Friday, June 6, 2014

Time To Start Cleaning

Mom turned ninety years old yesterday.

She lives in a memory care facility since Dad died. Her dementia is moderate - for instance she asked me at least a dozen times at lunch yesterday if she had read the birthday card I brought her!

But as you can see, Mom is a radiant, beautiful ninety years old and one of the happiest residents at her facility.
Above all else, Mom taught integrity.
I visit Mom about twice a week. It's difficult maintaining that schedule with all of the work and other activities I'm involved in, but Mom was at my side most of my childhood (except after the Christmas holidays when Dad would whisk her off to Tahiti for a few weeks and leave me and my brother with our grandfather - but that's a couple of other stories!).

I was raised Catholic, so perhaps this is just part of that Catholic guilt thing, but every time I visit Mom I come away with that worrisome feeling that there must be something more that I can, or should, do.

I did buy her new, state of the art, hearing aids. This made a world of difference. She can hear normal conversational levels, seems to be more alert and cognizant, and I can tell that she is much more engaged.

Mom has always been social (now you know where my extroversion comes from - double barreled genes!) and has always been a happy soul, except for the numerous times when my brother or I, or the both of us together, challenged her sense of humor with our antics ("Just wait 'till your father gets home!"). When I visit staff and other visitors at the facility always tell me how pleasant she is and how much fun she is to have around.

I can vouch for that - she never misses an opportunity to tell a joke or pull some senior prank.

For instance, recently designated incontinent, I was escorting Mom from lunch and asked if she would like to use the bathroom. She said she would, so I told her I would get a care taker to assist her. She looked at me and dead pan said, "it's easier if I just pee in my diaper."

That's Mom.

Mom's fortunate. Dementia can be a very troublesome condition. She's lived with painful arthritis, particularly in her fingers, for the past 10 years. She frets about keeping her teeth clean (her husband after all was a dentist). And though she asked me yesterday about a dozen times whether she had already read the birthday card I brought her, she can tell some amazing stories about growing up during the Great Depression.

Despite these afflictions, though, Mom troops on through. She really doesn't seem to be too bothered by her living situation. She knows her memory isn't very good, so she jokes about it. Farting is funny to her. She makes funny faces and comments about the way others at the residence dress, act, or look.

She's obsessive compulsive and can't stand things out of place. She's always been clean. I grew up in a very clean house, and Mom is still very clean and detail oriented. That can be dangerous because if she sees something on the floor that she feels doesn't belong there she will attempt to pick it up rather than have housekeeping take care of it.

She attained a Master's degree in Art from Loyola/Marymount and she still has a fantastic eye. When the residents do art work her's always stands out.

But most of all, I'd have to say that Mom developed, retained, and taught a great sense of integrity. She has always maintained a very high sense of morality and honesty - and with her dementia she really does wear her emotions on her face; it's easy to tell what she's thinking.

Unlike the institution that's just about as old as Mom, the California Department of Industrial Relations (established 1927) seems to have lost the moral compass and does not appear to be trustworthy.

Yesterday WorkCompCentral News reported a delay in the bidding of the Independent Medical Review contract to Maximus Federal Services, Inc. because of two bid protests. Today, WCC News gets into the details of those protests, and if the allegations are correct I see no possibility to trust our government.

The investigation by Greg Jones reveals last minute notifications depriving bidders (not Maximus) of a reasonable opportunity to present their best case, leaked bid information so that Maximus can lower its bid to be more competitive with the other bidders, tweaking of the bid process to give Maximus an unfair advantage in the process, inconsistency in the application of so called objective disqualifying criteria, and a complete lack of transparency to the public for the entire procedure, including the withholding of documentation that is supposed to be public information.

The allegations raised by the protests are numerous, and very, very serious.

If these allegations are proven to be true, I'd be willing to bet that there are other serious, nefarious activities going on within the DIR and it's child, the DWC, that question the integrity of these agencies to the point, as I said yesterday, that trust is highly misplaced.

If we can not trust those in charge of a $30 billion system to do the right thing, to make sure that the system operates efficiently, fairly, and within the ethical boundaries that we all should operate within, how can anyone in the system trust anyone else?

The guiding lamp of morality and ethics seems to have dimmed. Integrity at the top is missing.

Some time ago the Los Angeles Times ran a series of stories about the shenanigans that Deloitte Consulting, LLP engaged in to win, and then exploit, computing contracts with the State of California (and other states), including the highly criticized EAMS system. Deloitte was exposed to have made some generous contributions to key people to gain favors in the contract bid process.

Perhaps Maximus, with over $1.3 billion in revenue, also has extraordinary lobbying strength (people on the street refer to that as "money") and is using it to test the integrity of of the DIR and the people that are responsible for running this system.

I don't know, but perhaps we will find out soon enough.

Regardless, the actions of the DIR as alleged by protestors, CID Management and Peer Review, is reprehensible and is a complete lack of integrity.

We run stories all the time about fraud, corporate wrong doing, people cheating, others suffering as a consequence - if CID and Peer Review are correct in their allegations we have a long, long way to go to resolve California's workers' compensation problems.

