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Category: Daily News

Five Thousand Dollar Surgery Costs Quarter Million – In Monterey Park!

When it comes to reducing one’s hospital bills, a key factor is location, location, location. A patient who undergoes joint-replacement surgery in Ada, Oklahoma, might receive a $5,300 hospital invoice for services rendered. But, according to an article in The Atlantic Cities, somebody who gets the same operation in Monterey Park, California, could be staring down the barrel of a much huger bill – $223,000, to be exact.

These were the average lowest and highest prices in 2011 for one particular joint-swapping procedure in the United States, according to federal data. They show in stark light how hospitals charge vastly different amounts for almost identical services, a peculiarity of the American healthcare system that Steven Brill wrote about this year in a Time cover story. Brill spent months investigating how hospitals calculate the bills they stick to patients; here’s Time describing one of his findings:

“Hospitals arbitrarily set prices based on a mysterious internal list known as the “chargemaster.” These prices vary from hospital to hospital and are often ten times the actual cost of an item. Insurance companies and Medicare pay discounted prices, but don’t have enough leverage to bring fees down anywhere close to actual costs. While other countries restrain drug prices, in the United States federal law actually restricts the single biggest buyer – Medicare – from even trying to negotiate the price of drugs.”

While some people have taken issue with Brill’s facts, the basic point that hospital pricing is opaque and often unfair is on target. The Centers for Medicare and Medicaid Services seem to be on board with this assessment. After Brill’s article appeared, the centers disgorged a trove of information dealing with what hospitals charged and what Medicare actually paid for 100 common procedures in 2011. The data revealed not just major differences among the states, but local variations as well. Reports Health 2.0: “For example, average inpatient hospital charges for services that may be provided to treat heart failure range from a low of $21,000 to a high of $46,000 in Denver, Colo., and from a low of $9,000 to a high of $51,000 in Jackson, Miss.”

The higher-value hospitals are clumped in the center of the United States. Two of the best-ranked ones hail from Arkansas – the Surgical Hospital in Little Rock and the Physicians’ Specialty Hospital in Fayetteville – followed by medical centers in Villa Rica, Georgia; Grinnell, Iowa; Paola, Kansas; Boise, Idaho; and Wichita.

Some of the lowest-ranked hospitals can be found in California locales like Porterville, Hemet, and Fresno, and in Floridian burgs like Dade City, Fort Myers, and Saint Petersburg, with others in Illinois, Oklahoma, Tennessee, New Mexico and elsewhere:

Lawmakers Back Off Of Medical Board Overhaul

Legislation once seeking major reform of the Medical Board of California was gutted and passed by a key Assembly committee last week

The state agency that regulates doctors is facing sunset review this year, meaning it will cease to exist if lawmakers and the governor don’t reauthorize it.

Senate Bill 304 is a vehicle to make changes and unwind or reauthorize the agency. Initially authored by Sen. Curren Price, it is now carried by Sen. Ted Lieu. Price left office to take a seat on the Los Angeles City Council on July 1. This bill includes numerous provisions related to the Medical Board of California (MBC) that emerged during sunset review of the Board in 2012; The bill as it is now written, extends the Medical Board’s sunset date until January 1, 2018 and makes MBC subject to review by the appropriate policy committees of the Legislature.

Amendments approved Tuesday eliminated a key enforcement reform that would have moved all staff investigating dangerous doctors to the California Department of Justice. The bill now moves investigative staff to Division of Investigation in the California Department of Consumer Affairs, keeping enforcement split between that department and the medical board staff.

The bill was also amended to extend Medical Board operations for four years. Price had threatened to pull the plug on the agency if serious changes were not made.

San Jose Doctor Arrested for Controlled Substances Trafficking

The Medical Board of California’s Prescription Drug Strike Force arrested Dr. Duke D. Fisher at his San Jose office for allegedly prescribing controlled substances without a legitimate purpose.

The probable cause arrest came after the Board received a complaint alleging that Dr. Fisher would prescribe any medication the customer requested in exchange for cash. Multiple undercover operations were conducted. It was found that Dr. Fisher prescribed controlled substances without a legitimate medical purpose and prescribed controlled substances to a customer who admitted to using heroin and methamphetamines.

Fisher was charged with violations of Health and Safety Code sections 11153, prescribing without a legitimate medical purpose, and 11156, prescribing to an addict; and Business and Professions Code section 725, excessive prescribing of drugs.

Fisher has two offices, one in San Jose and one in Monterey, California. His bail is set at $64,000.

