Tag Archives: California

Sad News

Learned this afternoon of the sudden death of my fellow blogger, David De Paolo. See the link below. Never met him, but readers here know that I have always reported what he wrote fairly and honestly, and even though my comments to him have not appeared in my posts, I respected him as a fellow blogger.

He will be sorely missed, as he was a regular fixture in many of my posts.

http://www.workerscompensation.com/compnewsnetwork/news/24272-david-depaolo-founder-of-workcompcentral-dies-at-56.html

 

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Cross-Border Health Care in California Expands

In my earlier posts on cross-border health care, “Cross-border Workers’ Compensation a Reality in California“, “NAFTA, Work Comp and Cross-Border Medical Care: A Legal View“, “NAFTA, Work Comp and Cross-Border Medical Care: A Legal View: Update“, and “Cross-border Health Care and the ACA“, I discussed the way some Mexican workers living in Mexico, but working in the US or traveling between the US and Mexico, have been able to get health care on both sides of the border.

An article in Fierce Healthcare.com last month,  says that Scripps Health will help run a hospital in Tijuana, along with Sistemas Medicos Nacionales S.A. de C.V. (SIMNSA).

SIMNSA is the medical insurer in Mexico that the Insurance Company of the West (ICW) contracted with some time ago to treat Mexican workers of ICW’s US insureds in the San Diego/Imperial Valley area of CA.

According to the article by Ilene MacDonald, the insurer will design, build and operate the facility, and will seek accreditation from the international arm of the Joint Commission, the Joint Commission International (JCI), and will be an affiliate of the Scripps Health Network.

Those who think that cross-border health care, whether general or work comp-related is not going to happen better think again, because it is, and while this is just now involving the areas along the US-Mexico border, with or without that stupid wall some jerk wants to build and have Mexico pay for, medical travel on this continent is moving forward.

The only thing that is not happening yet is travel further down into Mexico and into the other countries in Central and South America. But that will happen, no matter what you or any putz running for president says.


I am willing to work with any broker, carrier, or employer interested in saving money on expensive surgeries, and to provide the best care for their injured workers or their client’s employees.

Ask me any questions you may have on how to save money on expensive surgeries under workers’ comp.

I am also looking for a partner who shares my vision of global health care for injured workers.

I am also willing to work with any health care provider, medical tourism facilitator or facility to help you take advantage of a market segment treating workers injured on the job. Workers’ compensation is going through dramatic changes, and may one day be folded into general health care. Injured workers needing surgery for compensable injuries will need to seek alternatives that provide quality medical care at lower cost to their employers. Caribbean and Latin America region preferred.

Call me for more information, next steps, or connection strategies at (561) 738-0458 or (561) 603-1685, cell. Email me at: richard_krasner@hotmail.com.

Will accept invitations to speak or attend conferences.

Connect with me on LinkedIn, check out my website, FutureComp Consulting, and follow my blog at: richardkrasner.wordpress.com.

Transforming Workers’ Blog is now viewed all over the world in 250 countries and political entities. I have published nearly 300 articles, many of them re-published in newsletters and other blogs.

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WCRI – Day One, Part One

Day One of the WCRI’s annual conference began with WCRI’s Chairman, Vincent Armentano, of The Travelers Companies, introducing new President and CEO John Ruser. He presented the first s…

Source: WCRI – Day One, Part One

Cross-border Health Care and the ACA

From the ‘before you go to the WCRI conference’ department is an article about a subject not on the agenda in Boston this week, and since I convinced the WCRI that crossing the Hudson river is not medical travel, nonetheless, people are leaving the country and one US state for medical care, and not just for work-related issues.

Jim Arriola, COO of MediExcel Health in California, and Caitlin Gadel, an attorney at Seaton, Peters & Revnew, wrote an article this month in California Broker magazine (pg. 20-22), outlining how cross-border health plans in California are complying with many of the provisions of the Affordable Care Act (ACA).

