- Blue Cross Sues L.A. "Insurance Advocate" for $7.6M Fraudon February 18, 2025 at 3:53 PM
Blue Cross of California d/b/a Anthem Blue Cross is a California Stock Corporation with its principal place of business in Woodland Hills, California. Anthem sells health insurance and related administrative services to California employers, individuals, and families.
AA Insurance Advocacy, Inc. is a California-based company that was incorporated on May 21, 20212. The company is registered as a California Stock Corporation and is currently active. The principal address for the company is 1421 Ambassador Street, Unit #212, Los Angeles, CA 900352. Alanna Apfel is listed as the Chief Executive Officer, Chief Financial Officer, Director, and Secretary of the company. She is an insurance patient advocate who helps patients with employer-sponsored PPO insurance negotiate with insurance companies to cover their out-of-pocket mental health therapy costs or services provided by out-of-network therapists.
According to a Civil Complaint filed on February 3, 2025 in the Los Angeles County Superior Court, Anthem alleges that Apfel and her Corporation submitted "fraudulent claims for out-of-network healthcare services that were misrepresented, inflated, or never provided at all." Anthem further alleges that "This scheme was carried out by Alanna Apfel, on her own behalf and through AA Insurance Advocacy, Inc., an entity through which she presents herself to Anthem members and the public as an “insurance advocate” that will negotiate with Anthem (and other insurers) to maximize reimbursement for certain out-of-network medical expenses."
To date, Anthem alleges it "has already identified more than $7.6 million dollars in payments that were directly caused by Ms. Apfel’s fraudulent requests for out-of-network authorizations and/or submission of claims on behalf of more than 480 Anthem members." And it further alleges that this "figure is highly conservative, with the true amount of loss expected to grow dramatically as Anthem continues its investigation." Anthem provided details in the allegations of its lawsuit.
"In reality, Ms. Apfel generates additional reimbursement not through advocacy, but rather by falsely seeking out-of-network authorizations and creating sham out-of-network medical claims for healthcare services. She then submits those claims to Anthem to obtain reimbursement payments to her member-clients for services never rendered or which are far in excess of what the healthcare providers actually charged and the members actually paid for." Anthem further alleges that "Ms. Apfel then charges Anthem members a fee for her “services,” typically based on a percentage of these inflated reimbursements as a kickback for submitting the falsified claims on the members’ behalf."
"Ms. Apfel typically starts with a request for a “network exception” for the member: a way for the member to see an out-of-network provider so that, in theory, the member can receive reimbursement from Anthem for the full out-of-pocket costs supposedly paid to the provider by the member for that authorized, out-of-network care." Anthem then claims that when "Anthem, predictably, is unable to identify an appropriate in-network provider satisfying Ms. Apfel’s numerous requirements, it will authorize the out-of-network referral and provide the member with a network exception which requires Anthem to reimburse the member for the actual out-of-pocket costs paid to that out-of-network provider."
"Ms. Apfel’s and Defendants’ “advocacy” was designed to fraudulently intervene and capitalize on this out-of-network reimbursement process by, depending on the case, grossly inflating or completely fabricating services supposedly rendered by the out-of-network provider and paid for by the member. This caused, and continues to cause, Anthem to pay out millions of dollars to reimburse members for costs they never actually incurred."
Anthem provided several examples of the alleged fraudulent scheme, all involving inflated schemes for psychotherapy with various mental health practitioners. In one example, "Anthem member K.S. retained Ms. Apfel to obtain reimbursement for treatment from out-of-network provider Dr. Joseph Whitcomb, PsyD, LMFT, a provider who had previously treated K.S."
"Based on Ms. Apfel’s representations, Anthem authorized an out-of-network referral/network exception for K.S., in good faith, to treat with Dr. Whitcomb for in-office treatment from May 1, 2023 through April 29, 2024. On or about January 9, 2024, Anthem renewed the authorization for in-office treatment from Dr. Whitcomb from January 1, 2024 through December 31, 2024."
"Dr. Whitcomb, however, could not have treated K.S. during this timeframe because he had moved to Europe years earlier in 2021, shortly after K.S. had originally stopped treating with him." Anthem alleges that "Apfel submitted a claim for reimbursement on behalf of K.S. which included a fraudulent bill Ms. Apfel had created purporting to show that, in March 2024, K.S. had received 17 sessions of psychotherapy from Dr. Whitcomb at a cost of $675 per session, and that K.S. had paid Dr. Whitcomb $11,475 for this period."
Further, Anthem alleges "Dr. Whitcomb died suddenly on May 18, 2024 while in Europe. Roughly one month after his death, on June 16, 2024, Ms. Apfel submitted a claim for reimbursement on behalf of K.S. which included a fraudulent bill Ms. Apfel had created showing that, in May 2024, K.S. supposedly had received 23 sessions of psychotherapy from Dr. Whitcomb at a cost of $995 per session, including 10 sessions that purportedly occurred after Dr. Whitcomb’s May 18, 2024 death, and that K.S. had paid Dr. Whitcomb $22,885 for this period."
No answer or other responsive document has been filed in the Superior Court by any defendants as of the date of this report.
- Health Net to Pay Over $11M for False Cybersecurity Certificationon February 18, 2025 at 3:53 PM
Centene Corporation is a leading healthcare enterprise that provides access to healthcare services. The company focuses on government-sponsored healthcare programs, including Medicaid and Medicare, as well as individuals and families served by the Health Insurance Marketplace. Centene operates in all 50 states and serves over 28.6 million managed care members.
Health Net Federal Services, Inc. (HNFS) of Rancho Cordova, is a subsidiary of Centene Corporation. HNFS provides healthcare services to military service members, retirees, and their families through the TRICARE program. HNFS is responsible for managing the TRICARE West Region, which includes processing claims, providing customer service, and ensuring access to healthcare for beneficiaries.
HNFS and its corporate parent, Centene Corporation, have agreed to pay $11,253,400 to resolve claims that HNFS falsely certified compliance with federal contractor cybersecurity requirements, The cybersecurity requirements were contained in a contract between HNFS and the U.S. Department of Defense (DoD) to administer the Defense Health Agency’s (DHA) health insurance program TRICARE for servicemembers and their families.
The settlement resolves allegations that, between 2015 and 2018, HNFS failed to meet certain cybersecurity controls and falsely certified compliance with them in annual reports to DHA that were required under its contract. The United States alleged that HNFS failed to timely scan for known vulnerabilities and to remedy security flaws on its networks and systems, in accordance with its System Security Plan and the response times HNFS had established.
Furthermore, the United States alleged HNFS ignored reports from third-party security auditors and its internal audit department of cybersecurity risks on HNFS’s networks and systems related to asset management; access controls; configuration settings; firewalls; end-of-life hardware and software in use; patch management (i.e., installing critical security updates released by vendors to counter known threats); vulnerability scanning; and password policies. Nonetheless, the United States alleged, HNFS annually certified to DHA that it complied with controls that it violated and, for all of these reasons, its claims for payment were false.
