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AFLAC Employee Gets 10 Years for Fake Disability Claims

A one-time sales representative for AFLAC was sentenced to 10 years in federal prison after being convicted of federal fraud charges related to a scheme that used bogus disability claims to bilk the insurance company out of more than $4 million.

Patricia Diane Smith Sledge, 61, of Redlands, was sentenced by United States District Judge James V. Selna. In addition to the prison term, Judge Selna ordered Sledge to pay $4,166,063 in restitution.

Following a two-week jury trial late last year, Sledge was found guilty of six counts of mail fraud, as well as two counts of witness tampering.

The fraud scheme involved fictitious employers and bogus employees who falsely claimed to have suffered injuries that prevented them from working.

The evidence presented at trial showed that Sledge – who was residing in Irvine while working for the company formally known as American Family Life Assurance Company – sold disability insurance policies to bogus companies and people who supposedly worked for those companies. Sledge then orchestrated the filing of fraudulent disability claims and directed the purported employees to doctors that would sign off on the fake injury claims.

Sledge made money both from the commissions related to the sale of the fraudulent insurance policies and from kickbacks she received from the supposedly injured “employees.”

Sledge exploited her knowledge of AFLAC’s internal policies and underwriting procedures to further the scheme. For example, Sledge and others involved in the scheme listed artificially inflated incomes on the applications for insurance because the amount AFLAC paid on disability claims was based on the policyholder’s income.

Sledge was also found guilty of witness tampering for encouraging potential witnesses to lie to federal investigators and discouraging them from cooperating in the investigation. One of these crimes was committed while she was on bond in this case.

Three others have been prosecuted for acting as fake employers and fake employees in this scheme.

The case against Sledge and the others involved in the scheme is the result of an investigation by United States Department of Labor – Office of Inspector General, the Federal Bureau of Investigation, and California’s Department of Insurance.

This case is being prosecuted by Assistant United States Attorney Vibhav Mittal of the Santa Ana Branch Office and Assistant United States Attorney Joshua O. Mausner of the Violent and Organized Crime Section.

O.C. Deputies File Comp Claims for Vegas Shooting

The Orange County Register reports that four Orange County sheriff’s deputies have filed workers compensation claims against the county for physical and psychological injuries they say they suffered when they attended a country music festival in Las Vegas where a gunman killed 58 people.

Several Orange County deputies at the Route 91 Harvest festival quickly assumed life-saving roles – protecting the perimeter of the area with a shotgun in one case and administering medical care in other instances. Though the deputies were in Las Vegas on their personal time, their workers’ compensation claims will make the case that they acted as on-duty law enforcement officers when they sprang into action to help others.

The Orange County Board of Supervisors is set to meet Tuesday, Oct. 17, in closed session to discuss the claims.

The deputies filed their claims only a few days after the Oct. 1 shooting in which 64-year-old retiree Stephen Paddock fired into the festival crowd, killing 58 people and wounding more than 500.

Tom Dominguez, president of the Association of Orange County Deputy Sheriffs, said he traveled to Las Vegas the day after the shooting and, while there, encouraged his deputies who had helped others the night before to file claims. Those claims, if approved, could require the county to pay medical bills connected to the episode. The deputies also wouldn’t have to use vacation or sick days to take time off for their injuries.

“The sheriff’s department has an expectation that its deputy sheriffs, that when they are faced with circumstances where the public is in grave danger – they should take action,” Dominguez said.

“The county has to be very cautious in these cases,” Dominguez added. “If they deny the claims, then the message that they’re sending to their peace officers is not to take action when it is certainly warranted.”

The county did not name the deputies who submitted claims. But following the shooting, the Southern California News Group reported the experiences of several Orange County deputies on the scene.

Deputy Joe Owen, sustained non-life-threatening injuries after he was shot in the abdomen and thigh. Deputy Melanie Cooper administered CPR on six of seven people, later saying the event was the “most traumatic thing I’ve ever been through.” Deputies Mark Seamans and Brandon Mundy helped people escape and applied medical care to others. And Deputy Garrett Eggert, using a shotgun given to him by local law enforcement, helped to protect the perimeter.

