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

Case No. VNO 0435305
Regular
Dec 14, 2007

RENEE JACKSON vs. JEWISH FAMILY SERVICES OF LOS ANGELES, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board rescinded a prior award and returned the case to the trial level for further proceedings regarding the reasonable value of services provided by lien claimant Wilshire Surgicenter, Inc. The Board found that neither party presented sufficient evidence according to the precedent set in *Kunz v. Patterson Floor Coverings, Inc.* regarding usual fees accepted by providers. The case will be reheard to allow both parties to develop evidence regarding the usual fees accepted by providers in the geographic area for the services rendered.

Wilshire SurgicenterKunzComparative Study SummaryBill Review ExpertReasonable ValueOutpatient Surgery Facility FeesMedicare Reimbursement RatesLabor Code § 4903.1(c)Due ProcessRebuttal Evidence
References
Case No. MON 0304414
Regular
Sep 17, 2007

SHEENA WILSON vs. BEVERLY HILLS, LTD., THE ZENITH

This case involves a lien claimant, Wilshire Surgicenter, Inc., challenging a Workers' Compensation Appeals Board (WCAB) decision that limited their recovery for outpatient services. The WCAB granted reconsideration solely to correct the lien claimant's name, affirming the administrative law judge's (ALJ) finding that the reasonable value of the services was $3,843.74, despite the invoiced amount of $19,165.00. The WCAB determined that while the fee schedule implemented after the services were rendered did not directly apply, it served as relevant evidence for determining the reasonableness of the facility fee.

Wilshire SurgicenterOutpatient Surgical Facility Fee SchedulePetition for ReconsiderationFindings of FactOrderCompromise and Releasecumulative injuryreasonable valuefacility feeWCJ
References
Case No. ADJ764462 (AHM 0129343)
Regular
Oct 22, 2008

STEVE TEAYS vs. CITY OF SANTA FE SPRINGS, SOUTHERN CALIFORNIA RISK MANAGEMENT

The Appeals Board granted reconsideration and rescinded the WCJ's order, finding that the WCJ misapplied *Kunz v. Patterson Floor Coverings* and failed to make necessary findings on the reasonableness of the lien claimant's fee. The case was returned to the trial level for a new trial, where the defendant will be allowed to present evidence regarding the reasonableness of the lien claim. The Board also noted that the award of interest under Labor Code section 4603.2 was incorrect as no official fee schedule existed at the time of service.

Wilshire Surgicenterlien claimantreasonableness of feeexpert testimony exclusiondiscovery violationKunz v. PattersonTapia v. Skill MastersLabor Code 4603.2substantial justicedue process
References
Case No. MON 0292635
Regular
May 20, 2008

ZENA GARCIA vs. SANTA MONICA MALIBU UNIFIED SCHOOL DISTRICT

The Appeals Board denied the lien claimant's petition for reconsideration, upholding the administrative law judge's decision that the lien claimant failed to meet its burden of proving the reasonableness of its charges for surgery. Despite prior direction to develop the record regarding rebuttal evidence, the lien claimant presented no further evidence, leaving its charges appearing disproportionate. The Board affirmed the use of the 2004 fee schedule as a guide to establish the reasonable value of the services.

KunzOutpatient Surgery Fee ScheduleReconsiderationLien ClaimantReasonable ValueRebuttal EvidenceBurden of ProofGeographic ComparablesComparative StudyIndustrial Injury
References
Case No. PAS 37026, LAO 771108
Regular
Aug 04, 2008

Betty Noujaim vs. TRANSAMERICA FINANCIAL, CRAWFORD AND COMPANY

The Workers' Compensation Appeals Board granted reconsideration and rescinded an order dismissing a lien claimant's claim. The claimant had failed to appear at a lien trial, leading to a notice of intention to dismiss the lien. Although the administrative law judge believed the claimant's subsequent objection lacked good cause, the Board found that due process required consideration of the objection's merits. The case is returned to the trial level for further proceedings on the lien claimant's entitlement to payment.

Wilshire SurgicenterNotice of Intention to DismissLien claimantPetition for ReconsiderationOrder Dismissing Lien ClaimsWCJGood causeDue processJoint Compromise and Release AgreementCumulative trauma injuries
References
Case No. LAO 0832662
Regular
Mar 18, 2008

RIVALDO CASTILLO vs. BENTLEY-SIMONSON, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration and rescinded the prior award, remanding the case to the trial level. The WCJ erred by applying the Official Medical Fee Schedule to a 2003 surgery and failing to consider the *Kunz* factors for reasonableness when determining the lien claimant's facility fees. The Board will allow the WCJ to determine the reasonableness of the lien claimant's charges under *Kunz*, with the OMFS as one factor.

