A Carson woman has been sentenced to 156 months in federal prison in an $8 million Medicare fraud case in which she illegally paid kickbacks for referrals to patients whose beneficiary information was used to make bogus claims to the government health care program.
Uben Ogbu Rush, 54, received the 13-year sentence from United States District Judge George H. King. During the sentencing hearing, Judge King said Rush was motivated by greed and the lengthy sentence was necessary, in part, to send a message of deterrence to others who might commit crimes against Medicare.
Rush owned or controlled six companies that ostensibly sold durable medical equipment, such as motorized wheelchairs and powered pressure-reducing mattresses. The companies were located in Carson, Gardena, Torrance, and Paramount.
At a trial in November 2011, federal prosecutors showed a jury how Rush paid marketers to recruit Medicare beneficiaries who would allow their identities and Medicare numbers to be used for the submission of false claims. The evidence also showed how Rush paid kickbacks to marketers, who in turn paid kickbacks to doctors who fraudulently wrote prescriptions, even though the physicians had not examined the patients or an examination revealed that the medical equipment was not medically necessary.
During the course of a scheme that ran from 1999 until 2008, Rush submitted more than $15 million in fraudulent claims to Medicare seeking payment for motorized wheelchairs, hospital beds, air pressure mattresses, and other items for patients who did not need the equipment. Medicare paid more than $8.1 on the bogus claims.
A co-defendant in the case, Carlos Alberto Rezabala, 60, of Downey, was sentenced by Judge King in June 2012 to 41 months in federal prison. Rezabala was a recruiter who brought Medicare beneficiaries into the scheme so their information could be used to submit fraudulent bills.
Another co-defendant, Phitsamay Syvoravong, 58, of Orange County, another recruiter who brought Medicare beneficiaries into the scheme, is scheduled to be sentenced by Judge King on May 20.
A related defendant, Dr. Alfred Glover, 57, of Playa Vista, testified at trial that he was paid for writing fraudulent prescriptions for Medicare beneficiaries, many of whom he never saw. Glover is schedule to be sentenced on May 28.
The investigation into Rush and her Medicare fraud scheme was conducted by the Federal Bureau of Investigation ...
Uben Ogbu Rush, 54, received the 13-year sentence from United States District Judge George H. King. During the sentencing hearing, Judge King said Rush was motivated by greed and the lengthy sentence was necessary, in part, to send a message of deterrence to others who might commit crimes against Medicare.
Rush owned or controlled six companies that ostensibly sold durable medical equipment, such as motorized wheelchairs and powered pressure-reducing mattresses. The companies were located in Carson, Gardena, Torrance, and Paramount.
At a trial in November 2011, federal prosecutors showed a jury how Rush paid marketers to recruit Medicare beneficiaries who would allow their identities and Medicare numbers to be used for the submission of false claims. The evidence also showed how Rush paid kickbacks to marketers, who in turn paid kickbacks to doctors who fraudulently wrote prescriptions, even though the physicians had not examined the patients or an examination revealed that the medical equipment was not medically necessary.
During the course of a scheme that ran from 1999 until 2008, Rush submitted more than $15 million in fraudulent claims to Medicare seeking payment for motorized wheelchairs, hospital beds, air pressure mattresses, and other items for patients who did not need the equipment. Medicare paid more than $8.1 on the bogus claims.
A co-defendant in the case, Carlos Alberto Rezabala, 60, of Downey, was sentenced by Judge King in June 2012 to 41 months in federal prison. Rezabala was a recruiter who brought Medicare beneficiaries into the scheme so their information could be used to submit fraudulent bills.
Another co-defendant, Phitsamay Syvoravong, 58, of Orange County, another recruiter who brought Medicare beneficiaries into the scheme, is scheduled to be sentenced by Judge King on May 20.
A related defendant, Dr. Alfred Glover, 57, of Playa Vista, testified at trial that he was paid for writing fraudulent prescriptions for Medicare beneficiaries, many of whom he never saw. Glover is schedule to be sentenced on May 28.
The investigation into Rush and her Medicare fraud scheme was conducted by the Federal Bureau of Investigation ...
A former Riverside Transit Authority worker has pleaded guilty to worker’s comp fraud charges. RTA issued a statement that George Bateman, 46, of Corona pleaded guilty March 7 to one count of insurance fraud, resulting in 180 days in jail and a $5,000 fine. He was sentenced on May 30.
According to the story in the Press Enterprise, Bateman was placed on permanent disability in February 2012 after complaining of neck, shoulder and back pain. DA investigators began monitoring Bateman following his medical leave and reports of fraud. During the investigation, which combined the efforts of both RTA and the DA’s office, Bateman was observed operating his own limousine service, and he was videotaped driving, handling customer luggage, lifting bags of ice, tire rims and cases of water without any sign of restriction. Employees who are on TTD are required to report any outside income. Bateman did not report any income from his limousine business.
Roughly 360 RTA employees are covered by workers' compensation, which provides for medical treatment and loss of earnings that result from work-related injuries.
"Workers’ compensation fraud is not a victimless crime,"said RTA Chairman of the Board Marion Ashley. "We are committed to detecting and deterring fraud in workers’ compensation by any means possible."
The Riverside District Attorney’s Office has a designated unit of two deputy district attorneys and six senior investigators who are specially tasked to investigate and prosecute workers’ compensation fraud. Because of the huge impact this type of fraud has on the community it is one of District Attorney Paul Zellerbach’s priorities since he’s been in office ...
According to the story in the Press Enterprise, Bateman was placed on permanent disability in February 2012 after complaining of neck, shoulder and back pain. DA investigators began monitoring Bateman following his medical leave and reports of fraud. During the investigation, which combined the efforts of both RTA and the DA’s office, Bateman was observed operating his own limousine service, and he was videotaped driving, handling customer luggage, lifting bags of ice, tire rims and cases of water without any sign of restriction. Employees who are on TTD are required to report any outside income. Bateman did not report any income from his limousine business.
Roughly 360 RTA employees are covered by workers' compensation, which provides for medical treatment and loss of earnings that result from work-related injuries.
"Workers’ compensation fraud is not a victimless crime,"said RTA Chairman of the Board Marion Ashley. "We are committed to detecting and deterring fraud in workers’ compensation by any means possible."
The Riverside District Attorney’s Office has a designated unit of two deputy district attorneys and six senior investigators who are specially tasked to investigate and prosecute workers’ compensation fraud. Because of the huge impact this type of fraud has on the community it is one of District Attorney Paul Zellerbach’s priorities since he’s been in office ...
CMS published a new 88-page reference guide for Workers' Compensation Medicare Set-Asides (WCMSAs). The publication's purpose is to serve as a reference guide for claimants, attorneys, WCMSA consultants and others by consolidating information from previous CMS WCMSA Regional Office (RO) Memorandums and other information on the CMS website. For more comprehensive information, readers are requested to continue to refer to the WCMSA RO Memorandums.
The format of the guide (with version numbers, version history and paragraph numbers) is structured to make it expandable for future updates. This guide is in response to users requests for CMS to provide clearer guidance on the WCMSA program.
This guide was written to help litigants understand CMS’ Workers’ Compensation Medicare Set - Aside Arrangement (WCMSA) amount approval process and to serve as a reference for those electing to submit such proposals to CMS for approval. Submitters of arrangements may include injured workers themselves, their attorneys, Workers’ Compensation Medicare Set-Aside Arrangement agents or consultants, or claimants’ other appointed representatives. This guide reflects information compiled from all WCMSA Regional Office (RO) Memorandums issued by CMS, and from information provided on the CMS website.
A WCMSA allocates a portion of the WC settlement for all future work injury related medical expenses that are covered and otherwise reimbursable by Medicare. When a proposed WCMSA amount is submitted to CMS for review and the individual or beneficiary obtains CMS’approval, the CMS - approved WCMSA amount must be appropriately exhausted before Medicare will begin to pay for care related to the beneficiary’s settlement, judgment, award, or other payment.
The goal of establishing a WCMSA is to estimate, as accurately as possible, the total cost that will be incurred for all medical expenses otherwise reimbursable by Medicare for work-related conditions during the course of the claimant’s life, and to set aside sufficient funds from the settlement, judgment, or award to cover that cost. WCMSAs may be funded by a lump sum or may be structured, such that a fixed amount of funds are provided each year for a fixed number of years.
Any claimant who receives a WC settlement, judgment, or award that includes an amount for future medical expenses must take Medicare’s interest with respect to future medicals into account. If Medicare’s interests are not considered, CMS has a priority right of recovery against any entity that received a portion of a third party payment either directly or indirectly. Medicare may also refuse to pay for future medical expenses related to the WC injury until the entire settlement is exhausted. These arrangements are typically not created until the individual’s condition has stabilized so that it can be determined, based on past experience, what the future medical expenses may be.
