The Blob of Fraud

The medical malpractice and associated complaints stemming from the kickback and counterfeiting schemes alleged of Michael D. Drobot and Pacific Hospital of Long Beach have long tentacles and are starting to populate California courts with allegations against other physicians, medical facilities and companies along the manufacturing and supply chain.

A complaint filed in June alleges that Parkview Community Hospital in Riverside, CA knew or should have known that surgeons were using counterfeit devices, but “turned a blind eye” because it profited from the procedures that were performed at its facility.

Another complaint filed in January alleges that Olympia Medical Center in Los Angeles was part of a criminal enterprise designed to defraud insurance companies through the use of phony implants, in violation of the Racketeer Influenced and Corrupt Organizations Act.

Drobot and Pacific Hospital are not named as defendants in the latest cases. But the allegations in the suits are similar to those in a 2012 whistleblower case filed by Mark Sersansie, chief executive officer of MedHealth Medical in Irvine, and William Reynolds, a former investigator for Berkshire Hathaway and Travelers Insurance Co. and now pending in Los Angeles Superior Court.

The allegations are that surgeons used counterfeit implants not approved by the Food and Drug Administration prepared by Crowder’s Machine and Tool Shop of Temecula, CA and distributed by Spinal Solutions in fusions performed at Pacific Hospital of Long Beach, Riverside Community Hospital, St. Bernardino Medical Center in San Bernardino and Tri-City Regional Medical Center in Hawaiian Gardens.

The individual owners of the various defendant entities are also named in the complaints.

These activities combined with the recent indictment and ongoing legal issues involving Landmark Medical and people associated with compound pharmaceuticals, also all out of the Greater Los Angeles area, could account for a large part of the "LA Bubble" noted by recent reports published by the California Workers' Compensation Institute.

The Blob of Medical Fraud

In the Landmark case, indictments, filed with the court on June 17, allege more than $25 million in kickbacks to doctors who prescribed and dispensed three different compound creams formulated based on the profitability of the ingredients being used.

The indictments allege the kickbacks were concealed by the purchasing of accounts receivables from physicians.

It should be noted that, other than Drobot's guilty plea in the criminal case against him, none of the defendants have admitted any wrongdoing and in fact have said publicly that they are innocent. Drobot sold Pacific Hospital some time ago and its current management is not implicated in these schemes.

Nevertheless, if one considers that workers' compensation tends to be a microcosm of society in general, the breadth and depth of medical fraud could be astounding if spread to the general health and Medicare markets.

I suspect that the fallout from the scheme will continue to expand.

Unknown for now is whether attorneys or other individuals who referred their clients to physicians that were part of the scheme could be liable for claimed damages as a result of the surgeries, the counterfeit hardware or whether there were any kickback schemes involving referrals or other parts of the alleged conspiracy.

Though its sad to see workers' compensation cast against the negative light of medical fraud, the optimist in me says that at least an effort is being made to start cleaning. Sure, there's probably others out there, and perhaps all of this action won't deter those with nefarious intent in the future.

What will be interesting is whether future statistics will show a decrease in the LA Bubble, and if so by how much.

I suspect the answer to the first part is "yes" and that it will be measurable.

In the meantime this story will continue to spread like The Blob. How much and whom it consumes along the way depends upon how many fire extinguishers can be deployed by those who encounter it.

Sad Testimonials

When a business has something good and people like it, you can bet on testimonials from customers. In the Internet age we look for reviews of products or services before we buy, hoping to capitalize on the experience of others so we either make the same great choice or avoid a poor decision.

A WorkCompCentral Forum thread recently popped up that is a sad commentary on our system because the people that are actually in the system providing goods and services have very little faith in workers' compensation to do what it is supposed to do.

And that is a sad state of affairs indeed.

Bowzer won't run into the Wall of Comp again...

I've edited the posts for brevity and succinctness (we all know how forum posts tend to drift off topic). Maybe you want to add your two cents on the topic of "To file a claim or not?"
_____________________________________________________________________

I wonder, if I was an employee of a company, suffered a potentially severe and life changing injury, would I report it to the employer and file a claim. Or, if I had decent medical insurance, say through my spouse, would I simply seek all treatment through my private medical coverage? Knowing what I know about the nature of medical care received through today's workers comp insurance carriers, with the inordinate delays, arbitrary and consistent denials of treatment, generally poor treatment when compared to the private sector, and the adversarial relationship with the carrier, would I really put all of that on the line and stay within the system? What would I recommend to a loved one or friend facing the same questions?
_____________________________________________________________________

I have asked myself the same question. As an adjuster, I see the whole picture, medical care, wage replacement, permanent disability, and the need to interact with the injured employees, attorneys on both sides, and some liens thrown in.

