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DIR Publishes Progress Report on Anti-Fraud Efforts

The DIR issued a progress report on its anti-fraud efforts, including updates on the suspension of 227 medical providers from treating California’s injured workers and the dismissal of 292,000 illegitimate liens with claims valued at over $2.5 billion.

“DIR’s anti-fraud efforts have allowed us to remove fraudulent providers and their claims for payment from the system, with the aim to improve services and reduce premium costs,” said DIR Director Christine Baker. “Our fraud prevention work also involves identifying fraudulent activity through data analytics and defending anti-fraud laws in court.”

DIR’s efforts to eliminate medical provider fraud and illegitimate liens were bolstered by two new laws effective January 1, 2017:

– SB 1160 requires DIR to automatically stay liens belonging to providers who have been indicted or charged with crimes until the disposition of criminal proceedings.

According to this provision, 465,000 liens filed by or on behalf of criminally charged providers have been automatically stayed. These liens have been designated “4615” in DWC’s electronic adjudication management system (EAMS) to alert workers’ compensation judges and parties of the action.

23,000 active and pending liens filed by or on behalf of 28 suspended providers have been consolidated for adjudication in special lien proceedings. 10,000 active and pending liens are being processed for consolidation. 30,000 liens filed by or on behalf of suspended providers have been voluntarily dismissed.

– AB 1244 requires the Division of Workers’ Compensation (DWC) Administrative Director to suspend any medical provider, physician or practitioner from participating in the workers’ compensation system when convicted of fraud.

DWC has adopted provider suspension regulations and has suspended 227 medical providers. Twenty-one providers were issued notices that their suspension will occur in 30 days unless appealed. A total of 527 who qualify for suspension under Labor Code section 139.21 have been identified.

More detail on DIR’s fraud prevention efforts has been posted online, including information on suspended providers and dismissed liens.

DIR’s Anti-Fraud Unit operates within the Office of the Director. The unit identifies providers who are subject to suspension and assists with lien dismissals, stays and consolidations. Anti-Fraud Unit research and investigative work uses data analytics to aid criminal prosecutors throughout the state and its attorneys handle legal challenges to anti-fraud laws.

At the direction of the Secretary of the California Labor and Workforce Development Agency, DIR and the Department of Insurance convened working groups in 2016 to gather stakeholder input and evidence of fraudulent activity in the workers’ compensation system. DIR issued a report in January 2017 on the recommendations to combat fraud and provided an update on anti-fraud activities.

WCAB En Banc Approves Electronic Signatures on Lien Forms

A WCJ issued a Findings of Fact wherein she found that lien claimant Monrovia Memorial Hospital is not barred from proceeding on its lien due to a “dismissal” notation in the Electronic Adjudication Management System (EAMS) pursuant to Jose Guillermina Rodriguez v. Garden Planting Co., et al. (2017) 82 Cal.Comp.Cases 1390 (Appeals Bd. en banc).

The WCJ then found that lien claimant had until the close of business at 5:00 p.m. on Monday, July 3, 2017 to file a lien claim declaration pursuant to Labor Code section 4903.05.

Defendant contends that lien claimant’s lien is dismissed by operation of law because its section 4903.05(c) declaration was not timely filed before the close of business, i.e., 5:00 p.m., on Friday,June 30, 2017 pursuant to section 4903.05, subsection (c)(2); and because it was unsigned in violation of subsection (c)(3).

The Appeals Board issued an en banc decision in the case of Hernandez v Henkel Loctite Corporation, determining that Labor Code section 4903.05(c) declarations filed after the close of business at 5:00 p.m. on Friday, June 30, 2017 through the close of business at 5:00 p.m. on Monday July 3, 2017 are timely filed.

Labor Code section 4903.05(c)(2) states that lien claimants “shall have until July 1, 2017” to file the declaration identified in Labor Code section 4903.05(c)(1), thereby establishing the last date for performance of an act required by statute as July 1, 2017, a Saturday.

When the last date for performance of an act required by any workers’ compensation statute falls on a weekend or holiday, “the act or response may be performed or exercised upon the next business day.” (Cal. Code Regs., tit. 8, § 10508; see Code Civ. Proc., § 12a(a) and Gov. Code, § 6707.)

