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Pharmaceutical Company and Its CEO Pay $47M to Resolve Kickback Case

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Pharmaceutical company QOL Medical, LLC (QOL) and its CEO, Frederick E. Cooper, have agreed to pay $47 million to resolve allegations that they caused the submission of false claims to federal health care programs, in violation of the False Claims Act, by offering kickbacks, in the form of free Carbon-13 breath testing services, to induce claims for QOL’s drug Sucraid.

Sucraid is an FDA-approved therapy for the rare genetic condition, Congenital Sucrase-Isomaltase Deficiency (CSID). CSID patients have difficulty digesting sucrose (table sugar) and suffer from chronic gastrointestinal symptoms such as diarrhea, abdominal pain, bloating and gas.  

As part of the settlement, QOL and Mr. Cooper admitted and accepted responsibility for certain facts providing the basis of the settlement. Beginning in 2018, QOL, with Mr. Cooper’s approval, distributed free Carbon-13 breath test kits to health care providers and asked providers to give the kits to patients with common gastrointestinal symptoms. QOL claimed that the test could “rule in or rule out” CSID. In fact, the test does not specifically diagnose CSID. Conditions other than CSID can cause a patient to test “positive” for low sucrase activity on a Carbon-13 breath test. Approximately 30% of the Carbon-13 breath tests from QOL were positive for low sucrase activity.

QOL paid a laboratory to analyze the breath tests, report the results to health care providers, and provide the results to QOL. The results QOL received from the laboratory did not contain patient names, but did contain the name of the health care provider who ordered the test, along with the patient’s age, gender, symptoms and test result. Between 2018 and 2022, QOL disseminated this information to its sales force with instructions to make sales calls for Sucraid to health care providers whose patients had positive Carbon-13 breath test results. QOL tracked whether sales representatives converted “positive” Carbon-13 breath tests into Sucraid prescriptions. As QOL’s CEO, Mr. Cooper was aware of and approved the implementation and continuation of this marketing program.

Some QOL sales representatives also made claims regarding the Carbon-13 test’s ability to definitively diagnose CSID that were not supported by published scientific literature. For example, in slides at a 2019 national sales training, which Mr. Cooper reviewed, QOL suggested that sales representatives tell health care providers, “If you have a positive breath test, the patient will not improve unless you treat with Sucraid.”  

The allegations resolved by the settlement agreement were, in part, originally bought in a case filed under the qui tam or whistleblower provisions of the False Claims Act by former QOL Medical employees. The case is captioned United States ex rel. John Doe 1, et al. v. QOL Medical, LLC, et al., No. 1:20-cv-11243 (D. Mass.).

Of the total $47 million recovery, approximately $43.6 million constitutes the federal portion of the recovery and approximately $3.4 million constitutes a recovery for State Medicaid programs. The whistleblowers will receive approximately $8 million as their share of the recovery.

This matter was handled by Assistant U.S. Attorneys Brian LaMacchia and Lindsey Ross for the District of Massachusetts and Trial Attorneys Emily Bussigel and Paige Ammons of the Justice Department’s Civil Division. The case was investigated by HHS-OIG, FBI, DCIS and the Office of Inspector General for the Department of Veterans Affairs.

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Fall 2024 Hospital Safety Grade Show Nationwide Progress in Patient Safety

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The Leapfrog Group, an independent nonprofit focused on patient safety, released its fall 2024 Hospital Safety Grade, evaluating nearly 3,000 hospitals on their ability to prevent medical errors, accidents and infections. The Hospital Safety Grade uses up to 30 performance measures to assign an A, B, C, D or F to individual hospitals and uses a public, peer-reviewed methodology, calculated by top patient safety experts under the guidance of a National Expert Panel. It is transparent and free to the public. Leapfrog analysts use the data to observe national performance trends and state rankings.  

For fall 2024, Utah ranks number one with the highest percentage of “A” hospitals for the third cycle in a row, followed by Virginia and Connecticut in second and third. The latest Grades also show hospitals are making progress in patient safety across several performance measures including notable improvements in healthcare-associated infections, hand hygiene and medication safety.

