The National Insurance Crime Bureau (NICB) just released an analysis of workers’ compensation questionable claims (QC) referrals submitted from Jan. 1, 2011, through June 30, 2013. The report finds that while the total number of WC claims has been decreasing, the percentage that is deemed "questionable" has been rising.
QCs are claims that NICB member insurance companies refer to NICB for closer review and investigation based on one or more indicators of possible fraud. A single claim may contain up to seven referral reasons.
California ranked first generating a total of 2,270 WC QCs. It was followed by Illinois with 689. New York was third with 688.
In 2011, 3,349,925 WC claims were found in the Insurance Services Office (ISO) ClaimSearch® database. That number decreased to 3,244,679 in 2012, and is on track to decrease again in 2013 based on the 1,498,725 claims received in the first half of 2013.
In 2011, 3,474 WC QCs were referred to NICB. That number increased to 4,460 in 2012 - a 28 percent rise. WC QCs accounted for 3.5 percent of the 100,201 QCs submitted in 2011, and increased to 3.8 percent of the 116,171 QCs in 2012. Through the first half of 2013, 2,325 WC CQs have been referred to NICB (3.7 percent of 62,352 total QCs), compared with 1,681 through the first half of 2011 and 2,174 through the first half of 2013.
The distribution of WC QCs follows a standard Monday - Friday workweek with the QCs almost evenly divided during the week with steep drop-offs in the numbers for Saturday and Sunday.
There are several referral reasons from which NICB member companies can select to further describe a QC. The top three referral reasons were the same in each year. First was "claimant fraud" with 6,107. Second was "prior injury/not related to work" with 2,319, and third was "malingering" with 1,380.
An injury not related to work is typically a person who suffers an injury during a recreational or day off activity but fails to report it until at work, thus claiming the injury happened on the job. A malingerer is someone who has suffered a legitimate injury but continues to feign symptoms, thus collecting benefits long after he or she has fully recovered.
The full report is available online ...
QCs are claims that NICB member insurance companies refer to NICB for closer review and investigation based on one or more indicators of possible fraud. A single claim may contain up to seven referral reasons.
California ranked first generating a total of 2,270 WC QCs. It was followed by Illinois with 689. New York was third with 688.
In 2011, 3,349,925 WC claims were found in the Insurance Services Office (ISO) ClaimSearch® database. That number decreased to 3,244,679 in 2012, and is on track to decrease again in 2013 based on the 1,498,725 claims received in the first half of 2013.
In 2011, 3,474 WC QCs were referred to NICB. That number increased to 4,460 in 2012 - a 28 percent rise. WC QCs accounted for 3.5 percent of the 100,201 QCs submitted in 2011, and increased to 3.8 percent of the 116,171 QCs in 2012. Through the first half of 2013, 2,325 WC CQs have been referred to NICB (3.7 percent of 62,352 total QCs), compared with 1,681 through the first half of 2011 and 2,174 through the first half of 2013.
The distribution of WC QCs follows a standard Monday - Friday workweek with the QCs almost evenly divided during the week with steep drop-offs in the numbers for Saturday and Sunday.
There are several referral reasons from which NICB member companies can select to further describe a QC. The top three referral reasons were the same in each year. First was "claimant fraud" with 6,107. Second was "prior injury/not related to work" with 2,319, and third was "malingering" with 1,380.
An injury not related to work is typically a person who suffers an injury during a recreational or day off activity but fails to report it until at work, thus claiming the injury happened on the job. A malingerer is someone who has suffered a legitimate injury but continues to feign symptoms, thus collecting benefits long after he or she has fully recovered.
The full report is available online ...
The Law Offices of Mark R. Leeds entered into a contract with the Law Offices of Donald J. Reino, whereby Leeds agreed to refer workers’ compensation cases to Reino in consideration for payment of 25 percent of the attorney fees earned on those cases, 100 percent of all deposition fees (Lab. Code, § 5710) if "handled" by Leeds, and 25 percent of the vocational rehabilitation attorney fees.
Three years later, in 1997, Reino and Iida, a Professional Corporation, and Law Offices of Myles Iida were formed as successors of Reino. By this time, plaintiff had referred over 1,000 cases to Reino pursuant to the agreement. Leeds entered into a new agreement to the successor firm that is substantially similar to the original agreement with Reino
Reino and the successor firms paid plaintiff in accordance with the terms of the agreements for about 16 years.
On October 1, 2010, Leeds separated from the successor firms and formed his own firm in Long Beach California. at separation, many of the referred clients manifested their intent to substitute Leeds as counsel of record while others elected to remain with Reino; and some of the previously referred clients had substituted other firms to handle their claims. Reino then refused to pay any attorney fees to Leeds, and Leeds filed a civil action in Superior Court to collect the fees he claims to have earned.
Reino demurred to the complaint on three grounds: (1) the trial court lacked subject matter jurisdiction over the subject of the cause of action, because WCAB has exclusive jurisdiction over disputes regarding attorney fees in workers’ compensation matters; (2) another action is pending before the WCAB entitled Lovato v. The Kroger Co. dba Ralph’s Grocery, case No. ADJ7354967 (Lovato) between the same parties on the same issues, i.e., "the alleged failure of Defendants to pay Plaintiff[’s] referral fees allegedly earned under the alleged contract . . . including California Labor Code section 5710 deposition fees;" and (3) no cause of action for declaratory relief is stated. The trial court sustained the demurrer without leave to amend on all grounds asserted in the demurrer and entered its order (judgment) dismissing the complaint with prejudice.
Leeds appealed the dismissal, and the Court of Appeal reversed in the unpublished case of Leeds v. Reino and Iida.
The Court of Appeal concluded that the distribution of attorney fees in a final award pursuant to a fee splitting agreement is not subject to the exclusive jurisdiction of the WCAB. "Once the WCAB has resolved the 'reasonable amount' of the attorney fees and makes a final award in this amount, the WCAB has no further interest in, or obligation to determine, how the fees are to be disbursed or otherwise disposed of by the lien claimant. We therefore conclude that a dispute between the lien claimant and a third party regarding allocation or division of the attorney fees in a final award issued by the WCAB is outside the jurisdiction of the WCAB. " ...
Three years later, in 1997, Reino and Iida, a Professional Corporation, and Law Offices of Myles Iida were formed as successors of Reino. By this time, plaintiff had referred over 1,000 cases to Reino pursuant to the agreement. Leeds entered into a new agreement to the successor firm that is substantially similar to the original agreement with Reino
Reino and the successor firms paid plaintiff in accordance with the terms of the agreements for about 16 years.
On October 1, 2010, Leeds separated from the successor firms and formed his own firm in Long Beach California. at separation, many of the referred clients manifested their intent to substitute Leeds as counsel of record while others elected to remain with Reino; and some of the previously referred clients had substituted other firms to handle their claims. Reino then refused to pay any attorney fees to Leeds, and Leeds filed a civil action in Superior Court to collect the fees he claims to have earned.
Reino demurred to the complaint on three grounds: (1) the trial court lacked subject matter jurisdiction over the subject of the cause of action, because WCAB has exclusive jurisdiction over disputes regarding attorney fees in workers’ compensation matters; (2) another action is pending before the WCAB entitled Lovato v. The Kroger Co. dba Ralph’s Grocery, case No. ADJ7354967 (Lovato) between the same parties on the same issues, i.e., "the alleged failure of Defendants to pay Plaintiff[’s] referral fees allegedly earned under the alleged contract . . . including California Labor Code section 5710 deposition fees;" and (3) no cause of action for declaratory relief is stated. The trial court sustained the demurrer without leave to amend on all grounds asserted in the demurrer and entered its order (judgment) dismissing the complaint with prejudice.
Leeds appealed the dismissal, and the Court of Appeal reversed in the unpublished case of Leeds v. Reino and Iida.
The Court of Appeal concluded that the distribution of attorney fees in a final award pursuant to a fee splitting agreement is not subject to the exclusive jurisdiction of the WCAB. "Once the WCAB has resolved the 'reasonable amount' of the attorney fees and makes a final award in this amount, the WCAB has no further interest in, or obligation to determine, how the fees are to be disbursed or otherwise disposed of by the lien claimant. We therefore conclude that a dispute between the lien claimant and a third party regarding allocation or division of the attorney fees in a final award issued by the WCAB is outside the jurisdiction of the WCAB. " ...
The U.S. Food and Drug Administration has issued final rules governing the development of mobile medical apps, saying it will focus its oversight on those products that have the potential to harm consumers if they do not function properly.