The government’s pursuit of this matter is part of its ongoing efforts to hold accountable entities or individuals that put sensitive information at risk by knowingly providing deficient cybersecurity products or services, knowingly misrepresenting their cybersecurity practices or protocols or knowingly violating obligations to monitor and report cybersecurity incidents. Information on how to report cyberfraud can be found here.
The claims asserted against defendants are allegations only; there has been no determination of liability.
- Judge Limits New California Anti "Pay-for-Delay" Pharma Lawon February 17, 2025 at 3:44 PM
On October 7, 2019, California Governor Gavin Newsom signed Assembly Bill 824 (“AB 824”) into law. AB 824 creates a presumption that “reverse payment” settlement agreements regarding patent infringement claims between brand-name and generic pharmaceutical companies are anticompetitive and unlawful.
Reverse payment settlement agreements arise primarily - if not exclusively - in the context of pharmaceutical drug regulations and suits brought under the statutory provisions of the Drug Price Competition and Patent Term Restoration Act of 1984, commonly referred to as the Hatch-Waxman Act.
Under the Hatch-Waxman Act, once a brand-name company has submitted a new prescription drug to the U.S. Food and Drug Administration (“FDA”) and gained approval to market it, a manufacturer of a generic drug with the same active ingredients that is biologically equivalent to the approved brand-name drug can gain approval to market the generic through an abbreviated FDA process.
The New Drug Application (“NDA”) process to which new prescription drugs are subject is long, comprehensive, and expensive, whereas the Abbreviated New Drug Application (“ANDA”) process to which generic drugs are subject is substantially less expensive and requires far less testing.
In order to gain approval through the FDA, the generic company must file an ANDA. As part of this application, the generic company must assure the FDA that its drug will not infringe on any patents owned by the brand-name company. The brand-name company can and often does bring suit against the generic drug manufacturer over patent rights.
Settlements of the resulting lawsuits sometimes include reverse payments in which the plaintiff, the brand-name company, pays the defendant, the infringing generic company, a sum of money for the promise that the generic company will keep its drug off the market for an agreed-upon length of time. These have become known as "pay-for-delay" agreements in the drug industry.
AB 824 targets these types of settlements. According to the State, AB 824 closes this loophole in the Hatch-Waxman Act and ensures a brand-name company cannot continue to enforce an otherwise weak patent against generic companies through these reverse payment settlement agreements. AB 824 imposes a presumption that a settlement agreement involving a brand-name company compensating the generic company for keeping its drug off the market is anticompetitive under California antitrust law.
A nonprofit, voluntary association comprised of the leading manufacturers and distributors of generic and biosimilar medicines, manufacturers and distributors of bulk active pharmaceutical ingredients, and suppliers of other goods and services to the generic and biosimilar pharmaceutical industry, filed a federal lawsuit in an attempt to invalidate AB 824 in the case of Association for Accessible Medicines v Bonta - 2:20-cv-01708-TLN-SCR.
On September 15, 2023, the State of California and Plaintiff Association-for-Accessible-Medicines filed motions for summary judgment. The State argued the participation of each of Plaintiff’s members is necessary to establish associational standing and all of Plaintiff’s claims fail on the merits. Plaintiff argued there are no genuine disputes of fact regarding its standing and that it succeeds on the merits of its dormant Commerce Clause claim.
On February 12, 2025 the motions were granted in part and denied in part. The Court converted "the current preliminary injunction into a permanent injunction. The State may enforce the provisions of AB 824 with respect to settlement agreements negotiated, completed, or entered into within California’s borders. The injunction bars the Attorney General of the State of California, as well as the Attorney General’s officers, agents, employees, attorneys, and all persons in active concert or participation with them from implementing or enforcing AB 824 against Plaintiff, its member entities, or their agents and licensees, with the exception of settlement agreements negotiated, completed, or entered into within California’s borders."
- Musk Escalates AI Battle As OpenAI Rejects $97B Takeover Bidon February 17, 2025 at 3:44 PM
OpenAI was founded in December 2015 by a group of tech visionaries, including Sam Altman, Elon Musk, Ilya Sutskever, Greg Brockman, and others. Their mission was to develop artificial intelligence in a way that benefits all of humanity. OpenAI is headquartered in San Francisco, California, nestled in the heart of Silicon Valley, what some say is the global hub for technology and innovation.
Initially, OpenAI was a non-profit organization, but in 2019, it transitioned to a capped-profit model to attract more funding and talent. The organization consists of the non-profit OpenAI, Inc., registered in Delaware, and its for-profit subsidiary introduced in 2019, OpenAI Global, LLC. Microsoft owns roughly 49% of OpenAI's equity, having invested US$13 billion. It also provides computing resources to OpenAI through its cloud platform, Microsoft Azure.
A dispute between OpenAI and Elon Musk has been brewing for some time. Musk, who was one of the co-founders and early investors in OpenAI, has been critical of the organization's direction and its shift towards a for-profit model.There has been an ongoing power struggle within OpenAI, with Musk and Altman having differing visions for the company's future.
Musk has taken legal action against OpenAI, claiming that the organization is violating the terms of his foundational contributions. He has also accused OpenAI of unfairly stifling business competition, particularly with his own AI startup, xAI. In response to Musk’s lawsuit, OpenAI has said it will move to dismiss Musk’s claims and that Musk “should be competing in the marketplace rather than the courtroom”.
“Something is going to trial in this case,” US District Judge Yvonne Gonzalez Rogers in Oakland, California, said earlier this month as Judge Rogers was considering Musk’s recent request for a preliminary injunction to block OpenAI’s conversion before going to trial.
The stakes on OpenAI’s corporate transition have now escalated, as OpenAI’s last fundraising round of $6.6bn and a new round of up to $25bn under discussion with SoftBank are conditioned on the company restructuring to remove the nonprofit’s control.
Recently, Musk led a group of investors in an unsolicited $97.4 billion bid to buy OpenAI. This bid was unanimously rejected by OpenAI's board over the weekend. OpenAI has accused Musk of contradicting his own lawsuit with his takeover bid, arguing that his actions are at odds with his legal claims.
AI models like ChatGPT, has become a dominant force in the field. Musk’s vision of a more open-source, safety-oriented approach to AI development stands in contrast to OpenAI’s evolving business model, which increasingly focuses on monetization. The situation remains dynamic, with both legal and business maneuvers playing out publicly.
- CDI to Assess Carriers $1B for FAIR Plan Bailout After LA Fireson February 13, 2025 at 4:14 PM
Ordering the insurance companies’ FAIR Plan to continue swiftly paying claims to Southern California wildfire survivors, Insurance Commissioner Ricardo Lara today took action to maintain its solid financial footing. The FAIR Plan, an insurance safety net that the state requires insurance companies to operate, requested the Commissioner’s approval for $1 billion in additional funds from its member companies and also released detailed data about its claims paid to wildfire survivors.