Supervisor Todd Spitzer said he asked the board to consider the claims in closed session after he learned the county likely would have rejected them administratively. Spitzer said under a strict interpretation of California law, workers’ compensation might only extend to law enforcement officers responding to an emergency within the state. But he said he didn’t want the claims to be rejected summarily because he didn’t want to dissuade deputies from helping in emergencies in the future.

“These police officers went into their instinctive training mode, and I’m not going to send a message that Orange County is going to abandon any of its peace officers who are trying to save lives,” said Spitzer, who is running for district attorney.

Dominguez disagreed with Spitzer’s interpretation of California workers’ compensation law but acknowledged that it is an extremely rare occurrence for police officers to file claims stemming from incidents that occurred out of state. He could not recall another time that had happened in Orange County.

DOJ Attempts Prosecution of Chinese Nationals for Illegal Fentanyl

The DOJ announced that federal grand juries in the Southern District of Mississippi and the District of North Dakota returned indictments against two Chinese nationals and their North American based traffickers and distributors for conspiracies to distribute large quantities of fentanyl and fentanyl analogues and other opiate substances in the United States.

The Chinese nationals are the first manufacturers and distributors of fentanyl and other opiate substances to be designated as Consolidated Priority Organization Targets (CPOTs). CPOT designations are those who have “command and control” elements of the most prolific international drug trafficking and money laundering organizations.

Xiaobing Yan, 40, of China, was indicted in the Southern District of Mississippi on two counts of conspiracy to manufacture and distribute multiple controlled substances, including fentanyl and fentanyl analogues, and seven counts of manufacturing and distributing the drugs in specific instances. Yan allegedly operated websites selling acetyl fentanyl and other deadly fentanyl analogues directly to U.S. customers in multiple cities across the country.

Yan also operated at least two chemical plants in China that were capable of producing ton quantities of fentanyl and fentanyl analogues. Yan monitored legislation and law enforcement activities in the United States and China, modifying the chemical structure of the fentanyl analogues he produced to evade prosecution in the United States.

Over the course of the investigation, federal agents identified more than 100 distributors of synthetic opioids involved with Yan’s manufacturing and distribution networks. Federal investigations of the distributors are ongoing in 10 judicial districts.

Jian Zhang, 38, of China, five Canadian citizens, two residents of Florida, and a resident of New Jersey were indicted in the District of North Dakota for conspiracy to distribute fentanyl and fentanyl analogues in the United States. Zhang allegedly ran an organization that manufactured fentanyl in at least four known labs in China and advertised and sold fentanyl to U.S. customers over the Internet.

Elizabeth Ton, 26, and Anthony Gomes, 33, both of Davie, Florida were arrested. On Oct. 12, Darius Ghahary, 48, of Ramsey, New Jersey was arrested. Ton, Gomes, and Ghahary are charged with drug trafficking conspiracy in the Zhang indictment.

The investigations revealed a new and disturbing facet of the opioid crisis in America: fentanyl and fentanyl analogues are coming into the United States in numerous ways, including highly pure shipments of fentanyl from factories in China directly to U.S. customers who purchase it on the Internet.

“Zhang and Yan are the first Chinese nationals designated as Consolidated Priority Organization Targets (CPOTs),” said Deputy Attorney General Rosenstein. “CPOTs are among the most significant drug trafficking threats in the world.” Twenty-one individuals in total have been indicted on federal drug charges in both North Dakota and Oregon as part of the investigation.

Panel Allows “Interrogatory” in Comp Litigation

On March 18, 2015, Margaret Nadey submitted a Workers’ Compensation Form DWC-1 to her employer Pleasant Valley State Prison, claiming injury to her right shoulder. She later filed an application for adjudication, claiming she suffered a specific injury to her shoulders and lower extremities  on November 11, 2014 while employed by defendant as a nurse.

Defendant sent Nadey a letter stating: “Pursuant to Labor Code section 4663(d), we hereby request disclosure of ALL permanent disabilities or physical impairments that existed prior to the injury.”

