Featured Sponsor

Oscar Rodriguez is a Hearing Representative with our firm’s Pasadena location. Mr. Rodriguez is not only a certified Workers’ Compensation Claims Adjuster (WCCA), but he completed his certificate with advanced courses provided by the Insurance Education Associates for his WCCP. Before joining our firm, Mr. Rodriguez obtained over 10 years of experience in the California workers' compensation system as a hearing representative. With that sophistication, Mr. Rodriguez is able to analyze medical and legal evidence, and he is able to resolve lien matters quickly and efficiently, saving both time and litigation costs to his clients.


Our School

Please visit our online school.

The WorkCompAcademy is a full featured online learning experience. Our faculty includes the leading practitioners in the California Workers' Compensation Community. Our online curriculum covers all aspects of Workers' Compensation Claims, from basic concepts to advanced topics of value to experienced practitioners such as senior claims exectives, attorneys, and Qualified Medical Evaluators. Students can access classes any time, from any internet connected computer. Courses can be completed at an individualized pace.

Workers' Compensation Daily News for Mar 22, 2018

No Settement - Yet - in Opioid MDL Litigation
Wed, 21 Mar 2018 10:11:31 - Pacific Time
A push to resolve more than 350 lawsuits against the makers and distributors of opioid painkillers has hit a snag, so a federal judge cleared the way for lawyers to start collecting evidence for trials.

U.S. District Judge Dan Polster in Cleveland said Wednesday "substantial progress" has been made in talks between U.S. cities and counties and Purdue Pharma LLP and other opioid makers and distributors, but both sides have found "barriers to a global settlement."

Allowing local governments’ and opioid makers’ attorneys to get ready to go to trial is the "quickest way to surmount at least some of those barriers," Polster said in an order the day after the most recent negotiating session.

"We are pleased Judge Polster is pursuing settlement possibilities while simultaneously allowing for litigation steps to be taken," Paul Hanly, a New York-based lawyer helping to lead the case on behalf of cities and counties. "Hopefully, the two tracks converge in a global resolution."

The judge is backing away from an earlier decision to put litigation efforts on hold while lawyers for Purdue, Johnson & Johnson, McKesson Corp., Endo International Plc, Teva Pharmaceutical Industries Ltd. and other companies talked with cities’ and counties’ attorneys about settling the cases.

Polster has made clear he wants a "meaningful" resolution of cases blaming the companies for creating a public-health crisis that is claiming the lives of more than 100 Americans every day. The judge has said he wants a deal addressing the companies’ business practices and the roots of the crisis.

Opioid Crisis Point Man Is Cleveland Judge in Midst of Epidemic

City and county officials contend Purdue and other opioid makers downplayed the painkillers’ health risks and oversold their benefits through hyper-aggressive marketing campaigns. They are seeking to recoup the societal costs of dealing with opioid addictions and overdoses as part of a settlement similar to the 1998 Big Tobacco accord that generated $246 billion.

"We are committed to being part of the ongoing dialogue and to doing our part to find ways to address this crisis," said Jessica Castles Smith, a spokeswoman for J&J’s Janssen unit.

Teva spokeswoman Kaelan Hollon declined to comment. Purdue spokesman John Puskar declined to comment. Heather Zoumas Lubeski, an Endo spokeswoman, declined to comment

The companies also have been in settlement talks with a group of states attorneys general, some of whom have already sued opioid makers and distributors seeking to recoup tax dollars spent to address the crisis. Polster also has had some AGs involved in his settlement negotiations.

Polster has said if the federal opioid cases must be weighed by juries, he’d set the state of Ohio’s claims for trial in 2019. Oklahoma has a May 28 trial date set for its claims against Purdue and the other companies in state court.

Mike DeWine, Ohio’s attorney general, hasn’t said how much he wants from pharmaceutical companies and distributors to address the crisis in his state, but noted an Ohio State University study found that opioids cost the Buckeye State as much as $8 billion annually.

Polster is giving lawyers for both sides until March 16 to come up a litigation plan for the consolidated cases and will hold the next negotiating session on May 10. As with others, the session won’t be open to the public.