The rules, announced on Monday, come more than two years after the FDA released draft guidance in which it proposed regulating any mobile app deemed to be a medical device.
The FDA said it will only regulate products that transform smartphones into devices the agency currently regulates, such as electrocardiography (ECG) machines that can determine whether a patient is having a heart attack.
The agency will also regulate apps that would be used as an accessory to a regulated device, such as one that displays images used by physicians to diagnose patients.
The agency said it will not regulate the sale or general consumer use of smartphones or tablets or mobile app distributors such as the iTunes store or Google Play store. Nor will it regulate personal wellness apps such as pedometers or heart-rate monitors.
Dr. Jeffrey Shuren, director of the FDA's medical device division, said on a conference call with reporters that whether the agency regulates a product will depend on its function and its risk. If a heart device used in a hospital is currently regulated, chances are a mobile app will be too.
"It's not about the platform. It's about the functionality," Shuren said. "An ECG is an ECG."
Such products will need to be cleared by the FDA before being allowed on the market. The agency has cleared about 100 mobile medical apps over the past decade, of which 40 were cleared in the last two years. Shuren said the average review time was 67 days.
The agency said it is not going to enforce its powers on mobile apps it considers relatively safe such as those that help patients organize and track their health information, or promote strategies for maintaining a healthy weight or adhering to medication dosing schedules.
According to a report published in March by research2guidance, a research firm, the market for mobile health apps will reach $26 billion by 2017. Currently, there are about 97,000 mobile health applications in major app stores, the report said ...
The rules, announced on Monday, come more than two years after the FDA released draft guidance in which it proposed regulating any mobile app deemed to be a medical device.
The FDA said it will only regulate products that transform smartphones into devices the agency currently regulates, such as electrocardiography (ECG) machines that can determine whether a patient is having a heart attack.
The agency will also regulate apps that would be used as an accessory to a regulated device, such as one that displays images used by physicians to diagnose patients.
The agency said it will not regulate the sale or general consumer use of smartphones or tablets or mobile app distributors such as the iTunes store or Google Play store. Nor will it regulate personal wellness apps such as pedometers or heart-rate monitors.
Dr. Jeffrey Shuren, director of the FDA's medical device division, said on a conference call with reporters that whether the agency regulates a product will depend on its function and its risk. If a heart device used in a hospital is currently regulated, chances are a mobile app will be too.
"It's not about the platform. It's about the functionality," Shuren said. "An ECG is an ECG."
Such products will need to be cleared by the FDA before being allowed on the market. The agency has cleared about 100 mobile medical apps over the past decade, of which 40 were cleared in the last two years. Shuren said the average review time was 67 days.
The agency said it is not going to enforce its powers on mobile apps it considers relatively safe such as those that help patients organize and track their health information, or promote strategies for maintaining a healthy weight or adhering to medication dosing schedules.
According to a report published in March by research2guidance, a research firm, the market for mobile health apps will reach $26 billion by 2017. Currently, there are about 97,000 mobile health applications in major app stores, the report said ...
A 78-year-old Auburn man pleaded guilty in federal court in Sacramento to making false statements to obtain federal workers' compensation benefits.
According to the plea agreement, Bruce Lee Cearlock has been receiving workers' compensation benefits under the Federal Employees' Compensation Act for an injury that he suffered as a civilian employee for the U.S. Navy on Aug. 26, 1987. When filing the periodic reports required by the Office of Workers' Compensation Program to justify continued payments, between 2006 and 2008, Cearlock stated under penalty of perjury that he was neither self-employed nor involved in "any business enterprise."
Court documents, however, state that from at least 1999 until 2011, Cearlock was involved in operating Fuse, a bar in San Francisco. Cearlock hired and fired employees, made decisions on capital expenditures and dealt with private citizens and public officials as the owner of Fuse.
During that time, Cearlock also was president and secretary of a privately held corporation, Alleycorp Inc., the sole purpose of which was to own the Fuse nightclub, authorities said. Shares in Alleycorp were equally split between Cearlock and his wife.
On the basis of his statements to the Office of Workers' Compensation Program that he was not involved in any business enterprise, Cearlock continued to receive federal disability benefits.
Cearlock is to be sentenced Dec. 5 by U.S. District Judge Troy L. Nunley.
The case resulted from an investigation by the Department of Defense, Defense Criminal Investigation Service, Sacramento; the Naval Criminal Investigative Service; and the U.S. Department of Labor ...
According to the plea agreement, Bruce Lee Cearlock has been receiving workers' compensation benefits under the Federal Employees' Compensation Act for an injury that he suffered as a civilian employee for the U.S. Navy on Aug. 26, 1987. When filing the periodic reports required by the Office of Workers' Compensation Program to justify continued payments, between 2006 and 2008, Cearlock stated under penalty of perjury that he was neither self-employed nor involved in "any business enterprise."
Court documents, however, state that from at least 1999 until 2011, Cearlock was involved in operating Fuse, a bar in San Francisco. Cearlock hired and fired employees, made decisions on capital expenditures and dealt with private citizens and public officials as the owner of Fuse.
During that time, Cearlock also was president and secretary of a privately held corporation, Alleycorp Inc., the sole purpose of which was to own the Fuse nightclub, authorities said. Shares in Alleycorp were equally split between Cearlock and his wife.
On the basis of his statements to the Office of Workers' Compensation Program that he was not involved in any business enterprise, Cearlock continued to receive federal disability benefits.
Cearlock is to be sentenced Dec. 5 by U.S. District Judge Troy L. Nunley.
The case resulted from an investigation by the Department of Defense, Defense Criminal Investigation Service, Sacramento; the Naval Criminal Investigative Service; and the U.S. Department of Labor ...
A Spring Valley woman pleaded guilty to taking part in a multi-year scheme to falsify medical certifications while working as an advocate for immigrants seeking help in obtaining U.S. citizenship or government benefits.
Nawal Talia, 57, admitted during a hearing in federal court in San Diego that she recruited patients for National City psychologist Roberto Velasquez, who was sentenced earlier this year to 21 months in prison and ordered to repay more than $1.5 million to the Social Security Administration in the largest single restitution order in the agency's history.
As part of her job, Talia for several years submitted documents to federal agencies on behalf of her clients, certifying that they were mentally disabled. Rather than obtain benefits legitimately, she and Velasquez worked together to falsify medical certifications and fabricate patient histories, according to prosecutors.
Talia admitted that she helped Velasquez falsify disability-exception certification forms used by the Department of Homeland Security during the naturalization process and medical letters used by the Social Security Administration to award Supplemental Security Income and disability payments. She conceded that she lied on both types of documents about the length of time her clients had been under the care of Velasquez. In one case, she certified that a patient had been treated by Velasquez for a year, when the person actually had met Velasquez only once, court papers show.
In another instance, she filed a Social Security appeal falsely certifying that a man had been treated by Velasquez for 11 months. Talia simply made up that number so he appeared to be eligible for disability benefits, when Talia knew he was not, according to court documents. Investigators established that Talia repeatedly lied about durations of treatment in order to create a "track record" that would satisfy reviewers at the Social Security Administration and immigration agencies.
The scheme came to light during an undercover operation conducted jointly by the Department of Homeland Security, Immigration and Customs Enforcement, and the Office of Inspector General, Social Security Administration ...
Nawal Talia, 57, admitted during a hearing in federal court in San Diego that she recruited patients for National City psychologist Roberto Velasquez, who was sentenced earlier this year to 21 months in prison and ordered to repay more than $1.5 million to the Social Security Administration in the largest single restitution order in the agency's history.
As part of her job, Talia for several years submitted documents to federal agencies on behalf of her clients, certifying that they were mentally disabled. Rather than obtain benefits legitimately, she and Velasquez worked together to falsify medical certifications and fabricate patient histories, according to prosecutors.
Talia admitted that she helped Velasquez falsify disability-exception certification forms used by the Department of Homeland Security during the naturalization process and medical letters used by the Social Security Administration to award Supplemental Security Income and disability payments. She conceded that she lied on both types of documents about the length of time her clients had been under the care of Velasquez. In one case, she certified that a patient had been treated by Velasquez for a year, when the person actually had met Velasquez only once, court papers show.
In another instance, she filed a Social Security appeal falsely certifying that a man had been treated by Velasquez for 11 months. Talia simply made up that number so he appeared to be eligible for disability benefits, when Talia knew he was not, according to court documents. Investigators established that Talia repeatedly lied about durations of treatment in order to create a "track record" that would satisfy reviewers at the Social Security Administration and immigration agencies.