Healthcare-Associated Infections (HAIs).

Since Leapfrog reported Hospital Safety Grades in fall 2022, when HAI rates were at their highest peak since 2016, average HAI scores have declined dramatically:

– – Central line-associated bloodstream infections (CLABSI) decreased by 38%.
– – Catheter-associated urinary tract infections (CAUTI) decreased by 36%
– – Methicillin-resistant Staphylococcus aureus (MRSA) decreased by 34%

Hand Hygiene

As Leapfrog detailed in its 2024 Hand Hygiene Report, since Leapfrog began public reporting a tough new standard for hand hygiene in 2020, the percentage of hospitals achieving the standard has soared from 11% to 78%.

Medication Safety

Medication errors are the most common type of error that occur in hospitals and the new Hospital Safety Grade suggests improvements in how hospitals prevent them. Two of the measures in the Leapfrog Hospital Safety Grade show this progress:

Computerized Physician Order Entry (CPOE): Leapfrog tracks how well hospitals use CPOE systems to catch common errors in prescribing, such as prescribing the wrong dose or prescribing a medication with a dangerous interaction with other medications the patient takes. Studies have shown CPOE systems can reduce harm from prescriber errors by as much as 55%. In 2018, only 65.6% of hospitals met Leapfrog’s Standard, while this year, that number rose to 88.1%.

Bar Code Medication Administration (BCMA): Leapfrog scores hospitals on deployment of BCMA systems, which use barcodes at the bedside to ensure the right patient gets the right medication at the right time. In 2018, 47.3% of graded hospitals met the standard, while this year, 86.9% did.

Trends in Safety Grades by State

Key findings on state performance on the fall 2024 Leapfrog Hospital Safety Grade include:

– – The states with the highest percentages of “A” hospitals are Utah, Virginia, Connecticut, North Carolina, New Jersey, California, Rhode Island, Idaho, Pennsylvania, Colorado and South Carolina
– – Utah ranks #1 in percentage of “A” hospitals for the third Safety Grade cycle in a row.
– – California ranks in the top 10 for the first time since fall 2014.
– – There were no “A” hospitals in Iowa, North Dakota, South Dakota or Vermont.

The Leapfrog Hospital Safety Grade is the only hospital ratings program focused exclusively on preventing medical errors and patient harm. It is fully transparent, free to the public and updated biannually in the fall and spring.

Detailed hospital performance information, including patient experience and safety measures, as well as grades for individual hospitals searchable by states and localities is available.

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$3B Annual Increase in USPS WorkComp Costs Drive $9.8B 2024 Loss

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The U.S. Postal Service announced its financial results for the 2024 fiscal year ended September 30.

Controllable loss, which excludes certain expenses that are not controllable by management, was $1.8 billion for the year, compared to over $2.2 billion for the prior year. The net loss for the year under generally accepted accounting principles (GAAP) totaled $9.5 billion, compared to a net loss of $6.5 billion for the prior year, an increase of $3.0 billion primarily attributed to the year-over-year increase in non-cash workers’ compensation expense. Over 80% of our current year net loss is attributed to factors that are outside of management’s control, specifically, the amortization of unfunded retiree pension liabilities and non-cash workers’ compensation adjustments.

September 30, 2024 saw the release of Delivering for America 2.0 – Fulfilling the Promise, which revisits and reexamines our original 10-year transformation and modernization plan issued in March 2021, describes the significant progress made over the past three years, and summarizes the evolution of our major strategies that are now driving the organization forward to financial stability and sustained service excellence..

“Our pricing and product strategies are continuing to improve our revenue picture and fuel market share gains in our package business, demonstrating the increasing competitiveness of the Postal Service,” said Postmaster General Louis DeJoy. “While we continue to reduce our costs, there remain many economic, legislative and regulatory obstacles for us to overcome. We look forward to continuing our focus on transforming and modernizing the Postal Service, driving revenue, reducing the cost to deliver, improving operational performance, and positioning the organization for long-term financial sustainability.”