Once the CMS-approved set-aside amount is exhausted and accurately accounted for to CMS, Medicare will pay primary for future Medicare-covered expenses related to the WC injury that exceed the approved set-aside amount.
To view the new WCMSA reference guide, click here ...
The format of the guide (with version numbers, version history and paragraph numbers) is structured to make it expandable for future updates. This guide is in response to users requests for CMS to provide clearer guidance on the WCMSA program.
This guide was written to help litigants understand CMS’ Workers’ Compensation Medicare Set - Aside Arrangement (WCMSA) amount approval process and to serve as a reference for those electing to submit such proposals to CMS for approval. Submitters of arrangements may include injured workers themselves, their attorneys, Workers’ Compensation Medicare Set-Aside Arrangement agents or consultants, or claimants’ other appointed representatives. This guide reflects information compiled from all WCMSA Regional Office (RO) Memorandums issued by CMS, and from information provided on the CMS website.
A WCMSA allocates a portion of the WC settlement for all future work injury related medical expenses that are covered and otherwise reimbursable by Medicare. When a proposed WCMSA amount is submitted to CMS for review and the individual or beneficiary obtains CMS’approval, the CMS - approved WCMSA amount must be appropriately exhausted before Medicare will begin to pay for care related to the beneficiary’s settlement, judgment, award, or other payment.
The goal of establishing a WCMSA is to estimate, as accurately as possible, the total cost that will be incurred for all medical expenses otherwise reimbursable by Medicare for work-related conditions during the course of the claimant’s life, and to set aside sufficient funds from the settlement, judgment, or award to cover that cost. WCMSAs may be funded by a lump sum or may be structured, such that a fixed amount of funds are provided each year for a fixed number of years.
Any claimant who receives a WC settlement, judgment, or award that includes an amount for future medical expenses must take Medicare’s interest with respect to future medicals into account. If Medicare’s interests are not considered, CMS has a priority right of recovery against any entity that received a portion of a third party payment either directly or indirectly. Medicare may also refuse to pay for future medical expenses related to the WC injury until the entire settlement is exhausted. These arrangements are typically not created until the individual’s condition has stabilized so that it can be determined, based on past experience, what the future medical expenses may be.
Once the CMS-approved set-aside amount is exhausted and accurately accounted for to CMS, Medicare will pay primary for future Medicare-covered expenses related to the WC injury that exceed the approved set-aside amount.
To view the new WCMSA reference guide, click here ...
California's former Fair Employment and Housing Commission adopted new disability regulations that are in effect as of January 1, 2013. These regulations directly impact workers’ compensation cases by requiring that an employer initiate an interactive process if "an employer or other covered entity becomes aware of the possible need for an accommodation because the employee has exhausted leave under the California Workers’ Compensation Act..." in addition to imposing significant other new obligations on employers related to employees suffering from a work related or non- work related injury/disability.
Floyd, Skeren and Kelly is pleased to announce its 3rd Annual Employment Law Conference, to be held on May 9, 2013 at the Disneyland Hotel, which will feature as keynote speaker, Phyllis Cheng, Director of the California Department of Fair Employment and Housing (DFEH). Ms. Cheng, will review these important new disability regulations including the following key points:
Floyd, Skeren and Kelly is pleased to announce its 3rd Annual Employment Law Conference, to be held on May 9, 2013 at the Disneyland Hotel, which will feature as keynote speaker, Phyllis Cheng, Director of the California Department of Fair Employment and Housing (DFEH). Ms. Cheng, will review these important new disability regulations including the following key points:
- A Review of the Expanded Definition of a Disability
- Examples of Qualifying Physical and Mental Disabilities
- Clarification on Who is a "Qualified" Individual with a Disability?
- Heightened Emphasis on Engaging in Interactive Process
- Clarification on Employer Interactive Process Obligations
- New Interactive Process Requirements in Work Comp Cases
- New Reasonable Accommodation Guidelines and Examples
- Transfer to an Alternative/Vacant Position as an Accommodation
- New Obligations Related to Job Descriptions
- New Procedures Related to Medical Certifications
- Medical Leave of Absence Obligations
- Termination Issues Related to Disabled Employees
On April 26, 2009, applicant Luis Enriquez was working on a farm when he was gored by a bull, ultimately resulting in his death. Mercy Air Services provided air ambulance services by airlifting Enriquez from the injury site to a hospital in Modesto, a distance of about 26 miles. Mercy billed Zenith in the amount of $11,132.93. Pursuant to AD Rule 9789.70(a), Zenith reimbursed Mercy in the amount of $4,756.42.
Administrative Director Rule 9789.70(a) provides, in relevant part, that "[t]he maximum reasonable fee for ambulance services rendered after January 1, 2004 shall not exceed 120% of the applicable fee for the Calendar Year 2004 set forth in CMS’s Ambulance Fee Schedule, which is established pursuant to Section 1834 of the Social Security Act (42 U.S.C. § 1395m) and applicable to California." (Cal. Code Regs., tit.8, § 9789.70.)
The workers’ compensation judge concluded that, to the extent it purports to apply to air ambulance services covered by the federal Airline Deregulation Act of 1978 ("ADA"), AD Rule 9789.70 is preempted by federal law. The WCJ therefore found that "on April 26, 2009, [AD Rule 9789.70] did not apply to the provision of air ambulance services[,]" and that "lien claimant Mercy Air Services has established that the reasonable value of its services on behalf of defendant’s employee Luis Enriquez on April 26, 2009 is $11,132.93." The WCJ ordered Zenith Insurance Company to pay that sum to Mercy.
Zenith petitioned for reconsideration in the case of Luis Enriquez (deceased) v Couto Dairy and Zenith Insurance Company, contending that (1) by making a substantive ruling on preemption, the WCJ exceeded his authority under the California Constitution; (2) the WCJ erred in concluding that AD Rule 9789.70 is preempted by the ADA; and (3) if the ADA preempts Rule 9789.70, it also preempts Labor Code section 4600, in which case Zenith allegedly "owes Mercy nothing."
An amicus brief and request for an en banc decision was filed by California Shock Trauma Air Rescue and Reach Air Medical Services, two air ambulance companies who allege they have hundreds of pending lien claims similar to Mercy’s.
Article III, section 3.5(c) of the California Constitution declares that "[a]n administrative agency ... has no power ... [t]o declare a statute unenforceable, or to refuse to enforce a statute on the basis that federal law ... prohibit[s] the enforcement of such statute unless an appellate court has made a determination that the enforcement of such statute is prohibited by federal law ..." (Italics added.). The WCAB noted however that "it has no bearing on the Appeals Board’s ability to declare a regulation preempted by federal law. This is because the provision refers only to an administrative agency’s lack of power "[t]o declare a statute unenforceable[.]" As further discussed below, we are finding preemption of AD Rule 9789.70, a regulation".
However, the WCAB concluded that Mercy has the burden of showing that it is an air carrier subject to the provisions of the ADA. In order to be considered an "air carrier" under the ADA’s preemption provision, the air ambulance provider must show all of the following: (1) it is a "citizen of the United States undertaking by any means, directly or indirectly, to provide air transportation" (49 U.S.C. § 40102(a)(2); (2) it provides foreign, interstate, or mail transportation by air as a common carrier (49 U.S.C. § 40102(a)(5), (25));13 and (3) it is subject to regulation under 49 U.S.C. §§ 41101 et seq. (Med-Trans Corp., supra, 581 F.Supp.2d at 731-732.) Of course, air ambulance liens do not involve either foreign air transportation or the transportation of mail. Therefore, the essential question is whether the air ambulance "may provide" interstate air transportation.In this case, the record requires clarification as to whether Mercy is an “air carrier that may provide air transportation” within the meaning of the preemption provision of the ADA ...
Administrative Director Rule 9789.70(a) provides, in relevant part, that "[t]he maximum reasonable fee for ambulance services rendered after January 1, 2004 shall not exceed 120% of the applicable fee for the Calendar Year 2004 set forth in CMS’s Ambulance Fee Schedule, which is established pursuant to Section 1834 of the Social Security Act (42 U.S.C. § 1395m) and applicable to California." (Cal. Code Regs., tit.8, § 9789.70.)
The workers’ compensation judge concluded that, to the extent it purports to apply to air ambulance services covered by the federal Airline Deregulation Act of 1978 ("ADA"), AD Rule 9789.70 is preempted by federal law. The WCJ therefore found that "on April 26, 2009, [AD Rule 9789.70] did not apply to the provision of air ambulance services[,]" and that "lien claimant Mercy Air Services has established that the reasonable value of its services on behalf of defendant’s employee Luis Enriquez on April 26, 2009 is $11,132.93." The WCJ ordered Zenith Insurance Company to pay that sum to Mercy.
