Category: Daily News

With numbers still coming in and some important races still too close to call, Ricardo Lara, a Democratic California state senator known for his “health for all” legislation, is likely the winner of the race for California insurance commissioner post.. The California Secretary of State reports that as of 8:36 am on November 8, 100% of the precincts have reported, and Lara has the lead over Steve Poisner by 50.8% to 49.2%

Lara, has represented California’s 33rd District in the state Senate since 2012. He has a narrow lead over Steve Poizner, a former California insurance commissioner who ran as an independent. Lara supports universal, comprehensive health coverage for all Californians.

As a state senator, Lara wrote the Health4All Kids Act. The act extended the state’s Medicaid program, Medi-Cal, to cover about 250,000 California children in families that have trouble documenting the children’s immigration status.

Lara later co-introduced S.B. 562, a bill that could create a single-payer health care system for California. The bill would prohibit insurers from offering traditional major medical coverage in competition with the universal health coverage program, according to a copy of the bill text. Because the proposed program would cover dental care, vision care, chiropractic care, home health care and acupuncture, the bill might also ban the sale of some kinds of supplemental health insurance products, such as dental insurance, vision insurance, alternative health care insurance, and long-term care insurance that covers home health care.

Members of the California state Senate passed S.B. 562 by a 23-14 vote on June 1, 2017. California Assembly Speaker Anthony Rendon declined to have the Assembly act on the bill. Rendon said the bill was incomplete, according to a statement Rendon released in June 2017.

Lara is expected to work with the incoming governor, Gavin Newsom, and the state legislature on health care. Health care came up as a top issue in polling.

Lara – who was endorsed by outgoing California Gov. Jerry Brown, as well as by the Union of Health Care Professionals and the United Farm Workers of America – has also been talking about the possible effects of wildfires and climate-caused events on Californians’ health.

Lara has pledged in his campaign materials to support consumers, patients, working families and vulnerable populations. His platform also includes efforts to improve infrastructure and education.

In an official ballot statement, Lara notes that his father was a factory worker. He says his parents believed in the value of having insurance to protect their modest property. He states that, as his parents aged, “they sacrificed a little more to buy life insurance. They did it because they knew they were one accident, one fire, one burglary, one serious illness away from losing everything they had worked for.”

The WCIRB has released the California Workers’ Compensation Aggregate Medical Payment Trends report comparing medical payment information from 2015 to 2017. The WCIRB analysis is based on medical payment data representing 92% of the California workers’ compensation insurance market.

Overall, there was a cumulative 8% reduction in medical payments per claim from CY2015 through CY2017, comparable to the cumulative two-year reduction (10%) from CY2014 to CY2016 (Table 1). The decline in paid per claim was largely driven by the declines in utilization (e.g., paid transactions per claim declined by 8%).

The downward trend reflects a continuation of the savings generated by the reforms to the medical care delivery enacted by Senate Bill No. SB 863 in 2012, anti-fraud efforts and the continued sharp decline in pharmaceutical costs.

There were sharp declines in the average paid per transaction for pharmaceuticals (24%), pharmacies (28%) and pharmacists (27%) since 2015. This continues to be a result of reductions in the prescribing of controlled substances, reduced physician office dispensing, implementation of the Federal Upper Limits on prescription drug prices, as well as the continued shift from brand to generic drugs. (These reductions pre-date the implementation of the new drug formulary implemented in January 2018 pursuant to Assembly Bill No. 1124).

There were sharp decreases in the share of workers’ compensation claims with any opioid prescription from 18.2% in 2015 to 11.6% in 2017. The medical payments on the claims with at least one opioid prescription were, on average, more than three times higher than those on the claims without opioid prescriptions.

Common non-opiate analgesics and topicals, Topical Corticosteroids, and other medications sometimes used to relieve pain such as Anticonvulsants and Central Muscle Relaxants experienced a combined increase of 4.8%. On the other hand, Opioid Agonists, Opioid Partial Agonists and Opioid Combinations totaled a 2.8% decrease in their share of pharmaceutical payments from CY2016 to CY2017.

There was a significant change in the mix of Medical-Legal (ML) services in 2017. The share of ML104 (the most comprehensive and expensive service) transactions declined by 22.7%, while that for ML102 (the most basic ML evaluation) increased by 42.6%. This resulted in an 8% decline in the average cost of a medical-legal report in 2017 following a number of years of increases.

The procedure code set related to Physical Medicine and Rehabilitation was the greatest gainer between CY2016 and CY2017 and received the second largest amount of payments (21.7%). The Office or Other Outpatient Services continued to grow, and received the largest amount of payments (33.5%).

