Author: WorkCompAcademy

John Thomas Terrence, 75, of Marina del Rey, pleaded guilty to health care fraud involving a scheme to defraud the California workers’ compensation insurance system.

According to court documents, Terrence, a clinical psychologist, saw patients in Bakersfield by “Skype,” generated reports for each patient that were virtually word-for-word identical, and then submitted identical bills to the insurance companies.

Co-defendants Bhahar Gharib-Danesh, 41, of Woodland Hills, and Na Young Eoh, 44, of Bakersfield, were chiropractors working at the same company. They previously pleaded guilty to health care fraud charges in this case.

According to a federal indictment Gharib-Danesh was a chiropractor and the manager of Pain Relief Health Centers (PRHC). PRHC was headquartered in Los Angeles, and had clinics in Bakersfield, Visalia and Fresno, as well as in Los Angeles County.

Na Young Eoh was also a chiropractor, and was the treating physician for PRHC’s Kern County workers’ compensation claims..

PRHC recruited patients who were workers claiming to have an injury. In treating the patients, Gharib instructed her staff to add as many injured body parts for treatment as possible to generate higher billings. The treatment plan generally included shock wave therapy, electro stimulation therapy, myo-facial release/massage, physical therapy, chiropractic manipulation, compound creams, and psychological evaluation.

Nearly every patient was scheduled for the same treatments, and the maximum amount of treatments allowed by law was generally billed to the insurance company.

Eoh operated out of the Bakersfield Clinic, the Visalia Clinic, and the Fresno Clinic and would sign the treatment plans and referral forms. The indictment further alleges that Gharib directed Eoh to refer all patients who came into the clinic to Terrence for a psychological evaluation, regardless of the injury the patient reported. Terrence submitted bills and reports for each patient that were virtually identical. He also allegedly fraudulently billed for patients at a rate higher than legally allowed. According to the indictment,

Terrence provided each patient with approximately 20.8 hours of psychological evaluations in a single day. On one day, Terrence billed a total of 291.2 hours for treating 14 patients. In one period of two weeks, Terrence billed over a thousand hours treating patients and writing reports. Between 2005 and 2012, Terrence submitted claims for psychological services in workers’ compensation cases totaling in excess of $5.6 million.

Pain Free Diagnostics Inc. (dba Pain Free Management) pleaded guilty on July 9, 2018, to conspiracy to commit health care fraud and agreed to pay restitution to the defrauded worker’s compensation insurers in the amount of $1.2 million.

A stunning investigative report published by the Los Angeles Times provides several examples of Los Angeles police officers and fire fighters filing and recovering what it claims are exaggerated or outright fake “skin and contents” workers compensation claims costing taxpayers billions of dollars.

In one example, the Times reports that former LAPD Officer Jonathan Hall ended his career the way many veteran officers do these days, claiming job-related injuries across most of his body. Hall filed claims saying he’d injured his knees, hips, heart (high blood pressure), back, right shoulder – even his right middle finger.

The ailments had existed for months, in some cases years, and had not previously prevented him from working, Hall said in a recent interview. But he was burned out, the target of an internal affairs investigation and desperate to avoid going back to the station. Hall’s timing raised suspicion, and he was soon videotaped leading scuba dives and lifting heavy equipment despite the alleged injuries.

But, according to the Los Angeles Times, he is far from alone in asserting that so many parts of his body had been injured on the job.

In fact, claims involving at least five injured body parts have become by far the most common in California, according to a Times data analysis of millions of workers’ compensation cases spanning nearly three decades. In the past, injuries to a single body part – a knee, a shoulder, the lower back – were the most prevalent, the data show.

The strategy is common among veteran cops and firefighters who get up to a year off at their full salary, tax free, for each job-related injury their doctor diagnoses. Their employers also pay the associated medical bills and often a hefty cash settlement based on the extent and severity of the injuries.

Multiple lawyers and patients involved with the workers’ compensation system described a similar process: An officer nearing the end of his career goes to an attorney’s office complaining about a sore shoulder and is asked how his knees feel, if his back aches or if he is under a lot of stress. He is then referred to a doctor with whom the attorney has a long-standing relationship.

After a few decades on the job, it’s not hard for a client to fill out what industry insiders call a “skin and contents” case, attorney Paul Young said. Young is an attorney who was a partner at two high-profile Los Angeles-area law firms that represent cops and firefighters.

