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DWC Suspends 18 More Medical Providers

The DWC has suspended 18 more medical providers from participating in California’s workers’ compensation system, bringing the total number of providers suspended to 263. The following are those added to the list.

–  Obiageli Brooke Agbu of Carson, owner of durable medical equipment provider Ibon, Inc., and Emmanuel Adebayo Ayodele of Rolling Hills, physician and business owner.

– Joseph R. Altamirano, Newport Beach physician, was convicted in federal court in 2017 of health care fraud.  

– Aniceto Baliton of Diamond Bar and Nestor Domingo of La Verne, co-owners of Bliss Hospice in Glendora, were convicted in federal court in 2017 of conspiracy to pay and receive illegal remunerations for health care referrals..

– Theresa Fisher and Vi Nguyen (a.k.a. Vi Anderson), both physicians of Orange, were convicted in federal court in 2015 of mail fraud for their involvement in an illegal scheme to defraud health insurance carriers.

– Hakop Gambaryan, Van Nuys durable medical equipment provider and owner of Colonial Medical Supply, was convicted in federal court of health care fraud in 2015.

– Hovik “John” Simitian and Anahit “Anna” Shatvoryan of Los Angeles operated the Columbia Medical Group, Inc., Life Care Medical Clinic and Safe Health Medical Clinic. They were convicted in federal court of health care fraud and paying and receiving kickbacks for their involvement in an illegal scheme to defraud Medicare.

– L’Tanya Smith, Los Angeles physician assistant, was convicted in federal court in 2016 of health care fraud for her involvement in an illegal scheme to defraud Medicare by recruiting Medicare beneficiaries to her clinic and ordering medically unnecessary items and services.

– Knarik Vardumyan, Burbank owner of Angeleno Clinic, was convicted in federal court in 2017 of healthcare fraud for directing staff to sign prescriptions and orders for medically unnecessary tests, equipment and home health services to Medicare beneficiaries.

– Oxana Loutseiko of Granada Hills, general manager of Mauran Ambulance Service, Inc., was convicted in federal court in 2017 of conspiracy to commit healthcare fraud.

– John Couch, Mobile, Alabama physician, had his California medical license revoked in 2017 after he surrendered to the Alabama State Board of Medical Examiners his authority to order, manufacture, distribute, posses, dispense, administer or prescribe controlled substances.

– Herbert Kloss, Mercer Island, Washington physician, surrendered his California medical license in 2017, after the Washington Medical Quality Assurance Commission entered into a stipulation with Kloss following allegations of unprofessional conduct.

– Thomas Murnane, Delmar, New York physician, had his California medical license revoked in 2017, after the New York State Board for Professional Medical Conduct took disciplinary action against him for negligence and failure to maintain records.

– Frederick Dumas, Mendocino physician, surrendered his medical license in 2016 after the Medical Board accused him of gross negligence and failure to maintain adequate and accurate records.

New SCOTUS Ruling ends NY Uber Workers’ Comp Class Action

On May 22, In an important 5-4 decision, the U.S. Supreme Court held that class or collective action waivers, particularly in wage/hour cases, and contained in arbitration agreements between employers and employees are valid and enforceable.

Companies can use arbitration clauses in employment contracts to prohibit workers from banding together to take legal action over workplace issues. The vote was 5 to 4, with the court’s more conservative justices in the majority. The court’s decision in Epic Systems Corp v Lewis could affect some 25 million employment contracts.

And perhaps the first victory for an employer under this new case law involves an Uber driver who claims in a federal case pending in New York that the ride-hailing company illegally charged him and other drivers a workers’ compensation fee. On May 31, the United States District court ordered that he must pursue his argument in arbitration as an individual, not a class action.

Gustavo Camilo agreed to arbitrate any disputes with Uber Technologies Inc. on “an individual basis only,” Judge Alvin K. Hellerstein of the U.S. District Court for the Southern District of New York said. Camilo therefore can’t proceed with a class action alleging various theories against the company.

