Author: WorkCompAcademy

An investigation by the Central Valley Workers’ Compensation Fraud Task Force resulted in the arraignment of Paul Steve Ramirez, 59, for allegedly fraudulently billing for workers’ compensation voucher services and failing to provide adequate training at the for-profit school he owns.

Ramirez was charged with 11 felony counts, including insurance fraud and prohibited referrals. The fraudulent insurance claims are estimated to reach $200,000.

Ramirez owns P. Steve Ramirez Vocational Training Centers, a private post-secondary educational institution and Supplemental Job Displacement Benefit (SJDB) training provider. Ramirez owns a second business which provides vocational counseling. SJDB vouchers provide up to $6,000 for educational retraining or skill enhancement to injured workers who have a permanent partial disability and are unable to return to work at their employer. Ramirez gained access to students at the counseling center and then self-referred them directly to his educational institution, allowing him to maximize his billing.

A Central Valley Workers’ Compensation Fraud Task Force investigation, led by the Fresno County District Attorney’s Office and the California Department of Insurance, found Ramirez fraudulently collected SJDB voucher funds related to 37 different students over a three-year period. Ramirez billed insurance companies for services even though the students did not meet the minimum qualifications for the program and also engaged in prohibited referrals for services.

Ramirez’s actions led to many of these injured workers not having a choice in the program they were in enrolled in and many of them not receiving the benefit because of unsuccessful completion of the course they should never have been placed into.

The Fresno County District Attorney’s Office is prosecuting this case.

The Workers Compensation Research Institute (WCRI) is an independent, not-for-profit research organization based in Cambridge, MA. Founded in 1983, the Institute does not take positions on the issues it researches; rather, it provides information obtained through studies and data collection efforts, which conform to recognized scientific methods.

A new set of studies from the WCRI found that utilization of medical services by workers with injuries declined in the majority of the 17 study states. The studies address two aspects of utilization: the percentage of claims receiving a particular medical service, and the number of services provided.

“We continue to see the effects of the pandemic on 2022 claims with experience through March 2023,” said Sebastian Negrusa, vice president of research for WCRI. “Besides strained hospital capacity and avoided medical care by many people out of fear of COVID-19 in the early months of the pandemic, waves of increased COVID-19 cases and medical provider shortages may have also affected the delivery of medical care. Even in the few cases where utilization in certain states has begun to rebound, we do not see it reaching pre-pandemic levels yet.”

The studies, CompScope Medical Benchmarks, 25th Edition, examined medical payments, prices, and utilization overall and by provider and type of service across 17 states and how these metrics of medical payments have changed over time. The following are sample findings for some of the study states:

– – California: Utilization of medical services decreased in 2022, particularly in the percentage of claims with inpatient care and facility services (both hospital outpatient departments and ambulatory surgery centers).
– – Indiana: Utilization declined in 2022, particularly for major surgery and facility services.
– – Minnesota: Unlike most study states, utilization of most services in Minnesota either stayed stable or began to increase in 2022.
– – North Carolina: Decreasing utilization was a driver of the state’s decline in medical payments per claim in 2022, in contrast to many study states which experienced growth.
– – Pennsylvania: The share of claims with facility services in the state declined more than most study states since 2019.

The analysis results reflect experience on claims through March 2023, including non-COVID-19 claims from the pandemic period (March 2020-September 2022). The studies, therefore, provide a look at how the pandemic impacted non-COVID-19 workers’ compensation claims. The 17 study states ― Arkansas, California, Florida, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Michigan, Minnesota, New Jersey, North Carolina, Pennsylvania, Tennessee, Texas, Virginia, and Wisconsin ― represent about 60 percent of all workers’ compensation benefit payments nationwide. Individual reports are available for every state except Arkansas, Iowa, and Tennessee.

Click here for more information on these studies.

The Business Group on Health 2025 Employer Health Care Strategy Survey explored ways employers address health care costs and key benefit strategy considerations in the near future and long-term. Among inflationary pressures in the health care sector, worsening chronic condition burden in the population and the demand for many ground breaking – albeit expensive – treatments, employers are juggling many priorities. Strategies to lower costs, improve outcomes and strengthen the employee experience were explored in this survey.

Fielded between June 3 and July 12, the survey was completed by 125 employers that cover more than 17.1 million lives in the United States. Companies that completed the survey represent a broad range of industries and are diverse in size.

The role of a HR/Benefits leader has never been more complex and demanding. The 2025 survey results highlight the challenges employers face. Based on the findings of this survey, the following emerged as top focus areas among employers.