Thousands of such claims have been filed by participants in Los Angeles’ controversial Deferred Retirement Option Plan – or DROP, as it’s known – which allows veteran cops and firefighters to collect their salaries and pensions simultaneously for the last five years of their careers.

A Times investigation in February found that nearly half of the people who have joined the program since its inception in 2002 subsequently went out on injury leave – at nearly twice their normal pay – typically for bad backs, sore knees and other injuries that afflict aging bodies regardless of profession.

As an example, the Times reports that  former Los Angeles Fire Capt. John Kitchens was paid more than $1.5 million while in DROP – $645,000 of that in extra pension payments – despite missing more than a year and a half on injury and sick leave, city payroll records show.

Despite his health issues, Kitchens was able to travel to the Galapagos Islands in January 2013 to dive with hammerhead sharks, according to his Facebook page. In the comments beneath a photo of him in scuba gear on a boat at Gordon Rocks – a bucket-list destination for many divers – his only complaint was that the photos he took of the massive sharks underwater turned out blurry.

There’s nothing unusual about what he did, Hall said, and he knows many other officers who have engaged in more strenuous physical activity while out with injuries.

He’s willing to speak out about the workers’ compensation abuse because he has nothing left to lose, Hall said. Other cops and firefighters who have been through the system won’t talk, he said, because doing so would “screw over a lot of their friends. It’s corrupt, and a lot of people do it.”

A high-contrast, black-and-white image of your bones is an effective tool for spotting fractures or breaks. But after 120+ years, x-ray imaging is getting a remarkable update with 3D, full-color images that reveal far more than just the bones inside you. These images will improve what a doctor can diagnose without cutting you open.

The traditional approach to imaging the insides of a patient involves blasting them with x-rays. This electromagnetic radiation has a shorter wavelength than visible light, so it can easily pass through soft tissue, but it has more trouble passing through harder materials like bones. On the other side of your body, a sensor, or film, produces an image based on the intensity of the x-rays that make it through, thus revealing what’s inside you.

A New Zealand company called Mars Bioimaging has developed a new type of medical imaging scanner that works in a similar fashion, but borrows technology developed for the Large Hadron Collider at CERN to produce far more detailed results. The Medipix3 chip works similar to the sensor in your digital camera, but it detects and counts the particles hitting each pixel when a shutter opens.

When used in the new scanner developed by father and son scientists Phil and Anthony Butler from the Universities of Canterbury and Otago in New Zealand, the Medipix3 chip, enhanced with custom data-processing algorithms, can detect the change in wavelengths as x-rays pass through different materials in the body. This allows the scanner to differentiate bone, muscle, fat, liquids, and all the other material in the human body, while additional software uses that data to produce stunning full-color images that allow a three-dimensional view of the inside of the body.

While the flat black-and-white x-rays doctors currently use are typically enough for them to notice if the bone in your arm has a fracture, they reveal very little about the tissue and muscle surrounding that bone. Doctors could use these new 3D x-rays to help diagnose issues in the bone and everything around it, too.

So while a doctor is examining images of your arm, looking for signs of a break or fracture after a nasty fall, he or she could also look for other potentially dangerous medical conditions that might not be apparent in typical x-ray results. In fact, smaller test versions of this scanner are already being used to study cancer, as well as bone and joint health in patients—but the technology will be useful in countless other medical fields as well, from dentistry to brain surgery.

It will be years before the new Spectral CT scanner receives all the clearances and approvals it needs so that it can be used in hospitals and clinics. But it’s well past the research stages at this point, and clinical trials are expected to get underway in New Zealand in the coming months.

“This technology sets the machine apart diagnostically because its small pixels and accurate energy resolution mean that this new imaging tool is able to get images that no other imaging tool can achieve,” Phil Butler said in a CERN news release.

Gaetan H. Bourgoin worked as a paper machine laborer for Fraser Papers. which was subsequently acquired by Twin Rivers, at a paper mill when he sustained a work-related back injury.

Bourgoin suffers from severe chronic pain syndrome. He consulted with a number of pain management specialists and attempted a variety of treatments, including opioid medications, for his pain. Due to adverse side effects of his continued use of opioids, and on the recommendation of his primary care physician, Bourgoin stopped using narcotic medications.