The drivers sue on three counts; breach of contract, unjust enrichment and unlawful wage deduction. The class action suit was filed in the Supreme Court of the State of New York, and was timely removed to federal court under the Class Action Fairness Act.They demanded a jury trial, and seek reimbursement and restitution.

Uber moved to compel arbitration of the claims alleged against the Uber Defendants, to strike Plaintiff’s class allegation, and to dismiss the Complaint, on the basis of the arbitration and class waiver clause contained in Plaintiffs agreement with Uber.

In first registering as an Uber driver, a prospective driver must agree to a technology services agreement with Uber. Plaintiff signed an agreement with Uber requiring that all disputes or issues, including the question of arbitrability, be resolved through binding arbitration.The arbitration provision contains a class waiver, preventing the arbitrator from considering claims on a class or representative basis

In ruling on the motion, the court referenced the new Supreme Court decision when it said “More recently, and subsequent to the briefing in this case, the Supreme Court held that waivers of class actions are valid and not precluded by Section 7 of the NLRA, 29 U.S.C. § 157. See Epic Sys. Corp. v. Lewis, No. 16-285, 2018 WL 2292444 (U.S. May 21, 2018).”

Accordingly the court ordered “Plaintiff is directed to arbitrate his claims on an individual basis and this action will be stayed pending the arbitration.”

Employees of Two Riverside Companies Arrested

The co-owner of a Riverside-based janitorial company has been charged by the Riverside County District Attorney’s Office with defrauding five insurance carriers of $2.7 million and, in a separate case, the owner of a substance abuse treatment center in Temecula has been charged with defrauding an insurance company of more than $250,000.

The two defendants in these separate insurance fraud cases were arraigned on May 30.

Following a joint investigation by the DA’s Bureau of Investigation and the Inland Empire Premium Fraud Task Force, Patricia Morales, DOB: 4-6-72, of Riverside, has been charged with seven counts of workers’ compensation premium fraud as well as an aggravated white collar crime enhancement.

Morales co-owned Riverside-based Mac & Mor Cleaning Services which had business contracts and employees in nine states. Morales was responsible for handling the workers’ compensation insurance policies for the company’s more than 100 employees. She is charged with defrauding five insurance carriers of $2.7 million during the years 2012-2017 by falsely under reporting the company’s payroll. She is accused of forging state payroll records to match what she reported to insurance carriers.

She entered not guilty pleas to all counts and now has a felony settlement conference scheduled for June 5, 2018, in Dept. 61.

David Leo Johnson, DOB: 3-17-63, of Temecula, is charged with 30 counts of insurance fraud and an aggravated white collar crime enhancement. Johnson owned Temecula-based Southern California Detox Treatment and Recovery (SCDTR). From February 2015 to May 2016, Johnson is accused of billing more than 90 Health Net policies for treatment SCDTR provided to its clients. An examination of the claims of dozens of policies revealed that they had been double billed and Health Net paid on both sets before it was discovered.

An examination of the Health Net policies billed by SCDTR by investigators showed some policy applications used the SCDTR address as the policyholder’s residence. Johnson’s credit card was used to make the initial premium payments on 62 percent of the policies.

Interviews with clients showed that they did not submit the applications for their health insurance policies and were not aware of how the coverage was obtained. When interviewed, the clients also advised that Johnson did not charge them any of the required patient costs, including deductibles and co-payments.

Per the policies that were billed by SCDTR, Health Net does not pay until deductibles are met. These policies carried a 50 percent deductible for substance abuse treatment by out-of-network providers, including SCDTR, up to an annual limit of $5,000 or more. Health Net would not have accepted or paid on the claims had it been aware that SCDTR had violated the policy provisions by waiving the required patient costs.

Johnson entered not guilty pleas to all counts and now is scheduled for a felony settlement conference on June 4, 2018, in Dept. 61.

RAND Reports on Return-To-Work Fund

A new report published by CHSWC describes work undertaken by the RAND Corporation for the Department of Industrial Relations (DIR) to evaluate California’s Return-to-Work (RTW) Fund as it approaches its third year of implementation. This research builds directly on a number of past RAND studies for DIR and the Commission on Health and Safety and Workers’ Compensation (CHSWC).

