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AHA Reports Massive Dissatisfaction With Insurer Healthcare Practices

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The American Hospital Association (AHA), founded in 1898, is a not-for-profit association that advocates on behalf of its nearly 5,000 member hospitals, health systems and other health care organizations, its clinician partners – including more than 270,000 affiliated physicians, 2 million nurses and other caregivers – and the 43,000 health care leaders who belong to its professional membership groups.

The AHA released findings of three new surveys conducted by Morning Consult that examined how some commercial insurer practices impact the patient and provider health care experience.

The surveys found that the vast majority of patients, nurses and physicians say insurer policies and practices are reducing access to medical care, driving up health care costs and increasing clinician burden and burnout.

The surveys found:

– – Most patients (62%) have had medical care delayed because of their insurance provider in the last two years. Nearly half of those patients (43%) say their health has gotten worse as a result.
– – Most patients (83%) want their health care provider to determine what care they receive, not their insurance company.
– – Over half of patients (54%) have difficulty affording insurance costs and premiums.
– – Nurses overwhelmingly believe (84%) insurance administrative policies delay patient care. About three in four nurses (74%) say it reduces the quality of care and 63% say it interferes with a patient being transferred to the right care setting.
– – Meanwhile, more than 80% of physicians said insurance practices and policies affect their ability to practice medicine.
– – The increase in insurance administrative requirements has taken a toll on clinicians with 56% of nurses saying their job satisfaction has decreased because of it and 84% of physicians said these policies make it difficult to operate a solo practice.

“These surveys bear out what we’ve heard for years – certain insurance companies’ policies and practices are reducing health care access and making it more difficult for our already overwhelmed clinicians to provide care,” said AHA President and CEO Rick Pollack. “Health insurance should be a bridge to medical care, not a barrier to it for patients. If policymakers are serious about expanding access and addressing the health care workforce crisis, then we must hold insurance companies accountable for these harmful practices.”

The surveys were conducted by Morning Consult on behalf of the AHA. The surveys included nationally representative samples of patients (1,502 adults), nurses (500 nurses) and physicians (500 physicians). Interviews were conducted online between December 2022 and April 2023. Results have a margin of error plus or minus three or four percentage points. See the new survey findings.

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Represented Worker Not Required to Repeat QME Procedural Steps

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Fernando Yanes claimed injury to his left knee while employed as a respiratory therapist by defendant Valley Children’s Hospital on October 24, 2021. The employer admitted injury arising out of and in the course of employment, but contested the nature and extent of the injury.

On January 20, 2022, Yanes, as an unrepresented worker, requested a panel of orthopedic Qualified Medical Evaluators, pursuant to Labor Code section 4062.1. On January 27, 2022, the Division of Workers’ Compensation (DWC) Medical Unit issued panel no. 2802519. Yanes however did not have an evaluation as a result of that panel.

On March 3, 2022, Yanes retained legal counsel. On March 7, 2022, his counsel requested a replacement panel in the specialty of chiropractic medicine. In response, on March 21, 2022, the DWC Medical Unit issued QME panel no. 2839682, in the specialty of chiropractic medicine. On March 31, 2022, the employer objected to panel no. 2389682 on the grounds that the panel request letter was procedurally deficient.

On April 13, 2022, the parties proceeded to trial on issues of the validity of the Replacement Panel Request pursuant to Labor Code Section 4062.2 and Romero v. Costco Wholesale (2007) 72 Cal.Comp.Cases 824 [2007 Cal. Wrk. Comp. LEXIS 168] (Romero), and whether the defendant was entitled to a new panel in orthopedic surgery, and whether substantial justice required the parties to restart the panel QME process under section 4062.2.1

The WCJ issued the F&O, invalidating the chiropractic panel 2839682, and determining that defendant was not entitled to a new panel of QMEs in orthopedic surgery, and directing the parties to obtain a new panel of QMEs pursuant to section 4062.2.

The WCAB granted a Petition for Removal filed by Yanes, and substituted new Findings of Fact that QME chiropractic Panel No. 2389682 was valid, and rescind the order that the parties obtain a new panel of QMEs. in the case of Yanes v Valley Children’s Hospital ADJ15870256 (May 2023).

