United States District Judge Lawrence K. Karlton sentenced Robert Daniel Castillo, 50, of Vacaville,;to one year and one day in prison for workers’ compensation and disability benefits fraud. Judge Karlton also ordered Castillo to pay $138,997 in restitution.
"The American public expects Postal Service employees to be diligent and honest. Through its investigations, the Office of Inspector General helps to maintain that integrity. When US Postal Service employees’ actions turn to criminal violations, such as the abuse of the workers’ compensation program, those individuals are aggressively investigated by USPS OIG Special Agents," said Scott Pierce, Special Agent in Charge, US Postal Service Office of Inspector General, Pacific Area Field Office.
According to court documents, on October 15, 1998, Castillo, while working for the U.S. Postal Service in Fresno, claimed that he had injured his lower back while on the job. He submitted a claim for workers’ compensation benefits. For more than 10 years, Castillo received federal workers’ compensation benefits based on that injury. Castillo also received Social Security Disability and Veterans Benefits based on claims of 100 percent disability. Altogether, Castillo received more than $6,000 a month based on his claimed disability. Castillo was observed playing basketball and softball, driving, shopping, washing a boat, performing yard work, and performing volunteer work. At doctor’s appointments and meetings with officials from the Department of Labor and Social Security, Castillo claimed an inability to do all of these things.
A federal grand jury indicted Castillo on July 19, 2012, and on April 24, 2013, he pleaded guilty to theft of United States property and false statements made to the government in seeking compensation payments the charges.
This case was the product of an investigation by the United States Postal Service, Office of Inspector General and the Social Security Administration, Office of Inspector General. Assistant U.S. Attorney Jared C. Dolan prosecuted the case ...
"The American public expects Postal Service employees to be diligent and honest. Through its investigations, the Office of Inspector General helps to maintain that integrity. When US Postal Service employees’ actions turn to criminal violations, such as the abuse of the workers’ compensation program, those individuals are aggressively investigated by USPS OIG Special Agents," said Scott Pierce, Special Agent in Charge, US Postal Service Office of Inspector General, Pacific Area Field Office.
According to court documents, on October 15, 1998, Castillo, while working for the U.S. Postal Service in Fresno, claimed that he had injured his lower back while on the job. He submitted a claim for workers’ compensation benefits. For more than 10 years, Castillo received federal workers’ compensation benefits based on that injury. Castillo also received Social Security Disability and Veterans Benefits based on claims of 100 percent disability. Altogether, Castillo received more than $6,000 a month based on his claimed disability. Castillo was observed playing basketball and softball, driving, shopping, washing a boat, performing yard work, and performing volunteer work. At doctor’s appointments and meetings with officials from the Department of Labor and Social Security, Castillo claimed an inability to do all of these things.
A federal grand jury indicted Castillo on July 19, 2012, and on April 24, 2013, he pleaded guilty to theft of United States property and false statements made to the government in seeking compensation payments the charges.
This case was the product of an investigation by the United States Postal Service, Office of Inspector General and the Social Security Administration, Office of Inspector General. Assistant U.S. Attorney Jared C. Dolan prosecuted the case ...
In 2009 a website began tracking the Top Ten Fraud Cases by the amount of money involved, and 100% of the Top Ten between 2009-2012 involved employers or shady characters posing as legitimate businesses. The amount of employer fraud in terms of cost was staggering. In 2013 one California employee fraud case did crack the Top Ten, so the record is now 49-1 (employer fraud v. employee fraud) over the past five years. This year California has the distinction of having four out of the Top Ten in the nation. Here is the list organized by the amount of fraud involved.
1) Florida: Owners of Diaz Supermarkets in Miami-Dade are Accused of $35 Million Fraud (4/16/13) - John Diaz and his wife Mercedes Avila-Diaz owned and operated four supermarkets in the Miami-Dade area. They have been arrested and accused of workers’ compensation fraud and other fraudulent transactions totaling $35 million. One business they operated had no coverage for employees for ten years. They allegedly engaged in a scam to help subcontractors obtain false certificates of insurance that allowed the subs to work for general contractors who required the certificates.
2) California: Hanford Farm Labor Contractor Convicted of Fraud in the Amount of $4,195,900 (12/6/2013) - Richard Escamilla, Jr. (47), owner of ROC Harvesting, misrepresented information to workers’ compensation insurance carriers by using new business names to obtain insurance and avoid providing a claim history. Escamilla pleaded guilty on October 29th and was sentenced to pay restitution of $4.1 million and serve six years in prison.