Commissioner Lara approved the FAIR Plan’s request - known as an “assessment” - for the funding necessary to continue meeting its obligations to Californians. The fee will be divided among insurers based on their market share. The $1 billion assessment is the largest since the FAIR Plan was created in 1968, and the first time since the 1994 Northridge earthquake. State regulations allow insurers to pass along as much as half the cost of the assessment to customers, in the form of higher charges. Insurers must absorb the other half.
Additional key actions include:
- - Directing the FAIR Plan to hire additional staff needed to process and pay claims fairly, fully, and quickly.
- - Requiring the FAIR Plan to utilize all available funds, including reserves and reinsurance funds.
- - Protecting consumers from bearing the full cost of an assessment, with insurance companies responsible for half the assessment under an agreement reached last year. Subject to the Commissioner’s prior approval under Proposition 103, insurance companies may issue a temporary supplemental fee as a percentage of the policy premium and cannot pass assessment costs on to consumers in future rates.
- - Maintaining a healthy FAIR Plan reserve fund for future claims as the summer wildfire season approaches.
- - Requiring the FAIR Plan to comply with all laws applicable to other insurance companies, including advance payments for living expenses and personal property without the need for an inventory.
Commissioner Lara claims he finalized the Sustainable Insurance Strategy in 2024 - the largest insurance reform in 30 years - aimed at increasing the issuance of regular insurance policies in higher-risk areas and reducing reliance on the FAIR Plan.
Further underscoring the need for this reform, the most recent FAIR Plan assessments followed the 1993 Kinneloa Fire in Altadena and the Old Topanga Fire in Malibu and Topanga, which affected some of the same areas as the 2025 fires - claiming three lives and destroying nearly 550 structures in those devastating incidents. Previous insurance commissioners approved $260 million, or approximately $563 million in today’s dollars, in assessments for those fires and for the fires following the 1994 Northridge Earthquake.
Commissioner Lara expects to file the Department’s Report of Examination for an ongoing financial examination of the FAIR Plan, including its compliance with recommendations from the Department’s 2022 Operational Assessment Report in coming months. The report called for significant changes in the FAIR Plan’s governance, operations, underwriting and claims handling, risk management, customer service, and financial planning strategies and policies.
Using FAIR Plan data from the Property Insurance Plans Service Office (PIPSO), the AM Best Commentary titled, “California Wildfires: Multiple Credit Negative Impacts for Insurers,” reveals that the number of California FAIR Plan policies rose by 276 percent from 2018 through 2024 (based on fiscal years ending September 30). And the premium attributable to these policies jumped to $1.4 billion in 2024, up more than 15-times higher than the $87.2 million recorded for the California FAIR plan in 2018.
- Legislature Seeks to Limit Misleading AI Healthcareon February 13, 2025 at 4:14 PM
A new proposed law was introduced on February 10, 2025, AB 489, that is aimed to protect Californians from AI systems that misrepresent “themselves” as health professionals. Specifically, the bill will provide regulators the authority to enforce title protections against those who develop or deploy AI systems that claim to be a licensed or certified health professional.
This legislation, sponsored by SEIU California and the California Medical Association, comes after multiple stories of individuals developing unhealthy relationships with AI chatbots and these same chatbots being found to pose as licensed practitioners.
Additionally, the Bill author claims AI is taking the health field by storm, with some companies pushing staff to use Generative AI to respond to patients and others developing for-hire "AI nurses." This bill ensures consumers are clear about who they are or are not talking to.
This bill would make provisions of law that prohibit the use of specified terms, letters, or phrases to falsely indicate or imply possession of a license or certificate to practice a health care profession, as defined, enforceable against an entity who develops or deploys artificial intelligence technology that uses one or more of those terms, letters, or phrases in its advertising or functionality.
The bill would prohibit the use by AI technology of certain terms, letters, or phrases that indicate or imply that the advice or care being provided through AI is being provided by a natural person with the appropriated health care license or certificate.
This bill would make a violation of these provisions subject to the jurisdiction of the appropriate health care profession board, and would make each use of a prohibited term, letter, or phrase punishable as a separate violation.
- WCAB Grants Removal to Avoid Undue Burden on Adjusteron February 12, 2025 at 2:18 PM
Dario Morales Dominguez was employed by Shield Platinum Protection LLC when he claimed industrial injuries as a result of a cumulative trauma during the period January 1, 2020 through September 1, 2020 to multiple parts of body. His claim was resolved by Compromise and Release and WCJ Joy issued an Order approving the C&R on May 12, 2022.
On December 15, 2022, lien claimant ABC International (ABC) filed a lien for interpreting services rendered to applicant as a result of his claimed injuries.
After several lien conferences, the case was set for lien trial on April 24, 2024 before WCJ Joy. At the lien trial of April 24, 2024, the WCJ continued the matter to another trial date, and issued the following comments and Order on the Minutes:
- - “[P]arties appear unable to resolve lien and as of this dispo, LC’s exhibits are pending population in EAMS.
- - WCJ has concerns re: Defendant and CCR 10880(a)(3)1. Defendant’s claim adjuster and adjuster’s supervisor are to appear in person at next trial to discuss. IT IS SO ORDERED.”
The Defendant Petitioned Removal of the case to the WCAB in response to the Order issued by the workers compensation administrative law judge (WCJ) on April 24, 2024. In that petition the Defendant argued that no good cause exists to compel the personal appearance of the adjuster and the adjuster's supervisor at an in person trial.
The WCAB granted removal, and rescinded the Order of the WCJ to appear in person, and substitute a new order stating that the claims adjuster and the adjuster’s supervisor must be available by virtual or telephonic appearance at the upcoming trial of this matter in the case of Morales-Dominguez v Shield Platinum Protection LLC -ADJ14175141 (February 2025).
The Petitioner claimed that that an order to appear in person constitutes an undue burden on the adjuster, as it causes a practical hardship, and prevents them from handling other cases that would be impacted by a physical appearance. Petitioner further contended that no monies are due lien claimant as there are unresolved legal issues that prevent settlement, but that the claims adjuster is available either telephonically or by other electronic means, and defendant has complied with WCAB Rule 10880(a).
In response, the WCAB panel noted that "The WCJ has broad authority to issue orders to ensure proper adjudication of each claim, including “any interim, interlocutory and final orders, findings, decisions and awards as may be necessary to the full adjudication of the case.” (Cal. Code Regs., tit. 8, § 10330.) This may include Orders that a party appear at a given hearing, should same be warranted."
"While the WCJ retains the authority to order the adjuster to appear in person for a hearing for good cause if the circumstances warrant it, consideration should be given as to the subject or the nature of the hearing, as well as the dispute, the relief sought, the utility of the adjuster appearing in person versus appearing by phone, and the practical hardship and burden of having to appear in person, factoring in the distance and nature of the travel required. (Derrick Burford v. Cook Concrete Prods., (board panel decision) 2016 Cal. Wrk. Comp. P.D. LEXIS 1, 8.)"