Wilshire SurgicenterOpinion and Order Granting ReconsiderationFindings and AwardLien ClaimantOutpatient Surgery Facility FeesOfficial Medical Fee ScheduleKunz v. Patterson Floor CoveringLabor Code section 4600Reasonableness of Facility FeeUsual Fee
References
Case No. ADJ988798 (VNO 0472280) ADJ1479665 (VNO 0472281) ADJ2424544 (VNO 0472282) ADJ3975160 (VNO 0472283)
Regular
Jun 01, 2009

CECILIA MACIAS vs. GOOD SHEPHERD CONVALESCENT HOSPITAL, STATE COMPENSATION INSURANCE FUND

This case involves a lien claimant, Wilshire Surgicenter, seeking reconsideration of a Workers' Compensation Appeals Board (WCAB) decision that disallowed the majority of its $\$18,148$ lien claim. Wilshire argued the judge improperly considered the Official Medical Fee Schedule (OMFS) and requested removal due to alleged bias. The WCAB denied reconsideration and removal, affirming that Wilshire failed to meet its burden of proving the reasonableness of its charges, as even its own witness suggested a lower "reasonable" amount. The WCAB also clarified that the judge's decision was based on evidence of unreasonableness, not bias.

Workers' Compensation Appeals BoardLien claimantReconsiderationRemovalWorkers' compensation judgeIndustrial injuriesCertified nursing assistantState Compensation Insurance FundCompromise and ReleaseOutpatient surgery center
References
Case No. ADJ1160447 (AHM 0089571)
Regular
Apr 30, 2010

EDWARD RUBINO vs. PACIFIC UTILITY PRODUCT, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration to modify a prior order regarding lien claimants' bills. The Board found that the lien claimants, Tustin Hospital Medical Center and Tustin Surgicenter, failed to meet their burden of proving the reasonableness of their charges, as required by law. Consequently, the Board limited the payment to Tustin Hospital Medical Center to $3,953.02 and Tustin Surgicenter to $522.00, in full satisfaction of their respective liens. The applicant's underlying injury claim had previously been settled via compromise and release.

Workers Compensation Appeals Boardlien claimantDRG fee schedulecompromise and releasereasonableness of chargesburden of proofpreponderance of the evidenceKunz v. PattersonTapia v. Skill Master Staffingfacility fees
References
Case No. ADJ195121 (SBR 328555)
Regular
Dec 15, 2008

VIRGINIA CROM vs. STATE OF CALIFORNIA / DEPARTMENT OF TRANSPORTATION, STATE COMPENSATION INSURANCE FUND

This case involves a lien claimant's request for reconsideration of a Workers' Compensation Appeals Board (WCAB) decision regarding payment for medical services. The WCAB denied reconsideration, upholding the administrative law judge's award of $\$ 990.00$ in addition to prior payments, totaling $\$ 2,642.00$ for one procedure. The lien claimant's attempt to introduce a comparative study to prove the reasonableness of its charges was rejected due to a lack of foundation, as no witness was present to authenticate the document.

Lien claimantReconsiderationFindings and AwardOfficial Medical Fee ScheduleMedicare reimbursementHearsayFoundationDeclarationsComparative StudyProbative force
References
Case No. LAO 835734
Regular
Nov 19, 2007

MARINA SANCHEZ vs. KEELING PROPERTY, THE ZENITH INSURANCE COMPANY

The Appeals Board granted reconsideration and rescinded the WCJ's decision, finding insufficient evidence to support the award for the lien claimant's services. The Board determined that the WCJ failed to address whether the medical treatment was reasonably required and that neither party presented sufficient evidence regarding the reasonableness of the facility fees according to *Kunz* guidelines. The case was returned to the trial level for further proceedings to develop the record on these issues and for a new decision.

Wilshire Surgical CenterKeeling PropertyZenith Insurance CompanyMarina SanchezKunz v. Patterson Floor CoveringFindings and AwardPetition for Reconsiderationusual and customary feesoutpatient surgery facility feesreasonableness of charges
References
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