The Medicare Fraud Strike Force in six cities charged 90 individuals -- 27 doctors, nurses and other medical professionals -- for their alleged participation in Medicare fraud schemes involving hundreds of millions. According to the story in Southern California Public Radio, eight of the people charged in Tuesday's nationwide Medicare fraud crackdown operated in the Los Angeles area, and were responsible for $32 million in fraudulent billing. All told, the government's Medicare Fraud Strike Force charged 90 health care workers, including doctors and suppliers, for allegedly bilking Medicare out of $260 million. he Medicare Fraud Strike Force charged people in six cities, including Los Angeles. The Strike Force is part of the Health Care Fraud Prevention and Enforcement Action Team, a joint initiative of the Justice Department and the Health and Human Services Department. Among the eight in the Los Angeles area, two are doctors, several run medical supply companies and the rest are marketers, whose job it is to bring Medicare beneficiaries to the doctors. The group is responsible for $32 million in fraudulent payments for equipment that was not necessary and for treatments that were never provided, according to the government.
Below are the individuals charged in California on Tuesday:
1) Robert A. Glazer, doctor at Glazer Medical Clinic in Los Angeles. Glazer allegedly billed for services that were never provided. He also allegedly received kickbacks for signing home health certificates that were not necessary and for prescribing equipment like power wheelchairs that were not needed. Between 2006 and 2014 Glazer was paid $735,000 by Medicare. Medical equipment companies were paid $2.6 million based on Glazer’s false prescriptions and Home Health Agencies received $16.4 million based on Glazer’s prescriptions. Glazer's office did not return a call seeking comment.
2) Sylvia Ogbenyeanu Walter-Eze, Judith Bongcayoa Estrella and Wilmer David Guzman. Walter-Eze is owner of Ezcore 900, a durable medical equipment company in Valencia. Estrella and Guzman were marketers that brought Medicare patients to Ezcore. Walter-Eze is accused of filing false and fraudulent claims for power wheelchairs and accessories to Medicare. The company received nearly $2 million in payments from Medicare. The phone number for Ezcore 900 was disconnected, and the link to the company's website is no longer functional.
3) Zoila O’Brien, patient recruiter/marketer for a medical equipment company. According to the court documents, she found Medicare beneficiaries and took them to a doctor for prescriptions they didn’t need and worked with the medical supplier to submit fraudulent claims. The indictment says she received $600 to $700 per beneficiary she found. In total, the court file alleges, the company she worked with was paid 356,000.
4) Eucharia Okeke, owner of Eastern Medical Supply in Inglewood. The indictment alleges she worked with a doctor who wrote fraudulent prescriptions for power wheelchairs. The lawsuit says she would pay marketers and doctors kickbacks for referring Medicare beneficiaries. Okeke’s company received $311,000 in payment. The phone number for Eastern Medical Supply was disconnected.
5) Jason Ling, medical doctor in Spring Valley, near San Diego. He wrote unnecessary prescriptions for Medicare recipients. He was working with Eucharia Okeke (above). His alleged activities resulted in payment of about $311,000 from Medicare. Ling did not return a call seeking comment.
6) Hakop Gambaryan, owner of Colonial Medical Supply in Van Nuys. According to the court documents Gambaryan was paid $1.7 million by Medicare for false and fraudulent claims. Gambaryan did not return calls seeking comment.
...
Below are the individuals charged in California on Tuesday:
1) Robert A. Glazer, doctor at Glazer Medical Clinic in Los Angeles. Glazer allegedly billed for services that were never provided. He also allegedly received kickbacks for signing home health certificates that were not necessary and for prescribing equipment like power wheelchairs that were not needed. Between 2006 and 2014 Glazer was paid $735,000 by Medicare. Medical equipment companies were paid $2.6 million based on Glazer’s false prescriptions and Home Health Agencies received $16.4 million based on Glazer’s prescriptions. Glazer's office did not return a call seeking comment.
2) Sylvia Ogbenyeanu Walter-Eze, Judith Bongcayoa Estrella and Wilmer David Guzman. Walter-Eze is owner of Ezcore 900, a durable medical equipment company in Valencia. Estrella and Guzman were marketers that brought Medicare patients to Ezcore. Walter-Eze is accused of filing false and fraudulent claims for power wheelchairs and accessories to Medicare. The company received nearly $2 million in payments from Medicare. The phone number for Ezcore 900 was disconnected, and the link to the company's website is no longer functional.
3) Zoila O’Brien, patient recruiter/marketer for a medical equipment company. According to the court documents, she found Medicare beneficiaries and took them to a doctor for prescriptions they didn’t need and worked with the medical supplier to submit fraudulent claims. The indictment says she received $600 to $700 per beneficiary she found. In total, the court file alleges, the company she worked with was paid 356,000.
4) Eucharia Okeke, owner of Eastern Medical Supply in Inglewood. The indictment alleges she worked with a doctor who wrote fraudulent prescriptions for power wheelchairs. The lawsuit says she would pay marketers and doctors kickbacks for referring Medicare beneficiaries. Okeke’s company received $311,000 in payment. The phone number for Eastern Medical Supply was disconnected.
5) Jason Ling, medical doctor in Spring Valley, near San Diego. He wrote unnecessary prescriptions for Medicare recipients. He was working with Eucharia Okeke (above). His alleged activities resulted in payment of about $311,000 from Medicare. Ling did not return a call seeking comment.
6) Hakop Gambaryan, owner of Colonial Medical Supply in Van Nuys. According to the court documents Gambaryan was paid $1.7 million by Medicare for false and fraudulent claims. Gambaryan did not return calls seeking comment.
...
El Dorado County District Attorney Vern Pierson announced the sentencing of Michael Adams and Brenda Adams, the owners of Poor Reds in Diamond Springs, who failed to report $1,320,400 in taxes and committed insurance fraud.Poor Red's opened in 1948 and is best known for its signature drink, the Golden Cadillac, a frothy blend of Galliano, half-and-half, white cream de cacao and ice.
Defendant Michael Adams was sentenced to 6 years 8 months in state prison, and ordered to pay $629,818 as restitution for the unpaid taxes and investigation costs. Defendant Brenda Adams was sentenced to a year in county jail, and also ordered to pay $629,818 as restitution for the unpaid taxes and investigation costs. The length of time from plea to sentencing was much longer than had been anticipated, but necessary in order to attempt to obtain transfer of ownership of Poor Reds. The sentence was the result of guilty pleas to 8 felony counts, including insurance fraud, tax evasion and an admission of an aggravated white collar crime enhancement.
This case was textbook example of multi-agency collaboration and joint investigation by the California Board of Equalizations (BOE), Employment Development Department (EDD) Franchise Tax Board (FTB), Department of Insurance (DOI), and investigators from the El Dorado County District Attorney’s Office. County of El Dorado ...
Defendant Michael Adams was sentenced to 6 years 8 months in state prison, and ordered to pay $629,818 as restitution for the unpaid taxes and investigation costs. Defendant Brenda Adams was sentenced to a year in county jail, and also ordered to pay $629,818 as restitution for the unpaid taxes and investigation costs. The length of time from plea to sentencing was much longer than had been anticipated, but necessary in order to attempt to obtain transfer of ownership of Poor Reds. The sentence was the result of guilty pleas to 8 felony counts, including insurance fraud, tax evasion and an admission of an aggravated white collar crime enhancement.
This case was textbook example of multi-agency collaboration and joint investigation by the California Board of Equalizations (BOE), Employment Development Department (EDD) Franchise Tax Board (FTB), Department of Insurance (DOI), and investigators from the El Dorado County District Attorney’s Office. County of El Dorado ...
The Workers’ Compensation Appeals Board and the Division of Workers’ Compensation have created a new form and made modifications to two existing forms for use in the Electronic Adjudication Management System (EAMS). The new and modified forms will be posted on DWC’s website today. The changes were necessitated by SB 863. The forms are:
1) DWC-CA 10214 a-1 [Stipulations with Request for Award (Rev. 4/2014)]
2) DWC-CA 10208.3 [Declaration of Readiness to Proceed (Expedited Trial) (Rev. 4/2014)]
3)DWC-CA 10232.2 [Document Separator Sheet]
The DWC-CA 10214 a-1 [Stipulations with Request for Award DOI post 1-1-2013 (Rev. 4/2014)] is a new form to be used for injuries on or after January 1, 2013. Pursuant to SB 863, the 15 percent increase or decrease in permanent disability under Labor Code 4658(d) has been eliminated. This form is used by e-form filers and it is now available for use by OCR filers. The old form will be accepted for OCR filing for injuries on or after January 1, 2013 until October 1, 2014. At a later date, the revised form will be placed in use for JET filers.
The current form DWC-CA 10214(a) [Stipulations with Request for Award (Rev 11/2008)] remains in use for e-form and OCR filers for injuries before January 1, 2013. JET filers will continue to use this form for all dates of injury.