"Here, while the WCJ may wish to bring the parties together and discuss settlement options or inquire further as to issues in dispute prior to commencing trial, we find an Order for both the adjuster and supervisor to appear in person for that purpose excessive. That same goal may be accomplished by an Order for the adjuster and supervisor to appear at trial by either virtual or telephonic means."
- DIR Proposes to Adopt New ACOEM Cannabis Guidelineon February 12, 2025 at 2:18 PM
The Division of Workers’ Compensation (DWC) has issued a Notice of Public Hearing for proposed evidence-based update and adoption to the Medical Treatment Utilization Schedule (MTUS), which can be found at California Code of Regulations, title 8, update to section 9792.24.2 and adoption of section 9792.24.8.
The proposed evidence-based updates and adoption to the MTUS incorporate by reference the latest published guidelines from the American College of Occupational and Environmental Medicine (ACOEM) for the following:
- - Proposed Amendment to Section 9792.24.2. Chronic Pain Guidelines. (ACOEM December 19, 2024)
- - Proposed Adoption of Section 9792.24.8 Cannabis Guideline (ACOEM January 28, 2025)
The proposed evidence-based update and adoption to the MTUS regulations are exempt from Labor Code sections 5307.3 and 5307.4 and the rulemaking provisions of the Administrative Procedure Act. DWC is required under Labor Code section 5307.27 to have a 30-day public comment period, hold a public hearing, and respond to all the comments received during the public comment period prior to publishing the order adopting the update online.
Members of the public may review and comment on the proposed updates. Written comments must be submitted no later than March 14, 2025.
Members of the public may attend the virtual and conference call public hearing
- - Time: March 14, 2025 10 a.m. Pacific Time (US and Canada)
- - Join from PC, Mac, Linux, iOS or Android: https://dir-ca-gov.zoom.us/j/86193231447
Of interest is the Summary of Recommendations seen on page 1 of the proposed Cannabis Guideline (ACOEM January 28, 2025). The Guideline reported that adverse effects of the use of Cannabis are "common." It continued for the next several pages to list perhaps more than 100 of them. It goes on to elaborate on each topic.
Unsurprisingly, the weight of this evidence supported this overall recommendation:
- - Cannabinoids for Chronic Pain - Not Recommended - Evidence C
- - Cannabinoids for Acute Pain - Not Recommended - Evidence C
- - Cannabinoids for Chronic Pain - Moderately Not Recommended - Evidence B
- - Cannabinoids for Safety-Critical Workers - Not Recommended - Evidence C
- Cal/OSHA Fines Plumbing Companies $530K for Trench Collapseon February 11, 2025 at 1:32 PM
The Division of Occupational Safety and Health, known as Cal/OSHA, has cited employers Smelly Mel’s Plumbing and Sewer Rat Plumbing a total of $529,640 in proposed penalties for violating safety regulations that resulted in serious injuries to a construction worker during a trench collapse in San Mateo on August 1, 2024.
Cal/OSHA, a division of the Department of Industrial Relations, found a total of 16 violations, evenly split between both businesses. Among these citations were two willful, serious accident-related violations - meaning the businesses were aware of the safety hazards, had prior warning, and still failed to take corrective action.
On August 1st, 2024, a crew was handling a sewer line project at a private residence in San Mateo. The job took a near-deadly turn when the walls of the trench collapsed, burying a worker under the debris and causing serious injuries that required hospitalization.
The citations issued include violations for improper protective systems, inadequate training, and failure to inspect the trench and surrounding conditions including:
- - Inspection Failure: Employers did not ensure that a competent person conducted daily inspections of the trench, adjacent areas, and protective systems that could have detected hazardous conditions such as cave-ins.
- - Lack of safe exit routes: Both employers failed to provide the construction workers a ladder or other safe means of exiting the trench that was approximately 9 feet and 3 inches in depth.
- - No adequate protective systems in trench: Neither employer provided adequate protective systems, such as shoring, shielding, sloping, or benching to the trench to prevent its collapse.
- - Failure to protect workers from falling debris: Neither employer protected their workers from excavated materials or equipment that could pose a hazard by falling or rolling into the trench.
- - Foot Protection: The employer failed to ensure that their workers had proper foot protection, which exposed at least one worker to foot injuries when using a jackhammer.
- - Insufficient emergency medical provisions: The employers did not have an appropriate number of trained persons to render first aid at the jobsite.
- - Permit Requirements: The employers failed to notify the division prior to the start of the annual permit-required activity of constructing an excavation over 5-feet in depth.
- - Injury and Illness Prevention Program: The employers failed to conduct a toolbox safety meeting at the jobsite with the crew for the duration of the project.
Employers have the right to appeal any Cal/OSHA citation and notification of penalty by filing an appeal with the Occupational Safety and Health Appeals Board within 15 working days from the receipt of notification.
Cal/OSHA Chief Debra Lee said “Trench collapses remain one of the most serious hazards in construction, and employers must take all necessary steps to protect their employees. These citations serve as a reminder that businesses must prioritize worker safety, especially during high-risk operations to avoid tragic accidents.”
- SoCal Man Pleads Guilty to $17M Hospice Fraudon February 11, 2025 at 1:32 PM
A California man pleaded guilty to health care fraud, aggravated identity theft, and money laundering in connection with a years-long scheme to defraud Medicare of more than $17 million through sham hospice companies and his home health care company.
According to court documents, Petros Fichidzhyan, 43, of Granada Hills, engaged in a scheme with others to operate a series of sham hospice companies. Fichidzhyan, along with co-schemers, impersonated the identities of foreign nationals to use as the purported owners of the hospices - including using the identities to open bank accounts and sign property leases - and submitted false and fraudulent claims to Medicare for hospice services that were not medically necessary and not provided. In submitting the false claims,
Fichidzhyan and his co-schemers also misappropriated the identifying information of doctors, claiming to Medicare that the doctors had determined hospice services were necessary, when in fact the purported recipients of these hospice services were not terminally ill and had never requested nor received care from the sham hospices.
As a result of the scheme, Medicare paid the sham hospices nearly $16 million. Fichidzhyan personally received nearly $7 million of the proceeds from the fraud scheme, including more than $5.3 million in transfers to his personal and business bank accounts, which were laundered through a dozen shell and third-party bank accounts.
Fichidzhyan additionally admitted to wrongfully obtaining more than $1 million for his home health care agency through the fraudulent use of a doctor’s name and identifying information in certifying Medicare beneficiaries for home health care, which he attempted to cover up by paying the doctor $11,000.
Fichidzhyan pleaded guilty to health care fraud, aggravated identity theft, and money laundering. He is scheduled to be sentenced on April 14 and faces a mandatory penalty of two years in prison on the aggravated identity theft charge, a maximum penalty of 10 years in prison on the health care fraud charge, and a maximum penalty of 20 years in prison on the money laundering charge. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.
Today’s guilty plea is the most recent conviction in the Justice Department’s ongoing effort to combat hospice fraud in the greater Los Angeles area. Last year, a doctor was convicted at trial for his role in a scheme to bill Medicare for hospice services patients did not need, and two other defendants were sentenced for their roles in a hospice fraud scheme.
