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Access over workers' compensation decisions, including En Banc, Significant Panel Decisions, and writ-denied cases.

Case No. SBR 0311485
Regular
Jun 28, 2006

KIMBERLY STOKES vs. PATTON STATE HOSPITAL / DEPARTMENT OF MENTAL HEALTH / STATE OF CALIFORNIA, legally uninsured, administered by STATE COMPENSATION INSURANCE FUND

This case concerns the lien claim of Ambulatory Surgery Center of Pomona (ASCP) for services rendered to an injured worker. The prior decision disallowed the lien because ASCP lacked a fictitious-name permit from the Medical Board of California. ASCP argues a permit wasn't required for "facility fees" and it possessed necessary accreditations. The Appeals Board rescinded the decision, remanding for a determination of whether ASCP operated as a "clinic" requiring a permit or an "outpatient setting" exempt from such if accredited, and whether its accreditation was valid for ASCP.

Fictitious-name permitMedical BoardAmbulatory Surgery CenterClinicOutpatient settingAccreditationBusiness and Professions CodeHealth and Safety CodeLien claimantProfessional services
References
6
Case No. ADJ4661222 (MON 0354694)
Regular
Jul 05, 2016

LAKEISHA HICKS vs. WAL-MART ASSOCIATES, INC., AMERICAN HOME ASSURANCE COMPANY, INC., YORK RISK SERVICES GROUP, INC.

The Appeals Board granted reconsideration for lien claimants Beverly Hills Ambulatory Surgery Center and Beverly Hills Anesthesia. The WCJ had dismissed their liens due to non-appearance at a conference, but the lien claimants claimed they never received notice of the conference or the intent to dismiss. Crucially, the Board noted the conflict between the defendant's proof of service and the lien claimants' verified assertion of non-receipt, without any credibility determination. Therefore, the case was rescinded and returned to the trial level for an evidentiary hearing to resolve these notice and service issues.

Lien claimantsReconsiderationPetition for ReconsiderationOrder Dismissing LienNon-appearanceLien conferenceNotice of hearingNotice of intention to dismissCode of Civil Procedure section 473(b)Mistake
References
3
Case No. ADJ1480264 (FRE 0200339) MF
Regular
Dec 29, 2015

JOSE ACOSTA vs. PETERSON FAMILY, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) rescinded a prior decision concerning the retroactive application of a 2012 statutory fee reduction for ambulatory surgical centers. This decision was made after the defendant, State Compensation Insurance Fund (SCIF), and lien claimant Sierra Pacific Surgical Center (SPSC) reached a settlement agreement. The WCAB returned the case to the trial level for approval of this settlement, allowing the WCJ to reissue the rescinded decision if the settlement is not approved. The original decision had found that the fee reduction did not apply retroactively to services provided before January 1, 2004.

Workers' Compensation Appeals BoardState Compensation Insurance FundSierra Pacific Surgical Centerambulatory surgical centeroutpatient surgical centerMedicare reimbursementSenate Bill 863Labor Code section 5307.1(c)(1)retroactive applicationsettlement agreement
References
0
Case No. ADJ4409749
Regular
Feb 07, 2011

Jill Johnson vs. Ventura Unified School District, York Oxnard

Lien claimant Access Mediquip sought reimbursement for over $68,000 for durable medical equipment, specifically neurostimulators. The WCJ denied this, finding the defendant school district had already paid for the equipment through the surgical facility's charges. The Appeals Board affirmed this denial, concluding the evidence showed the neurostimulator costs were bundled into the surgery center's facility fees, aligning with Medicare bundling rules for ambulatory surgery centers. The Board distinguished this case from a prior one where the defendant contested the inclusion of costs in the facility bill, emphasizing the defendant here demonstrated payment via the bundled facility charge.