The DWC-CA 10208.3 [Declaration of Readiness to Proceed (Expedited Trial) (Rev. 4/2014)], which is used for expedited trials, was also modified. Medical treatment issues are limited to those not arising out of utilization review. Medical Provider Network (MPN) issues for medical treatment purposes have been added. Vocational rehabilitation appeal has been removed. This form is in use for e-form filers and it is now available for use by OCR filers. The older version of this form will be accepted for OCR filing until October 1, 2014. At a later date, the new form will be placed in use for JET filers.
DWC-CA 10232.2 [Document Separator Sheet] (Rev. 4/2014) for OCR filing also updates the document types and titles used for OCR filers and the Unstructured E-form. At a later date it will be placed in use for JET filers.
The modifications to existing document types or document titles are posted in the DWC website. These changes to document types and titles are in use for OCR and e-form filers currently. The older version of this form will be accepted for OCR filing until October 1, 2014 ...
1) DWC-CA 10214 a-1 [Stipulations with Request for Award (Rev. 4/2014)]
2) DWC-CA 10208.3 [Declaration of Readiness to Proceed (Expedited Trial) (Rev. 4/2014)]
3)DWC-CA 10232.2 [Document Separator Sheet]
The DWC-CA 10214 a-1 [Stipulations with Request for Award DOI post 1-1-2013 (Rev. 4/2014)] is a new form to be used for injuries on or after January 1, 2013. Pursuant to SB 863, the 15 percent increase or decrease in permanent disability under Labor Code 4658(d) has been eliminated. This form is used by e-form filers and it is now available for use by OCR filers. The old form will be accepted for OCR filing for injuries on or after January 1, 2013 until October 1, 2014. At a later date, the revised form will be placed in use for JET filers.
The current form DWC-CA 10214(a) [Stipulations with Request for Award (Rev 11/2008)] remains in use for e-form and OCR filers for injuries before January 1, 2013. JET filers will continue to use this form for all dates of injury.
The DWC-CA 10208.3 [Declaration of Readiness to Proceed (Expedited Trial) (Rev. 4/2014)], which is used for expedited trials, was also modified. Medical treatment issues are limited to those not arising out of utilization review. Medical Provider Network (MPN) issues for medical treatment purposes have been added. Vocational rehabilitation appeal has been removed. This form is in use for e-form filers and it is now available for use by OCR filers. The older version of this form will be accepted for OCR filing until October 1, 2014. At a later date, the new form will be placed in use for JET filers.
DWC-CA 10232.2 [Document Separator Sheet] (Rev. 4/2014) for OCR filing also updates the document types and titles used for OCR filers and the Unstructured E-form. At a later date it will be placed in use for JET filers.
The modifications to existing document types or document titles are posted in the DWC website. These changes to document types and titles are in use for OCR and e-form filers currently. The older version of this form will be accepted for OCR filing until October 1, 2014 ...
A study issued by the Workers Compensation Research Institute shows medical costs for injured workers in California moderated before sweeping reforms were implemented.
CompScope Medical Benchmarks for California 14th Edition provides baseline data for monitoring the impact of the California’s reform legislation Senate Bill 863, which took effect on Jan. 1, 2013. For the study, WCRI examined the bill's effect on the state workers' compensation system and compared changes implemented through SB 863 with reforms in other states. The goal of the study is to set benchmarks for such systems in order to weigh their costs and benefits.
Researchers found that in 2010 and 2011, medical payments per claim in California grew by about 3%, down from 8% annual growth since 2005. According to the Insurance Journal, the drop can be attributed to stability of: prices paid for professional services; and use of non hospital services. However, hospital payments per inpatient visit increased significantly between 2006 and 2011, according to the report.
Based on experiences in other states, WCRI predicted that California's shift to a "resource-based relative value scale fee schedule" likely will shift payments from specialty care to primary care providers ...
CompScope Medical Benchmarks for California 14th Edition provides baseline data for monitoring the impact of the California’s reform legislation Senate Bill 863, which took effect on Jan. 1, 2013. For the study, WCRI examined the bill's effect on the state workers' compensation system and compared changes implemented through SB 863 with reforms in other states. The goal of the study is to set benchmarks for such systems in order to weigh their costs and benefits.
Researchers found that in 2010 and 2011, medical payments per claim in California grew by about 3%, down from 8% annual growth since 2005. According to the Insurance Journal, the drop can be attributed to stability of: prices paid for professional services; and use of non hospital services. However, hospital payments per inpatient visit increased significantly between 2006 and 2011, according to the report.
Based on experiences in other states, WCRI predicted that California's shift to a "resource-based relative value scale fee schedule" likely will shift payments from specialty care to primary care providers ...
A new study in the Journal of Occupational and Environmental Medicine reveals a negative impact on medical costs, indemnity costs and lost time from work on workers' compensation claims when physicians, rather than pharmacies, dispense narcotic-related drugs to injured workers within the first 90 days of injury. The study, titled "The Effect of Physician Dispensed Medication on Workers' Compensation Claim Outcomes in the State of Illinois," was authored by Jeffrey Austin White, director of Medical Management Practices & Strategy, and members of the Medical Center of Excellence team of Accident Fund Holdings, Inc., in partnership with researchers from the Johns Hopkins University School of Medicine.
The authors studied a sample of 6824 workers' compensation indemnity claims that were opened and closed between January 1, 2007, and December 31, 2012, by Accident Fund Holdings in the State of Illinois.The number of prescriptions per claim and pharmaceutical, medical, and indemnity costs, as well as time out from work, were significantly higher in claims where a pharmaceutical was dispensed by the physician within 90 days of injury than in claims where physician dispensing did not occur. These differences persisted controlling for age, sex, attorney involvement, and injury complexity.The major findings of the study align with previous research from a February 2013 report on physician-dispensed repackaged drugs in the state of California by the California Workers' Compensation Institute. "These studies leave little doubt that physician dispensing of medications, especially opioid medications, results in poor outcomes for injured workers," said Dr. Dan Hunt, corporate medical director of Accident Fund Holdings. "Longer recoveries, more time away from work and increased medical costs are all unfortunate outcomes of this prescribing practice in workers' compensation."
In the last several years, there has been a surge in the cost and quantity of drugs dispensed from physician offices in workers' compensation insurance. A 43% increase in drugs dispensed by physicians and a 63% percent increase in medication payments in the state of Illinois prompted researchers to perform an investigation on claims outcomes. The analysis demonstrated a 2.99 times higher number of prescriptions dispensed from the physician's office in comparison to the pharmacy. When opioids were dispensed by the physician, the medical costs were 78% higher, the indemnity costs were 57% higher and the number of days off work were 85% higher than pharmacy dispensations after adjusting for differences in age, gender, attorney involvement and injury complexity.
"The ability of physicians to profit from dispensed narcotics in workers' compensations puts a burden on the industry and jeopardizes the safety and well being of our injured workers," said White. "State laws for managing and controlling physician dispensing in workers' compensation are mostly non-existent and are, at the very least, in serious need of careful evaluation and reform." ...
The authors studied a sample of 6824 workers' compensation indemnity claims that were opened and closed between January 1, 2007, and December 31, 2012, by Accident Fund Holdings in the State of Illinois.The number of prescriptions per claim and pharmaceutical, medical, and indemnity costs, as well as time out from work, were significantly higher in claims where a pharmaceutical was dispensed by the physician within 90 days of injury than in claims where physician dispensing did not occur. These differences persisted controlling for age, sex, attorney involvement, and injury complexity.The major findings of the study align with previous research from a February 2013 report on physician-dispensed repackaged drugs in the state of California by the California Workers' Compensation Institute. "These studies leave little doubt that physician dispensing of medications, especially opioid medications, results in poor outcomes for injured workers," said Dr. Dan Hunt, corporate medical director of Accident Fund Holdings. "Longer recoveries, more time away from work and increased medical costs are all unfortunate outcomes of this prescribing practice in workers' compensation."
In the last several years, there has been a surge in the cost and quantity of drugs dispensed from physician offices in workers' compensation insurance. A 43% increase in drugs dispensed by physicians and a 63% percent increase in medication payments in the state of Illinois prompted researchers to perform an investigation on claims outcomes. The analysis demonstrated a 2.99 times higher number of prescriptions dispensed from the physician's office in comparison to the pharmacy. When opioids were dispensed by the physician, the medical costs were 78% higher, the indemnity costs were 57% higher and the number of days off work were 85% higher than pharmacy dispensations after adjusting for differences in age, gender, attorney involvement and injury complexity.
"The ability of physicians to profit from dispensed narcotics in workers' compensations puts a burden on the industry and jeopardizes the safety and well being of our injured workers," said White. "State laws for managing and controlling physician dispensing in workers' compensation are mostly non-existent and are, at the very least, in serious need of careful evaluation and reform." ...
The fact that the workers compensation combined ratio was 101 in 2013, a seven-point decrease from 2012 and a 14-point decline since 2011, is a sign that the workers’ compensation market is returning to a state of "balance," according to the industry’s statistical and rating organization, NCCI.
"We are finally starting to see an industry in balance with these results," said NCCI President and CEO Steve Klingel, reporting on the state of the industry at NCCI’s annual symposium. "Today, industry costs are largely contained, claims frequency continues to decline, and the system in most states is operating efficiently. In short, the market is operating as it should on behalf of most stakeholders."