- Blue Cross Sues L.A. "Insurance Advocate" for $7.6M Fraudon February 18, 2025 at 3:53 PM
Blue Cross of California d/b/a Anthem Blue Cross is a California Stock Corporation with its principal place of business in Woodland Hills, California. Anthem sells health insurance and related administrative services to California employers, individuals, and families.
AA Insurance Advocacy, Inc. is a California-based company that was incorporated on May 21, 20212. The company is registered as a California Stock Corporation and is currently active. The principal address for the company is 1421 Ambassador Street, Unit #212, Los Angeles, CA 900352. Alanna Apfel is listed as the Chief Executive Officer, Chief Financial Officer, Director, and Secretary of the company. She is an insurance patient advocate who helps patients with employer-sponsored PPO insurance negotiate with insurance companies to cover their out-of-pocket mental health therapy costs or services provided by out-of-network therapists.
According to a Civil Complaint filed on February 3, 2025 in the Los Angeles County Superior Court, Anthem alleges that Apfel and her Corporation submitted "fraudulent claims for out-of-network healthcare services that were misrepresented, inflated, or never provided at all." Anthem further alleges that "This scheme was carried out by Alanna Apfel, on her own behalf and through AA Insurance Advocacy, Inc., an entity through which she presents herself to Anthem members and the public as an “insurance advocate” that will negotiate with Anthem (and other insurers) to maximize reimbursement for certain out-of-network medical expenses."
To date, Anthem alleges it "has already identified more than $7.6 million dollars in payments that were directly caused by Ms. Apfel’s fraudulent requests for out-of-network authorizations and/or submission of claims on behalf of more than 480 Anthem members." And it further alleges that this "figure is highly conservative, with the true amount of loss expected to grow dramatically as Anthem continues its investigation." Anthem provided details in the allegations of its lawsuit.
"In reality, Ms. Apfel generates additional reimbursement not through advocacy, but rather by falsely seeking out-of-network authorizations and creating sham out-of-network medical claims for healthcare services. She then submits those claims to Anthem to obtain reimbursement payments to her member-clients for services never rendered or which are far in excess of what the healthcare providers actually charged and the members actually paid for." Anthem further alleges that "Ms. Apfel then charges Anthem members a fee for her “services,” typically based on a percentage of these inflated reimbursements as a kickback for submitting the falsified claims on the members’ behalf."
"Ms. Apfel typically starts with a request for a “network exception” for the member: a way for the member to see an out-of-network provider so that, in theory, the member can receive reimbursement from Anthem for the full out-of-pocket costs supposedly paid to the provider by the member for that authorized, out-of-network care." Anthem then claims that when "Anthem, predictably, is unable to identify an appropriate in-network provider satisfying Ms. Apfel’s numerous requirements, it will authorize the out-of-network referral and provide the member with a network exception which requires Anthem to reimburse the member for the actual out-of-pocket costs paid to that out-of-network provider."
"Ms. Apfel’s and Defendants’ “advocacy” was designed to fraudulently intervene and capitalize on this out-of-network reimbursement process by, depending on the case, grossly inflating or completely fabricating services supposedly rendered by the out-of-network provider and paid for by the member. This caused, and continues to cause, Anthem to pay out millions of dollars to reimburse members for costs they never actually incurred."
Anthem provided several examples of the alleged fraudulent scheme, all involving inflated schemes for psychotherapy with various mental health practitioners. In one example, "Anthem member K.S. retained Ms. Apfel to obtain reimbursement for treatment from out-of-network provider Dr. Joseph Whitcomb, PsyD, LMFT, a provider who had previously treated K.S."
"Based on Ms. Apfel’s representations, Anthem authorized an out-of-network referral/network exception for K.S., in good faith, to treat with Dr. Whitcomb for in-office treatment from May 1, 2023 through April 29, 2024. On or about January 9, 2024, Anthem renewed the authorization for in-office treatment from Dr. Whitcomb from January 1, 2024 through December 31, 2024."
"Dr. Whitcomb, however, could not have treated K.S. during this timeframe because he had moved to Europe years earlier in 2021, shortly after K.S. had originally stopped treating with him." Anthem alleges that "Apfel submitted a claim for reimbursement on behalf of K.S. which included a fraudulent bill Ms. Apfel had created purporting to show that, in March 2024, K.S. had received 17 sessions of psychotherapy from Dr. Whitcomb at a cost of $675 per session, and that K.S. had paid Dr. Whitcomb $11,475 for this period."
Further, Anthem alleges "Dr. Whitcomb died suddenly on May 18, 2024 while in Europe. Roughly one month after his death, on June 16, 2024, Ms. Apfel submitted a claim for reimbursement on behalf of K.S. which included a fraudulent bill Ms. Apfel had created showing that, in May 2024, K.S. supposedly had received 23 sessions of psychotherapy from Dr. Whitcomb at a cost of $995 per session, including 10 sessions that purportedly occurred after Dr. Whitcomb’s May 18, 2024 death, and that K.S. had paid Dr. Whitcomb $22,885 for this period."
No answer or other responsive document has been filed in the Superior Court by any defendants as of the date of this report. - Health Net to Pay Over $11M for False Cybersecurity Certificationon February 18, 2025 at 3:53 PM
Centene Corporation is a leading healthcare enterprise that provides access to healthcare services. The company focuses on government-sponsored healthcare programs, including Medicaid and Medicare, as well as individuals and families served by the Health Insurance Marketplace. Centene operates in all 50 states and serves over 28.6 million managed care members.
Health Net Federal Services, Inc. (HNFS) of Rancho Cordova, is a subsidiary of Centene Corporation. HNFS provides healthcare services to military service members, retirees, and their families through the TRICARE program. HNFS is responsible for managing the TRICARE West Region, which includes processing claims, providing customer service, and ensuring access to healthcare for beneficiaries.
HNFS and its corporate parent, Centene Corporation, have agreed to pay $11,253,400 to resolve claims that HNFS falsely certified compliance with federal contractor cybersecurity requirements, The cybersecurity requirements were contained in a contract between HNFS and the U.S. Department of Defense (DoD) to administer the Defense Health Agency’s (DHA) health insurance program TRICARE for servicemembers and their families.
The settlement resolves allegations that, between 2015 and 2018, HNFS failed to meet certain cybersecurity controls and falsely certified compliance with them in annual reports to DHA that were required under its contract. The United States alleged that HNFS failed to timely scan for known vulnerabilities and to remedy security flaws on its networks and systems, in accordance with its System Security Plan and the response times HNFS had established.
Furthermore, the United States alleged HNFS ignored reports from third-party security auditors and its internal audit department of cybersecurity risks on HNFS’s networks and systems related to asset management; access controls; configuration settings; firewalls; end-of-life hardware and software in use; patch management (i.e., installing critical security updates released by vendors to counter known threats); vulnerability scanning; and password policies. Nonetheless, the United States alleged, HNFS annually certified to DHA that it complied with controls that it violated and, for all of these reasons, its claims for payment were false.