The case is In Re: National Prescription Opiate Litigation, 17-cv-2804, U.S. District Court, Northern District of Ohio (Cleveland). Read More...

Feds Promise Action to Lower Drug Prices
Wed, 21 Mar 2018 10:16:05 - Pacific Time
President Donald Trump promised to bring down prescription drug prices on Monday, saying U.S. citizens pay far more than people in other countries do for the same product and that his administration would announce new measures in about a month.

"If you compare our drug prices to other countries in the world, in some cases it’s many times higher for the exact same pill or whatever it is, in the exact same package made in the exact same plant,” Trump said. “We’re going to change that."

Trump made the remarks during a speech in Manchester, New Hampshire that focused on the administration’s efforts to battle the nation’s opioid addiction crisis. Trump said he planned a news conference in about a month to roll out drug price proposals.

"We’re driving ‘em down," Trump said. "We pay as a country so much more for drugs because of the drugs lobbies and other reasons, and the complexity of distribution, which is basically another term for saying, ‘How do we get more money?’."

His comments reflect growing scrutiny over what patients end up spending for their medicines after insurers, distributors, hospitals and pharmacies are paid for their roles in delivering the drugs. U.S. Food and Drug Administration Commissioner Scott Gottlieb recently criticized such players for "Kabuki drug-pricing" constructs that drive up prices for consumers.

On Monday, Health and Human Services Secretary Alex Azar said the new proposals will focus on "how we decrease the price of drugs and how we bring discounts that the middlemen right now are getting, how those will go to our patients."

Azar, a former president of the U.S. arm of drugmaker Eli Lilly and Co, joined Trump at the New Hampshire event.

Trump has vowed since his election to tackle rising drug prices. His proposed 2019 budget outlined some steps to do so, including by allowing up to five states more flexibility over which drugs are covered by Medicaid, the government health insurance program for the poor and disabled.

That could give the states more leverage to negotiate lower prices for prescription medicines.

Trading volume in the ishares Nasdaq Biotechnology exchange-traded fund picked up as Trump began talking about drug prices, but the ETF’s price closed down about 2 percent.

Shares in pharmacy benefits managers Express Scripts Holding Co and CVS Health Corp closed down 4 percent and 3.1 percent, respectively.

Reporting by Roberta Rampton; Additional reporting by Yasmeen Abutaleb in Washington and Caroline Valetkevitch in New York; Writing by Doina Chiacu; Editing by Leslie Adler and James Dalgleish Read More...

Drugmaker Bribes Doctors with Lap Dances to Prescribe Opioid
Tue, 20 Mar 2018 08:15:35 - Pacific Time
Five Manhattan doctors were paid more than $800,000 by a pharmaceutical company to prescribe a spray version of the highly potent and addictive opioid fentanyl to more and more patients whether they needed it or not, according to an indictment unsealed last Friday in federal court.

The money was earmarked as "speaker fees" for educational lectures on the drug that the doctors had agreed to give to medical professionals. In reality, according to federal prosecutors, the "lectures" were just booze-fueled social gatherings, and the fees were kickbacks paid to prescribe the drug, Subsys.

And doctors who went along with the arrangement got other perks, prosecutors say: tickets to sporting events, free meals delivered to their office workers, casino and nightclub outings and a $4,100 evening of lap dances at a strip club -- all paid for by the drugmaker, Insys Therapeutics.

On Friday, the five physicians, several of whom are affiliated with prestigious hospitals, were indicted on conspiracy and other charges that carry up to 20 years in prison. Drs. Gordon Freedman, Jeffrey Goldstein, Todd Schlifstein, Dialecti Voudouris and Alexandru Burducea all pleaded not guilty and were released on $200,000 bond each.

At the same time, prosecutors unsealed the guilty pleas of two former Insys executives, Jonathan Roper and Fernando Serrano, who were charged last year and are now cooperating. The company's billionaire founder, John Kapoor, and other Insys officials and employees are also under indictment in a scandal that has been unfolding since 2014.

The 75-page indictment, unsealed Friday in New York, alleges that as the doctors pocketed more money from Insys, the more Subsys they prescribed.

