ADJ13071035 · April 24, 2026

Defendant repeatedly denied payment for authorized medical care, violating Labor Code section 4610.3 and causing delay in compensation under Labor Code section 5814. The delay was egregious and harmed the applicant's medical care and recovery.

From the decision · page 8Substantial evidence supports my finding of a delay in medical treatment that gave rise to my assessment of penalties under Labor Code section 5814, attorneys' fees under Labor Code section 5814.5 and sanctions in the form of lien claimant's attorneys' fees. Labor Code section 5814 provides for a penalty for the unreasonable delay of compensation. Medical treatment is considered compensation, and a delay in its provision can give rise to a penalty under Labor Code section 5814. (See, Grubb & Ellis v. Workers' Comp. Appeals Bd. (1997) 62 Cal. Comp. Cases 807; Paula Ins. Co. v. Workers' Comp. Appeals Bd. (1997) 62 Cal. Comp. Cases 820.)

Lien claimant met burden of proof that defendant did not timely pay the bill for services of February 5 through February 18, 2024, entitling lien claimant to 15% penalties and interest from receipt to payment date.

From the decision · page 106. Lien claimant did, in fact, meet its burden of proof that defendant did not timely pay the bill for the services of February 5 § 18, 2024.

Lien claimant met its burden of proof that the services were subject to a PPO contract based on testimony and defendant's Explanation of Reviews referencing the Multiplan contract and pricing.

From the decision · page 62. Lien claimant met its burden of proof that the services were subject to a PPO contract.

The January 22, 2025 utilization review was untimely as the request for authorization was faxed on January 15, 2025 and denied on January 22, 2025, exceeding the 72-hour timeline for concurrent review under Labor Code section 4610(i)(3). The treatment was medically necessary based on the applicant's PTP report.

From the decision · page 5The applicant was an inpatient of Casa Colina at the time of the January 15, 2025 request for authorization, so it is considered a concurrent review. (Reg 9792.6.1(c).) Therefore, the timeline for concurrent review is 72 hours. (Labor Code section 4610(i)(3); Garcia v. Barrett Business Services Inc., (2018) 84 Cal. Comp. Cases 350.) As the request for authorization regarding continued stay at Casa Colina was faxed to defendant on January 15, 2025 and denied on January 22, 2025, it was untimely. (Exhibits 13, 26).

Defendant did not timely pay multiple invoices from Casa Colina, resulting in penalties and interest under Labor Code section 4603.2. Defendant's objections on Explanation of Reviews were inaccurate or immaterial, and payments were not made despite authorization.

From the decision · page 63. Substantial evidence supports my finding that there was no timely payment to lien claimant, and the invoices are subject to penalties and interest pursuant to Labor Code section 4603.2.

The January 22, 2025 utilization review was untimely, exceeding the 72-hour timeline for concurrent review.

Favours Applicant prevailed

This established that the requested treatment was medically necessary and that defendant's denial was improper, favoring applicant's claim for medical benefits.

From the decision · page 5The applicant was an inpatient of Casa Colina at the time of the January 15, 2025 request for authorization, so it is considered a concurrent review. (Reg 9792.6.1(c).) Therefore, the timeline for concurrent review is 72 hours. (Labor Code section 4610(i)(3); Garcia v. Barrett Business Services Inc., (2018) 84 Cal. Comp. Cases 350.) As the request for authorization regarding continued stay at Casa Colina was faxed to defendant on January 15, 2025 and denied on January 22, 2025, it was untimely. (Exhibits 13, 26).

Lien claimant's services were subject to a PPO contract and not subject to OMFS, supported by testimony and defendant's Explanation of Reviews referencing the Multiplan contract.

Favours Applicant prevailed

This established defendant's liability for payment under the PPO contract, favoring applicant's claim for payment of medical services.

From the decision · page 6As a rehabilitation hospital, lien claimant was not subject to the Official Medical Fee Schedule (OMFS) pursuant to Title 8, Cal. Code of Regulation 9789.22(k). I further found that the services were subject to a PPO and was therefore obligated to pay for the services pursuant to that contract. This finding was based on the testimony of Jennyfer Podeska, who testified that the applicant was admitted under the Multiplan contract. (Summary of Evidence of June 2, 2025 trial, 26:8-12.) The testimony was bolstered by defendant's Explanation of Reviews ("EOR") that reduced payment to lien claimant based on a PPO contract, and referenced the "Multiplan" contract and pricing. (Exhibits 123-136 and 138-152.) Defendant states that this finding was not supported by the facts, with no further argument, so it is why defendant believes that the services were not subject to a PPO contract with lien claimant.