Senate Bill (SB) 863 sought to improve the adequacy of permanent partial disability benefits by raising the maximum weekly PPD benefit and by increasing disability ratings for selected injuries; both changes would lead to more generous PPD benefits. To address remaining concerns about the adequacy and targeting of PPD benefits, SB 863 also instructed the Director of the Department of Industrial Relations (DIR) to design and implement a new $120 million program named the Return-to-Work Supplement Program (RTWSP). It was established on April 13, 2015.

California’s Return-to-Work Supplement Program (RTWSP) is a new benefit for permanently disabled workers who suffer disproportionately high earnings loss in comparison to their workers’ compensation benefits. The RTWSP provides a one-time $5,000 payment to workers who cannot return to work following a permanently disabling workplace injury.

DIR has authority to adjust the design and implementation of the RTWSP through additional regulations. To determine the need for modifications to the program, DIR asked RAND to evaluate the RTWSP’s performance and suggest improvements. RAND conducted an evaluation of the program’s performance and identified options for improving the RTWSP. The study included an environmental scan, stakeholder interviews, and analysis of program data. RAND also held a Technical Advisory Group meeting with key stakeholders.

RAND found that the RTWSP is performing well on several dimensions. The eligibility criteria have accurately targeted workers with more severe disability and program administration is efficient, with little evidence of fraud or abuse.

However, take-up of the program is low: in a sample of eligible workers, just over half applied to receive the benefit. The most important factor predicting access to the program was legal representation, suggesting that many workers are failing to navigate the process on their own despite the intent of the program’s designers. RAND also found that the eligible population is larger than initially anticipated, a trend driven in part by rising utilization of California’s voucher-based vocational rehabilitation benefit (the Supplemental Job Displacement Benefit).

Based on these findings, RAND recommends that modifications to the RTWSP focus on increasing program take-up among currently eligible workers. DIR could accomplish this by making issuance of the Return-to-Work Supplement automatic, or through outreach and notification efforts. DIR should also improve monitoring of SJDB voucher issuance to track emerging changes in the RTWSP-eligible population and to facilitate oversight of the SJDB.

URAC Accredits TRISTAR® for Utilization Management!

TRISTAR® has received URAC accreditation for Workers’ Compensation Utilization Management.

URAC is an independent, nonprofit accreditation entity, founded in 1990, that promotes healthcare quality through leadership, accreditation, measurement and innovation.

The URAC accreditation process serves as a framework to improve business processes through benchmarking organizations against nationally recognized standards.

URAC is named as a designated accreditor of workers’ compensation utilization review in California, Delaware, District of Columbia, Illinois, Indiana, Maine, Nevada, New York and Ohio. The application was submitted late last year, and in May, TRISTAR® received notice of accreditation.

“This was a great effort by the entire medical management team and we are honored to have achieved this high level of recognition. It demonstrates TRISTAR’s commitment to quality and our clients can be assured that our processes meet URAC’s recognized national standards,” said Mary Ann Lubeskie, VP of TRISTAR® Managed Care.

TRISTAR® is officially accredited as of June 1st, 2018.

TRISTAR® was founded in 1987. It is the largest independently owned third party multi-line claims administrator in the United States with operations focused within three divisions: property and casualty claims management (“TRISTAR® Risk Management”), benefits administration (“TRISTAR® Benefits Administrators”), and managed care and medical cost containment services (“TRISTAR® Managed Care”).

Each division provides services nationwide, and with nearly 1,000 employees across the country.

Bay Area Pain Doctors Pay $260K to Resolve DEA Charges

Drs. William Longton, Ruben Kalra, and Richard Shinaman have agreed to collectively pay $260,000 to settle allegations by the U.S. Department of Justice that they failed to keep and maintain adequate records and other allegations pertaining to controlled substances at their Novato, Pleasant Hill, and Pleasanton offices.

The physicians operate under the name Pain Medicine Consultants, Inc., with offices in multiple Bay Area locations.

