Monday, January 25, 2016

Kick backs causing unnecessary Surgeries-inquiry of why S CA has more liens by Sen. Mendoza

This is an excellent piece on workers' compensation from Bill Zachry Risk Manager at Safeway. SB Cal was a major supporter of  SB 899. Thanks Bill for sending.

Scott Hauge
Small Business California
2311 Taraval Street
San Francisco, CA  94116


 For those who are interested in the California workers Compensation System, I have attached several articles on recent arrests of physicians who plied their trade in Southern California.
Those who are familiar with the California workers compensation system are aware that much of the fraud, and a very high percentage of the liens produced in California are geographically focused in Southern California.

Because of the propensity for a certain group of physicians in Southern California to treat on a lien basis outside of the networks the California WCIRB (Workers Compensation Insurance Rating Bureau) has identified a significant cost differential between Northern CA and Southern CA.

Many of these providers argue that providing care outside of the networks is offering care to injured workers who would otherwise have no access to medical care in he workers compensation system.

The differences in costs between Northern California and Southern California are now showing up in the insurance underwriting process.

The articles listed below are excellent examples of why the Southern Ca workers compensation system is so expensive.

Those with limited experience in California (or who were not working in the system prior to the passage of SB-899) may not recall back then when there was one back fusion surgery for every laminectomy provided in Workers compensation system in California.

During the same time frame, the group health providers had only three percent of their laminectomy’s resulting in fusions…these articles help provide insight into why there was a difference in the number of surgeries as well as the results of those surgeries…

Prior to SB-899 it was almost impossible for the payers to say no to the physicians requests for multiple surgeries.  Back then massive abuses of six and seven unnecessary back surgeries on one injured worker were not uncommon. 

To compound the problems for the injured workers, when the multiple back surgeries were not successful, the employees was then given opioids for the intractable pain from the failed surgeries.  This resulted in a large number of injured workers who are now opioid addicts.

Opioid addicted injured workers account for a high percentage of the complex and advanced IMRs (Independent Medical Reviews done by Maximus).

The pending regulations from the Division of Workers Compensation for a pharmacy formulary (using evidence based medicine) will help reduce the number of inappropriate requests and questionable denials associated with opioid use and abuse.

Prior to the passage of SB 899 and SB-863 the abuses foisted on the innocent injured workers was appalling and very difficult to stop.

The advent of SB-863 with a focus on Evidence Based Medicine and medical decisions made by medical professionals significantly helped significantly reduce the abuses.

The IMR (Independent Medical Review using evidence based medicine) process outlined in SB-863 takes medical decisions away from non-medical professionals.  It protects the injured workers from abuses like those outlined by the FBI in the article printed below.

With the arrest of those physicians listed below we can better understand why the doctors were doing the surgeries.. It would be interesting to see how many of the millions of the liens filed in the system are associated with the doctors indicted in the article below.  

Bill Zachry


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