Applicant’s Petition for Removal argued that the WCJ’s decision was inconsistent with the significant panel decision in Romero, and subsequent jurisprudence applying Romero. Applicant asserts that under Romero, the parties are not required to “start all over and submit a new objection letter to that which has already been objected to in the first place when the original unrepresented Panel was requested.”  Applicant also argues that he was entitled to obtain a new panel of QMEs after obtaining legal representation because the “evaluation” process described in section 4062.2(a) is separate and distinct from the process for obtaining a panel.

Defendant’s Answer argued that Romero and the subsequent panel decisions cited by applicant “do not specifically address the procedural requirements for obtaining a new panel under Romero and in compliance with the provision set forth in Labor Code §4062.2(b).”

The parties, while applicant was unrepresented, identified a medical dispute, and initiated the QME evaluation process. Defendant accepted liability for the left knee only, and liability was denied for left knee ACL findings and need for surgery. Once the parties have identified a medical dispute, the procedure for obtaining a panel of QMEs where applicant is not represented is governed by Labor Code section 4062.1. The parties at this point satisfied the procedure for obtaining a panel, and the DWC Medical Unit issued panel no. 2802519. The parties did not dispute that this panel was valid when originally issued, and that applicant never attended a QME evaluation with any of the physicians from that panel.

In Romero the WCAB panel noted that “because applicant had not attended and participated in the examination by the panel QME when she changed from being not represented by an attorney to being represented, she had not ‘received’ a comprehensive medical-legal evaluation pursuant to section 4062.1 and is, therefore, not precluded from requesting a new QME panel pursuant to section 4062.2.“

Similarly, in City of Tracy v. Workers’ Comp. Appeals Bd. (Luckhardt) (2019) 84 Cal.Comp.Cases 838 [2019 Cal. Wrk. Comp. LEXIS 73] (Luckhardt), the parties satisfied the prerequisites to obtaining a QME panel in orthopedic surgery while applicant was unrepresented. Following issuance of the panel, but prior to any QME evaluation, applicant retained counsel. Applicant’s counsel then requested and received a new panel of QMEs in pain management, pursuant to Romero. The WCAB affirmed the WCJ’s determination that while the parties had completed the process necessary to obtaining a QME while applicant was unrepresented, the applicant had not yet received a comprehensive medical-legal evaluation by a QME, and was thus entitled to a new panel of QMEs under section 4062.2. (Id. at 840-841.)

Applicant’s request for a new panel of QMEs on March 7, 2022 was made only after the parties had identified the medical dispute that required a QME evaluation, and had taken the appropriate steps to obtain a valid panel of QMEs. The parties were not thereafter required to reinitiate a dispute resolution process that was already underway and had appropriately resulted in the issuance of a prior panel.

The WCAB further noted that “requiring the parties to repeat the procedural steps necessary to obtaining a panel of QMEs once applicant obtains counsel is inconsistent with our constitutional mandate to “accomplish substantial justice in all cases expeditiously, inexpensively, and without incumbrance of any character.” (Cal. Const., art. XIV, § 4.)”

Thus the panel was persuaded that “the decision of the WCJ to invalidate panel no. 2839682 will result in significant prejudice or irreparable harm.”

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9th Circuit En Banc to Rule on Student/State Bar ADA Accommodation Dispute

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Benjamin Kohn is a law school graduate who registered to take the October 2020 sitting of the California Bar Examination.

He suffers from and has been diagnosed with several physical and psychological conditions including autism and neurological/attention disorders, digestive system conditions (gastroparesis, postoperative dysphagia, pelvic floor dyssynergia, and irritable bowel syndrome with chronic constipation), and visual impairments (keratoconus, dry eye syndrome, uncorrectable astigmatism, floaters).

Because of his conditions, Kohn has been granted several accommodations on past exams administered at various levels and by various institutions.

Kohn has previously taken the California Bar Exam in July 2018, February 2019, and February 2020 and for each exam he was granted some testing accommodations but denied others. Examples of denied accommodations included: 150% extra time on the written portion of the exam, a cap of no more testing time per day than non-disabled test takers, ergonomic/physical equipment supplied in the exam room, specialized disability proctors, and 30 minutes of break time per 90 minutes of testing.

On March 19, 2020, Kohn submitted a petition for testing accommodations for the October 2020 exam. In his petition, he sought all accommodations that the Committee previously granted on his prior attempts at the California Bar Exam, as well as accommodations that were previously denied.