According to the story in the Insurance Journal, overall, the workers compensation line showed a number of positive results in 2013, said Kathy Antonello, NCCI chief actuary. Premiums grew for the third consecutive year, and at the same time, the combined ratio fell by seven points. The overall reserve position for private carriers improved in 2013, following five consecutive years of deterioration. NCCI estimates the year-end 2013 reserve position to be an $11 billion deficiency for private carriers. The workers compensation residual market experienced a second straight year of significant growth in 2013. Premiums grew by more than 30 percent, and the average market share in the residual market increased from 7 percent to 8 percent. NCCI’s latest data shows the pace of growth has slowed in the first quarter of 2014.
In other good news, lost-time claim frequency maintained a path of decline in 2013, down 2 percent, on average, in NCCI states. The 2 percent decline is within NCCI’s long-term annual estimate of a of 2-4 percent decline per year ...
"We are finally starting to see an industry in balance with these results," said NCCI President and CEO Steve Klingel, reporting on the state of the industry at NCCI’s annual symposium. "Today, industry costs are largely contained, claims frequency continues to decline, and the system in most states is operating efficiently. In short, the market is operating as it should on behalf of most stakeholders."
According to the story in the Insurance Journal, overall, the workers compensation line showed a number of positive results in 2013, said Kathy Antonello, NCCI chief actuary. Premiums grew for the third consecutive year, and at the same time, the combined ratio fell by seven points. The overall reserve position for private carriers improved in 2013, following five consecutive years of deterioration. NCCI estimates the year-end 2013 reserve position to be an $11 billion deficiency for private carriers. The workers compensation residual market experienced a second straight year of significant growth in 2013. Premiums grew by more than 30 percent, and the average market share in the residual market increased from 7 percent to 8 percent. NCCI’s latest data shows the pace of growth has slowed in the first quarter of 2014.
In other good news, lost-time claim frequency maintained a path of decline in 2013, down 2 percent, on average, in NCCI states. The 2 percent decline is within NCCI’s long-term annual estimate of a of 2-4 percent decline per year ...
David Brian Lewis was employed by the California Department of Corrections at Centinela State Prison starting in 1998, where he worked most recently as a plumber. During the course of his employment, Lewis filed several claims for workers' compensation benefits. In the instant proceeding, Lewis was prosecuted for insurance fraud concerning claims arising from an injury to his left arm in 2006 and an injury to his heels that he reported in 2009.
On October 24, 2006, Lewis filled out a workers' compensation claim form reporting an injury that occurred at work on September 16, 2006, when he hit his left hand while using pliers and developed soreness in his forearm. Unbeknownst to his treating doctors, Lewis had a previous diagnosis of epicondylitis. Despite general questions about Lewis's previous injuries and medical conditions during the patient intake process, Lewis did not disclose that he had been previously diagnosed with epicondylitis. While Lewis was off work because of the arm injury, coworkers noticed and reported certain activity by Lewis that they suspected to be inconsistent with Lewis's claimed arm injury. In late 2006 or early 2007, a coworker saw Lewis driving his truck on a bumpy dirt road using his left hand. A coworker also noticed a photo of Lewis displayed at a gas station, in which Lewis was using his left hand to hold up a large fish that he caught in September 2007. Another coworker drove past Lewis's house in March 2007 and observed Lewis getting his trailer ready to transport his all terrain vehicles on a camping trip.
On August 25, 2009, after having been back to work for approximately a year and a half following recovery from his arm injury, Lewis submitted an injury report and a workers' compensation claim form stating that he had a cumulative trauma injury to his left and right heels. Unbeknownst to his treating doctors in the workers' compensation system, Lewis had a previous history with plantar fasciitis and heel spurs. In June 1999, he reported to his family doctor that he was having pain in his left foot, and he was referred for further evaluation and was diagnosed bilateral plantar fasciitis. Lewis told his doctors 1999 that he had been having heel pain for the past 15 years. Lewis was asked when he first visited his PTP's office in August 2009 whether he had any significant past medical history and specifically any previous foot injury. He did not disclose the prior problems with his heels. At trial, the People introduced evidence of certain activities that Lewis engaged in while being treated for heel pain that may have been inconsistent with his condition. Among other things, the jury heard evidence that during the period 2008 to 2012, Lewis was participating in a bowling league.
Lewis was charged with insurance fraud based on his 2006 claim and his 2009 claim. After a month-long trial, a jury convicted Lewis of eight counts of insurance fraud in connection with workers' compensation benefits that he received during two different time periods. Lewis appealed, and the court of appeal reversed in the unpublished opinion of People v Lewis.
Lewis challenged the judgment, arguing (among other things) that the trial court prejudicially erred in not giving a unanimity instruction to the jury; Defense counsel requested that the trial court instruct the jury on the requirement that the jury reach a unanimous decision as to which acts Lewis committed in violation of each count. The trial court declined to give the instruction, stating that the instruction was not needed "when there is a continuous course of conduct." Lewis contends that the trial court prejudicially erred in declining to deliver a unanimity instruction. The Court of Appeal agreed and reversed.
The requirement that the jury be instructed on unanimity in certain cases is based on the principle that "[i]n a criminal case, a jury verdict must be unanimous." Cases have long held that when the evidence suggests more than one discrete crime, either the prosecution must elect among the crimes or the court must require the jury to agree on the same criminal act. This requirement of unanimity as to the criminal act is intended to eliminate the danger that the defendant will be convicted even though there is no single offense which all the jurors agree the defendant committed.
The judgment is reversed and this matter is remanded for further proceedings ...
On October 24, 2006, Lewis filled out a workers' compensation claim form reporting an injury that occurred at work on September 16, 2006, when he hit his left hand while using pliers and developed soreness in his forearm. Unbeknownst to his treating doctors, Lewis had a previous diagnosis of epicondylitis. Despite general questions about Lewis's previous injuries and medical conditions during the patient intake process, Lewis did not disclose that he had been previously diagnosed with epicondylitis. While Lewis was off work because of the arm injury, coworkers noticed and reported certain activity by Lewis that they suspected to be inconsistent with Lewis's claimed arm injury. In late 2006 or early 2007, a coworker saw Lewis driving his truck on a bumpy dirt road using his left hand. A coworker also noticed a photo of Lewis displayed at a gas station, in which Lewis was using his left hand to hold up a large fish that he caught in September 2007. Another coworker drove past Lewis's house in March 2007 and observed Lewis getting his trailer ready to transport his all terrain vehicles on a camping trip.
On August 25, 2009, after having been back to work for approximately a year and a half following recovery from his arm injury, Lewis submitted an injury report and a workers' compensation claim form stating that he had a cumulative trauma injury to his left and right heels. Unbeknownst to his treating doctors in the workers' compensation system, Lewis had a previous history with plantar fasciitis and heel spurs. In June 1999, he reported to his family doctor that he was having pain in his left foot, and he was referred for further evaluation and was diagnosed bilateral plantar fasciitis. Lewis told his doctors 1999 that he had been having heel pain for the past 15 years. Lewis was asked when he first visited his PTP's office in August 2009 whether he had any significant past medical history and specifically any previous foot injury. He did not disclose the prior problems with his heels. At trial, the People introduced evidence of certain activities that Lewis engaged in while being treated for heel pain that may have been inconsistent with his condition. Among other things, the jury heard evidence that during the period 2008 to 2012, Lewis was participating in a bowling league.
Lewis was charged with insurance fraud based on his 2006 claim and his 2009 claim. After a month-long trial, a jury convicted Lewis of eight counts of insurance fraud in connection with workers' compensation benefits that he received during two different time periods. Lewis appealed, and the court of appeal reversed in the unpublished opinion of People v Lewis.
Lewis challenged the judgment, arguing (among other things) that the trial court prejudicially erred in not giving a unanimity instruction to the jury; Defense counsel requested that the trial court instruct the jury on the requirement that the jury reach a unanimous decision as to which acts Lewis committed in violation of each count. The trial court declined to give the instruction, stating that the instruction was not needed "when there is a continuous course of conduct." Lewis contends that the trial court prejudicially erred in declining to deliver a unanimity instruction. The Court of Appeal agreed and reversed.
The requirement that the jury be instructed on unanimity in certain cases is based on the principle that "[i]n a criminal case, a jury verdict must be unanimous." Cases have long held that when the evidence suggests more than one discrete crime, either the prosecution must elect among the crimes or the court must require the jury to agree on the same criminal act. This requirement of unanimity as to the criminal act is intended to eliminate the danger that the defendant will be convicted even though there is no single offense which all the jurors agree the defendant committed.
The judgment is reversed and this matter is remanded for further proceedings ...
Insurance broker James William Riley, 50, of Murrieta is facing 16 months in prison for multiple felony counts involving theft and embezzlement of over $172,000 from Casino Pauma.
According to investigators, Riley targeted Casino Pauma's worker's compensation insurance policy. Since insurance premiums are calculated at both the beginning and end of every year, it is common for liability, and thus premiums, to fluctuate as the number of employees grows or shrinks. A return of excess premiums is possible at the end of a policy cycle, and in 2007, the Casino Pauma was due a premium refund of over $172,000. Riley failed to return the premium refund, which was his duty as a licensed agent. In 2010, the loss to the casino was discovered and prompted the criminal investigation.