The Appeals Board clarified that pursuant to the plain language in Labor Code section 4903.05(c)(2) and WCAB Rule 10770.7, declarations filed at or before 5:00 p.m. on the next business day, Monday, July 3, 2017, are timely filed.

Another issue discussed in dicta was the validity of an electronic signature rather than a wet signature on lien documents filed in EAMS. “We note that our rules require all liens, including the supportive required documentation, to be electronically filed on an e-form approved by the Appeals Board and submitted by the Administrative Director’s electronic filing or JET-filing procedures. (Cal. Code Regs., tit. 8, § 10770(b)(1)(A), (B), and (C)(i).) The Administrative Director’s approved electronic filing technical requirements10 allow the use of an ‘S Signature,’ which shall be ‘rebuttably presumed to be that of the individual whose name is on the document signature line.’ (BR-16 S Signatures; Guide, p. 42.) Defendant compares section 4903.05(c) declarations to settlement documents; however, settlement documents require a ‘wet’ signature. (See BR-18 Wet/Actual Signatures [‘The following documents will require actual wet/actual signatures(s) be used: Scanned in signed settlement documents.’]; and Guide, p. 42.) The electronic signature rules and procedures adopted by the Administrative Director are consistent with California’s statutory rules of procedure. (See Civ. Code, §§ 1633.2, 1633.7.)”

En banc decisions of the Appeals Board are binding precedent on all Appeals Board panels and WCJs. (Cal. Code Regs., tit. 8, § 10341; City of Long Beach v. Workers’ Comp. Appeals Bd. (Garcia) (2005) 126 Cal.App.4th 298, 313, fn. 5 [70 Cal.Comp.Cases 109]; Gee v. Workers’ Comp. Appeals Bd. (2002) 96 Cal.App.4th 1418 [67 Cal.Comp.Cases 236].) This en banc decision is also adopted as a precedent decision pursuant to Government Code section 11425.60(b).

Foster Farms Worker Sentenced for Fraud

The Modesto Bee reports that a former Foster Farms worker has pleaded no contest to a misdemeanor charge in Stanislaus County Superior Court to resolve a case involving allegations of workers compensation fraud.

Carlos Maldonado Romero, 51, pleaded no contest in November to false impersonation and was sentenced to three years’ summary probation, 160 hours of community service and ordered to pay $3,500 in restitution to Foster Farms, according to a news release issued this week by Probe Information Services, which investigates workers compensation cases for Foster Farms.

He also had been charged with three felonies, which were dismissed.

Maldonado Romero worked for Foster Farms’ Crystal Creamery facility in Fresno as a milker. He no longer is with the company, according to a Probe Information Services official.

Indivior Loses Opioid Treatment Patent Suit

Indivior lost a second legal case in recent months in its battle to protect the patent of its opioid addiction treatment that generates 80 percent of its revenues.

A U.S. District Court ruled that American generic drugs maker Alvogen had not infringed three Indivior patents, the British company said, weakening its defense against rival versions of its big seller, Suboxone Film.

Indivior said it believed it has grounds to appeal.

The case comes six months after the Delaware District Court ruled Indivior could not rely on patents to stop Indian drugmaker Dr. Reddy’s launching a generic version of Suboxone Film.

Generic rivals in tablet form are already on the market in the United States which is grappling with an opioid addiction epidemic that killed 33,000 people 2015.

But Suboxone Film leads the market for a version which is placed under the tongue to suppress cravings. Its U.S. market share was 56 percent at the end of 2017, down from 61 percent the previous year.

Indivior is also in patent disputes with Allergan Plc’s Actavis Laboratories, Endo International’s Par Pharmaceutical, Teva Pharmaceutical Industries and Mylan NV. Indivior settled a case with Mylan in September.

Analysts said the impact of the latest ruling was “less significant” than the September one and most companies would remain wary of launching a generic against Indivior and Dr. Reddy’s was likely to be first.

Indivior launched a once-a-month injectable drug to suppress opioid craving in the United States this month. It hopes Sublocade will become a blockbuster medicine although expects initial sales to be slow.

Sublocade, which could be launched in Canada, Australia and Europe from late 2019, is designed to eliminate the risk that treatment drugs could be missed or misused.

Ventura Medical Biller to Serve 210 Days for Fraud

Ventura County District Attorney Gregory D. Totten announced that Anna Maria Ruiz (DOB 10/20/1981) of Ojai, was sentenced to serve 210 days in the Ventura County jail for committing medical insurance fraud.