You may recall that I wrote about cross-border health care, especially for workers’ comp, in my article, “Cross-border Workers’ Compensation a Reality in California“, as well as these two articles, “NAFTA, Work Comp and Cross-Border Medical Care: A Legal View” and “NAFTA, Work Comp and Cross-Border Medical Care: A Legal View: Update“.

According to the article, almost twenty years ago, the California Department of Managed Health Care (DMHC), began regulating a consumer driven phenomena for receiving employer-sponsored health coverage south of the border.

As stated in the article, on a daily basis, up to 40,000 workers cross the border from Mexico to work in California. These workers and their families live in Mexico, and prefer to get their medical care in Mexico.

Changes to the Knox-Keen HMO Act allowed US and Mexican health plans to establish cross-border coverage. Much of this is occurring in the San Diego and Imperial county area, as discussed in “Cross-border Workers’ Compensation a Reality in California” with the Mexican HMO, SIMNSA, as well as others such as Blue Shield of CA, Health Net, Cigna, Aetna, and MediExcel Health Plan.

Depending upon the benefits of the plan, some cross-border coverage plans have premiums that are 40% to 50% lower than those in California.

There are an estimated 60,000 enrollees in various health coverage plans in California, and some experts predict the total number will increase to over 100,000 as more employers offer coverage as a result of the ACA rules and regulations, according to Gadel and Arriola.

Gadel and Arriola report that many ACA provisions (as well as the thousands of pages of regulations), apply to cross-border coverage, especially if the coverage is not a qualified expatriate plan.

Gadel and Arriola advanced the idea that some brokers may be concerned whether a cross-border plan satisfies the ACA definition of a minimu-essential coverage (MEC) when the provider network is in Mexico.

They also said that legal experts have noted that under federal regulations, employer-sponsored plans approved by state regulators are MEC plans.

In order to receive approval from the DMHC, such plans must submit evidence of their compliance with ACA regulations.

Brokers, it is suggested by the authors should not offer cross-border plans exclusively because of the differences between cross-border plans and expatriate plans.

However, the authors note, because of the complexity of the ACA’s conflicting interpretations, some cross-border plans may have been erroneously classified themselves as group expatriate coverage.

The reality, they say, is that the vast majority of cross-border plans and their enrollees do not meet the federal criteria for expatriate classification.

My last post, “Borderless Healthcare: A Model for the Future of Medical Care in Workers’ Comp” was based upon a presentation given last Thursday about medical tourism to Mexico. So if there are health care plans in California providing cross-border health care into Mexico, and there is also cross-border workers’ comp occurring between California and Mexico, and in both of these cases, the mode of transporatation is generally automotive, and the presentation by Manatt, Phelps & Phillips requires airfare to Mexico, why is it that workers’ comp cannot do the same?

I don’t want to hear excuses, I want to hear why this industry refuses to join the 21st century, why it points to laws and statutes nearly a hundred years old that restrict injured workers to their own states or to the US for medical care requiring expensive orthopedic surgery, when there are less expensive and better alternatives a short flight away?

A fellow blogger wrote today about this industry’s failure to fully embrace technology, and the answer to his questions, and to mine were right there…if this industry were to change, the status quo would be undone and many companies would be forced to go out of business and their profits with them.

Our workers’ comp “system” mirrors the general health care system in many ways, as per this quote from Uncle Walter:

“America’s health care system is neither healthy, caring, nor a system.”

Walter Cronkite

It is a profit-making endevour that preys upon the sick and injured and lines the pockets of lawyers and vendors. That is why no one in this industry is listening to us…greed.

 

 

Medical Management Internship Paper, Summer 2011

No doubt, many of my readers have wondered what I learned in my MHA degree program, and why my writing has been of interest to so many of you.

Upon checking my stats for the blog, I noticed that someone had viewed a paper I wrote in the summer of 2011 for my Summer Internship course, as part of my MHA degree program requirements. The school I attended required all students without a health care background to take a one-credit course as an Intern in a health care organization.

The organization I choose was one my school already contracted with, Broadspire. At the end of the course, we were expected to write a paper about our internship for a grade in the course.