On August 27, 2020, the Committee granted some of his requests, but denied requests for administration of the exam over weekend days only, testing in a private room, pre-scheduled breaks to be taken instead at Kohn’s discretion, a complete ergonomic workstation provided by the Committee, a hotel room for Kohn provided by the Committee, and assignment to an experienced proctor.

Kohn filed a complaint in the Federal District Court alleging seven violations of the Americans with Disabilities Act (“ADA”) and seven corresponding violations of California’s Unruh Act, Cal. Civ. Code § 51(f). Dkt. The same day, he filed a motion for preliminary injunction, which the court denied on August 13, 2020, finding that plaintiff’s motion was not ripe for adjudication.

Kohn then filed a first amended complaint with fifteen claims: (1) violation of ADA related to the February 2019 Bar Exam; (2) violation of the ADA for deliberate indifference related to the February 2019 Bar Exam; (3) violation of the ADA related to the February 2020 Bar Exam; (4) violation of the ADA related to the October 2020 Bar Exam; (5) – (7) violations of the ADA and California Government Code §§ 11135 et seq. & 12944 et seq. for deliberate indifference for each of plaintiff’s past three exams; (8) – (14) violations of the Unruh Act, Cal. Civ. Code § 51(f) for each ADA violation; (15) violation of the ADA for failure to provide reasonable accommodations for the October 2020 Exam and defendants’ deliberate indifference.

Defendants moved to dismiss the First Amended Complaint in its entirety pursuant to Federal Rules of Civil Procedure 12(b)(1) and 12(b)(6). The trial court dismissed the case of Kohn v State Bar of California -4:20-cv-04827-PJH (July 2020)

Defendants’ first argument was dispositive of the First through Seventh & Fifteenth Claims (ADA). The Eleventh Amendment provides: “The Judicial power of the United States shall not be construed to extend to any suit in law or equity, commenced or prosecuted against one of the United States by Citizens of another State, or by Citizens or Subjects of any Foreign State.” U.S. Const. amend. XI. Accordingly, no state or its agencies may be sued in federal court without consent. See Pennhurst State Sch. & Hosp. v. Halderman, 465 U.S. 89, 100, 104 S.Ct. 900, 79 L.Ed.2d 67 (1984). This immunity extends to defendants, which are state agencies. Hirsh v. Justices of Supreme Ct. of State of Cal., 67 F.3d 708, 715 (9th Cir. 1995) (per curiam) (“The Eleventh Amendment’s grant of sovereign immunity bars monetary relief from state agencies such as California’s Bar Association and Bar Court.“

Plaintiff’s fifth through seventh claims also allege that defendants acted with deliberate indifference in violation of California Government Code § 11135 et seq. and § 12944 et seq. Defendants argue that the State Bar Act, Cal. Bus. & Prof. Code § 6001, exempts the State Bar from the requirements of Division 3 of Title 2 of the California Government Code.

California Business and Professions Code § 6001 states in relevant part: “No law of this state restricting, or prescribing a mode of procedure for the exercise of powers of state public bodies or state agencies, or classes thereof, including, but not by way of limitation, the provisions contained in Division 3 (commencing with Section 11000) … of Title 2 of the Government Code, shall be applicable to the State Bar, unless the Legislature expressly so declares.” Thus the District Court dismissed these causes of action with prejudice as well.

Plaintiff’s eighth through fourteenth claims are for violations of the Unruh Act, Cal. Civ. Code § 51(f). Plaintiff alleges that each predicate violation of the ADA is also a violation of the Unruh Act. Id. Defendants contend that plaintiff’s Unruh Act claims fail because plaintiff has failed to plead compliance with the California Government Claims Act and the State Bar is not subject to claims attempting to incorporate alleged Title II ADA violations into the Unruh Act.

In dismissing these cause of actions the court concluded that “Because plaintiff fails to state a claim for violation of the ADA, it follows that he cannot state a claim for violation of section 51(f). Plaintiff’s claim also fails because the Unruh Act only applies to “business establishments,” Cal. Civ. Code § 51(b), and California courts have held that government entities are not “business establishments” and not subject to the Unruh Act, see, e.g.,

In November 2020 Kohn appealed this case to the 9th Circuit Court of Appeal. The case was briefed by the parties and Amicus. In November 2022 in accordance with Federal Rule of Appellate Procedure 44 and 28 U.S.C. § 2403(b), the Court of Appeals certified to the United States Attorney General a constitutional challenge to a federal statute raised in a pending appeal in which the United States is not a party. The case was argued (video recording) in San Francisco and submitted on February 15, 2023. However, on 5/9/2023 a judge of this court called for a vote to determine whether this case should be heard en banc.

