Category: Daily News

Paris-based Shift Technology has raised another $60 million funding round, and announced a new contract with CNA. Shift Technology claims to have a 70% hit rate in detecting fraudulent insurance claims.

Bessemer Venture Partners is leading the round and existing investors Accel, General Catalyst, Iris Capital and Elaia Partners are also participating.

This March it announced that it has entered into an agreement with CNA Financial Corporation, one of the largest commercial property and casualty insurance companies in the United States, to automate the carrier’s fraud detection capabilities. CNA is the first commercial insurer based in the United States to partner with Shift Technology to take advantage of FORCE, the company’s AI-native, SaaS-based fraud detection solution.

FORCE uses advanced artificial intelligence (AI) and data science to not only detect potentially fraudulent claims but also provide contextual guidance for investigation and resolution.

Unlike other technologies which rely heavily on the use of static business rules to identify those claims which may be non-meritorious, FORCE uses AI to analyze vast amounts of data from multiple sources. The result is a dynamically generated fraud score for each claim that indicates how suspicious the claim is, contributing factors, and how the claim could be investigated.

“CNA continues to focus on, and invest in, technology and analytics to advance claims,” said Rob Thomas, Senior Vice President of Claim Analytics, Finance and Operations for CNA’s Worldwide P&C Claim unit. “By partnering with Shift Technology, CNA will optimize its special investigations efforts by focusing on the most suspicious cases with pre-identified paths for investigation.”

There are 70 insurance companies around the world relying on its product, such as MACIF in France, Axa in Spain, and CNA and HyreCar in the U.S.

The startup has already grown quite a lot since its previous funding round. They now have 200 employees, and customers all around the globe. In addition to its headquarters in Paris, Shift Technology also has offices in Boston, London, Hong Kong, Madrid, Singapore and Zurich.

With today’s funding round, the company plans to hire more people in Boston, including data scientists and developers. The company is also developing an automated claim-processing solution.

Jorge Orozco was a carpenter for Southland Framers. On September 7, 2001, he sustained and industrial injury to his back, neck, and head, and filed three claims for benefits.

His primary treating physician noted in 2012 that he was ambulating with a wheeled walker and that his wife was providing continuous home care services for him. He said “Patient requires home care assistance. He is a candidate at least eight hours a day, five days a week for home care assistance to assist with bathing, dressing, food preparation, laundering, and cleaning.” The request was later increased to 12 hours a day.

On May 15, 2012, Anthem Workers’ Compensation, and the PTP agreed that, as part of the UR process, “a relatively expedited RN evaluation should be done to assess the patient’s needs.”

On July 25, 2014, 26 months after this agreement, the nurse case manager performed the evaluation. She found applicant “requires maximum assistant with the majority of his activities of daily living.” She recommended home health care assistance 12 hours per day, seven days a week to assist applicant with nutritional meal preparation, grocery shopping, grooming, hygiene, transfers into and out of the shower, bathing, dressing, transportation services and assistance in and out of vehicles, home cleaning, laundry, opening medication bottles, and verbal reminders to take medications.

The PTP reviewed nurse case manager’s report and adopted its recommendations in his own October 13, 2014 report. On October 17 he submitted an RFA to the employer.

On December 9, 2014, the RFA was denied on the grounds that the Medicare Benefits Manual indicates “services should be part-time and not exceeding 28 hours per week, and authorization should not be made if these services are regularly performed by a member of the patient’s household.” The RFA was received on November 25, 2014, and the decision to deny was made on December 8, 2014.

The WCJ found that defendant did not conduct timely utilization review of the May 9, 2012 and November 25, 2014 requests for authorization (RFAs) for home health care services. The WCJ also found that defendant was liable for home health care services after May 1, 2012, up to 12 hours a day, seven days a week.

Defendant contended on reconsideration that the WCJ erred by awarding home health care services, arguing that she should not have found that the UR determination was untimely, among other arguments. The WCAB affirmed the WCJ’s decision in the case of Orozco v Southland Framers, SCIF.

Here, the initial delay was timely. However, no UR determination issued within the statutory period, “14 days from the date of the medical treatment recommendation by the physician.” (Former L.C. § 4610(g)(l).).

The RFA was received no later than November 25, 2014. Former AD Rule 9792.9.l(e)(3), in effect at the time of defendant’s UR determination, provided in pertinent part, “[A] decision to modify, delay, or deny shall be communicated to the requesting physician within 24 hours of the decision, and shall be communicated to the requesting physician initially by telephone, facsimile, or electronic mail.” (Former Cal. Code Regs., tit. 8, § 9792.9.l(e)(3).

The record reflects that defendant’s UR notified the PTP of the determination on December 9, 2014, nine working days after receipt of the RFA on November 25, 2014, and four days after the statutory time period lapsed. Therefore, the Board has jurisdiction to determine the medical necessity of the requests for home health care services.

Business Insurance reports that OxyContin maker Purdue Pharma LP is exploring filing for bankruptcy to address potentially significant liabilities from thousands of lawsuits alleging the drug manufacturer contributed to the deadly opioid crisis sweeping the United States, people familiar with the matter said Monday.

Purdue and its wealthy owners, the Sackler family, are under pressure to respond to mounting litigation accusing the pharmaceutical company of misleading doctors and patients about risks associated with prolonged use of its prescription opioids.