The scheme came to light during an undercover operation conducted jointly by the Department of Homeland Security, Immigration and Customs Enforcement, and the Office of Inspector General, Social Security Administration ...
Douglas Lambert, 48, of West Hills and owner of Lambert Air Conditioning was convicted of committing workers' compensation insurance premium fraud for failing to properly report employee payroll to the insurance carrier.
Lambert was ordered to pay more than $110,300 in restitution to Clarendon National and the State of California.
In response to a complaint in February 2010, the Department of Insurance in a joint effort with the Tulare County District Attorney's Office began an investigation into Lambert. Lambert, a licensed air conditioning contractor operating in Tulare County, did not report any employee payroll to Clarendon National Insurance Company causing his business to pay at a lower premium. The investigation uncovered evidence Lambert failed to properly report employee payroll to the carrier from 2006 to 2009.
Lambert reported no employee payroll to Clarendon for the first three quarters of 2006 yet the business reported more than $8,800 in wages to the Employment Development Department during this same time period.
Further investigation revealed Lambert reported an employee injury to Clarendon National as a workers' compensation claim although he was reporting no employee wages to them.
Douglas Lambert pled guilty to one count of insurance fraud ...
Lambert was ordered to pay more than $110,300 in restitution to Clarendon National and the State of California.
In response to a complaint in February 2010, the Department of Insurance in a joint effort with the Tulare County District Attorney's Office began an investigation into Lambert. Lambert, a licensed air conditioning contractor operating in Tulare County, did not report any employee payroll to Clarendon National Insurance Company causing his business to pay at a lower premium. The investigation uncovered evidence Lambert failed to properly report employee payroll to the carrier from 2006 to 2009.
Lambert reported no employee payroll to Clarendon for the first three quarters of 2006 yet the business reported more than $8,800 in wages to the Employment Development Department during this same time period.
Further investigation revealed Lambert reported an employee injury to Clarendon National as a workers' compensation claim although he was reporting no employee wages to them.
Douglas Lambert pled guilty to one count of insurance fraud ...
Scans of people's knees are less likely to reveal a problem when the referring doctor has a financial stake in the imaging center or the equipment used, suggesting some tests may be unnecessary, according to a new study published in the journal Radiology and summarized by Reuters Health.
Researchers concluded that When doctors have a financial interest in the imaging facility, their patients are 33 percent more likely to get a test result that shows nothing wrong, compared to patients of doctors with no financial interest. "It does raise the questions: Are these studies being performed unnecessarily? Are these machines being over utilized because of an unconscious bias?" Dr. Matthew Lungren, the study's lead author who did the research while at Duke Medicine in Durham, North Carolina, said.
In medical circles, it is known as "self referral" when doctors send patients to get images or scans taken at centers they partially own.
Lungren and his colleagues reviewed 700 MRIs of knees taken between January and April 2009 at a single imaging facility and ordered by two groups of doctors practicing in the same geographic area. One set of doctors had a financial stake in the imaging facility and the other did not. The patients in each group were similar to each other in age and the doctors in each practice also had similar training.
Of the 350 MRIs ordered by the group with a financial interest in the imaging equipment, 117 of the tests were negative for a problem with the knee. That compared to 88 negative results among the 350 MRIs ordered by the group without a financial interest in the MRI machines.
"There are a lot of possible explanations for this but the bottom line is that there is a significantly higher number of negative studies coming out of the one specific group," Lungren said. He cautioned the new study cannot show that owning a stake in an imaging center or its equipment caused doctors to order unnecessary tests.
For example, Lungren and his colleagues write that the doctors in the group that owns part of the imaging center and its equipment may have a culture of ordering more tests, compared to the group without a stake in the imaging centers or equipment.
But Dr. David Levin, professor and chairman emeritus of the Department of Radiology at Thomas Jefferson University in Philadelphia, said he is not surprised by the results. "This whole issue of self-referral and imaging has a long history," he said. "Every study that's ever been done shows self-referring physicians are going to do more imaging than physicians who refer patients to hospitals or imaging centers."
An MRI of the knee can cost between $700 and $1,000 ...
Researchers concluded that When doctors have a financial interest in the imaging facility, their patients are 33 percent more likely to get a test result that shows nothing wrong, compared to patients of doctors with no financial interest. "It does raise the questions: Are these studies being performed unnecessarily? Are these machines being over utilized because of an unconscious bias?" Dr. Matthew Lungren, the study's lead author who did the research while at Duke Medicine in Durham, North Carolina, said.
In medical circles, it is known as "self referral" when doctors send patients to get images or scans taken at centers they partially own.
Lungren and his colleagues reviewed 700 MRIs of knees taken between January and April 2009 at a single imaging facility and ordered by two groups of doctors practicing in the same geographic area. One set of doctors had a financial stake in the imaging facility and the other did not. The patients in each group were similar to each other in age and the doctors in each practice also had similar training.
Of the 350 MRIs ordered by the group with a financial interest in the imaging equipment, 117 of the tests were negative for a problem with the knee. That compared to 88 negative results among the 350 MRIs ordered by the group without a financial interest in the MRI machines.
"There are a lot of possible explanations for this but the bottom line is that there is a significantly higher number of negative studies coming out of the one specific group," Lungren said. He cautioned the new study cannot show that owning a stake in an imaging center or its equipment caused doctors to order unnecessary tests.
For example, Lungren and his colleagues write that the doctors in the group that owns part of the imaging center and its equipment may have a culture of ordering more tests, compared to the group without a stake in the imaging centers or equipment.
But Dr. David Levin, professor and chairman emeritus of the Department of Radiology at Thomas Jefferson University in Philadelphia, said he is not surprised by the results. "This whole issue of self-referral and imaging has a long history," he said. "Every study that's ever been done shows self-referring physicians are going to do more imaging than physicians who refer patients to hospitals or imaging centers."
An MRI of the knee can cost between $700 and $1,000 ...
28 year old Keri Atwood of Santa Paula, was sentenced to 36 months probation, 150 days in county jail, and restitution in the amount of $18,319.
Her husband, 37 year old Michael Atwood, also of Santa Paula, was sentenced to 36 months probation and 60 days in county jail.
On August 14, 2013, Keri Atwood entered guilty pleas to four counts of workers' compensation insurance fraud.
Michael Atwood entered a guilty plea to one count of conspiracy to commit workers' compensation fraud.
Defendant Keri Atwood, a civilian employee of the Ventura County Sheriffs Office, reported to her supervisors that she sustained an injury to her left ankle. According to Keri Atwood, the injury occurred when another employee accidentally hit the back of her foot with a mail cart. She was placed on Temporary Totally Disabled (TTD) status. Over the next several months, Atwood remained on TTD and received over $29,000 in disability pay.
She used crutches or a wheelchair to get to her medical appointments. After her medical appointments, she was seen walking freely without the aid of crutches or a wheelchair. She was also observed engaging in a number of physical activities that she told her treating her physicians she could not perform. Michael Atwood drove Keri Atwood to her doctors' visits and failed to disclose her true physical condition. At the time of the sentencing, Keri Atwood paid restitution to the County of Ventura.
This case was investigated by the Valencia office of the California Department of Insurance ...
Her husband, 37 year old Michael Atwood, also of Santa Paula, was sentenced to 36 months probation and 60 days in county jail.
On August 14, 2013, Keri Atwood entered guilty pleas to four counts of workers' compensation insurance fraud.
Michael Atwood entered a guilty plea to one count of conspiracy to commit workers' compensation fraud.
Defendant Keri Atwood, a civilian employee of the Ventura County Sheriffs Office, reported to her supervisors that she sustained an injury to her left ankle. According to Keri Atwood, the injury occurred when another employee accidentally hit the back of her foot with a mail cart. She was placed on Temporary Totally Disabled (TTD) status. Over the next several months, Atwood remained on TTD and received over $29,000 in disability pay.
She used crutches or a wheelchair to get to her medical appointments. After her medical appointments, she was seen walking freely without the aid of crutches or a wheelchair. She was also observed engaging in a number of physical activities that she told her treating her physicians she could not perform. Michael Atwood drove Keri Atwood to her doctors' visits and failed to disclose her true physical condition. At the time of the sentencing, Keri Atwood paid restitution to the County of Ventura.
This case was investigated by the Valencia office of the California Department of Insurance ...
Allstate Insurance Company received a judgment this month of more than $7 million, following a Racketeering Influenced in Corrupt Organizations (RICO) investigation nearly 10 years in the making.