Zenith petitioned for reconsideration in the case of Luis Enriquez (deceased) v Couto Dairy and Zenith Insurance Company, contending that (1) by making a substantive ruling on preemption, the WCJ exceeded his authority under the California Constitution; (2) the WCJ erred in concluding that AD Rule 9789.70 is preempted by the ADA; and (3) if the ADA preempts Rule 9789.70, it also preempts Labor Code section 4600, in which case Zenith allegedly "owes Mercy nothing."
An amicus brief and request for an en banc decision was filed by California Shock Trauma Air Rescue and Reach Air Medical Services, two air ambulance companies who allege they have hundreds of pending lien claims similar to Mercy’s.
Article III, section 3.5(c) of the California Constitution declares that "[a]n administrative agency ... has no power ... [t]o declare a statute unenforceable, or to refuse to enforce a statute on the basis that federal law ... prohibit[s] the enforcement of such statute unless an appellate court has made a determination that the enforcement of such statute is prohibited by federal law ..." (Italics added.). The WCAB noted however that "it has no bearing on the Appeals Board’s ability to declare a regulation preempted by federal law. This is because the provision refers only to an administrative agency’s lack of power "[t]o declare a statute unenforceable[.]" As further discussed below, we are finding preemption of AD Rule 9789.70, a regulation".
However, the WCAB concluded that Mercy has the burden of showing that it is an air carrier subject to the provisions of the ADA. In order to be considered an "air carrier" under the ADA’s preemption provision, the air ambulance provider must show all of the following: (1) it is a "citizen of the United States undertaking by any means, directly or indirectly, to provide air transportation" (49 U.S.C. § 40102(a)(2); (2) it provides foreign, interstate, or mail transportation by air as a common carrier (49 U.S.C. § 40102(a)(5), (25));13 and (3) it is subject to regulation under 49 U.S.C. §§ 41101 et seq. (Med-Trans Corp., supra, 581 F.Supp.2d at 731-732.) Of course, air ambulance liens do not involve either foreign air transportation or the transportation of mail. Therefore, the essential question is whether the air ambulance "may provide" interstate air transportation.In this case, the record requires clarification as to whether Mercy is an “air carrier that may provide air transportation” within the meaning of the preemption provision of the ADA ...
United Parcel Service agreed to forfeit $40 million to settle a probe into its shipments on behalf of illicit online pharmacies. According to the story in the Wall Street Journal, the deal was the latest move in the U.S. government's expanding crackdown on illegal sales of prescription painkillers. More than 16,000 people died of opioid overdoses in 2010, according to the Centers for Disease Control and Prevention.
Under the agreement between UPS and the U.S. attorney's office in San Francisco, the company won't be prosecuted. The Justice Department said UPS cooperated with investigators and has already made changes "to ensure that illegal Internet pharmacies can no longer use its services to ship drugs.'' UPS spokesman Bill Tanner said: "We believe we have an obligation and responsibility to help curb the sale and shipment of drugs sold through illegal Internet pharmacies.'' In addition to paying $40 million to the government, the company "has agreed to enhance its compliance policies with respect to Internet pharmacy shippers," he said.
The Drug Enforcement Administration has also been probing FedEx over similar issues, but FedEx wasn't part of the settlement announced Friday. The Justice Department said it has been looking into Internet pharmacies' use of shipping companies between 2003 and 2010.
Last year, a FedEx spokesman called the government investigation "absurd and deeply disturbing," saying drug agents wanted to "deputize" FedEx delivery workers to catch criminals, which he said wasn't their job.
After the UPS settlement was announced Friday, FedEx spokesman Patrick Fitzgerald said the company is confident it is complying with federal law. "It is unclear what federal laws UPS may have violated," he said. The company is ready to support law enforcement and is trying to persuade the DEA to provide a list of suspect pharmacies "so we can immediately shut off shipping services to those pharmacies," he said.
UPS and FedEx, the nation's two biggest shipping companies, were served with subpoenas starting more than four years ago, according to their public disclosures. Last year, a lawyer for FedEx said the company was informed by the Justice Department that it could soon face criminal charges. The company said it was innocent and planned to contest any charges.
UPS opted instead to negotiate a settlement. According to court papers filed as part of the settlement, UPS employees had numerous exchanges showing they were aware of legal problems surrounding many Internet pharmacies. As a result, UPS workers were told they couldn't offer discounted pricing to such customers.
In August 2005, a law-enforcement drug task force in Virginia wrote to UPS security officials expressing concern about the company's delivery practices there, citing evidence the company was making deliveries in parking lots and roadsides to customers of the Internet pharmacies."Your drivers and managers already know who these people and locations are," the letter said. The government said UPS continued to make such deliveries after receiving the letter ...
Under the agreement between UPS and the U.S. attorney's office in San Francisco, the company won't be prosecuted. The Justice Department said UPS cooperated with investigators and has already made changes "to ensure that illegal Internet pharmacies can no longer use its services to ship drugs.'' UPS spokesman Bill Tanner said: "We believe we have an obligation and responsibility to help curb the sale and shipment of drugs sold through illegal Internet pharmacies.'' In addition to paying $40 million to the government, the company "has agreed to enhance its compliance policies with respect to Internet pharmacy shippers," he said.
The Drug Enforcement Administration has also been probing FedEx over similar issues, but FedEx wasn't part of the settlement announced Friday. The Justice Department said it has been looking into Internet pharmacies' use of shipping companies between 2003 and 2010.
Last year, a FedEx spokesman called the government investigation "absurd and deeply disturbing," saying drug agents wanted to "deputize" FedEx delivery workers to catch criminals, which he said wasn't their job.
After the UPS settlement was announced Friday, FedEx spokesman Patrick Fitzgerald said the company is confident it is complying with federal law. "It is unclear what federal laws UPS may have violated," he said. The company is ready to support law enforcement and is trying to persuade the DEA to provide a list of suspect pharmacies "so we can immediately shut off shipping services to those pharmacies," he said.
UPS and FedEx, the nation's two biggest shipping companies, were served with subpoenas starting more than four years ago, according to their public disclosures. Last year, a lawyer for FedEx said the company was informed by the Justice Department that it could soon face criminal charges. The company said it was innocent and planned to contest any charges.
UPS opted instead to negotiate a settlement. According to court papers filed as part of the settlement, UPS employees had numerous exchanges showing they were aware of legal problems surrounding many Internet pharmacies. As a result, UPS workers were told they couldn't offer discounted pricing to such customers.
In August 2005, a law-enforcement drug task force in Virginia wrote to UPS security officials expressing concern about the company's delivery practices there, citing evidence the company was making deliveries in parking lots and roadsides to customers of the Internet pharmacies."Your drivers and managers already know who these people and locations are," the letter said. The government said UPS continued to make such deliveries after receiving the letter ...
A federal qui tam whistle-blower lawsuit filed in 2008 by former University of California-Irvine (UCI) Professor and Anesthesiologist Dr. Dennis O'Connor triggered a multi-year investigation by the United States Department of Justice, resulting in an agreement by the California Board of Regents to pay the United States $1.2 Million.
The False Claims Act lawsuit alleged that anesthesia was routinely administered at UCI by Certified Registered Nurse Anesthetists (CRNAs) or residents when there was no supervisory anesthesiologist present or immediately available, in violation of federal regulations. The complaint alleged that, in many instances, the supervisory anesthesiologist would be in a completely different building at the time, and that anesthesia records would be "pre-filled" to make it appear that the anesthesiologist was present. The complaint also alleged that required post-operative evaluations would routinely be performed by unsupervised and/or unlicensed residents, in violation of federal regulations, increasing the likelihood that post-operative complications would be missed.
In the Settlement Agreement with UCI, the United States contended that "it has certain civil claims against the Regents arising out of ... the submission of claims by or on behalf of the Regents for payment by the Medicare program and the federal portion of the Medicaid program for anesthesia services performed at UCI in a manner inconsistent with federal healthcare program documentation requirements for those services, or inconsistent with federal healthcare program payment requirements for supervision of residents or CRNAs." The Regents agreed to pay $1.2 Million to the United States to resolve such claims. UC Regents denied the allegations.
According to the story in the Los Angeles Times, the UCI Medical Center had come under fire in the past for similar accusations. The medical center was placed under state supervision in 2008 because of the anesthesiology department's "inability to provide quality healthcare in a safe environment," according to a federal report. Among the most serious failings federal inspectors cited was filling out reports in advance of care.
In 2008, the California Medical Board accused the former head of the anesthesiology department, Peter Breen, of gross negligence and incompetence. Two years later, the medical board gave him a public reprimand for writing that a patient was "stable" and "comfortable" during each phase of the procedure before anesthesia had been administered. Breen was ordered to take ethics and medical record-keeping courses. He also was reprimanded by the Illinois Department of Professional Regulation. Breen, who remains at UCI, did not return phone calls or an email Wednesday.