On July 21, 2023 upon the vote of a majority of nonrecused active judges, it was ordered that this case be heard en banc pursuant to Federal Rule of Appellate Procedure 35(a) and Circuit Rule 35-3. Judge Koh did not participate in the deliberations or vote in this case. En banc oral argument will take place during the week of September 18, 2023, in San Francisco, California. The date and time will be determined by separate order.

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64% of 2000 Hospitals Non-Compliant with 2021 Price Transparency Law

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The federal Hospital Price Transparency Rule, which took effect on January 1, 2021, requires hospitals to post all prices online, easily accessible and searchable, in the form of (1) a single machine-readable standard charges file pricing for all items, services, and drugs by all payers and all plans, the de-identified minimum and maximum negotiated rates, and all discounted cash prices, as well as (2) prices for the 300 most common shoppable services either as a consumer-friendly standard charges display listing actual prices or, alternatively, as a price estimator tool.

Combined with requirements for disclosure of systemwide prices and historical claims in the Transparency in Coverage Rule and the Consolidated Appropriations Act of 2021 respectively, the Hospital Price Transparency Rule is intended to empower healthcare consumers – patients, employers, and unions as purchasers – with ease of access to compare prices.

The nonprofit Patient Rights Advocate (PRA) released its fifth semi-annual report, which found that only 36 percent of 2,000 surveyed hospitals were in complete compliance with the rule.

Its latest review was published on July 20, 2023, two and a half years after the Hospital Price Transparency Rule took effect. It analyzed the websites of 2,000 U.S. hospitals and found only 36% of them (721) to be fully compliant with all requirements of the rule.

Although the majority of hospitals have posted files, the widescale noncompliance of 64% of hospitals is due to most hospitals’ files being incomplete or not having prices clearly associated with both payer and plan.

In this report, 69 of the hospitals reviewed had no usable standard charges file.

Compliance varied widely among the largest hospital systems it reviewed.

– – None (0%) of the hospitals it reviewed which were owned by HCA Healthcare, Tenet Healthcare, Providence, Avera Health, UPMC, Baylor Scott & White Health, and Mercy were found to be fully compliant.
– – Consistent with prior reports, none of the hospitals owned by the largest hospital system in the country, HCA Healthcare, were found to be in full compliance, with a significant amount of its hospitals posting illegible, nonconforming files.
– – Substantial improvements since its last report include: 88% of hospitals owned by CommonSpirit Health, 97% of hospitals owned by Community Health Systems, and 98% of hospitals owned by Kaiser Permanente were found to be in full compliance.

The Health and Human Services (HHS) Department’s Centers for Medicare and Medicaid Services (CMS) are responsible for enforcing the rule. In June of 2022 (eighteen months after the rule’s inception), CMS imposed its first two civil monetary penalties (CMPs) on hospitals for not complying with the rule.

Both hospitals immediately came into compliance with exemplary files to date.

In February of 2023, CMS acknowledged in a blog post that 30% of hospitals (approximately 1,800) were still noncompliant. Yet, in April of 2023, only two more hospitals were fined. Both were still found to be noncompliant in this review.

As of the time of this report, a total of four hospitals have been penalized, 0.2% of the hospitals that CMS recognized as noncompliant. Clearly, CMS is not strongly enforcing the rule.

“Unfortunately, our findings show that the majority of hospitals across the country are still failing to comply with the Hospital Price Transparency Rule,” said Cynthia Fisher, Founder and Chairman of PatientsRightsAdvocate.org.

“When hospitals hide behind estimates or don’t post all real prices, they are leaving consumers in the dark. Making all actual prices available upfront will empower patients, employers, and unions to choose the best care at prices they know they can afford, and protect all Americans from overcharges, errors, and fraud.”

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Four Arrested in SoCal Multimillion-Dollar Health Care Business Scam

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The owner of a now-shuttered health care business management services company and three other people were arrested on a nine-count federal grand jury indictment alleging they defrauded lenders and investors out of millions of dollars via false claims that the owner’s struggling business was booming.

