Author: WorkCompAcademy

The Labor Commissioner’s Office (LCO) has collected $2.9 million in wages and penalties owed to 187 former tow truck drivers, dispatchers and mechanics who worked for Pride Towing in Anaheim and Stride Towing and Recovery in Oakland.

To date, 96 workers have received nearly $1.6 million in back wages and penalties, and the LCO is searching for 91 employees who worked for the companies between June 15, 2014 and February 16, 2017 to provide them with their earned wages.  

The Labor Commissioner’s Office cited the companies, owned and operated by Noel Yaqo and his son Aram Yaco, in 2017 for violations of minimum wage, overtime, meal and rest periods for 129 workers at Pride Towing and 58 workers at Stride Towing.

The citations included liquidated damages and waiting time penalties, as well as itemized wage statement violations. Once the citations were affirmed after appeal, judgments were issued for over $4.8 million.

Employees who worked for Pride Towing in Anaheim from June 15, 2014 to February 16, 2017 and for Stride Towing in Oakland from August 15, 2015 to February 16, 2017 are urged to call the LCO at (833) 526-4636 for information on how to collect their back wages.

“My office used every tool available to get owed wages to workers,” said Labor Commissioner Lilia García-Brower. “This case demonstrates the blatant disregard by some employers for paying judgments. Furthermore, the time it takes to recover the money creates another barrier in finding the workers. We now need the media’s help in amplifying this case to encourage workers to contact us quickly to be paid.”

The U.S. Department of Labor announced that its Occupational Safety and Health Administration has begun a National Emphasis Program to prevent falls, the leading cause of fatal workplace injuries and the violation the agency cites most frequently in construction industry inspections.

The emphasis program will focus on reducing fall-related injuries and fatalities for people working at heights in all industries. This instruction provides guidance to Occupational Safety and Health Administration’s (OSHA) National, Regional, Area, and State Plan offices for implementation of an OSHA National Emphasis Program (NEP) to reduce or eliminate workplace fall hazards associated with working at heights.

This instruction applies OSHA-wide. All construction inspections related to falls will be conducted pursuant to this NEP. For non-construction inspections, this NEP will target the following activities:

1. Roof top mechanical work/maintenance
2. Utility line work/maintenance (electrical, cable)
3. Arborist/tree trimming
4. Holiday light installation
5. Road sign maintenance/billboards
6. Power washing buildings (not connected to painting)
7. Gutter cleaning
8. Chimney cleaning
9. Window cleaning
10. Communication Towers

For other non-construction work activities where a worker is observed working at height, an inspection may be initiated upon approval by area office management.

The program establishes guidance for locating and inspecting fall hazards and allows OSHA compliance safety and health officers to open inspections whenever they observe someone working at heights.

Considering that falls remain the leading cause of fatalities and serious injuries in all industries, the agency has determined that an increase in enforcement and outreach activities is warranted.

The targeted enforcement program is based on historical Bureau of Labor Statistics data and OSHA enforcement history. BLS data shows that of the 5,190 fatal workplace injuries in 2021, 680 were associated with falls from elevations, about 13 percent of all deaths.

“This national emphasis program aligns all of OSHA’s fall protection resources to combat one of the most preventable and significant causes of workplace fatalities,” said Assistant Secretary for Occupational Safety and Health Doug Parker.

“We’re launching this program in concert with the 10th annual National Safety Stand-Down to Prevent Falls in Construction and the industry’s Safety Week. Working together, OSHA and employers in all industries can make lasting changes to improve worker safety and save lives.”

An outreach component of the program will focus on educating employers about effective ways to keep their workers safe.

If a compliance officer determines an inspection is not necessary after entering a worksite and observing work activities, they will provide outreach on fall protection and leave the site.

Learn more about federally required fall protection on the OSHA website.

The Cigna Group recently notified network providers that it will deny payment for Evaluation and Management (E/M) services reported with modifier 25 if records documenting a significant and separately identifiable service are not submitted with the claim. Modifier 25 records and bills for E/M service on the same day of another service or procedure when it is performed by the same physician or provider.

This triggered a contentious response from the American Medical Association (AMA) and more than 100 other provider trade associations who have taken issue with a new policy from Cigna regarding claims with modifier 25.

Evaluation and management (E/M) services represent a category of Current Procedural Terminology (CPT®) codes used for billing purposes. E&M coding involves use of CPT codes ranging from 99202 to 99499. Office visits, hospital visits, home services and preventive medicine services are considered E&M codes. Codes for procedures like surgeries, radiology and diagnostic tests, and certain treatment therapies are not considered evaluation and management services.