An email from one sales representative to Freedman gave explicit instructions on how many new patients were needed to help meet a company target, according to the indictment.

"I'd rather you put 20 (or more, of course LOL) new patients (commercially insured of course, as always) on it in April even if we wind up getting only 10-14 approved, rather than only have you go with the safe 6-7 that you think will all get approved," the email said. Freedman replied: "Got it."

Prosecutors said Freedman received approximately $308,000 in "speaker program fees" and by the last quarter of 2014 was the fourth-highest prescriber of Subsys in the nation, accounting for more than $1 million in sales.

The indictment says that when Goldstein began prescribing a lot of a competing product, Insys put pressure on him and he began recommending Subsys more often. After a bitter argument with a company executive, he convinced Insys to send him a $9,800 check for a home security system and then dummied up an invoice without buying one, prosecutors alleged.

Burducea married an Insys sales rep and then lied to federal investigators about how long they had been dating so their relationship couldn't be linked to his high prescription rate, the indictment says. Voudouris had Insys' Serrano take an exam for her so she would be eligible to prescribe Subsys, prosecutors said.

When she didn't write enough prescriptions, the indictment says, Insys got upset. An email from Roper to sales reps said they had "invested way too much" to be satisfied with just a few patients.

"1 new PT [patient] a day is what was agreed upon," the email said. "Don't let the doctor sell you, you sell the doctor!"

A.I. as Accurate as Pathologist at Cancer Diagnosis
Tue, 20 Mar 2018 08:19:15 - Pacific Time
Chinese researchers have developed an artificial intelligence system which can diagnose cancerous prostate samples as accurately as any pathologist, holding out the possibility of streamlining and eliminating variation in the process of cancer diagnosis.

The system may also help overcome shortages of trained pathologists and in the longer term lead to automated or partially-automated prostate diagnosis.

Confirmation of a prostate cancer diagnosis normally requires a biopsy sample to be examined by a pathologist. Now the Chinese AI system has shown similar levels of accuracy to pathologists and can also accurately classify the level of malignancy of the cancer, eliminating the variability which can creep into human diagnoses.

Details of the AI system were presented at the European Association of Urology Congress taking place in Copenhagen this March.

"This is not going to replace a human pathologist," said Hongqian Guo, who led the research. "We still need an experienced pathologist to take responsibility for the final diagnosis. What it will do is help pathologists make better, faster diagnoses, as well as eliminating the day-to-day variation in judgment which can creep into human evaluations."

Guo’s group took 918 prostate samples from 283 patients and ran these through the AI system, with the software gradually learning and improving diagnosis. The pathology images were subdivided into 40,000 smaller samples of which 30,000 were used to train the software while the remaining 10,000 were used to test accuracy.

The results showed an accurate diagnosis in 99.38 per cent of cases, using a human pathologist as a gold standard. Guo said that means the AI system is as accurate as a pathologist.

The system was programmed to learn and gradually improve how it interpreted the samples. "Our results show that the diagnoses the AI system reported were at a level comparable to that of a pathologist. Furthermore, the system could accurately classify the malignancy level of prostate cancer," said Guo.

Until now, automated systems have had limited clinical value. "We believe this is the first automated system to offer an accurate reporting and diagnosis of prostate cancer. In the short-term, this can offer a faster throughput, plus a greater consistency in cancer diagnosis from pathologist to pathologist, hospital to hospital, country to country," Guo said. "It is important that cancer detection and diagnosis takes advantage of these changes."

"This is interesting work which shows how artificial intelligence will increasingly step into clinical practice," said Rodolfo Montironi, professor of pathology, Polytechnic University of the Marche, Ancona, Italy. "This may be very useful in some areas where there is a lack of trained pathologists. Like all automation, this will lead to a lesser reliance on human expertise, but we need to ensure that the final decisions on treatment stay with a trained pathologist." Read More...

Silicon Valley Medical Startup Resolves Fraud Charges
Mon, 19 Mar 2018 09:20:21 - Pacific Time
Elizabeth Holmes raised hundreds of millions of dollars from investors on the promise that her California Silicon Valley based medical-testing startup Theranos Inc. would change medicine with a single drop of blood. Now securities regulators called her a fraud and forced her to give up the company she built.