The RICO complaint was filed in 2008 in the Las Vegas Federal District Court against chiropractor Obteen Nassiri, D.C., and his businesses: Advanced Accident Chiropractic Care, ONN Management, Digital Imaging Services and Digital X-Ray. Since the suit was filed, the Chiropractic Physicians' Board of Nevada revoked Obteen Nassiri's license.
Allstate's lawsuit alleged Nassiri began defrauding Allstate in 2003 by exaggerating clinical findings, submitting improbable diagnoses, charging for treatment he did not provide, providing unnecessary and excessive treatment, grossly misrepresenting billing, making inappropriate referrals, and exhibiting a general pattern of illegal and fraudulent conduct. The jury in the case also found Nassiri's spouse, Jennifer Nassiri, liable for negligent misrepresentation in the overall fraudulent scheme to harm Allstate. The verdict sided with Allstate in June and the final judgment and award was made this month. The total judgment against the defendants included an award to Allstate for $3.59 million in compensatory damages, $2.51 million in punitive damages and $1 million in pre-judgment interest. The company is also pursuing more than a million dollars in attorney's fees and costs.
Over the last decade, Allstate has filed a series of civil fraud related cases against alleged perpetrators in various states across the nation.
Allstate recently filed a $5.6 million lawsuit in August in New Jersey. It alleges that Shams M. Qureshi MD, age 63, made payments to individuals who acted as middlemen by brokering auto accident patients from New Jersey and New York clinics to Qureshi's surgery center.
In early 2013 Allstate filed against three New York-area medical providers who allegedly engaged in a fraudulent medical billing scheme seeking $1.7 million Property Casualty 360 reports that since 2003, the insurer has filed a total of 46 fraud lawsuits in the state of New York State seeking more than $233 million in damages.
Last year A Los Angeles Superior Court Judge has ordered Daniel H. Dahan, D.C., and his business, Progressive Diagnostic Imaging, to pay Allstate Insurance Company $7 million in a qui tam ("Whistleblower") lawsuit arising out of a scheme to defraud insurance companies. Dahan is president of Practice Perfect Management and Consulting Services, of Long Beach, California, which specializes in helping chiropractors set up clinics that combine chiropractic, medical, and physical therapy services. Allstate's lawsuit alleged that Dahan purchased report-writing software that purported to analyze x-rays and form medical opinions and diagnoses, including opinions concerning permanent impairment ratings, and thereafter formed Progressive Diagnostic Imaging to solicit x-rays from chiropractors, with the assurance that "board certified radiologists" would analyze the films.
As far back as 2004 a Dallas jury found that Texas’ largest chiropractic chain, Accident and Injury Pain Center Inc., conspired in a statewide scheme designed to defraud Allstate. The jury ordered them to pay $2.8 million in actual damages and $3 million in punitive damages ...
The RICO complaint was filed in 2008 in the Las Vegas Federal District Court against chiropractor Obteen Nassiri, D.C., and his businesses: Advanced Accident Chiropractic Care, ONN Management, Digital Imaging Services and Digital X-Ray. Since the suit was filed, the Chiropractic Physicians' Board of Nevada revoked Obteen Nassiri's license.
Allstate's lawsuit alleged Nassiri began defrauding Allstate in 2003 by exaggerating clinical findings, submitting improbable diagnoses, charging for treatment he did not provide, providing unnecessary and excessive treatment, grossly misrepresenting billing, making inappropriate referrals, and exhibiting a general pattern of illegal and fraudulent conduct. The jury in the case also found Nassiri's spouse, Jennifer Nassiri, liable for negligent misrepresentation in the overall fraudulent scheme to harm Allstate. The verdict sided with Allstate in June and the final judgment and award was made this month. The total judgment against the defendants included an award to Allstate for $3.59 million in compensatory damages, $2.51 million in punitive damages and $1 million in pre-judgment interest. The company is also pursuing more than a million dollars in attorney's fees and costs.
Over the last decade, Allstate has filed a series of civil fraud related cases against alleged perpetrators in various states across the nation.
Allstate recently filed a $5.6 million lawsuit in August in New Jersey. It alleges that Shams M. Qureshi MD, age 63, made payments to individuals who acted as middlemen by brokering auto accident patients from New Jersey and New York clinics to Qureshi's surgery center.
In early 2013 Allstate filed against three New York-area medical providers who allegedly engaged in a fraudulent medical billing scheme seeking $1.7 million Property Casualty 360 reports that since 2003, the insurer has filed a total of 46 fraud lawsuits in the state of New York State seeking more than $233 million in damages.
Last year A Los Angeles Superior Court Judge has ordered Daniel H. Dahan, D.C., and his business, Progressive Diagnostic Imaging, to pay Allstate Insurance Company $7 million in a qui tam ("Whistleblower") lawsuit arising out of a scheme to defraud insurance companies. Dahan is president of Practice Perfect Management and Consulting Services, of Long Beach, California, which specializes in helping chiropractors set up clinics that combine chiropractic, medical, and physical therapy services. Allstate's lawsuit alleged that Dahan purchased report-writing software that purported to analyze x-rays and form medical opinions and diagnoses, including opinions concerning permanent impairment ratings, and thereafter formed Progressive Diagnostic Imaging to solicit x-rays from chiropractors, with the assurance that "board certified radiologists" would analyze the films.
As far back as 2004 a Dallas jury found that Texas’ largest chiropractic chain, Accident and Injury Pain Center Inc., conspired in a statewide scheme designed to defraud Allstate. The jury ordered them to pay $2.8 million in actual damages and $3 million in punitive damages ...
Cal/OSHA cited Covina-based Los Angeles Engineering, Inc. following a trench collapse in March which killed one employee and severely injured another. The two pipe layers were checking the depth of the trench when an unshored wall caved in. 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. The workers had been excavating with back hoes on a city storm water project. The Temescal Canyon project was part of a $50-million city program, funded by voter-approved bonds, to clean up Santa Monica Bay.
Cal/OSHA issued four citations to Los Angeles Engineering, Inc., one general, two serious and a willful serious violation, totaling $100,635. Violations included failure to properly protect the trench from caving in, not inspecting the trench after a cave-in that occurred earlier in the day, lack of employee training on heat illness prevention, and lack of an effective Injury and Illness Prevention Plan. The citation was classified as Willful because the employer failed to install the required shoring in the trench after the earlier cave-in and still sent workers into the unprotected trench.
A Willful violation is cited when an employer is aware that a hazardous condition exists but makes no reasonable effort to eliminate it. A Serious workplace safety violation is cited when there is a realistic possibility that death or serious physical harm could result from the actual hazard created by the violation. A General violation is one in which an accident or illness may result but would probably not cause death or serious harm.
"Incidents like this are heartbreaking because they are so unnecessary," said Acting Cal/OSHA Chief Juliann Sum. "Employers must be more vigilant in protecting worker safety." "When safety is not a priority, there can be tragic consequences, and this incident is a sad reminder of that fact," said Christine Baker, director of the Department of Industrial Relations (DIR). Cal/OSHA, also known as the Division of Occupational Safety and Health, is a division of DIR.
Construction is a dangerous business. Of the 4,609 worker deaths nationally in 2011, 721, or nearly one in six, happened during construction, according to the federal Bureau of Labor Statistics. By way of comparison, 125 law enforcement officers that year died in the performance of their duties ...
Cal/OSHA issued four citations to Los Angeles Engineering, Inc., one general, two serious and a willful serious violation, totaling $100,635. Violations included failure to properly protect the trench from caving in, not inspecting the trench after a cave-in that occurred earlier in the day, lack of employee training on heat illness prevention, and lack of an effective Injury and Illness Prevention Plan. The citation was classified as Willful because the employer failed to install the required shoring in the trench after the earlier cave-in and still sent workers into the unprotected trench.
A Willful violation is cited when an employer is aware that a hazardous condition exists but makes no reasonable effort to eliminate it. A Serious workplace safety violation is cited when there is a realistic possibility that death or serious physical harm could result from the actual hazard created by the violation. A General violation is one in which an accident or illness may result but would probably not cause death or serious harm.
"Incidents like this are heartbreaking because they are so unnecessary," said Acting Cal/OSHA Chief Juliann Sum. "Employers must be more vigilant in protecting worker safety." "When safety is not a priority, there can be tragic consequences, and this incident is a sad reminder of that fact," said Christine Baker, director of the Department of Industrial Relations (DIR). Cal/OSHA, also known as the Division of Occupational Safety and Health, is a division of DIR.
Construction is a dangerous business. Of the 4,609 worker deaths nationally in 2011, 721, or nearly one in six, happened during construction, according to the federal Bureau of Labor Statistics. By way of comparison, 125 law enforcement officers that year died in the performance of their duties ...