The UCI statement said "new leadership took over and transformed" the anesthesiology department in 2008, putting in place new training and policies, including "an electronic record keeping system that does not permit the practices alleged."
O'Connor, who now works at the Veterans Administration Hospital in Long Beach, remains wary of UCI Medical Center. "I won't go there, and I wouldn't take my family there," he said.
The medical center has suffered a number of scandals in the last 18 years. In 1995, fertility doctors were accused of stealing patients' eggs and embryos and implanting them in other women without permission. In 2005, the hospital shut its liver transplant program after federal funding was withdrawn. The action came after The Times reported that 32 people died awaiting livers, even as doctors turned down organs that later were transplanted elsewhere ...
The False Claims Act lawsuit alleged that anesthesia was routinely administered at UCI by Certified Registered Nurse Anesthetists (CRNAs) or residents when there was no supervisory anesthesiologist present or immediately available, in violation of federal regulations. The complaint alleged that, in many instances, the supervisory anesthesiologist would be in a completely different building at the time, and that anesthesia records would be "pre-filled" to make it appear that the anesthesiologist was present. The complaint also alleged that required post-operative evaluations would routinely be performed by unsupervised and/or unlicensed residents, in violation of federal regulations, increasing the likelihood that post-operative complications would be missed.
In the Settlement Agreement with UCI, the United States contended that "it has certain civil claims against the Regents arising out of ... the submission of claims by or on behalf of the Regents for payment by the Medicare program and the federal portion of the Medicaid program for anesthesia services performed at UCI in a manner inconsistent with federal healthcare program documentation requirements for those services, or inconsistent with federal healthcare program payment requirements for supervision of residents or CRNAs." The Regents agreed to pay $1.2 Million to the United States to resolve such claims. UC Regents denied the allegations.
According to the story in the Los Angeles Times, the UCI Medical Center had come under fire in the past for similar accusations. The medical center was placed under state supervision in 2008 because of the anesthesiology department's "inability to provide quality healthcare in a safe environment," according to a federal report. Among the most serious failings federal inspectors cited was filling out reports in advance of care.
In 2008, the California Medical Board accused the former head of the anesthesiology department, Peter Breen, of gross negligence and incompetence. Two years later, the medical board gave him a public reprimand for writing that a patient was "stable" and "comfortable" during each phase of the procedure before anesthesia had been administered. Breen was ordered to take ethics and medical record-keeping courses. He also was reprimanded by the Illinois Department of Professional Regulation. Breen, who remains at UCI, did not return phone calls or an email Wednesday.
The UCI statement said "new leadership took over and transformed" the anesthesiology department in 2008, putting in place new training and policies, including "an electronic record keeping system that does not permit the practices alleged."
O'Connor, who now works at the Veterans Administration Hospital in Long Beach, remains wary of UCI Medical Center. "I won't go there, and I wouldn't take my family there," he said.
The medical center has suffered a number of scandals in the last 18 years. In 1995, fertility doctors were accused of stealing patients' eggs and embryos and implanting them in other women without permission. In 2005, the hospital shut its liver transplant program after federal funding was withdrawn. The action came after The Times reported that 32 people died awaiting livers, even as doctors turned down organs that later were transplanted elsewhere ...
The Division of Workers’ Compensation (DWC) has posted updated fact sheets for injured workers on its website. The updated fact sheets provide injured workers with answers to frequently asked questions about issues affecting their benefits, and include changes mandated by Senate Bill 863.
"The fact sheets help injured workers and other parties understand the sometimes complicated process of workers’ compensation," said DWC acting Administrative Director Destie Overpeck. "We have updated the fact sheets to reflect the changes made by SB 863."
The fact sheets cover such topics as temporary disability benefits, permanent disability benefits, supplemental job displacement benefits, and medical care. They are available to employers and insurers who are required to comply with benefit notice regulations.
The updated fact sheets are available for immediate use in English and Spanish ...
"The fact sheets help injured workers and other parties understand the sometimes complicated process of workers’ compensation," said DWC acting Administrative Director Destie Overpeck. "We have updated the fact sheets to reflect the changes made by SB 863."
The fact sheets cover such topics as temporary disability benefits, permanent disability benefits, supplemental job displacement benefits, and medical care. They are available to employers and insurers who are required to comply with benefit notice regulations.
The updated fact sheets are available for immediate use in English and Spanish ...
A federal government watchdog has issued a warning about the risk for fraud when doctors buy an ownership interest in a medical device distributor and then share in its profits from sales to hospitals.
In its March 20 report, the Department of Health and Human Services, Office of Inspector General issued a "Special Fraud Alert" that addresses physician-owned entities that derive revenue from selling, or arranging for the sale of, implantable medical devices ordered by their physician-owners for use in procedures the physician-owners perform on their own patients at hospitals or ambulatory surgical centers (ASCs).
These entities frequently are referred to as physician-owned distributorships, or "PODs." A "POD" is any physician-owned entity that derives revenue from selling, or arranging for the sale of, implantable medical devices and includes physician-owned entities that purport to design or manufacture, typically under contractual arrangements, their own medical devices or instrumentation. Although this Special Fraud Alert focuses on PODs that derive revenue from selling, or arranging for the sale of, implantable medical devices, the same principles would apply when evaluating arrangements involving other types of physician-owned entities.
PODs are most commonly used in orthopedics.
Longstanding OIG guidance makes clear that the opportunity for a referring physician to earn a profit, including through an investment in an entity for which he or she generates business, could constitute illegal remuneration under the anti-kickback statute. The anti-kickback statute is violated if even one purpose of the remuneration is to induce such referrals.
OIG has repeatedly expressed concerns about arrangements that exhibit questionable features with regard to the selection and retention of investors, the solicitation of capital contributions, and the distribution of profits. Such questionable features may include, but are not limited to: (1) selecting investors because they are in a position to generate substantial business for the entity, (2) requiring investors who cease practicing in the service area to divest their ownership interests, and (3) distributing extraordinary returns on investment compared to the level of risk involved. PODs that exhibit any of these or other questionable features potentially raise four major concerns typically associated with kickbacks - corruption of medical judgment, overutilization, increased costs to the Federal health care programs and beneficiaries, and unfair competition. The OIG does not believe that disclosure to a patient of the physician’s financial interest in a POD is sufficient to address these concerns.
OIG is concerned about the proliferation of PODs. This Special Fraud Alert reiterates our longstanding position that the opportunity for a referring physician to earn a profit, including through an investment in an entity for which he or she generates business, could constitute illegal remuneration under the anti-kickback statute. OIG views PODs as inherently suspect under the anti-kickback statute ...
In its March 20 report, the Department of Health and Human Services, Office of Inspector General issued a "Special Fraud Alert" that addresses physician-owned entities that derive revenue from selling, or arranging for the sale of, implantable medical devices ordered by their physician-owners for use in procedures the physician-owners perform on their own patients at hospitals or ambulatory surgical centers (ASCs).
These entities frequently are referred to as physician-owned distributorships, or "PODs." A "POD" is any physician-owned entity that derives revenue from selling, or arranging for the sale of, implantable medical devices and includes physician-owned entities that purport to design or manufacture, typically under contractual arrangements, their own medical devices or instrumentation. Although this Special Fraud Alert focuses on PODs that derive revenue from selling, or arranging for the sale of, implantable medical devices, the same principles would apply when evaluating arrangements involving other types of physician-owned entities.
PODs are most commonly used in orthopedics.
Longstanding OIG guidance makes clear that the opportunity for a referring physician to earn a profit, including through an investment in an entity for which he or she generates business, could constitute illegal remuneration under the anti-kickback statute. The anti-kickback statute is violated if even one purpose of the remuneration is to induce such referrals.
OIG has repeatedly expressed concerns about arrangements that exhibit questionable features with regard to the selection and retention of investors, the solicitation of capital contributions, and the distribution of profits. Such questionable features may include, but are not limited to: (1) selecting investors because they are in a position to generate substantial business for the entity, (2) requiring investors who cease practicing in the service area to divest their ownership interests, and (3) distributing extraordinary returns on investment compared to the level of risk involved. PODs that exhibit any of these or other questionable features potentially raise four major concerns typically associated with kickbacks - corruption of medical judgment, overutilization, increased costs to the Federal health care programs and beneficiaries, and unfair competition. The OIG does not believe that disclosure to a patient of the physician’s financial interest in a POD is sufficient to address these concerns.