Labor Code section 4663(d) states: “An employee who claims an industrial injury shall, upon request, disclose all previous permanent disabilities or physical impairments.”

After Nadey and her attorney failed to respond, defendant filed a Motion to Compel, seeking to compel applicant to respond to the letters it had sent. The WCJ issued a ruling denying the Motion to Compel and the defendant filed a Petition for Removal. A panel reversed and remanded the issue in the case of Nadey v Pleasant Valley State Prison.

The Report of the WCJ in opposition to removal appeared to suggest that defendant should be required to depose applicant if defendant wishes to obtain information about applicant’s prior disabilities. The WCAB panel found “no support for this contention in the language of the statute, which states clearly and unequivocally that applicant “shall” disclose such information ‘upon request.’ “

The panel went on to note that “If the Legislature intended such information to be only discoverable at a deposition, it would not have worded the statute in the manner it did. Moreover, we see little sense in mandating that such a basic disclosure be accomplished via the costly and time-consuming method of taking a deposition.”

“We note that the Petition to Compel Disclosure does not include a timeframe for response, or mandate any particular method of response. We will therefore return the matter to the trial level for further proceedings. We suggest the parties confer among themselves and resolve the details amicably in a mutually satisfactory manner; if the parties cannot do so, they make seek a hearing before the WCJ, who can then determine the details of how applicant shall make the required Labor Code section 4663(d) disclosures.”

Fallout from 60 Minutes Opiate Expose Hits Proposed Drug Czar

Over the weekend, “60 Minutes” broadcast a story describing how a change in federal law last year curbed the ability of the Drug Enforcement Administration to freeze suspicious narcotic shipments from those companies.

Joe Rannazzisi, former head of the Office of Diversion Control for the DEA, was interviewed. He said members of Congress and the drug industry ultimately overcame earlier objections from law enforcement and won the day.

And it turned out that Trump’s nominee to head the Office of National Drug Control Policy championed the industry-friendly legislation that vexed lawman Rannazzisi. Rep. Tom Marino (R-Pa.), the nominee, helped steer the drive to go easier on the drug companies.

And there was substantial fallout from the story. President Donald Trump tweeted Tuesday that Rep. Tom Marino, a Pennsylvania Republican, has withdrawn his name from consideration to become the nation’s next drug czar. A replacement candidate will have to be picked.

Sen. Joe Manchin (D-W.Va.) was among those calling for the withdrawal on Monday. Before Trump’s announcement Tuesday, Manchin, who represents one of the hardest-hit states in the epidemic, told CNN’s Chris Cuomo on “New Day” that Marino’s bill “allowed hundreds and hundreds of thousands of people get killed.”

“Over my dead body will he be the drug czar,” he said.

“There’s no way that in having the title of the drug czar that you’ll be taken seriously or effectively by anyone in West Virginia and the communities that have been affected by this knowing that you were involved in something that had this type of effect,” Manchin said.

The congressman’s withdrawal comes after a joint CBS “60 Minutes” and Washington Post report revealed that Marino took nearly $100,000 from the pharmaceutical lobby while sponsoring a bill that made it easier for drug companies to distribute opioids across American communities and thwart the Drug Enforcement Agency.

Trump spoke with radio host Brian Kilmeade following Marino’s decision. “He told me, look, if there is even a perception that he has a conflict of interest with insurance companies, essentially, but if there is even a perception of a conflict of interest, he doesn’t want anything to do with it,” Trump said.

It was not immediately clear what Trump meant when he referred to insurance companies. “There was a couple of articles having to do with him and drug companies and I will tell you, he felt compelled, he feels very strong about the opioid problem,” the President added. “Tom Marino said, ‘Look, I’ll take a pass, I have no choice, I really will take a pass, I want to do it.'”

60 Minutes – Washington Post Investigates 2016 Opioid Friendly Law

According to a joint explosive investigative report by “60 Minutes”  that aired this Sunday and the concurrent story published the same day by  the Washington Post, at the height of the deadliest drug epidemic in U.S. history, Congress effectively stripped the Drug Enforcement Administration in April 2016 of its potent weapon against large drug companies suspected of spilling prescription narcotics onto the nation’s streets.