Heriberto Hernandez was an employee of Thermal Structures Inc. As part of his job, he used a power press to shape sheet metal. The press was not supposed to operate unless two buttons were pushed simultaneously. The buttons were mounted on a pedestal, three and a half feet apart from each other The pedestal was separate from the main body of the press, though connected to it by a cable. Hernandez suffered a gruesome on-the-job injury when his hands were crushed in the power press.
Under the worker’s compensation exclusivity rule (Lab. Code, § 3600, subd. (a)), and under the power press exception to that rule (Lab. Code, § 4558), Hernandez cannot recover against his employer in the tort action he filed against Thermal Structures, Inc. unless he can show that the accident occurred because Thermal either removed or failed to install a point of operation guard on the press.
The trial court granted the employer's summary judgment ruling that there was no triable issue of fact that would cause this exception to the exclusive remedy to apply. Hernandez appealed, and the Court of Appeal sustained the dismissal in the unpublished case of Hernandez v Thermal Structures Inc.
When the accident occurred, the press did have a point of operation guard -- two buttons, mounted on a pedestal; the press was not supposed to operate unless both buttons were pushed simultaneously. Hernandez’s theory was that Thermal "removed" the guard by adding wheels to the pedestal, which allowed the pedestal to move so close to the main body of the press that he could push the buttons with his elbows while his hands were still dangerously close to the press.
The problem with this theory was that, in discovery, Hernandez admitted that (1) Thermal did not remove a point of operation guard, (2) no changes were ever made to the press, and (3) the buttons were not being pushed when the accident occurred. Hernandez argues that the questions he was asked on this topic -- and hence his responses -- were ambiguous. The Court of Appeal reviewed his question and answer. "So as far as you know, no changes were ever made to the machine?"; he answered, "That I know of, no." The Court concluded that this "was unambiguous and flatly inconsistent with his later testimony that Thermal added wheels.".
Accordingly, the trial court properly granted summary judgment in favor of the employer ...
Under the worker’s compensation exclusivity rule (Lab. Code, § 3600, subd. (a)), and under the power press exception to that rule (Lab. Code, § 4558), Hernandez cannot recover against his employer in the tort action he filed against Thermal Structures, Inc. unless he can show that the accident occurred because Thermal either removed or failed to install a point of operation guard on the press.
The trial court granted the employer's summary judgment ruling that there was no triable issue of fact that would cause this exception to the exclusive remedy to apply. Hernandez appealed, and the Court of Appeal sustained the dismissal in the unpublished case of Hernandez v Thermal Structures Inc.
When the accident occurred, the press did have a point of operation guard -- two buttons, mounted on a pedestal; the press was not supposed to operate unless both buttons were pushed simultaneously. Hernandez’s theory was that Thermal "removed" the guard by adding wheels to the pedestal, which allowed the pedestal to move so close to the main body of the press that he could push the buttons with his elbows while his hands were still dangerously close to the press.
The problem with this theory was that, in discovery, Hernandez admitted that (1) Thermal did not remove a point of operation guard, (2) no changes were ever made to the press, and (3) the buttons were not being pushed when the accident occurred. Hernandez argues that the questions he was asked on this topic -- and hence his responses -- were ambiguous. The Court of Appeal reviewed his question and answer. "So as far as you know, no changes were ever made to the machine?"; he answered, "That I know of, no." The Court concluded that this "was unambiguous and flatly inconsistent with his later testimony that Thermal added wheels.".
Accordingly, the trial court properly granted summary judgment in favor of the employer ...
MRSA infections are often picked up while patients are in the hospital being treated for something else. When they are being treated for an industrial injury, the infection can become a compensable consequence claim. Symptoms of a staph infection include small red bumps on the skin, which can turn into more severe sores. When the bacteria spread past the skin, they may cause life-threatening infections in bones, organs and the bloodstream.
Hospitals and other healthcare providers have been making a big push to cut down on transmission of MRSA inside their facilities. Reducing methicillin-resistant Staphylococcus aureus (MRSA) in both healthcare and community settings continues to be a high priority for the Centers for Disease Control and Prevention. The agency is engaged in several short- and long-term surveillance (infection tracking) projects that involve collaboration with partners including health departments, individual hospitals, and academic medical centers, among others. Understanding the burden of MRSA - how much is occurring, where it is happening, and how it is being spread - is essential for developing effective prevention programs and measuring their impact.
In 2010, encouraging results from a CDC study published in the Journal of the American Medical Association showed that invasive (life-threatening) MRSA infections in healthcare settings are declining. Invasive MRSA infections that began in hospitals declined 28% from 2005 through 2008. Decreases in infection rates were even bigger for patients with bloodstream infections. In addition, the study showed a 17% drop in invasive MRSA infections that were diagnosed before hospital admissions (community onset) in people with recent exposures to healthcare settings.
This study (or report) complements data from the National Healthcare Safety Network (NHSN) that found rates of MRSA bloodstream infections occurring in hospitalized patients fell nearly 50% from 1997 to 2007.
In newer CDC studies reported in Reuters Health, researchers analyzed 2011 data on infections from selected counties in nine U.S. states, and compared it to a 2005 CDC report on MRSA incidence. Overall, the number of serious MRSA infections diagnosed while people were in the hospital fell by 54 percent between 2005 and 2011 - from about 9.7 infections per 100,000 people to about 4.5 per 100,000 people. The incidence of serious infections diagnosed while people were home but after being in contact with a healthcare setting also decreased, by about 28 percent, during that time - from 21 infections per 100,000 people to about 15 infections per 100,000 people.
While the new study cannot explain why infection rates are dropping, it's likely attributable, in part, to hospital efforts to reduce the spread of infections. "It's also possible that there has been evolution of these strains and they're less invasive," Dr. Franklin Lowy, from the Columbia University College of Physicians and Surgeons in New York who wrote an editorial accompanying the new study in JAMA Internal Medicine, said ...
Hospitals and other healthcare providers have been making a big push to cut down on transmission of MRSA inside their facilities. Reducing methicillin-resistant Staphylococcus aureus (MRSA) in both healthcare and community settings continues to be a high priority for the Centers for Disease Control and Prevention. The agency is engaged in several short- and long-term surveillance (infection tracking) projects that involve collaboration with partners including health departments, individual hospitals, and academic medical centers, among others. Understanding the burden of MRSA - how much is occurring, where it is happening, and how it is being spread - is essential for developing effective prevention programs and measuring their impact.
In 2010, encouraging results from a CDC study published in the Journal of the American Medical Association showed that invasive (life-threatening) MRSA infections in healthcare settings are declining. Invasive MRSA infections that began in hospitals declined 28% from 2005 through 2008. Decreases in infection rates were even bigger for patients with bloodstream infections. In addition, the study showed a 17% drop in invasive MRSA infections that were diagnosed before hospital admissions (community onset) in people with recent exposures to healthcare settings.
This study (or report) complements data from the National Healthcare Safety Network (NHSN) that found rates of MRSA bloodstream infections occurring in hospitalized patients fell nearly 50% from 1997 to 2007.
In newer CDC studies reported in Reuters Health, researchers analyzed 2011 data on infections from selected counties in nine U.S. states, and compared it to a 2005 CDC report on MRSA incidence. Overall, the number of serious MRSA infections diagnosed while people were in the hospital fell by 54 percent between 2005 and 2011 - from about 9.7 infections per 100,000 people to about 4.5 per 100,000 people. The incidence of serious infections diagnosed while people were home but after being in contact with a healthcare setting also decreased, by about 28 percent, during that time - from 21 infections per 100,000 people to about 15 infections per 100,000 people.
While the new study cannot explain why infection rates are dropping, it's likely attributable, in part, to hospital efforts to reduce the spread of infections. "It's also possible that there has been evolution of these strains and they're less invasive," Dr. Franklin Lowy, from the Columbia University College of Physicians and Surgeons in New York who wrote an editorial accompanying the new study in JAMA Internal Medicine, said ...
The Workers’ Compensation Insurance Rating Bureau’s Governing Committee voted unanimously last week to authorize the WCIRB to submit a Jan. 1, 2014 Advisory Pure Premium Rate Filing to the California Insurance Commissioner. The pure premium rates for the 494 standard classifications proposed to be effective January 1, 2014 average $2.70 per $100 of payroll. This is $0.17, or 6.9%, greater than the corresponding industry average filed pure premium rate of $2. 53 as of July 1, 2013.