The government’s pursuit of this matter is part of its ongoing efforts to hold accountable entities or individuals that put sensitive information at risk by knowingly providing deficient cybersecurity products or services, knowingly misrepresenting their cybersecurity practices or protocols or knowingly violating obligations to monitor and report cybersecurity incidents. Information on how to report cyberfraud can be found here.
The claims asserted against defendants are allegations only; there has been no determination of liability. - Judge Limits New California Anti "Pay-for-Delay" Pharma Lawon February 17, 2025 at 3:44 PM
On October 7, 2019, California Governor Gavin Newsom signed Assembly Bill 824 (“AB 824”) into law. AB 824 creates a presumption that “reverse payment” settlement agreements regarding patent infringement claims between brand-name and generic pharmaceutical companies are anticompetitive and unlawful.
Reverse payment settlement agreements arise primarily - if not exclusively - in the context of pharmaceutical drug regulations and suits brought under the statutory provisions of the Drug Price Competition and Patent Term Restoration Act of 1984, commonly referred to as the Hatch-Waxman Act.
Under the Hatch-Waxman Act, once a brand-name company has submitted a new prescription drug to the U.S. Food and Drug Administration (“FDA”) and gained approval to market it, a manufacturer of a generic drug with the same active ingredients that is biologically equivalent to the approved brand-name drug can gain approval to market the generic through an abbreviated FDA process.
The New Drug Application (“NDA”) process to which new prescription drugs are subject is long, comprehensive, and expensive, whereas the Abbreviated New Drug Application (“ANDA”) process to which generic drugs are subject is substantially less expensive and requires far less testing.
In order to gain approval through the FDA, the generic company must file an ANDA. As part of this application, the generic company must assure the FDA that its drug will not infringe on any patents owned by the brand-name company. The brand-name company can and often does bring suit against the generic drug manufacturer over patent rights.
Settlements of the resulting lawsuits sometimes include reverse payments in which the plaintiff, the brand-name company, pays the defendant, the infringing generic company, a sum of money for the promise that the generic company will keep its drug off the market for an agreed-upon length of time. These have become known as "pay-for-delay" agreements in the drug industry.
AB 824 targets these types of settlements. According to the State, AB 824 closes this loophole in the Hatch-Waxman Act and ensures a brand-name company cannot continue to enforce an otherwise weak patent against generic companies through these reverse payment settlement agreements. AB 824 imposes a presumption that a settlement agreement involving a brand-name company compensating the generic company for keeping its drug off the market is anticompetitive under California antitrust law.
A nonprofit, voluntary association comprised of the leading manufacturers and distributors of generic and biosimilar medicines, manufacturers and distributors of bulk active pharmaceutical ingredients, and suppliers of other goods and services to the generic and biosimilar pharmaceutical industry, filed a federal lawsuit in an attempt to invalidate AB 824 in the case of Association for Accessible Medicines v Bonta - 2:20-cv-01708-TLN-SCR.
On September 15, 2023, the State of California and Plaintiff Association-for-Accessible-Medicines filed motions for summary judgment. The State argued the participation of each of Plaintiff’s members is necessary to establish associational standing and all of Plaintiff’s claims fail on the merits. Plaintiff argued there are no genuine disputes of fact regarding its standing and that it succeeds on the merits of its dormant Commerce Clause claim.
On February 12, 2025 the motions were granted in part and denied in part. The Court converted "the current preliminary injunction into a permanent injunction. The State may enforce the provisions of AB 824 with respect to settlement agreements negotiated, completed, or entered into within California’s borders. The injunction bars the Attorney General of the State of California, as well as the Attorney General’s officers, agents, employees, attorneys, and all persons in active concert or participation with them from implementing or enforcing AB 824 against Plaintiff, its member entities, or their agents and licensees, with the exception of settlement agreements negotiated, completed, or entered into within California’s borders." - Musk Escalates AI Battle As OpenAI Rejects $97B Takeover Bidon February 17, 2025 at 3:44 PM
OpenAI was founded in December 2015 by a group of tech visionaries, including Sam Altman, Elon Musk, Ilya Sutskever, Greg Brockman, and others. Their mission was to develop artificial intelligence in a way that benefits all of humanity. OpenAI is headquartered in San Francisco, California, nestled in the heart of Silicon Valley, what some say is the global hub for technology and innovation.
Initially, OpenAI was a non-profit organization, but in 2019, it transitioned to a capped-profit model to attract more funding and talent. The organization consists of the non-profit OpenAI, Inc., registered in Delaware, and its for-profit subsidiary introduced in 2019, OpenAI Global, LLC. Microsoft owns roughly 49% of OpenAI's equity, having invested US$13 billion. It also provides computing resources to OpenAI through its cloud platform, Microsoft Azure.
A dispute between OpenAI and Elon Musk has been brewing for some time. Musk, who was one of the co-founders and early investors in OpenAI, has been critical of the organization's direction and its shift towards a for-profit model.There has been an ongoing power struggle within OpenAI, with Musk and Altman having differing visions for the company's future.
Musk has taken legal action against OpenAI, claiming that the organization is violating the terms of his foundational contributions. He has also accused OpenAI of unfairly stifling business competition, particularly with his own AI startup, xAI. In response to Musk’s lawsuit, OpenAI has said it will move to dismiss Musk’s claims and that Musk “should be competing in the marketplace rather than the courtroom”.
“Something is going to trial in this case,” US District Judge Yvonne Gonzalez Rogers in Oakland, California, said earlier this month as Judge Rogers was considering Musk’s recent request for a preliminary injunction to block OpenAI’s conversion before going to trial.
The stakes on OpenAI’s corporate transition have now escalated, as OpenAI’s last fundraising round of $6.6bn and a new round of up to $25bn under discussion with SoftBank are conditioned on the company restructuring to remove the nonprofit’s control.
Recently, Musk led a group of investors in an unsolicited $97.4 billion bid to buy OpenAI. This bid was unanimously rejected by OpenAI's board over the weekend. OpenAI has accused Musk of contradicting his own lawsuit with his takeover bid, arguing that his actions are at odds with his legal claims.
AI models like ChatGPT, has become a dominant force in the field. Musk’s vision of a more open-source, safety-oriented approach to AI development stands in contrast to OpenAI’s evolving business model, which increasingly focuses on monetization. The situation remains dynamic, with both legal and business maneuvers playing out publicly. - CDI to Assess Carriers $1B for FAIR Plan Bailout After LA Fireson February 13, 2025 at 4:14 PM
Ordering the insurance companies’ FAIR Plan to continue swiftly paying claims to Southern California wildfire survivors, Insurance Commissioner Ricardo Lara today took action to maintain its solid financial footing. The FAIR Plan, an insurance safety net that the state requires insurance companies to operate, requested the Commissioner’s approval for $1 billion in additional funds from its member companies and also released detailed data about its claims paid to wildfire survivors.