Bourgoin was then issued a certification to use medical marijuana. He successfully petitioned the Workers’ Compensation Board for an order requiring his former employer, Twin Rivers Paper Company, LLC, to pay for the medical marijuana.

Twin Rivers appealed to the Appellate Division, which affirmed the hearing officer’s decision in August of 2016. Twin Rivers Paper Company, LLC, and Sedgwick Claims Management Services appealed to the Maine Supreme Court..

The Maine Supreme Judicial Court was are called upon for the first time to consider the relationship between the federal Controlled Substances Act (CSA) and the Maine Medical Use of Marijuana Act (MMUMA).

Twin Rivers argues that the Controlled Substances Act, 21 U.S.C.S. §§ 801-904, preempts application of the MMUMA as a predicate for an order that would compel Twin Rivers to reimburse Bourgoin for the use of medical marijuana.

The preemption analysis must begin with the Supremacy Clause of the United States Constitution, which “unambiguously provides that if there is any conflict between federal and state law, federal law shall prevail.”

Federal law can preempt state law in three ways: first, by express preemption, where Congress expressly states that federal law preempts the state law; second, by field preemption, where Congress explicitly or implicitly leaves “no room” for state law, or where federal law is “so dominant” that it “will be assumed to preclude enforcement” of the state law; and third, by conflict preemption, where the state law “actually conflicts with federal law.”

Congress has specified that the principles of conflict preemption are to be invoked to determine if state laws must yield to the CSA. Consequently, when framed in terms of the conflict preemption rubric, the dispositive question presented here is whether Twin Rivers is necessarily in violation of the CSA if it were to comply with the Board’s order to pay for the medical marijuana that Bourgoin is authorized to use pursuant to the MMUMA.

We conclude that in the narrow circumstances of this case – where an employer is subject to an order that would require it to subsidize an employee’s acquisition of medical marijuana – there is a positive conflict between federal and state law, and as a result, the CSA preempts the MMUMA as applied here. We therefore vacate the decision of the Appellate Division.

A former professional basketball player was just sentenced in federal court on charges related to an extensive charity fraud scheme.

Kermit Alan Washington, 66, of Las Vegas, Nevada., was sentenced by U.S. District Judge Greg Kays six years in federal prison without parole. The court also ordered Washington to pay $967,158 in restitution. Washington was taken into federal custody at the conclusion of his sentencing hearing.

Washington played for five NBA teams in the 1970s and 1980s. Washington may be best known for knocking out Houston’s Rudy Tomjanovich with a devastating punch in a 1977 game

He was with the Los Angeles Lakers when he hit Tomjanovich in what has since been remembered as “The Punch.” Washington was suspended for 60 days after Tomjanovich was hospitalized for several injuries — a fractured skull, broken jaw, broken nose and leakage of spinal fluid. He eventually needed surgery to reconstruct his face.

Washington admitted in federal court that he referred professional athletes to attorney Ronald Jack Mix, 80, of San Diego, Calif., so that Mix could file workers’ compensation claims in the state of California on behalf of the athletes. Mix then agreed to make donations to Washington’s charity, as well as a PayPal fraudulent charity scheme and other offenses.

Washington accepted approximately $155,000 in donations to his charity, which were actually illegal referral payments from Mix and his law firm. Washington diverted those funds from the charity’s bank account to pay himself or for personal spending. Washington admitted that he failed to account for this income to the charity on Project Contact Africa’s IRS filings during those years.

Former San Diego Chargers great Ron Mix, a member of the Pro Football Hall of Fame, pleaded guilty back in 2016 in federal court in Missouri to a tax fraud charge stemming from his post-football career as a workers compensation lawyer.

He was a former offensive lineman who played for the Chargers from 1960 to 1969 and then two years for the Oakland Raiders, Mix has been a successful workers compensation lawyers since his retirement from the game. Many of his clients are former professional athletes who made claims for injuries suffered during their playing days, usually years after their careers ended. State Bar records reflect he is no longer eligible to practice law in California.

Federal prosecutors said that Mix got referrals for clients from Washington, a non-lawyer. He would then file claims on behalf of those clients. In return, Mix donated to a charity called Project Contact Africa. He then claimed those donations as charitable deductions on his tax forms, court records show. The government says the donations were payments for the referrals, and should not have been claimed as deductions.

Mix’s lawyer argued that Mix thought Washington’s charity was legitimate. Mix represented many older athletes who did not make the kind of money in their day that athletes make today.