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Missing Unattached Safety Device Cannot Be Used for Power Press Exception

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Lucia Gonzalez was working for Seal Methods, Inc. (SMI) when she was severely injured while loading material onto a die in a power press. She sought damages from SMI in a lawsuit filed under Labor Code section 4558, known as the “power press exception” which allows an employee to “bring an action at law for damages against the employer where the employee’s injury or death is proximately caused by the employer’s knowing removal of, or knowing failure to install, a point of operation guard on a power press, and this removal or failure to install is specifically authorized by the employer under conditions known by the employer to create a probability of serious injury or death.” (§ 4558, subd. (b).) The trial court granted SMI’s motion for summary judgment, finding that section 4558 did not apply under the undisputed facts of this case.

The accident occurred while Gonzalez was operating a power press, referred to as Preco Punch Press No. 4. At the time of the accident, Gonzalez was operating the Press in “manual” mode because the material being shaped had to be moved onto and off of the die by hand. The Press was equipped with a two-hand activator system for operation in manual mode; the die would not strike unless the operator used both hands to press buttons located outside the strike zone (the “point of operation”). The purpose of this two-hand activator system was to ensure that the operator’s hands were outside the point of operation during the machine stroke. There was no evidence that SMI bypassed, removed, or tampered with the two-hand activator system on the Press used by Gonzalez. Nevertheless, on March 17, 2011, the Press activated while Gonzalez was loading material onto the die, crushing her hand.

Gonzalez subsequently filed the instant lawsuit for general, special, and punitive damages, alleging that SMI knowingly removed or failed to install a point of operation guard on the Press. SMI moved for summary judgment on the ground that the point of operation guard specified by the manufacturer of the Press – the two-hand activator system – was properly installed and activated, and the manufacturer did not specify or require any other point of operation guard. Gonzalez opposed the motion, contending that the operation manual for the Press requires the use of safety blocks (which are small wooden or metal blocks that are placed in the point of operation to physically prevent the machine from striking) whenever the operator’s hands are in the point of operation, and that those safety blocks constitute a point of operation guard. The trial court found there was no evidence that SMI received any communication from the manufacturer that safety blocks needed to be installed or otherwise attached to the Press, and granted SMI’s summary judgment motion. Gonzalez timely filed a notice of appeal from the resulting judgment.

The Court of Appeal affirmed in the published opinion of Gonzalez v Seal Methods Inc.

Labor Code section 4558 authorizes an injured worker to bring a civil action for tort damages against his or her employer where the injuries were “proximately caused by the employer’s knowing removal of, or knowing failure to install, a point of operation guard on a power press,” where the ‘manufacturer [had] designed, installed, required or otherwise provided by specification for the attachment of the guards and conveyed knowledge of the same to the employer.” Whether the section 4558 exception applies in this case hinges upon whether a safety block is a “point of operation guard” within the meaning of section 4558. If it is, the determination whether the manufacturer communicated to SMI that safety blocks must be used whenever a worker must manually position material on the die is a question of fact, and the facts are disputed in this case. But if a safety block is not a point of operation guard, section 4558 does not apply and the judgment must be affirmed.

Section 4558 does not define “point of operation guard,” but the language of the statute lead the Court of Appeals to conclude that a point of operation guard does not include an unattached device, such as a safety block, that the worker moves into and out of the point of operation. The Court concluded “Although we are sympathetic to Gonzalez, who suffered a horrible injury that might have been prevented had a safety block been used, we are bound by the Supreme Court’s directive to construe the section 4558 exception to the workers’ compensation exclusivity rule narrowly. Read in its entirety, section 4558 applies when an employer fails to attach or removes only those guards or devices, designed to protect workers, that are capable of being permanently installed by the manufacturer or the employer. The kind of safety block at issue in this case, which is not attached to the Press and is moved into and out of the point of operation by the worker, is not such a guard or device.”

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Federal Case Accuses California Hospitals of $50 Million Fraud

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An employee whistle-blower alleges Prime Healthcare Services, Inc., which boasts its flagship Desert Valley Hospital in Victorville, systematically misdiagnosed and extended stays of patients to collect on lucrative Medicare billings. In an amended False Claims Act lawsuit filed in California federal court June 11 and unsealed last week, the Ontario-based hospital company is accused of overcharging Medicare and Medicaid more than $50 million over three years – a claim which Prime denied this week. While the lawsuit is centered around activities at Alvarado Hospital in San Diego – acquired by Prime in November 2010 – the complaint also names Desert Valley Hospital, several other Prime hospitals and Prime founder and chairman Dr. Prem Reddy.

