Author: WorkCompAcademy

The U.S. Department of Justice and attorneys general from multiple states and the District of Columbia filed litigation to block Anthem’s proposed acquisition of Cigna and Aetna’s proposed acquisition of Humana, alleging that the transactions would increase concentration and harm competition across the country, reducing from five to three the number of large, national health insurers in the nation.

The department and state attorneys general filed these two merger challenges in the U.S. District Court for the District of Columbia; The complaints allege that the two mergers – valued at $54 billion and $37 billion – would harm seniors, working families and individuals, employers and doctors and other healthcare providers by limiting price competition, reducing benefits, decreasing incentives to provide innovative wellness programs and lowering the quality of care.

Eleven states – California, Colorado, Connecticut, Georgia, Iowa, Maine, Maryland, New Hampshire, New York, Tennessee and Virginia – and the District of Columbia joined the department’s challenge of Anthem’s $54 billion acquisition of Cigna; Eight states – Delaware, Florida, Georgia, Iowa, Illinois, Ohio, Pennsylvania and Virginia – and the District of Columbia joined the department’s challenge of Aetna’s $37 billion acquisition of Humana.

The suit against Anthem and Cigna alleges that their merger would substantially reduce competition for millions of consumers who receive commercial health insurance coverage from national employers throughout the United States; from large-group employers in at least 35 metropolitan areas, including New York, Los Angeles, San Francisco, Denver and Indianapolis; and from public exchanges created by the Affordable Care Act in St. Louis and Denver. The complaint also alleges that the elimination of Cigna threatens competition among commercial insurers for the purchase of healthcare services from hospitals, physicians and other healthcare providers. The merger would eliminate substantial head-to-head competition in all these markets, and it would remove the independent competitive force of Cigna, which has been a leader in the industry’s transition to value-based care.

The lawsuit against Aetna and Humana alleges that their merger would substantially reduce Medicare Advantage competition in more than 350 counties in 21 states, affecting more than 1.5 million Medicare Advantage customers in those counties. Before seeking to acquire Humana, Aetna had pursued aggressive expansion in Medicare Advantage. Aetna, the nation’s fourth-largest Medicare Advantage insurer by membership, has nearly doubled its Medicare Advantage footprint over the past four years. Humana is the nation’s second-largest Medicare Advantage insurer by membership. The lawsuit also alleges that Aetna’s purchase of Humana would substantially reduce competition to sell commercial health insurance to individuals and families on the public exchanges in 17 counties in Florida, Georgia and Missouri, affecting more than 700,000 people in those counties. The lawsuit alleges that by buying Humana, Aetna would eliminate one of its strongest and most capable competitors in these markets.

Anthem, Inc. is headquartered in Indianapolis, Indiana. It is the nation’s second-largest health insurer and the largest member of the Blue Cross and Blue Shield Association. It holds the Blue Cross license in 14 states and provides health insurance to 39 million people. In 2015, Anthem reported over $79 billion in revenues.

Cigna Corp. is headquartered in Hartford, Connecticut. It is the nation’s fourth-largest health insurer. It operates in every state and the District of Columbia and provides health insurance to 15 million people. In 2015, Cigna reported $38 billion in revenues.

Aetna Inc. is headquartered in Hartford, Connecticut. It is the nation’s third-largest health insurer. It operates in every state and the District of Columbia and provides health insurance to 23 million people. In 2015, Aetna reported $60 billion in revenues.

Humana Inc. is headquartered in Louisville, Kentucky. It is the nation’s fifth-largest health insurer, operates in every state and the District of Columbia and provides health insurance to 14 million people. In 2015, Humana reported $54 billion in revenues.

Packaging medical records and moving them over to a PTP, or UR or IMR or the WCAB within the time constraints imposed by law is an incessant, repetitive, and time consuming task for claim administrators.

Yet many health industry experts say patients should not be finding data-sharing a challenge in 2015. In the era of such user-friendly Internet services as Facebook and Google, it is shocking to some that pertinent and sensitive medical information should still live in PDF files attached to emails, or be delivered by fax machine.

Calls for the digitization of health information, with a goal of lowering costs and delivering higher quality care, date back to the Clinton era. Former President George W. Bush also chose the issue as a personal passion project, noting in his 2004 State of the Union address that doctors could save more lives when armed with modern technology.

It was not until 2009, however, that President Obama signed a law that attempted to speed the transition from paper records to electronic records by offering doctors and hospitals incentive payments through Medicare and Medicaid if they used electronic medical records. The law, called the Health Information Technology for Economic and Clinical Health Act, or “HITECH Act,” provided roughly $30 billion over 10 years for the payments. It took effect on January 1, 2011. The law supposedly provided incentives for providers to adopt electronic medical records, and as a result hospitals have spent millions, sometimes billions, on computer systems to facilitate the purpose of the HITECH Act..

“The government provided the funding, but private developers created the system,” said Dena Mendelsohn, a health policy analyst with Consumers Union, based in San Francisco, “and the medical providers were incentivized to purchase the system. But nowhere in the conversation was it said that these systems had to talk with each other.” There is a fancy word for this, it’s called interoperability. Mendelsohn said the inability to share health information across medical systems is slowing down the consumers’ ability to access high-quality health care. Patients who walk into a hospital are complete strangers.