The law was the crowning achievement of a multifaceted campaign by the drug industry to weaken aggressive DEA enforcement efforts against drug distribution companies that were supplying corrupt doctors and pharmacists who peddled narcotics to the black market. The industry worked behind the scenes with lobbyists and key members of Congress, pouring more than a million dollars into their election campaigns.

The chief advocate of the law that hobbled the DEA was Rep. Tom Marino, a Pennsylvania Republican who is now President Trump’s nominee to become the nation’s next drug czar. Marino spent years trying to move the law through Congress. It passed after Sen. Orrin G. Hatch (R-Utah) negotiated a final version with the DEA.

Marino declined repeated requests for comment. Marino’s staff called the U.S. Capitol Police when The Post and “60 Minutes” tried to interview the congressman at his office on Sept. 12. In the past, the congressman has said the DEA was too aggressive and needed to work more collaboratively with drug companies.

For years, some drug distributors were fined for repeatedly ignoring warnings from the DEA to shut down suspicious sales of hundreds of millions of pills, while they racked up billions of dollars in sales.The new law makes it virtually impossible for the DEA to freeze suspicious narcotic shipments from the companies.

Political action committees representing the industry contributed at least $1.5 million to the 23 lawmakers who sponsored or co-sponsored four versions of the bill, including nearly $100,000 to Marino and $177,000 to Hatch. Overall, the drug industry spent $106 million lobbying Congress on the bill and other legislation between 2014 and 2016, according to lobbying reports.

“The drug industry, the manufacturers, wholesalers, distributors and chain drugstores, have an influence over Congress that has never been seen before,” said Joseph T. Rannazzisi, who ran the DEA’s division responsible for regulating the drug industry and led a decade-long campaign of aggressive enforcement until he was forced out of the agency in 2015. “I mean, to get Congress to pass a bill to protect their interests in the height of an opioid epidemic just shows me how much influence they have.”

Besides the sponsors and co-sponsors of the bill, few lawmakers knew the true impact the law would have. It sailed through Congress and was passed by unanimous consent, a parliamentary procedure reserved for bills considered to be noncontroversial. The White House was equally unaware of the bill’s import when President Barack Obama signed it into law, according to interviews with former senior administration officials.

Top officials at the White House and the Justice Department have declined to discuss how the bill came to pass. Loretta E. Lynch, who was attorney general at the time, declined a recent interview request. Obama also declined to discuss the law.

A senior DEA official said the agency fought the bill for years in the face of growing pressure from key members of Congress and industry lobbyists. But the DEA lost the battle and eventually was forced to accept a deal it did not want.

The DEA and Justice Department have denied or delayed more than a dozen requests filed by The Post and “60 Minutes” under the Freedom of Information Act for public records that might shed additional light on the matter. Some of those requests have been pending for nearly 18 months. The Post is now suing the Justice Department in federal court for some of those records.

The successful effort of the opiate drug industry was also related to inside information on the DEA strategies obtained by the drug industry as a result of the “revolving door” of former DEA attorneys and investigators hired by the drug industry. At least 46 investigators, attorneys and supervisors from the DEA, including 32 directly from the division that regulates the drug industry, have been hired by the pharmaceutical industry since the scrutiny on distributors began.

Among them, Linden Barber, former associate chief council at the DEA. He’s now a senior vice president at Cardinal Health, one of the nation’s top drug distributors. Mike Gill, chief of staff for the former acting DEA administrator, was hired by one of the country’s largest healthcare law firms. And most recently, Jason Hadges, a senior DEA attorney overseeing enforcement, joined the pharmaceutical division of a high-powered D.C. law firm.

Soon after the report aired on “60 Minutes” Sen. Claire McCaskill announced she will push to repeal the 2016 law. The ranking member on the Senate Homeland Security and Governmental Affairs Committee, said her legislation is being introduced in response to the joint Washington Post and “60 Minutes” investigation.