Purdue denies the allegations, arguing that the U.S. Food and Drug Administration-approved labels for its opioids carried warnings about the risk of abuse and misuse associated with the drugs.

Filing for Chapter 11 protection would halt the lawsuits and allow the drugmaker to negotiate legal claims with plaintiffs under the supervision of a U.S. bankruptcy judge, the sources said.

More than 1,000 lawsuits accusing Purdue and other opioid manufacturers of using deceptive practices to push addictive drugs that led to fatal overdoses are consolidated in an Ohio federal court.

A lesser-known opioid case: Oklahoma v. Purdue Pharma, is scheduled for trial in May in Norman, Oklahoma. The Oklahoma trial could presage many of the arguments the jury may be presented in the national case set in the fall on 2019.

The Oklahoma lawsuit seeks to hold Purdue and three other opioid-makers, Allergan, Cephalon and Janssen Pharmaceuticals, responsible for economic damages to the state and its residents stemming from the opioid addiction and overdose crisis.

The presiding judge in the Oklahoma case ruled that television cameras may be used in the courtroom, every detail of what promises to be a dramatic trial could be broadcast to the American public, potentially affecting the outcome of any future opioid trials.

A Purdue bankruptcy filing is not certain, the sources said. The Stamford, Connecticut, drugmaker has not made any final decisions and could instead continue fighting the lawsuits, they said.

Purdue tapped law firm Davis Polk & Wardwell LLP for restructuring advice, Reuters reported in August, fueling concerns among litigants including Oklahoma Attorney General Mike Hunter that the company might seek bankruptcy protection before the trial.

The Supreme Court has ruled that payments to injured employees for lost wages by a railway company are taxable under the Railroad Retirement Tax Act (RRTA).

The opinion in BNSF Railway Co. vs. Loos by Justice Ruth Bader Ginsburg, in which six other justices joined, likens the payments to wages under the Social Security system.

Michael Loos sued BNSF Railway Co. under the Federal Employers’ Liability Act (FELA) for injuries he received while working at BNSF’s rail yard. A jury awarded him $126,212.78, with $30,000 of that amount ascribed to wages lost during the time Loos was unable to work.

BNSF claimed that the lost wages constituted “compensation” that is taxable under the Railroad Retirement Tax Act (RRTA) and asked to withhold $3,765 of the $30,000 to cover Loos’s share of the RRTA taxes.

The District Court and the Eighth Circuit rejected BNSF’s requested offset, holding that an award of damages compensating an injured railroad worker for lost wages is not taxable under the RRTA.

But the high court has now overturned those lower courts with this ruling that a railroad’s payment to an employee for working time lost due to an on-the-job injury is taxable “compensation” under the RRTA.

The RRTA is a self-sustaining retirement benefits system for railroad workers that is funded by a payroll tax on both railroads and their employees, referring to the railroad’s contribution as an “excise” tax and the employee’s share as an “income” tax. The Railroad Retirement Act (RRA) entitles railroad workers to various benefits.

Taxes under the RRTA and benefits under the RRA are measured by the employee’s “compensation,” which both statutes define as “any form of money remuneration paid to an individual for services rendered as an employee.”

According to the court, the railroad retirement system mirrors that of the Social Security system. The Federal Insurance Contributions Act (FICA) taxes employers and employees to fund benefits distributed pursuant to the Social Security Act (SSA). Tax and benefit amounts are determined by the worker’s “wages,” the Social Security equivalent to “compensation.” Both the FICA and the SSA define “wages” employing language resembling the RRTA and the RRA definitions of “compensation.”

Citing previous decisions, the court held that “compensation” under the RRTA “encompasses not simply pay for active service but also pay for periods of absence from active service” provided that the remuneration in question stems from the “employer-employee relationship.”

Justice Gorsuch filed a dissenting opinion in which Justice Thomas joined.

Two recent California Department of Insurance investigations have led to the arrests of insurance agents who allegedly stole tens of thousands of dollars from clients and failed to place insurance coverage for those clients, exposing them to significant financial risk.

Maria Aquino, 34, of South Gate, was charged with multiple felony counts of embezzlement and theft for allegedly pocketing over $48,000 in clients’ insurance premium payments and failing to place insurance coverage for her clients between 2011 and 2018.

The premium payments collected by Aquino, while doing business as Kino Insurance and Tax Services, were never sent to insurance carriers.

Aquino falsified certificates of insurance for more than eight clients in order to hide her embezzlement. Aquino’s license was revoked on July 12, 2018.

In a separate case, Chih Ming Huang, also known as James Huang, 41, of Rowland Heights, was charged with multiple counts of embezzlement, theft and forgery after allegedly stealing nearly $14,000 dollars from more than three clients and also failing to place insurance coverage for his clients.

After receiving a complaint from Farmers Insurance, where Huang had been previously employed, the department found that between 2011 and 2013, Huang embezzled premium payments by placing coverage for clients then canceling the coverage without his clients’ knowledge.

Cancelling the coverage generated refund checks to his clients, which he received because he had changed their address on record to a location he controlled.

Huang then applied the refunds to policies in the names of his aliases and cancelled those polices to get refunds in his own name, which he deposited into his personal bank account. The department is taking immediate action against Huang’s license.

Both of these cases are being prosecuted by the Los Angeles County District Attorney’s Office. Aquino surrendered on February 27, 2019 to the Downey Police Department. Huang will surrender on March 4, 2019.