Redding Pain Doctor Arrested

Investigators from the Medical Board of California’s Prescription Drug Strike Force along with t he Redding Police Department , arrested Dr. James Gregory White for prescribing drugs without a legitimate purpose, prescribing to a known addict, and excessive prescribing. Dr. White along with his physician assistant , Cheri Hougland , were arrested at his place of business the North Valley Medical Corporation at 473 South Street in Redding, California.

According to a representative from the Medical Board of California, White and Hougland are being charged on nine counts including prescribing a controlled substance without a legitimate purpose, prescribing to a known addict, and excessive prescribing.

After the arrest, the Drug Enforcement Agency, the Office of the Inspector General and the Bureau of Medi-cal Fraud and Elder Abuse served a search warrant on the business and seized medical files. White and Hougland are being accused of aiding and abetting and filing fraudulent claims.

White’s medical license was suspended back in May. The California State Medical Board was asked to revoke White’s license, citing 18 causes for discipline including gross negligence and over-prescribing pain-killing drugs that led to death.

White is a pain doctor who had his license revoked back in 2005 as well for issues surrounding his prescribing practices.

Medical Billing Company Resolves Fraudulent Comp Claims for $3.4 Million

United States Attorney Melinda Haag announced that a billing manager, her billing company, and her son have agreed to pay $1.7 million to settle allegations that they violated the civil False Claims Act in connection with claims submitted to the Department of Labor, Office of Workers’ Compensation Programs (DOL-OWCP).

The settlement resolves a whistleblower lawsuit filed in the United States District Court for the Northern District of California. In July 2012, the United States settled with six other defendants for $3.15 million — Advanced Physical Medicine and Rehab Group Inc. (located in Oakland, Calif. and Rhonert Park, Calif.), Advanced Occupational Rehabilitation, Inc. (located in Oklahoma), Advanced Medicine and Rehabilitation of Texas, Inc. (located in Texas), Advanced Medicine and Rehabilitation of Texas, P.A. (located in Texas), and the two physicians located in Oakland who own these clinics. The remaining three defendants — Farideh Heidarpour, her billing company A.B.C. Billing Inc., and her son Ali Heidarpour (who was also her employee) – will pay an additional $1.7 million.

The United States alleges that, from 2005 through 2008, Heidarpour, her company, and her son submitted or caused to be submitted to DOL-OWCP false claims by the clinics for supplies and services not provided, not supported by medical documentation and/or not medically necessary, resulting in millions of dollars of damages to the United States. The majority of the patients at issue were United States Postal Service (USPS) employees claiming work-related injuries.

U.S. Attorney Haag, said. that “this settlement demonstrates this office’s continued commitment to protecting the federal health care programs from fraud and false claims.”

A physician who formerly worked at the clinic in Texas filed the case pursuant to the qui tam provisions of the False Claims Act. Under those provisions, private citizens, called “relators,” may file lawsuits on behalf of the United States and receive a portion of the proceeds of a settlement or judgment. The relator will receive $323,000 as her share of the government’s recovery from the three defendants. This is in addition to the relator’s share of $598,000 from the earlier settling defendants.

Assistant U.S. Attorneys Sara Winslow and Melanie Proctor handled the matter on behalf of the U.S. Attorney’s Office for the Northern District of California, with assistance from Financial Fraud Investigator Michael Zehr and Legal Assistants Yvette Baird and Kathy Terry. The matter was investigated by DOL-OWCP and the USPS Office of Inspector General.

Skid Row Capper Sentenced to Federal Prison

Estill Mitts, 68, who lives near the Miracle Mile district of Los Angeles, recruited homeless people from the “Skid Row” section of Los Angeles as part of a widespread scheme to defraud Medicare and Medi-Cal by providing unnecessary health services. He was sentenced this week to 18 months in federal prison and ordered Mitts to pay more than $9.8 million in restitution. In sentencing Mitts the federal judge stated that Mitts’ conduct was “fueled by greed to enrich himself,” and “breeds contempt for, leads to a lack of confidence in, and threatens the stability of” the Medicare program.

The Skid Row “capping” — or illegal referral — scheme was discovered in the fall of 2006 after local authorities observed some patients discharged from a local hospital being “dumped” on Skid Row. The patients subsequently reported that they had been paid to go to the hospital.

Mitts “was a ring-leader in a significant, long-term, serious crime that used the homeless as fodder for exploiting the Medicare and Medi-Cal programs,” prosecutors wrote in a sentencing memo filed with the court. Mitts admitted that he received more than $1 million in kickbacks from three hospitals that took in the illegally referred patients from Skid Row.