OIG is concerned about the proliferation of PODs. This Special Fraud Alert reiterates our longstanding position that the opportunity for a referring physician to earn a profit, including through an investment in an entity for which he or she generates business, could constitute illegal remuneration under the anti-kickback statute. OIG views PODs as inherently suspect under the anti-kickback statute ...
Even with the volume of job injury claims reported by California public self-insured entities hovering near a 10-year low last year, total paid and incurred workers' compensation claim costs for cities, counties and other public agencies in the state remained near their 10-year highs according to a California Workers' Compensation Institute (CWCI) analysis of data from the Office of Self-Insurance Plans (OSIP).
The OSIP summary of public self-insured data for fiscal year 2011/2012, dated March 5, provides the first snapshot of public self-insured claims experience - including the number of claims, total loss payments and total incurred (paid losses plus reserves) -- for the 12 months ending June 30, 2012. The agency compiles the data annually from reports submitted by hundreds of public self-insured entities other than the state itself, including cities and counties, local fire, school, transit, utility and special districts and joint powers authorities. The new summary shows that in FY 2011/2012, these employers provided workers' compensation coverage to 1.9 million California public workers whose wages and salaries totaled $96 billion for the year.
CWCI compared the latest results to those included in the initial report from the prior year and found almost no change (-0.3%) in the number of employees covered by public self-insured employers. Likewise, overall public self-insured claim frequency held steady at 6.2 claims per 100 employees, with no change in the incidence of either medical-only or indemnity claims. Though claim frequency was unchanged, and last year's first report claim count was the second lowest tally of the last decade, public self-insured employers' paid losses for FY 2011/2012 still amounted to nearly $340 million. That total was within 1 percent of the 10-year high recorded in FY 2010/2011 first reports and was nearly $80 million (or about 30%) more than the post-reform low recorded in the FY 2005/2006 first reports.
Calculating the first report average paid losses by benefit type, CWCI found that the $80 million increase in public self-insured loss payments over the past six years is associated with increased claim severity (average loss per claim) as average paid indemnity at the first report rose nearly 30% from a post-reform low $1,112 in FY 2005/2006 to $1,441 on last year's claims, while over the same period the average paid for medical climbed 32.5% from the post-reform low of $1,073 to $1,422 last year.
The incurred data show a similar pattern, with incurred losses for California public self-insured employers totaling $1.1 billion in the FY 2011/2012 first reports, $244 million (28.6%) more than the post-reform low of $853 million noted in the FY 2005/2006 first reports, even though the number of claims is down. As with the paid loss data, the incurred results indicated that the increase in first report total incurred losses over the past 6 years are associated with rising claim severity, as the average incurred indemnity at first report jumped 19.5% from $3,106 in FY 2005/2006 to $3,713 last year, while average incurred medical at first report on public S-I claims rose more than 36% from $4,065 to $5,539.
CWCI ‘s analysis of the OSIP public self-insured data tracks changes in the volume and frequency of California public self-insured claims, and examines the 10-year trends in the total and average paid and incurred amounts for these claims ...
The OSIP summary of public self-insured data for fiscal year 2011/2012, dated March 5, provides the first snapshot of public self-insured claims experience - including the number of claims, total loss payments and total incurred (paid losses plus reserves) -- for the 12 months ending June 30, 2012. The agency compiles the data annually from reports submitted by hundreds of public self-insured entities other than the state itself, including cities and counties, local fire, school, transit, utility and special districts and joint powers authorities. The new summary shows that in FY 2011/2012, these employers provided workers' compensation coverage to 1.9 million California public workers whose wages and salaries totaled $96 billion for the year.
CWCI compared the latest results to those included in the initial report from the prior year and found almost no change (-0.3%) in the number of employees covered by public self-insured employers. Likewise, overall public self-insured claim frequency held steady at 6.2 claims per 100 employees, with no change in the incidence of either medical-only or indemnity claims. Though claim frequency was unchanged, and last year's first report claim count was the second lowest tally of the last decade, public self-insured employers' paid losses for FY 2011/2012 still amounted to nearly $340 million. That total was within 1 percent of the 10-year high recorded in FY 2010/2011 first reports and was nearly $80 million (or about 30%) more than the post-reform low recorded in the FY 2005/2006 first reports.
Calculating the first report average paid losses by benefit type, CWCI found that the $80 million increase in public self-insured loss payments over the past six years is associated with increased claim severity (average loss per claim) as average paid indemnity at the first report rose nearly 30% from a post-reform low $1,112 in FY 2005/2006 to $1,441 on last year's claims, while over the same period the average paid for medical climbed 32.5% from the post-reform low of $1,073 to $1,422 last year.
The incurred data show a similar pattern, with incurred losses for California public self-insured employers totaling $1.1 billion in the FY 2011/2012 first reports, $244 million (28.6%) more than the post-reform low of $853 million noted in the FY 2005/2006 first reports, even though the number of claims is down. As with the paid loss data, the incurred results indicated that the increase in first report total incurred losses over the past 6 years are associated with rising claim severity, as the average incurred indemnity at first report jumped 19.5% from $3,106 in FY 2005/2006 to $3,713 last year, while average incurred medical at first report on public S-I claims rose more than 36% from $4,065 to $5,539.
CWCI ‘s analysis of the OSIP public self-insured data tracks changes in the volume and frequency of California public self-insured claims, and examines the 10-year trends in the total and average paid and incurred amounts for these claims ...
Three lawsuits from former National Football League players who are seeking California workers compensation benefits have been consolidated in U.S. District Court in San Francisco after a request from the NFL and several teams.
According to the story on the Business Insurance website, the cases involve 67 former NFL players who want to vacate a December 2012 arbitration award that requires them to withdraw workers comp claims in California, according to court records. The players played for the Buffalo Bills, Denver Broncos, New York Giants and Philadelphia Eagles.
California law allows NFL players to make a claim in California if they have played at least one game in the state. The plaintiffs argue that the arbitration award violates California and federal law and public policy by waiving their ability to seek workers comp in California, records show.
U.S. District Court Judge William H. Alsup ordered the three cases to be consolidated on March 13. The NFL Management Council and the four NFL teams filed a countersuit on March 8 asking the court to require the players to file any workers comp claims in the state specified by their respective player contracts.
The California comp lawsuits are part of several claims being made against the NFL by former players seeking compensation for injuries suffered on the field. At least 2,400 former players have sued the league over neurological and cognitive problems that they allege were caused by football-related head injuries. Most of the concussion-related cases have been consolidated into multidistrict litigation in the U.S. District Court in Philadelphia. The NFL is expected to use an exclusive remedy defense in those lawsuits ...
According to the story on the Business Insurance website, the cases involve 67 former NFL players who want to vacate a December 2012 arbitration award that requires them to withdraw workers comp claims in California, according to court records. The players played for the Buffalo Bills, Denver Broncos, New York Giants and Philadelphia Eagles.
California law allows NFL players to make a claim in California if they have played at least one game in the state. The plaintiffs argue that the arbitration award violates California and federal law and public policy by waiving their ability to seek workers comp in California, records show.
U.S. District Court Judge William H. Alsup ordered the three cases to be consolidated on March 13. The NFL Management Council and the four NFL teams filed a countersuit on March 8 asking the court to require the players to file any workers comp claims in the state specified by their respective player contracts.
The California comp lawsuits are part of several claims being made against the NFL by former players seeking compensation for injuries suffered on the field. At least 2,400 former players have sued the league over neurological and cognitive problems that they allege were caused by football-related head injuries. Most of the concussion-related cases have been consolidated into multidistrict litigation in the U.S. District Court in Philadelphia. The NFL is expected to use an exclusive remedy defense in those lawsuits ...
The Division of Workers’ Compensation’s lien filing fee payment system has been updated as of March 2, 2013 so that JET Filers can pay the required filing fee and file their liens in one integrated process.
JET Filers who filed liens requiring payment of the filing fee between Jan. 1 and March 2, 2013 but did not pay the fee are reminded that Labor Code Section 4903.05(c)(2) provides that liens that are filed or lodged prior to payment of the required fee are deemed invalid.
DWC had previously advised JET Filers to file their liens and then use the public search tool to pay the filing fees. JET Filers who have filed liens between Jan. 1 and March 2, 2013 but failed to pay the fee are advised that the public search payment option for those liens will not be available after April 5, 2013 at 5 p.m. All lien claimants using JET File are now able to use the new integrated process.
JET Filers who have questions about the payment of lien filing fees should consult the DWC website ...
JET Filers who filed liens requiring payment of the filing fee between Jan. 1 and March 2, 2013 but did not pay the fee are reminded that Labor Code Section 4903.05(c)(2) provides that liens that are filed or lodged prior to payment of the required fee are deemed invalid.