Commissioner Lara approved the FAIR Plan’s request - known as an “assessment” - for the funding necessary to continue meeting its obligations to Californians. The fee will be divided among insurers based on their market share. The $1 billion assessment is the largest since the FAIR Plan was created in 1968, and the first time since the 1994 Northridge earthquake. State regulations allow insurers to pass along as much as half the cost of the assessment to customers, in the form of higher charges. Insurers must absorb the other half.
Additional key actions include:
- - Directing the FAIR Plan to hire additional staff needed to process and pay claims fairly, fully, and quickly.
- - Requiring the FAIR Plan to utilize all available funds, including reserves and reinsurance funds.
- - Protecting consumers from bearing the full cost of an assessment, with insurance companies responsible for half the assessment under an agreement reached last year. Subject to the Commissioner’s prior approval under Proposition 103, insurance companies may issue a temporary supplemental fee as a percentage of the policy premium and cannot pass assessment costs on to consumers in future rates.
- - Maintaining a healthy FAIR Plan reserve fund for future claims as the summer wildfire season approaches.
- - Requiring the FAIR Plan to comply with all laws applicable to other insurance companies, including advance payments for living expenses and personal property without the need for an inventory.
Commissioner Lara claims he finalized the Sustainable Insurance Strategy in 2024 - the largest insurance reform in 30 years - aimed at increasing the issuance of regular insurance policies in higher-risk areas and reducing reliance on the FAIR Plan.
Further underscoring the need for this reform, the most recent FAIR Plan assessments followed the 1993 Kinneloa Fire in Altadena and the Old Topanga Fire in Malibu and Topanga, which affected some of the same areas as the 2025 fires - claiming three lives and destroying nearly 550 structures in those devastating incidents. Previous insurance commissioners approved $260 million, or approximately $563 million in today’s dollars, in assessments for those fires and for the fires following the 1994 Northridge Earthquake.
Commissioner Lara expects to file the Department’s Report of Examination for an ongoing financial examination of the FAIR Plan, including its compliance with recommendations from the Department’s 2022 Operational Assessment Report in coming months. The report called for significant changes in the FAIR Plan’s governance, operations, underwriting and claims handling, risk management, customer service, and financial planning strategies and policies.
Using FAIR Plan data from the Property Insurance Plans Service Office (PIPSO), the AM Best Commentary titled, “California Wildfires: Multiple Credit Negative Impacts for Insurers,” reveals that the number of California FAIR Plan policies rose by 276 percent from 2018 through 2024 (based on fiscal years ending September 30). And the premium attributable to these policies jumped to $1.4 billion in 2024, up more than 15-times higher than the $87.2 million recorded for the California FAIR plan in 2018. - Legislature Seeks to Limit Misleading AI Healthcareon February 13, 2025 at 4:14 PM
A new proposed law was introduced on February 10, 2025, AB 489, that is aimed to protect Californians from AI systems that misrepresent “themselves” as health professionals. Specifically, the bill will provide regulators the authority to enforce title protections against those who develop or deploy AI systems that claim to be a licensed or certified health professional.
This legislation, sponsored by SEIU California and the California Medical Association, comes after multiple stories of individuals developing unhealthy relationships with AI chatbots and these same chatbots being found to pose as licensed practitioners.
Additionally, the Bill author claims AI is taking the health field by storm, with some companies pushing staff to use Generative AI to respond to patients and others developing for-hire "AI nurses." This bill ensures consumers are clear about who they are or are not talking to.
This bill would make provisions of law that prohibit the use of specified terms, letters, or phrases to falsely indicate or imply possession of a license or certificate to practice a health care profession, as defined, enforceable against an entity who develops or deploys artificial intelligence technology that uses one or more of those terms, letters, or phrases in its advertising or functionality.
The bill would prohibit the use by AI technology of certain terms, letters, or phrases that indicate or imply that the advice or care being provided through AI is being provided by a natural person with the appropriated health care license or certificate.
This bill would make a violation of these provisions subject to the jurisdiction of the appropriate health care profession board, and would make each use of a prohibited term, letter, or phrase punishable as a separate violation. - WCAB Grants Removal to Avoid Undue Burden on Adjusteron February 12, 2025 at 2:18 PM
Dario Morales Dominguez was employed by Shield Platinum Protection LLC when he claimed industrial injuries as a result of a cumulative trauma during the period January 1, 2020 through September 1, 2020 to multiple parts of body. His claim was resolved by Compromise and Release and WCJ Joy issued an Order approving the C&R on May 12, 2022.
On December 15, 2022, lien claimant ABC International (ABC) filed a lien for interpreting services rendered to applicant as a result of his claimed injuries.
After several lien conferences, the case was set for lien trial on April 24, 2024 before WCJ Joy. At the lien trial of April 24, 2024, the WCJ continued the matter to another trial date, and issued the following comments and Order on the Minutes:
- - “[P]arties appear unable to resolve lien and as of this dispo, LC’s exhibits are pending population in EAMS.
- - WCJ has concerns re: Defendant and CCR 10880(a)(3)1. Defendant’s claim adjuster and adjuster’s supervisor are to appear in person at next trial to discuss. IT IS SO ORDERED.”
The Defendant Petitioned Removal of the case to the WCAB in response to the Order issued by the workers compensation administrative law judge (WCJ) on April 24, 2024. In that petition the Defendant argued that no good cause exists to compel the personal appearance of the adjuster and the adjuster's supervisor at an in person trial.
The WCAB granted removal, and rescinded the Order of the WCJ to appear in person, and substitute a new order stating that the claims adjuster and the adjuster’s supervisor must be available by virtual or telephonic appearance at the upcoming trial of this matter in the case of Morales-Dominguez v Shield Platinum Protection LLC -ADJ14175141 (February 2025).
The Petitioner claimed that that an order to appear in person constitutes an undue burden on the adjuster, as it causes a practical hardship, and prevents them from handling other cases that would be impacted by a physical appearance. Petitioner further contended that no monies are due lien claimant as there are unresolved legal issues that prevent settlement, but that the claims adjuster is available either telephonically or by other electronic means, and defendant has complied with WCAB Rule 10880(a).
In response, the WCAB panel noted that "The WCJ has broad authority to issue orders to ensure proper adjudication of each claim, including “any interim, interlocutory and final orders, findings, decisions and awards as may be necessary to the full adjudication of the case.” (Cal. Code Regs., tit. 8, § 10330.) This may include Orders that a party appear at a given hearing, should same be warranted."
"While the WCJ retains the authority to order the adjuster to appear in person for a hearing for good cause if the circumstances warrant it, consideration should be given as to the subject or the nature of the hearing, as well as the dispute, the relief sought, the utility of the adjuster appearing in person versus appearing by phone, and the practical hardship and burden of having to appear in person, factoring in the distance and nature of the travel required. (Derrick Burford v. Cook Concrete Prods., (board panel decision) 2016 Cal. Wrk. Comp. P.D. LEXIS 1, 8.)"