Riley's arrest and sentencing are the result of a yearlong multi-agency investigation that included the San Diego County District Attorney's Office, the California Department of Justice, Bureau of Gambling Control and the California Department of Insurance, with cooperation from the Pauma-Yuima Band of Lusieños Indians and Casino Pauma.
"This investigation highlights the collaborative work between Department of Justice Special Agents and Investigative Auditors, as well as, the mutually respectful Tribal, State and County Government relationships in the pursuit of justice," said California Department of Justice, Bureau of Gambling Control, Bureau Chief Wayne J. Quint, Jr ...
According to investigators, Riley targeted Casino Pauma's worker's compensation insurance policy. Since insurance premiums are calculated at both the beginning and end of every year, it is common for liability, and thus premiums, to fluctuate as the number of employees grows or shrinks. A return of excess premiums is possible at the end of a policy cycle, and in 2007, the Casino Pauma was due a premium refund of over $172,000. Riley failed to return the premium refund, which was his duty as a licensed agent. In 2010, the loss to the casino was discovered and prompted the criminal investigation.
Riley's arrest and sentencing are the result of a yearlong multi-agency investigation that included the San Diego County District Attorney's Office, the California Department of Justice, Bureau of Gambling Control and the California Department of Insurance, with cooperation from the Pauma-Yuima Band of Lusieños Indians and Casino Pauma.
"This investigation highlights the collaborative work between Department of Justice Special Agents and Investigative Auditors, as well as, the mutually respectful Tribal, State and County Government relationships in the pursuit of justice," said California Department of Justice, Bureau of Gambling Control, Bureau Chief Wayne J. Quint, Jr ...
Leopoldo Benavides worked as a roofer. On February 7, 2005 he lost his footing and fell a distance of about 12 feet. The fall fractured his right ankle and injured his back. Benavides and his employer’s workers’ compensation insurance carrier agreed to a July 23, 2008, a stipulated award reflecting that Benavides’s injury had left him 51 percent permanently disabled. The stipulation was based upon the evaluations of the AME, orthopedic surgeon Roger S. Sohn, M.D.
After the stipulated award, Dr. Sohn examined Benavides again on December 28, 2010, and issued a new report increasing Benavides’s whole person impairment rating for the spine. This time, Dr. Sohn opined that Benavides had impairment secondary to the fractured femur and "increasing impairment" of the spine. In a subsequent deposition, Dr. Sohn explained that he changed his opinion based on the May 9, 2008 EMG finding, which he stated "automatically boost[ed]" Benavides’s DRE to a category V under the American Medical Association guidelines. Under further questioning, Dr. Sohn acknowledged that the EMG finding confirmed the decline in Benavides’s condition had occurred before the stipulated award was entered on July 23, 2008.
On February 8, 2010, Benavides filed a petition to reopen, alleging his condition had worsened and that his disability exceeded the rating provided by the July 23, 2008 stipulated award. The WCJ initially denied the petition, concluding that Benavides had not sustained a new and further disability following that award. The WCJ vacated his initial finding and decision, after Benavides filed a petition for reconsideration. In his new findings and decision, the WCJ explained that Dr. Sohn now rated Benavides as more disabled than the July 23, 2008 stipulated award reflected, and Benavides should therefore be rated as 72 percent permanently disabled.
On reconsideration, a two-to-one majority of the appeals board disagreed. The majority found that Benavides had not sustained a "new and further disability" as required under Labor Code section 5410, because the decline in Benavides’s condition occurred before entry of the award. The majority also concluded that "good cause" to reopen the case under section 5803 was not established, because there was nothing "in the record to suggest that [Benavides] was unable to send the EMG study to Dr. Sohn before the award was issued." In that regard, the majority noted that Benavides had not shown why the new evidence could not have been discovered and produced at a hearing held prior to the July 23, 2008 award.
In the unpublished decision of Benavides v WCAB, the Court of Appeal reversed and concluded there was good cause to reopen the case and annulled the decision of the appeals board and remand with directions to reinstate the WCJ’s award of a 72 percent disability rating.
Labor Code section 5803 accords the appeals board continuing jurisdiction to rescind or revise its awards, "upon good cause shown." Such cause may consist of newly discovered evidence previously unavailable, a change in the law, or "any factor or circumstance unknown at the time the original award or order was made which renders the previous findings and award ‘inequitable.’ " (LeBoeuf v. Workers’ Comp. Appeals Bd. (1983) 34 Cal.3d 234, 242) More specifically, an award based upon a stipulation may be reopened or rescinded if the "stipulation has been ‘entered into through inadvertence, excusable neglect, fraud, mistake of fact or law, . . . or where special circumstances exist rendering it unjust to enforce the stipulation.' " (Huston v. Workers’ Comp. Appeals Bd. (1979) 95 Cal.App.3d 856, 865-866)
Dr. Sohn issued a pre-award report rating Benavidas’s impairment without first requesting and reviewing an EMG, and the WCJ approved the parties’ stipulation, unaware of the fact that an existing EMG demonstrated Benavidas’s spinal condition was significantly worse than reflected in Dr. Sohn’s report. Whether the stipulation was the result of inadvertence, excusable neglect, or mistake of fact, the error justifies reopening the resulting award. "Indeed, when Benavides brought his petition to reopen, the evidence clearly established that the stipulated award was inequitable." ...
After the stipulated award, Dr. Sohn examined Benavides again on December 28, 2010, and issued a new report increasing Benavides’s whole person impairment rating for the spine. This time, Dr. Sohn opined that Benavides had impairment secondary to the fractured femur and "increasing impairment" of the spine. In a subsequent deposition, Dr. Sohn explained that he changed his opinion based on the May 9, 2008 EMG finding, which he stated "automatically boost[ed]" Benavides’s DRE to a category V under the American Medical Association guidelines. Under further questioning, Dr. Sohn acknowledged that the EMG finding confirmed the decline in Benavides’s condition had occurred before the stipulated award was entered on July 23, 2008.
On February 8, 2010, Benavides filed a petition to reopen, alleging his condition had worsened and that his disability exceeded the rating provided by the July 23, 2008 stipulated award. The WCJ initially denied the petition, concluding that Benavides had not sustained a new and further disability following that award. The WCJ vacated his initial finding and decision, after Benavides filed a petition for reconsideration. In his new findings and decision, the WCJ explained that Dr. Sohn now rated Benavides as more disabled than the July 23, 2008 stipulated award reflected, and Benavides should therefore be rated as 72 percent permanently disabled.
On reconsideration, a two-to-one majority of the appeals board disagreed. The majority found that Benavides had not sustained a "new and further disability" as required under Labor Code section 5410, because the decline in Benavides’s condition occurred before entry of the award. The majority also concluded that "good cause" to reopen the case under section 5803 was not established, because there was nothing "in the record to suggest that [Benavides] was unable to send the EMG study to Dr. Sohn before the award was issued." In that regard, the majority noted that Benavides had not shown why the new evidence could not have been discovered and produced at a hearing held prior to the July 23, 2008 award.
In the unpublished decision of Benavides v WCAB, the Court of Appeal reversed and concluded there was good cause to reopen the case and annulled the decision of the appeals board and remand with directions to reinstate the WCJ’s award of a 72 percent disability rating.
Labor Code section 5803 accords the appeals board continuing jurisdiction to rescind or revise its awards, "upon good cause shown." Such cause may consist of newly discovered evidence previously unavailable, a change in the law, or "any factor or circumstance unknown at the time the original award or order was made which renders the previous findings and award ‘inequitable.’ " (LeBoeuf v. Workers’ Comp. Appeals Bd. (1983) 34 Cal.3d 234, 242) More specifically, an award based upon a stipulation may be reopened or rescinded if the "stipulation has been ‘entered into through inadvertence, excusable neglect, fraud, mistake of fact or law, . . . or where special circumstances exist rendering it unjust to enforce the stipulation.' " (Huston v. Workers’ Comp. Appeals Bd. (1979) 95 Cal.App.3d 856, 865-866)
Dr. Sohn issued a pre-award report rating Benavidas’s impairment without first requesting and reviewing an EMG, and the WCJ approved the parties’ stipulation, unaware of the fact that an existing EMG demonstrated Benavidas’s spinal condition was significantly worse than reflected in Dr. Sohn’s report. Whether the stipulation was the result of inadvertence, excusable neglect, or mistake of fact, the error justifies reopening the resulting award. "Indeed, when Benavides brought his petition to reopen, the evidence clearly established that the stipulated award was inequitable." ...
Susette Boggs, 52 of Palmdale, was arrested for alleged workers' compensation fraud. Boggs worked for the Los Angeles County Department of Parks and Recreation for over 10 years at the Placerita Canyon Nature Center in Newhall handling a variety of animals, including owls, skunks, reptiles and opossums. Boggs reported that she had been bitten by a tick, contracted Lyme disease and as a result filed a workers' compensation claim with a date of injury of April 19, 2007.
Boggs claimed a multitude of symptoms prevented her from working and made her daily life miserable. According to physicians' records, Boggs reported difficulty sitting for long periods due to pain, trouble holding items due to weakness in her hands as well as other symptoms.