In January 2018, Ruiz pled guilty to 11 counts of violating Penal Code section 550(a)(l), felony insurance fraud. In addition, she admitted an excessive taking allegation for stealing more than $65,000 and an aggravated white-collar crime special allegation for taking more than $100,000.

She was facing about 30 counts of the felony offense, which she initially denied, but admitted to some of the counts as part of a plea agreement.

Prosecutors said Ruiz was employed by Ventura County Pulmonary Medical Group when she submitted 30 fraudulent insurance claims to American Family Life Assurance Co. of Columbus (AFLAC). Ruiz used her knowledge of medical billing to submit the fraudulent claims.

She received payments of $127,710 for these completely fabricated insurance claims.

In addition to the jail sentence, Ruiz was placed on probation for 72 months and ordered to pay $127,710 in restitution to AFLAC.

This case was the result of an investigation by the Valencia Office of the California Department of Insurance.

Punitive Damages Upheld Against Uninsured Employer

While employed by Activor Corporation in 2007, Mahavir Mehta fell 12 feet off a ladder and sustained serious injuries, including one to his left wrist that required surgery. Activor did not carry workers’ compensation insurance and was not permissibly self-insured.

Mehta initiated workers’ compensation proceedings and sued Activor and the principle stockholder Chanda Zaveri for damages pursuant to Labor Code section 3706. The suit (Metha I) resulted in a judgment in plaintiff’s favor against Activor only in the total sum of $184,850.22, which included $129,850.22 in attorney fees. Through a writ of execution, plaintiff collected $55,000 from Activor.

After entry of the Mehta I judgment, Activor began transferring assets and accounts receivable to Chanda Zaveri and to Actiogen Corporation and Chanda LLC, two newly formed entities controlled by Zaveri. Activor subsequently initiated a “no asset” bankruptcy proceeding, omitting more than $900,000 accounts receivable due and owing to Activor.

In order to collect the outstanding attorney fee portion of the judgment, Mehta commenced this action (Mehta II) for compensatory and punitive damages against Activor, Zaveri, Actiogen, and Chanda based on common law and statutory fraudulent transfer theories.

The trial court awarded plaintiff compensatory damages of $207,760.35 and punitive damages of $621,781.05, for a total judgment of $829,041.40, plus interest, attorney fees and costs. There was no court reporter or live witness testimony. Instead, counsel stipulated the evidence would consist of deposition testimony and documents. The court of appeal modified but otherwise affirmed the judgment in the unpublished case of Mehta v Activor Corp.

On appeal defendants did not provide a settled statement or other suitable substitute. The clerk’s transcript was incomplete. Before any appellate briefs were filed, this court issued a briefing order, directing the parties to include in their briefs a discussion of the effect of defendants’ failure to provide most of the relevant papers as part of the record in an appendix. Defendants failed to heed the briefing order.

The court noted that where the appellate record is inadequate to permit us to assess whether the trial court has erred or the judgment is not supported by substantial evidence, it must affirm. A party on appeal has the duty to support the arguments in the briefs by appropriate reference to the record, which includes providing exact page citations. We have no duty to search the record for evidence and may disregard any factual contention not supported by proper citations to the record.

On appeal defendants contend the right to sue for the unpaid attorney fees portion is vested in plaintiff’s law firm, not plaintiff himself. Stated another way, defendants insist plaintiff is no longer a judgment creditor entitled to sue defendants for fraudulent transfers.

The Supreme Court acknowledged more than 80 years ago, a judgment for attorney fees belongs “to the party to the action for fees paid or incurred by him, and not directly to the attorney, who is not a party to the action.- (Los Angeles v. Knapp (1936) 7 Cal.2d 168, 173.).

The trial court found by clear and convincing evidence that all defendants entered into a fraudulent scheme.

Fraud Unit Compliance Check Finds 50% of Employers Fail

Investigators from the Tulare County District Attorney’s Office Workers’ Compensation Fraud Unit conducted a two-day workers’ compensation insurance compliance check on March 7th and 8th, 2018, in Visalia and Porterville.

The purpose of the compliance check was to inform and educate local employers of the requirements of carrying the proper state-mandated contractor’s license and workers’ compensation insurance.