The proposed advisory pure premium rates reflect deterioration in the projected cost of losses and loss adjustment expenses of approximately 5.9 % as compared to the WCIRB’s amended January 1, 2013 filing. Below are some of the reasons for the recommended increase.
SB 863 provided for significant increases to permanent partial disability maximum weekly benefits effective January 1, 2014. While policies incepting in 2013 were partially impacted by the January 1, 2014 SB 863 permanent disability benefit increases, the full impact of these increases will be reflected in policy year 2014 cost levels. Almost one-third of the 5.9% deterioration in the indicated pure premium rate level is attributable to the January 1, 2014 SB 863 increases in permanent disability benefits.
In general, for many years, indemnity claim frequency has declined. This decades-long decrease in indemnity claim frequency, which has averaged approximately 3% to 4% per year, is attributable to multiple factors including long-term shifts from heavy manufacturing to a more service-based economy, increased mechanization within industries, and increased employer-sponsored safety efforts. However, in 2010, there was a sharp increase in claim frequency that was partly attributable to a spike in cumulative injury claims in the immediate post-recession environment. Rather than returning to the long-term pattern of decline, indemnity claim frequency in 2011 and 2012 remained high and early indicators for 2013 suggest a further indemnity claim frequency increase.
An increase in cumulative injury claims has been a driver in the recent high level of indemnity claim frequency. Not only does an influx of cumulative injury claims affect indemnity claim frequency, but WCIRB research has indicated that changes in the proportion of indemnity claims involving cumulative injuries is a strong predictor of changes in the number of non-cumulative injury indemnity claims.
The pure premium rates approved by the California Insurance Commissioner are only advisory in that insurers may, and often do, file and use rates other than those approved by the Insurance Commissioner ...
The proposed advisory pure premium rates reflect deterioration in the projected cost of losses and loss adjustment expenses of approximately 5.9 % as compared to the WCIRB’s amended January 1, 2013 filing. Below are some of the reasons for the recommended increase.
SB 863 provided for significant increases to permanent partial disability maximum weekly benefits effective January 1, 2014. While policies incepting in 2013 were partially impacted by the January 1, 2014 SB 863 permanent disability benefit increases, the full impact of these increases will be reflected in policy year 2014 cost levels. Almost one-third of the 5.9% deterioration in the indicated pure premium rate level is attributable to the January 1, 2014 SB 863 increases in permanent disability benefits.
In general, for many years, indemnity claim frequency has declined. This decades-long decrease in indemnity claim frequency, which has averaged approximately 3% to 4% per year, is attributable to multiple factors including long-term shifts from heavy manufacturing to a more service-based economy, increased mechanization within industries, and increased employer-sponsored safety efforts. However, in 2010, there was a sharp increase in claim frequency that was partly attributable to a spike in cumulative injury claims in the immediate post-recession environment. Rather than returning to the long-term pattern of decline, indemnity claim frequency in 2011 and 2012 remained high and early indicators for 2013 suggest a further indemnity claim frequency increase.
An increase in cumulative injury claims has been a driver in the recent high level of indemnity claim frequency. Not only does an influx of cumulative injury claims affect indemnity claim frequency, but WCIRB research has indicated that changes in the proportion of indemnity claims involving cumulative injuries is a strong predictor of changes in the number of non-cumulative injury indemnity claims.
The pure premium rates approved by the California Insurance Commissioner are only advisory in that insurers may, and often do, file and use rates other than those approved by the Insurance Commissioner ...
An article in the Insurance Journal says that the reaction from an employers’ group to a suggested hike in California’s advisory workers’ compensation rates of nearly 7 percent was - surprisingly - cautiously optimistic. The Workers’ Compensation Action Network, a group that represents the interests of employers, expressed hope that reforms ushered in last year will take hold and keep rates from continuing to head upward.
"It’s too early to tell whether the 2012 reforms will help blunt or reverse the trend," Jerry Azevedo, a WCAN spokesman said. "The system is in the process of absorbing substantial benefit increases under SB 863. Regulators are only partially through their efforts to implement a variety of process changes intended to make the system work more efficiently. These changes, however, were really intended to offset the benefit increase, rather than cut costs." What the group finds most distressing has been a 35 percent increase in premiums since 2009 is that the both the cost and frequency of claims now seem to be trending up again in 2013 after a few flat years. "It’s too early to tell whether the 2012 reforms will help blunt or reverse the trend," Azevedo said. "The system is in the process of absorbing substantial benefit increases under SB 863. Regulators are only partially through their efforts to implement a variety of process changes intended to make the system work more efficiently. These changes, however, were really intended to offset the benefit increase, rather than cut costs."
"The margin of error in getting the SB 863 reforms right is very small, and we still won’t know their impact for months or years," Azevedo said. "There’s also litigation and other attacks that could undermine what the legislature was attempting to achieve. We’re cautiously optimistic, but employers continue to look for ways to make the system more fair and efficient for all parties." ...
"It’s too early to tell whether the 2012 reforms will help blunt or reverse the trend," Jerry Azevedo, a WCAN spokesman said. "The system is in the process of absorbing substantial benefit increases under SB 863. Regulators are only partially through their efforts to implement a variety of process changes intended to make the system work more efficiently. These changes, however, were really intended to offset the benefit increase, rather than cut costs." What the group finds most distressing has been a 35 percent increase in premiums since 2009 is that the both the cost and frequency of claims now seem to be trending up again in 2013 after a few flat years. "It’s too early to tell whether the 2012 reforms will help blunt or reverse the trend," Azevedo said. "The system is in the process of absorbing substantial benefit increases under SB 863. Regulators are only partially through their efforts to implement a variety of process changes intended to make the system work more efficiently. These changes, however, were really intended to offset the benefit increase, rather than cut costs."
"The margin of error in getting the SB 863 reforms right is very small, and we still won’t know their impact for months or years," Azevedo said. "There’s also litigation and other attacks that could undermine what the legislature was attempting to achieve. We’re cautiously optimistic, but employers continue to look for ways to make the system more fair and efficient for all parties." ...
Insurance fraud is on the rise That’s the consensus of a majority of respondents to a 2013 survey commissioned by FICO. With just a few exceptions, most survey respondents expect most categories of personal lines to experience an increase in fraud losses of 10% to 20% or more in 2012 versus the prior year. A majority of those surveyed, more than 60%, attribute the continued rise in fraud, more than any other factor, to sustained economic hardship in America.
Some 57% of respondents anticipate an increase in personal property fraud by individual policy holders. Around 58% said the same for personal auto insurance fraud, and 69% expect a rise in workers’ compensation fraud.
Only around 11% of respondents view criminal gangs as the number-one factor driving insurance fraud increases. Yet 61% expect to see an increase in auto insurance fraud perpetrated by organized rings, and 55% believe the same for workers’ compensation fraud. This underscores a growing need for solutions that enable insurers to identify organized criminal activity. Some 30% of respondents report that they are already using link analysis in their efforts to detect fraud today, applying predictive analytics to find patterns among different claims that suggest organized activity.
When asked to identify their major priorities in the fight against fraud (from a list of 12 choices), 52.2% cited the detection of fraud in a claim before it is paid, and 39.6% cited adopting or upgrading their fraud analytics capabilities. These two top priorities go hand in hand --predictive analytics offer the most effective and efficient solution for accurately detecting fraud early in the claims process, enabling carriers to sharply limit their losses due to payments against fraudulent claims. About 45% of the survey respondents said they are using predictive analytics for fraud detection in their operations today, compared to around 29% using rules-based systems in an attempt to stop known types of fraud. This is a strong indication that analytics-powered solutions are becoming more widespread, although there is still plenty of room for adoption in the industry. Besides being more efficient and yielding fewer false positives compared to stand-alone, rules-based systems, analytics have the advantage of being able to adapt quickly to new and emerging fraud schemes beyond those already known.
Around 54% of the respondents surveyed employ anti-fraud teams, either centralized or dedicated to specific lines of business. However, only 20% cited the hiring of additional special investigative unit personnel among their major priorities. This suggests that many of the insurers surveyed continue to face headcount constraints, and need to figure out ways that smaller teams can work larger caseloads ...
Some 57% of respondents anticipate an increase in personal property fraud by individual policy holders. Around 58% said the same for personal auto insurance fraud, and 69% expect a rise in workers’ compensation fraud.
Only around 11% of respondents view criminal gangs as the number-one factor driving insurance fraud increases. Yet 61% expect to see an increase in auto insurance fraud perpetrated by organized rings, and 55% believe the same for workers’ compensation fraud. This underscores a growing need for solutions that enable insurers to identify organized criminal activity. Some 30% of respondents report that they are already using link analysis in their efforts to detect fraud today, applying predictive analytics to find patterns among different claims that suggest organized activity.