The investigation into Boggs' workers' compensation claim revealed that she failed to be truthful and misrepresented her involvement in a band as a drummer/singer to her doctors. Video evidence showed Boggs maintaining a physically active lifestyle as a drummer/singer in a band since 2007, in direct conflict with symptoms she reported to her physicians about her physical capabilities.
The activities captured on video, and reviewed by her physicians, greatly impacted their opinion as to whether Boggs has 100 percent whole body impairment. Her physicians have since concluded that Boggs is capable of gainful employment. The reversal of the medical diagnosis impacts the workers' compensation benefits allowed to Boggs. One hundred percent permanent disability exposure was valued at $409,552. After review of the video evidence the final permanent disability value was lowered to 39 percent permanent disability or $44,620, a difference of $364,932.
"Exaggerating symptoms and deceiving physicians in hopes of a monetary workers' compensation windfall is not a smart retirement plan," said Insurance Commissioner Jones. "The detectives in my department are diligent in their investigations to uncover discrepancies and bring criminals to justice. My department is sending a clear message to discourage anyone considering the same path of deception. You will be caught and you will be held accountable."
If convicted Boggs faces a possible sentence of maximum seven years in prison and restitution of $364,932 ...
Boggs claimed a multitude of symptoms prevented her from working and made her daily life miserable. According to physicians' records, Boggs reported difficulty sitting for long periods due to pain, trouble holding items due to weakness in her hands as well as other symptoms.
The investigation into Boggs' workers' compensation claim revealed that she failed to be truthful and misrepresented her involvement in a band as a drummer/singer to her doctors. Video evidence showed Boggs maintaining a physically active lifestyle as a drummer/singer in a band since 2007, in direct conflict with symptoms she reported to her physicians about her physical capabilities.
The activities captured on video, and reviewed by her physicians, greatly impacted their opinion as to whether Boggs has 100 percent whole body impairment. Her physicians have since concluded that Boggs is capable of gainful employment. The reversal of the medical diagnosis impacts the workers' compensation benefits allowed to Boggs. One hundred percent permanent disability exposure was valued at $409,552. After review of the video evidence the final permanent disability value was lowered to 39 percent permanent disability or $44,620, a difference of $364,932.
"Exaggerating symptoms and deceiving physicians in hopes of a monetary workers' compensation windfall is not a smart retirement plan," said Insurance Commissioner Jones. "The detectives in my department are diligent in their investigations to uncover discrepancies and bring criminals to justice. My department is sending a clear message to discourage anyone considering the same path of deception. You will be caught and you will be held accountable."
If convicted Boggs faces a possible sentence of maximum seven years in prison and restitution of $364,932 ...
Xerox announced a definitive agreement to acquire ISG Holdings, Inc. for $225 million, creating a comprehensive workers’ compensation suite of offerings for clients in the property and casualty insurance industry. In addition to Xerox’s current workers’ compensation business offered through CompIQ, Xerox will add the following ISG subsidiaries and their offerings to its portfolio:
-- StrataCare, based in Irvine, Calif., provides comprehensive web-based medical bill review software, workflow and outsourcing solutions.
-- Bunch CareSolutions, based in Lakeland, Fla., provides medical management solutions with real-time integration between medical bill review and nurse case management.
StrataCare provides web-based medical bill management software. It has more than 350 employees across its operations here and a regional office in Amarillo, Texas.
The acquisition of ISG expands Xerox’s services to property and casualty insurance carriers, third-party administrators, managed care services providers, governments and self-administered employers who require comprehensive reviews of medical bills and implementation of care management plans stemming from workers’ compensation claims. This acquisition complements Xerox’s current support of the top 20 U.S. property, casualty and commercial health insurance companies, touching nearly two-thirds of the nation’s insured population.
"The workers’ compensation industry generates $60 billion in medical payments each year - that equates to approximately 75 million bills in need of financial validation," said Bob Zapfel, president, Xerox Services. "This acquisition demonstrates our commitment to the property and casualty sector and makes us an industry leader in workers’ compensation bill review software and care management services."
ISG’s secure and compliant SaaS (Software as a Service) cloud delivery platform, care management services and analytics blended with Xerox’s world-class transactional expertise will allow clients to benefit from a true end-to-end solution. "Xerox provides a solid, secure foundation to continue to enhance our software and technology based services," Paul Glover, ISG’s chairman and CEO. "The depth and breadth of Xerox’s services and resources provide ISG’s customers confidence in our ability to meet and exceed their needs into the future."
Once the acquisition is complete, the brands will go to market as StrataCare, A Xerox Company and Bunch CareSolutions, A Xerox Company. The operations of StrataCare and Bunch CareSolutions and its 700 employees in Irvine, Calif., Lakeland, Fla., and Amarillo, TX, will continue to be led by Glover, who will report to Connie Harvey, chief operating officer of Xerox’s commercial healthcare and insurance business. The two units, which will be branded as Xerox companies, are expected to have about 700 employees overall when the transaction is completed.
...
-- StrataCare, based in Irvine, Calif., provides comprehensive web-based medical bill review software, workflow and outsourcing solutions.
-- Bunch CareSolutions, based in Lakeland, Fla., provides medical management solutions with real-time integration between medical bill review and nurse case management.
StrataCare provides web-based medical bill management software. It has more than 350 employees across its operations here and a regional office in Amarillo, Texas.
The acquisition of ISG expands Xerox’s services to property and casualty insurance carriers, third-party administrators, managed care services providers, governments and self-administered employers who require comprehensive reviews of medical bills and implementation of care management plans stemming from workers’ compensation claims. This acquisition complements Xerox’s current support of the top 20 U.S. property, casualty and commercial health insurance companies, touching nearly two-thirds of the nation’s insured population.
"The workers’ compensation industry generates $60 billion in medical payments each year - that equates to approximately 75 million bills in need of financial validation," said Bob Zapfel, president, Xerox Services. "This acquisition demonstrates our commitment to the property and casualty sector and makes us an industry leader in workers’ compensation bill review software and care management services."
ISG’s secure and compliant SaaS (Software as a Service) cloud delivery platform, care management services and analytics blended with Xerox’s world-class transactional expertise will allow clients to benefit from a true end-to-end solution. "Xerox provides a solid, secure foundation to continue to enhance our software and technology based services," Paul Glover, ISG’s chairman and CEO. "The depth and breadth of Xerox’s services and resources provide ISG’s customers confidence in our ability to meet and exceed their needs into the future."
Once the acquisition is complete, the brands will go to market as StrataCare, A Xerox Company and Bunch CareSolutions, A Xerox Company. The operations of StrataCare and Bunch CareSolutions and its 700 employees in Irvine, Calif., Lakeland, Fla., and Amarillo, TX, will continue to be led by Glover, who will report to Connie Harvey, chief operating officer of Xerox’s commercial healthcare and insurance business. The two units, which will be branded as Xerox companies, are expected to have about 700 employees overall when the transaction is completed.
...
State Compensation Insurance Fund's 2013 Annual Report, released on its Web site today, shows an increase in net premiums to more than one billion dollars and a decrease in its combined ratio of more than 10 percent. The strong growth in 2013 premiums was a result of a hardening market combined with its introduction of Tiered pricing in March. Other key financial highlights for 2013 include:
1) A $100 million dividend;
2) Policyholders' surplus increased by six percent compared to last year;
3) More than 98.4 percent of its bond portfolio received the National Association of Insurance Commissioners' highest quality credit rating.
State Fund maintained a balanced investment portfolio that was focused on both credit quality and investment yield. In 2013, State Fund started investing in stocks as a result of the passage of SB 1513 which expanded State Fund’s investment authority. At year end, State Fund had $917 million in common stocks.
"State Fund has seen tremendous successes in one hundred years of doing business and supported those that have shaped California to succeed and grow," said Carol Newman, Acting President and CEO in the report. "As we enter our next century, we've implemented an ambitious plan to redesign our operations and reduce costs to California's employers, making us a financially stronger and more efficient organization."
In 2010, State Fund began a transformation that has reduced annual fixed expenses by $300 million dollars. These savings will help State Fund maintain fair pricing and bring greater value to more California employers ...
1) A $100 million dividend;
2) Policyholders' surplus increased by six percent compared to last year;
3) More than 98.4 percent of its bond portfolio received the National Association of Insurance Commissioners' highest quality credit rating.
State Fund maintained a balanced investment portfolio that was focused on both credit quality and investment yield. In 2013, State Fund started investing in stocks as a result of the passage of SB 1513 which expanded State Fund’s investment authority. At year end, State Fund had $917 million in common stocks.
"State Fund has seen tremendous successes in one hundred years of doing business and supported those that have shaped California to succeed and grow," said Carol Newman, Acting President and CEO in the report. "As we enter our next century, we've implemented an ambitious plan to redesign our operations and reduce costs to California's employers, making us a financially stronger and more efficient organization."
In 2010, State Fund began a transformation that has reduced annual fixed expenses by $300 million dollars. These savings will help State Fund maintain fair pricing and bring greater value to more California employers ...
