Author: WorkCompAcademy

A former California Employment Development Department employee has agreed to plead guilty to a federal criminal charge for causing nearly 200 fraudulent COVID-related unemployment relief claims to be filed in other people’s names, resulting in more than $1.6 million in ill-gotten gains.

Gabriela Llerenas, a.k.a. “Maria G. Sandoval,” 49, of Perris, signed a plea agreement in which she has agreed to plead guilty to a single-count information charging her with mail fraud.

Court records show that Llerenas previously worked at EDD as a disability insurance program representative. She resigned in March 2002 after admitting to fraudulently authorizing and paying disability benefits administered by EDD. She was sentenced to 37 months in federal prison in connection with that scheme.

The new scheme that Llerenas has admitted running took advantage of the expanded eligibility for unemployment insurance benefits made possible by the Coronavirus Aid, Relief, and Economic Security (CARES) Act passed by Congress and signed into law in March 2020.

From April to October 2020, Llerenas filed and caused the filing with EDD that falsely asserted the named claimants were self-employed independent contractors – often identifying them as cake decorators or event attendants – who were negatively affected by the COVID-19 pandemic. Llerenas obtained some of the names, Social Security numbers and other identifying information she used to submit the fraudulent claims through her prior work as a tax preparer.

In her plea agreement, Llerenas also admitted to falsely stating on some of the applications that the claimants were residents of California entitled to unemployment insurance benefits administered by EDD when in fact they lived elsewhere. She also admitted that, on some applications, she inflated the amounts of income she reported for the claimant to maximize the benefit amount. She also admitted to sometimes filing a dozen or more fraudulent EDD claims in a day.

As a result of the fraudulent unemployment benefits applications that Llerenas filed and caused to be filed, EDD authorized Bank of America to mail debit cards in the names of the claimants to addresses she provided, including her residence, her husband’s business location, her mother’s apartment and the addresses of friends and other family members.

Llerenas admitted that she charged the named claimants a fee for filling the applications, which was often paid out of the fraudulently obtained benefits. In at least one case, she told the named claimant that she was still employed at EDD and could control the distribution of the unemployment insurance benefits, and then demanded an additional payment for “releasing” the benefits.

In total, 197 debit cards were fraudulently issued because of this scheme, resulting in losses to EDD and the United States Treasury that Llerenas has admitted were at least $1,633,487.

Llerenas is scheduled to make her initial appearance on September 22. The criminal offense to which Llerenas has agreed to plead guilty carries a statutory maximum sentence of 20 years in federal prison.

Sampson Parker worked as a bus driver for AC Transit in December 2016 when he injured his his left leg, left ankle, left foot, and right wrist.Following his injury, he underwent multiple surgeries.

The last surgery occurred on October 15, 2019, when he underwent the placement of a revision intramedullary tibial nail placed in a locking fashion along with an open reduction, internal fixation (ORIF) utilizing two plates and screws for fixation along with the implantation of bone morphogenic protein and that the surgery caused a shortening of his left lower leg.

On February 8, 2021, his primary treating physician, Scott Petersen, M.D., issued a report stating that he was maximally medically improved. Dr. Peterson’s physical examination revealed that his left leg was six centimeters shorter than the right. Dr. Petersen described the last surgical procedure as a “limb shortening surgery.”

On May 18, 2021, the matter proceeded to trial on the issues of whether he qualified for the amputation exception to the 104 week cap on temporary total disability indemnity and if so, whether his entitlement to receive temporary disability indemnity would run continuously or whether it would stop after 104 weeks had been paid and resume on the date of the last surgery.

A Findings and Award issued concluding that the surgical removal of bone from Parker’s left lower extremity combined with a shortening of the limb constituted an amputation pursuant to Labor Code section 4565(c)(3)(C), and that he was entitled to receive temporary disability indemnity for the period beginning on December 17, 2018 and continuing through February 7, 2021.

Reconsideration of this finding was denied in the panel case of Parker v AC Transit (ADJ10741808).

The Labor Code provides that for an employee who suffers from the certain injuries or conditions (in this case an amputation), aggregate disability payments for a single injury occurring on or after April 19, 2004, causing temporary disability shall not extend for more than 240 compensable weeks within a period of five years from the date of the injury. Otherwise the limit is 104 weeks.

In Cruz v. Mercedes-Benz of San Francisco, (2007) 72 Cal. Comp. Cases 1281, 1283 (Appeals Board en banc), the Appeals Board defined “amputation” as “the severance or removal of a limb, part of a limb, or other body appendage.”

It is undisputed that as a result of a “limb shortening surgery,” Parker lost approximately two inches from his left lower extremity, a protruding external body part. The amputation exception does not require the severance of an entire body part

Three former National Football League players have pleaded guilty for their roles in a nationwide scheme to defraud a health care benefit program for retired NFL players. A total of 15 defendants have pleaded guilty in connection with this scheme.

Clinton Portis, 40, of Fort Mill, South Carolina, and Tamarick Vanover, 47, of Tallahassee, Florida, pleaded guilty on Friday, Sept. 3. Robert McCune, 40, of Riverdale, Georgia, pleaded guilty on Aug. 24. The former players admitted to participating in a scheme to defraud the Gene Upshaw NFL Player Health Reimbursement Account Plan. The Plan was established pursuant to the NFL’s 2006 collective bargaining agreement and provided for tax-free reimbursement of out-of-pocket medical care expenses that were not covered by insurance, and that were incurred by former players, their spouses, and their dependents – up to a maximum of $350,000 per player.