Holmes began to rise to national attention in 2013 when she claimed that Theranos had developed a medical technology that could do what seemed impossible: Its secret machines could run thousands of medical tests using the blood from a tiny finger-prick, and do so quickly and cheaply.

High-profile board members joined as well -- including the diplomat Henry Kissinger, James Mattis -- now the Trump administration’s Secretary of Defense, and David Boies, the lawyer who tried to stop revelations about film producer Harvey Weinstein’s sexual harassment.

Holmes had claimed her machines could process 90 percent of the tests performed by standard lab equipment. Those statements won the company an agreement with a national pharmacy chain in 2010 even though the technology was not yet "commercially ready," according to the SEC. Theranos publicly announced a partnership with the drugstore chain Walgreens, which later sued Theranos. The companies eventually settled.

The Securities and Exchange Commission charged Theranos Inc., its founder and CEO Elizabeth Holmes, and its former President Ramesh "Sunny" Balwani with raising more than $700 million from investors through an elaborate, years-long fraud in which they exaggerated or made false statements about the company’s technology, business, and financial performance.

The complaints allege that Theranos, Holmes, and Balwani made numerous false and misleading statements in investor presentations, product demonstrations, and media articles by which they deceived investors into believing that its key product - a portable blood analyzer - could conduct comprehensive blood tests from finger drops of blood, revolutionizing the blood testing industry.

In truth, according to the SEC’s complaint, Theranos’ proprietary analyzer could complete only a small number of tests, and the company conducted the vast majority of patient tests on modified and industry-standard commercial analyzers manufactured by others.

The complaints further charge that Theranos, Holmes, and Balwani claimed that Theranos’ products were deployed by the U.S. Department of Defense on the battlefield in Afghanistan and on medevac helicopters and that the company would generate more than $100 million in revenue in 2014. In truth, Theranos’ technology was never deployed by the U.S. Department of Defense and generated a little more than $100,000 in revenue from operations in 2014.

Theranos and Holmes have agreed to resolve the charges against them. Importantly, in addition to a penalty, Holmes has agreed to give up majority voting control over the company, as well as to a reduction of her equity which, combined with shares she previously returned, materially reduces her equity stake.

"The Theranos story is an important lesson for Silicon Valley," said Jina Choi, Director of the SEC’s San Francisco Regional Office. "Innovators who seek to revolutionize and disrupt an industry must tell investors the truth about what their technology can do today, not just what they hope it might do someday."

CWCI Elects Directors for 2018
Mon, 19 Mar 2018 09:20:16 - Pacific Time
Rose Barrett of the Berkshire Hathaway Group was elected chair of the California Workers’ Compensation Institute board of directors for 2018.

Barrett was first elected to the CWCI board as a representative of AIG in 2014 and has been a member of the institute’s executive committee since 2015, serving as vice-chair in 2017.

Also on CWCI’s 2018 executive committee will be Martin Brady of Schools Insurance Authority, an associate member; Susan Gordon, Zurich North America; David Mitchell, Republic Indemnity Company of America; Rob Shatsnider, CompWest Insurance Co.; Vernon Steiner, State Compensation Insurance Fund; and Matthew Zender, AmTrust North America.

Those elected to serve on CWCI’s 2018 board were:

- Sharon Thaler, AIG;
- Roger Moseley, Alaska National Insurance Co.;
- Paul Ziegler, Allianz Global Corporate and Specialty;
- Justin Boardman, CHUBB;
- David Macy, EMPLOYERS;
- Gretchen Thompson, The Hartford Insurance Group;
- Amanda Granger, ICW Group;
- John Dickey, Liberty Mutual Insurance;
- Kris Mathis, Pacific Compensation Insurance Company;
- Eric Hansen, Preferred Employers Group;
- Eric Belk, Travelers;
- Diana Harrelson, Zenith Insurance Co.; and
- Kevin Confetti, University of California, an associate member.