When asked to identify their major priorities in the fight against fraud (from a list of 12 choices), 52.2% cited the detection of fraud in a claim before it is paid, and 39.6% cited adopting or upgrading their fraud analytics capabilities. These two top priorities go hand in hand --predictive analytics offer the most effective and efficient solution for accurately detecting fraud early in the claims process, enabling carriers to sharply limit their losses due to payments against fraudulent claims. About 45% of the survey respondents said they are using predictive analytics for fraud detection in their operations today, compared to around 29% using rules-based systems in an attempt to stop known types of fraud. This is a strong indication that analytics-powered solutions are becoming more widespread, although there is still plenty of room for adoption in the industry. Besides being more efficient and yielding fewer false positives compared to stand-alone, rules-based systems, analytics have the advantage of being able to adapt quickly to new and emerging fraud schemes beyond those already known.
Around 54% of the respondents surveyed employ anti-fraud teams, either centralized or dedicated to specific lines of business. However, only 20% cited the hiring of additional special investigative unit personnel among their major priorities. This suggests that many of the insurers surveyed continue to face headcount constraints, and need to figure out ways that smaller teams can work larger caseloads ...
In 2007, California became the first state to change reimbursement rules with the intention of equalizing the prices paid for physician- and pharmacy-dispensed prescriptions.
A 2012 WCRI study found that the 2007 change in California reduced the average prices paid for physician-dispensed prescriptions to close to the prices paid to pharmacies for the same drug. After the reform, many physicians continued to dispense in California - nearly half of all prescriptions were dispensed at doctors’ offices in post-reform California.
Since then, the WCRI says that a number of states have adopted reforms similar to those in California. As of July 2013, at least 13 other states have made law or rule changes with the intention of reducing the prices paid for physician-dispensed drugs while continuing to allow physicians to dispense drugs directly to their patients. These states include Alabama, Arizona, Connecticut, Florida, Georgia, Idaho, Illinois, Indiana, Michigan, Mississippi, Oklahoma, South Carolina, and Tennessee. Florida also made law changes, effective July 2011, that were aimed at eliminating so-called pill mills by prohibiting all Florida physicians from dispensing Schedules II and III narcotics.
A few states have sought to prohibit or severely limit physicians from dispensing prescription drugs directly to their patients. In the United States, six states prohibit physician dispensing in general; Massachusetts, New York, and Texas, Montana, Utah, and Wyoming. Louisiana limits physician dispensing of narcotics to a 48-hour supply.
According to the new WCRI study, The Prevalence and Costs of Physician-Dispensed Drugs, most states still allow physicians to dispense prescription drugs at their offices directly to the patient. Previous WCRI studies reported considerably higher prices paid for physician-dispensed prescriptions when compared with prices paid to pharmacies for the same drug. These studies also reported rapid growth of physician dispensing in several study states ...
A 2012 WCRI study found that the 2007 change in California reduced the average prices paid for physician-dispensed prescriptions to close to the prices paid to pharmacies for the same drug. After the reform, many physicians continued to dispense in California - nearly half of all prescriptions were dispensed at doctors’ offices in post-reform California.
Since then, the WCRI says that a number of states have adopted reforms similar to those in California. As of July 2013, at least 13 other states have made law or rule changes with the intention of reducing the prices paid for physician-dispensed drugs while continuing to allow physicians to dispense drugs directly to their patients. These states include Alabama, Arizona, Connecticut, Florida, Georgia, Idaho, Illinois, Indiana, Michigan, Mississippi, Oklahoma, South Carolina, and Tennessee. Florida also made law changes, effective July 2011, that were aimed at eliminating so-called pill mills by prohibiting all Florida physicians from dispensing Schedules II and III narcotics.
A few states have sought to prohibit or severely limit physicians from dispensing prescription drugs directly to their patients. In the United States, six states prohibit physician dispensing in general; Massachusetts, New York, and Texas, Montana, Utah, and Wyoming. Louisiana limits physician dispensing of narcotics to a 48-hour supply.
According to the new WCRI study, The Prevalence and Costs of Physician-Dispensed Drugs, most states still allow physicians to dispense prescription drugs at their offices directly to the patient. Previous WCRI studies reported considerably higher prices paid for physician-dispensed prescriptions when compared with prices paid to pharmacies for the same drug. These studies also reported rapid growth of physician dispensing in several study states ...
A new study published in the JAMA Internal Medicine and summarized by Reuters Health says that more than one in ten patients being treated in intensive care units (ICUs) was at some point receiving what doctors deemed to be futile care. In those cases, critical care doctors believed people would never survive outside an ICU or that the burdens of their care "grossly outweighed" any benefits. And, researchers found, treating each of those patients cost about $4,000 every day.
"Many physicians find that the provision of futile care is not only contradictory to their professional responsibility, but harmful to patients," Dr. Neil Wenger, director of the UCLA Healthcare Ethics Center at the David Geffen School of Medicine, and senior author of the study, said. "The biggest issue, more important than the cost issue, is the use of highly advanced medical care that was designed to rescue people that instead gets used to prolong the dying process," such as ventilators and medicines that raise blood pressure, he told Reuters Health.
For their study, Wenger and his colleagues first convened a group of 13 doctors who worked in critical care to agree on a definition of futile treatment. Categories included care for patients who were permanently unconscious or for whom death was imminent, or treatment that could not achieve the patient's goals.
Then, the researchers surveyed the attending critical care specialist in five ICUs every day for three months about each of that doctor's patients to find out how many were receiving futile care under the focus group's definition. During the study period, 36 doctors assessed 1,136 patients, with an average of six assessments per patient. Of those patients, 123 - or 11 percent - were determined to be receiving futile treatment, and another 98 (8.6 percent) were perceived as receiving probably futile treatment.
Eighty-four of those receiving futile care died before discharge, and another 20 died within six months of their ICU stay, the researchers reported in JAMA Internal Medicine. The rest were left in "severely compromised" states, with many kept alive by machines. Wenger and his team calculated hospital costs for futile care were about $4,000 per day, adding up to $2.6 million of treatment provided unnecessarily.
Dr. Michael Niederman, chair of the department of medicine at Winthrop-University Hospital in Mineola, New York, said how often futile care is provided is likely to vary between ICUs. "It's very difficult to come up with a definition of futile care," he told Reuters Health. "I think there are many things we do where over time we realize we're unable to help the patient."
Niederman, who has studied futile care but wasn't involved in the new research, said along with the costs of providing intensive care that is unlikely to help, there may be times when such treatment hurts other patients as well. For example, many very sick patients in the ICU are on antibiotics, even if they don't currently have an infection. One study he cited showed one quarter of them developed multi-drug resistant bacteria - which could then be spread to other patients on the unit.
Of course, the researchers said, doctors are not making treatment decisions on their own, and families may have different opinions on what constitutes futile care, or when the benefits of treatment outweigh the burdens. "Many times family members have a sense of guilt and responsibility to their loved ones that they want everything done, and I think many times they don't understand what it means to do everything," Niederman said.
"The implied discussion here is, do we have the resources in this country to give people care whenever they want it regardless of whether we think the care has benefit?" he said. "That's a very difficult discussion." Wenger said for him, the study highlights the importance of having conversations with patients about their end-of-life care while they are still able to participate in those talks. "It's a very complex process making decisions for very ill patients who are on the brink of death," he said. "The main message is that early discussions and advance planning are absolutely critical." ...
"Many physicians find that the provision of futile care is not only contradictory to their professional responsibility, but harmful to patients," Dr. Neil Wenger, director of the UCLA Healthcare Ethics Center at the David Geffen School of Medicine, and senior author of the study, said. "The biggest issue, more important than the cost issue, is the use of highly advanced medical care that was designed to rescue people that instead gets used to prolong the dying process," such as ventilators and medicines that raise blood pressure, he told Reuters Health.
For their study, Wenger and his colleagues first convened a group of 13 doctors who worked in critical care to agree on a definition of futile treatment. Categories included care for patients who were permanently unconscious or for whom death was imminent, or treatment that could not achieve the patient's goals.
Then, the researchers surveyed the attending critical care specialist in five ICUs every day for three months about each of that doctor's patients to find out how many were receiving futile care under the focus group's definition. During the study period, 36 doctors assessed 1,136 patients, with an average of six assessments per patient. Of those patients, 123 - or 11 percent - were determined to be receiving futile treatment, and another 98 (8.6 percent) were perceived as receiving probably futile treatment.