Total operating revenue was $79.5 billion for the year, an increase of $1.4 billion, or 1.7 percent, compared to the prior year.

Revenue from Shipping and Packages, First-Class Mail and Marketing Mail all increased for the year. Shipping and Packages revenue increased $625 million, or 2.0 percent, compared to the prior year. First-Class Mail revenue increased $830 million, or 3.4 percent, compared to the prior year. Marketing Mail revenue increased $292 million, or 1.9 percent, compared to the prior year.

Total GAAP operating expenses were $89.5 billion for the year, an increase of $4.1 billion, or 4.8 percent, compared to the prior year. The overall increase in operating expenses was due to non-cash workers’ compensation adjustments and inflationary impacts on compensation costs, retirement costs and other operating costs, partially offset by lower transportation costs.

“The financial results for the year and the ongoing trend of declining mail volume and increasing package volume reinforce our commitment to the full implementation of the Delivering for America plan,” said Chief Financial Officer Joseph Corbett. “Adherence to the tenets of the plan, for example, has allowed us to reduce work hours for the third consecutive year, cumulatively reducing 45 million hours that will result in $2.3 billion in annual savings prospectively, and to save $1.3 billion in transportation costs in fiscal year 2024. The plan delivers the framework for us to better innovate to grow revenue, work more efficiently, and achieve financial sustainability to fulfill our universal service mission over an integrated network to deliver both mail and packages.”

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Supreme Ct. Rejected Long Standing Rule in Carrier Subrogation Case

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On June 16, 2009, fire destroyed the building in which defendant Cory Michael Hoehn and his roommate, Forest Kroll, had leased an apartment.

An investigator for the building’s insurer, plaintiff California Capital Insurance Company determined that “careless smoking” on the patio caused the fire. Although the investigator reached no conclusion about who started the fire or who was present when it began, California Capital sued Hoehn and Kroll in March 2010 for “general negligence,” alleging that they caused the fire due to “improperly discarded smoking materials.” The company asked for $472,326 in damages.

In March 2010, the company attempted to serve Hoehn with a complaint and summons in the lawsuit. The affidavit supporting the return of service stated that the summons and complaint were left with Shannon Smith and identified Smith as “Girlfriend,” “Co-Occupant,” and “a competent member of the household.” A copy of the summons and complaint was also mailed to Hoehn’s address. California Capital was unable to serve Kroll and dismissed him from the lawsuit.

In April 2011, approximately a year after attempting to serve Hoehn, California Capital requested and obtained a default judgment against Hoehn for $486,528, based on an investigator’s declaration that careless smoking habits caused the fire.

In March 2018, California Capital assigned its rights to the default judgment to Sequoia Concepts, Inc. Based on a May 2018 writ of execution, the sheriff of Placer County, in January 2020, served on Hoehn’s employer an earnings withholding order, placing a lien on Hoehn’s wages in order to begin payment of the default judgment.

In March 2020, Hoehn filed a motion to set aside the default judgment. In a supporting declaration, he stated as follows: He did “not recall receiving or seeing the Summons or Complaint at any time.” Shannon Smith “did not live with” him at the apartment and he “never received a summons or complaint or any legal paperwork from [her] at any time. He “did not receive any request for judgment or notice of a default judgment hearing” in the case. He learned that there had been a default judgment against him in January 2020, when his employer informed him that a lien had been placed on his wages. He promptly contacted an attorney who filed the motion to set aside the default judgment.

Hoehn’s motion sought relief on two theories: (1) the court should exercise its power under section 473(d) to vacate the judgment; and (2) the judgment was obtained by extrinsic fraud or mistake. The trial court, following a long line of appellate court opinions, held that relief under section 473(d) was not available because Hoehn made the motion more than two years after entry of the default judgment. Regarding Hoehn’s second asserted ground for relief, the court concluded that “the fact that the proof of service of summons misidentifies Shannon Smith as a co-occupant” did not “demonstrate that the statement constitutes extrinsic fraud.”