The Insurance Journal just published a special report that highlights 10 current workers’ compensation challenges ahead for the industry. One of the 10 that stands out deals with innovation and technology.
According to the report, when it comes to technological innovations, the health care industry’s advancements dwarf anything that’s developed in the workers’ comp industry for years, says Thomas Lynch, founder and CEO of Lynch Ryan and Associates Inc., a management consulting firm for workers’ compensation cost control based in Wellesley, Mass., and publisher of the blog WorkersCompInsider.com. "The P/C insurance industry is very slow to innovate and is lagging behind other industries, as well as other parts of the insurance industry, in adoption and rapid movement to technology usage and innovation," he says.
In Lynch’s view, the workers’ comp industry is way behind and it must catch up.
"For example, there’s a huge move now in the Veterans Administration called the Blue Button Project, where if you’re a patient you have a portal. You can go in and you can see all your medical records. You can communicate with your doctors. It’s a great back and forth system." There’s nothing quite like it the workers’ comp industry, he says. "That kind of patient back and forth could really be a benefit in, wellness programs, in claims administration."
The workers’ comp industry also lags in providing mobile claims reporting technology."Even now, today, the usual way is that when you have a claim, you’ll go online and file a report online or you’ll make a phone call. Why couldn’t you take out your smartphone, have a voice activated app that could allow you to report directly into your carrier’s system which would, in real time, display for a claims adjuster?" he says. "Why can’t you, at the same time, take a picture of the incident on your smartphone and include that with the report " the whole claim reported and done in five minutes. We can’t do that now and yet we can do it in other areas."
"Workers’ comp and the rest of P/C has to get its act together, has to rededicate itself to delighting the customer, to having a dynamic relationship with the customer, and understanding that the customer is the most important thing in its universe," Lynch says ...
According to the report, when it comes to technological innovations, the health care industry’s advancements dwarf anything that’s developed in the workers’ comp industry for years, says Thomas Lynch, founder and CEO of Lynch Ryan and Associates Inc., a management consulting firm for workers’ compensation cost control based in Wellesley, Mass., and publisher of the blog WorkersCompInsider.com. "The P/C insurance industry is very slow to innovate and is lagging behind other industries, as well as other parts of the insurance industry, in adoption and rapid movement to technology usage and innovation," he says.
In Lynch’s view, the workers’ comp industry is way behind and it must catch up.
"For example, there’s a huge move now in the Veterans Administration called the Blue Button Project, where if you’re a patient you have a portal. You can go in and you can see all your medical records. You can communicate with your doctors. It’s a great back and forth system." There’s nothing quite like it the workers’ comp industry, he says. "That kind of patient back and forth could really be a benefit in, wellness programs, in claims administration."
The workers’ comp industry also lags in providing mobile claims reporting technology."Even now, today, the usual way is that when you have a claim, you’ll go online and file a report online or you’ll make a phone call. Why couldn’t you take out your smartphone, have a voice activated app that could allow you to report directly into your carrier’s system which would, in real time, display for a claims adjuster?" he says. "Why can’t you, at the same time, take a picture of the incident on your smartphone and include that with the report " the whole claim reported and done in five minutes. We can’t do that now and yet we can do it in other areas."
"Workers’ comp and the rest of P/C has to get its act together, has to rededicate itself to delighting the customer, to having a dynamic relationship with the customer, and understanding that the customer is the most important thing in its universe," Lynch says ...
A 33-year-old former Salinas resident and truck driver was sentenced Friday to more than eight years in prison for workers’ compensation and welfare fraud, according to the Monterey County District Attorney’s Office.
The Salinas Californian reports that Chip Kyle Bolton, of Arizona, was found guilty after a jury trial in April of seven felony counts. Monterey County Superior Court Judge Russell Scott sentenced him to eight years and eight months in prison, a maximum penalty. Bolton claimed an on the job injury in 2011 and was receiving worker's compensation payments, but was later caught on camera playing basketball. That's despite his claims that he was having difficulty standing for more than hour and holding his baby daughter,
In 2011, Bolton reported an on-the-job injury to his employer. He received immediate and continued medical treatment under the workers’ compensation system and was placed on total temporary disability for injuries he described to his doctor, prosecutors said. Bolton also told a claims adjuster he couldn’t stand for more than an hour without a numbing sensation running from his hips to his knees, rendering him unable to hold his baby daughter, prosecutors said. Later that day, he was filmed at the YMCA exercising on an elliptical and playing basketball - activities he later denied at his deposition, the DA’s Office said.
Bolton also received periodic public assistance beginning in 2009. In 2012, while receiving this assistance, Bolton applied for and received unemployment insurance benefits. He signed, under penalty of perjury, documents attesting that he wasn’t receiving unemployment benefits when, in fact, he received and had cashed unemployment checks, prosecutors said. He was subsequently denied any benefits whatsoever because he didn’t accurately and truthfully provide information regarding his income, expenses and the number of people in his household, the DA’s Office said.
Judge Scott called Bolton a "perennial liar" in his sentencing, according to the DA’s Office. Per new realignment laws, Bolton will serve his prison sentence in Monterey County Jail. In total, Bolton will be responsible for $84,350.34 in restitution paid to the Department of Social Services and the Employment Development Department ...
The Salinas Californian reports that Chip Kyle Bolton, of Arizona, was found guilty after a jury trial in April of seven felony counts. Monterey County Superior Court Judge Russell Scott sentenced him to eight years and eight months in prison, a maximum penalty. Bolton claimed an on the job injury in 2011 and was receiving worker's compensation payments, but was later caught on camera playing basketball. That's despite his claims that he was having difficulty standing for more than hour and holding his baby daughter,
In 2011, Bolton reported an on-the-job injury to his employer. He received immediate and continued medical treatment under the workers’ compensation system and was placed on total temporary disability for injuries he described to his doctor, prosecutors said. Bolton also told a claims adjuster he couldn’t stand for more than an hour without a numbing sensation running from his hips to his knees, rendering him unable to hold his baby daughter, prosecutors said. Later that day, he was filmed at the YMCA exercising on an elliptical and playing basketball - activities he later denied at his deposition, the DA’s Office said.
Bolton also received periodic public assistance beginning in 2009. In 2012, while receiving this assistance, Bolton applied for and received unemployment insurance benefits. He signed, under penalty of perjury, documents attesting that he wasn’t receiving unemployment benefits when, in fact, he received and had cashed unemployment checks, prosecutors said. He was subsequently denied any benefits whatsoever because he didn’t accurately and truthfully provide information regarding his income, expenses and the number of people in his household, the DA’s Office said.
Judge Scott called Bolton a "perennial liar" in his sentencing, according to the DA’s Office. Per new realignment laws, Bolton will serve his prison sentence in Monterey County Jail. In total, Bolton will be responsible for $84,350.34 in restitution paid to the Department of Social Services and the Employment Development Department ...
The Division of Workers’ Compensation (DWC) has posted a third 15-day notice of modification to the proposed medical provider networks (MPN) regulations to the DWC website. Members of the public are invited to present written comments regarding the proposed modifications to dwcrules@dir.ca.gov until 5 p.m. on Monday, May 19. The proposed modifications include:
1) Clarification of the definition of an Entity that Provides Physician Network Services.
2) Requirement for an Entity that Provides Physician Network services to provide an affirmation that they contract with physicians and other medical providers or contract with physician networks in their MPN application.
3) Specifies a 90-day time frame from the effective date of these regulations for DWC to assign a unique MPN Identification Number to existing MPNs.
4) Clarification of the instructions to submit an MPN application or MPN modification.
5) Deletion of the requirement to indicate if a physician is not currently taking new workers’ compensation patients in the MPN’s internet website posting of its roster of all treating physicians.
6) Added Civil Code sections 1633.1 et seq. governs electronically signed documents between private parties when obtaining physician acknowledgments.
The notice, text of the regulations, and forms can be found on the proposed regulations page ...
1) Clarification of the definition of an Entity that Provides Physician Network Services.
2) Requirement for an Entity that Provides Physician Network services to provide an affirmation that they contract with physicians and other medical providers or contract with physician networks in their MPN application.
3) Specifies a 90-day time frame from the effective date of these regulations for DWC to assign a unique MPN Identification Number to existing MPNs.
4) Clarification of the instructions to submit an MPN application or MPN modification.
5) Deletion of the requirement to indicate if a physician is not currently taking new workers’ compensation patients in the MPN’s internet website posting of its roster of all treating physicians.
6) Added Civil Code sections 1633.1 et seq. governs electronically signed documents between private parties when obtaining physician acknowledgments.
The notice, text of the regulations, and forms can be found on the proposed regulations page ...
An Adelanto man who claimed he was bitten by a pit bull and injured while working as a cable installer has been charged with felony workers’ compensation fraud.
On March 27, 2008, Dario Rudas-Ortega, 53, reported that he had sustained an injury during the course of his employment. According to Senior Investigator Hector Vidal, Rudas-Ortega claimed he was bitten by a pit bull on his hands and forearms, and later alleged he sustained a left knee injury during the same attack. "Rudas-Ortega is charged with making a false statement in support of this claim for benefits, as well as failing to disclose information regarding his prior medical condition and prior medical treatment to the same body part," Vidal said. It is alleged that as a result of his false statements and omissions, Rudas-Ortega received workers’ compensation benefits to which he was not entitled.