The settlement agreement resolves allegations by the government that a January 2014 DEA inspection uncovered multiple violations by Longton, Kalra, and Shinaman of the Controlled Substances Act, 21 U.S.C. § 801.

In the agreement, the physicians acknowledge that they each, at the relevant time, were registered with the DEA as Practitioners, providing them with authorizations to handle Schedules II through V controlled substances. They also acknowledge they had an obligation to “keep and maintain” records related to their receipt and distribution of controlled substances in connection with their practices.

According to the agreement, following the DEA’s inspection, the government concluded that between January 10, 2012, through January 17, 2014, Shinaman, Longton, and Kalra failed to keep and maintain adequate records pertaining to controlled substances, as required by 21 C.F.R. § 1304, et seq.; failed to include the address of the patient on controlled substance prescriptions that they each issued as required by 21 C.F.R. § 1306.05(a); and exceeded the authority of their registrations by filling a prescription for a controlled substance, in violation of 21 C.F.R. § 1306.06.

According to the terms of the agreement, Longton, Kalra, and Shinaman will collectively pay the government $260,000 to resolve all civil claims related to the violations identified in the investigation.

Assistant U.S. Attorney Rebecca A. Falk is handling the matter on behalf of the U.S. Attorney’s Office for the Northern District of California, with assistance from the DEA San Francisco Field Division, Oakland Resident Office Diversion Group.

Anthem SIU Investigator Charged in $20M Fraud Scheme

Five people linked to two San Fernando Valley clinics were arrested on federal health care fraud charges for allegedly participating in a scheme that submitted fraudulent claims to health insurance companies. A federal grand jury indictment alleges that the five defendants – including a former fraud investigator at Anthem Blue Cross – engaged in a multi-year conspiracy to commit health care fraud against at least eight health insurance companies.

Those arrested include the owner and operator of the clinics, Roshanak Khadem, also known as “Roxanne” and “Roxy” Khadem, 50, of Sherman Oaks. Khadem owned and operated the two clinics at the center of the alleged scheme – R&R Med Spa, which was located in Valley Village until early 2016, and its successor company, Nu-Me Aesthetic and Anti-Aging Center, which operated in Woodland Hills.

The indictment alleges that Khadem and others induced patients to visit the clinics to receive free cosmetic procedures – including facials, laser hair removal and Botox injections – which were not covered by insurance. The conspirators obtained the insurance information from the patients and fraudulently billed insurance companies for unnecessary medical services or for services that were never provided. Using the fraudulent proceeds from the insurance companies, Khadem and other conspirators calculated a “credit” that patients could use to receive “free” or discounted cosmetic procedures.

During the course of the conspiracy, Khadem and her conspirators allegedly submitted at least $20 million in claims to the insurance companies, which paid approximately $8 million on those claims, according to the indictment.

The other four defendants who were arrested are:

– Dr. Roberto Mariano, 59, of Rancho Cucamonga, a physician who helped operate the clinics;

– Marina Sarkisyan, 49, of Panorama City, who was the office manager at the clinics;

– Lucine Ilangezyan, 38, of North Hills, an employee and insurance biller for the clinics; and

– Gary Jizmejian, 44, of Santa Clarita, a former senior investigator at the Anthem Special Investigations Unit, the anti-fraud unit within Anthem that is responsible for investigating health care fraud committed against the insurance company.

The indictment alleges that, in return for cash payments, Jizmejian assisted Khadem and others by providing them with confidential Anthem information that helped them submit fraudulent bills to Anthem. In September 2012, Jizmejian gave Khadem insurance billing codes – CPT Codes – that Jizmejian knew could be used to submit fraudulent claims to Anthem without Anthem detecting the fraudulent claims. Jizmejian gave Khadem the billing code for an allergy-related lab test and instructed her to submit to Anthem large numbers of bills with this CPT code. Khadem and other members of the conspiracy used this billing code to submit approximately $1 million in fraudulent claims to Anthem, according to the indictment.

The indictment further alleges that Jizmejian worked to prevent the insurance companies from detecting the fraud at the clinics, which included helping Khadem to avoid responding to inquiries from fraud investigators, diverting attention of other Anthem SIU investigators away from the clinics, and closing Anthem investigations into fraud that was being committed at the clinics.