"Here, while the WCJ may wish to bring the parties together and discuss settlement options or inquire further as to issues in dispute prior to commencing trial, we find an Order for both the adjuster and supervisor to appear in person for that purpose excessive. That same goal may be accomplished by an Order for the adjuster and supervisor to appear at trial by either virtual or telephonic means." - DIR Proposes to Adopt New ACOEM Cannabis Guidelineon February 12, 2025 at 2:18 PM
The Division of Workers’ Compensation (DWC) has issued a Notice of Public Hearing for proposed evidence-based update and adoption to the Medical Treatment Utilization Schedule (MTUS), which can be found at California Code of Regulations, title 8, update to section 9792.24.2 and adoption of section 9792.24.8.
The proposed evidence-based updates and adoption to the MTUS incorporate by reference the latest published guidelines from the American College of Occupational and Environmental Medicine (ACOEM) for the following:
- - Proposed Amendment to Section 9792.24.2. Chronic Pain Guidelines. (ACOEM December 19, 2024)
- - Proposed Adoption of Section 9792.24.8 Cannabis Guideline (ACOEM January 28, 2025)
The proposed evidence-based update and adoption to the MTUS regulations are exempt from Labor Code sections 5307.3 and 5307.4 and the rulemaking provisions of the Administrative Procedure Act. DWC is required under Labor Code section 5307.27 to have a 30-day public comment period, hold a public hearing, and respond to all the comments received during the public comment period prior to publishing the order adopting the update online.
Members of the public may review and comment on the proposed updates. Written comments must be submitted no later than March 14, 2025.
Members of the public may attend the virtual and conference call public hearing
- - Time: March 14, 2025 10 a.m. Pacific Time (US and Canada)
- - Join from PC, Mac, Linux, iOS or Android: https://dir-ca-gov.zoom.us/j/86193231447
Of interest is the Summary of Recommendations seen on page 1 of the proposed Cannabis Guideline (ACOEM January 28, 2025). The Guideline reported that adverse effects of the use of Cannabis are "common." It continued for the next several pages to list perhaps more than 100 of them. It goes on to elaborate on each topic.
Unsurprisingly, the weight of this evidence supported this overall recommendation:
- - Cannabinoids for Chronic Pain - Not Recommended - Evidence C
- - Cannabinoids for Acute Pain - Not Recommended - Evidence C
- - Cannabinoids for Chronic Pain - Moderately Not Recommended - Evidence B
- - Cannabinoids for Safety-Critical Workers - Not Recommended - Evidence C - Cal/OSHA Fines Plumbing Companies $530K for Trench Collapseon February 11, 2025 at 1:32 PM
The Division of Occupational Safety and Health, known as Cal/OSHA, has cited employers Smelly Mel’s Plumbing and Sewer Rat Plumbing a total of $529,640 in proposed penalties for violating safety regulations that resulted in serious injuries to a construction worker during a trench collapse in San Mateo on August 1, 2024.
Cal/OSHA, a division of the Department of Industrial Relations, found a total of 16 violations, evenly split between both businesses. Among these citations were two willful, serious accident-related violations - meaning the businesses were aware of the safety hazards, had prior warning, and still failed to take corrective action.
On August 1st, 2024, a crew was handling a sewer line project at a private residence in San Mateo. The job took a near-deadly turn when the walls of the trench collapsed, burying a worker under the debris and causing serious injuries that required hospitalization.
The citations issued include violations for improper protective systems, inadequate training, and failure to inspect the trench and surrounding conditions including:
- - Inspection Failure: Employers did not ensure that a competent person conducted daily inspections of the trench, adjacent areas, and protective systems that could have detected hazardous conditions such as cave-ins.
- - Lack of safe exit routes: Both employers failed to provide the construction workers a ladder or other safe means of exiting the trench that was approximately 9 feet and 3 inches in depth.
- - No adequate protective systems in trench: Neither employer provided adequate protective systems, such as shoring, shielding, sloping, or benching to the trench to prevent its collapse.
- - Failure to protect workers from falling debris: Neither employer protected their workers from excavated materials or equipment that could pose a hazard by falling or rolling into the trench.
- - Foot Protection: The employer failed to ensure that their workers had proper foot protection, which exposed at least one worker to foot injuries when using a jackhammer.
- - Insufficient emergency medical provisions: The employers did not have an appropriate number of trained persons to render first aid at the jobsite.
- - Permit Requirements: The employers failed to notify the division prior to the start of the annual permit-required activity of constructing an excavation over 5-feet in depth.
- - Injury and Illness Prevention Program: The employers failed to conduct a toolbox safety meeting at the jobsite with the crew for the duration of the project.
Employers have the right to appeal any Cal/OSHA citation and notification of penalty by filing an appeal with the Occupational Safety and Health Appeals Board within 15 working days from the receipt of notification.
Cal/OSHA Chief Debra Lee said “Trench collapses remain one of the most serious hazards in construction, and employers must take all necessary steps to protect their employees. These citations serve as a reminder that businesses must prioritize worker safety, especially during high-risk operations to avoid tragic accidents.” - SoCal Man Pleads Guilty to $17M Hospice Fraudon February 11, 2025 at 1:32 PM
A California man pleaded guilty to health care fraud, aggravated identity theft, and money laundering in connection with a years-long scheme to defraud Medicare of more than $17 million through sham hospice companies and his home health care company.
According to court documents, Petros Fichidzhyan, 43, of Granada Hills, engaged in a scheme with others to operate a series of sham hospice companies. Fichidzhyan, along with co-schemers, impersonated the identities of foreign nationals to use as the purported owners of the hospices - including using the identities to open bank accounts and sign property leases - and submitted false and fraudulent claims to Medicare for hospice services that were not medically necessary and not provided. In submitting the false claims,
Fichidzhyan and his co-schemers also misappropriated the identifying information of doctors, claiming to Medicare that the doctors had determined hospice services were necessary, when in fact the purported recipients of these hospice services were not terminally ill and had never requested nor received care from the sham hospices.
As a result of the scheme, Medicare paid the sham hospices nearly $16 million. Fichidzhyan personally received nearly $7 million of the proceeds from the fraud scheme, including more than $5.3 million in transfers to his personal and business bank accounts, which were laundered through a dozen shell and third-party bank accounts.
Fichidzhyan additionally admitted to wrongfully obtaining more than $1 million for his home health care agency through the fraudulent use of a doctor’s name and identifying information in certifying Medicare beneficiaries for home health care, which he attempted to cover up by paying the doctor $11,000.
Fichidzhyan pleaded guilty to health care fraud, aggravated identity theft, and money laundering. He is scheduled to be sentenced on April 14 and faces a mandatory penalty of two years in prison on the aggravated identity theft charge, a maximum penalty of 10 years in prison on the health care fraud charge, and a maximum penalty of 20 years in prison on the money laundering charge. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.
Today’s guilty plea is the most recent conviction in the Justice Department’s ongoing effort to combat hospice fraud in the greater Los Angeles area. Last year, a doctor was convicted at trial for his role in a scheme to bill Medicare for hospice services patients did not need, and two other defendants were sentenced for their roles in a hospice fraud scheme.