I am not sure that I would file a claim, unless it happened right in front of my manager, or something. In that instance, if I felt that I needed better or different treatment than what I was getting, you bet I'd self-procure.
_____________________________________________________________________

I would only file a claim if I did not have STD and LTD that covered everything. But we speak from a position of privilege in that most of the people who post here have group health and the opportunity and means to purchase disability insurance. So some people have no choice.
_____________________________________________________________________

There are a few injured workers forums and one on this site where injured workers ask this question regularly. Many who have been through the system tell others to not file the claim and use their private insurance. This is due to delays in medical treatment they have been victims of and receiving sub standard medical treatment in the workers compensation system. I have seen many instances that an injured worker actually becomes disabled further due to delays in treatment.

My response is if the injury is minor, no I would never claim it. If the injury was catastrophic... I am still pondering if I would claim it from the knowledge I have now of what happens to injured workers in California.
_____________________________________________________________________

No I would not file a claim, knowing what I know now about the California workers compensation system. I think the medical treatment with delays and denials is sub-standard and can cause a person with a treatable injury to become disabled for life. Dealing with UR and now IMR... I and would not wish this upon anyone. My only question would be is it fraud to not file a workers compensation claim for an injury that occurred at work? If so then I would most likely file the claim. I have read conflicting responses to this some stating it is fraudulent not to file a claim when the injury occurred at work, while others have stated you have a choice.
_____________________________________________________________________

I have had a lot of QME cases where the original orthopedic injury was treated by a private insurance MD who did not report it as a work injury when the worker told them it was a work injury, and kept treating it as non-industrial as it filled billable time and procedures and helped make the doctors house payment.

Isn't it illegal to NOT report an industrial injury.... ?? .... but I think it happens all the time.

When when a WC claim was finally filed, it totally messed up the case. The insurance company can easily say, 'oh look, his private insurance treated it so it is clearly non-industrial"
_____________________________________________________________________

Perhaps what is being said above reflects declining claim frequency in most geographic areas (except of course the greater Los Angeles area, but we've all seen the latest news stories about atypical behavior coming out of various ne'er-do-wells that seems to account for the volume there) though increasing indemnity claims with attorney involvement.

I've asked myself this question throughout the years of my professional life in work comp. I used to have faith in the system and would have had no qualms about seeking care through the work comp system.

Now I would answer in the negative.

And that really is a sad testimonial.

If you don't have faith in the own system you work in, how can anyone else?

And what is the point in having a mandatory system of insurance if no one uses it?

The Walt Kelly comic strip from the 1960s and 70s, "Pogo," is most famous for this singular quote: "We have met the enemy and he is us."

The Pixelated Middle

It's a tale of two systems.

One system works nearly perfectly. The statistics support this perspective. Insurance companies make money. Injured workers get treatment. Physicians get paid. Employer's premiums are reasonable.

The other system is dysfunctional. There is anecdotal evidence of case after case where treatment requests are delayed, physician decisions are second guessed, and the social obligation is disregarded in the name of profit.

If you look out to the right or the left, you get a clear picture and it's one of the two alternatives above - polar opposites.

Look in the middle though and it's hard to reconcile the two different perspectives. The picture is pixelated, muddy, unclear - who knows the truth?

Why's the middle so fuzzy?

I go to conferences and talk with industry people and no one, it seems, can see the middle. Everyone seems to have a distinct opinion about how well workers' compensation does its job. Either it's doing swimmingly or it's a complete disaster, and there is not a whole lot of opinion in between other than "we can do better," which is a complete cop-out in itself.

The Texas Tribune published a blistering rebuke of that state's system, providing four vignettes of stories where the system failed, and failed miserably. Some take issue with the stories, saying they are atypical. Others say those stories should never have had to be told.

On the heels of that series is an editorial by Texas Commissioner Rod Borderlon citing statistics that make it seem the Texas system should be the model of all states.

In California there's this interesting cycle that folks just can't seem to leave alone. Some interests either want more money or want to spend less money so they come up with certain new twists on the law.

The courts get a hold of those new laws and apply their rationale and interpretation, which ends up being different that the originating interests had in mind, which, by the way, was never aligned in the middle any how.

Once judicial fiat issues there's a new round of interest group wrangling - again all out on the peripheries.