DWC had previously advised JET Filers to file their liens and then use the public search tool to pay the filing fees. JET Filers who have filed liens between Jan. 1 and March 2, 2013 but failed to pay the fee are advised that the public search payment option for those liens will not be available after April 5, 2013 at 5 p.m. All lien claimants using JET File are now able to use the new integrated process.
JET Filers who have questions about the payment of lien filing fees should consult the DWC website ...
A former Oxnard police officer pleaded guilty Monday to two counts of workers’ compensation fraud and was ordered to pay $70,000 in restitution to the state. According to the report in the Ventura County Star, 28 year old Edward Idukas handed over a check during the court proceedings to cover the full amount, prosecutor Ernesto Acosta said.
Ventura County Superior Court Judge Kevin McGee set sentencing for June 13. Idukas faces up to four years behind bars but will not likely get a harsh sentence, Acosta said. "Other than committing workers’ compensation fraud, he doesn’t have anything else on his record," Acosta said. "The guy is a former cop."
Outside the courtroom, Idukas’ lawyer, David S. Kestenbaum, said his client was remorseful. "He’s lost his whole career and had to move his family out of state and picked up a new career. This is all he wanted to be: a police officer," Kestenbaum said. "I hope in the interest of justice the judge reduces it to a misdemeanor and doesn’t impose jail. He’s suffered a lot as a result of his mistake. But before that he had done a lot of good for the community and received a lot of commendations ... from the Oxnard PD."
Idukas was placed on temporary total disabled status after he told a supervisor on Dec. 29, 2009, that he hurt his back while bending over at his locker and had pain and limited mobility, according to court records. He received disability pay for several months.
Investigators discovered Idukas was playing baseball weekly in a local adult league while receiving disability benefits from the city of Oxnard, according to court records. While these activities were taking place, Idukas told doctors and physical therapists that he was too disabled to return to his duties as a police officer, prosecutors said.
Kestenbaum said he thinks Idukas, who was arrested in June 2011, is innocent. But he was offered a good plea bargain, so he took it, Kestenbaum said. "He was not hiding what he was doing and felt he had received bad advice - that he could resume playing baseball to strengthen his back," Kestenbaum said. "From our standpoint, there is a big difference in playing baseball, where you can say timeout if your back hurts, than being in a squad car in El Rio and there is no timeout in the field. Psychologically, he didn’t feel he could be a police officer (with a back injury). That was one of the problems." ...
Ventura County Superior Court Judge Kevin McGee set sentencing for June 13. Idukas faces up to four years behind bars but will not likely get a harsh sentence, Acosta said. "Other than committing workers’ compensation fraud, he doesn’t have anything else on his record," Acosta said. "The guy is a former cop."
Outside the courtroom, Idukas’ lawyer, David S. Kestenbaum, said his client was remorseful. "He’s lost his whole career and had to move his family out of state and picked up a new career. This is all he wanted to be: a police officer," Kestenbaum said. "I hope in the interest of justice the judge reduces it to a misdemeanor and doesn’t impose jail. He’s suffered a lot as a result of his mistake. But before that he had done a lot of good for the community and received a lot of commendations ... from the Oxnard PD."
Idukas was placed on temporary total disabled status after he told a supervisor on Dec. 29, 2009, that he hurt his back while bending over at his locker and had pain and limited mobility, according to court records. He received disability pay for several months.
Investigators discovered Idukas was playing baseball weekly in a local adult league while receiving disability benefits from the city of Oxnard, according to court records. While these activities were taking place, Idukas told doctors and physical therapists that he was too disabled to return to his duties as a police officer, prosecutors said.
Kestenbaum said he thinks Idukas, who was arrested in June 2011, is innocent. But he was offered a good plea bargain, so he took it, Kestenbaum said. "He was not hiding what he was doing and felt he had received bad advice - that he could resume playing baseball to strengthen his back," Kestenbaum said. "From our standpoint, there is a big difference in playing baseball, where you can say timeout if your back hurts, than being in a squad car in El Rio and there is no timeout in the field. Psychologically, he didn’t feel he could be a police officer (with a back injury). That was one of the problems." ...
Liberty Mutual Holding Co. Inc. was the largest workers compensation insurer nationwide in 2012 with about $4.2 billion in direct written premiums, according to the latest market share report by the National Association of Insurance Commissioners.
Boston-based Liberty Mutual held 8.73% of the workers comp market for 2012, according to data published Monday by Washington-based NAIC.
Travelers Cos. Inc. was the second-largest comp insurer with 7.94% of the market, or $3.8 billion in direct written premiums, while The Hartford Financial Services Group Inc. held the third-largest share with 6.86% of the market, or nearly $3.3 billion in written premiums.
American International Group Inc. held 6.16% of last year’s comp market with nearly $3 billion in written premiums, and Zurich Insurance Co. Ltd. captured 5.79% of the market with $2.8 billion in premiums.
The list of top 25 workers comp insurers, as well as other property/casualty insurance lines is available on the NAIC’s website. The tentative data is scheduled to be finalized by the end of this month ...
Boston-based Liberty Mutual held 8.73% of the workers comp market for 2012, according to data published Monday by Washington-based NAIC.
Travelers Cos. Inc. was the second-largest comp insurer with 7.94% of the market, or $3.8 billion in direct written premiums, while The Hartford Financial Services Group Inc. held the third-largest share with 6.86% of the market, or nearly $3.3 billion in written premiums.
American International Group Inc. held 6.16% of last year’s comp market with nearly $3 billion in written premiums, and Zurich Insurance Co. Ltd. captured 5.79% of the market with $2.8 billion in premiums.
The list of top 25 workers comp insurers, as well as other property/casualty insurance lines is available on the NAIC’s website. The tentative data is scheduled to be finalized by the end of this month ...
Claims administrators are reminded that the 2013 annual report of inventory (ARI) for claims reported in calendar year 2012 is due to be submitted to the Division of Workers' Compensation (DWC) Audit Unit no later than April 1, 2013.
The California Code of Regulations,title 8, section 10104 requires claims administrators to file an annual report of inventory (ARI) with the number of claims reported at each adjusting location for the preceding calendar year. Even if there were no claims reported in 2013, the report must be completed and submitted to the DWC Audit Unit. Each adjusting location is required to submit an ARI, whether or not they receive a form for reporting claims from the Audit Unit, unless their ARI requirement has been waived by the AD.
In 2011, the Audit Unit began requesting the federal employer identification number (FEIN) for each adjusting location and for all underwriting companies and/or clients for which claims are administered at the given location. A claims administrator’s obligation to submit an ARI can be waived if the AD determines that they are in compliance with electronic data reporting requirements of the Workers’ Compensation Information System (WCIS). FEIN information will be used by the DWC Research Unit to match claims information submitted electronically to the WCIS with that reported to the Audit Unit on the ARI. This will allow the AD to waive ARI requirements for claims administrators, as appropriate.
When ARI requirements are waived, claims administrators must file an annual report of adjusting locations. This report is to be filed annually on April 1 of each calendar year for the adjusting location operations as of Dec. 31 of the prior year. DWC has provided a form which can be used for this purpose.
Claims administrators are also required to report any change in the information reported in the ARI or annual report of adjusting location within 45 days of the effective date of the change.
The forms for the required 2013 ARI and annual report of adjusting locations, along with advice for claims administrators, are posted on the website.
Questions about submission of the ARI or the annual report of adjusting locations may be directed to the DWC Audit Unit by email, phone or U.S. mail: to the State of California Department of Industrial Relations, Division of Workers’ Compensation - Audit Unit, 160 Promenade Circle, Suite #340, Sacramento, CA 95834-2962. E-mail: DWCAuditUnit@dir.ca.gov., Facsimile: 916.928.3183. Telephone inquiry: 916.928.3180 ...
The California Code of Regulations,title 8, section 10104 requires claims administrators to file an annual report of inventory (ARI) with the number of claims reported at each adjusting location for the preceding calendar year. Even if there were no claims reported in 2013, the report must be completed and submitted to the DWC Audit Unit. Each adjusting location is required to submit an ARI, whether or not they receive a form for reporting claims from the Audit Unit, unless their ARI requirement has been waived by the AD.
In 2011, the Audit Unit began requesting the federal employer identification number (FEIN) for each adjusting location and for all underwriting companies and/or clients for which claims are administered at the given location. A claims administrator’s obligation to submit an ARI can be waived if the AD determines that they are in compliance with electronic data reporting requirements of the Workers’ Compensation Information System (WCIS). FEIN information will be used by the DWC Research Unit to match claims information submitted electronically to the WCIS with that reported to the Audit Unit on the ARI. This will allow the AD to waive ARI requirements for claims administrators, as appropriate.
When ARI requirements are waived, claims administrators must file an annual report of adjusting locations. This report is to be filed annually on April 1 of each calendar year for the adjusting location operations as of Dec. 31 of the prior year. DWC has provided a form which can be used for this purpose.