Tammy Le, 48, of San Clemente, the former owner and CEO of CareAccess MSO Inc., a Cerritos-based company that purported to help primary care physician groups manage their business affairs, was arrested without incident this morning.

Also arrested today were:

– – Macy Zia, 50, of Fullerton, a former senior accounting manager at CareAccess;
– – Galen Clark, 31, of Simi Valley, a former CareAccess information technology manager; and
– – Chris Ruiz, 52, of Pasadena, the owner of Auxilium Health Network, an Arcadia-based independent physician association (IPA).

All four defendants are charged with one count of conspiracy to commit wire fraud. Le, Zia and Ruiz are charged with six counts of wire fraud. Clark, who allegedly joined the conspiracy in November 2020, is charged with three counts of wire fraud. Le also is charged with one count of aggravated identity theft and one count of money laundering.

According to an indictment returned on Tuesday, from January 2020 to July 2021, the defendants conspired to fraudulently obtain money from their victims by falsely representing the scope of CareAccess’ business and its anticipated revenue – one victim company was duped into loaning money to CareAccess while the other victim company was deceived into acquiring Le’s company. Neither victim knew the weak state of CareAccess, the indictment alleges.

Le allegedly caused CareAccess to contract with a New Jersey-based finance company that would make loans to CareAccess in exchange for rights to collect against her company’s accounts receivable, including fees due from Auxilium and other IPAs.

The defendants allegedly induced the lender by making false statements regarding the business performance of CareAccess, including by sending fake copies of invoices the company purportedly issued to IPAs. The bogus invoices were accompanied by spreadsheets containing the number of patients purportedly enrolled with the IPAs. The fraudulent invoices and spreadsheets inflated the amount of fees due to CareAccess and the amount of money the lender would loan to it.

To impede the lender’s ability to detect the fraud, Le allegedly arranged for Ruiz to be the point of contact at Auxilium and, when contacted by the lender’s representatives, he verified the false information contained in the fraudulent invoices and spreadsheets.

Le, Zia and Ruiz allegedly caused this lender to wire approximately $6.1 million in loans into a Le-controlled bank account.

Also, starting in November 2020, the defendants, now including Clark, allegedly solicited a Utah-based health care investment company to invest in and eventually acquire CareAccess. The defendants allegedly provided this investor fraudulent reports that inflated its business performance and the size of its customer base.

Through these misrepresentations the defendants allegedly caused the investor to provide approximately $12.7 million for the acquisition of CareAccess, of which Le allegedly directed $2.2 million to be deposited in her bank account. A substantial portion of the latter amount was to be used by the defendants for their personal benefit.

Within months of the acquisition, CareAccess filed for bankruptcy protection.

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Applicant Attorney Robert Slater’s Conviction Affirmed

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Robert Irving Slater was admitted to practice law in California since 1975. He was a solo practitioner who had handled workers’ compensation cases since at least the late 1990’s.

USA Photocopy, located in Santa Ana, provided attorney services, including photocopying and sending subpoenas for records for workers’ compensation cases. The company would then bill insurance carriers for its services. During the relevant time period, Edgar Gonzalez was the owner of USA Photocopy and Enrique Villagomez was the manager.

Peter Ayala worked as a “legal investigator performing intake services.” He learned that Villagomez had work in the form of “sign-up services available,” and subsequently had a meeting with Gonzalez and Villagomez at the USA Photocopy office. During the course of the conversation, it was brought up that Ayala would be working directly for one attorney – Robert Irving Slater. After working out a payment structure with Gonzalez and Villagomez, all three of them went to Slater’s office and met with him.

Ayala’s role was to meet with the potential “workers’ compensation client to fill out the intake retainer . . . and also get the retainer signed for the claim.” Ayala would also have the client, with his assistance, complete various forms, including the workers’ compensation appeals board application for adjudication, medical release forms, and fee disclosure forms, among others. With regard to copy services, there was a form signed by clients giving USA Photocopy permission to perform copy services “and the medical release forms as well.” Ayala would return the forms to Slater’s office in digital form, and returned the originals in person approximately every two weeks.

Ayala was told to send an invoice for his services every two weeks to USA Photocopy, which paid him for his services. Ayala had done similar work in the past for approximately 13 attorneys, and this was the first time he would be paid by a party other than an attorney.