Defendant did not timely pay multiple invoices from lien claimant, resulting in penalties and interest under Labor Code section 4603.2.

Favours Applicant prevailed

This supported the award of penalties and interest to lien claimant for untimely payment, favoring applicant.

From the decision · page 6In my Findings and Award, I found that 26 of the invoices from Casa Colina were not timely paid and therefore were subject to a 15% penalty and interest pursuant

Defendant repeatedly denied payment for authorized medical care, violating Labor Code section 4610.3 and causing delay in compensation under Labor Code section 5814.

Favours Applicant prevailed

This supported the imposition of penalties and attorney's fees for delay in compensation, favoring applicant.

From the decision · page 8Once an employer authorizes "medical treatment [they] shall not rescind or modify that authorization after the medical treatment has been provided based on that authorization for any reason." (Labor Code section 4610.3(a).) The numerous bill review EORs that specifically deny payment based on the fact that authorization was rescinded is a clear violation of Labor Code section 4610.3. Defendant's failure to pay for the medical care that their own utilization review felt was reasonable and necessary was a denial of medical care and violation of the award of medical care in this case. As the treatment was reasonable and necessary (as evidenced by the UR authorization), and provided, defendant is obligated to pay for that treatment. Defendant's failure to pay is a delay in compensation under Labor Code section 5814.

Lien claimant met burden of proof that defendant did not timely pay the bill for services of February 5 through February 18, 2024, entitling lien claimant to 15% penalties and interest.

Favours Applicant prevailed

This corrected an error in the original Findings and Award and increased the penalties awarded to lien claimant, favoring applicant.

From the decision · page 11FINDINGS OF FACT 14. Defendant did not timely pay lien claimant's bill for the services of

Applicant was not sufficiently recovered to be discharged to an outpatient facility; continued care at Casa Colina was medically necessary.

Based on the reporting of applicant's PTP, Dr. Huang, the applicant was not sufficiently recovered to be discharged to an outpatient facility, and therefore continued care in Casa Colina's TLC Interdisciplinary Residential program was medically necessary.

From the decision · page 5The requested continued stay at Casa Colina was consistent with the Medical Treatment Utilization Scheduled. The MTUS selectively recommends inpatient comprehensive interdisciplinary rehabilitation programs for acute severe traumatic brain (TBI) injuries. As the defendant authorized the inpatient program initially, they agreed the inpatient program was medically necessary. The Medical Treatment Utilization Schedule (MTUS) states that discontinuation is recommended when there is sufficient recovery that the patient can be discharged to an outpatient facility. (MTUS for Traumatic Brain Injury, page 210.) Based on the reporting of applicant's PTP, Dr. Huang, the applicant was not sufficiently recovered to be discharged to an outpatient facility, and therefore continued care in Casa Colina's TLC Interdisciplinary Residential program, 7 days a week for the period of January 28, 2025 through April 22, 2025, was medically necessary.

Labor Code section 4610(i)(3); Regulation 9792.6.1(c); Garcia v. Barrett Business Services Inc. (2018) 84 Cal. Comp. Cases 350

Utilization review concurrent review timeline is 72 hours for inpatient care requests.

The January 22, 2025 utilization review was untimely as the request was faxed on January 15, 2025 and denied on January 22, 2025, exceeding the 72-hour timeline.

From the decision · page 5The applicant was an inpatient of Casa Colina at the time of the January 15, 2025 request for authorization, so it is considered a concurrent review. (Reg 9792.6.1(c).) Therefore, the timeline for concurrent review is 72 hours. (Labor Code section 4610(i)(3); Garcia v. Barrett Business Services Inc., (2018) 84 Cal. Comp. Cases 350.) As the request for authorization regarding continued stay at Casa Colina was faxed to defendant on January 15, 2025 and denied on January 22, 2025, it was untimely. (Exhibits 13, 26).

Title 8, Cal. Code of Regulation 9789.22(k)

Lien claimant services at rehabilitation hospital not subject to OMFS but subject to PPO contract.

Services were subject to PPO contract based on testimony and defendant's Explanation of Reviews referencing Multiplan contract.