Workers Compensation Appeals BoardLien ClaimantDurable Medical EquipmentNeurostimulatorSurgical ProceduresFacility ChargeBill ReviewCPT CodeMedicare RulesAmbulatory Surgery Center
References
1
Case No. MISSING
Regular Panel Decision

Silvanic v. Wall-To-Wall Sound & Video

This case concerns an appeal from a Workers’ Compensation Board decision, filed October 7, 1991, which ruled that a subsequent employer was entitled to reimbursement for wages paid to the claimant during a period of compensable disability. The appellate court affirmed the Board's decision, dismissing the claimant's arguments regarding the untimeliness of the appeal and the inapplicability of Workers’ Compensation Law § 25 (4) (a) to bar reimbursement for a subsequent employer. The court highlighted that denying reimbursement would unjustly benefit the claimant by allowing them to receive both workers’ compensation benefits and full salary for the same period, thereby creating an unwarranted imbalance that necessitates the employer's reimbursement.

Workers' CompensationEmployer ReimbursementWage ReimbursementCompensable DisabilityTimeliness of AppealWorkers' Compensation LawDouble RecoveryAppellate ReviewBoard Decision
References
5
Case No. ADJ2806916 (SDO 0271727)
Regular
Oct 30, 2013

SOVEIDA MAGANA vs. CENTER FOR EMPLOYMENT TRAINING, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for RELIANCE INSURANCE COMPANY

This case consolidates numerous claims involving unresolved lien claims for ambulatory surgical center facility fees. The Workers' Compensation Appeals Board affirmed the Administrative Law Judge's decision establishing reasonable facility fees by averaging the January 1, 2004, Official Medical Fee Schedule for ASCs with the average amount paid to San Diego hospitals under an older inpatient fee schedule. The Board found this methodology appropriately considered extensive evidence and relevant factors for determining reasonable fees. Defendants' arguments that only the January 1, 2004, OMFS should apply or that SB 863's independent bill review process was mandatory were rejected.

Workers' Compensation Appeals BoardSoveida MaganaCenter for Employment TrainingCalifornia Insurance Guarantee AssociationReliance Insurance CompanyLien ClaimantsPoint Loma Surgical CenterElite Surgical CentersAmbulatory Surgical CenterFacility Fees
References
0
Case No. MISSING
Regular Panel Decision

Claim of Jones v. Chevrolet-Tonawanda Division, GMC

This case involves appeals from two decisions by the Workers’ Compensation Board concerning a self-insured employer’s entitlement to credit for holiday wages paid to disabled employees. Claimants Hanks and Jones were injured during employment, resulting in lost time, including holidays. The employer paid them compensation for lost time but also provided full wages for holidays as per collective bargaining agreements, subsequently seeking reimbursement under Workers’ Compensation Law § 25 (4)(a). The Board denied these reimbursement requests, stating that holiday pay was a contractual right and not intended to be in lieu of compensation. The appellate court reversed the Board’s decisions, ruling that denying reimbursement would lead to claimants receiving both full wages and compensation for the holidays, creating an imbalance. Therefore, the employer is entitled to reimbursement, and the matters are remitted to the Workers’ Compensation Board for further proceedings consistent with this decision.

Workers' CompensationHoliday PayReimbursementCollective Bargaining AgreementDisabled EmployeesLost WagesSelf-Insured EmployerAppellate ReviewBoard Decision ReversalStatutory Interpretation
References
2
Case No. 25 NY3d 907
Regular Panel Decision
2015-XX-XX

Government Employees Insurance v. Avanguard Medical Group, PLLC

This case addresses whether no-fault insurance carriers are obligated to pay facility fees to New York State-accredited office-based surgery (OBS) centers for the use of their premises and support services. The court concluded that neither existing statutes nor regulations mandate such payments. Plaintiffs, a group of GEICO insurers, successfully sought a declaratory judgment that they are not legally required to reimburse Avanguard Medical Group, PLLC, for OBS facility fees, totaling over $1.3 million. The decision affirmed the Appellate Division's ruling, emphasizing that OBS facility fees are not explicitly covered by statute or fee schedules, nor do they fall under reimbursable "professional health services" as per 11 NYCRR 68.5. The court highlighted the distinct regulatory frameworks for OBS centers compared to hospitals and ambulatory surgery centers, declining to mandate policy changes best left to the legislature.

No-Fault InsuranceOffice-Based Surgery (OBS)Facility FeesInsurance LawBasic Economic LossFee SchedulesWorkers' Compensation BoardDepartment of Financial ServicesStatutory InterpretationRegulatory Framework
References
16
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