Prime issued a news release on Tuesday denying that Alvarado Hospital or any of the company’s 24 other hospitals submitted false claims with the Medicare program.

Karin Berntsen – former director of Quality and Risk Management, then Case Management at Alvarado Hospital – contends in the complaint that top Prime executives routinely encouraged hospital staff to admit patients for short stays in favor of outpatient/observation status, regardless of whether the patient’s medical condition warranted it. Berntsen said it was a dubious effort to increase the hospital’s Medicare reimbursement, which is a violation of government rules.Berntsen was employed by PHS in various director roles related to quality and risk management, case management, and performance improvement for Alvarado Hospital, which it acquired in November 2010. She alleges that PHS purchases floundering hospitals and boosts their finances by implementing false claims practices.

Medicare reimbursement is greater for inpatient services than it is for observation services, and roughly 70 percent of patients at Alvarado are covered by Medicare and other federal healthcare programs, according to the complaint.

The complaint alleges that Prime executives also instructed staff to exaggerate patient diagnoses and remove references to observation status on hospital admission forms while eliminating internal oversight into decisions regarding inpatient admissions. Additionally, Reddy is alleged to have altered patient records during a Sept. 6, 2011 instructional exercise and appealed to staff four months earlier to find a reason to make an outpatient an inpatient, according to the complaint. “If the patient is elderly,” he allegedly said during a meeting on May 3, 2011, “you should add encephalopathy for a higher payment. You are missing some of these elderly patients. But, be careful … I don’t want to go to jail, ha, ha, ha.”

Berntsen estimates that more than $4 million in billings to government healthcare programs since 2010 were the result of fraudulent patient stays. She further estimated that the alleged fraud likely extended to the company’s 24 other hospitals nationwide, exceeding an estimated windfall of $50 million.

Troy Schell, Prime Healthcare’s general counsel, called the $50-million estimate “speculative nonsense because Ms. Berntsen’s specific allegations are only about Alvarado Hospital, and she clearly had no knowledge about whether other Prime hospitals supposedly operated in a similar manner.” Schell said in a written statement that Prime hospitals have been under tight scrutiny ever since a workers union accused them in 2010 of submitting claims for unnecessary admissions. “Prime hospitals have been the subject of numerous government agency audits and investigations,” he said, “but none of them have found any significant issues regarding such admissions or the lengths of stay.” He also said oversight and quality control programs and reporting at Alvarado Hospital have always been “robust.” “It defies common sense that Alvarado Hospital has been engaged in a false claims scheme,” he said, “when the entire Prime Healthcare system has been under … heightened and aggressive regulatory scrutiny for years.”

The case is U.S. ex rel. Karin Berntsen v. Prime Healthcare Services Inc. et al., case number 2:11-cv-08214, in the U.S. District Court for the Central Division of California.

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Orthopedic Surgeons Clueless As to Medical Device Costs

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People wondering how much their new artificial hip will cost probably won’t find the answer with their surgeon, according to a new study. According to the article in Reuters, researchers who surveyed 503 orthopedic surgeons found the doctors could only accurately estimate the price of implantable medical devices between 17 and 21 percent of the time. “My suspicion was that knowledge would be low, but I think we were all surprised by how little we knew about the price of the devices we were implanting,” Dr. Kanu Okike told Reuters Health. Okike, the study’s lead author, worked on the research while at the University of Maryland School of Medicine in Baltimore. He is now an orthopedic surgeon at the Kaiser Permanente Moanalua Medical Center in Honolulu.

Over $150 billion is spent every year on medical devices in the U.S., Okike and his colleagues write in the journal Health Affairs. The devices themselves are often the most expensive part of surgery, according to the researchers. And prices of comparable devices can vary even if they are equally effective. Orthopedic surgeons have been asked to help conserve resources by considering the price of devices, they write. But there are several barriers to that information. For example, some hospitals sign agreements with vendors not to disclose the price they pay for devices and the prices may vary between hospitals and change over time. Also, surgeons don’t usually have a need to know the prices.

