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

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
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The Workers' Compensation Appeals Board (WCAB) rescinded a prior decision concerning the retroactive application of a 2012 statutory fee reduction for ambulatory surgical centers.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 The WCAB returned the case to the trial level for approval of this settlement, allowing the WCJ to reissue the rescinded decision if the settlement is not approved.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
Case No. ADJ4525685
Regular
Apr 08, 2011

MAGDALENA CASTILLEJA vs. COUNTY OF TULARE, AMERICAN HOME ASSURANCE COMPANY

This case involves a lien claimant, Summit Surgical Center (formerly Sierra Pacific Surgical Center), seeking reconsideration of a decision denying their lien for $11,799.50. The Workers' Compensation Appeals Board denied reconsideration because the lien claimant failed to provide any legal or factual support for their petition. The Board also issued a Notice of Intention to Impose Sanctions of $500 against the lien claimant and their representative for filing a frivolous and unsubstantiated petition. The lien claimant argued the carrier should be liable for treatment costs without the provider having to prove compensability.

WCABPetition for ReconsiderationLien ClaimantIndustrial InjuryAOE/COEMedical TreatmentMedical Legal ServicesSanctionsLabor Code § 5813Bad Faith
References
Case No. AHM 0082920
Regular
Mar 10, 2008

RAUL REYES vs. DUDDY DRYWALL COMPANY, STATE COMPENSATION INSURANCE FUND

This Workers' Compensation Appeals Board decision denies a lien claimant's petition for reconsideration. The WCAB affirmed the trial judge's disallowance of a medical lien, finding the claimant failed to prove either the reasonableness of its charges or proper licensure for the services provided under the name "SB Surgery Center" on the date of service. The Board held the lien claimant bore the burden of proving licensure and did not meet that burden.

Lien claimantSB Surgery CenterS&B Surgery Centerlicensingreasonableness of chargesburden of proofsubstantial evidenceLabor Code sections 59025904Zenith Insurance Company v. Workers' Comp. Appeals Bd.
References
Case No. ADJ2089759 (FRE 0209611)
Regular
Nov 10, 2008

Alma Pena vs. HYE CUISINE, INC., FARMERS INSURANCE EXCHANGE

The Workers' Compensation Appeals Board granted reconsideration for lien claimant Summit Surgical Center (SSC) and rescinded the imposed $\$2,000.00$ sanction, finding SSC was not provided adequate notice of the basis for the sanction under Labor Code section 5813. However, the Board affirmed the decision that SSC's lien claim was untimely filed under Labor Code section 4903.5, as it was filed more than five years after the injury and nearly four years after the settlement approval, and the partial payment did not toll the statute of limitations. Therefore, SSC will take nothing further on its lien claim.

Workers' Compensation Appeals BoardLien claimantReconsiderationFindings and OrderLabor Code sections 4903.559045813California Code of Regulations title 8 section 10561Fees and costsSummit Surgical Center
References
Case No. POM 0261983
Regular
Feb 08, 2009

SARA LARA vs. POMONA UNIFIED SCHOOL DISTRICT, CALIFORNIA COMPENSATION INSURANCE/BROADSPIRE

The lien claimant, Premier Outpatient Surgery Center, sought reconsideration of an administrative law judge's decision that reduced their billed costs for applicant's medical treatment. The Workers' Compensation Appeals Board denied the petition, upholding the judge's finding that the billed costs were unreasonable and that the lien claimant failed to present a persuasive case supporting their charges. The Board also found no evidence of a violation of Labor Code section 4603.2 regarding timely reimbursement.

Kunz v. PattersonWCABLien claimantAmended Findings of FactReasonable and necessary costsBilled costs unreasonableStipulations with Request for AwardIndustrial injuryBilateral upper extremitiesNeck injury
References
Case No. SBR 0332538
Regular
Mar 28, 2009

RUBY JONES vs. STATE OF CALIFORNIA / DEPARTMENT OF MENTAL HEALTH, STATE COMPENSATION INSURANCE FUND, PREMIER OUTPATIENT SURGERY CENTER, INC.

The Appeals Board granted reconsideration, rescinded the prior order, and returned the case for further proceedings on the reasonableness of Premier Outpatient Surgery Center's (POSC) $\$16,578.00$ lien claim for surgical services. While POSC was properly licensed as a surgical clinic and did not require a fictitious-name permit, the Appeals Board found the record insufficient to establish the reasonableness of the charged fee, noting a significant disparity between the billed amount and what was paid based on Medicare rates. The Board also rescinded the award of attorney's fees to POSC's counsel, finding no basis for such an award under Labor Code sections 5811 or 5813.

Workers' Compensation Appeals BoardRuby JonesState Compensation Insurance FundPremier Outpatient Surgery Centerfictitious-name permitMedical Board of CaliforniaDepartment of Health Servicessurgical clinic licenseoutpatient settingreasonable fee
References
Case No. ADJ6512547
Regular
Sep 16, 2011

JUAN SANDOVAL vs. MILKY WAY DAIRY, VIRGINIA SURETY COMPANY, APPLIED RISK SERVICES

This case concerns a dispute over a $8,177.09 balance owed to a lien claimant, Summit Surgical, for outpatient surgical services. The defendant sought reconsideration of the Workers' Compensation Judge's award, arguing the lien claimant failed to prove the treatment was reasonable and necessary per *Kunz* and *Tapia*, and that the claim was barred by the statute of limitations. The Appeals Board granted reconsideration, rescinded the award, and returned the matter for further proceedings. The Board found the WCJ failed to rule on the statute of limitations defense, which is a mandatory issue to address.

Workers' Compensation Appeals BoardLien ClaimantReconsiderationFindings of FactAwardWCJSummit SurgicalStatute of LimitationsLabor Code Section 5405Reasonableness of Treatment
References
Case No. LA0 0866858
Regular
Feb 04, 2008

JESUS LEON vs. EDWARD SERVICES, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board (WCAB) granted reconsideration of a decision that denied a lien claim by SB Surgery Center. The WCAB found that SB Surgery Center was properly licensed by the Department of Health Services as a "surgical clinic" and did not require a fictitious-name permit from the Medical Board. The case was returned to the trial level to determine the reasonableness of the facility fee.

Workers' Compensation Appeals BoardLien claimantSB Surgery CenterEdward ServicesState Compensation Insurance FundLA0 0866858Findings and OrderPetition for ReconsiderationAdministrative Law JudgeLicensed
References
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
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