From the decision · page 6As a rehabilitation hospital, lien claimant was not subject to the Official Medical Fee Schedule (OMFS) pursuant to Title 8, Cal. Code of Regulation 9789.22(k). I further found that the services were subject to a PPO and was therefore obligated to pay for the services pursuant to that contract. This finding was based on the testimony of Jennyfer Podeska, who testified that the applicant was admitted under the Multiplan contract. (Summary of Evidence of June 2, 2025 trial, 26:8-12.) The testimony was bolstered by defendant's Explanation of Reviews ("EOR") that reduced payment to lien claimant based on a PPO contract, and referenced the "Multiplan" contract and pricing. (Exhibits 123-136 and 138-152.) Defendant states that this finding was not supported by the facts, with no further argument, so it is why defendant believes that the services were not subject to a PPO contract with lien claimant.

Labor Code section 4603.2

Penalties and interest apply for untimely payment of medical bills under Labor Code section 4603.2.

Defendant did not timely pay multiple invoices, resulting in penalties and interest under section 4603.2.

From the decision · page 6In my Findings and Award, I found that 26 of the invoices from Casa Colina were not timely paid and therefore were subject to a 15% penalty and interest pursuant

Labor Code section 4610.3

Once medical treatment is authorized, employer shall not rescind or modify authorization after treatment has been provided.

Defendant's repeated denial of payment for authorized care violated section 4610.3 and caused delay in compensation under section 5814.

From the decision · page 8Once an employer authorizes "medical treatment [they] shall not rescind or modify that authorization after the medical treatment has been provided based on that authorization for any reason." (Labor Code section 4610.3(a).) The numerous bill review EORs that specifically deny payment based on the fact that authorization was rescinded is a clear violation of Labor Code section 4610.3. Defendant's failure to pay for the medical care that their own utilization review felt was reasonable and necessary was a denial of medical care and violation of the award of medical care in this case. As the treatment was reasonable and necessary (as evidenced by the UR authorization), and provided, defendant is obligated to pay for that treatment. Defendant's failure to pay is a delay in compensation under Labor Code section 5814.

Defendant's Explanation of Reviews (EORs) showed zero payment for lien claimant's bills at issue, despite authorization of services.

From the decision · page 7to Labor Code section 4603.2. Defendant's petition appears to appeal my findings on only five of those invoices. Defendant also contends that no "additional" payment is due, however, there is no substantial evidence that defendant has made any payment for the lien claimant's bills at issue for this trial. All of defendant's Explanation of Reviews (EORs) for the date of service at issue show zero payment. I found that the defendant did not timely pay the invoice for the period of services for the period of December 20, 2024 through January 2, 2025 (Finding of Fact No. 57.) Defendant's Explanation of Review denied the services because (1) the provider was not certified or eligible to be paid, (2) resolution manager denial (3) the referring/providing/rendering provider was not eligible to refer/prescribe or perform the billed service. (Exhibit 54.) Defendant had in fact authorized these services to this provider through UR so these were inaccurate objections. Defendant's argument that the services billed were not properly documented is immaterial. Although defendant elicited testimony on cross examination of lien claimant's bill review expert regarding inconsistencies in the documentation, the claim that the services were not properly documented was not an objection defendant listed on the EOR when they denied all payment.

Lien claimant's credible testimony that nonpayment of authorized care subjected applicant to discharge from Casa Colina.

From the decision · page 9I did consider factors such as the amount delayed, the length of the delay, and whether the delay was inadvertent and corrected when I assessed a penalty in this matter. (Ramirez v. Drive Financial Services (2008) 73 Cal. Comp. Cases 1324, 1329-1330 (Appeals Bd En Banc.) Defendant's behavior in this case was, quite frankly, egregious. "The broad purpose of workmen's compensation is to secure an injured worker seasonable cure or relief from industrially caused injuries in order to return him to the work force at the earliest possible time." (Davison v. Industrial Acc. Com. (1966) 241 Cal.App.2d 15, 18 (emphasis added.) By unconscionably refusing to pay for authorized in patient care, defendant failed to provide seasonable cure or relief of benefits. The unpaid invoices of lien claimant span close to a year of the applicant's hospitalization and lien claimant's facility. Lien claimant credibly testified that the nonpayment of this authorized care subjected the applicant to discharge from Casa Colina.