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

Case No. ADJ3172767
Regular
May 10, 2017

VICTOR GONZALEZ vs. CITISTAFF SOLUTIONS, STATE COMPENSATION INSURANCE FUND

The Appeals Board affirmed the WCJ's decision finding the lien claimant, Monrovia Memorial Hospital, was entitled to nothing for its services. The WCJ properly excluded the lien claimant's expert declaration as it was submitted after discovery closed. The lien claimant failed to meet its burden of proving its charges were reasonable and based on a reasonable cost basis, as required by precedent in cases exempt from the Official Medical Fee Schedule. Mere presentation of usual and customary charges, without evidence of reasonableness or comparability, is insufficient.

Workers' Compensation Appeals BoardVictor GonzalezCitistaff SolutionsState Compensation Insurance FundMonrovia Memorial Hospitallien claimantbill review expertdue processreasonableness of chargesOMFS exemption
References
Case No. AD-J7246984
Regular
Apr 05, 2016

COURDES ESTRADA vs. OXNARD HARVEST COMPANY, LIBERTY MUTUAL INSURANCE COMPANY

This case concerns a lien claimant's petition for reconsideration of a Workers' Compensation Appeals Board decision. The claimant argued the administrative law judge (WCJ) erred in valuing their services at $105,972.59 and denying interest. The Board denied reconsideration, finding the bill reviewer appropriately considered usual and customary charges and relied on a reasonable cost basis per administrative directives. The Board also found the defendant complied with Labor Code section 4603.2 regarding payment and explanation of bill review.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardLien claimantMonrovia Memorial HospitalInnovative Medical Managementreasonable value of servicesinterest on awardindependent bill reviewerusual and customary charges
References
Case No. ADJ1158684 (GOL 0099195)
Regular
Nov 14, 2008

CAROLINA VELA vs. SERVICE MASTER CBM, AMERICAN ALL-RISK LOSS ADMINISTRATORS

The Workers' Compensation Appeals Board granted the defendant's petition for reconsideration to correct a clerical error, reducing the lien awarded to Lorena Ortiz-Schneider from $4,025.00 to $1,995.00. The Board also denied Associated Reproduction Services' petition, affirming the WCJ's decision to award copy charges at a reasonable rate of 20 cents per page, referencing precedent established by *Kunz* and *Sweet*. This decision clarifies the correct lien amount and upholds the application of reasonable rates for reproduction services.

WCABPetition for ReconsiderationLien ClaimantInterpreting ServicesCopy ChargesReasonableness of ChargesMedical-Legal ExpensesClerical ErrorDecision After ReconsiderationKunz v. Patterson
References
Case No. ADJ1634986
Regular
Sep 10, 2013

REGINA CAMACHO vs. RIO SCHOOL DISTRICT, YORK INSURANCE SERVICES

This Workers' Compensation Appeals Board decision denies a lien claimant's petition for reconsideration. The lien claimant, Pueblo Surgery Center, failed to meet its burden of proof to establish the reasonableness of its $18,940.00 surgical charges. The Board adopted the WCJ's reasoning that Pueblo's submitted exhibits lacked necessary substantiation and were insufficient to prove their charges were reasonable. Therefore, the denial of reconsideration stands, upholding the original determination regarding the lien claim.

Workers' Compensation Appeals BoardPetition for ReconsiderationLien ClaimantReasonableness of ChargesOutpatient Surgery CenterBillingDeclarations Under Penalty of PerjuryComparative BillingBurden of ProofIndependent Bill Review
References
Case No. ADJ2831572 (OXN 0131269)
Regular
Dec 09, 2008

GRACIELA BELTRAN vs. TECHSTAFF WEST, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied a lien claimant's petition for reconsideration, upholding the original finding that the reasonable value of their services was $4,792.00, not the $12,435.54 claimed. The Board affirmed the Administrative Law Judge's decision, finding the lien claimant failed to meet its burden of proving the reasonableness of its charges under established precedent. The judge properly considered various evidence, including comparative data and the reasonableness of the charges in context, to arrive at the determined amount.

Workers' Compensation Appeals BoardLien ClaimantPetition for ReconsiderationFindings and OrderReasonable ValueIndustrial InjuryCompromise and ReleaseDiagnostically Related GroupMedicareFee Schedule
References
Case No. ADJ2980735 (SBR 0315690)
Regular
Oct 24, 2008

Patrick Young vs. Ken Anderson Construction, State Compensation Insurance Fund

The Workers' Compensation Appeals Board denied reconsideration of a decision that disallowed a lien claimant's remaining balance of $\$ 31,044.00$ for surgical facility fees. The Board affirmed the finding that the lien claimant failed to prove the reasonableness of its charges, as the submitted bills were inadmissible and unauthenticated. Citing recent case law, the Board clarified that lien claimants bear the burden of proving the reasonableness of their charges.