The full report is available in the Research section of the WCIRB website, California Workers’ Compensation Aggregate Medical Payment Trends – Updated through Calendar Year 2017

Spyros Panos M.D., was an orthopedic surgeon practicing in New York. For years, he seemed like a successful orthopedic surgeon, seeing dozens of patients a day and bringing in millions of dollars in fees for his suburban New York medical group.

Behind the scenes, however, he was inflating charges and billing for surgeries he didn’t perform, perpetrating a years-long fraud that culminated in a guilty plea on a single count in federal court in 2013. In 2013, he surrendered his license to practice medicine following his conviction for health care fraud.

In 2014, Panos began serving a 54-month sentence, and was released in 2016 to a halfway house and then, about a month later, to home confinement. He also faced more than 250 malpractice lawsuits, including some claiming that he botched surgeries.

Since March 2017, he has been serving a two-year term of supervised release. It did not take him long to get into trouble again. But even as he was waiting to be sentenced, federal prosecutors say, Panos was beginning a new criminal scheme that would go undetected for years until he was arrested again in April 2018.

In April 2018, he was charged with wire fraud, health care fraud, and aggravated identity theft, in connection with a scheme in which he assumed the identity of a licensed orthopedic surgeon and obtained over $860,000 in payments for reviewing patient files in Workers Compensation cases.

In about December 2013, after Panos pled guilty on October 31, 2013, and before he surrendered to serve his sentence on April 2, 2014, a company called Excel O LLC was formed. The registered agent for Excel O is a Panos family member and is not a licensed physician. Panos allegedly used this company to hide his identity, and assume the stolen identity of another physician, to dupe utilization review companies who evaluated cases nationwide.

In the latest criminal case, prosecutors say Panos defrauded six utilization review companies for $876,000, using a fake Google email address, a shell company registered in the name of a family member to a Brooklyn address and the credentials of another physician. He is charged with infiltrating an obscure but essential piece of the American health-care business: a $4 billion industry that provides independent doctors to render expert opinions on which treatments are appropriate. He has plead not guilty to the charges.

Over the past five months, thousands of patients have received notices from several insurance companies that Panos had posed as another doctor in order to review their medical records in coverage disputes. At least 2,500 people nationwide were affected, according to data compiled by Bloomberg, but the full reach of the alleged fraud hasn’t been made public.

Prosecutors did not name the six independent review companies that Panos worked for, but disclosure letters identify some of them: Advanced Medical Reviews and Network Medical Review are both subsidiaries of a company called ExamWorks, which was acquired by the private equity firm Leonard Green & Partners LP for $2 billion in 2016.

At least one company, Gallagher Bassett, a subsidiary of insurance brokerage Arthur J. Gallagher, told California authorities last August, that 1,294 workers’ compensation claims in the state may have been affected through vendors who hired Panos.

Perry Roy Segal M.D., License No. C 39242, is a 1976 graduate of Johns Hopkins University School of Medicine, and is certified by the American Board of Psychiatry and Neurology. He was licensed as a California Physician and Surgeon in June 1980. He is listed as a QME in psychiatry with an office at 250 Blossom Hill Road, in Los Gatos California.

The DWC Disciplined Physicians List shows that his QME certification has been revoked with revocation stayed. He was placed on probation from 10/18/2018 through 10/18/2019 concurrent with Medical Board probation and discipline order..

The Accusation filed against Dr. Segal in July 2015 claimed he engaged in “unprofessional conduct amounting to gross negligence and/or repeated negligent acts and/or incompetence in the care and treatment of Patient T.D.” He had been treating this patient for depression and anxiety, allegedly stemming in part from a possible work-related injury since March, 1999.

On August 6, 2013, the Medical Board received a complaint from a pharmacist, Dr. R. W., at the Fox Army Health Center in Redstone Arsenal, Alabama, regarding Dr. Segal’s prescriptions of pain medication to Patient T.D.

In an interview with the Medical Board, Dr. R. W . detailed that Patient T.D. was receiving prescriptions for Percocet from the Respondent which she filled in Alabama, but that Patient T.D. also filled other pain medication prescriptions in California. Dr. R. W .also reported that it appeared that Respondent, a psychiatrist, was prescribing pain medications and performing pain management without conducting proper physical examinations.

Dr. R. W. reported that she tried repeatedly to discuss the situation with Respondent, who would not contact her. Eventually, Dr. R. W. reached Respondent, who was uncooperative and evasive, telling her that Patient T . D . was a family friend. Ultimately, the Fox Army Health Center refused to fill additional prescriptions for Patient T.D.