The Court of Appeal affirmed. Relying on Trackman v. Kenney (2010) 187 Cal.App.4th 175 (Trackman) and Rogers v. Silverman (1989) 216 Cal.App.3d 1114 (Rogers) – and rejecting Hoehn’s criticisms of those decisions – the court concluded that relief under section 473(d) was time-barred. It further concluded, like the trial court, that the mistake in service was insufficient to make out a claim of extrinsic fraud that would support equitable relief from a default judgment.

The California Supreme Court reversed in the case of California Capital Insurance Co. v. Hoehn -S277510 (November 2024)

Code of Civil Procedure section 473, subdivision (d) provides in relevant part that a court “may . . . on motion of either party after notice to the other party, set aside any void judgment or order.” Under this provision, a party may move to vacate a judgment on the ground of improper service of process.

A line of decisions, followed by the Court of Appeal has held that such motions must be made within a “reasonable time” if the challenged judgment is not void on its face and its invalidity must be established by extrinsic evidence. To set the outer limit for what constitutes a reasonable time, courts have borrowed the two-year time limit of section 473.5, which applies where proper constructive service was given but the defendant did not receive actual notice.

The California Supreme Court granted review in this case to decide whether these decisions are correct. It held that they are not, and said that this judicially created rule finds no footing in the statute’s text, has not been adopted by the Legislature, and lacks any sound justification.

The Supreme Court therefore reversed the Court of Appeal’s judgment.

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CWCI Analyzes the Impact of Inflation on OMFS

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A new California Workers’ Compensation Institute (CWCI) analysis that examines how medical inflation impacts allowable fees under the California workers’ compensation Official Medical Fee Schedule (OMFS) finds that physician and non-physician practitioner service fees represent more than half of treatment payments in the system and that differences in inflationary factors used between OMFS and Medicare explain the growing differential between California workers’ compensation and Medicare rates for professional services.

The new analysis focuses on the price indices used to adjust various OMFS payment rates. Maximum fees for different types of medical services provided to injured workers in California are regulated by the OMFS, but each OMFS section uses distinct rules for payment calculation and different inflation factors to update payment rates. For example, the Inpatient, Outpatient Facility, Ambulatory Surgical Center, Ambulance Service, and the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) sections of the fee schedule use Medicare’s inflationary factors, and the cumulative percentage increase in the OMFS inflationary factors for these fee schedules has been lower than economy-wide inflation. But over the past decade, inflationary adjustments for the OMFS conversion factor used to calculate fees in the Professional Services section of the schedule, which account for 53 percent of California workers’ compensation medical care payments, have not aligned with Medicare, as in 2015 Medicare suspended use of the Medicare Economic Index (MEI), a measure of inflation faced by physicians with respect to their practice costs and wage levels, and shifted to statutory changes set by the U.S. Congress.

In contrast, in California workers’ compensation, use of the MEI remains mandated by statute. From 2015 to 2019, statutory annual adjustments to the Medicare conversion factor were minimal (0.5 percent), and the state Division of Workers’ Compensation did not adopt them, but from 2021 to 2024, Congress mandated increases ranging between 1.25 percent and 3.75 percent per year for Medicare, which the state incorporated into the OMFS along with the MEI adjustments. As a result, the OMFS conversion factor as a percentage of Medicare for professional services rose from 124.4 percent in 2017 to 145.7 percent in 2024.

In addition to the inflation adjustments, each year fee schedule rates (e.g., price levels) are affected by changes in other factors including:

– – the Relative Value Units used in the Resource-Based Relative Value Scale system to quantify the complexity and resources required for medical services;
– – the weights assigned to Diagnosis-Related Groups which are used to classify patients based on their principal diagnosis, surgical procedure, age, presence of comorbidities, complications and other factors;
– – the weights assigned to the Ambulatory Payment Classification for hospital outpatient services; and
– – geographic adjustment variables (like Geographic Practice Cost Indices and wage indexes).