Investigators contacted over 36 businesses which included landscapers, construction companies, tree trimmers, garage door repair companies, and concrete masonry workers.

As a result, 18 of the 36 businesses contacted were in compliance with the mandated State of California workers’ compensation insurance laws and carried the proper State Contractor’s license.

The noncompliant businesses were educated on the requirements regarding workers’ compensation insurance and holding the proper contractor’s license.

Follow-up investigations will be conducted to ensure compliance with these companies has been met, and future compliance checks will be completed throughout the County in the coming months to ensure employers, employees, and consumers are all protected to the fullest extent of the law.

The Office of the District Attorney has a dedicated prosecutor and criminal investigator assigned to workers’ compensation fraud. Anyone with information regarding businesses allegedly out of State compliance may contact Assistant Chief Gilbert Cardenas at (559) 636-5410.

Feds Promise Action to Lower Drug Prices

President Donald Trump promised to bring down prescription drug prices on Monday, saying U.S. citizens pay far more than people in other countries do for the same product and that his administration would announce new measures in about a month.

“If you compare our drug prices to other countries in the world, in some cases it’s many times higher for the exact same pill or whatever it is, in the exact same package made in the exact same plant,” Trump said. “We’re going to change that.”

Trump made the remarks during a speech in Manchester, New Hampshire that focused on the administration’s efforts to battle the nation’s opioid addiction crisis. Trump said he planned a news conference in about a month to roll out drug price proposals.

“We’re driving ‘em down,” Trump said. “We pay as a country so much more for drugs because of the drugs lobbies and other reasons, and the complexity of distribution, which is basically another term for saying, ‘How do we get more money?’.”

His comments reflect growing scrutiny over what patients end up spending for their medicines after insurers, distributors, hospitals and pharmacies are paid for their roles in delivering the drugs. U.S. Food and Drug Administration Commissioner Scott Gottlieb recently criticized such players for “Kabuki drug-pricing” constructs that drive up prices for consumers.

On Monday, Health and Human Services Secretary Alex Azar said the new proposals will focus on “how we decrease the price of drugs and how we bring discounts that the middlemen right now are getting, how those will go to our patients.”

Azar, a former president of the U.S. arm of drugmaker Eli Lilly and Co, joined Trump at the New Hampshire event.

Trump has vowed since his election to tackle rising drug prices. His proposed 2019 budget outlined some steps to do so, including by allowing up to five states more flexibility over which drugs are covered by Medicaid, the government health insurance program for the poor and disabled.

That could give the states more leverage to negotiate lower prices for prescription medicines.

Trading volume in the ishares Nasdaq Biotechnology exchange-traded fund picked up as Trump began talking about drug prices, but the ETF’s price closed down about 2 percent.

Shares in pharmacy benefits managers Express Scripts Holding Co and CVS Health Corp closed down 4 percent and 3.1 percent, respectively.

Reporting by Roberta Rampton; Additional reporting by Yasmeen Abutaleb in Washington and Caroline Valetkevitch in New York; Writing by Doina Chiacu; Editing by Leslie Adler and James Dalgleish

No Settement – Yet – in Opioid MDL Litigation

A push to resolve more than 350 lawsuits against the makers and distributors of opioid painkillers has hit a snag, so a federal judge cleared the way for lawyers to start collecting evidence for trials.

U.S. District Judge Dan Polster in Cleveland said Wednesday “substantial progress” has been made in talks between U.S. cities and counties and Purdue Pharma LLP and other opioid makers and distributors, but both sides have found “barriers to a global settlement.”

Allowing local governments’ and opioid makers’ attorneys to get ready to go to trial is the “quickest way to surmount at least some of those barriers,” Polster said in an order the day after the most recent negotiating session.

“We are pleased Judge Polster is pursuing settlement possibilities while simultaneously allowing for litigation steps to be taken,” Paul Hanly, a New York-based lawyer helping to lead the case on behalf of cities and counties. “Hopefully, the two tracks converge in a global resolution.”

The judge is backing away from an earlier decision to put litigation efforts on hold while lawyers for Purdue, Johnson & Johnson, McKesson Corp., Endo International Plc, Teva Pharmaceutical Industries Ltd. and other companies talked with cities’ and counties’ attorneys about settling the cases.