Claims administrators are also required to report any change in the information reported in the ARI or annual report of adjusting location within 45 days of the effective date of the change.
The forms for the required 2013 ARI and annual report of adjusting locations, along with advice for claims administrators, are posted on the website.
Questions about submission of the ARI or the annual report of adjusting locations may be directed to the DWC Audit Unit by email, phone or U.S. mail: to the State of California Department of Industrial Relations, Division of Workers’ Compensation - Audit Unit, 160 Promenade Circle, Suite #340, Sacramento, CA 95834-2962. E-mail: DWCAuditUnit@dir.ca.gov., Facsimile: 916.928.3183. Telephone inquiry: 916.928.3180 ...
The U.S. Supreme Court will hear arguments today over whether big drug companies can settle patent litigation with generic rivals by making deals to keep cheaper products off the market. U.S. and state regulators say the practice costs consumers, insurers and government billions of dollars annually.
The story in Reuters Health says that the Federal Trade Commission, which has dubbed the arrangements "pay for delay," has fought them in court for more than a decade with mixed success, culminating in the case now before the U.S. Supreme Court. "The continuing stream of monopoly profits is large enough to pay the generic competitors more than they could hope to earn if they entered the market at competitive prices," the FTC said in a brief. At the same time, the brand-name manufacturer receives greater profits than it could earn in the face of generic competition, the regulatory agency argued.
The Justice Department, the European Union and more than two dozen U.S. state attorneys general view the deals as illegal, but drug companies defend them as a way to avoid potentially lengthy patent litigation. "In every case that we've been involved in that resulted in a settlement, it has resulted in years being taken off the patent life," said Paul Bisaro, chief executive of generic drug maker Actavis, Inc. Actavis was formerly Watson Pharmaceuticals. "It's very unsophisticated to say 'Oh, they get paid a bunch of money to stay off the market,'" said Bisaro.
In the case before the court, Solvay Pharmaceuticals Inc, now owned by AbbVie, sued generic drug makers Watson, Paddock Laboratories Inc and Par Pharmaceutical Cos in 2003 to stop them from making cheaper versions of AndroGel, which is used to treat men with low testosterone. The firms settled in 2006, reaching a deal that generic AndroGel would not be marketed until 2015. The patent expires in 2020. In exchange, the FTC alleges, the generic manufacturers were each paid as much as $30 million annually. AbbVie's 2012 sales of AndroGel totaled $1.2 billion.
Solvay internal documents dating from April 2006 which were released at the Supreme Court on Friday, show that months before the companies struck their deal, Solvay concluded that it would make about $1.4 billion from AndroGel if it won the court fight and $359 million if it did not. The documents also show what appear to be a list of ideas of what to offer the generic firms to make it attractive to them to settle and delay entry. One was to allow Watson to promote the drug to urologists, while Solvay would not.
AbbVie spokeswoman Adelle Infante described the papers as "a single document among hundreds of thousands of pages of documents that were provided to the FTC." "This internal analysis is insignificant because the negotiated patent settlement led to generic entry years in advance of the expiration of the patent, she said. The company also said that it expected to prevail. "The federal district and appellate courts have both previously ruled that the plaintiff's allegations lacked merit. We are confident that these decisions will be upheld," Adelle Infante, an AbbVie spokeswoman, said in a statement.
AbbVie's arrangement with the generic manufacturers is similar to the 40 deals made in the 2012 fiscal year, which ended on September 30. That was up from 28 the previous year, despite FTC efforts to stop them. The FTC said the agreements involved 31 different brand-name drugs with total U.S. sales of more than $8.3 billion annually. The FTC sued to stop the AndroGel arrangement, arguing that it was illegal under antitrust law because the companies divided up the market. The FTC lost at the district court level and lost an appeal as well. But another appellate court has said the deals were illegal, prompting the Supreme Court to step in.
The Supreme Court is expected to issue a decision by the end of June ...
The story in Reuters Health says that the Federal Trade Commission, which has dubbed the arrangements "pay for delay," has fought them in court for more than a decade with mixed success, culminating in the case now before the U.S. Supreme Court. "The continuing stream of monopoly profits is large enough to pay the generic competitors more than they could hope to earn if they entered the market at competitive prices," the FTC said in a brief. At the same time, the brand-name manufacturer receives greater profits than it could earn in the face of generic competition, the regulatory agency argued.
The Justice Department, the European Union and more than two dozen U.S. state attorneys general view the deals as illegal, but drug companies defend them as a way to avoid potentially lengthy patent litigation. "In every case that we've been involved in that resulted in a settlement, it has resulted in years being taken off the patent life," said Paul Bisaro, chief executive of generic drug maker Actavis, Inc. Actavis was formerly Watson Pharmaceuticals. "It's very unsophisticated to say 'Oh, they get paid a bunch of money to stay off the market,'" said Bisaro.
In the case before the court, Solvay Pharmaceuticals Inc, now owned by AbbVie, sued generic drug makers Watson, Paddock Laboratories Inc and Par Pharmaceutical Cos in 2003 to stop them from making cheaper versions of AndroGel, which is used to treat men with low testosterone. The firms settled in 2006, reaching a deal that generic AndroGel would not be marketed until 2015. The patent expires in 2020. In exchange, the FTC alleges, the generic manufacturers were each paid as much as $30 million annually. AbbVie's 2012 sales of AndroGel totaled $1.2 billion.
Solvay internal documents dating from April 2006 which were released at the Supreme Court on Friday, show that months before the companies struck their deal, Solvay concluded that it would make about $1.4 billion from AndroGel if it won the court fight and $359 million if it did not. The documents also show what appear to be a list of ideas of what to offer the generic firms to make it attractive to them to settle and delay entry. One was to allow Watson to promote the drug to urologists, while Solvay would not.
AbbVie spokeswoman Adelle Infante described the papers as "a single document among hundreds of thousands of pages of documents that were provided to the FTC." "This internal analysis is insignificant because the negotiated patent settlement led to generic entry years in advance of the expiration of the patent, she said. The company also said that it expected to prevail. "The federal district and appellate courts have both previously ruled that the plaintiff's allegations lacked merit. We are confident that these decisions will be upheld," Adelle Infante, an AbbVie spokeswoman, said in a statement.
AbbVie's arrangement with the generic manufacturers is similar to the 40 deals made in the 2012 fiscal year, which ended on September 30. That was up from 28 the previous year, despite FTC efforts to stop them. The FTC said the agreements involved 31 different brand-name drugs with total U.S. sales of more than $8.3 billion annually. The FTC sued to stop the AndroGel arrangement, arguing that it was illegal under antitrust law because the companies divided up the market. The FTC lost at the district court level and lost an appeal as well. But another appellate court has said the deals were illegal, prompting the Supreme Court to step in.
The Supreme Court is expected to issue a decision by the end of June ...
The California Workers’ Compensation Insurance Rating Bureau says that California experienced a significant increase in lien filings from workers compensation service providers after the state adopted S.B. 863 in September.
BusinessInsurance.com reports that San Francisco-based WCIRB discussed the impact of S.B. 863 on California's workers comp loss development during an actuarial committee meeting on Wednesday. The bill included several workers comp reform provisions, including a lien filing fee of $150 and a three-year statute of limitations for new lien filings - both of which took effect Jan. 1. Another statute of limitations of 1.5 years for new lien filings will go into effect July 1.
During the fourth quarter of 2012, there were 513,129 lien filings from copy services, interpreters, medical providers and other workers comp services, according to a presentation posted on WCIRB's website. That’s compared with 323,294 liens filed in the third quarter of 2012 and 463,856 liens filed in all of 2011.
WCIRB expects that 640,000 liens will be filed in 2013, according to the rating bureau's presentation. The lien filing fee is expected to reduce the projected number of workers comp liens by 30% and reduce California's comp system costs by $480 million ...
BusinessInsurance.com reports that San Francisco-based WCIRB discussed the impact of S.B. 863 on California's workers comp loss development during an actuarial committee meeting on Wednesday. The bill included several workers comp reform provisions, including a lien filing fee of $150 and a three-year statute of limitations for new lien filings - both of which took effect Jan. 1. Another statute of limitations of 1.5 years for new lien filings will go into effect July 1.
During the fourth quarter of 2012, there were 513,129 lien filings from copy services, interpreters, medical providers and other workers comp services, according to a presentation posted on WCIRB's website. That’s compared with 323,294 liens filed in the third quarter of 2012 and 463,856 liens filed in all of 2011.
WCIRB expects that 640,000 liens will be filed in 2013, according to the rating bureau's presentation. The lien filing fee is expected to reduce the projected number of workers comp liens by 30% and reduce California's comp system costs by $480 million ...