The following link will direct the reader to a copy of my paper that I hope the reader will find interesting, and will highlight my skills as a researcher and writer. Speaking engagements as well as research opportunities are most welcome, as are full-time positions and consulting opportunities.

https://www.dropbox.com/s/5573hm8xo074po0/Medical%20Management%20Internship%20Paper.docx?dl=0

As the summer session was very short, only three projects were undertaken, and the last one was truncated due to time constraints and the report presented to Broadspire concentrated on only two states, Florida and California.

Let me know your thoughts.

The Miasma of Fraud

One last post before you celebrate Thanksgiving.

Business Insurance’s Stephanie Goldberg reported today, that five people have been charged  with workers’ comp insurance fraud in California, and that the insurance commissioner called it, “one of the largest workers’ compensation insurance fraud cases we have ever seen.”

In July, 2014, I wrote two articles about fraud in California, “The Stench of Fraud: Why Workers’ Comp Can No Longer Be a Closed System” and “The Stench of Fraud, Continued.”

Charged in the case was the former CFO of Pacific Hospital, James L. Canedo, two orthopedic surgeons, a chiropractor, and Paul Richard Randall, a health care marketer.

They were charged with illegally referring more than 4,000 patients for spinal surgeries, and generated more that $580 million in fraudulent bills during an eight-year period, according to the US Department of Justice, in a statement released yesterday.

Many of the claims were paid by the California work comp system, the rest by the federal government.

Canedo and Randall have pled guilty, and the other three have agreed to plead guilty, and under the terms of their plea agreements, each defendant could face prison terms and be required to pay restitution to their victims.

The US Attorney’s office for the Central District of California said in a statement that Canedo faces 10 years in prison and at least $20 million in restitution.

The scheme consisted of kickbacks of $15,000 for each lumbar fusion surgery, and $10,000 for each cervical fusion surgery, according to the US Attorney’s statement.

The ongoing investigation, dubbed “Operation Spinal Cap”, discovered that some of the patients lived hundreds of miles away from Pacific Hospital, and closer to other qualified facilities, the patients were not informed that medical professionals were offered kickbacks for referrals, and that insurers had paid the hospital more than $226 million for the surgeries.

Once again, we see that workers’ comp, especially in California, but also in other states, is like a fetid pool of rotting vegetation and other foul matter, so that what was once called a stench, is now a miasma that hangs over the surface of the system.

It does not have to be like that. It can be better. You can find an alternative to expensive surgeries and illegal payoffs, if only you would consider new ideas and new possibilities.

Or you can continue to breathe in the foul air. The choice is yours.

 

 

 

California Work Comp: What a Mess!

Kevin Tremblay, V.P., National Accounts for SMS National Solutions in Altamonte Springs, Florida, and a connection of mine on LinkedIn, penned the following article about California work comp and liens.

Normally, I shy away from articles involving California work comp, but on one or two occasions have written articles about it that I feel fit the subject of this blog. This article is one of those, but is more about the mismanagement of one state’s work comp system, rather than the state of affairs of the entire system nationwide.

Here is Kevin’s article in full:

California Workers Compensation System – Liens, Waste and Medical Provider Billed Charges

The California workers’ compensation system is unique like no other state in the country. There are two distinct sides of the equation in California workers’ compensation, Applicant and Defense.

Applicant-The party, usually the claimant that opens a case at the local Workers Compensation Appeals Board (WCAB) office by filing an application for adjudication of claim.

Defense-The party, usually the employer or its insurance company opposing the claimant in a dispute over services and benefits.

Lien-A right or claim for payment against a workers’ compensation case. A lien claimant, such as a medical provider, can file a form with the local Workers Compensation Appeals Board to request payments of money owed in a workers’ compensation case.

OMFS-The official medical fee schedule is promulgated by the DWC, Department of workers Compensation administrative director under labor code section 5307.1 and can be found in section 9789.10 of title 8, California code of regulations. It is used for payment of medical services required to treat work related injuries and illnesses. The California Official Medical Fee Schedule is considered prima facie evidence of reasonableness.