3) Michigan: Insurance Executive Embezzled $2.6 Million from Workers’ Comp TPA (06/06/2013) - Jerry Stage (67), the former CEO of a non-profit workers’ compensation insurance company, and George Bauer (55), the bookkeeper, both pleaded guilty to embezzling from the Compensation Advisory Organization of Michigan (CAOM) for more than a decade. Mr. Stage embezzled $2.6 million from the company and conspired with Mr. Bauer to cover up the embezzlement.
4) California: Employee Wasn’t Wheelchair Bound After All - Fraudulently Took $1.5 Million in Benefits (8/9/13) - Yolandi Kohrumel, 35, claimed for nine years that she was wheelchair bound after complications from toe surgery, but after she had collected $1.5 million in benefits, it was revealed her claim was false. Her father, a South African native, was also engaged in the scam. Both pleaded guilty to insurance fraud, grand theft and perjury. Ms Kohrumel was sentenced to one year in jail, plus restitution.
5) California: Father and Son Landscapers Accused of $1.45 Million in Insurance Fraud (5/7/13) - Jesse Garcia Contreras (57) and Carlos Contreras (33), who operate a Thousand Palms landscaping business, are accused of committing $1.45 million in insurance fraud. They are accused of defrauding the California State Compensation Insurance Fund by misclassifying employees from January 2008 to March 2012. Mr. Jesse Contreras is the president and CEO of Sunshine Landscaping and his son is Director of Accounting. If convicted, they each face up to 19 years and 8 months in prison.
6) Florida: Workers’ Compensation Check Cashing Operation Charged with $1 Million in Fraud (2/27/13) - As a result of an investigation of I and T Financial Services, LLC, a company that was allegedly set up to execute a large scale check cashing scheme for the purpose of evading the cost of workers’ compensation coverage, the company was shut down. Domenick Pucillo, the ringleader of the fraud scheme, was arrested and charged with filing a false and fraudulent document, forgery, uttering a forged instrument, and operating an unlicensed money service business. If convicted on all charges, he faces up to 45 years in prison. One million dollars was seized during this investigation.
7) California and North Carolina: Cleaning Company Owner Convicted of Underreporting Payroll and Ordered to Pay $898,000 (8/3/2013) - The president of Awesome Products, a cleaning company in California, was convicted and sentenced for underreporting his payroll by over $8 million, resulting in a premium loss of $898,000. Loksarang Dinkar Hardas (53) was sentenced to five years in state prison, stayed pending successful completion of 10 years of formal probation, a $250,000 fine, and restitution payment of $898,000. Notwithstanding his conviction, the town of Mount Airy, NC was standing by Mr. Hardas and willing to give his company taxpayer money in hopes that Awesome Products would build a manufacturing facility and create jobs in Surry County, NC.
8) West Virginia: Coal Company Contractor in Mingo County Caught in $405,000 Scam to Avoid Workers’ Comp Premiums (11/6/13) - Jerame Russell (50), an executive with Aracoma Contracting, LLC, a company that provided labor to coal companies on a contract basis, entered a guilty plea to a scam that involved funneling over $2 million through a local bank to pay employees in cash, thus avoiding payroll taxes and $405,000 in workers’ compensation premiums. Aracoma also bribed an insurance auditor to cover up its true payroll.
9) Ohio: Roofing Business Owners Guilty of $283,592 in Workers’ Comp Fraud (7/30/2013) - The owners of Triple Star Roofing were found guilty of fraud on July 15 for failing to report payroll to the Ohio Bureau or Workers’ Compensation(BWC). The company failed to report to the BWC from 2004 to 2008, resulting in under-reported premiums of $283,592.
10) Florida: Owner of Staffing Company arrested for $130,000 in Workers’ Comp Fraud (8/1/2013) - The owner of Preferred Staffing of America, Inc., a temporary staffing agency in Tampa, has been arrested for allegedly running an organized workers’ compensation fraud scheme. Preferred Staffing’s owner misled clients into believing that his company was a licensed professional employer organization (PEO) and could provide workers’ compensation insurance coverage. Employers were reportedly charged more than $130,000 for workers’ compensation insurance and other services that were never provided ...
1) Florida: Owners of Diaz Supermarkets in Miami-Dade are Accused of $35 Million Fraud (4/16/13) - John Diaz and his wife Mercedes Avila-Diaz owned and operated four supermarkets in the Miami-Dade area. They have been arrested and accused of workers’ compensation fraud and other fraudulent transactions totaling $35 million. One business they operated had no coverage for employees for ten years. They allegedly engaged in a scam to help subcontractors obtain false certificates of insurance that allowed the subs to work for general contractors who required the certificates.