For the new study, the researchers surveyed 217 senior orthopedic surgeons, known as attendings, and 286 orthopedic surgeons-in-training, known as residents, at seven U.S. academic medical centers. The doctors were asked to estimate the costs of 13 common orthopedic implantable devices, such as a hip implant. They were also asked to estimate the price of three pairs of devices which are considered to be equal in quality but differ in price, like plates used to treat broken bones.

The researchers found that over a third of attendings and three quarters of residents said their knowledge of device prices was “below average” or “poor.” Attending surgeons were able to estimate the correct price of the devices – within a 20 percent margin of error – 21 percent of the time. Residents could only estimate the correct price 17 percent of the time. In general, the participants underestimated the cost of the more expensive devices and overestimated the cost of the less expensive devices for the three pairs they were shown. “You systematically don’t appreciate the amount that could be saved by choosing the lower cost item,” Okike said.

Despite the high rate of inaccurate estimates, more than 80 percent of participants said price should play an important part in the process of selecting devices.

Okike cautioned that the results of the new study may not apply to all surgeons. Those in private practice may know more or less about pricing than the surgeons surveyed. “The results are not surprising that you would have so small a percentage of attendings and residents guess the right price,” Jeffrey Lerner, president and CEO of the ECRI Institute in Plymouth Meeting, Pennsylvania, told Reuters Health. Lerner was not involved with the new study but has researched transparency of device prices. “I think there should be price transparency so people can compare costs and quality just as they can when they buy a tomato, house or car,” he said. “Comparison is an integral part of non-healthcare and healthcare shopping.”

“Surgeons face a number of barriers in learning these prices because of the non-disclosure agreements and lack of transparency,” Okike said. “I think the net result of that is just higher costs to the healthcare system.” He added, however, that surgeons may become more knowledgeable about prices as accountable care organizations, or ACOs, become more popular and doctors are incentivized to keep costs down. ACOs bring together doctors, hospitals and other players in the healthcare system to care for patients in an effort to bring down costs.

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NICB Outlines Fraud Trends for 2014

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Medical, auto and workers’ compensation fraud are expected to be at the forefront of the National Insurance Crime Bureau focus on insurance fraud trends in 2014, according to Chief Communications Officer Roger Morris. The article in the Claims Journal says that the medical and workers’ comp business is where most of the fraud occurs today, Morris said. “The scheme is the same. It’s always been — continuing treatment, malingering as we call it, without really needing it. That’s why there’s been quite a bit of analysis of provider bills lately,” said Morris.

Medical fraud is such a huge business that the NICB established major medical fraud task forces around the country starting in 2002. There will be eight by the end of the year – with the latest one in Chicago. “We focus on strictly the medical component of the auto and the workers’ comp side, and we look at some of the fraud schemes that are being perpetrated particularly in states where there’s no-fault or PIP coverage, personal injury protection coverage, states like Florida, New York, Michigan. We’re seeing some of that move into other states like Minnesota and Kentucky,” Morris said.

He said that staged accidents are a big component in PIP states where there is typically a huge industry of organized crime involving cappers, runners, doctors, chiropractors, physical therapists and lawyers. According to Morris, it’s “all in the name of generating claims.” Medical fraud in Florida became so pervasive the state began a major crackdown initiative in 2012.

“These states are ripe for fraud, and the criminals that have been doing this in Florida have seen a lot of pressure on them now because of the medical fraud task forces and the law enforcement action that we have had in Florida and recent changes, the tightening of the fraud laws there, the PIP laws. A lot of them are moving their operations or expanding them into states like Minnesota and Kentucky,” he said. NICB has held fraud summits in Florida the past two years, as well as in Minnesota last year and in Kentucky last October.

Morris described two common auto insurance fraud scams. “One of the common, pervasive auto scams we see is the crash-and-buy scenario. A person has an accident but doesn’t have the insurance or the right coverage, so they purchase insurance and then wait a day or two and submit a claim saying the accident happened after they bought the policy,” he said. “This started very heavily during the recession and continues today, very similar to the hit-while-parked claim — the insured has an accident, they don’t have the right coverage, or circumstances exist that they don’t want the insurer to know about. They park their car somewhere and they say that when they came back, they found someone had hit it and left, and then they filed a claim,” the NICB chief communications officer explained.