The case was referred to the San Bernardino County District Attorney’s Worker’s Compensation Fraud Unit in 2012 by the Zenith insurance company, after the company’s internal investigation concluded that false statements were made.Felony charges were filed April 14, 2014 (see attached complaint), and Rudas-Ortega was taken into custody by District Attorney Investigators and transported to West Valley Detention Center in Rancho Cucamonga where he was released on his own recognizance.
If convicted on all counts, Rudas-Ortega faces more than five years in County Prison. Arraignment is scheduled for June 19 in San Bernardino Superior Court. The case is being prosecuted by Deputy District Attorney David Simon of the Workers’ Compensation Insurance Fraud Unit ...
On March 27, 2008, Dario Rudas-Ortega, 53, reported that he had sustained an injury during the course of his employment. According to Senior Investigator Hector Vidal, Rudas-Ortega claimed he was bitten by a pit bull on his hands and forearms, and later alleged he sustained a left knee injury during the same attack. "Rudas-Ortega is charged with making a false statement in support of this claim for benefits, as well as failing to disclose information regarding his prior medical condition and prior medical treatment to the same body part," Vidal said. It is alleged that as a result of his false statements and omissions, Rudas-Ortega received workers’ compensation benefits to which he was not entitled.
The case was referred to the San Bernardino County District Attorney’s Worker’s Compensation Fraud Unit in 2012 by the Zenith insurance company, after the company’s internal investigation concluded that false statements were made.Felony charges were filed April 14, 2014 (see attached complaint), and Rudas-Ortega was taken into custody by District Attorney Investigators and transported to West Valley Detention Center in Rancho Cucamonga where he was released on his own recognizance.
If convicted on all counts, Rudas-Ortega faces more than five years in County Prison. Arraignment is scheduled for June 19 in San Bernardino Superior Court. The case is being prosecuted by Deputy District Attorney David Simon of the Workers’ Compensation Insurance Fraud Unit ...
The Department of Industrial Relations (DIR) has released a 102 page report "Ambulatory Surgical Services Provided Under California Workers’ Compensation: An Assessment of the Feasibility and Advisability of Expanding Coverage."
Senate Bill 863, which was signed into law in 2012, requires DIR to study the feasibility of establishing a facility fee for Medicare’s "inpatient only" procedures performed in Ambulatory Surgery Centers (ASCs) and report its finding to the legislative committees. At present, Medicare does not have a fee schedule for these procedures when performed in outpatient settings.
The study’s key recommendations are to retain current OMFS policies with regard to "inpatient only" procedures performed in an ambulatory setting; and strengthen patient protections when procedures are performed in an ambulatory setting..
1) ASCs that are currently eligible for an Official Medical Fee Schedule (OMFS) facility fee are likely to be equipped to provide services that do not require a one-night stay. However, Medicare has several requirements for patient protection that are not found in the minimum accreditation requirements for physician-owned facilities that are not Medicare certified. These include accepting only patients who are likely to require less than a 24-hour stay, assuring appropriate post-discharge arrangements are made, and providing the patient with written disclosure of any financial interests between the ASC and the physician.
2) Data analyses and review of the literature do not provide strong support for removing any procedures from the "inpatient only" list with the possible exception of procedures related to anterior cervical spinal fusions.
3) Few "inpatient only" procedures are currently being performed in an ASC on either workers’ compensation or privately insured patients ages 18-64, with the exception of spinal instrumentation.
4) Current OMFS policies of prior authorization process for performing an "inpatient only" procedure in an ASC setting, which allows for individual consideration of the anticipated services, other procedures that will be performed during the same encounter, and post-discharge services, before the services are provided are preferable to an across-the-board pricing methodology.
Under current OMFS policies, "inpatient only" procedures are covered as an exception that permits a payer to authorize payment for an "inpatient only" service in an ambulatory setting at an agreed-upon rate when medically appropriate. If any services are to be removed from the "inpatient only" list for WC patients, an OMFS allowance is needed for those services. In this regard, Section 74 of SB 863 requires DIR to consider a fee set at 85 percent of the Medicare fee schedule amount for the service when performed on an inpatient basis.
RAND examined two basic policy alternatives for paying for these procedures in an ambulatory setting. Consistent with SB 863, the first option would be to pay for the ambulatory surgery based on a multiple of the Medicare inpatient rate for the procedures. The second option would be to base the rate on the amounts paid for comparable services under the hospital prospective payment system. It concluded that the less problematic approach would be to build on the current OMFS for outpatient services. The "inpatient only" procedures could be assigned to the most comparable APC ...
Senate Bill 863, which was signed into law in 2012, requires DIR to study the feasibility of establishing a facility fee for Medicare’s "inpatient only" procedures performed in Ambulatory Surgery Centers (ASCs) and report its finding to the legislative committees. At present, Medicare does not have a fee schedule for these procedures when performed in outpatient settings.
The study’s key recommendations are to retain current OMFS policies with regard to "inpatient only" procedures performed in an ambulatory setting; and strengthen patient protections when procedures are performed in an ambulatory setting..
1) ASCs that are currently eligible for an Official Medical Fee Schedule (OMFS) facility fee are likely to be equipped to provide services that do not require a one-night stay. However, Medicare has several requirements for patient protection that are not found in the minimum accreditation requirements for physician-owned facilities that are not Medicare certified. These include accepting only patients who are likely to require less than a 24-hour stay, assuring appropriate post-discharge arrangements are made, and providing the patient with written disclosure of any financial interests between the ASC and the physician.
2) Data analyses and review of the literature do not provide strong support for removing any procedures from the "inpatient only" list with the possible exception of procedures related to anterior cervical spinal fusions.
3) Few "inpatient only" procedures are currently being performed in an ASC on either workers’ compensation or privately insured patients ages 18-64, with the exception of spinal instrumentation.
4) Current OMFS policies of prior authorization process for performing an "inpatient only" procedure in an ASC setting, which allows for individual consideration of the anticipated services, other procedures that will be performed during the same encounter, and post-discharge services, before the services are provided are preferable to an across-the-board pricing methodology.
Under current OMFS policies, "inpatient only" procedures are covered as an exception that permits a payer to authorize payment for an "inpatient only" service in an ambulatory setting at an agreed-upon rate when medically appropriate. If any services are to be removed from the "inpatient only" list for WC patients, an OMFS allowance is needed for those services. In this regard, Section 74 of SB 863 requires DIR to consider a fee set at 85 percent of the Medicare fee schedule amount for the service when performed on an inpatient basis.
RAND examined two basic policy alternatives for paying for these procedures in an ambulatory setting. Consistent with SB 863, the first option would be to pay for the ambulatory surgery based on a multiple of the Medicare inpatient rate for the procedures. The second option would be to base the rate on the amounts paid for comparable services under the hospital prospective payment system. It concluded that the less problematic approach would be to build on the current OMFS for outpatient services. The "inpatient only" procedures could be assigned to the most comparable APC ...
Mobile medicine is helping chronic pain patients cope with and manage their condition thanks to new smartphone apps, which can track patients from a distance and monitor pain, mood, physical activity, drug side effects, and treatment compliance.
According to Robert Jamison, PhD, professor of anesthesia and psychiatry at Harvard Medical School and pain psychologist with Brigham and Women’s Hospital, smartphone apps are helping the shrinking ranks of pain specialists treat and monitor rapidly increasing populations of chronic pain sufferers. "Today the ratio is one pain specialist for every 10,000 patients, but mobile technology allows for easy time-effective coverage of patients at a low cost, offering significant opportunities to improve access to health care, contain costs, and improve clinical outcomes," Jamison explained.
At the American Pain Society annual meeting, Jamison presented results of his research on smartphone apps, developed at Brigham and Women’s, for monitoring pain patients. He found that internet-based cognitive behavioral therapy could significantly decrease pain levels, improve function, and decrease costs compared to standard care. "Online networks, for example, can promote communication, distraction, information sharing, self expression and social support," Jamison said. "We also believe online networks decrease feelings of withdrawn behavior and instill a greater willingness to return for treatment." Jamison added that electronic diaries maintained by patients are more effective than paper diaries for evaluating pain levels, daily activities, treatment compliance and mood. Jamison said that while few studies have been conducted on text messaging as a pain management tool, texting has proven to be effective for managing patients with diabetes, hypertension, asthma, smoking cessation and weight loss.
In his ongoing research, Jamison is studying 60 patients with chronic cancer and non-cancer pain who use a pain management smartphone app. "We hypothesized that the pain management smartphone app will help providers track patients and reduce emergency department visits and hospitalizations by 50 percent," said Jamison.
A key feature of the pain management app is daily pain tracking in which patients are asked five questions about their pain, activity interference, sleep, mood, and overall status on a sliding scale of 1 to 10, and compare these with baseline ratings. Should pain ratings significantly increase from baseline or reach 9 or 10, the patient gets an immediate response that the pain specialist has been contacted. "The pain management smartphone app can deliver non-pharmacological, cognitive behavioral treatment as well as prompt patients to stay active, comply with therapy, and develop pain coping skills," Jamison reported. He added that the smartphone data can be summarized and transmitted every day into the patient’s electronic medical record.