– – Health care costs are expected to grow at the highest rate in a decade.Since 2022, the projected increase in health care trend, before plan design changes, rose from 6% in 2022 to almost 8% for 2025.
– – Pharmacy costs are largely responsible for overall increases and consume a growing share of the health care budget. Between 2021 and 2023, the median percentage of health care dollars spent on pharmacy has jumped from 21% to 27%, suggesting that nearly all of the health care cost increase noted above is related to pharmacy cost.
– – Employers are seeing cost pressures from GLP-1 medications (which regulates blood sugar, appetite, and digestion), which are considered a top driver of health care costs this year. Seventy-nine percent of employers have seen an increase in interest in obesity medications – including GLP-1s – among their covered members.
– – Managing and reassessing vendor partnerships are at the center of employers’ plans to address costs and improve performance. Employers are reassessing the quality and effectiveness of their partnerships and looking to integrate their benefits to reduce costs and simplify the member experience.
– – Cancer remains the top condition driving cost; however, more employers say that cardiovascular conditions are among their top three cost drivers.Concerns about the cost of cancer care may be further fueled by increased prevalence in younger populations. Furthermore, the growing cost of cancer treatments, including gene and cell therapies currently in the pipeline, leaves employers questioning how their plans will be impacted.
– – Protecting ERISA preemption is employers’ highest priority for the Administration and Congress.This finding reflects the importance of ERISA to employers, which allows them to offer their employees comprehensive benefits in a nationally consistent and competitive manner.
– – Mental health continues to be a priority for employers, with a focus on access and ways to eliminate cost barriers. Seventy-nine percent of employers say that access is one of their top three mental health priorities for 2025. To address access and costs, employers continue to pursue strategies, such as virtual counseling, eliminating out-of-network barriers and using on-site counselors.
– – Employers remain committed to health equity efforts that address disparities. Employers continue to pursue a number of targeted approaches to narrow health disparities within their plans and programs. Holistically, the most common tactic found in the survey is collaborating with employee resource groups (ERGs) to promote benefits and well-being initiatives to specific groups.

Business Group on Health CEO Ellen Kelsay expects employers to react by being more selective about the care that people receive. They also will try to manage the use of expensive treatments for obesity and diabetes.The CEO spoke recently with The Associated Press, and answered questions about implementation of expected strategies by employers.

The former longtime head of the accounting department at the now-shuttered Los Angeles plaintiffs’ personal injury law firm Girardi Keese pleaded guilty to enabling the embezzlement of tens millions of dollars from the firm’s injured clients and to embezzling money from Girardi Keese itself.

Christopher Kazuo Kamon, 51, formerly of Encino and Palos Verdes and who was residing in The Bahamas at the time of his November 2022 arrest, pleaded guilty to two counts of wire fraud.

According to his plea agreement, from 2004 until December 2020, Kamon was the head of the accounting department at Girardi Keese, a plaintiffs’ personal injury law firm based in downtown Los Angeles. In this position, Kamon worked closely with Thomas Vincent Girardi, 85, formerly a resident of Pasadena but who now resides in Seal Beach, as well as other senior lawyers at the law firm.

In December 2020, Girardi Keese’s creditors forced the once-prominent law firm into bankruptcy proceedings. The law firm dissolved in January 2021 and the State Bar of California disbarred Girardi in July 2022. On August 27, a federal jury in Los Angeles found Girardi guilty of four counts of wire fraud. Girardi’s sentencing hearing is scheduled for December 6.

In addition to supervising the law firm’s accounting department, Kamon oversaw facilitating payment of the law firm’s expenses. Kamon had a duty to keep accurate books and records of Girardi Keese, including accounting of money held in its attorney-client trust accounts. Typically, Girardi determined and directed which clients would be paid, how much they would be paid, when they would be paid, and signed all outgoing checks to clients. Kamon had signatory authority on additional Girardi Keese bank accounts.

From at least 2010 until December 2020, Girardi and Kamon schemed to defraud Girardi Keese clients out of their settlement money, using the misappropriated funds to pay the law firm’s payroll, the law firm’s credit card bills, and to pay Girardi and Kamon’s personal expenses.

Specifically, one victim – a Girardi Keese client who suffered severe burns all over his body when a natural gas pipeline exploded in San Bruno, California, in September 2010 – had a $53 million settlement negotiated. This deal was negotiated and agreed to without the client’s prior approval. Per the terms of the settlement, $25 million was invested into an annuity. The remaining $28 million was wired into a Girardi Keese client trust account in January 2013. Girardi, assisted by Kamon, misappropriated, and embezzled that client’s settlement money and used the funds to pay other Girardi Keese expenses and liabilities unrelated to this client, including payments to other law firm clients whose own settlement funds previously had been misappropriated by Girardi and others.

To prevent the victim from discovering Girardi’s embezzlement, Girardi lied to the client by saying the funds had been transferred into a separate interest-bearing account. In fact, no such transfers had been made and no such interest-bearing account containing these funds existed.

Girardi and Kamon sent lulling payments to the victim as purported “interest payments” deriving from the purported interest-bearing account. In July 2019, they sent the victim a $2.5 million check, purportedly as disbursement of the victim’s settlement funds. In fact, Girardi and Kamon knew these settlement proceeds belonged to other Girardi Keese clients. Girardi already had spent the victim’s settlement funds through disbursements unrelated to the victim’s case.