But, what’s happened, experts say, is that private, competing companies sold proprietary software to hospitals that can’t talk with each other. Also, several of the largest electronic health records systems have prioritized billing and regulatory reporting over other aspects of care. And many hospitals are still wedded to “fee for service” models, which reward doctors for pricey procedures and tests, rather than patient outcomes. The medical record vendors are helping these hospitals thrive in the status quo and there is little incentive to share access to the records of those lucrative patients.

“These fee-for-service hospitals are fighting tooth and nail to retain patients – and the vendors are responding to these needs,” said Dr. Bob Kocher, one of the key architects of the Affordable Care Act, and a partner who focuses on health care with Venrock, a Palo Alto venture capital firm. “They [some hospitals] have not wanted features that make it easier to share information.”

Now the government is trying to address the interoperability problem. Through April 3, the U.S. Department of Health and Human Services was taking public comments on a new “roadmap” designed to approve more uniform technical standards for electronic records.

It’s a huge undertaking. Arien Malec, a former technology coordinator for the department, said most doctors are now using some type of electronic records, but overhauling the entire system will take time. “This is like 15 percent of the economy going from the Stone Age to the Internet age in five years,” Malec said. “It’s like going from paper ledgers to online banking in five years. Wow, that would be painful.”

The payoff of getting it right is big, experts say. Benefits of seamless electronic medical records including personalized medicine, better preventative care and accessing doctors and medical information through mobile devices such as smart phones and tablets. And for claim administrators, the movement of medical records from PTP to IMR may end up as easy as point and click.

The California Department of Insurance reached a $30 million settlement with pharmaceutical giant Bristol-Myers Squibb over allegations of drug marketing fraud and physician kickbacks. The settlement stems from charges in a whistleblower lawsuit filed by three former Bristol-Myers Squibb sales representatives. The California Department of Insurance joined the whistleblowers in the lawsuit.

This lawsuit was initially filed by former Bristol-Myers Squibb employees Michael Wilson and Lucius and Eve Allen, all of whom are represented by the law firm of Waters Kraus & Paul in Los Angeles. Lucius Allen is a former Los Angeles Lakers basketball player.

The plaintiffs alleged that Bristol-Myers Squibb violated the California Insurance Frauds Prevention Act by employing and using sales representatives for the purpose of defrauding private commercial health insurers by using kickbacks to procure patients or clients. The kickbacks were designed to increase physician prescriptions of several drugs produced by Bristol-Myers Squibb including Pravachol, used to lower cholesterol. As part of its alleged scheme, Bristol-Myers Squibb provided physicians and their families with gifts and cash to induce physicians to increase prescriptions for Bristol-Myers Squibb products.

Enticements included box suites at sporting events where physicians were provided tickets, food, drinks, and parking. Enrollment in a Lakers basketball camp for doctors and their children. Pre-paid golf outings at luxurious golf courses. Tickets for physicians and their families to see Broadway plays in California cities.Monetary incentives given to doctors responsible for prescription-drug decisions for formularies. Lavish dinners, resort hotel trips, and concert tickets, given to doctors who were large-volume prescribers, to induce more prescriptions in the future.

Insurers alleged to have been defrauded: Prudential, Cigna, Maxicare, Blue Cross/Blue Shield of California (name of entity at time lawsuit was filed), HMSA Health Plan Hawaii, Scan Health Plus, United Health Plan, CalOptima, Argus, Merck-Medco, PCS, Prosever, Express RX/Value RX/DPS, Caremark, MedImpact/MedCare, Envoy, Aetna Pharmacy Management, Pharmaceutical Care Net, Advance PCS, Rx America, Prescription Solutions, WellPoint Pharmaceutical Management, First Health, Save-Rx, PacifiCare, and Health Net.

Medications in kickback scheme included: Plavix, Pravachol, Monopril, Abilify, Glucovance, Metaglip, Glucophage, Glucophage XR, Cefzil, BuSpar, Serzone, Tequin, Pravigard, and Avapro.

In addition to the $30 million payment, the settlement agreement requires Bristol-Myers Squibb to affirm its commitment to abiding by California laws regulating its sales representatives’ interactions with doctors, including compliance with pertinent provisions of the California Health and Safety Code and the California Insurance Frauds Prevention Act. Among other requirements, Bristol-Myers Squibb is required to utilize a Comprehensive Compliance Program that is in accordance with the Office of Inspector General’s “Compliance Program Guidance for Pharmaceutical Manufacturers.”

As required by the state’s insurance whistleblower law, Bristol-Myers Squibb’s settlement payment will be divided between the whistleblowers and the State of California. The state will receive $14.1 million, to be used to enhance the investigation and prevention of insurance fraud. Bristol-Myers Squibb did not admit to wrongdoing in the settlement agreement.

56-year-old David John DePaolo, the CEO of WorkCompCentral.com died on Sunday afternoon on Yerba Buena Road in the Santa Monica Mountains. while riding on his Honda 250 motorcycle that he nicknamed “the Sewing Machine.”