Pharmacy and medical records show that during a sample three-year period, Dr. Segal prescribed Patient T.D. various doses and quantities of Demerol, Percocet, Valium, Ambien, Dilaudid, Soma, and Xanax. During this time, Patient T.D. also received pain medications from at least four other doctors.

During his interview with the Board, Segal admitted that he had prescribed pain medications to Patient T.D .for at least a decade, and that he did so as a stop-gap measure to support her during a time when he believed that she had difficulty receiving pain medications from her other health care providers. He stated that he prescribed several dangerous drugs and narcotics to Patient T.D. because she asked for them by name.

During his interview with the Board, Dr. Segal admitted that in the more than ten years of prescribing her pain medication, he had never checked with Patient T. D. s other doctors to ensure that she was not receiving pain medication from multiple providers. He also admitted that he had never checked the Control led Substance Utilization Review and Evaluation System (CURES) to verify her claims that she could not get pain medication from other providers. During his interview with the Board, he admitted that he did not know that CURES existed.

Had he checked CURES or with Patient T. D .’s other health care providers, he would have learned that she was receiving pain medication from at least four other doctors.

In May 2016, Dr. Segal and his attorney signed a Stipulated Settlement with the California Medical Board.

Four chiropractors and a capper were charged this week with insurance fraud in a massive multi-million dollar workers’ compensation insurance referral scheme that exploited persons in predominantly Spanish-speaking communities.

Last year, 10 attorneys and six cappers were charged as part of the same investigation. This is the second phase of filing resulting from a 4-year insurance fraud investigation by the Orange County District Attorney’s Office Bureau of Investigation, Insurance Fraud Unit.

Three defendants charged in Phase I of this investigation have pleaded guilty to participating in the unlawful referral scheme, with one pleading to multiple counts of insurance fraud. In 2014, the OCDA received a tip from a major insurance carrier and initiated an investigation in conjunction with CDI, which ultimately involved more than 20 insurance carriers and self-insured entities conducting business in California.

In 2005, Carlos Arguello III formed Centro Legal Internacional, an “advertising” company, and secured unlawful referral contracts with 20 to 40 workers’ compensation insurance and personal injury attorneys. Arguello required all participating attorneys to sign annual contracts entitled “joint advertising agreement.” Based on the contracts, the attorneys paid Arguello a specified monthly fee for procuring and delivering a minimum number of retained clients per month. Arguello used several names for his referral scheme, including Centro Legal Int’l, Justicia Legal Int’l, and Centro de Abogados Int’l.

He had websites created to advertise these legal services, including iwantmylawyernow.com, instantlawyeraccess.com, centrodeabogadosinternacional.com, uniondeabogadoslatinos.com, and unitedinjuryattorneys.com. Each website and advertisement offered a “free consultation” via an online consultation form or a toll-free number. The toll-free numbers for Centro Legal Int’l, Justicia Legal Int’l, and Centro de Abogados were all directed to a call center in Tijuana, Mexico.

Arguello also owned or was affiliated with other companies that he had the attorneys refer business to, including C & E Technology, Professional Document Management, and Providence Scheduling.

Edgar Gonzalez, another charged defendant in Phase I, is accused of paying attorneys for referral of business to his copy service company, called USA Photocopy, and billing the work to workers’ compensation insurance carriers.

The new Phase II involves Arguello’s call center operators and sign-up agents who were required to stress to the callers the importance of medical treatment to their workers’ compensation or personal injury case, encouraging them to show up to all appointments.

Once the caller agreed to become represented by an attorney from Arguello’s scheme, the “client” was then sold to Providence Scheduling, a service Fermin Iglesias is accused of owning and operating. Iglesias is accused of having arrangements with several chiropractors, including defendants Afsoun Naderi, Bahar Danesh Gharib, Bryan Aun, and John Larson, who are accused of paying Providence Scheduling for patients under the guise of a “Promotion and Scheduling Services Agreement.”

Iglesias is accused of directing these chiropractors to also prescribe durable medical equipment (DME) to their patients through his several DME companies, including Meridian Rehab, Bright Rehab Solutions, Prime Medical Resources, and Prime Orthopedics, all of which he billed to workers’ compensation insurance carriers.

Iglesias is further accused of requiring the chiropractors to refer all diagnostic imaging tests, such as MRI’s, through a scheduling company owned by Iglesias and Arguello called Medex Solutions.

The diagnostic facility owners are accused of paying Iglesias and Medex Solutions kickbacks disguised as “scheduling service” fees for each completed scan. All diagnostic services were billed to workers’ compensation insurance carriers.