In September 2015, based on confidential information obtained from Anthem, Jizmejian tipped Khadem off about a federal criminal investigation into the clinics, according to the indictment.

The scheme involving the two clinics allegedly defrauded the International Longshore and Warehouse Union, Pacific Maritime Association Benefit Plan, which is the health benefit plan that covers longshore workers in Southern California and their dependents, according to the indictment. Another victim was the Federal Employees Health Benefits Program, which provides health insurance for federal employees.

Known Undocumented Workers Prevail on Wage and Hour Claim

The California Court of Appeal affirmed the rule that after discovery of undocumented worker status by an employer, the workers are entitled to most of the legal rights and remedies provided to employees by state and federal laws. This includes wage and hour laws.

Juan Luis Lepe, Virgilio Flores-Juarez, and Berna Vargas filed a lawsuit against their former employer, Luft Enterprises, a California Corporation, doing business as Inn-Decor and Otmar Luft, alleging unpaid overtime wages, failure to provide meal and rest periods, and other Labor Code violations and unfair business practices

The Company manufactures furniture for businesses such as restaurants and casinos. Plaintiffs worked 10 or more hours per day without an afternoon or second meal break. The Company failed to pay overtime wages or provide meal and rest periods. Prior to May 2010, defendants were aware that plaintiffs were not authorized to work in the United States due to their immigration status. This was the agreed upon claim period in this case.

The trial court entered judgment in favor of plaintiffs in the total amount of $140,016 (Lepe – $59,776; Flores-Juarez -$59,776; and Vargas – $20,464) and against all defendants jointly and severally. Plaintiffs were also awarded their attorney’s fees and costs.

Defendants appealed and challenge the judgment, contending (1) they may not be compelled, as a matter of law, to pay past wages allegedly due because plaintiffs were not legally authorized to work in the United States; (2) there is insufficient evidence that defendants issued inaccurate wage statements; (3) the trial court erroneously granted plaintiffs’ attorney’s fees motion; and (4) the trial court abused its discretion in awarding certain costs.

The Court of Appeal found merit in defendants’ challenge to the award of costs but otherwise affirmed in the unpublished case of Lepe v. Luft Enterprises, Calif. Ct. App., No. E067382 (May 10, 2018).

In support of their contention, defendants rely on the holding in Salas v. Sierra Chemical Co. (2014) 59 Cal.4th 407, 414, 424-425 (Salas). The Court of Appeal found such reliance to be misplaced.

In Salas, the plaintiff sued his former employer under the California Fair Employment and Housing Act (FEHA) alleging defendant employer failed to reasonably accommodate his physical disability and refused to rehire him in retaliation for filing a worker’s compensation claim. After the complaint was filed in Salas, the defendant learned that the plaintiff may have used another man’s Social Security number in order to gain employment. Defendant successfully moved for summary judgment.

The California Supreme Court reversed, holding that the federal Immigration Reform and Control Act of 1986 (8 U.S.C. § 1101 et seq.) did not preempt application of the antidiscrimination provisions of California’s FEHA to workers who are unauthorized aliens, but that “federal preemption does bar an award of lost pay damages under the FEHA for any period of time after an employer’s discovery of the employee’s ineligibility under federal law to work in the United States.”

In reaching this holding, the Salas court noted that its “preemption analysis for the postdiscovery period is limited to employers who discover the plaintiff employee’s unauthorized status after the employee has been discharged or not rehired. . . . Because imposing full liability for lost wages would provide a disincentive for such immigration law violations, thereby furthering the goals of federal immigration law, in these situations arguably federal law would not preempt lost wages remedies for violations of state laws like California’s FEHA.”

Here, defendants concede knowledge of plaintiffs’ unauthorized work status during the “agreed-upon claim period in this case.”

“Since defendants were aware of plaintiffs’ unauthorized work status during the time of their employment, defendants actively joined in the violation of federal immigration law. Under this circumstance, the Salas court holding does not apply, and plaintiffs are not barred from recovering their lost wages.”