State of Emergency Declared Over Hepatitis A Outbreak

Gov. Jerry Brown declared a state of emergency over the deadly hepatitis A outbreak in California. An increase in the incidence of infectious diseases related to geographic risk may give rise to industrial injury claims under several theories of California law on AOE-COE.

The emergency proclamation, which was issued by Brown on Friday, allows the state to increase its supply of hepatitis A vaccines in order to control the current outbreak.

The Los Angeles County Department of Public Health declared a local outbreak of hepatitis A in September. San Diego and Santa Cruz have also declared local outbreaks.

According to the CDPH, there have been a total of 18 deaths so far – all in the San Diego area, which has reported 490 cases of hepatitis A and 342 hospitalizations. The CDPH said the Santa Cruz area has 71 reported cases and 33 hospitalizations; Los Angeles has 8 reported cases and 6 hospitalizations; and other regions in California have 7 reported cases and 5 hospitalizations. This brings the total number of cases in the state to 576 with 386 hospitalizations.

California is experiencing the largest hepatitis A outbreak in the United States transmitted from person to person – instead of by contaminated food – since the vaccine became available in 1996. According to the CDPH, the hepatitis A virus is spread when the virus is ingested by mouth from contact with hands, objects, food or drinks that are contaminated by the feces of an infected person.

The Department of Industrial Relations has a webpage dedicated to the topic of “Protecting Workers from Hepatitis A.” As part of their duty to correct unsafe or unhealthy conditions in the workplace (title 8 section 3203), The DIR says “employers should ask their local health departments whether hepatitis A vaccinations should be offered to employees who are at increased risk and if so, whether the local health department is available to assist.”

Employers must ensure that workplace restrooms are kept clean and sanitary (title 8 section 1526 in construction and section 3364 for other workplaces). Additional cleaning may be needed if persons outside of the workplace who are at greatest risk for hepatitis A infection (i.e., homeless persons or persons using illicit drugs) have used or have had access to workplace restrooms. The County of San Diego Department of Environmental Health has posted Hepatitis A Disinfection Guidelines.

Cal/OSHA is encouraging employers and workers at risk of exposure to the hepatitis A virus to review preventive measures posted online.In outbreak locations, workers who have direct contact with persons who are homeless or use illicit drugs have an increased risk of hepatitis A exposure in settings that include the following:

– Health care and laboratory
– Public safety and emergency medical services
– Sanitation and janitorial
– Homeless services and substance use treatment facilities

A person can be exposed to the hepatitis A virus after coming into contact with objects, food or drinks contaminated by an infected person. Employers should maintain a clean and sanitary workplace and provide proper handwashing facilities and protective equipment.

DWC Suspends 3 More Providers for Fraud

The Division of Workers’ Compensation (DWC) has suspended three more medical providers from participating in California’s workers’ compensation system, bringing the total number of providers suspended this year to 49.

DWC Acting Administrative Director George Parisotto issued Orders of Suspension against the following providers:

1) Samuel H. Albert of Tustin, psychiatrist, pled guilty in the U.S. District Court for the Central District of California on June 20, 2016 to conspiracy to commit health care fraud. Albert had submitted over $4.2 million in fraudulent claims to the Federal Office of Workers’ Compensation Programs.

2) Barry Julian Broomberg of San Diego, physician and owner of La Jolla Medical Associates, pled guilty in the U.S. District Court for the Southern District of California on September 4, 2013 to visa fraud, and surrendered his Physician’s and Surgeon’s Certificate on September 9, 2014. Broomberg knowingly made false statements under penalty of perjury on visa applicants’ Report of Medical Examination and Vaccination Record forms (United States Citizenship and Immigration Services Form I-693) without performing the required tests and examinations.

3) Robert E. Brizendine of San Diego, psychologist, surrendered his Psychologist’s License to the California Board of Psychology on March 20, 2014.

New law requires the division’s Administrative Director to suspend any medical provider, physician or practitioner from participating in the workers’ compensation system in circumstances as described above.