CWCI notes that while fee schedule rates set the maximum reimbursable fee for each service, average payments for physician services are also influenced by changes in utilization, service mix, and discounting practices.

CWCI has published its analysis of the impact of inflation on OMFS fees in a Report to the Industry which is available for free under the Research tab on the Institute’s website at www.cwci.org.

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Think Tank Study Says U.S. Spent $2B for Unnecessary Spine Surgeries

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The Lown Institute is an independent think tank advocating bold ideas for a just and caring system for health. The Lown Hospitals Index, a signature project of the Institute, is the first ranking to assess the social responsibility of U.S. hospitals by applying measures never used before like racial inclusivity, avoidance of overuse, and pay equity.

As many as 30 million people receive medical care for a spine problem each year. While surgery is an appropriate treatment option for some, many procedures are performed despite little to no evidence of benefit, and they come with risks. Possible complications include infection, blood clots, stroke, heart and lung problems, paralysis, and even death.

In this current study, hospital overuse was measured using Medicare fee-for-service and Medicare Advantage claims data for three years of the most recently available data (2020-2022 for fee-for-service and 2019-2021 for Medicare Advantage).

Spinal fusion and/or laminectomy was defined as overuse for patients with low-back pain if they did not have radicular symptoms, trauma, herniated disc, discitis, spondylosis, myelopathy, radiculopathy, radicular pain or scoliosis. Spinal fusion-only cases were not considered overuse for patients with stenosis with neural claudication and spondylolisthesis. Laminectomy-only cases were not considered overuse for patients with stenosis who had neural claudication. Vertebroplasty was defined as overuse for patients with spinal fractures caused by osteoporosis, excluding patients with bone cancer, m- yeloma, or hemangioma.

Researchers examined hospital data for common back surgeries, including spinal fusion, laminectomy, and vertebroplasty, for which clinical trials have repeatedly shown lack of benefit for certain patients. Patients with low-back pain caused by aging (excluding cases with neurologic symptoms, trauma, or structural abnormalities) receive little to no benefit from spinal fusion or laminectomy. Patients with spinal fractures caused by osteoporosis (excluding cases with bone cancer, myeloma, or hemangioma) receive little to no benefit from vertebroplasty.

Key Takeaways Include:

– – More than 200,000 procedures met criteria for overuse and are estimated to have cost Medicare around $2 billion over a three-year period.
– – On average, 14% of spinal fusions/laminectomies met criteria for overuse, with individual hospital overuse rates ranging from less than 1% to more than 50%.
– – On average, 11% of patient visits for osteoporotic fracture resulted in an unnecessary vertebroplasty, with individual hospital rates of overuse ranging from zero to 50%.
– – New Hampshire, Iowa, Massachusetts, and Pennsylvania had the highest overuse rates of spinal fusion/laminectomy with rates over 18%. Arkansas, Kansas, Oklahoma, and Nevada had the highest overuse rates of vertebroplasty, with rates over 16%.
– –  California overuse rate for Vetebrosplasty was 7.3% and was 13.4% for Spinal Fusion/Laminectomy.
– – U.S. News Honor Roll hospitals had varied performance. At Cleveland Clinic fewer than 1% of patient visits with osteoporotic fracture resulted in an unnecessary vertebroplasty, compared to nearly 20% at Mayo Clinic Phoenix.
– – A total of 3,454 physicians performed a measurable number of low-value back surgeries. Over three years, these physicians received a total of $64 million from device and drug companies for consulting, speaking fees, meals, and travel, according to Open Payments data analyzed by Conflixis.

Mount Nittany Medical Center in Pennsylvania has the highest rate of unnecessary spinal fusion/laminectomy in the nation at 62.8%. The hospital performed 535 procedures with 336 of them meeting criteria for overuse. Lown’s research also found that a single physician is responsible for 92% (308) of those overuse procedures.

Notable variation in spinal fusion/laminectomy overuse rates are present even among the nation’s most prestigious hospitals, including those on the U.S. News & World Report Honor Roll for America’s Best Hospitals. At UC San Diego (1.2% overuse rate), the hospital performed 783 procedures with only 15 meeting criteria for overuse. While at the Hospital of the University of Pennsylvania (32.6% overuse rate), 641 procedures were performed with 209 meeting overuse criteria.