Ayala was paid by USA Photocopy as an independent contractor. Between September 2012 and September 2015, Ayala invoiced a total of $196,280.00 to USA Photocopy. Over the six years his relationship with USA Photocopy and defendant lasted, Ayala estimated he performed intake services for about 2,000 clients for defendant, and USA Photocopy was the only copy service used for those clients. Ayala did not perform any service for USA Photocopy other than the services he performed for Slater.

Slater was charged with conspiracy (Pen. Code, § 182, subd. (a)(1), Lab. Code, § 32151 (count 1)); submitting a false and fraudulent claim (Pen. Code, § 549 (count 2)); and 21 counts of insurance fraud based on concealing or failing to disclose information that affects a person’s right to an insurance benefit (Pen. Code, § 550, subd. (b)(3) (counts 3-23)). The complaint also alleged that Slater had engaged in a pattern of related fraudulent conduct involving the taking of more than $100,000.00. A jury convicted Slater on all 23 counts, and also found the enhancement regarding the pattern of fraudulent conduct true.

The court sentenced Slater to serve a total of 183 days, with 182 of those days suspended on the successful completion of two years of supervised probation. Six months of the probation term was to be served with an ankle bracelet. The court also ordered him to pay $356,175.24 in victim restitution in addition to statutory fines and fees.

Slater appealed his conviction. The court of appeal affirmed the trial court in the unpublished case of People v Slater -G061331 (July 2023)

Slater’s sole contention on appeal is that he did not possess the requisite state of mind to violate Labor Code section 3215, which was an element of each of the crimes of which he was convicted with the exception of count 2, submitting a false and fraudulent claim under Penal Code section 549.

Section 3215 states: “Except as otherwise permitted by law, any person acting individually or through his or her employees or agents, who offers, delivers, receives, or accepts any rebate, refund, commission, preference, patronage, dividend, discount or other consideration, whether in the form of money or otherwise, as compensation or inducement for referring clients or patients to perform or obtain services or benefits pursuant to this division, is guilty of a crime.“

In reviewing his opening brief on appeal, the Court noted that he “included nothing that could possibly be interpreted as an even-handed account of the evidence presented. This violates rules 8.204(a)(2)(C) and 8.360(a) of the California Rules of Court.”

“It also violates the principles set forth in Sanghera, supra, 139 Cal.App.4th 1567: ‘Perhaps the most fundamental rule of appellate law is that the judgment challenged on appeal is presumed correct, and it is the appellant’s burden to affirmatively demonstrate error.’ “

The Court went to to say “How does a defendant make such a showing? Perhaps the best way to understand that point is to understand how a defendant does not make such a showing. He does not show the evidence is insufficient by citing only his own evidence, or by arguing about what evidence is not in the record, or by portraying the evidence that is in the record in the light most favorable to himself.”

After the Court of Appeal sad that “Defendant failed these requirements rather spectacularly” it concluded by finding “Even if defendant had adequately briefed this appeal, our own review of the record demonstrates substantial evidence to uphold the verdicts.”

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San Jose Roofing Contractor Faces $460K Premium Fraud Case

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On June 19, 2020, a fatal accident occurred in San Jose, California on southbound Highway 101 near the Blossom Hill Road exit.

Four employees from CD All Roofing were returning from a roofing job in two company trucks when the tire of one of the trucks, a 2015 Ford F-150, blew out. The driver of the truck overcorrected, causing the truck to roll over.

One of the passengers, 62-year-old David Pham, was ejected from the truck and died at the scene. He was Duong’s longtime second-in-command. The other three passengers were taken to the hospital with injuries.

A truck accident that left one man dead exposed a $460,000 workers’ insurance fraud scheme by the owner of a San Jose roofing company.

Charlie Duong, 64-year-old owner of CD All Roofing, tried to cover up that the dead employee had been working full-time for years. Duong’s falsified records, which showed that the driver was part-time and had just started, ended up cutting benefits to the deceased’s wife.

Prosecutors claim that Duong asked the survivor of the accident to lie to investigators by saying that the victim had only started working a few days before and was only working part-time. The employee refused to lie, telling investigators that his dead coworker had been on the job eight years, working six days a week.

Duong also tried to show that the deceased was not on the job when the truck crashed, even though the employees were in company trucks driving back from a job when the accident occurred

Accused of faking information for his employees to avoid insurance premiums, Duong was arraigned on insurance fraud felonies. He is scheduled to go to trial in January 2024.

