gilpin v Porterville USD 2017 Cal. Wrk. Comp. P.D. LEXIS 4

Gilpin filed two actions against two separate employers. One of the defendants filed a Petition for Consolidation.

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Maxham v California Department of Corrections Clarifies Agreed Medical Examiner (AME) Distinction

When is a communication not information? Is there a distinction between the two or are there consequences from a failure to correctly categorize? The Workers’ Compensation Appeals Board, in its January 23, 2017 En Banc Decision in Maxham v California Department of Corrections, has provided the answers.

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DIR Stays 200,000 Liens with Claimed Value of $1 Billion

The Department of Industrial Relations (DIR) announced on January 18, 2017 that it stayed 200,000 liens worth more than $1 billion in an effort to prevent ongoing workers’ compensation fraud.

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Billing Fraud

As reported by workcompcentral, The Division of Workers’ posted proposed emergency regulations to implement the legislative mandate to suspend doctors convicted of billing fraud or harming patients.

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Your MPN May Still Be Valid, Despite a Lack of Multiple Physicians

Maria Soto v. Sambrailo Packaging, Zenith Insurance Company, 2016 Cal. Wrk. Comp. P.D. LEXIS 26, a panel decision, reaffirms the WCAB’s recent trend of finding valid MPN access standards where there are no physicians available within applicant’s preferred specialty.

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Petitions for Dismissal for Failure to Appear

In Nunez v Petrochem Insulation, Inc, 2016 Cal. Wrk. Comp P.D. LEXIS, the Court was presented with a scenario which did not result in the achievement of the objective of the California Constitution, Article 16, that cases be resolved expeditiously, inexpensively and without encumbrance of any character.

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UR IMR versus MPN IMR

On October 13, 2016, applicant attorney filed a Petition for Writ of Review to the 4th DCA in Parrent v. Workers’ Compensation Appeals Board/Pacific Bell Telephone Co. SBC, Case Number D071162, with the defendant filing an Answer on November 7, 2016.

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What Is A Good Faith Personnel Action

A WCAB panel clarified that not all actions taken by an employee are considered “personnel actions” under LC3208.3(h) in Ferrell v. County of Riverside 2016 Cal. Wrk. Comp PD Lexis.

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A Penalty Under LC5814 Is Possible For Unreasonable Delay of SJDB Vouchers But Only On the Amount Actually Delayed

The WCAB has issued several cases recently in which they essentially state that LC § 5814 does apply to the unreasonable delay/denial of supplemental job displacement benefits, but the penalty of up to 25% is only on the amount actually used by the applicant, not the entire amount.

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Three Physicians In Any Specialty Are All That Is Needed For A Valid MPN

In a split panel decision of Luna v. The Home Depot, the WCAB stated that the defendant’s MPN is valid even though it did not have three orthopedists within the applicable geographic radius to act as primary treating physician (PTP).

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Independent Medical Review (IMR)

One of the hallmark provisions of the most recent statutory amendments to the Labor Code, Independent Medical Review (IMR) has generated much litigation and even more speculation as to its ramifications and ultimate constitutionality.

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SCIF v. WCAB (Margaris) 2016 Cal. App. LEXIS 491 (DCA opinion on 6/22/16)

As noted above and in previous Quarterly Reviews, SB 863 continues to generate controversy, the California workers’ compensation community is still trying to make sense of UR/IMR and learn how to incorporate the basic process into their practice.

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A Look at “Predominant Cause” for Psychiatric Injuries”

In State of California/Department of Corrections & Rehabilitation v. WCAB (Van Dyk) (2016) 81 Cal. Comp. Cases 458, Applicant had a specific injury to the lumbar spine, which settled. A CT claim was subsequently filed, alleging injury to his back and psyche.

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Doctors Cannot Circumvent the AMA Guides

Moten v. City of Los Angeles 2015 Cal. Wrk. Comp. P.D. LEXIS 566: In this unanimous panel decision, the applicant was evaluated by an AME who diagnosed multiple ailments. On cross-examination, the AME changed his impairment rating for the lumbar spine from 2% WPI to 20% WPI apparently taking into account the applicant’s loss of function and utilizing Almaraz/Guzman.

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A “Violent Act” Is Not Limited to Criminal or Quasi-Criminal Activity

Larsen v. Securitas Services 2016 Cal.Wrk.Comp. PD Lexis – (Appeals Board Noteworthy Panel Decision): The WCJ found that Applicant’s psychological permanent disability resulted from a “violent act” in accordance with Labor Code §4660.1(c)(1) and was compensable.

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Movie Extra Gets Lost and Dies – Industrial Causation found

New CAPPS LLC v. WCAB, Daniel Harris (Dec’d), Victoria Harris (Widow), 2016 Cal.Wrk. Comp: Decedent, who was employed as a movie extra by a production company, was found dead in his car on 10/1/12 almost 14 hours after leaving the movie set and approximately one-half mile from the road to the movie production base-camp where he was working.

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An Alcoholic Death – Industrial Causation Found

City of Stockton v. WCAB, Andrew Prouty (Dec’d), Theresa Prouty (Widow), 2016 Cal. Wkr. Comp.: Decedent, while employed as a firefighter, sustained and admitted injury to his low back on 9/12/2006.

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C&R Settlement Language

Johns Mansville v. WCAB (Cooper) 2016 Cal.Wrk.Comp LEXIS 2 (W/D): After settling an asbestos related case involving lungs and respiratory system by way of CNR, applicant died and his widow was allowed to bring another claim against same defendant.

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No Penalties Due To “colorable Basis” For Denial

In ARS Construction, et al v. Worker’s Compensation Appeals Board, Wayne Davis, Respondents, the Board, in a split decision, found defendant’s delay in providing workers compensation benefits, arguing the panel QME report did not constitute substantial medical evidence, did not warrant the imposition of penalties after an ultimate AOE/COE finding following trial.

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Scheduling a PQME Re-evaluation in 60 days

Lopez v. Hemington Landscape discusses the 60 day requirement as it relates to PQME re-evaluations.

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Codefendant obtaining its own PQME

In Chanchavac v. LB Industries, Inc., the WCAB held that a codefendant was entitled to obtain its own PQME evaluation in a continuous trauma injury for which they both had coverage even though the other codefendant had already secured such an evaluation when there was no election against either defendant.

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Proper Deferral of Utilization REVIEW

Millette v. 81 Grand holdings, Inc. (writ denied) is a good overview of what is necessary for a proper deferral of utilization review.

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