Workers' Compensation Appeals BoardPremier Outpatient Surgery CenterLien ClaimantReconsiderationFindings and OrderFacility FeesReasonableness of ChargesLabor Code Section 5703AdmissibilityCross-examination
References
Case No. ADJ4638638 [SBR 0299210] ADJ326587 [SBR 0299211] ADJ3373174 [SBR 0312295]
Regular
Dec 19, 2008

, Applicant, MELINDA HATTABAUGH vs. STATE OF CALIFORNIA, CDCR/CALIFORNIA INSTITUTION FOR MEN; Legally Uninsured, STATE COMPENSATION INSURANCE FUND/STATE CONTRACT SERVICES, Adjusting Agency

The Workers' Compensation Appeals Board denied a lien claimant's petition for reconsideration, upholding the denial of over $22,000 in outstanding charges for outpatient surgery services. The lien claimant failed to meet its burden of proof to demonstrate the reasonableness of its charges, as required by Kunz v. Patterson Floor Covering. Defendant's evidence, including expert testimony, supported the finding that the amount paid was reasonable reimbursement.

Workers' Compensation Appeals BoardLien ClaimantReconsiderationOutpatient Surgery CenterBurden of ProofReasonableness of ChargesKunzTapiaFee ScheduleBill Reviewer
References
Case No. ADJ194128 (SBR 0298661)
Regular
Apr 04, 2011

MICHELLE ASTLEY vs. REDLANDS UNIFIED SCHOOL DISTRICT, COREGA aka WESTPOINT INSURANCE COMPANY c/o YORK INSURANCE SERVICE

The Workers' Compensation Appeals Board granted reconsideration to address the defendant's petition challenging a prior finding that Rancho Specialty Hospital's $223,400.28 bill was reasonable. The Board found the trial judge incorrectly placed the burden of proof on the defendant to prove the charges were unreasonable, rather than on the lien claimant to prove their charges were reasonable. Consequently, the case was returned to the trial level for a new decision with the correct burden of proof applied.

Workers' Compensation Appeals BoardLien ClaimantRancho Specialty HospitalRedlands Unified School DistrictReconsiderationFindings and OrderWCJLabor Code section 4603(b)Penalties and InterestLong Term Acute Care Hospital
References
Case No. ADJ10160197 ADJ8200777
Regular
Sep 03, 2019

JOSE CARDENAS vs. COSTA VIEW FARMS, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board denied Monrovia Hospital's petition for reconsideration, upholding the original decision that the hospital was entitled to nothing further on its lien. The Board found that the hospital failed to meet its burden of proving its charges were based on a "reasonable cost basis" as required for long-term care facilities exempt from the Official Medical Fee Schedule. Expert testimony presented by both parties, particularly regarding cost-to-charge ratios derived from OSHPD data, supported the finding that the hospital's proposed methodologies did not adequately demonstrate reasonable costs. The Board affirmed that the hospital, not the defendant, bears the affirmative burden of proving the reasonableness of its lien.

Workers' Compensation Appeals BoardLien claimantPetition for ReconsiderationFindings and OrderMonrovia HospitalCosta View FarmsZenith Insurance CompanyWCJLabor Code section 5906reasonable cost basis
References
Case No. ADJ4024660 (LAO 0887729)
Regular
Feb 03, 2017

ALFREDO COLLAZO vs. MECA NAG CORPORATION, EMPLOYERS COMPENSATION

The Appeals Board granted reconsideration, rescinded the prior order, and returned the case to the trial level for a new decision. The WCJ erred in determining the lien claimant's entitlement to payment solely on a multiplier of Medicare rates, rather than a reasonable cost basis. The Board clarified that while the facility's charges are not subject to the Official Medical Fee Schedule, their entitlement must be based on their actual costs plus a reasonable profit. Therefore, further proceedings are required to properly assess the reasonable cost basis for the services rendered.

Workers' Compensation Appeals BoardReconsiderationFindings and OrderLien ClaimantReasonable Cost BasisMedicare ReimbursementOfficial Medical Fee ScheduleLong Term Care HospitalKunz StudyTapia
References
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