According to a study published by Journal of Family Medicine and Primary Care, the side effects and risks associated with the medical intervention are called iatrogenesis. Iatrogenesis is composed of two Greek words, “iatros,” which means physicians and “genesis,” which means origin. Hence, iatrogenic ailments are those where doctors, drugs, diagnostics, hospitals, and other medical institutions act as “pathogens” or “sickening agents.”

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Decline in WC Opioid Use Outpaced Decline in Overall Population

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The decline in opioid use in California workers’ compensation has outpaced the decline among the state’s overall population according to a new California Workers’ Compensation Institute (CWCI) analysis of 2017-2023 opioid prescription data from the California Department of Justice’s Controlled Substance Utilization Review and Evaluation System (CURES) database.

The analysis builds on prior CWCI studies by tracking multiple opioid utilization metrics, noting the percentage change in the number of opioid patients over the study period, changes in the average strength of the daily dose of morphine equivalents (the “morphine equivalent dose” or MED), and the average duration of opioid use for workers’ comp opioid patients. Duration of use and MED level are highly correlated with addiction and harmful side effects of opioids, including overdose and overdose-related death. The study also compares these metrics to opioid treatment guidelines to identify the proportion of patients whose opioid use exceeded guideline recommendations and how these proportions changed over time.

Key findings include:

– – Nearly 22.3 million Californians were prescribed opioids between 2017 and 2023, with workers’ comp patients accounting for 1.1% of that total. The number of Californians who were prescribed opioids each year fell 34% from 6.8 million in 2017 (17.3% of the population) to 4.5 million in 2023 (11.5% of the population), while the number of workers’ comp patients prescribed opioids fell 62% from 91,620 in 2017 to 34,744 in 2023.

– – Breaking the opioid utilization results out by level of patient acuity showed that:

– – – – The number of acute opioid workers’ comp patients (<30 days of opioid use) declined an average of 9.2% per year vs. 4.9% for all acute California opioid patients.

– – – – The number of subacute opioid workers’ comp patients (30-89 days of opioid use) declined an average of 12.6% per year vs. 9.8% for all subacute California opioid patients.

– – – – The number of chronic opioid workers’ comp patients (90 or more days) declined an average of 10.6% per year vs. 6.3% for all chronic California opioid patients.

– – Over the study period the average daily morphine equivalent dose for workers’ comp patients declined across the board, falling 26% for chronic patients, 23.6% for acute patients, and 17.6% for subacute patients. The proportion of new acute workers’ comp patients that exceeded the recommended 50 MED per day threshold fell by 9.9 percentage points and the proportion that was within the 20-50 MED range rose by 13.3 percentage points.

– – The proportion of new acute workers’ comp patients receiving opioid prescriptions that exceeded the recommended 5-day supply decreased by 8.2 percentage points during the study period, with 2/3 of that decrease occurring in 2018, immediately after the state incorporated Pain Management and Opioid Treatment Guidelines into the Medical Treatment Utilization Schedule (MTUS) and implemented the MTUS Formulary.

– – Among chronic workers’ comp patients, the share of total days’ supply with an MED over 50 dropped from 27.1% in 2017 to 21.3% in 2023.

– – During each calendar year in the study period, most workers’ comp chronic opioid patients also received opioid prescriptions from other payer systems, but the percentage of those patients who received opioids from both workers’ compensation and other systems declined from 72.1% in 2017 to 68.7% in 2023.

– – From 2017-2023, the total daily morphine equivalent dose (from all payers) for workers’ compensation patients declined by 17.1 MED. The portion of the MED covered by workers’ comp declined by 8.4 MED or 24.1%, the portion covered by other payers declined by 8.6 MED or 32.6%.