Though auto theft is down, according to Morris, law enforcement is seeing an uptick in organized criminal rings that are sophisticated enough to switch vehicle identification numbers (VINs) or export cars illegally. One such ring was recently uncovered in Los Anegles.

“We monitor exports of vehicles. We check the VINs and so forth for Customs and Border Control. We had a ring that was stealing cars from local dealerships, rental agencies or from parking lots, high-end luxury cars, and they were loading them up on ships to be shipped out of the country overseas and labeling them as scrap metal,” Morris said. “When we had those containers turned around, every one of those containers — more than 25 of them — contained two high-end vehicles that had been stolen and were being shipped out of the country to be sold overseas for a much higher price. I think they sometimes get two or three times the price overseas that they get here.” There was also a recent case in New York involving 46 high-end vehicles. The vehicles, worth $2.4 million, were stolen from dealerships and other places and were being VIN-switched and resold to supposedly unsuspecting buyers.

Listen to the podcast with Roger Morris: Fraud Trends in 2014 for more information.

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Postal Worker Gets Jail Time for Comp Fraud

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United States District Judge Lawrence K. Karlton sentenced Robert Daniel Castillo, 50, of Vacaville,;to one year and one day in prison for workers’ compensation and disability benefits fraud. Judge Karlton also ordered Castillo to pay $138,997 in restitution.

“The American public expects Postal Service employees to be diligent and honest. Through its investigations, the Office of Inspector General helps to maintain that integrity. When US Postal Service employees’ actions turn to criminal violations, such as the abuse of the workers’ compensation program, those individuals are aggressively investigated by USPS OIG Special Agents,” said Scott Pierce, Special Agent in Charge, US Postal Service Office of Inspector General, Pacific Area Field Office.

According to court documents, on October 15, 1998, Castillo, while working for the U.S. Postal Service in Fresno, claimed that he had injured his lower back while on the job. He submitted a claim for workers’ compensation benefits. For more than 10 years, Castillo received federal workers’ compensation benefits based on that injury. Castillo also received Social Security Disability and Veterans Benefits based on claims of 100 percent disability. Altogether, Castillo received more than $6,000 a month based on his claimed disability. Castillo was observed playing basketball and softball, driving, shopping, washing a boat, performing yard work, and performing volunteer work. At doctor’s appointments and meetings with officials from the Department of Labor and Social Security, Castillo claimed an inability to do all of these things.

A federal grand jury indicted Castillo on July 19, 2012, and on April 24, 2013, he pleaded guilty to theft of United States property and false statements made to the government in seeking compensation payments the charges.

This case was the product of an investigation by the United States Postal Service, Office of Inspector General and the Social Security Administration, Office of Inspector General. Assistant U.S. Attorney Jared C. Dolan prosecuted the case.

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California Has Four Out of Top Ten Comp Fraud Cases in Nation

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In 2009 a website began tracking the Top Ten Fraud Cases by the amount of money involved, and 100% of the Top Ten between 2009-2012 involved employers or shady characters posing as legitimate businesses. The amount of employer fraud in terms of cost was staggering. In 2013 one California employee fraud case did crack the Top Ten, so the record is now 49-1 (employer fraud v. employee fraud) over the past five years. This year California has the distinction of having four out of the Top Ten in the nation.  Here is the list organized by the amount of fraud involved.

1) Florida: Owners of Diaz Supermarkets in Miami-Dade are Accused of $35 Million Fraud (4/16/13) – John Diaz and his wife Mercedes Avila-Diaz owned and operated four supermarkets in the Miami-Dade area. They have been arrested and accused of workers’ compensation fraud and other fraudulent transactions totaling $35 million. One business they operated had no coverage for employees for ten years. They allegedly engaged in a scam to help subcontractors obtain false certificates of insurance that allowed the subs to work for general contractors who required the certificates.

2) California: Hanford Farm Labor Contractor Convicted of Fraud in the Amount of $4,195,900 (12/6/2013) – Richard Escamilla, Jr. (47), owner of ROC Harvesting, misrepresented information to workers’ compensation insurance carriers by using new business names to obtain insurance and avoid providing a claim history. Escamilla pleaded guilty on October 29th and was sentenced to pay restitution of $4.1 million and serve six years in prison.