We see extreme cases where an injured worker decides to be his own lawyer, making workers' compensation his sole reason for existence to the point where he ignores The Rule of Law, perhaps in his quest to "stick it to The Man."

There are research groups identifying distinct geographic anomalies in statistical measures, but a failure in law enforcement to take any action for years until the pressure becomes unconscionable and then, after millions and millions of dollars have escaped the system and many injured workers have been broken does any action get taken.

The workforce demographic most in need of workers' compensation protection can't get the support of politicians in either state or federal government to recognize their participation in the economy, and consequently suffer disproportionately when an unfortunate accident occurs.

Though most states workers' compensation programs don't garner media attention, I don't know of any single state that isn't without controversy.

And it's easy to say, "it is what it is." Of course that is a simple excuse and base rationalization equivalent to Alfred E. Newman's "What me worry?" or Bart Simpson's "Don't look at me, I didn't do it."

Yes, quoting fictional characters is intentional here - because workers' compensation is a fiction. There is nothing in workers' compensation that is real. The system was created out of legislative bargaining. Statistics tell only part of the story. Shell games are done with accounting, and others just want to protect their jobs so there's little dissent.

The system functions acceptably if it's not used...

But the people for whom the system was originally created - those who basically live pay check to pay check - need the assurance of insurance.

When that pay check is interrupted by a work injury the social program should step in and start working immediately - not denials, not delays, not second guessing.

Those are the people in the middle where there is a lack of focus. They're the ones that are caught up between the extremes. The ones where the system fails because they are not a simple medical only, fix it and go back to work type of claim.

Those are the claims that actually require work on the part of the industry - all industry members - to get right.

I know there are success stories out there. I have blogged on them before. But there needs to be more. There needs to be a concerted effort on the part of professionals in workers' compensation to show the rest of the world that privatized social benefit systems work - and not just "some" of the time or even "most" of the time.

I suggest we start with this moral directive - that when the social mission collides with the business mission, the business mission take the back seat.

The business of work comp needs to be tempered and when someone or some group seeks to take advantage of others we need to do our concerted best to bring those folks to the forefront for public recusal regardless of whether they're operating as public officials or as private business persons.

A couple years ago I was asked to speak about the media's role in a healthy workers' compensation system. Though I went on for nearly an hour about The Press throughout history, the bottom line is that there's stories to be told, people to be kept honest and in check, that there are lies, damned lies, and statistics...

Not all stories can be told, nor can all statistics be examined. Hopefully though the picture of the middle will be clear. Not that we can ignore the extremes, but the extremes don't make for a well functioning system. Everything needs to work in concert.

A Yorky and Her Wardrobe

One of my dogs, Tina, was caught the other day trying to make some tough decisions about her wardrobe - seems she has too many clothes in her closet.

Seems she was overwhelmed with all the choices - I mean she's only 3.4 pounds and frankly doesn't really like all the attention she gets when she dresses up anyhow.

Not unlike a California case published last week about a little subrogation dispute and too many available choices confusing the courts about jurisdiction, applicable law, and some inventiveness on the part of counsel.

And though counsel tried to dress up the claim, the 6th District Court of Appeals wasn't impressed.

Attorney John Stein of The Boccardo Law Firm filed an action for damages in San Joaquin Superior Court on behalf of Albert Carabello, who, while acting in the course and scope of his employment, was injured when his pickup collided with a vehicle operated by Beverly Casby.

Old Republic Construction Program Group provided workers' compensation insurance coverage and paid Carabello over $100,000 in benefits.

Old Republic filed a complaint in intervention in the San Joaquin Superior Court, asserting a right to be reimbursed for its payments to Carabello.

In answer to both Carabello's and Old Republic's complaints, Casby raised a Witt v. Jackson defense, which is based on a 1961 California Supreme Court case that limits the ability of an employer, or its insurer, to obtain reimbursement out of an injured worker's recovery against a third party where the employer's own negligence contributed to the worker's injuries.

So many choices...

Carabello and Casby later agreed to settle for Casby's $100,000 auto liability insurance policy limit. Casby's auto liability insurance carrier made the settlement check payable to Carabello, Boccardo and Old Republic.

Stein and counsel for Old Republic then signed a written agreement for the money to be deposited into an interest-bearing account while Old Republic's reimbursement claim was worked out. The agreement between Stein and Old Republic stated that the signatures from Stein and Old Republic's attorneys would be required to withdraw any money from the account where the settlement check was deposited.

In January 2010, counsel for Old Republic filed a request to dismiss Old Republic's complaint in intervention with prejudice.