2) California: Hanford Farm Labor Contractor Convicted of Fraud in the Amount of $4,195,900 (12/6/2013) - Richard Escamilla, Jr. (47), owner of ROC Harvesting, misrepresented information to workers’ compensation insurance carriers by using new business names to obtain insurance and avoid providing a claim history. Escamilla pleaded guilty on October 29th and was sentenced to pay restitution of $4.1 million and serve six years in prison.
3) Michigan: Insurance Executive Embezzled $2.6 Million from Workers’ Comp TPA (06/06/2013) - Jerry Stage (67), the former CEO of a non-profit workers’ compensation insurance company, and George Bauer (55), the bookkeeper, both pleaded guilty to embezzling from the Compensation Advisory Organization of Michigan (CAOM) for more than a decade. Mr. Stage embezzled $2.6 million from the company and conspired with Mr. Bauer to cover up the embezzlement.
4) California: Employee Wasn’t Wheelchair Bound After All - Fraudulently Took $1.5 Million in Benefits (8/9/13) - Yolandi Kohrumel, 35, claimed for nine years that she was wheelchair bound after complications from toe surgery, but after she had collected $1.5 million in benefits, it was revealed her claim was false. Her father, a South African native, was also engaged in the scam. Both pleaded guilty to insurance fraud, grand theft and perjury. Ms Kohrumel was sentenced to one year in jail, plus restitution.
5) California: Father and Son Landscapers Accused of $1.45 Million in Insurance Fraud (5/7/13) - Jesse Garcia Contreras (57) and Carlos Contreras (33), who operate a Thousand Palms landscaping business, are accused of committing $1.45 million in insurance fraud. They are accused of defrauding the California State Compensation Insurance Fund by misclassifying employees from January 2008 to March 2012. Mr. Jesse Contreras is the president and CEO of Sunshine Landscaping and his son is Director of Accounting. If convicted, they each face up to 19 years and 8 months in prison.
6) Florida: Workers’ Compensation Check Cashing Operation Charged with $1 Million in Fraud (2/27/13) - As a result of an investigation of I and T Financial Services, LLC, a company that was allegedly set up to execute a large scale check cashing scheme for the purpose of evading the cost of workers’ compensation coverage, the company was shut down. Domenick Pucillo, the ringleader of the fraud scheme, was arrested and charged with filing a false and fraudulent document, forgery, uttering a forged instrument, and operating an unlicensed money service business. If convicted on all charges, he faces up to 45 years in prison. One million dollars was seized during this investigation.
7) California and North Carolina: Cleaning Company Owner Convicted of Underreporting Payroll and Ordered to Pay $898,000 (8/3/2013) - The president of Awesome Products, a cleaning company in California, was convicted and sentenced for underreporting his payroll by over $8 million, resulting in a premium loss of $898,000. Loksarang Dinkar Hardas (53) was sentenced to five years in state prison, stayed pending successful completion of 10 years of formal probation, a $250,000 fine, and restitution payment of $898,000. Notwithstanding his conviction, the town of Mount Airy, NC was standing by Mr. Hardas and willing to give his company taxpayer money in hopes that Awesome Products would build a manufacturing facility and create jobs in Surry County, NC.
8) West Virginia: Coal Company Contractor in Mingo County Caught in $405,000 Scam to Avoid Workers’ Comp Premiums (11/6/13) - Jerame Russell (50), an executive with Aracoma Contracting, LLC, a company that provided labor to coal companies on a contract basis, entered a guilty plea to a scam that involved funneling over $2 million through a local bank to pay employees in cash, thus avoiding payroll taxes and $405,000 in workers’ compensation premiums. Aracoma also bribed an insurance auditor to cover up its true payroll.
9) Ohio: Roofing Business Owners Guilty of $283,592 in Workers’ Comp Fraud (7/30/2013) - The owners of Triple Star Roofing were found guilty of fraud on July 15 for failing to report payroll to the Ohio Bureau or Workers’ Compensation(BWC). The company failed to report to the BWC from 2004 to 2008, resulting in under-reported premiums of $283,592.
10) Florida: Owner of Staffing Company arrested for $130,000 in Workers’ Comp Fraud (8/1/2013) - The owner of Preferred Staffing of America, Inc., a temporary staffing agency in Tampa, has been arrested for allegedly running an organized workers’ compensation fraud scheme. Preferred Staffing’s owner misled clients into believing that his company was a licensed professional employer organization (PEO) and could provide workers’ compensation insurance coverage. Employers were reportedly charged more than $130,000 for workers’ compensation insurance and other services that were never provided ...