– – A declining share of workers’ compensation opioid patients had prescriptions in which their days’ supply of opioids from other payers overlapped with their workers’ comp prescriptions. The proportion of days’ supply that overlapped multiple systems declined from 8.0% in 2017 to 3.7% in 2023, so it appears that the declines in opioid utilization in workers’ comp did not lead to increased opioid use in other systems.

While opioid use nationwide has declined across different health care systems, the steep decline in California workers’ compensation, which the CWCI study shows exceeded the decline noted for the general population, reflects the success of reforms enacted over the past two decades. These included a mandate that medical care provided to injured workers conform to evidence-based treatment standards; the addition of Chronic Pain and Opioid Guidelines into the MTUS; implementation of the MTUS Formulary; a requirement that opioid dispensers enter prescription and patient information into CURES within one day of dispensing the drug; and a requirement that doctors check CURES before prescribing a controlled substance to a patient for the first time, and at least once every four months when continuing to prescribe the drugs to the patient.

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Four SoCal Residents Arrested for Faked Bear Attacks and Insurance Fraud

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Four Los Angeles area residents were arrested after a Department of Insurance investigation found the suspects allegedly committed insurance fraud by claiming a bear had caused damage to their vehicles, but it was actually a person in a bear costume.

Ruben Tamrazian, 26, of Glendale, Ararat Chirkinian, 39, of Glendale, Vahe Muradkhanyan, 32, of Glendale, and Alfiya Zuckerman, 39, of Valley Village, have all been charged with insurance fraud and conspiracy.

The Department’s investigation began after an insurance company suspected fraud. The suspects claimed on January 28, 2024 in Lake Arrowhead a bear entered their 2010 Rolls Royce Ghost and caused interior damage to the vehicle. They provided video footage to their insurance company, which showed the alleged bear in the vehicle.

Upon further scrutiny of the video, the investigation determined the bear was actually a person in a bear costume.

Detectives found two additional insurance claims with two different insurance companies, for the suspects with the same date of loss and at the same location. Each of those claims involved two different vehicles, a 2015 Mercedes G63 AMG and a 2022 Mercedes E350, and the suspects again appeared to use a bear costume to make it appear that a bear also entered and damaged those vehicles. They provided the video footage to the other insurance companies as well to substantiate their claims.

To further ensure it was not actually a bear in the video, the Department had a biologist from the California Department of Fish and Wildlife review the three alleged bear videos and they also opined it was clearly a human in a bear suit. After executing a search warrant, detectives found the bear costume in the suspects’ home.

The insurance companies were defrauded of $141,839, because of the alleged fraud committed by the suspects. Department detectives were assisted by the Glendale Police Department and the California Highway Patrol. The San Bernardino County District Attorney’s Office is prosecuting this case.

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Fresno County Man Indicted for Falsified Disability Insurance Claims

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U.S. Attorney Phillip A. Talbert announced that a federal grand jury returned an eight-count indictment against Leonel Hernandez, 51, of Parlier, charging him with mail fraud.

According to court documents, Hernandez was employed as a supervisor for a farm labor contractor in Sanger. Between March 2017 and October 2020,

Hernandez submitted falsified disability insurance claims using identities of individuals known to him, including some who were already deceased and some who were farm laborers in Sanger or Fresno.

Hernandez forged physician signatures on the disability insurance claim forms, falsely certifying that the physicians had examined the claimants and falsely certifying other medical information that was allegedly obtained through such examinations. Hernandez used the U.S. mail to submit at least 20 claims and caused losses exceeding $300,000.

If convicted, Hernandez faces a maximum statutory penalty of 20 years in prison and a $250,000 fine. Any sentence, however, would be determined at the discretion of the court after consideration of any applicable statutory factors and the Federal Sentencing Guidelines, which take into account a number of variables. The charges are only allegations; the defendant is presumed innocent until and unless proven guilty beyond a reasonable doubt.

This case is the product of an investigation by the Federal Bureau of Investigation and the California Employment Development Department. Assistant U.S. Attorneys Chan Hee Chu and Joseph Barton are prosecuting the case.