Jamison noted that the average response rate to text messages to pain patients is 70 to 90 percent and that high responders show improved pain levels ...
According to Robert Jamison, PhD, professor of anesthesia and psychiatry at Harvard Medical School and pain psychologist with Brigham and Women’s Hospital, smartphone apps are helping the shrinking ranks of pain specialists treat and monitor rapidly increasing populations of chronic pain sufferers. "Today the ratio is one pain specialist for every 10,000 patients, but mobile technology allows for easy time-effective coverage of patients at a low cost, offering significant opportunities to improve access to health care, contain costs, and improve clinical outcomes," Jamison explained.
At the American Pain Society annual meeting, Jamison presented results of his research on smartphone apps, developed at Brigham and Women’s, for monitoring pain patients. He found that internet-based cognitive behavioral therapy could significantly decrease pain levels, improve function, and decrease costs compared to standard care. "Online networks, for example, can promote communication, distraction, information sharing, self expression and social support," Jamison said. "We also believe online networks decrease feelings of withdrawn behavior and instill a greater willingness to return for treatment." Jamison added that electronic diaries maintained by patients are more effective than paper diaries for evaluating pain levels, daily activities, treatment compliance and mood. Jamison said that while few studies have been conducted on text messaging as a pain management tool, texting has proven to be effective for managing patients with diabetes, hypertension, asthma, smoking cessation and weight loss.
In his ongoing research, Jamison is studying 60 patients with chronic cancer and non-cancer pain who use a pain management smartphone app. "We hypothesized that the pain management smartphone app will help providers track patients and reduce emergency department visits and hospitalizations by 50 percent," said Jamison.
A key feature of the pain management app is daily pain tracking in which patients are asked five questions about their pain, activity interference, sleep, mood, and overall status on a sliding scale of 1 to 10, and compare these with baseline ratings. Should pain ratings significantly increase from baseline or reach 9 or 10, the patient gets an immediate response that the pain specialist has been contacted. "The pain management smartphone app can deliver non-pharmacological, cognitive behavioral treatment as well as prompt patients to stay active, comply with therapy, and develop pain coping skills," Jamison reported. He added that the smartphone data can be summarized and transmitted every day into the patient’s electronic medical record.
Jamison noted that the average response rate to text messages to pain patients is 70 to 90 percent and that high responders show improved pain levels ...
Katherine Zalewski, 51, of Richmond, has been appointed to the California Workers’ Compensation Appeals Board by Governor Brown.
Zalewski has served as chief counsel at the California Department of Industrial Relations since 2012. Immediately prior to her appointment as Chief Counsel, Ms. Zalewski was a Special Advisor in the Division of Workers’ Compensation’s Administrative Director’s office. Prior to that, she was a trial judge in the WCAB’s San Francisco District Office.
Prior to her appointment as a Workers’ Compensation Judge in 2009, Ms. Zalewski represented insurers and self-insured employers in workers’ compensation matters throughout Northern California. She was senior associate at Schmit Law Office from 2000 to 2009 and manager and attorney at Pacific Coast Services from 1998 to 2000 and at Express Network and Direct Legal Support Services from 1993 to 1998. She was an attorney at Kinder and Wuerfel from 1990 to 1993 at Finnegan and Marks from 1988 to 1990 and at Foreman and Brasso from 1986 to 1988.
Ms. Zalewski received her B.A. from the University of California, Berkeley in 1983 and her J.D. from Hastings College of the Law in 1986. This position requires Senate confirmation and the compensation is $131,952. Zalewski is registered to vote without party preference ...
Zalewski has served as chief counsel at the California Department of Industrial Relations since 2012. Immediately prior to her appointment as Chief Counsel, Ms. Zalewski was a Special Advisor in the Division of Workers’ Compensation’s Administrative Director’s office. Prior to that, she was a trial judge in the WCAB’s San Francisco District Office.
Prior to her appointment as a Workers’ Compensation Judge in 2009, Ms. Zalewski represented insurers and self-insured employers in workers’ compensation matters throughout Northern California. She was senior associate at Schmit Law Office from 2000 to 2009 and manager and attorney at Pacific Coast Services from 1998 to 2000 and at Express Network and Direct Legal Support Services from 1993 to 1998. She was an attorney at Kinder and Wuerfel from 1990 to 1993 at Finnegan and Marks from 1988 to 1990 and at Foreman and Brasso from 1986 to 1988.
Ms. Zalewski received her B.A. from the University of California, Berkeley in 1983 and her J.D. from Hastings College of the Law in 1986. This position requires Senate confirmation and the compensation is $131,952. Zalewski is registered to vote without party preference ...
U.S. doctors said on Wednesday they have succeeded in coaxing the regeneration of muscle tissue lost in people who suffered traumatic injuries, including wartime bomb wounds, with a new type of treatment that uses material from a pig's bladder. Implanting the pig material at the wound site enticed the patient's own stem cells - master cells that can transform into various kinds of cells in the body - to become muscle cells and regenerate tissue that had been lost, the researchers said.
According to the report in Reuters Health, the study was small, involving only five male patients, but its results suggested that this procedure could offer new hope to a category of patients, including troops who suffered major war injuries, with scant good treatment options, they added. All five patients, including two U.S. soldiers hurt by bombs planted by insurgents, had badly damaged leg muscles. The research was backed by $3 million in funding over five years from the U.S. Defense Department, said Dr. Stephen Badylak of the University of Pittsburgh, who led the study.
Thousands of American troops have been left with serious physical impairments after sustaining wounds involving major loss of muscle tissue in roadside bombings and other incidents since 2001 in the wars in Iraq and Afghanistan. When a large amount of muscle is lost in vehicle crashes, industrial accidents, bomb blasts or other traumas, the body is unable to replace it and the site forms scar tissue that lacks the functionality of the lost muscle.
Existing treatments include surgery to remove scar tissue or replace it with muscle from somewhere else in the body, but these methods do not yield satisfying results and are hard on patients, the researchers said. "Nothing has ever worked. There's been multiple things tried: the hype and the hope of stem cell therapy, new surgical techniques," Badylak said.
This study, published in the journal Science Translational Medicine, demonstrated for the first time the regeneration of functional muscle tissue in people with major muscle loss. "While the number of patients was small, we were very encouraged by the data. And we were seeing very dramatic improvements in quality of life for some of our patients," added Dr. J. Peter Rubin of the University of Pittsburgh School of Medicine, another of the researchers.
The doctors implanted material from a pig's urinary bladder called "extracellular matrix" - the non-cellular component including collagen present within all tissues and organs - to serve as scaffolding for the rebuilding of lost muscle mass. This material acted as a "homing device" to recruit existing stem cells in the body to rebuild healthy muscle tissue at the site of the injury, the researchers said.Pig parts have been used for years in surgical procedures. Pig bladder "extracellular matrix" has been used in hernia repair and fixing chest wall defects after cancer removal.
Before trying the procedure in people, the researchers said they successfully tested it in mice with muscle injuries ...
According to the report in Reuters Health, the study was small, involving only five male patients, but its results suggested that this procedure could offer new hope to a category of patients, including troops who suffered major war injuries, with scant good treatment options, they added. All five patients, including two U.S. soldiers hurt by bombs planted by insurgents, had badly damaged leg muscles. The research was backed by $3 million in funding over five years from the U.S. Defense Department, said Dr. Stephen Badylak of the University of Pittsburgh, who led the study.
Thousands of American troops have been left with serious physical impairments after sustaining wounds involving major loss of muscle tissue in roadside bombings and other incidents since 2001 in the wars in Iraq and Afghanistan. When a large amount of muscle is lost in vehicle crashes, industrial accidents, bomb blasts or other traumas, the body is unable to replace it and the site forms scar tissue that lacks the functionality of the lost muscle.
Existing treatments include surgery to remove scar tissue or replace it with muscle from somewhere else in the body, but these methods do not yield satisfying results and are hard on patients, the researchers said. "Nothing has ever worked. There's been multiple things tried: the hype and the hope of stem cell therapy, new surgical techniques," Badylak said.
This study, published in the journal Science Translational Medicine, demonstrated for the first time the regeneration of functional muscle tissue in people with major muscle loss. "While the number of patients was small, we were very encouraged by the data. And we were seeing very dramatic improvements in quality of life for some of our patients," added Dr. J. Peter Rubin of the University of Pittsburgh School of Medicine, another of the researchers.
The doctors implanted material from a pig's urinary bladder called "extracellular matrix" - the non-cellular component including collagen present within all tissues and organs - to serve as scaffolding for the rebuilding of lost muscle mass. This material acted as a "homing device" to recruit existing stem cells in the body to rebuild healthy muscle tissue at the site of the injury, the researchers said.Pig parts have been used for years in surgical procedures. Pig bladder "extracellular matrix" has been used in hernia repair and fixing chest wall defects after cancer removal.
Before trying the procedure in people, the researchers said they successfully tested it in mice with muscle injuries ...
