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

Case No. ADJ 1293553 (VNO 0460149)
Regular
May 12, 2016

CHARLES HOLDER vs. TROY CHRISTIAN dba ADVENTURE LIMOUSINE, THE HARTFORD INSURANCE COMPANY

This case concerns a billing dispute for medical treatment provided to applicant Charles Holder. The Workers' Compensation Appeals Board (WCAB) has remanded the matter for the trial judge to determine if Independent Bill Review (IBR) was properly initiated for services rendered on or after January 1, 2013. The Court of Appeal ordered this remand due to uncertainty regarding whether the defendant provided adequate explanations of review, which is a prerequisite for IBR. If IBR was not properly initiated, the WCAB retains jurisdiction over the dispute.

Workers' Compensation Appeals BoardRemandIndependent Bill ReviewExplanation of ReviewLabor Code section 4603.2Official Medical Fee ScheduleLien ClaimantJurisdictionTrial LevelFindings
References
1
Case No. ADJ7038469
Regular
Sep 17, 2014

AZIZA SAYED vs. GIORGIO ARMANI, FEDERAL INSURANCE COMPANY

The defendant's petition to appeal an Administrative Director's Independent Bill Review (IBR) determination was dismissed. The Board found the petition premature as it was not first heard by a trial level Workers' Compensation Judge (WCJ). Additionally, the petition failed to comply with numerous procedural requirements, including proper captioning, verification, service, and stating specific grounds for appeal. Consequently, both the petition for reconsideration and the petition appealing the IBR determination were dismissed.

Workers' Compensation Appeals BoardIndependent Bill ReviewPetition for ReconsiderationAdministrative DirectorLabor Code section 4603.6MAXIMUS Federal ServicesInc.Lien claimantOfficial Medical Fee ScheduleWCAB Rules of Practice and Procedure
References
0
Case No. ADJ11329981
Regular
Jan 14, 2019

JEFFERY DANHAUSER vs. HOWROYD WRIGHT EMPLOYMENT AGENCY, INC., ACE AMERICAN INSURANCE COMPANY, GALLAGHER BASSETT SERVICES, INC., UNITEDHEALTH GROUP, INC., TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA, SEDGWICK CLAIMS MANAGEMENT SERVICES, INC.

This case involved a petition for reconsideration and removal by a lien claimant disputing medical bill payments. The Appeals Board denied reconsideration and dismissed the removal petition, affirming the WCJ's findings. The Board reiterated that disputes over medical bill amounts after review must proceed to Independent Bill Review (IBR), not through the Appeals Board. A decision directing a party to IBR is a threshold determination, making reconsideration the appropriate remedy, not removal.

Workers' Compensation Appeals BoardPetition for ReconsiderationPetition for RemovalAdministrative Law Judge (WCJ)Independent Bill Review (IBR)Substantive RightLiabilityQuasijurisdictionalThresholdLien Claimant
References
2
Case No. ADJ1003604 (VNO 0473994)
Regular
May 10, 2016

MARIO CARRASCO vs. CITY OF LOS ANGELES

Lien claimant Western Medical Center (Western) sought reconsideration of an Independent Bill Review (IBR) determination that found no reimbursement warranted for medical services. Western argued the IBR determination was plainly erroneous because the defendant failed to provide a contract justifying payment below the official medical fee schedule. However, the Board dismissed Western's petition, finding it premature and improperly filed. Western failed to exhaust the required statutory appeal process to the Workers' Compensation Appeals Board trial level before filing for reconsideration.

Workers' Compensation Appeals BoardIndependent Bill ReviewAdministrative DirectorMaximus Federal ServicesOfficial Medical Fee ScheduleStipulations and AwardCumulative Trauma InjuryLumbar Spinal SurgerySecond Bill ReviewExplanation of Benefits
References
5
Case No. ADJ8824674
Regular
Mar 15, 2018

MIGUEL MONTES vs. KOLE, INC. DBA QUALITY TUNE UP #8, ILLINOIS MIDWEST INSURANCE AGENCY, LLC, PROCENTURY INSURANCE COMPANY

This case concerns a Petition for Removal that the Workers' Compensation Appeals Board (WCAB) dismissed as untimely. The petitioner failed to file their removal petition within the prescribed 20-day period plus additional mailing time, submitting it one day late. Even if timely, the WCAB would have denied it on the merits, agreeing with the WCJ that the billing dispute was subject to Independent Bill Review (IBR) and not the WCAB's jurisdiction. The WCAB emphasized that if the sole dispute is the amount of payment and a second review failed, IBR is the proper avenue under Labor Code section 4603.6.