According to court documents, Portis caused the submission of false and fraudulent claims to the Plan on his behalf over a two-month period, obtaining $99,264 in benefits for expensive medical equipment that was not actually provided. Vanover recruited three other former NFL players into the fraudulent scheme and assisted them in causing false and fraudulent claims to be submitted to the Plan, obtaining $159,510 for expensive medical equipment that was not actually provided. McCune orchestrated the nationwide fraud, which resulted in approximately $2.9 million in false and fraudulent claims being submitted to the Plan and the Plan paying out approximately $2.5 million on those claims between June 2017 and April 2018.

Portis and Vanover pleaded guilty two days after a trial against them resulted in a hung jury and a mistrial on certain counts against Vanover. McCune, the third defendant in that trial, pleaded guilty to all charges against him on the second day of trial. A retrial on the charges against Portis and Vanover had been scheduled.

Portis and Vanover were originally indicted, along with McCune and seven other defendants, in the Eastern District of Kentucky in December 2019 for their roles in the fraud. Since the initial charges were announced, five additional retired NFL players were charged in the scheme. All 12 of the other defendants charged have pleaded guilty to conspiracy to commit health care fraud: Joseph Horn, Correll Buckhalter, Carlos Rogers, James Butler, Etric Pruitt, Ceandris Brown, John Eubanks, Antwan Odom, Darrell Reid, Anthony Montgomery, Fredrick Bennett, and Donald “Reche” Caldwell, who passed away in June 2020.

Portis and Vanover pleaded guilty to conspiracy to commit health care fraud and agreed to pay full restitution to the Plan. Portis is scheduled to be sentenced on Jan. 6, 2022, and Vanover is scheduled to be sentenced on Jan. 22, 2022. They each face a maximum penalty of 10 years in prison.

McCune pleaded guilty to conspiracy to commit wire fraud and health care fraud, 13 counts of health care fraud, 11 counts of wire fraud, and three counts of aggravated identity theft. McCune is scheduled to be sentenced on Nov. 19. He faces a maximum penalty of 20 years in prison for conspiracy to commit wire fraud and health care fraud, 10 years for each count of health care fraud, 20 years for each count of wire fraud, and two years for each count of aggravated identity theft.

A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

This case was investigated by the FBI and included efforts by various FBI Field Offices and Resident Agencies, including Los Angeles, San Diego, Sacramento, and Newport Beach, California.

San Diego area pain clinic doctor Brenton Wynn, M.D., has paid $200,000 to resolve allegations that he illegally prescribed opioids and other dangerous drugs to his patients. Wynn has an office at 502 Euclid Ave., Suite 200, in National City.  He was a graduate of Howard University College of Medicine in 1998.

The Controlled Substances Act provides that doctors may write prescriptions for opioids only for a legitimate medical purpose while acting in the usual course of their professional practice. The United States alleged that Dr. Wynn wrote opioid prescriptions to patients without a legitimate medical purpose and/or outside the usual course of his professional practice for more than five years.  Dr. Wynn wrote prescriptions for fentanyl, oxycodone, hydromorphone, methadone, oxymorphone, and morphine.

The United States further alleged that Dr. Wynn prescribed at the same time a dangerous combination of opioids and benzodiazepines such as Xanax and Valium.  Of even more concern, Dr. Wynn allegedly prescribed to some patients a combination of at least one opioid, one benzodiazepine and one muscle relaxant such as Soma.  Drug abusers colloquially refer to the opioid, benzodiazepine, and muscle relaxant combination as the “Trinity” or “Holy Trinity” because of its rapid euphoric effects.  These drug combinations are known to significantly increase the risk of addiction, abuse, and overdose.

Based on its investigation, the United States alleged that Dr. Wynn prescribed large quantities of opioids to his patients that reached high daily MME levels, often even exceeding 120 MME.  The United States further alleged that Dr. Wynn sometimes continued to prescribe dangerous opioids even when his patients’ urine drug test results showed that they were not taking the drugs Dr. Wynn prescribed.

The DEA has a pending administrative action against Dr. Wynn (Docket No. 20-10) to revoke his ability to prescribe opioids and other controlled substances.

“While the vast amount of medical professionals prescribe opioids legitimately and are meeting their patients’ standard of care, DEA will vigorously pursue information from the public about the doctors who are not,” said DEA Special Agent in Charge John W. Callery. “DEA will always protect the public from doctors who put their patients in harm’s way.”

Assistant U.S. Attorney Dylan M. Aste of the U.S. Attorney’s Office for the Southern District of California handled this matter along with DEA investigators.

The Workers’ Compensation Insurance Rating Bureau of California has released the 2020 California Workers’ Compensation Aggregate Medical Payment Trends report comparing medical payment information from 2018 to 2020.

This report analyzes medical payment and utilization trends by provider type, service locations and different service types. The report also includes an analysis on utilization and cost of opioid prescriptions and physical medicine services over time and by region.

General Trends in the Medical Payments and Transactions in CY2020

– – Overall medical payments declined significantly, largely driven by a sharp drop in the number of claims during the COVID-19 pandemic.
– – Average medical payment per claim and the number of transactions per claim started to increase despite the continuous declines in prior years, potentially due to a decrease in the number of smaller medical-only claims in 2020.
– – Utilization of telehealth services increased sharply, in particular, during the pandemic

Fastest Growing Physician Services Procedures and Therapeutic Group

– – Physical Medicine and Rehabilitation procedures continued to grow and are the fastest growing physician services.
– – Use of Analgesics Anti-Inflammatory increased more significantly than that of any other therapeutic groups.

Opioid and Physical Medicine Utilization and Costs

– – The share of claims that involve opioid prescriptions continued to decrease. Suburban and rural areas have seen higher shares of claims involving opioid prescriptions, while urban areas generally have lower shares.
– – On the contrary, the share of claims that involve physical medicine services increased steadily. Urban areas had a higher share of claims involving physical medicine services, while more suburban and rural areas had lower shares.

The report is available in the Research section of the WCIRB website.