CWCI members include 24 insurer groups comprised of nearly 200 underwriting companies that write and service more than 83 percent of California statewide workers’ comp premium, as well as 32 of the largest public and private self-insured employers in the state. Read More...

L.A. Drug Treatment Center Owner Sentenced to 11 Years
Fri, 16 Mar 2018 10:25:22 - Pacific Time
The co-owner of a Los Angeles drug and alcohol treatment facility pleaded guilty to 46 felony counts related to a $175 million fraudulent health care billing scheme.

Deputy District Attorney Shaun Gipson of the Healthcare Fraud Division said that Los Angeles County Superior Court Judge Charlaine Olmedo immediately sentenced Kirsten Wallace (dob 4/3/73) to 11 years in state prison,.

Wallace entered an open plea to five counts of insurance fraud, seven counts of grand theft of personal property, six counts of identity theft and 28 counts of money laundering. The open plea means a sentence was not negotiated with the District Attorney’s Office. A restitution hearing is scheduled for April 17 in Department 105 of the Foltz Criminal Justice Center.

Wallace and Christopher Bathum (dob 9/22/61), who together owned Community Recovery of Los Angeles, were charged in the billing scheme in November 2016. The company operated treatment centers in Southern California and Colorado.

Gipson said the two defendants allegedly obtained multiple health care insurance policies for their clients by using their personal identifying information and falsified the clients’ circumstances to obtain the policies. The patients were unaware that policies had been issued in their name, the prosecutor said.

Bathum and Wallace also are accused of billing former clients after their treatment ended while those clients were still working at Community Recovery and no longer receiving treatment. Between June 2012 and December 2015, Bathum and Wallace allegedly fraudulently billed an estimated $175 million, Gipson said.

In most instances, bills were sent for services allegedly never provided. About $44 million was paid out by five insurance companies, the prosecutor said.

Bathum is charged with the same 46 counts as Wallace had faced. His next scheduled court appearance is a pretrial conference also April 17 in Department 105.

Bathum faces up to 45 years and four months in state prison if convicted as charged.

Last month in a separate case, Bathum was convicted of sexually assaulting seven women who were patients at his treatment center. A sentencing setting hearing in that case is scheduled April 17 in Department 105. The defendant faces a maximum possible sentence of about 65 years in state prison and lifetime sex offender registration.

Case BA451664 was investigated by the California Department of Insurance and the District Attorney’s Office’s Bureau of Investigation. Read More...

So. Cal. Physician to Serve 13 Years for Drug Trafficking
Fri, 16 Mar 2018 10:25:16 - Pacific Time
A San Gabriel Valley doctor who pleaded guilty to a federal drug trafficking charge for illegally distributing OxyContin was sentenced to over 13 years in federal prison.

Dr. Daniel Cham, 49, a Covina resident who formerly operated a clinic in La Puente, was sentenced by United States District Judge Andrew J. Guilford.

Acting on tip about a pharmacy that was filling a large number of prescriptions written by Cham, special agents with the Drug Enforcement Administration discovered a "large-scale criminal operation" in which Cham was writing thousands of prescriptions for powerful painkillers, often in combination with alprazolam (often sold under brand name Xanax) or carisoprodol (often sold under the brand name Soma), according to court documents. "The combination of these drugs is particularly dangerous, and is associated with the majority of overdose deaths," according to a sentencing memorandum filed in court.

An affidavit previously filed in this case discussed how an undercover officer made three visits to Cham’s La Puente office in 2014, and how Cham wrote prescriptions for controlled substances in exchange for $200 or $300 in cash or money orders. As discussed in the court document, Cham issued a prescription for oxycodone even though the undercover operative said he "had been high and drunk while receiving controlled substance prescriptions" previously from Cham.

On another occasion, Cham prescribed oxycodone even though the undercover law enforcement officer presented, in lieu of photo identification, a written notice that his license had been suspended for driving under the influence.

Cham pleaded guilty in April 2016 to one count of distribution of oxycodone, a powerful and addictive painkiller marketed under various names, including OxyContin, Vicodin and Norco. Cham also pleaded guilty to one count of money laundering.