Upon learning of Old Republic's dismissal of the complaint in intervention, Stein filed a motion to authorize the release of the settlement funds to Carabello, arguing that by dismissing its pleading, Old Republic had forfeited any right to litigate the issue of employer negligence, and thus to recover on its lien.

The trial judge who had been presiding over the case, however, found the court no longer had jurisdiction to grant the requested relief.

On July 9, 2010, Stein wrote to counsel for Old Republic indicating that he intended to distribute the deposited funds, and he did so one week later.

Old Republic filed a petition with the Workers' Compensation Appeals Board in September 2010, demanding disbursement of the settlement money that Stein had already given to Carabello.

A workers' compensation judge denied Old Republic's petition, finding he too lacked jurisdiction to grant the relief sought by Old Republic. But the Workers' Compensation Appeals Board disagreed on reconsideration and ordered the matter remanded for a trial on Old Republic's entitlement to the money.

Old Republic then filed a breach-of-contract claim against Boccardo and Stein, asserting they had breached the written agreement on how the settlement money was supposed to be handled. Old Republic also asserted claims for fraudulent inducement, conversion, breach of fiduciary duty and negligence.

Boccardo and Stein demurred, and a trial judge sustained the demurrer as to the conversion and fiduciary duty claims.

Boccardo and Stein then filed a motion to dismiss the remaining claims under Code of Civil Procedure Section 425.16, which is known as the "anti-SLAPP" statute.

This statute provides a means for a party to obtain the dismissal of strategic lawsuits filed to chill a valid exercise of the constitutional rights of freedom of speech and petition for the redress of grievances.

The trial judge granted the defendants' motion to strike Old Republic's fraud claim only, and Boccardo and Stein appealed.

The 6th District Court of Appeal said that it "could not be seriously suggested that withdrawing funds from a bank account constitutes communicative conduct," and there was no indication that the defendants' non-communicative conduct in accessing the settlement money had any connection to an issue of public concern or interest.

It therefore falls outside the protection of the anti-SLAPP statute, the court said.

Seems to me to be a matter common sense.

But certainly counsel can not be said to lack imagination or creativity.

So many choices, but not all of them are good ones. Just ask Tina.

To read the decision, click here.

The Flying None

Sally Field played Sister Bertrille as the Flying Nun for 3 years and 82 episodes from 1967 to 1970.

The role was an embarrassment to Field, according to legend, because of the silliness of the base plot - a person with aerodynamic qualities due to light weight and a large lifting surface, that provided inspiration to solve (and sometimes create) problems when taking flight.

The Flying None

Imagine if Sally Field had been tasked with instituting one of the more silly measures of California's SB 863 - the photocopy shop fee schedule.

I understand where the proponents of this element of reform are coming from - they are upset that abuses occurred by copy shops and they want to curb those abuses.

As I have been proselytizing lately, the transgressions of The Few create illogical burden for the many.

And that's exactly why a copy shop fee schedule came about.

But like the rest of reform that is not based on a complete understanding of The Problem, it too will fail.

Because The Problem is caused by a couple of folks that don't play by the rules, and consequently they won't play by any new rules either.

Here's how The Few caused the problem for the many photocopy shops that do play by the rules.

First off, The Few don't actually get records all of the time. They get some reports and some records, then go through those for other names of physicians and facilities and "subpoena" those records too on behalf of a few lawyers who are also in on the scheme.

But those physicians and facilities that are "subpoenaed" don't produce any "records." That's because, a) they weren't subpoenaed and b) these acts are just billing entries - no work is actually done.

Second, The Few reuse and reuse records that are actually produced, creating multiple billing entries and, ergo, liens. When no actual work is done, what does a service care that it only collects ten cents on the dollar?

Third, The Few has the support, as indicated, of some additional peripheral players who get "favors" for assisting in the scheme. It's a round robin affair with referrals going in all directions all generated from a couple of records. The Few copy shops that are in these schemes are part of larger enterprises involved in recruiting "injured workers" to put through the mill, part of which are copy shops, to generate fees. Again, if no work is actually done, then what does one care if the return is "only" ten cents on the dollar? When the cost factor is zero everything that comes in the door is profit.

Fourth, the proposed regulations create incentives for applicant attorneys to use the new law to their advantage and order EVERY record they can think of VERY early in the case: right after the 30-day required waiting period in Labor Code 5307.9, but before the employer can truly respond. That way, the applicant can make sure they have access to their own discovery process and make sure the copy service fees are always payable.