Eighty-four of those receiving futile care died before discharge, and another 20 died within six months of their ICU stay, the researchers reported in JAMA Internal Medicine. The rest were left in "severely compromised" states, with many kept alive by machines. Wenger and his team calculated hospital costs for futile care were about $4,000 per day, adding up to $2.6 million of treatment provided unnecessarily.
Dr. Michael Niederman, chair of the department of medicine at Winthrop-University Hospital in Mineola, New York, said how often futile care is provided is likely to vary between ICUs. "It's very difficult to come up with a definition of futile care," he told Reuters Health. "I think there are many things we do where over time we realize we're unable to help the patient."
Niederman, who has studied futile care but wasn't involved in the new research, said along with the costs of providing intensive care that is unlikely to help, there may be times when such treatment hurts other patients as well. For example, many very sick patients in the ICU are on antibiotics, even if they don't currently have an infection. One study he cited showed one quarter of them developed multi-drug resistant bacteria - which could then be spread to other patients on the unit.
Of course, the researchers said, doctors are not making treatment decisions on their own, and families may have different opinions on what constitutes futile care, or when the benefits of treatment outweigh the burdens. "Many times family members have a sense of guilt and responsibility to their loved ones that they want everything done, and I think many times they don't understand what it means to do everything," Niederman said.
"The implied discussion here is, do we have the resources in this country to give people care whenever they want it regardless of whether we think the care has benefit?" he said. "That's a very difficult discussion." Wenger said for him, the study highlights the importance of having conversations with patients about their end-of-life care while they are still able to participate in those talks. "It's a very complex process making decisions for very ill patients who are on the brink of death," he said. "The main message is that early discussions and advance planning are absolutely critical." ...
Coccidioidomycosis commonly known as "cocci" or "valley fever" as well as "California fever" and "San Joaquin Valley fever" is a fungal disease.that is sometimes claimed to be an industrial injury especially among construction workers or those exposed to newly excavated work sties.
It is endemic in certain parts of Arizona, California, Nevada, New Mexico, Texas, Utah and northern Mexico. It is dormant during long dry spells, then develops as a mold with long filaments that break off into airborne spores when the rains come. The spores, known as arthroconidia, are swept into the air by disruption of the soil, such as during construction, farming, or an earthquake.
Infection is caused by inhalation of the particles. The disease is not transmitted from person to person. The infection ordinarily resolves leaving the patient with a specific immunity to re-infection. However, in some cases the infection may manifest itself repeatedly or permanently over the life of the patient. In those cases the industrial claim may be costly.
The U.S. national public health institute Centers for Disease Control and Prevention (CDC) called the disease a "silent epidemic" and acknowledged that there is no proven anticoccidioidal vaccine available.
And now a new CDC report shows an increase in California hospitalizations for Coccidioidomycosis over the last decade. Only 719 cases were reported annually in 1998. The annual number showed a steady increase up through 2011 when 5697 cases were reported. The incidence rate per 100,000 population increased from 2.1 in 1998 to a record of 14.9 in 2011 as well.
Similar increases were reported in Arizona, Nevada, New Mexico and Utah ...
It is endemic in certain parts of Arizona, California, Nevada, New Mexico, Texas, Utah and northern Mexico. It is dormant during long dry spells, then develops as a mold with long filaments that break off into airborne spores when the rains come. The spores, known as arthroconidia, are swept into the air by disruption of the soil, such as during construction, farming, or an earthquake.
Infection is caused by inhalation of the particles. The disease is not transmitted from person to person. The infection ordinarily resolves leaving the patient with a specific immunity to re-infection. However, in some cases the infection may manifest itself repeatedly or permanently over the life of the patient. In those cases the industrial claim may be costly.
The U.S. national public health institute Centers for Disease Control and Prevention (CDC) called the disease a "silent epidemic" and acknowledged that there is no proven anticoccidioidal vaccine available.
And now a new CDC report shows an increase in California hospitalizations for Coccidioidomycosis over the last decade. Only 719 cases were reported annually in 1998. The annual number showed a steady increase up through 2011 when 5697 cases were reported. The incidence rate per 100,000 population increased from 2.1 in 1998 to a record of 14.9 in 2011 as well.
Similar increases were reported in Arizona, Nevada, New Mexico and Utah ...
The Division of Workers’ Compensation’s (DWC) invites claims administrators, attorneys, and others to attend this online web training on the Qualified Medical Evaluator (QME) panel request process in order to obtain tips on how to successfully submit represented panel QME requests and to gain tools to make panel requests easier and more efficient leading to a shorter wait time to receive panels. The course will also help avoid common errors in incomplete or inappropriate requests.
The DWC says that up to 90% of represented panel QME requests are improperly submitted since SB 863 changes were implemented.
The course "The QME Process: How to Successfully Request a Represented Panel " will take place online on Thursday, September. 19 from 2:00 to 3:00 PM. Pre-registration is not required for this free webinar meeting; however ports available for the training are limited. Attendees are encouraged to gather in groups to participate in this online training. The technical specifications for accessing the webinar are posted on the DWC website.
Please note, in order to save time before the meeting, check your system to make sure it is ready to use Microsoft Office Live Meeting. The audio option is not available when you choose the web access option for the webinar program. Instead, launch the Microsoft Live Meeting Client (requires software download). The software download takes approximately 15 to 20 minutes. We recommend that you login approximately 5 minutes before the meeting ...
The DWC says that up to 90% of represented panel QME requests are improperly submitted since SB 863 changes were implemented.
The course "The QME Process: How to Successfully Request a Represented Panel " will take place online on Thursday, September. 19 from 2:00 to 3:00 PM. Pre-registration is not required for this free webinar meeting; however ports available for the training are limited. Attendees are encouraged to gather in groups to participate in this online training. The technical specifications for accessing the webinar are posted on the DWC website.
Please note, in order to save time before the meeting, check your system to make sure it is ready to use Microsoft Office Live Meeting. The audio option is not available when you choose the web access option for the webinar program. Instead, launch the Microsoft Live Meeting Client (requires software download). The software download takes approximately 15 to 20 minutes. We recommend that you login approximately 5 minutes before the meeting ...
Dr. Sri J. "Dr. J" Wijegunaratne of Anaheim and Godwin Onyeabor of Covina were convicted of fraudulently billing Medicare for medically unnecessary equipment and receiving paid kickbacks.
The Glendora Patch reports that Dr. Sri J. "Dr. J" Wijegunaratne was sentenced to 27 months for recommending motorized wheelchairs and other equipment that patients did not need and sometimes never used, according to Department of Justice prosecutors.
Co-defendant Godwin Onyeabor, who ran a San Bernardino medical supply firm, fraudulently billed Medicare for the medically unnecessary equipment and paid kickbacks to the doctor, according to the DOJ. Onyeabor, 50, of Covina, was sentenced to 51 months in federal prison.
During trial in Los Angeles federal court, several Medicare beneficiaries testified that they were lured to clinics with the promise of free items such as vitamins and juice, only to receive motorized wheelchairs that they did not need or want.
Over about five years, Onyeabor, Wijegunaratne and others submitted about $1.5 million in false claims to Medicare and received nearly $1 million in reimbursements, according to the DOJ. Wijegunaratne and Onyeabor were each found guilty in April of conspiracy and health care fraud charges.
Two others defendants, Heidi Morishita and Victoria N. Onyeabor, are scheduled to be sentenced Sept. 30 and Oct. 7, respectively ...
The Glendora Patch reports that Dr. Sri J. "Dr. J" Wijegunaratne was sentenced to 27 months for recommending motorized wheelchairs and other equipment that patients did not need and sometimes never used, according to Department of Justice prosecutors.
Co-defendant Godwin Onyeabor, who ran a San Bernardino medical supply firm, fraudulently billed Medicare for the medically unnecessary equipment and paid kickbacks to the doctor, according to the DOJ. Onyeabor, 50, of Covina, was sentenced to 51 months in federal prison.
During trial in Los Angeles federal court, several Medicare beneficiaries testified that they were lured to clinics with the promise of free items such as vitamins and juice, only to receive motorized wheelchairs that they did not need or want.
Over about five years, Onyeabor, Wijegunaratne and others submitted about $1.5 million in false claims to Medicare and received nearly $1 million in reimbursements, according to the DOJ. Wijegunaratne and Onyeabor were each found guilty in April of conspiracy and health care fraud charges.
Two others defendants, Heidi Morishita and Victoria N. Onyeabor, are scheduled to be sentenced Sept. 30 and Oct. 7, respectively ...