One person was seriously injured and another was hurt this month in a "minor" explosion at biotech firm Amgen's South San Francisco lab facility, a fire marshal confirmed. One employee suffered burns to their face and another employee suffered burns to their hands after an explosion that began in a "flammable liquids" cabinet in a third-floor laboratory, said South San Francisco deputy fire chief Travis Nuckolls. According to the report in the Mercury News, the explosion was reported about 3:30 p.m. Officials don't know what caused the dangerous mixture to explode, but the cabinet in which the explosion occurred was knocked over from the force, and windows on the third floor were also blown out, fire officials confirmed. Nuckolls said at least one of the chemicals involved was ether.
According to a spokeswoman at the St. Francis Memorial Hospital burn unit in San Francisco, one patient was taken there with injuries deemed "noncritical." She would not provide further information about the patient's condition. The region's other burn unit, at the Santa Clara Valley Medical Center in San Jose, reported no patients from Amgen.
All buildings in the complex in addition to the Amgen building were evacuated as a precaution. An Amgen spokeswoman did not respond to multiple calls for comment. Decontamination tents were set up for employees who may have been affected by chemicals or toxins that spread after the explosion, but Nuckolls said it had been determined early Wednesday night that nothing dangerous had gone airborne.
The incident was the second to injure a worker in the facility in the last year. In May, a worker for a waste disposal company was seriously burned while collecting waste at the facility. According to Cal-OSHA spokesman Peter Melton, the firm and two other businesses -- Clean Harbors Environmental Service Inc. and Thermo Fisher Scientific Inc.'s Unity Lab Services -- received "serious" citations for the May incident on Nov. 14. Melton said the most serious citation issued was in the amount of $77,400 to Clean Harbors Environmental Service Inc.
Clean Harbors, a San Jose-based company, provides hazardous waste disposal, emergency response, lab chemical packing, recycling, and vacuum services, among others. The person who was burned and hasn't been identified was working for Clean Harbors and was attempting to collect flammable liquids from one of the labs at Amgen at the time of the incident, Melton added.
Fires and explosions at pharma manufacturing facilities are not unusual, but there are few reports of events at research facilities. An explosion in 2012 at a Teva Pharmaceutical Industries plant in Croatia killed four workers and injured 17 others. A fire in a boiler room at a Sandoz plant in Boucherville, Quebec, did not cause injuries but exacerbated a shortage of one of the products made at that Novartis plant.
Thousand Oaks-based Amgen is one of the world's largest drugmakers, producer of popular osteoporosis drug Prolia and rheumatoid arthritis medication Enbrel ...
According to a spokeswoman at the St. Francis Memorial Hospital burn unit in San Francisco, one patient was taken there with injuries deemed "noncritical." She would not provide further information about the patient's condition. The region's other burn unit, at the Santa Clara Valley Medical Center in San Jose, reported no patients from Amgen.
All buildings in the complex in addition to the Amgen building were evacuated as a precaution. An Amgen spokeswoman did not respond to multiple calls for comment. Decontamination tents were set up for employees who may have been affected by chemicals or toxins that spread after the explosion, but Nuckolls said it had been determined early Wednesday night that nothing dangerous had gone airborne.
The incident was the second to injure a worker in the facility in the last year. In May, a worker for a waste disposal company was seriously burned while collecting waste at the facility. According to Cal-OSHA spokesman Peter Melton, the firm and two other businesses -- Clean Harbors Environmental Service Inc. and Thermo Fisher Scientific Inc.'s Unity Lab Services -- received "serious" citations for the May incident on Nov. 14. Melton said the most serious citation issued was in the amount of $77,400 to Clean Harbors Environmental Service Inc.
Clean Harbors, a San Jose-based company, provides hazardous waste disposal, emergency response, lab chemical packing, recycling, and vacuum services, among others. The person who was burned and hasn't been identified was working for Clean Harbors and was attempting to collect flammable liquids from one of the labs at Amgen at the time of the incident, Melton added.
Fires and explosions at pharma manufacturing facilities are not unusual, but there are few reports of events at research facilities. An explosion in 2012 at a Teva Pharmaceutical Industries plant in Croatia killed four workers and injured 17 others. A fire in a boiler room at a Sandoz plant in Boucherville, Quebec, did not cause injuries but exacerbated a shortage of one of the products made at that Novartis plant.
Thousand Oaks-based Amgen is one of the world's largest drugmakers, producer of popular osteoporosis drug Prolia and rheumatoid arthritis medication Enbrel ...