Before SB863, a lot of attorneys only ordered the records they truly needed... but I expect that if there is a perceived constriction on the ability to obtain evidence in the form of records attorneys will start ordering everything they can possibly think of JUST to make sure they CAN get the records when they need them. In other words, the changes to the applicant copy service process in SB863 are ultimately going to INCREASE the volume of copy service usage by applicant attorneys.

And I don't expect that a fee schedule and rules about timely payment for records will make any difference in the accounts receivables timeline for these shops. The financial industry, of which insurance is a part, completely understands that time is money - the more time you hold onto money the more money you end up with...

The Reverend Mother Superior Placido was cast as the "serious" character, chastising Sister Bertrille nearly every episode because she could not understand Bertrille's on and off again control over flight. 

There's no understanding of the dynamics of work comp cost flight. Solutions have been created for problems that don't exist, leaving the real problems unaffected.

Which is why all of this reform effort is a Flying None.

Bowzer Knows

The tentacles of workers' compensation politics and the tangled weave of questionable ethics and morals runs deep.

And I'm not saying that the following tale that is unraveling implicates any wrong doing on the part of vice chair of the New York Workers’ Compensation Board, Frances M. Libous, but the appearance of impropriety is pretty strong.

State Sen. Thomas W. Libous, R-Binghamton, the No. 2 Republican in the state Senate, and husband to Frances Libous, was is charged with one count of lying to the FBI about his alleged efforts to obtain a position at a Westchester law firm for his son, Matthew. He faces up to five years in prison.

The indictment relates the FBI had been investigating allegations that Libous arranged for the law firm to pay son Matthew an “inflated salary” in exchange for having legal business steered to it.

The indictment further alleges that Thomas Libous promised members of the firm they would need to “build a new wing” to accommodate the new work if they hired his son.

Prosecutors allege that an Albany lobbying firm, on the direction of Thomas Libous, paid the law firm $50,000 a year to cover part of the requested inflated salary, plus lease payments on a Range Rover for Matthew.

Son Matthew is charged separately with various other legal misdeeds, particularly income tax evasion for underreporting income.

For the record, Matthew is in good standing with the New York State Bar Association with no disciplinary history. Neither Frances nor Thomas are in the bar association's computer records system as members.

Bowzer knows it when he smells it...

Though Frances Libous is not charged or named in any of these criminal accusations, her husband Thomas Libous does have connections with the Texas consulting firm that was just recently replaced as the vendor to the WCB's botched computerization program.

One of Thomas Libous' largest campaign contributors over many years was a Texas company that maintained an office in his Binghamton district and benefited from a scanning contract awarded by the WCB for which the company ultimately billed $88 million to the state.

In April of this year, WorkCompCentral reported that Libous had received 17 campaign contributions totaling $17,875 from SourceHOV or its affiliate, SourceCorp. BPS Inc., between June 2004 and August 2012, according to OpenSecrets.org.

In January 2005, SourceCorp. BPS obtained the contract with the WCB to scan records. As of April, the company had received $75,793,904 from the WCB on that original contract and renewals.

However, in April the WCB reported that it had been experiencing “delays and difficulties” with its scanning operations.

In an announcement on its website, it stated that it was hiring Xerox as its new scanning subcontractor, which would work under a main contract awarded to the New York State Industries for the Disabled.

The WCB announcement never mentioned SourceHOV or SourceCorp. BPS or their long-term relationship with the board. Nor did it mention that in March the board granted the Texas contractor a “final extension” on its contract to the end of 2014 for $8.1 million.

In April, WorkCompCentral filed a Freedom of Information Law request with the state Comptroller for copies of several of the WCB’s largest contracts, including its contracts with SourceHOV/SourceCorp. BPS.

To help speed the process, the requests specified exact contract numbers and requested a prompt electronic response.

The Comptroller had not produced the copies of the contract in any form as of July 1.

On June 3, Jane Hall, a records access officer for the Comptroller, replied to WorkCompCentral, “This office is continuing to process your request.”

“This office will write you no later than 8/27/2014 and inform you of any cost associated with producing or photocopying any available records,” Hall’s letter said.

Four months to determine the cost associated with the production and copying of "available" records... or four months to determine IF there are "available" records?

The board basks in the glory of the press when it announces that a business, celebrity or other entity has been "corrected" for alleged failure to provide workers' compensation coverage for employees, and aggressively pursues bad actors allegedly responsible for failed group trusts.

But when it comes to cleaning up its own dirty underwear there seems to be a disassociation.