Authorities report that he was riding east on Yerba Buena Road in an unincorporated area of Ventura County near Vedder Motorway when “for reasons that are still under investigation” the motorcycle veered right into the road’s shoulder to the south, hitting a dirt embankment shortly after 4 p.m. The cause of the incident is still under investigation by the California Highway Patrol.

David graduated from Pepperdine University school of law in 1984. While in law school he noticed the building prominently located along the 101 freeway that sported the name of its law firm occupants “Miller and Folse – Attorneys at Law.” He stopped by one day to greet one of the partners, Rene Folse, as he announced he wanted to go to work for the firm when he graduated. At the time he did not know that the firm specialized in workers’ compensation defense.

As promised, David arrived again after graduation announcing that he was ready to go to work. He was hired, and eagerly learned the workers’ compensation defense industry. He remained with the Miller & Folse firm for the next fifteen years. He moved on to become the founder of WorkCompCentral.com an industry leading online publication.

David was the consummate competitive athlete. He was an avid bicyclist, surfer, an instrument rated and passionate airplane pilot, and his competitive skills were an excellent compliment to his professions as a litigator, and as the entrepreneur who formed WorkCompCentral.com. He was tireless and unrelenting when he set his mind toward any goal.

You will not find anyone who did not hold him in high regard. Positive comments were immediately posted to the WorkCompCentral article announcing this tragedy.

Christine Baker, DIR Director stated in her post “My most profound sympathies to David’s family at this time. The workers’ compensation world has lost a visionary and it is indeed a sad day.”

Alex Swedlow, President of the California Workers’ Compensation Institute said “A very dark, sad day. David was an intelligent, empathic and totally original voice and presence. I will miss him as a friend and colleague. Wishing all his family and friends peace and healing memories.

And the industry top litigators such as Saul Allweiss said “What a horrible and tragic loss. David was a visionary in his creation of WorkCompCentral, a leader in the Workers Compensation Community and a dear dear friend.”

And even his competitors have kind words. Robert Wilson owner of competing website Workerscompensation.com said “David DePaolo was an oversized personality packed into a thin and agile frame. He was passionate and robust, yet reflective and compassionate. He was both funny and deadly serious. He was one of a kind. David’s death is a tragic loss for his family, his company, and the industry he served.” and Robert went on to say “But the loss is much greater than the personal feelings for a competitor I grew to like and respect over the years. David DePaolo lived life to the fullest, and his robust character, brash honesty and unquestioned integrity have forever and indelibly influenced our industry for the better. His loss is a tremendous one for workers’ compensation.”

David is survived by his wife, Anne; daughter, Nichole; and son, Anthony, and the rest of us who will never forget him.

The claimant suffered an injury while employed by the University of California. The employer in the case was represented by Amanda Manukian Esq., a partner with Floyd, Skeren & Kelly, LLP.

The injured worker’s primary treating physician, Simon Lavi, D.O., submitted a request for authorization for medical treatment to the employer on January 20, 2016.

Pursuant to Labor Code section 4610(g)(l) and Administrative Director Rule 9792.9.1(c)(3) defendant had five business days to issue a decision to approve, modify, delay or deny the request.

Five business days later, on January 27, 2016, defendant’s UR provider issued a timely denial. At trial the defendant presented a fax transmission form showing that the UR denial was faxed to Dr. Lavi on the date of the decision. Additionally, in a report authored the very next day after the UR denial, Dr. Lavi confirms receipt of the UR denial. Thus, the UR denial was communicated to Dr. Lavi within 24 hours of the determination.

But applicant argued that the UR provider did not provide a proof of service as purportedly required by WCAB Rule 10505(f) (Cal. Code Regs., tit. 8, § 10505) and for that reason the UR denial was not timely and as a result the WCAB had jurisdiction to determine the medical necessity of the requested treatment.

The WCJ’s Findings of Fact of April 20, 2016, found that defendant timely completed utilization review (UR) of a January 20, 2016 request for authorization for medical treatment submitted by applicant’s treating physician. As a consequence of the finding that the UR denial was timely, the WCAB has no jurisdiction to determine the issue of whether the requested treatment was reasonably necessary, and any appeal of the utilization review decision must be determined by the independent medical review process outlined in Labor Code section 4610.5 et seq.

The WCAB denied reconsideration in the panel decision of Tabas v Regents of the University of California.

Applicant argued that the UR provider did not provide a proof of service as purportedly required by WCAB Rule 10505(f) (Cal. Code Regs., tit. 8, § 10505), But the WCAB concluded that Rule 10505 is part of the Workers’ Compensation Appeals Board Rules of Practice and Procedure, and applies to proceedings before the WCAB, not to UR proceedings.

“In any case, although the best practice is to include a proof of service, a proof of service is not the exclusive means for proving that a utilization review document has been timely served. In this case, the fax transmission sheet and Dr. Lavi’s confirmation, both of which were unrebutted, constitute ample evidence that utilization review timelines were met in the instant case.”

“Accordingly, we will deny the applicant’s Petition.”