3) Michigan: Insurance Executive Embezzled $2.6 Million from Workers’ Comp TPA (06/06/2013) – Jerry Stage (67), the former CEO of a non-profit workers’ compensation insurance company, and George Bauer (55), the bookkeeper, both pleaded guilty to embezzling from the Compensation Advisory Organization of Michigan (CAOM) for more than a decade. Mr. Stage embezzled $2.6 million from the company and conspired with Mr. Bauer to cover up the embezzlement.

4) California: Employee Wasn’t Wheelchair Bound After All – Fraudulently Took $1.5 Million in Benefits (8/9/13) – Yolandi Kohrumel, 35, claimed for nine years that she was wheelchair bound after complications from toe surgery, but after she had collected $1.5 million in benefits, it was revealed her claim was false. Her father, a South African native, was also engaged in the scam. Both pleaded guilty to insurance fraud, grand theft and perjury. Ms Kohrumel was sentenced to one year in jail, plus restitution.

5) California: Father and Son Landscapers Accused of $1.45 Million in Insurance Fraud (5/7/13) – Jesse Garcia Contreras (57) and Carlos Contreras (33), who operate a Thousand Palms landscaping business, are accused of committing $1.45 million in insurance fraud. They are accused of defrauding the California State Compensation Insurance Fund by misclassifying employees from January 2008 to March 2012. Mr. Jesse Contreras is the president and CEO of Sunshine Landscaping and his son is Director of Accounting. If convicted, they each face up to 19 years and 8 months in prison.

6) Florida: Workers’ Compensation Check Cashing Operation Charged with $1 Million in Fraud (2/27/13) – As a result of an investigation of I and T Financial Services, LLC, a company that was allegedly set up to execute a large scale check cashing scheme for the purpose of evading the cost of workers’ compensation coverage, the company was shut down. Domenick Pucillo, the ringleader of the fraud scheme, was arrested and charged with filing a false and fraudulent document, forgery, uttering a forged instrument, and operating an unlicensed money service business. If convicted on all charges, he faces up to 45 years in prison. One million dollars was seized during this investigation.

7) California and North Carolina: Cleaning Company Owner Convicted of Underreporting Payroll and Ordered to Pay $898,000 (8/3/2013) – The president of Awesome Products, a cleaning company in California, was convicted and sentenced for underreporting his payroll by over $8 million, resulting in a premium loss of $898,000. Loksarang Dinkar Hardas (53) was sentenced to five years in state prison, stayed pending successful completion of 10 years of formal probation, a $250,000 fine, and restitution payment of $898,000. Notwithstanding his conviction, the town of Mount Airy, NC was standing by Mr. Hardas and willing to give his company taxpayer money in hopes that Awesome Products would build a manufacturing facility and create jobs in Surry County, NC.

8) West Virginia: Coal Company Contractor in Mingo County Caught in $405,000 Scam to Avoid Workers’ Comp Premiums (11/6/13) – Jerame Russell (50), an executive with Aracoma Contracting, LLC, a company that provided labor to coal companies on a contract basis, entered a guilty plea to a scam that involved funneling over $2 million through a local bank to pay employees in cash, thus avoiding payroll taxes and $405,000 in workers’ compensation premiums. Aracoma also bribed an insurance auditor to cover up its true payroll.

9) Ohio: Roofing Business Owners Guilty of $283,592 in Workers’ Comp Fraud (7/30/2013) – The owners of Triple Star Roofing were found guilty of fraud on July 15 for failing to report payroll to the Ohio Bureau or Workers’ Compensation(BWC). The company failed to report to the BWC from 2004 to 2008, resulting in under-reported premiums of $283,592.

10) Florida: Owner of Staffing Company arrested for $130,000 in Workers’ Comp Fraud (8/1/2013) – The owner of Preferred Staffing of America, Inc., a temporary staffing agency in Tampa, has been arrested for allegedly running an organized workers’ compensation fraud scheme. Preferred Staffing’s owner misled clients into believing that his company was a licensed professional employer organization (PEO) and could provide workers’ compensation insurance coverage. Employers were reportedly charged more than $130,000 for workers’ compensation insurance and other services that were never provided.