One of two people who were trapped in a 15-foot trench in Pacific Palisades has died. The second worker in the construction project incident was rescued after an effort that lasted more than an hour after firefighters arrived on the scene.
The Los Angeles Times reports that the victims were working for a subcontractor on a storm-water treatment project at 200 Temescal Canyon Road and were excavating the trench, according to the Los Angeles Fire Department.
The worker who was pulled alive from the trench was rushed by ambulance to the nearby beach, where he was met by a helicopter and airlifted to UCLA Medical Center. The Los Angeles County coroner's office identified the dead man as 50 year old Gilbert Vargas. Emergency workers recovered his body after about nine hours of digging in the 200 block of North Temescal Canyon Road, just north of Pacific Coast Highway. Vargas and the unidentified injured man had been excavating with back hoes on a city storm water project.
Peter Melton, a spokesman for Cal-OSHA, said the agency has ordered work stopped at the site until any hazards have been resolved.
The state Division of Occupational Safety and Health has six months to complete its investigation, but Melton said Los Angeles Engineering Inc., the men's employer, "is going to want to get this taken care of as soon as possible to get back to work, if they can get back to work." ...
The Los Angeles Times reports that the victims were working for a subcontractor on a storm-water treatment project at 200 Temescal Canyon Road and were excavating the trench, according to the Los Angeles Fire Department.
The worker who was pulled alive from the trench was rushed by ambulance to the nearby beach, where he was met by a helicopter and airlifted to UCLA Medical Center. The Los Angeles County coroner's office identified the dead man as 50 year old Gilbert Vargas. Emergency workers recovered his body after about nine hours of digging in the 200 block of North Temescal Canyon Road, just north of Pacific Coast Highway. Vargas and the unidentified injured man had been excavating with back hoes on a city storm water project.
Peter Melton, a spokesman for Cal-OSHA, said the agency has ordered work stopped at the site until any hazards have been resolved.
The state Division of Occupational Safety and Health has six months to complete its investigation, but Melton said Los Angeles Engineering Inc., the men's employer, "is going to want to get this taken care of as soon as possible to get back to work, if they can get back to work." ...
An orthopedic surgeon accused of meeting a girl for sex in Novato surrendered his medical license pending the outcome of the criminal case. As a result of the medical license suspension, the Division of Workers' Compensation has also suspended his QME certificate. According to the report in the Marin Independent Journal, 53 year old Raymond Severt M.D. made his initial appearance in Marin Superior Court, where he is charged with four felony sex charges. Deputy District Attorney Aicha Mievis he delayed entering a plea until his next hearing on April 10.
Severt, in stipulating to the suspension of his medical practice, is also barred from prescribing or dispensing drugs, and he must surrender his wall certificates and prescription pads, according to a filing by Deputy Attorney General Brenda Reyes. At the time of his arrest last month Severt worked for Santa Rosa Orthopeadics. He is on leave.
Severt, a Santa Rosa resident, was arrested by Novato police on Feb. 11. The investigation began when police received information that a man was sending sexually explicit messages to the girl and had arranged to meet her in Novato. Investigators intercepted Severt in the area of South Novato Boulevard and Gateway Court. Police said he initially met the girl through an online chat room.
Severt's lawyer, Stephen Turer, said that the girl initially told Severt she was 21 years old. Police allege she later told Severt that she was under 18, but Severt agreed to meet anyway because he did not know which age she was telling the truth about, Turer said. Severt never actually had the chance to meet her and see that she was underage, because police arrested him first, Turer said. "It becomes one of those not-so-unique situations where people get involved online under, at least, ambiguous or confusing circumstances," he said. "It doesn't appear that initially his interest was in young girls," he added. "There's no indication he has any history in any way of soliciting minors. It's unfortunate what he did even if she was 21, given his age, but it's not a crime."
Severt is charged with attempted lewd acts with a child under 14, communicating with a minor for the purpose of lewd behavior, arranging a meeting with a minor for purposes of lewd behavior, and distribution of lewd material to a minor. The latter charge is for the sexually explicit messages he allegedly sent the girl. Severt could face up to four years in prison on charges of attempted lewd acts with a child under 14, communicating with a minor for the purpose of lewd behavior, arranging a meeting with a minor for purposes of lewd behavior, and distribution of lewd material to a minor. The latter charge is for the sexually explicit messages he allegedly sent the girl ...
Severt, in stipulating to the suspension of his medical practice, is also barred from prescribing or dispensing drugs, and he must surrender his wall certificates and prescription pads, according to a filing by Deputy Attorney General Brenda Reyes. At the time of his arrest last month Severt worked for Santa Rosa Orthopeadics. He is on leave.
Severt, a Santa Rosa resident, was arrested by Novato police on Feb. 11. The investigation began when police received information that a man was sending sexually explicit messages to the girl and had arranged to meet her in Novato. Investigators intercepted Severt in the area of South Novato Boulevard and Gateway Court. Police said he initially met the girl through an online chat room.
Severt's lawyer, Stephen Turer, said that the girl initially told Severt she was 21 years old. Police allege she later told Severt that she was under 18, but Severt agreed to meet anyway because he did not know which age she was telling the truth about, Turer said. Severt never actually had the chance to meet her and see that she was underage, because police arrested him first, Turer said. "It becomes one of those not-so-unique situations where people get involved online under, at least, ambiguous or confusing circumstances," he said. "It doesn't appear that initially his interest was in young girls," he added. "There's no indication he has any history in any way of soliciting minors. It's unfortunate what he did even if she was 21, given his age, but it's not a crime."
Severt is charged with attempted lewd acts with a child under 14, communicating with a minor for the purpose of lewd behavior, arranging a meeting with a minor for purposes of lewd behavior, and distribution of lewd material to a minor. The latter charge is for the sexually explicit messages he allegedly sent the girl. Severt could face up to four years in prison on charges of attempted lewd acts with a child under 14, communicating with a minor for the purpose of lewd behavior, arranging a meeting with a minor for purposes of lewd behavior, and distribution of lewd material to a minor. The latter charge is for the sexually explicit messages he allegedly sent the girl ...
The Division of Workers’ Compensation and Workers’ Compensation Appeals Board have revised their Policy and Procedural Manual (PPM) and posted it on the WCAB website.
The PPM is an internal employee guide, prepared under the authority of the administrative director of DWC and the chair of the WCAB. The manual is designed to promote uniformity and provide direction to judges and other employees in the day-to-day operation of DWC’s district offices and the Appeals Board. It is also a resource for attorneys, claims administrators and other parties wanting information on the rules of court. Because it an internal document, the PPM is not subject to regulations, which require formal rulemaking procedures and public hearings.
The PPM became operative in 2003, with some revisions made in the following years. The 2012-13 revisions, which are effective on March 8, were drafted by a committee consisting of Appeals Board Secretary and Deputy Commissioner Rick Dietrich, DWC Chief Judge Richard Newman, Associate Chief Judges Thomas Clarke, Mark Fudem and Ellen Flynn, and Marina del Rey Presiding Judge Paige Levy, who was the project manager.
DWC monitors the administration of workers' compensation claims, and provides administrative and judicial services to assist in resolving disputes that arise in connection with claims for workers' compensation benefits. The WCAB, a seven-member, judicial body appointed by the Governor and confirmed by the Senate, exercises all judicial powers vested in it by the Labor Code. Its major functions include review of petitions for reconsideration of decisions by workers’ compensation administrative law judges of the DWC and regulation of the adjudication process by adopting rules of practice and procedure ...
The PPM is an internal employee guide, prepared under the authority of the administrative director of DWC and the chair of the WCAB. The manual is designed to promote uniformity and provide direction to judges and other employees in the day-to-day operation of DWC’s district offices and the Appeals Board. It is also a resource for attorneys, claims administrators and other parties wanting information on the rules of court. Because it an internal document, the PPM is not subject to regulations, which require formal rulemaking procedures and public hearings.
The PPM became operative in 2003, with some revisions made in the following years. The 2012-13 revisions, which are effective on March 8, were drafted by a committee consisting of Appeals Board Secretary and Deputy Commissioner Rick Dietrich, DWC Chief Judge Richard Newman, Associate Chief Judges Thomas Clarke, Mark Fudem and Ellen Flynn, and Marina del Rey Presiding Judge Paige Levy, who was the project manager.
DWC monitors the administration of workers' compensation claims, and provides administrative and judicial services to assist in resolving disputes that arise in connection with claims for workers' compensation benefits. The WCAB, a seven-member, judicial body appointed by the Governor and confirmed by the Senate, exercises all judicial powers vested in it by the Labor Code. Its major functions include review of petitions for reconsideration of decisions by workers’ compensation administrative law judges of the DWC and regulation of the adjudication process by adopting rules of practice and procedure ...