Four men will be arraigned on an indictment today for defrauding over $36 million from insurance companies in an overbilling scheme. Jeffrey Edward Campau, 39, Yorba Linda, Abraham Khorshad, 62, Beverly Hills, and Landen Alan Mirallegro, 38, Yorba Linda, are charged with 22 felony counts of submitting multiple fraudulent claims, 22 felony counts of manufacturing documents in support of a fraudulent claim, one felony count of conspiracy, and sentencing enhancements for aggravated white collar crimes for loss over $500,000 and special loss over $3.2 million. If convicted on all counts, they each face a maximum sentence of 53 years in state prison. The defendants are out of custody on $1.5 million bail each.
Ryan Nathanil McCracken, 29, Rancho Cucamonga, is charged with one felony count of conspiracy and faces a maximum sentence of five years in state prison if convicted. He is out of custody on $20,000 bail.
They are scheduled to be arraigned today, Jan. 22, 2014, at 9:00 a.m. in Department C-30, Central Justice Center, Santa Ana.
In 2005, Campau, Mirallegro, and Khorshad are accused of forming a durable medical equipment (DME) company named Aspen Medical Resources, LLC (Aspen). Between 2005 and 2013, the defendants are accused of renting out a DME machine similar in function to an ice pack or heating pad, which provided both hot and cold modalities to alleviate inflammation and/or pain for patients. The three defendants are accused of fraudulently overbilling insurance carriers for this DME in two ways: for rental of one machine as two separate hot and cold machines, and for renting the hot and cold units which were valued at less than $500 for as much as $15,500 to $17,500 per patient.
Campau, Mirallegro, and Khorshad are accused of submitting hundreds of claims to the State Compensation Insurance Fund, Liberty Mutual, AIG (Chartis), Zenith Insurance, Birkshire Hathaway Homestead Companies, County of Orange, County of San Bernardino, County of Riverside, American Claims Management, First Comp Insurance, CNA Insurance, Comp West Insurance, Employers Insurance, Farmers Insurance, State Farm Insurance, Fireman’s Fund, Tristar (City of Los Angeles), Gallagher Basset, Republic Indemnity, Sentry, and Travelers Insurance.
If a claim was not paid, the defendants are accused of filing a lien at the Workers Compensation Appeals Board and aggressively collecting on these fraudulent claims. McCracken was employed as the collection manager for Aspen and is accused of negotiating the liens at the Workers Compensation Appeals Board with the carriers; McCracken is accused of receiving a commission on all of his collections. The defendants are accused of being informed by various insurance carriers that Aspen was billing for the units incorrectly,but continued to bill the same way and aggressively defended their fraudulent claims, making it more cost-effective for the insurance carriers to pay the fraudulent claims than fight them.
Campau, Mirallegro and Khorshad are accused of billing under other company names, National DME and Abrexis Orthocare LLC. They are accused of using different addresses and different Employment Tax Identification Numbers for each of these companies in order to mislead the insurance carriers and give the appearance that these companies were different companies and not Aspen. The defendants are accused of collecting over $12 million from insurance carriers under these business names.
Insurance companies contacted the Orange County District Attorney’s Office (OCDA) and the Department of Insurance, who jointly investigated this case. OCDA seized all assets of the companies, which are now under receivership. Deputy District Attorney Shaddi Kamiabipour of the Insurance Fraud Unit is prosecuting this case ...
Ryan Nathanil McCracken, 29, Rancho Cucamonga, is charged with one felony count of conspiracy and faces a maximum sentence of five years in state prison if convicted. He is out of custody on $20,000 bail.
They are scheduled to be arraigned today, Jan. 22, 2014, at 9:00 a.m. in Department C-30, Central Justice Center, Santa Ana.
In 2005, Campau, Mirallegro, and Khorshad are accused of forming a durable medical equipment (DME) company named Aspen Medical Resources, LLC (Aspen). Between 2005 and 2013, the defendants are accused of renting out a DME machine similar in function to an ice pack or heating pad, which provided both hot and cold modalities to alleviate inflammation and/or pain for patients. The three defendants are accused of fraudulently overbilling insurance carriers for this DME in two ways: for rental of one machine as two separate hot and cold machines, and for renting the hot and cold units which were valued at less than $500 for as much as $15,500 to $17,500 per patient.
Campau, Mirallegro, and Khorshad are accused of submitting hundreds of claims to the State Compensation Insurance Fund, Liberty Mutual, AIG (Chartis), Zenith Insurance, Birkshire Hathaway Homestead Companies, County of Orange, County of San Bernardino, County of Riverside, American Claims Management, First Comp Insurance, CNA Insurance, Comp West Insurance, Employers Insurance, Farmers Insurance, State Farm Insurance, Fireman’s Fund, Tristar (City of Los Angeles), Gallagher Basset, Republic Indemnity, Sentry, and Travelers Insurance.