“Insurance fraud is not a victimless crime,” District Attorney Jeff Rosen said. “This felony crime raises our premiums and leaves innocent workers and their families exposed to financial catastrophe. We will never look the other way.”

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July 10, 2023 – News Podcast

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Rene Thomas Folse, JD, Ph.D. is the host for this edition which reports on the following news stories: Top Court Says Employers Not Liable for COVID Spread to Family Members. Stay of Litigation Mandated During Appeal of Denial of Arbitration Motion. Cal/OSHA May Amend Citations Before, During and After ALJ Hearings. Money Launderer Convicted in Multi-Million Dollar Premium Fraud Scheme. SoCal Chiropractor Among 78 Charged in $2.5B in Health Care Fraud. Bay Area Construction Companies Charged with Premium Fraud. Jury Convicts San Jose Doctor For Illegal Opioid Prescribing. Jury Finds DME Company Owner Guilty of $24M in Fraudulent Claims. Cal/OSHA Cites The Two Employers of Seven Mass Shooting Victims. 2023 Survey of 18,000 Nurses Shows 30% Leaving Career.

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WCAB Rejects Vocational Apportionment Noting Recent En Banc Decision

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Rigoberto Gonzalez claimed injury to his heart, upper extremities, spine, and lower extremities while employed by Team Infinity as a service technician/mechanic during the period from August 28, 2001, through March 25, 2010.

The parties agreed to use Steven Nagelberg, M.D., an orthopedist and Edward J. O’Neill, M.D., and internist as AMEs in their respective fields, and Gonzalez was additionally evaluated by a rheumatology qualified medical examiner (QME) Seymour Levine, M.D.

As to the issue of apportionment, Dr. Nagelberg stated that 100% of the cervical and lumbar spine impairment was caused by the cumulative work injury, that 50% of the right wrist and bi-lateral knee impairment was due to the cumulative work injury, and 50% of the right wrist and bi-lateral knee impairment was due to a pre-existing non-industrial arthritic condition.

Dr. O’Neill stated that the hypertension caused 49% WPI, the coronary artery disease caused 20% WPI, the upper GI/GERD caused 7% WPI, and that applicant had 7% WPI as a result of his obstructive sleep apnea. He later said he would apportion the hypertension in the same fashion as the arthritic condition; namely, 75% non-occupational and 25% occupationally related. Regarding the coronary artery disease and the obstructive sleep apnea is that neither of those conditions are occupationally related and any impairment or disability is non-occupationally related with no apportionment to occupational factors.

Gonzalez had a “Facetime meeting” with Vocational Rehabilitation Counselor Paul Broadus. Mr. Broadus concluded that applicant was “not amenable to rehabilitation, solely due to his industrial impairments” and that he no longer had “the ability to return to work in the open labor market.”

After commenting on the apportionment given by the medical evaluators, he concluded that “Mr. Gonzalez is in a rather unusual situation in that none of his impairments by themselves preclude him from working in the open labor market. However, he has so many separate issues that when combined, the industrial portions alone make him not amenable to rehabilitation.  Conversely, if he only had the non-industrial impairments, these would be labor-disabling and preclude him from working by themselves.

At the October 13, 2021 trial the parties stipulated that applicant sustained injury AOE/COE to his heart, upper extremits, spine, and lower extremities; that “Applicant asserts he is 100 percent permanently totally disabled” and “Defendant asserts that, Applicant’s permanent disability is 86%;”

The WCJ found that the injuries caused 100% permanent disability. The employer’s Petition of Reconsideration was granted, and the award was rescinded in the panel decision of Gonzalez v Team Infinity -ADJ7263865 (July 2023).

The issue on Reconsideration was apportionment of permanent disability. On this issue the WCAB panel noted that pursuant to Labor Code 4663 “The Appeals Board must rely on expert medical opinion in determining apportionment; apportionment is a medical determination, and a non-medical opinion is not substantial evidence.”