Prosecutors wrote in court documents that Cham "stands before the court for selling prescriptions for massive amounts of oxycodone to persons he well knew were drug dealers and addicts, in exchange for hundreds of thousands of dollars in cash. Defendant’s illegal prescriptions killed at least two addicted youths, including a 22-year-old woman and 28-year-old man."

The young woman, who was a resident of Oregon, died after ingesting narcotics prescribed by Cham to members of Oregon-based drug trafficking conspiracy. Cham issued prescriptions in the names of the Oregon drug traffickers - many of whom he had never met - and Cham created fake paperwork to make it falsely appear he had examined the "patients." Investigators in Oregon identified over 12,000 pills of oxycodone that Cham illegally prescribed to the drug traffickers in that state.

In a plea agreement filed in this case, Cham admitted that he unlawfully prescribed oxycodone to an undercover agent posing as a patient in March 2014 in exchange for $300 in money orders, which Cham then deposited into a bank account held in the name of another business. Cham made the deposit "knowing that the transaction was designed to conceal and disguise the nature and source of the money orders," according to the plea agreement.


Injured Workers' Opioid Prescriptions Decline
Thu, 15 Mar 2018 09:46:03 - Pacific Time
Opioids remain the most common type of prescription drug used to treat California injured workers with lost-time injuries, but sustained efforts to curb their use are paying off as new data show that in the past decade they fell from about a third of indemnity claim prescriptions to less than a quarter, while there was a concurrent increase in anti-inflammatories and anticonvulsants which are often used as opioid alternatives.

A new study by researchers at the California Workers’ Compensation Institute (CWCI), based on data from 12.5 million prescriptions dispensed to California injured workers from 2007 to June 2017, measures changes in the prescription and payment distributions among major therapeutic drug groups used in indemnity claims, then takes an in-depth look at the trends in the volume, cost, potency and types of opioids used.

The authors found that although opioids remained the top drug group prescribed to workers with lost-time injuries, over the span of the study their share of indemnity claim prescriptions declined from a record 32.1% in 2008 and 2009 to 23.2% in 2017, while their share of the prescription payments fell from 30.5% to 18.6%.

As in prior research, the new data show the decline in opioid use accelerated in 2012, which tracks with tighter scrutiny by utilization review and independent medical review programs; restrictions by payors, pharmacy benefit managers, and medical provider networks; and increased physician and public awareness of opioid risks.

The 2017 data show that while opioid use has dwindled, both anti-inflammatories and anticonvulsants now account for increased shares of indemnity claim prescriptions, while dermatological drugs had the biggest increase in payments, more than doubling from 6.9% of the 2008 drug spend to 16.1% of the 2017 payments, largely due to the growing prevalence of high-cost dermatological creams.

As for the opioids, the study found they have become less prevalent in the early stages lost-time claims, which bodes well for the future as historically the percentage of claims involving opioids shows little change beyond one year post injury. The study also shows that the total number of morphine equivalents (MMEs) dispensed per opioid user at different levels of claim development has declined sharply since accident year 2012, though looking at the development data on claims from each accident year show that when opioids have been used to treat chronic pain, the average strength per opioid prescription has continued to increase over time, often doubling between 3 months and 60 months post injury, underscoring the importance of weaning injured workers off of these drugs.

In addition to the prevalence, payment and potency trends, the study also examines brand vs. generic opioid drug trends, as well as changes in the prescription and payment distributions for the most common opioids, based on drug ingredient.

CWCI has published its study in a Research Update report, "California Workers’ Comp Prescription Drug Distributions & Opioid Trends."

IMR Physicians Upheld 91% of UR Treatment Denials
Thu, 15 Mar 2018 09:45:57 - Pacific Time
New data on the Independent Medical Review (IMR) process used to resolve California workers’ comp medical disputes show that IMR volume dipped for the first time ever in 2017, but the outcomes were unchanged as IMR physicians again upheld 91.2% of modified or denied medical service requests that they reviewed.