If a claim was not paid, the defendants are accused of filing a lien at the Workers Compensation Appeals Board and aggressively collecting on these fraudulent claims. McCracken was employed as the collection manager for Aspen and is accused of negotiating the liens at the Workers Compensation Appeals Board with the carriers; McCracken is accused of receiving a commission on all of his collections. The defendants are accused of being informed by various insurance carriers that Aspen was billing for the units incorrectly,but continued to bill the same way and aggressively defended their fraudulent claims, making it more cost-effective for the insurance carriers to pay the fraudulent claims than fight them.
Campau, Mirallegro and Khorshad are accused of billing under other company names, National DME and Abrexis Orthocare LLC. They are accused of using different addresses and different Employment Tax Identification Numbers for each of these companies in order to mislead the insurance carriers and give the appearance that these companies were different companies and not Aspen. The defendants are accused of collecting over $12 million from insurance carriers under these business names.
Insurance companies contacted the Orange County District Attorney’s Office (OCDA) and the Department of Insurance, who jointly investigated this case. OCDA seized all assets of the companies, which are now under receivership. Deputy District Attorney Shaddi Kamiabipour of the Insurance Fraud Unit is prosecuting this case ...
The Division of Workers' Compensation (DWC) Audit Unit has posted on its website the form claims administrators can use for the required 2014 annual report of inventory (ARI) for claims reported in calendar year 2013, along with advice for claims administrators. This posting replaces individual notices previously sent to claims administrators.
California Code of Regulations, Title 8, section 10104 requires claims administrators to file an annual report of inventory indicating the number of claims reported at each adjusting location for the preceding calendar year. The report must be filed with the DWC administrative director (AD) by April 1 of each year. Even if there were no claims reported in the prior year, the report must be completed and submitted to the DWC Audit Unit. Each adjusting location is required to submit an ARI, whether or not they receive a form for reporting claims from the Audit Unit, unless their ARI requirement has been waived by the AD.
A claims administrator's obligation to submit an ARI can be waived if the AD determines that they are in compliance with electronic data reporting requirements of the Workers’ Compensation Information System (WCIS). When ARI requirements are waived, claims administrators must file an annual report of adjusting locations. This report is to be filed annually on April 1 of each calendar year for the adjusting location operations as of December 31 of the prior year; DWC has provided a form for this purpose.
Claims administrators are also required to report any change in the information reported in the ARI or annual report of adjusting location within 45 days of the effective date of the change ...
California Code of Regulations, Title 8, section 10104 requires claims administrators to file an annual report of inventory indicating the number of claims reported at each adjusting location for the preceding calendar year. The report must be filed with the DWC administrative director (AD) by April 1 of each year. Even if there were no claims reported in the prior year, the report must be completed and submitted to the DWC Audit Unit. Each adjusting location is required to submit an ARI, whether or not they receive a form for reporting claims from the Audit Unit, unless their ARI requirement has been waived by the AD.
A claims administrator's obligation to submit an ARI can be waived if the AD determines that they are in compliance with electronic data reporting requirements of the Workers’ Compensation Information System (WCIS). When ARI requirements are waived, claims administrators must file an annual report of adjusting locations. This report is to be filed annually on April 1 of each calendar year for the adjusting location operations as of December 31 of the prior year; DWC has provided a form for this purpose.
Claims administrators are also required to report any change in the information reported in the ARI or annual report of adjusting location within 45 days of the effective date of the change ...
The WCIRB launched Classification Search - an online tool to help users search for and find the right standard classification based on keywords or industry groups. The tool includes other useful features including the pure premium rate history for each classification, classification phraseologies sorted numerically or alphabetically, and classification listings by industry group or other classification attributes. Classification Search is available in the Learning Center section of the WCIRB’s website (www.wcirb.com) and is accessible by both desktop and mobile browsers.
Classification Search allows users to do a full text search across all standard classifications or by industry group. Users may enter keywords to see a list of all classification phraseologies that contain the keyword or that are commonly associated with the keyword. Advanced search features allow users to combine or exclude keywords or use wildcard search characters.
"Questions about classifications - and which classifications apply to a business - are the number one reason that people call our customer service department," according to Eric Riley, the WCIRB’s Chief Customer Officer. "This tool is the latest addition to the online resources we’ve created to give insurers, agents and brokers, and employers easy and effective access to the information they need." ...
Classification Search allows users to do a full text search across all standard classifications or by industry group. Users may enter keywords to see a list of all classification phraseologies that contain the keyword or that are commonly associated with the keyword. Advanced search features allow users to combine or exclude keywords or use wildcard search characters.