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Amgen Faces Cal/OSHA Probe for Second Explosion in Last Year

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One person was seriously injured and another was hurt this month in a “minor” explosion at biotech firm Amgen’s South San Francisco lab facility, a fire marshal confirmed. One employee suffered burns to their face and another employee suffered burns to their hands after an explosion that began in a “flammable liquids” cabinet in a third-floor laboratory, said South San Francisco deputy fire chief Travis Nuckolls. According to the report in the Mercury News, the explosion was reported about 3:30 p.m. Officials don’t know what caused the dangerous mixture to explode, but the cabinet in which the explosion occurred was knocked over from the force, and windows on the third floor were also blown out, fire officials confirmed. Nuckolls said at least one of the chemicals involved was ether.

According to a spokeswoman at the St. Francis Memorial Hospital burn unit in San Francisco, one patient was taken there with injuries deemed “noncritical.” She would not provide further information about the patient’s condition. The region’s other burn unit, at the Santa Clara Valley Medical Center in San Jose, reported no patients from Amgen.

All buildings in the complex in addition to the Amgen building were evacuated as a precaution. An Amgen spokeswoman did not respond to multiple calls for comment. Decontamination tents were set up for employees who may have been affected by chemicals or toxins that spread after the explosion, but Nuckolls said it had been determined early Wednesday night that nothing dangerous had gone airborne.

The incident was the second to injure a worker in the facility in the last year. In May, a worker for a waste disposal company was seriously burned while collecting waste at the facility. According to Cal-OSHA spokesman Peter Melton, the firm and two other businesses — Clean Harbors Environmental Service Inc. and Thermo Fisher Scientific Inc.’s Unity Lab Services — received “serious” citations for the May incident on Nov. 14. Melton said the most serious citation issued was in the amount of $77,400 to Clean Harbors Environmental Service Inc.

Clean Harbors, a San Jose-based company, provides hazardous waste disposal, emergency response, lab chemical packing, recycling, and vacuum services, among others. The person who was burned and hasn’t been identified was working for Clean Harbors and was attempting to collect flammable liquids from one of the labs at Amgen at the time of the incident, Melton added.

Fires and explosions at pharma manufacturing facilities are not unusual, but there are few reports of events at research facilities. An explosion in 2012 at a Teva Pharmaceutical Industries plant in Croatia killed four workers and injured 17 others. A fire in a boiler room at a Sandoz plant in Boucherville, Quebec, did not cause injuries but exacerbated a shortage of one of the products made at that Novartis plant.

Thousand Oaks-based Amgen is one of the world’s largest drugmakers, producer of popular osteoporosis drug Prolia and rheumatoid arthritis medication Enbrel.

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Lien Claimant Aspen Medical Charged With $36 Million Comp Fraud

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Four men will be arraigned on an indictment today for defrauding over $36 million from insurance companies in an overbilling scheme. Jeffrey Edward Campau, 39, Yorba Linda, Abraham Khorshad, 62, Beverly Hills, and Landen Alan Mirallegro, 38, Yorba Linda, are charged with 22 felony counts of submitting multiple fraudulent claims, 22 felony counts of manufacturing documents in support of a fraudulent claim, one felony count of conspiracy, and sentencing enhancements for aggravated white collar crimes for loss over $500,000 and special loss over $3.2 million. If convicted on all counts, they each face a maximum sentence of 53 years in state prison. The defendants are out of custody on $1.5 million bail each.

Ryan Nathanil McCracken, 29, Rancho Cucamonga, is charged with one felony count of conspiracy and faces a maximum sentence of five years in state prison if convicted. He is out of custody on $20,000 bail.

They are scheduled to be arraigned today, Jan. 22, 2014, at 9:00 a.m. in Department C-30, Central Justice Center, Santa Ana.

In 2005, Campau, Mirallegro, and Khorshad are accused of forming a durable medical equipment (DME) company named Aspen Medical Resources, LLC (Aspen). Between 2005 and 2013, the defendants are accused of renting out a DME machine similar in function to an ice pack or heating pad, which provided both hot and cold modalities to alleviate inflammation and/or pain for patients. The three defendants are accused of fraudulently overbilling insurance carriers for this DME in two ways: for rental of one machine as two separate hot and cold machines, and for renting the hot and cold units which were valued at less than $500 for as much as $15,500 to $17,500 per patient.