Current Procedural Terminology (CPT®) modifiers (also referred to as Level I modifiers) are used to supplement the information or adjust care descriptions to provide extra details concerning a procedure or service provided by a physician. Code modifiers help further describe a procedure code without changing its definition. Several of these modifiers have become topics of controversy between providers and payers.

Modifier 25 is used to facilitate billing of E/M services on the day of a procedure for which separate payment may be made. It is used to report a significant, separately identifiable E/M service by the same physician on the day of a procedure.

For example, modifier 25 may be used in the rare circumstance of an E/M service the day before a major operation and represents a significant, separately identifiable service; it likely would be associated with a different diagnosis (for example, evaluation of a cough that might affect the operation).

The Centers for Medicare & Medicaid Services (CMS) has identified the overuse and misuse of Current CPT® code modifier 25, and has taken regulatory action hoping to circumvent the problems it has identified. The 59 modifier is considered the most misused modifier by coders. It is normally used to indicate that two or more procedures were performed during the same visit to different sites on the body.

According to a report by  RevCycle Intelligence, the groups wrote in a letter to Cigna CEO David Cordani last week that the new policy is burdensome for providers even though they understand inappropriate use of modifier 25 should be prevented.

“We urge Cigna to reconsider this policy due to its negative impact on practice administrative costs and burdens across medical specialties and geographic regions, as well as its potential negative effect on patients, and instead partner with our organizations on a collaborative educational initiative to ensure correct use of modifier 25,” they wrote in the letter.

The groups also said they questioned the standards or guidelines Cigna used to craft the new modifier 25 policy since the Current Procedural Terminology (CPT®) description states that modifier 25 enables reporting of a significant, separately identifiable E/M service by the same physician or other healthcare professional on the same day of a procedure or other service. The CPT code set was developed by the AMA.

CMS and CPT guidelines also indicate that an E/M service reported with a modifier 25 does not need a different diagnosis than what was reported for the concurrent procedure, which Cigna misinterpreted in its current modifier 25 policy, according to the letter.

Failing to rescind the policy would result in an enormous amount of office notes being sent with claims, which not only burdens network providers but also the insurer.

“Indeed, Cigna previously advised medical societies that only a small percentage (i.e., 10 percent) of submitted documentation would be reviewed under this program,” the groups explained. “This troubling admission demonstrates Cigna’s awareness of the unmanageable volume of records in question and, more importantly, highlights the pointless administrative waste created by the policy.”

Adding to data submission burdens is the lack of an electronic standard for clinical record exchange, the letter continued.

“All of these concerns underscore that Cigna’s policy is extremely ill-timed and will further hamper health care professionals already grappling with clinician burnout, workforce shortages, recovery from the COVID-19 public health emergency, and rising practice expenses due to inflation,” the groups wrote.

The groups said they are willing to collaborate with Cigna to ensure the appropriate use of modifier 25, including doing targeted outreach and coding education. They also advised the insurer to limit documentation so that only network providers with consistent miscoding have to send office notes along with their claims.

A California appeals court reinstated a class action against a medical center that allegedly violated unfair competition laws and consumer protections by charging emergency room patients an undisclosed “Evaluation and Management Services Fee.”

Joshua Naranjo filed a class action lawsuit against the Doctors Medical Center of Modesto Inc., seeking declaratory and injunctive relief, and alleging violations of the unfair competition law (UCL) and the Consumer Legal Remedies Act (CLRA) in connection with Medical Center’s emergency room billing practices.

Briefly summarized, Naranjo alleged Medical Center’s practice of charging him (and other similarly situated patients) an undisclosed “Evaluation and Management Services Fee” (EMS Fee) was an “unfair, deceptive, and unlawful practice.”

Naranjo alleged, “[Medical Center’s] summary billing statements are not itemized and do not list items separately.” As a result, “most emergency room patients never even realize they have been charged a separate EMS Fee, even after their visit.” “[E]ven for those patients who do request and receive an itemized billing statement, EMS Fees are listed only as ER ROOM LEVEL [I-V], which does not inform a patient that this is a separate charge simply for receiving treatment in the emergency room.”