"Questions about classifications - and which classifications apply to a business - are the number one reason that people call our customer service department," according to Eric Riley, the WCIRB’s Chief Customer Officer. "This tool is the latest addition to the online resources we’ve created to give insurers, agents and brokers, and employers easy and effective access to the information they need." ...
The Division of Workers’ Compensation (DWC) is now accepting applications for the Qualified Medical Evaluator (QME) examination set for Saturday, April 12.
QMEs are independent physicians certified by the DWC Medical Unit to conduct medical evaluations of injured workers. The application and exam packet can be downloaded from the DWC website .
Please note that Section 10 of the application requires the applicant to initial each of four boxes affirming the statements listed. The exam packet (which includes the Registration form, $125 Fee Notice, $15 Physicians Guide order form, 12 Hour Report Writing Provider list and the Reference List) may be downloaded here . The deadline for filing the exam applications is February 27, 2014.
In Northern California the examination will be held at the South San Francisco Conference Center, 255 South Airport Boulevard inSan Francisco. The Southern California examination will be at the Irvine Marriott Hotel, 18000 Von Karman Avenue in Irvine. For more information please contact Joanne Van Raam at 510 628 2004 or Francine Wooley at 510 628 - 2038.
...
QMEs are independent physicians certified by the DWC Medical Unit to conduct medical evaluations of injured workers. The application and exam packet can be downloaded from the DWC website .
Please note that Section 10 of the application requires the applicant to initial each of four boxes affirming the statements listed. The exam packet (which includes the Registration form, $125 Fee Notice, $15 Physicians Guide order form, 12 Hour Report Writing Provider list and the Reference List) may be downloaded here . The deadline for filing the exam applications is February 27, 2014.
In Northern California the examination will be held at the South San Francisco Conference Center, 255 South Airport Boulevard inSan Francisco. The Southern California examination will be at the Irvine Marriott Hotel, 18000 Von Karman Avenue in Irvine. For more information please contact Joanne Van Raam at 510 628 2004 or Francine Wooley at 510 628 - 2038.
...
Walter Martinez, 60, of Alta Loma, Calif. pled guilty to 43 felony counts of using cappers - recruiters paid from victims’ insurance settlement - to get clients for his practice. Martinez evidently embellished his scheme with at least three cappers. "The use of cappers is a problem because these individuals usually approach accident victims acting as an attorney with no training and give legal advice to people when they are vulnerable after a collision," California Insurance Commissioner Dave Jones said in a statement.
The Department of Insurance Auto Insurance Fraud Task Force received information and documentation that indicated Martinez was using cappers. In this case, bank records showed that more than $250,000 in checks were written to the alleged cappers between 2009 and 2012.
Martinez was sentenced to one year in jail, followed by three years felony probation and a $91,000 fine. Two of the cappers sentenced were: Israel Gonzales, 34, of Rancho Cucamonga, who plead guilty to eight counts 750(a) IC; an Michael Melcher, 58, of Covina, who plead guilty to two counts 750(a) IC.
State Bar records reflect that Martinez was suspended for one year, stayed, actually suspended for five months, and was ordered to make restitution, take the MPRE and comply with rule 9.20 of the California Rules of Court. The order took effect Feb. 23, 2012. Martinez stipulated in the State Bar case to 10 acts of misconduct in six matters. The State Bar information claims that for almost four years, he operated a branch law office in Westminster that was run by two non-lawyers who engaged in conduct that constituted the practice of law. Although he was not aware of their misconduct, he was grossly negligent in not knowing that they were engaged in activities that constituted legal practice. He stipulated that by failing to supervise his employees, he allowed them to engage in the unlawful practice of law. Among other things, the non-lawyers signed up clients, negotiated and settled their claims, paid some settlement funds, accepted settlement funds for other clients but never distributed the money, and did not pay medical bills.
The Orange County district attorney conducted an undercover investigation of Martinez’ law offices, creating paperwork to make it look as if they had been in an auto accident. Martinez’ employee conducted intake and signed up the investigators as clients without any attorney oversight. The employee negotiated and settled the investigators’ claims, received settlement checks from an insurance company and gave the two 50 percent of the proceeds. Several months later, the superior court assumed jurisdiction of Martinez’ practice, which was shut down after the State Bar seized his files and froze his bank accounts ...
The Department of Insurance Auto Insurance Fraud Task Force received information and documentation that indicated Martinez was using cappers. In this case, bank records showed that more than $250,000 in checks were written to the alleged cappers between 2009 and 2012.