A lien claimant has the burden of proving that any amount charged is reasonable, and a lien claimant must prove that there are “extraordinary circumstances” that justify a fee that exceeds the Official Medical Fee Schedule.

According to some recent reports, an expected 500,000 liens will be filed by treating medical providers in the California Workers Compensation system in 2015, costing employers and insurers an estimated $200 million dollars in loss adjustment expenses and delaying claims adjudication.

Some of these liens forces some employers or insurance companies to settle liens they may not be legally obligated to pay simply to settle and close the claim to avoid paying additional disability, administrative and legal costs. Emphasis here on, ‘forces

Some additional statistical findings reported by the DWC are:

  • Medical treatment liens account for more than 60 percent of the liens filed, and 80 percent of the dollars in dispute.
  • $1.5 billion per year is claimed in medical lien disputes after adjusting for amended lien files.
  • One-third of medical liens involve disputes over the application of the Official Medical Fee Schedule.
  • Authorization for treatment was in dispute in seven out of 10 medical liens surveyed.
  • Reasons treatment was not authorized were: 37 percent provider not authorized to treat (mostly out-of-network); 7 percent denied claims; 6 percent medical necessity of treatment rejected by utilization review; 1 percent contested body parts; 20 percent authorization status unknown or not stated.
  • The volume of liens filings is sensitive to procedural changes, such as the adoption or repeal of a $100 filing fee and the adoption of new filing procedures.
  • Up to 30 percent of medical liens are prematurely submitted before the time has elapsed for the claims administrator to pay or object to the provider’s bill.
  • Ten percent of medical liens are submitted on the date the service is provided.
  • Nearly one quarter of medical liens are filed more than two years after the last date of services for which payment is claimed, including 6 percent that are filed five or more years after the last date of services.

The report was based on information provided by the Division of Workers’ Compensation, and was an attempt to characterize the problem so policymakers can propose solutions to the lien problem.

Source: CHSWC/InsuranceJournal.com

The Lien System Game:

Bill ($5,000) – Paid ($1,000)-in accordance with OMFS

Fee to file the lien the claim in court by medical provider $150.00

Lien balance $4000

Demand: $3800

Offer: $2000

Negotiation continues

Collector says $3200 is the bottom line for him

Adjuster forced to pay and settle to avoid additional claim cost agreement at $3200

So while the DWC and legislators continue to sort over of resolve the issues of the lien process, what can adjuster’s implement to mitigate the process and reduce claims costs? The following strategies are a good place to start:

  • How much is the lien?
  • How much is the OMFS or reasonable value of the lien?
  • What are your lien defenses?
    • AOE/COE
    • MPN
    • OMFS or other fee schedules / IBR
    • Reasonableness & Necessity
    • UR / IMR
    • Other technical issues
  • What evidence do you have to support your position? Objection letters? MPN Notices?
  • Did you serve your evidence on the lien claimants and/or your counsel?
  • What are the probable economics of your decision to settle or fight?
  • How much are you willing to pay to settle or resolve the lien?
  • We paid per OMFS & DOS is after 1/1/13
  • You failed to request 2nd review within 90 days (LC 4603.2(e)(2))
  • You failed to request IBR within 30 days from 2nd review (LC 4603.6(a)
  • You are done. The Code says: “the bill shall be deemed satisfied and neither the employer nor the employee shall be liable for any further payments.”
  • Any appearance at the board on your lien will result in a petition for costs & sanctions! [LC 5811 & Valdez decision (en banc) (77 CCC 1113)]

The State of California has taken recent measures with the advent of SB863 and labor codes 9792.5.12 and 4903.1(b) regarding independent bill review process and tighter lien submission rules. California legislators need to continue to act and close the loop holes in existing laws to mitigate and eventually eliminate the magnitude of waste and abuse by certain medical providers that is currently taking place and plaguing the workers’ compensation system.

The lien process is certainly unique to the rest of the country’s state by state workers’ compensation system. So what is it? Unethical gaming of the system and adding tremendous unnecessary costs and clogging the California courts and workers’ compensation system, no question. Anything more, you decide…..