It's not about rates. It's not about doctors manipulating billing. It's not about carriers playing with premium factors. It's not about employers denying care. It's not about claimants falsifying injuries.

It IS about integrity. We can not trust our government.

Mom can't admonish, "wait 'till your father gets home," any longer. He's dead.

But trust me, she would send a steely glare in the direction of DIR if these accusation are true.

I get asked all of the time why California workers' compensation is so difficult and expensive. Just start at the top. If Mom could, she'd start the cleaning right now...

I don't think this is a Catholic guilt thing. In law we are counseled about appearances of impropriety. 'Nuff said.


  1. The DIR is so corrupt, I send in an IMR application with the copy of the UR denial, I also included a cover letter stating that the UR denial was done anonymously, no doctors name, no signature no specialty named, the nearest thing to a name on this UR denial was physician adviser and no name for this physician adviser, this was clearly an invalid UR denial yet the DIR approved this UR denial for Maximus who of course denied the treatment, and even when I filed a UR complaint I was told the copy of this UR denial was missing pages, it was not, the copy sent to the requesting doctor and my attorney were also anonymous.
    I would say a good house cleaning is in store and very much needed!

  2. Some folks Mama's really raise their kids well. This one sure did. Thank you for digger deep and telling us all the TRUTH sir. Our Country really needs more of that. And sorry if I came across a little harsh, but I've been fighting this thing for awhile now. And here in WA our admin board are not being impartial and its harming folks in comp and our HMO's, but any way, thanks to you and your Mom as well. We have to get the big money out. NOW Peace

  3. I have exper'd many times Maximus & C.I.D. committing fraud while conducting their reviews. Although I have told the Audit & Medical Unit, I & A officers, Judges & an Upper Admin throughout the last 3+ yrs, no one has done anything about it. C.I.D. has accepted UR requests knowing the ER doesn't have medical control to use their services. The orig. adjuster knew that the ER failed to provide & post not only their WC info, but ALL EE rights/ER obligated postings & pamphlets, claim forms/report forms; didn't have an MPN - nor the "insurer". C.I.D. conducts the reviews while knowing the adjuster frwd's the RFA's outside the 5-14 days. Is aware they don't have all of the medical & diagnostic reports & has evidence showing the adjuster denied a few RFA's & even removed an RFA, though a Rep. confirmed the PCP submitted one w/his report. I found it unbelievable when I told them that they were missing a 6 month period of records & that by not noticing, the reviewers were denying me treatment thinking that I wasn't seeing a Dr! Even though I faxed them copies of the "missing" reports, they have yet to include them on the list of reviewed reports to date. C.I.D.'s "Director" has an excuse for everything, just not the correct one. They have yet to use the Post Surgical guidelines. And although the ER doesn't have an MPN, or medical control, do the new adjuster's allow me to see up to 3 different Dr's if there's any question of what my PCP,  not PTP, finds necessary for me? Nope, it goes straight to C.I.D. to see what they say. When I appeal their reviews for another C.I.D. Dr. to conduct a review, of course they're going to deny it (now having been paid twice for unnecessary reviews), but now I'm fraudulently informed by the new adjuster's & C.I.D, that it's Maximus's turn. Maximus then commits their fraud when stating they rec'd records from the adjuster when none were ever sent by her; only by me. There's a big penalty for her, which I made sure the Audit Unit knew, but nothing happend. Nothing happend to the Maximus reviewer either when committing fraud in the statement that he/she used the CA's records to make the decision! Maximus has spent over 3 month's, twice now, to make a decision after C.I.D.'s denials. The reviewer didn't acknowledge any of my records, denied me using the same words as C.I.D.'s UR denial, while using the incorrect criteria's as C.I.D. did. Even though Maximus reversed 1 denial, the insurer has yet to pay for the treatment since the decision over 6 months ago! Yet again, the reviewer failed to mention my records, while the adjuster failed to provide ALL of my medical records & diagnostic reports. Everyone in the system knows of my situation, but for some reason, the ER's insurance co. still keeps grabbing for control. I can't trust anyone in the system. Which is why I ask: who are they accountable to?  Just the fact that the Insurer didn't submit my records to Maximus is a hefty penalty, but then add on that Maximus got away w/lying twice about the records they received,  3 month's to make a decision & use the UR's denial criteria at last minute when I called them out. For the adjuster not to remburse me or pay their prescription contract for over a year now, especially 6 months after Maximus overturned C.I.D.'s denial. Does everyone think that I don't know about the amount of penalties I can get? I might not have an atty or have been given any info as I am allowed to receive,  but wilfully holding back such info. is even worse. Integrity is a thing of the past.

  4. Beach lover blogger, you need to file for a hearing over the delay in treatment for a IMR approved treatment, that the IC refuses to approve. There is a time limit of two years for some penalties. I recommend contacting an I&A officer to assist you in filing for a hearing, and what to include. If you do not file for a hearing, they will not be fined, and may continue to do this to you.

    I also suggest filing audit unit complaints.