Denmark is over 3,800 miles from New York but, to paraphrase Shakespeare's Hamlet, me thinks there still be something rotten...

Cost Containment Isn't Contained

You mean you didn't get the memo?

I was talking with our Education Department's Curriculum Developer and Instructor Manager the other day about his experience within the education world, specifically about punctuality when a meeting is called.

"Mr. Weiss," as we like to address him, comes from the public education world and worked his way up from teacher, principal, to school district supervisor and other top level administrative positions.

Mr. Weiss was regaling about how there were so many in his experience at the higher levels of education administration who disdain any notion of punctuality and tend to arrive at meetings on their own schedules.

The sad part of his experience is that such behavior is condoned from the top down - a teacher that was over an hour late for a meeting told Mr. Weiss that it was "okay, my principal is right behind me."

Of course there are only a few that don't respect the time of others or the authority of the supervisor, and the behavior of The Few affect the attitude and mindset of the many. The majority are on time, ready to meet, discuss, learn...

So when a senior official finally got disgusted with the blatant tardiness and disrespect shown to others by The Few non-compliant passive aggressive individuals, a memo would go out to ALL employees chastising late comers to meetings and threatening some disciplinary action (albeit, being a public school district and union/tenured instructors, such threats are without any enforcement teeth).

Mr. Weiss commented on how dissociative it is to send a memo to EVERYONE for the transgressions of The Few because it reinforces the mindset of The Few; the psychology of The Few is first to deny that they are doing anything wrong or disrespectful, and then to read that memo and think to themselves that it's okay to be late because other people must be doing it, otherwise such a memorandum would not issue.

I realized that Mr. Weiss' experience with meetings in the public education world is descriptive of workers' compensation and the laws, regulations and rules we live by - those "memorandums" excoriate the behavior of The Few, with deleterious affect on the rest of us who don't need such constrictions on behavior because we have our own sound, reasonable boundaries and respect those of others.

So while The Few think to themselves that it really is okay to "cheat" the system because obviously others do it, the rest of us suffer the consequences.

This is what I think when I see Utilization Review Run Amok.

During the past six years, data from the Workers' Compensation Insurance Rating Bureau show that medical cost containment expenses have almost doubled since 2006.

The total expenses for medical cost containment were $446 million in California in 2013, representing about 8.58% of the $5.2 billion in total medical costs associated with workers' compensation claims in 2013.

The total amount for medical cost containment in 2006 was $226 million.

Commenters quoted in the WorkCompCentral News story this morning about the latest WCIRB's numbers blame the Supreme Court's 2008 Sandhagen decision, saying that the Court held that UR is mandatory under Labor Code section 4610.

That's not really what the Supreme Court said - the court said that a carrier cannot transgress the mandatory provision of UR and instead invoke LC 4062 to dispute an employee's treatment request.

Quoting the Sandhagen Court:

"We also conclude that section 4062 is not available to employers as an alternative avenue for disputing employees' requests for treatment. The Legislature made clear that an employer may not use section 4062 to object to a medical determination concerning medical issues 'subject to section 4610' while expressly permitting employees to use section 4062 to resolve disputes over an employer's decision not to approve treatment requests...

"Accordingly, in light of the clear statutory language and the Legislature's purpose in enacting the utilization review process in section 4610, we conclude the Legislature intended to require employers to conduct utilization review when considering employees' requests for medical treatment. Employers may not use section 4062 as an alternative method for disputing employees' treatment requests."

To paraphrase the psychology evoked by that tardy memo to the teachers: The Few didn't use UR to dispute treatment requests, so now ALL treatment requests must go through UR.

Not only is that NOT what the Sandhagen court said, it is completely illogical. A claims adjuster's review can fulfill the law's UR requirement - there is nothing in the code or regulations that says there must be formal submission to a UR company to APPROVE treatment.

"When the employer ... reviews the request and determines that treatment is reasonably required, the employer has engaged in utilization review," the supreme court wrote in its decision.

Duh!

Ergo, any wholesale requirement that all treatment requests go through UR must be coming from the top down, or we have a huge population of claims professionals who are either overworked, lazy, passive aggressive or a combination of all three, and I don't think it really is at that level.

The court is saying that IF the employer disputes the treatment request, THEN it must go through UR.

Instead we get URRA, increasing overall costs on the system directly, and indirectly by swelling the amount of time it takes to get an injured worker treated and off the temporary disability indemnity rolls.

Hey, but it's not my fault; everyone is doing it...

Oh, am I late to the meeting?