Medical Center’s EMS Fee is “set at one of five levels, determined after discharge, based on an internally developed formula known exclusively to [Medical Center].” The “algorithm used to determine the level of the EMS Fee (1, 2, 3, 4, or 5) is not disclosed to patients, making it virtually impossible for patients to know or seek to control the level or amount of the EMS Fee they will be charged for their emergency room visit.”

Medical Center charged Naranjo a total of $12,889.93 before any discounts or adjustments were applied. The gross charge included a “Level 4” EMS Fee in the amount of $8,833.35.

Medical Center demurred to each cause of action alleged in the first amended complaints on grounds each failed to state facts sufficient to state a cause of action. It was granted, and judgment was entered against Naranjo and in favor of Medical Center. The Court of Appeal reversed in the published case of Naranjo v Doctors Medical Center of Modesto Inc. -F083197 (April 2023).

On appeal, Naranjo contends he adequately alleged claims for declaratory and injunctive relief, violation of the UCL, and violation of the CLRA. Alternatively, he contends he should have been granted leave to amend to add a claim for breach of contract.

Naranjo has adequately alleged a claim under the Consumer Legal Remedies Act (CLRA) (Civ. Code, § 1750 et seq.). Naranjo has alleged Medical Center’s EMS Fee billing practices were known exclusively to Medical Center and that information in that regard was not reasonably accessible to Naranjo. And Naranjo sufficiently alleged the materiality of the nondisclosure. Naranjo also sufficiently alleged reliance, causation and damages.

The Court of Appeal also concluded that his CLRA claim is independently actionable under the unfair competition law (UCL) and is tethered to the legislative policies underlying the CLRA.

A plastic surgeon in Beverly Hills, along with his son, medical practices and billing company, have agreed to pay $23.9 million to resolve allegations that they violated the False Claims Act by submitting or causing the submission of false claims to both Medicare and Medicaid.

The settlement resolves allegations that Dr. Joel Aronowitz; Daniel Aronowitz; Joel A. Aronowitz, M.D., a medical corporation; Tower Multi-Specialty Medical Group; Tower Wound Care Center of Santa Monica, Inc.; Tower Outpatient Surgery Center, Inc.; and Tower Medical Billing Solutions falsified the place of service for skin grafts and billed multiple times for single-use skin substitute products.

The United States contends that the settling parties manipulated the place of service code on claims for skin grafts to fraudulently maximize reimbursement from Medicare and Medicaid. The United States further contends that Dr. Aronowitz failed to properly dispose of unused portions of single-use skin graft materials and, instead, used them in later procedures involving other Medicare and Medicaid beneficiaries, resulting in thousands of instances of double billing.

In connection with the settlement, the United States Department of Health and Human Services, Office of Inspector General (HHS OIG), negotiated the voluntary exclusion of Dr. Aronowitz and Tower Multi-Specialty Medical Group from Medicare, Medicaid, and all other federal health care programs for a period of 15 years. Daniel Aronowitz will be excluded for three years.

Medicaid is funded jointly by the states and the federal government. The state of California paid for a portion of the Medicaid claims at issue and will receive a total of approximately $497,619 from the settlement.

The civil settlement includes the resolution of claims brought under the qui tam, or whistleblower, provisions of the False Claims Act by parties that worked for Dr. Aronowitz and his associated medical practices and businesses: TDP, a billing company; Dr. Jason Morris, a podiatrist; and Harold Bautista, a billing department employee.

Under the qui tam provisions, a private party can file an action on behalf of the government and receive a portion of any recovery. The civil lawsuits, all of which were filed in federal court in Los Angeles, are captioned: United States ex rel. TDP RCM Servs., LLC v. Aronowitz, et al., United States ex rel. Morris, et al. v. Tower Wound Care Ctr. of Santa Monica, Inc., et al., and United States ex rel. Bautista et al. v. Tower Outpatient Surgery Center, Inc., et al.. The amount to be recovered by the private parties has not been determined.

The resolution obtained in this matter was the result of a coordinated effort between the United States Attorney’s Office in Los Angeles and the United States Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section. HHS OIG assisted in the investigation.

The matter was handled by Assistant United States Attorney Aaron Ezroj of the Civil Fraud Section and Trial Attorney Lyle Gruby of the Justice Department’s Civil Division. The exclusions of the individuals and entity were negotiated by Senior Counsel Patrice Drew for HHS OIG.

The investigation and resolution of this matter illustrates the government’s emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse and mismanagement can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477).

The claims resolved by the settlement are allegations only and there has been no determination of liability.