DWC Adjusts OMFS Inpatient Hospital Section

The Division of Workers’ Compensation (DWC) has posted an adjustment to the inpatient hospital section of the Official Medical Fee Schedule (OMFS) to conform to changes in the 2018 Medicare payment system as required by Labor Code section 5307.1.

The effective date of the changes is December 1, 2017. Further information and adjustments to the inpatient hospital section of the Official Medical Fee Schedule can be found on the DWC website’s OMFS page.

The Medicare FY18 update to the inpatient prospective payment system was published on August 14, 2017 in the Federal Register (Vol. 82 FR 37990) and is entitled “Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2018 Rates; Quality reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Program Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Provider-Based Status of Indian Health Services and Tribal Facilities and Organizations; Costs Reporting and Provider Requirements; Agreement Termination Notices” (CMS-1677-F).

Corrections to the final rule were published on October 4, 2017, in the Federal Register (Vol. 82 FR 46138, CMS-1677-CN – Final rule; correction). These documents are available online.

Rancho Mirage Surgeon Sentenced to 20 Years for $44M Fraud

A Rancho Mirage cosmetic surgeon who has been on the run for four months after pleading guilty in a scheme that duped health insurance companies into paying tens of millions of dollars for procedures that were not medically necessary was sentenced in absentia to 20 years in federal prison.

Dr. David M. Morrow, 72, a former Rancho Mirage resident whose current whereabouts are unknown, was sentenced by United States District Judge Josephine L. Staton. Judge Staton imposed the sentence after Morrow pleaded guilty last year to conspiracy to commit mail fraud and filing a false tax return.

Judge Staton noted that Morrow’s “greed knew no bounds,” and that he showed an “utter disregard for patients’ well-being and safety.” As part of the sentencing, Judge Staton found that the intended loss from Morrow’s scheme was $44,265,211.

“This defendant was a successful doctor who owned a medical clinic and multiple valuable residences, yet he engaged in a scheme designed to steal tens of millions of dollars from insurance companies by tricking them into paying for cosmetic surgery,” said Acting United States Attorney Sandra R. Brown. “After admitting guilt, he went on the lam in the hopes of avoiding the punishment that was sure to come. When he is taken into custody – and he will definitely be captured – he will serve the lengthy sentence he deserves as a result of his greed and fraud.”

Morrow, a dermatologist-turned-cosmetic-surgeon who was the owner of the Morrow Institute (TMI) in Rancho Mirage, specifically admitted that he submitted millions of dollars in claims for procedures that he certified were “medically necessary” – but in fact were cosmetic procedures. In some cases, according to court documents, patients underwent procedures they did not want in exchange for promises from Morrow that he would perform the cosmetic procedures that they really wanted.

When he pleaded guilty in March 2016, Morrow admitted participating in a health care fraud scheme, which included submitting altered documents to private insurance companies that claimed various procedures were “medically necessary” to induce insurers to pay for them. The guilty pleas followed a grand jury indictment two years ago that alleged Morrow, his wife, and TMI lured patients to the Coachella Valley surgery center with promises that cosmetic procedures would be paid for by their union or PPO health insurance plans. The victim health insurance companies included Anthem Blue Cross, Blue Cross/Blue Shield of California, Blue Cross/Blue Shield of Massachusetts, Regional Employer/Employee Partnership for Benefits, formerly known as Riverside Employer/Employee Partnership (REEP), and Cigna.

Some of the insurance companies refused to pay for patients who were employed by public entities. According to prosecutors, the Morrows then made claims against those entities, demanding more than $15 million from the California Highway Patrol, Desert Sands Unified School District, Palm Springs Unified School District and the city of Palm Springs.

Morrow and his wife are believed to have fled in May 2017. Prior to becoming fugitives, they failed to report to court officials, among other things, the sale of their $9.45 million home in Beverly Hills. Last month, prosecutors filed notice with the court that Morrow had breached his plea agreement by becoming a fugitive.

Charges against Morrow’s wife, Linda Morrow, 65, are currently pending.

The investigation into the Morrows and TMI was conducted by the Federal Bureau of Investigation, IRS – Criminal Investigation, and the California Department of Insurance.