Campau, Mirallegro, and Khorshad are accused of submitting hundreds of claims to the State Compensation Insurance Fund, Liberty Mutual, AIG (Chartis), Zenith Insurance, Birkshire Hathaway Homestead Companies, County of Orange, County of San Bernardino, County of Riverside, American Claims Management, First Comp Insurance, CNA Insurance, Comp West Insurance, Employers Insurance, Farmers Insurance, State Farm Insurance, Fireman’s Fund, Tristar (City of Los Angeles), Gallagher Basset, Republic Indemnity, Sentry, and Travelers Insurance.

If a claim was not paid, the defendants are accused of filing a lien at the Workers Compensation Appeals Board and aggressively collecting on these fraudulent claims. McCracken was employed as the collection manager for Aspen and is accused of negotiating the liens at the Workers Compensation Appeals Board with the carriers;  McCracken is accused of receiving a commission on all of his collections. The defendants are accused of being informed by various insurance carriers that Aspen was billing for the units incorrectly,but continued to bill the same way and aggressively defended their fraudulent claims, making it more cost-effective for the insurance carriers to pay the fraudulent claims than fight them.

Campau, Mirallegro and Khorshad are accused of billing under other company names, National DME and Abrexis Orthocare LLC. They are accused of using different addresses and different Employment Tax Identification Numbers for each of these companies in order to mislead the insurance carriers and give the appearance that these companies were different companies and not Aspen. The defendants are accused of collecting over $12 million from insurance carriers under these business names.

Insurance companies contacted the Orange County District Attorney’s Office (OCDA) and the Department of Insurance, who jointly investigated this case. OCDA seized all assets of the companies, which are now under receivership. Deputy District Attorney Shaddi Kamiabipour of the Insurance Fraud Unit is prosecuting this case.

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2014 Annual Report of Inventory Due April 1

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The Division of Workers’ Compensation (DWC) Audit Unit has posted on its website the form claims administrators can use for the required 2014 annual report of inventory (ARI) for claims reported in calendar year 2013, along with advice for claims administrators. This posting replaces individual notices previously sent to claims administrators.

California Code of Regulations, Title 8, section 10104 requires claims administrators to file an annual report of inventory indicating the number of claims reported at each adjusting location for the preceding calendar year. The report must be filed with the DWC administrative director (AD) by April 1 of each year. Even if there were no claims reported in the prior year, the report must be completed and submitted to the DWC Audit Unit. Each adjusting location is required to submit an ARI, whether or not they receive a form for reporting claims from the Audit Unit, unless their ARI requirement has been waived by the AD.

A claims administrator’s obligation to submit an ARI can be waived if the AD determines that they are in compliance with electronic data reporting requirements of the Workers’ Compensation Information System (WCIS). When ARI requirements are waived, claims administrators must file an annual report of adjusting locations. This report is to be filed annually on April 1 of each calendar year for the adjusting location operations as of December 31 of the prior year; DWC has provided a form for this purpose.

Claims administrators are also required to report any change in the information reported in the ARI or annual report of adjusting location within 45 days of the effective date of the change.

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WCIRB Launches Classification Search Tool

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The WCIRB launched Classification Search – an online tool to help users search for and find the right standard classification based on keywords or industry groups. The tool includes other useful features including the pure premium rate history for each classification, classification phraseologies sorted numerically or alphabetically, and classification listings by industry group or other classification attributes. Classification Search is available in the Learning Center section of the WCIRB’s website (www.wcirb.com) and is accessible by both desktop and mobile browsers.

Classification Search allows users to do a full text search across all standard classifications or by industry group. Users may enter keywords to see a list of all classification phraseologies that contain the keyword or that are commonly associated with the keyword. Advanced search features allow users to combine or exclude keywords or use wildcard search characters.

“Questions about classifications – and which classifications apply to a business – are the number one reason that people call our customer service department,” according to Eric Riley, the WCIRB’s Chief Customer Officer. “This tool is the latest addition to the online resources we’ve created to give insurers, agents and brokers, and employers easy and effective access to the information they need.”

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