The WCAB panel then noted its recent en banc decision on this issue stating “Accordingly, ‘vocational apportionment’ offered by a non-physician is not a statutorily authorized form of apportionment. In addition, apportionment determinations that deviate from the mandatory standards described in section 4663(c) are not a valid basis upon which to determine permanent disability. (Grace Nunes v. State of California, Dept. of Motor Vehicles (2023) Cal.Comp.Cases … [2023 Cal.Wrk.Comp. LEXIS … [ADJ8210063; ADJ8621818] (Appeals Board en banc)”

Also, Dr. Nagelberg and Dr. O’Neill did not review the VR reports in this case.

“It appears that notwithstanding the apportionment described by Drs. Nagelberg and O’Neill, it is Mr. Broadus’ opinion that applicant is 100% disabled as a result of his industrial cumulative injury. Clearly, his opinion is not consistent with the statutory and case law discussed above.”

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Allianz Unit Fined $5 Billion for Multibillion-Dollar Fraud Scheme

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Allianz Global Investors U.S. LLC (AGI) is an investment management firm that is part of the Allianz Group. AGI US was founded in 2010 and is headquartered in New York City. The company provides portfolio management and advisory services to individuals, corporations, public pension and profit-sharing plans, charitable institutions, foundations, and trusts in the United States. AGI Us is also an investment adviser registered with the Securities and Exchange Commission (“SEC”).

Allianz Group is a German multinational financial services company headquartered in Munich, Germany. It is one of the largest insurers and financial services groups in the world, with over 150 million customers in more than 70 countries. Allianz’s core businesses are insurance and asset management. The company offers a wide range of insurance products, including life insurance, property and casualty insurance, and health insurance. Allianz also manages over $2.4 trillion in assets, making it one of the largest asset managers in the world.

The United States Attorney for the Southern District of New York, announced that Allianz Global Investors U.S. LLC was sentenced by U.S. District Judge Colleen McMahon for a multi-year securities fraud involving a series of private investment funds managed by AGI. Those funds ultimately collapsed, leading to billions of dollars of investor losses.

AGI previously pled guilty to one count of securities fraud. The sentencing had been postponed since last year to give Allianz’s Pacific Investment Management Co (PIMCO) time to negotiate its ability to keep handling $170 billion in U.S. retirement funds despite AGI’s conviction.

AGI was sentenced to financial penalties comprised of over $463 million in forfeiture, over $3.23 billion in restitution, and over $2.33 billion in fines. These amounts include restitution to the victims, the forfeiture of proceeds traceable to the fraud, and the forfeiture by AGI’s corporate parent of the dividends that were paid from AGI to its corporate parent that are traceable to the fraud. AGI has paid these financial penalties in full and has compensated victims of the conduct through settlements in civil litigation filed against AGI in an aggregate amount of over $5 billion.

Prosecutors say AGI engaged in a scheme to defraud investors in multiple private funds within AGI’s “Structured Alpha Funds.” The Structured Alpha Funds were among the most profitable groups of funds AGI managed and, at their height, held over $11 billion in assets under management. The Funds employed a complex options trading strategy that sought to provide investors with guaranteed returns, while managing risk. AGI deceived the Funds and their investors by understating the risk to which investors’ assets were exposed, and therefore how the returns they touted were actually generated.

In particular, in order to generate the Funds’ positive returns and attract and retain capital, prosecutors say AGI fraudulently misled investors regarding the risk taken on by the funds. Among other things, AGI misrepresented the hedging and other risk-mitigation strategies that were undertaken to protect investor funds. Investors also received documents altered to hide the riskiness of the Funds’ investments. Instead of managing the Funds as promised to investors, AGI deployed an investment strategy that prioritized returns over risk management in ways that were fundamentally inconsistent with representations made to investors. As a result of this scheme to defraud, investors’ funds were exposed to higher risk than promised, and investors were deprived of information about the true risks to which their investments were exposed.

After the market dislocations following the onset of the COVID-19 pandemic in March 2020, the Funds lost in excess of $8 billion in market value and $3 billion in principal, faced margin calls and redemption requests, and ultimately were shut down. More than 100 investors were victims of this scheme, including, among others, pension funds for teachers, religious organizations, bus drivers, engineers, and other individuals, universities, and charitable organizations.

U.S. Attorney Damian Williams said: “Telling the truth to investors is the core duty of an investment adviser. AGI violated that central tenet and deceived investors by materially understating the risk to which their assets were exposed.”

In the wake of the criminal case, Allianz moved about $120 billion of investor assets to Voya Financial in exchange for a 24% stake in Voya’s asset management business.

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