From 2004 until October 2007, Mitts operated the Assessment Center, a facility on East Seventh Street in downtown Los Angeles that was also known as 7th Street Christian Day Center. “Mitts employed individuals he called ‘stringers’ to recruit homeless people with promises of small payments,” according to the sentencing memorandum. “The Assessment Center was not a medical clinic, but a site that defendant used for the purpose of recruiting homeless Medicare and Medi-Cal beneficiaries for referral to three hospitals — City of Angels Hospital, Los Angeles Metropolitan Medical Center, and Tustin Hospital and Medical Center. Defendant and others working for him would recruit homeless beneficiaries for in-patient hospital admissions whether or not such hospitalizations were medically necessary.”

In relation to the tax evasion count, Mitts admits in the plea agreement that he failed to report more than $479,000 in income in 2005 and more than $620,000 in income in 2006. By failing to report this income, the Internal Revenue Service suffered losses of $349,857.

Mitts pleaded guilty in 2008 to conspiracy to commit health care fraud, money laundering and tax evasion. Mitts’ sentencing was delayed a number of times as he provided assistance to the government’s investigation that has led to 11 defendants being charged and convicted.

Mitts is the latest in a series of defendant to be sentenced in relation to the Skid Row investigation. For example, Robert Bourseau, one of the owners of City of Angels, was sentenced to 37 months in prison, and Dante Nicholson, the director of marketing at City of Angels, who also cooperated with the government in its investigation, was sentenced to one year in prison. Late last year, a doctor who admitted homeless patients to the Tustin Hospital and Medical Center after they had been driven from Skid Row was sentenced to one year in federal prison.

NFL Player Dementia Civil Claims Near Settlement

Fox News reports that the NFL and more than 4,500 former players want to resolve concussion-related lawsuits with a $765 million settlement that would fund medical exams, concussion-related compensation and medical research. The plaintiffs include at least 10 members of the Pro Football Hall of Fame, including former Dallas Cowboys running back Tony Dorsett. They also include Super Bowl-winning quarterback Jim McMahon and the family of Pro Bowl linebacker Junior Seau, who committed suicide last year.

Many former players with neurological conditions believe their problems stem from on-field concussions. The lawsuits accused the league of hiding known risks of concussions for decades to return players to games and protect its image. The NFL has denied any wrongdoing and has insisted that safety has always been a top priority. Many have also filed workers’ compensation claims in California, even if they only played one game here.

Senior U.S. District Judge Anita Brody in Philadelphia announced the proposed settlement Thursday after months of court-ordered mediation. She still must approve it at a later date. The settlement likely means the NFL won’t have to disclose internal files about what it knew, when, about concussion-linked brain problems. Lawyers had been eager to learn, for instance, about the workings of the league’s Mild Traumatic Brain Injury Committee, which was led for more than a decade by a rheumatologist.

In court arguments in April, NFL lawyer Paul Clement asked Brody to dismiss the lawsuits and send them to arbitration under terms of the players’ contract. He said that individual teams bear the chief responsibility for health and safety under the collective bargaining agreement, along with the players’ union and the players themselves.

Players lawyer David Frederick accused the league of concealing studies linking concussions to neurological problems for decades. Brody had initially planned to rule in July, but then delayed her ruling and ordered the two sides to meet to decide which plaintiffs, if any, had the right to sue. She also issued a gag order, so it has been unclear in recent weeks whether any progress was being made. The lawyers were due to report back to her Tuesday, but Brody instead announced in court files Thursday that the case had settled.

In recent years, a string of former NFL players and other concussed athletes have been diagnosed after their deaths with chronic traumatic encephalopathy, or CTE. Those ex-players included Seau and lead plaintiff Ray Easterling, who filed the first suit in Philadelphia in August 2011 but later committed suicide.About one-third of the league’s 12,000 former players have joined the litigation since 2011. They include a few hundred “gap” players, who played during years when there was no labor contract in place, and were therefore considered likely to win the right to sue.

The timing of the settlement allowed the NFL to drop the issue from the national conversation before the start of the new season. All 32 clubs were scheduled to play their final exhibition games Thursday night, in preparation for the start of the regular season next week. The first real game is next Thursday, with the reigning Super Bowl champion Baltimore Ravens playing at the Denver Broncos.

Study Says National TTD Duration Decreasing With Unemployment Rate

Previous NCCI studies of Temporary Total Disability (TTD) indemnity benefits duration showed an increase in nationwide average duration following the onset of the Great Recession in 2007.

As this updated, post-recession research shows, Accident Year (AY) 2009 was the nationwide peak at 143 days, and average duration has since declined to 140 days in AY 2012. Average durations have risen or fallen in step with the national unemployment rate. Countrywide estimates in this study are based on data for 46 jurisdictions – all jurisdictions except ND, OH, WA, WV, and WY – and include large deductible and self-insured claims, where reported to NCCI.