In a separate criminal case, Kamon admitted to running a years-long scheme in which he embezzled Girardi Keese funds for his personal enrichment. From at least 2013 to December 2020, Kamon utilized co-schemers to pose as “vendors” who were providing goods and services to the law firm. Kamon caused the supposed vendors to issue fraudulent invoices to Girardi Keese for goods and services that they purportedly provided to the law firm.

Kamon caused Girardi Keese to pay the amounts due on the fraudulent invoices. In fact, the law firm was paying the “vendors” for Kamon’s personal benefit, including for construction projects at his homes in Palos Verdes and Encino.

According to evidence presented at the recent trial of Tom Girardi, part of Kamon’s scheme involved payments to a female companion amounting to hundreds of thousands of dollars, including a monthly stipend of $20,000, out of the Girardi Keese operating accounts despite the woman having no employment relationship with Girardi Keese.

United States District Judge Josephine L. Staton scheduled a January 31, 2025, sentencing hearing, at which time Kamon will face a statutory maximum sentence of 20 years in federal prison on each count. Kamon has been in federal custody since December 2022.

Kamon – along with Girardi and David R. Lira, Girardi’s son-in-law, and a former Girardi Keese lawyer – also faces federal fraud charges in Chicago. Trial in that case is scheduled for March 3, 2025.

IRS Criminal Investigation and the FBI investigated this matter.

Assistant United States Attorneys Ali Moghaddas of the Corporate and Securities Fraud Strike Force and Scott Paetty of the Major Frauds Section are prosecuting this case.

A man banned for life from California’s workers’ compensation system after being twice convicted of workers’ compensation insurance fraud has been charged along with a San Diego-based neurosurgeon and two other co-conspirators in connection with billing nearly $100 million in fraudulent fees as part of an extensive workers’ compensation fraud scheme.

The charges follow a three-year investigation by the Orange County District Attorney’s Office into twice convicted felon David Wayne Fish who is accused of continuing to control clinics and providers who would see patients, refer them to specific providers in order to receive illegal referral payments, and then unlawfully bill workers’ compensation insurance companies for these services.

Fish, 55 of Laguna Niguel, Martin Brill, 78 of Los Angeles, and Robert Lee, 61 of Rancho Mirage, formed Southern California Injured Workers (SCIW), a management company which offered medical management services, including marketing, billing, and collections. Fish worked for the company as a “consultant,” but exercised complete control over the operation.

David Fish was convicted back in 2010, as part of Premier Medical Management, of Workers’ Compensation kick-back schemes and permanently suspended from participating in the California Workers’ Compensation System. He was convicted in Los Angeles County Superior Court in 2010 for receiving compensation or inducement for the referral of clients. Fish organized dozens of lawyers and doctors to steer more than 4,000 cases to preferred medical providers in order to run up high bills. Fish was ordered to pay $10,000 in restitution and approximately $390,000 in unpaid taxes.

In the current case, these three codefendants, along with San Diego neurosurgeon Dr. Vrijesh Tantuwaya – who is listed as a QME with five offices – also created a medical group called Injured Workers Medical Group (IWMG), which was the main client for SCIW. Dr. Tantuwaya was named the owner and CEO of this medical professional corporation.

The four co-defendants have been charged with 13 separate felony counts which include violations of Labor Code 3215 (referral of clients for compensation), Penal Code 182(a)(1) (conspiracy to commit a crime), Penal Code 549 (false and fraudulent claim) and Penal Code 550 (b)(3) (insurance fraud).

Using the medical group,Southern California Injured Workers he allegedly controlled patient referrals to a limited network of providers which contracted with SCIW to pay for the patient referrals. In three years, these defendants billed nearly $100 million dollars to numerous workers’ compensation insurance carriers, and were illegally paid referral fees from providers of services such as diagnostic testing and compound pharmacies.

“The Orange County District Attorney’s Office remains fiercely committed to prosecuting bad actors who exploit the workers’ compensation system to line their own pockets rather than helping injured workers,” said Orange County District Attorney Todd Spitzer. “At a time when families across America are struggling to keep up with increasing prices for everything from gas and rent to just being able to put food on the table for their families, criminals like these only increase the cost of insurance premiums and put the American dream just that much further out of reach for so many hardworking people. I am incredibly proud of the men and women of our Insurance Fraud team and their continued dedication to fighting for the rights of workers.”

According to the Coalition Against Insurance Fraud, insurance fraud is responsible for more than $308.6 billion in theft every year from American consumers. The California Department of Insurance reports that insurance fraud totals $17.2 billion each year and costs California residents an average of $440 a year through higher premiums, higher taxes, and higher prices. Investigating and prosecuting this fraud benefits all Californians.

If convicted, Fish faces maximum sentence of 18 years and four months in prison. Brill faces maximum of 12 years and four months in prison, Tantuwaya faces 13 years, four months in state prison and Lee faces 12 years and four months in prison.

Deputy Dstrict Attorney Kelly Albright of the Insurance Fraud Unit is prosecuting this case.