The California Workers’ Compensation Institute (CWCI) analysis is based on a review of 648,450 IMR decision letters issued from 2014 through 2017 in response to applications submitted to the state after a UR physician modified or denied a requested medical service. In adopting IMR in 2012 state lawmakers anticipated that once doctors, attorneys and others came to know which services could be approved as meeting evidence-based medicine standards the process would reduce treatment disputes, but 2017 marks the first time in the five years since its inception that IMR volume has declined, as the Division of Workers’ Compensation data show 3,808 fewer cases in 2017 than in 2016, which translates to a relatively modest 2.2% decline.

A review of the 2017 IMR results shows that IMR physicians upheld the Utilization Review (UR) doctors’ modifications or denials of requested services 91.2% of the time, which was exactly the same uphold rate as in 2014 and in 2016.

The mix of service requests reviewed by IMR physicians in 2017 showed only minor changes from 2016, as prescription drug requests (29.1% of which were for opioids) again accounted for the largest share of the IMRs (46.0% vs. 47.9% in 2016), with UR determinations on pharmaceutical requests upheld 92.0% of the time. Aside from the opioid requests, requests for musculoskeletal drugs, dermatologicals, and anti-inflammatory drugs topped the list of pharmaceutical IMRs, while compound drug requests fell from 6.5% of the prescription drug IMRs in 2016 to 4.2% in 2017, the biggest decline of any prescription drug category, which may be linked to the fact that IMR physicians have consistently deemed them not medically necessary in 99% of the cases.

Similar results were noted for most of the dermatological requests, with IMR physicians upholding modifications or denials of requests for topical local anesthetics, manufactured topicals, and topical corticosteroids 97% to 98% of the time. Among other medical service categories, physical therapy, injections, and durable medical equipment once again combined for about a quarter of the IMRs in 2017, but no other medical service category represented more than 5% of the disputed requests. Among all medical service categories, requests for evaluation and management services (primarily referrals for consultations) again had the best chance of being overturned by IMR, (an IMR uphold rate of 79.2%), while modifications or denials of physical therapy and acupuncture were the least likely to be overturned, with IMR upheld 94.0% of the time for both categories.

As in prior years, most of the disputed requests that went through IMR in 2017 came from a small number of physicians, with the top 10% of physicians who were named in decision letters (1,150 physicians) accounting for 85% of the disputed requests, while the top 1% (115 providers) accounting for 45%. Los Angeles and Bay Area continue to represent a disproportionately high share of the IMR cases relative to their share of paid medical services, while the more rural areas have a disproportionately low share of the IMR cases.

CWCI has released a more detailed analysis of the 2017 IMR results in a Research Update, "Independent Medical Review Decisions: January 2014 Through December 2017." Read More...

Past Week News Archive

Ventura Hospital Worker Sentenced in Fraud Case: Wed, 14 Mar 2018 10:18:18 - Pacific Time: Read More...

Researchers Say a Third of CT and MRI Scans Unnecessary: Wed, 14 Mar 2018 10:18:12 - Pacific Time: Read More...

Employer's Obligation to Provide Interactive Process is Continuous: Tue, 13 Mar 2018 09:15:23 - Pacific Time: Read More...

Temp Agency CEO Convicted of Premium Fraud: Tue, 13 Mar 2018 09:15:17 - Pacific Time: Read More...

WCIRB Reports on Weaning Opioid Use: Mon, 12 Mar 2018 09:04:31 - Pacific Time: Read More...

Pending Case Pivotal in Health Care Fraud Litigation: Mon, 12 Mar 2018 09:04:24 - Pacific Time: Read More...

32 Year LAPD Veteran Arrested for Comp Fraud: Fri, 9 Mar 2018 08:36:06 - Pacific Time: Read More...

Camp Bootcamp, Inc., Cited for $8.3M Wage Theft Violations: Fri, 9 Mar 2018 08:36:00 - Pacific Time: Read More...

No Evidence of Equitable Estoppel in Volunteer's Injury Claim: Thu, 8 Mar 2018 09:35:57 - Pacific Time: Read More...

Experts Alarmed at Decline of QMEs: Thu, 8 Mar 2018 09:35:50 - Pacific Time: Read More...