Countrywide, the Contracting and Manufacturing industry groups had the steepest declines in average duration from AY 2009 to AY 2011, following substantial increases between AY 2006 and AY 2009. Recent duration trends in the other industry groups were either slight declines or modest increases.

The median of the average durations in states with seven-day waiting periods is about 20 days longer than in states with three-day waiting periods. Within most industry groups, average durations for women are longer than average durations for men. However, men have higher shares of claims than women in the longer-duration industry groups, so that when viewed overall, men’s average duration is longer than women’s.

Duration increased for all age groups between AY 2005 and AY 2009, with most age groups reflecting the countrywide duration increase of 10%. Duration for the youngest age group-workers under age 30 or less – stands out as about 30% lower than countrywide.

West Hollywood Doctor Convicted of Drug Trafficing

A West Hollywood doctor pleaded guilty to a federal drug trafficking charge for writing hundreds of prescriptions for various controlled substances after a federal order revoked his authority to prescribe drugs. James William Eisenberg, 72, who resides in the Venice district of Los Angeles, pleaded guilty to one count distribution of hydrocodone, a drug best known by the brand names Vicodin and Norco.Eisenberg wrote the prescriptions while he worked out of several medical offices in West Hollywood, including a Santa Monica Boulevard storefront he called Pacific Support Services. Eisenberg also issued “medical marijuana” recommendations from these West Hollywood locations. He has been prohibited from issuing such recommendations and from practicing medicine at medical marijuana clinics as a condition of his release on bail.

In order to legally prescribe controlled substances such as hydrocodone, physicians must be registered with the United States Attorney General and have a valid DEA registration number. On December 14, 2011, a DEA administrative judge determined that Eisenberg acted as a “drug dealer” and suspended his registration number. The DEA issued an order permanently revoking Eisenberg’s registration on July 24, 2012. The orders issued by the administrative judge were based on findings that Eisenberg, who at the time was working out of a “medical marijuana” club in Arizona, “lacked a legitimate medical purpose and acted outside of the usual course of professional practice” when he wrote prescriptions for oxycodone (the generic form of a drug often best known as the brand-name OxyContin) and Xanax in exchange for $150 cash payments. The DEA judge also found that Eisenberg wrote “medical marijuana” recommendations to undercover officers posing as patients, and that Eisenberg prescribed OxyContin to one of the undercover agents “before [Eisenberg] had even performed a physical examination.”

DEA investigators later learned that Eisenberg continued to prescribe controlled substances, including hydrocodone, in violation of the DEA’s orders. A review of a California Department of Justice database that can be used to track prescriptions showed that, following the suspension of Eisenberg’s registration number, patients filled more than 1,700 of his prescriptions for controlled substances, including more than 1,200 prescriptions for hydrocodone. As charged in the indictment, Eisenberg wrote one of those prescriptions on December 27, 2011, less than two weeks after his registration number was suspended.

DEA investigators executed a federal search warrant on one of Eisenberg’s West Hollywood offices on February 19, 2013. The affidavit in support of the search warrant outlines evidence, including surveillance and undercover operations, that Eisenberg continued to write prescriptions for controlled substances in violation of the DEA’s revocation order. The evidence included an operation in which an undercover agent, posing as a patient, obtained a prescription from Eisenberg for hydrocodone and alprazolam (the generic form of a drug best known as Xanax).

As a result of his guilty plea, Eisenberg faces a statutory maximum sentence of 10 years in federal prison when he is sentenced by United States District Judge Michael W. Fitzgerald on December 9, 2013.

DWC Posts Changes to Electronic Document Filing and Lien Filing Fee Rules

The Division of Workers’ Compensation has posted a 15-day notice of modification to the electronic document filing and lien filing fee rules to the DWC website. Members of the public are invited to present written comments regarding the proposed modifications to until 5 p.m. on September 11.

The proposed modifications include:revisions to the definitions of the terms “cost,” “party,” and “section 4903(b) lien” Revisions also add a new section that sets forth when lien filing or activation fee refunds will automatically take place and provides a procedure for requesting lien fee refunds. This new provision states that lien filing and or lien activation fees will automatically be refunded when (1) a payment was not processed due to a system error; (2) the fee was previously paid or the lien is not available for activation; (3) an improper amount is paid; or (4) a lien filing fee is properly paid, but due to a procedural defect in the filing of the lien, the filing is not effective and the filer was not able to re-file and cure the defect with 15 days. Iif the automatic refund is not issued, the Lien Filing Fee Refund Request form must be submitted with any required documentary proof. A refund will only be provided upon a showing of good cause. The bases for good cause are stated.
Finally there are new revisions to the EAMS reference guide and instructional manual and the JET File Business Rules and Technical Specifications.

The notice, text of the regulations, and forms can be found on the proposed regulations page.