Petition for RemovalWorkers' Compensation Appeals BoardUntimely FilingService of OrderLegal MailingIndependent Bill ReviewLabor Code Section 4603.2Labor Code Section 4603.6Medical Provider NetworkJurisdiction
References
1
Case No. ADJ8677592
Regular
Aug 27, 2018

LINDA DAVIES vs. SECURITAS SECURITY SERVICES USA, INC.

This case involves a dispute over reimbursement for medical-legal expenses incurred by a lien claimant, Dr. Kauss, who was designated as the applicant's primary treating physician. The Workers' Compensation Appeals Board (WCAB) rescinded the initial award, finding that the WCJ erred in determining the compensability of Dr. Kauss's reports. The WCAB remanded the case for further proceedings to evaluate compliance with specific statutory requirements regarding objections to medical-legal bills and the distinction between IBR and non-IBR disputes. A dissenting opinion argued Dr. Kauss did not fulfill the duties of a primary treating physician and should not be reimbursed.

Workers' Compensation Appeals BoardReconsiderationMedical-Legal ExpensesPrimary Treating PhysicianLabor Code Section 4060Labor Code Section 4061Lien ClaimantIndependent Bill ReviewExplanation of ReviewDefense Attorney
References
3
Case No. ADJ5829433
Regular
Nov 08, 2017

JESSICA SENQUIZ vs. CITY OF FREMONT, YORK INSURANCE

In this workers' compensation case, the Workers' Compensation Appeals Board (WCAB) reconsidered a prior decision regarding payment for medical services. The defendant reduced payments for epidural steroid injections based on National Correct Coding Initiative (NCCI) edits, arguing this was a fee schedule dispute subject to Independent Bill Review (IBR). The WCAB ultimately rescinded the prior decision, finding that disputes over procedure coding, even if not explicitly adopted in the fee schedule, are considered disputes over the amount payable under the Official Medical Fee Schedule. Therefore, the WCAB concluded that such billing disputes are subject to IBR and not within the WCAB's jurisdiction.

WCABJessica SenquizCity of FremontYork InsuranceADJ5829433Opinion and Decision After Reconsiderationtransforaminal epidural steroid injectionsFremont Surgery CenterIndependent Bill Review (IBR)National Correct Coding Initiative (NCCI)
References
0
Case No. ADJ9101616
Regular
Feb 20, 2018

MARIA MENCITAR vs. JESUS EDGARDO PACHECO, STAR INSURANCE CO., Administered by MEADOWBROOK INSURANCE

The Workers' Compensation Appeals Board (WCAB) granted removal and rescinded a WCJ's order that dismissed a medical-legal provider's petition for determination of non-IBR medical-legal dispute for lack of jurisdiction. The WCAB found the WCJ erred by not holding a hearing, as no procedural rule required the provider to file a lien first. This decision allows the provider to pursue its claim for medical-legal expenses at the trial level.

WCABPetition for RemovalPetition for ReconsiderationPetition for Determination of Non-IBR Medical-Legal DisputeWCJMinute OrderFinal OrderInterlocutory OrderMedical-Legal ExpensesLien Claimant
References
12
Case No. ADJ9237052
Regular
Apr 12, 2019

ANGELICA BERMUDEZ vs. JACK IN THE BOX, Administered by GALLAGHER BASSETT SERVICES

The Workers' Compensation Appeals Board granted the petitioner's (Tower Imaging) Petition for Removal, rescinded the WCJ's prior order, and returned the matter for further proceedings. The WCJ had rejected Tower Imaging's petition for non-IBR dispute resolution due to its failure to appear at a lien conference. The Board found that Tower Imaging was denied due process and a fair hearing. The Board also admonished Tower Imaging's representative for misleading statements in the petition.

Petition for RemovalOrder Rejecting Petition for Non-IBR DisputeDue ProcessFair HearingSubstantial JusticePetition for DeterminationLien ConferenceWCJWorkers' Compensation Appeals BoardCompromise and Release
References
5
Case No. ADJ7684442
Regular
Mar 08, 2019

JAIME VARGAS vs. SELIGMAN ENTERPRISES, OAK RIVER INSURANCE, BERKSHIRE HATHAWAY HOMESTATE COMPANY

This case concerns a lien claimant's request for reconsideration of a Workers' Compensation Appeals Board (WCAB) decision regarding payment for Kaiser record copying services. The WCAB granted reconsideration, amended the original findings to include a 10% penalty and 7% interest per annum on the Kaiser record invoices. The WCAB also vacated the prior order for Independent Bill Review (IBR) and returned the matter for further proceedings. Defendant claims to have paid the billed amount and penalties/interest, potentially rendering those issues moot.

Med-Legal PhotocopyIndependent Bill ReviewPetition for ReconsiderationWCJKaiser RecordsPenaltiesInterestLien ClaimantSeligman EnterprisesOak River Insurance
References
1
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