Polster has made clear he wants a “meaningful” resolution of cases blaming the companies for creating a public-health crisis that is claiming the lives of more than 100 Americans every day. The judge has said he wants a deal addressing the companies’ business practices and the roots of the crisis.

Opioid Crisis Point Man Is Cleveland Judge in Midst of Epidemic

City and county officials contend Purdue and other opioid makers downplayed the painkillers’ health risks and oversold their benefits through hyper-aggressive marketing campaigns. They are seeking to recoup the societal costs of dealing with opioid addictions and overdoses as part of a settlement similar to the 1998 Big Tobacco accord that generated $246 billion.

“We are committed to being part of the ongoing dialogue and to doing our part to find ways to address this crisis,” said Jessica Castles Smith, a spokeswoman for J&J’s Janssen unit.

Teva spokeswoman Kaelan Hollon declined to comment. Purdue spokesman John Puskar declined to comment. Heather Zoumas Lubeski, an Endo spokeswoman, declined to comment

The companies also have been in settlement talks with a group of states attorneys general, some of whom have already sued opioid makers and distributors seeking to recoup tax dollars spent to address the crisis. Polster also has had some AGs involved in his settlement negotiations.

Polster has said if the federal opioid cases must be weighed by juries, he’d set the state of Ohio’s claims for trial in 2019. Oklahoma has a May 28 trial date set for its claims against Purdue and the other companies in state court.

Mike DeWine, Ohio’s attorney general, hasn’t said how much he wants from pharmaceutical companies and distributors to address the crisis in his state, but noted an Ohio State University study found that opioids cost the Buckeye State as much as $8 billion annually.

Polster is giving lawyers for both sides until March 16 to come up a litigation plan for the consolidated cases and will hold the next negotiating session on May 10. As with others, the session won’t be open to the public.

The case is In Re: National Prescription Opiate Litigation, 17-cv-2804, U.S. District Court, Northern District of Ohio (Cleveland).

A.I. as Accurate as Pathologist at Cancer Diagnosis

Chinese researchers have developed an artificial intelligence system which can diagnose cancerous prostate samples as accurately as any pathologist, holding out the possibility of streamlining and eliminating variation in the process of cancer diagnosis.

The system may also help overcome shortages of trained pathologists and in the longer term lead to automated or partially-automated prostate diagnosis.

Confirmation of a prostate cancer diagnosis normally requires a biopsy sample to be examined by a pathologist. Now the Chinese AI system has shown similar levels of accuracy to pathologists and can also accurately classify the level of malignancy of the cancer, eliminating the variability which can creep into human diagnoses.

Details of the AI system were presented at the European Association of Urology Congress taking place in Copenhagen this March.

“This is not going to replace a human pathologist,” said Hongqian Guo, who led the research. “We still need an experienced pathologist to take responsibility for the final diagnosis. What it will do is help pathologists make better, faster diagnoses, as well as eliminating the day-to-day variation in judgment which can creep into human evaluations.”

Guo’s group took 918 prostate samples from 283 patients and ran these through the AI system, with the software gradually learning and improving diagnosis. The pathology images were subdivided into 40,000 smaller samples of which 30,000 were used to train the software while the remaining 10,000 were used to test accuracy.

The results showed an accurate diagnosis in 99.38 per cent of cases, using a human pathologist as a gold standard. Guo said that means the AI system is as accurate as a pathologist.

The system was programmed to learn and gradually improve how it interpreted the samples. “Our results show that the diagnoses the AI system reported were at a level comparable to that of a pathologist. Furthermore, the system could accurately classify the malignancy level of prostate cancer,” said Guo.

Until now, automated systems have had limited clinical value. “We believe this is the first automated system to offer an accurate reporting and diagnosis of prostate cancer. In the short-term, this can offer a faster throughput, plus a greater consistency in cancer diagnosis from pathologist to pathologist, hospital to hospital, country to country,” Guo said. “It is important that cancer detection and diagnosis takes advantage of these changes.”

“This is interesting work which shows how artificial intelligence will increasingly step into clinical practice,” said Rodolfo Montironi, professor of pathology, Polytechnic University of the Marche, Ancona, Italy. “This may be very useful in some areas where there is a lack of trained pathologists. Like all automation, this will lead to a lesser reliance on human expertise, but we need to ensure that the final decisions on treatment stay with a trained pathologist.”