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

Case No. ADJ4673406 (ANA 0403334) ADJ4233924 (ANA 0376527)
Regular
Sep 29, 2009

Joseph Vella vs. Hitchcock Automotive, State Compensation Insurance Fund

This case concerns a dispute over the reasonableness of a lien claimant's billing for outpatient surgery services. The Workers' Compensation Appeals Board granted reconsideration and rescinded the original award, finding the Administrative Law Judge (ALJ) erred by concluding the lien claimant met its burden based solely on its usual billing practices without a proper analysis of reasonableness. The Board remanded the case to the ALJ to determine a reasonable fee considering all evidence, including the lien claimant's and defendant's submissions, as outlined in *Kunz* and *Tapia*. The decision emphasizes that the lien claimant bears the affirmative burden to prove the reasonableness of its fee.

Kunz doctrinelien claimantreasonable feerebuttal evidenceTapiabillingmedical treatmentoutpatient surgeryinpatient hospitalDRG
References
Case No. FRE 0222651
Regular
Jul 15, 2008

CHRISTOPHER HUNT vs. MADERA COUNTY ROAD DEPARTMENT

The Appeals Board granted reconsideration of a WCJ's decision that limited a lien claimant's facility fees to the Official Medical Fee Schedule. The Board found the WCJ erred by not applying the correct *Kunz* standard for determining the reasonableness of outpatient surgery facility fees, which considers factors beyond the fee schedule. The case is remanded for further proceedings to properly develop the record according to *Kunz*.

KunzOfficial Medical Fee Scheduleoutpatient surgery facility feeslien claimantreconsiderationen banc decisionreasonableness of feesusual feegeographical areacontractually negotiated fees
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The Workers' Compensation Appeals Board granted reconsideration and rescinded the prior award, remanding the case to the trial level.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. LAO 0807776
Regular
Jan 08, 2008

Mason Dow vs. COMMERCIAL INTERIOR RESOURCES, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration and rescinded a prior award, returning the case to the trial level for further proceedings. The Board found that the Administrative Law Judge erred by improperly applying the Official Medical Fee Schedule to a lien claimant's surgical facility fees incurred prior to its adoption. The case is remanded for the judge to determine the reasonableness of the lien claimant's charges, considering factors outlined in *Kunz v. Patterson Floor Coverings*.

Workers' Compensation Appeals BoardLien ClaimantReconsiderationFindings and AwardSurgical Facility FeesKunz v. Patterson Floor CoveringsReasonable FeeOfficial Medical Fee Schedule (OMFS)Outpatient Surgery CenterUsual Fee
References
Case No. ADJ6861829
Regular
Jun 13, 2012

BART JAMES JOHNSON vs. BEYETTE'S TREE CARE

This case involves a supplemental award of attorney's fees to Bart James Johnson's attorney, pursuant to Labor Code § 5801. The Court of Appeal denied the employer's petition for writ of review, finding no reasonable basis. Consequently, the case was remanded for attorney's fees. The applicant's attorney requested $3,500.00 for ten hours of work at $350 per hour related to the writ of review. The Workers' Compensation Appeals Board deemed this fee reasonable and awarded it against the uninsured employer.

Workers' Compensation Appeals BoardSupplemental Attorney's FeesLabor Code § 5801Petition for Writ of ReviewRemandReasonable Attorney FeesStipulationPetition for FeeAnswer to PetitionLegal Services
References
Case No. GOL 0090664, GOL 0090665
Regular
Jul 14, 2008

CLIAZAR CARDENAS vs. WEST COAST HARVESTING, STATE COMPENSATION INSURANCE FUND

The Appeals Board granted reconsideration, rescinding the prior award to the lien claimant for outpatient surgery center fees and anesthesiology. The Board found that the lien claimant bore the burden to prove the reasonableness of its charges, and the WCJ erred in favoring the lien claimant's evidence over the defendant's rebuttal evidence. The matter is remanded for further proceedings to determine a reasonable fee based on all evidence presented.

WCABSCIFlien claimantreasonableness of chargesoutpatient surgery center feeanesthesiologist feesOMFSKunz v. Patterson Floor Coveringfacility feebill reviewer testimony
References
Case No. ADJ10307427
Regular
Mar 21, 2017

CHRISTOPHER DEVEREUX vs. STATE COMPENSATION INSURANCE FUND, Permissibly Self-Insured; administered by THE HARTFORD

This case concerns an award of additional attorney's fees for applicant's counsel, pursuant to Labor Code § 5801. The Third District Court of Appeal remanded the matter for this purpose after denying the defendant's Petition for Writ of Review. The parties stipulated to reasonable attorney's fees of $2,500.00. The Board has issued an award of these appellate attorney's fees in favor of the applicant's counsel, payable in addition to any compensation awarded to the applicant.

Workers' Compensation Appeals BoardLabor Code § 5801attorney's feesPetition for Writ of Reviewappellate attorney's feesstipulationawardState Compensation Insurance FundThe Hartfordremanded
References
Case No. SDO 313688
Regular
May 06, 2008

CRESENCIO BARRERA vs. HNR FRAMING, AMERICAN HOME ASSURANCE COMPANY

The Workers' Compensation Appeals Board rescinded a prior decision because the administrative law judge (WCJ) failed to apply the *Kunz* standard for determining reasonable facility fees for medical services. The WCJ's decision was found to be internally inconsistent and unsupported by the evidence, particularly regarding the consideration of contractually negotiated rates and usual fees accepted by other providers. The case is remanded for further proceedings and a new decision by a different WCJ.

WCABReconsiderationFacility FeesCPT CodesReasonablenessKunz v. PattersonAmbulatory Surgery CenterMedicareOfficial Medical Fee ScheduleGeographical Area
References
Case No. ADJ2340102 (LAO 0751270) ADJ4406096 (LAO 0784412)
Regular
Apr 27, 2017

JOSE MORFIN vs. WHITE MEMORIAL MEDICAL CENTER, ADVENTIST HEALTH

This case involves an award of additional attorney's fees for applicant's counsel in the California Court of Appeal. The court remanded the matter for supplemental fees after the defendant's unsuccessful Petition for Writ of Review. While applicant's attorney sought $11,480.00 in fees, the Board found this excessive and awarded $8,000.00 based on a review of the appellate work and the contentious history of the litigation. The Board also awarded the requested costs of $67.58, totaling $8,067.58 in additional appellate attorney's fees and costs.

Workers' Compensation Appeals BoardSupplemental Attorney's FeesPetition for Writ of ReviewLabor Code § 5801Labor Code § 5811Appellate Attorney's FeesItemization of Attorney's FeesExcessive Fee RequestReasonable Fee DeterminationCase-by-Case 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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