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DOJ Sues to Stop UnitedHealth’s Proposed $3.3B Merger With Amedisys

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UnitedHealth Group Incorporated is an American multinational health insurance and services company based in Minnetonka, Minnesota. Selling insurance products under UnitedHealthcare, and health care services under the Optum brand, it is the world’s eleventh-largest company by revenue and the largest health care company by revenue.

It was founded in 1977, UnitedHealth Group has grown significantly through strategic acquisitions and organic growth. Its focus on innovation, data-driven insights, and integrated care delivery models has positioned it as a major player in the healthcare industry.

In 1988, United HealthCare started its first pharmacy benefit management, through its Diversified Pharmaceutical Services subsidiary. It managed pharmacy benefits delivered both through retail pharmacies and mail. The subsidiary was sold to SmithKline Beecham in 1994 for $2.3 billion.[

In 1994, United HealthCare acquired Ramsey-HMO, a Florida insurer. In 1995, the company acquired The MetraHealth Companies Inc. for $1.65 billion. MetraHealth was a privately held company formed by combining the group healthcare operations of The Travelers Companies and MetLife. In 1996, United HealthCare acquired HealthWise of America, which operated HMOs in Arkansas, Maryland, Kentucky and Tennessee.

In 1998, the company was reorganized as the holding of independent companies UnitedHealthcare, Ovations, Uniprise, Specialized Care Services and Ingenix, and rebranded as “UnitedHealth Group”. Also in 1998, United Health Group acquired HealthPartners of Arizona, operator of Arizona’s largest AHCCCS provider

Over the following 25 years UnitedHealth continued these aggressive acquisition and merger strategies. More recently, in February 2022, UnitedHealth announced the acquisition of Change Healthcare, the largest health payments platform in the US, which the US Justice Department tried to block on antitrust grounds; the sale went through by September. But inn February 2024, the subsidiary was brought completely down by the 2024 Change Healthcare ransomware attack, and the Justice Department announced that it was opening a new antitrust and Medicare overcharging probe.

The company is ranked 8th on the 2024 Fortune Global 500.and had a market capitalization of $474.3 billion as of July 15, 2024. The company has a substantial impact on the U.S. healthcare system. Its scale and influence allow it to negotiate favorable contracts with healthcare providers, pharmaceutical companies, and medical device manufacturers. The company has also been at the forefront of initiatives to improve healthcare quality, reduce costs, and enhance patient outcomes.

In recent years, UnitedHealth Group has been actively expanding its global footprint and investing in emerging technologies like artificial intelligence and telemedicine. And it has recently proposed a $3.3 billion acquisition of Amedisys, a leading home health and hospice care provider. This deal aims to expand UnitedHealth’s presence in the home care market and integrate it with its existing healthcare services.

Founded in 1982, Amedisys has grown steadily over the years through organic growth and acquisitions. The company has a significant presence in the U.S., with operations in 37 states and the District of Columbia. Amedisys employs over 21,000 individuals and serves millions of patients annually.

However, Amedisys has been involved in legal disputes and regulatory scrutiny, including allegations of fraud and improper billing practices. The company has also faced challenges related to reimbursement rates and staffing shortages.

In 2023, Amedisys agreed to be acquired by Optum, a subsidiary of UnitedHealth Group, in a deal valued at $3.3 billion. And the U.S. Department of Justice (DOJ) and several states have filed a lawsuit this month in the United States District Court for the District of Maryland to block the deal, arguing that it would reduce competition and harm consumers. O

“We are challenging this merger because home health and hospice patients and their families experiencing some of the most difficult moments of their lives deserve affordable, high quality care options,” said Attorney General Merrick Garland in a statement following the complaint’s filing in Maryland federal court.

To address some of the overlaps between UnitedHealth and Amedisys, UnitedHealth has proposed to divest certain facilities to VitalCaring Group (VitalCaring). But as the complaint alleges, the proposed divestiture does not alleviate harm in over 100 home health, hospice, and labor markets, which generate at least a billion dollars in revenue annually, serve at least 200,000 patients, and employ at least 4,000 nurses.

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