CDI Criticizes Carriers for Excessive Comp Premiums

Insurance Commissioner Jones adopted and issued a revised workers’ compensation insurance advisory pure premium rate, lowering the benchmark to $1.74 per $100 of payroll for workers’ compensation insurance, effective July 1, 2018.

Jones has reduced the benchmark rate by 36.5 percent since January 2015, when the average pure premium rate was $2.74 per $100 of payroll.

With an average filed pure premium rate of $2.22 per $100 of payroll as of January 1, 2018, insurers are on average applying pure premium rates that are 27.6 percent more than the indicated pure premium rate approved by the Commissioner today. Even after considering the industry’s extensive use of rating plan credits, industry profitability appears to be substantial as a percentage of premium.

“It is time insurers do the right thing and pass along more cost savings to California employers who deserve to share in the benefits cost reductions have brought to the workers’ compensation system,” said Insurance Commissioner Jones. “In addition to the cost reductions that have led to higher profits, insurers are also benefiting from the federal income tax break, which should result on average in about another five percent decrease in premiums.”

Commissioner Jones’ order sets the advisory pure premium rate below the $1.80 average rate recommended by the Workers’ Compensation Insurance Rating Bureau (WCIRB) in its filing. Jones issued the advisory rate after a public hearing and careful review of the testimony and evidence submitted by stakeholders.

The pure premium benchmark rate is only advisory, as the Legislature has not given the insurance commissioner authority over workers’ compensation insurers’ rates.

The purpose of the pure premium benchmark rate process is to review costs in the workers’ compensation insurance system and to confirm that rates filed by insurance companies are adequate to cover benefits for injured workers and to provide information to employers, workers and the public about the cost trends in the system.

The WCIRB’s pure premium advisory rate filing established that overall costs continue to decline in California’s workers’ compensation insurance system. The pure premium advisory rate reduction is based on insurers’ cost data through December 31,2017. Insurers’ net costs in the workers’ compensation system continue to decline as a result of SB 863, SB 1160, and AB 1244 enacted by the

Legislature and Governor Brown. The WCIRB noted continued favorable medical loss development including acceleration in claim settlements.

Federal Right to Try Drug Law Moves to Senate

The U.S. House of Representatives passed “right to try” legislation that would allow people with life-threatening illnesses to bypass the Food and Drug Administration to obtain experimental medications, ending a drawn-out battle over access to unapproved therapies.

Now the legislation needs approval from the Senate. If so, President Trump is expected to quickly sign the measure, which was praised by supporters as a lifeline for desperate patients but denounced by scores of medical and consumer groups as unnecessary and dangerous.

The FDA would be largely left out of the equation under the new legislation and would not oversee the right-to-try process.  Drug manufacturers would have to report “adverse events” — safety problems, including premature deaths — only once a year. The agency also would be restricted in how it used such information when considering the experimental treatments for approval.

Patients would be eligible for right-to-try if they had a “life-threatening illness” and had exhausted all available treatment options. The medication itself must have completed early-stage safety testing, called Phase 1 trials, and be in active development with the goal of FDA approval.

One Congressman opposing the bill argued that eliminating FDA oversight would “provide fly-by-night physicians and clinics the opportunity to peddle false hope and ineffective drugs to desperate patients,” noting that the bill is opposed by over 100 patient advocacy and consumer groups.

Right-to-try laws exist in 40 states — including California. But this federal bill would introduce legislation across state lines. Right To Try was signed into law in California (Assembly Bill No. 1668) by Governor Jerry Brown on September 27, 2016. It allows very sick patients to plea for experimental treatments directly from drug companies, instead of waiting for years for drugs to hit the market or asking the Food and Drug Administration for early access.

But patients and advocates said the California law does not function well without a federal counterpart. As it stands, if someone experiences adverse effects while taking a drug acquired through California’s Right to Try policy, the FDA can pull the treatment from the clinical trial process. The mismatch has made drug companies reluctant to participate.

The federal right to try law would make California law more effective, or eliminate the need for the California law altogether