Martinez was sentenced to one year in jail, followed by three years felony probation and a $91,000 fine. Two of the cappers sentenced were: Israel Gonzales, 34, of Rancho Cucamonga, who plead guilty to eight counts 750(a) IC; an Michael Melcher, 58, of Covina, who plead guilty to two counts 750(a) IC.
State Bar records reflect that Martinez was suspended for one year, stayed, actually suspended for five months, and was ordered to make restitution, take the MPRE and comply with rule 9.20 of the California Rules of Court. The order took effect Feb. 23, 2012. Martinez stipulated in the State Bar case to 10 acts of misconduct in six matters. The State Bar information claims that for almost four years, he operated a branch law office in Westminster that was run by two non-lawyers who engaged in conduct that constituted the practice of law. Although he was not aware of their misconduct, he was grossly negligent in not knowing that they were engaged in activities that constituted legal practice. He stipulated that by failing to supervise his employees, he allowed them to engage in the unlawful practice of law. Among other things, the non-lawyers signed up clients, negotiated and settled their claims, paid some settlement funds, accepted settlement funds for other clients but never distributed the money, and did not pay medical bills.
The Orange County district attorney conducted an undercover investigation of Martinez’ law offices, creating paperwork to make it look as if they had been in an auto accident. Martinez’ employee conducted intake and signed up the investigators as clients without any attorney oversight. The employee negotiated and settled the investigators’ claims, received settlement checks from an insurance company and gave the two 50 percent of the proceeds. Several months later, the superior court assumed jurisdiction of Martinez’ practice, which was shut down after the State Bar seized his files and froze his bank accounts ...
In 36 states, the National Council on Compensation Insurance (NCCI) is the rating bureau that determines the rules for workers’ compensation and calculates the experience mods. Beginning in 2013, a substantial change to the experience mod calculation occurred. In 1991, the split point between primary and excess losses was set at $5,000. In 2013, it ballooned to $10,000.
According to the report in Property Casualty 360, in 2014 it’s going up to $13,500. Further, to disprove the theory that what goes up must come down, in 2015 it is predicted to exceed $15,000. The reason this amount keeps rising is simple: The cost of employee injuries has dramatically increased. Back in 1991, the average employee injury cost the insurance company around $3,000. In 2011, that amount approached almost $9,000. Because of this dramatic change, the experience mod needed adjusting.
The experience mod calculation splits injuries into two areas: primary loss and excess loss. The primary loss, which has been at $5,000, is counted 100 percent in the mod calculation. Everything above that is excess loss and it’s discounted depending on the size of the business. This means that the first dollars in the claim are the most important. So, if and employer suffered ten injuries at $5,000, the experience mod will be impacted more than if the employer recorded one $50,000 injury.
As the cost of employee injuries has increased, the impact that those injuries has had on the experience mod has decreased. It’s important to remember that the purpose of the experience mod is to adjust what an employer pays for workers’ compensation based on whether or not the employer is better or worse than the average similar business. NCCI has changed the split point in accordance with how the cost of employee injuries has changed, thus making the experience mod more responsive.
This will cause a change in the employer's experience mod, and not necessarily a good one. It’s impossible to know without looking at a specific experience mod whether or not the change will positively or negatively impact the mod. But it can be said that businesses that are substantially worse than average will see a higher experience mod, while businesses that are better than average are likely to see a decrease in their experience mod ...
According to the report in Property Casualty 360, in 2014 it’s going up to $13,500. Further, to disprove the theory that what goes up must come down, in 2015 it is predicted to exceed $15,000. The reason this amount keeps rising is simple: The cost of employee injuries has dramatically increased. Back in 1991, the average employee injury cost the insurance company around $3,000. In 2011, that amount approached almost $9,000. Because of this dramatic change, the experience mod needed adjusting.
The experience mod calculation splits injuries into two areas: primary loss and excess loss. The primary loss, which has been at $5,000, is counted 100 percent in the mod calculation. Everything above that is excess loss and it’s discounted depending on the size of the business. This means that the first dollars in the claim are the most important. So, if and employer suffered ten injuries at $5,000, the experience mod will be impacted more than if the employer recorded one $50,000 injury.
As the cost of employee injuries has increased, the impact that those injuries has had on the experience mod has decreased. It’s important to remember that the purpose of the experience mod is to adjust what an employer pays for workers’ compensation based on whether or not the employer is better or worse than the average similar business. NCCI has changed the split point in accordance with how the cost of employee injuries has changed, thus making the experience mod more responsive.
This will cause a change in the employer's experience mod, and not necessarily a good one. It’s impossible to know without looking at a specific experience mod whether or not the change will positively or negatively impact the mod. But it can be said that businesses that are substantially worse than average will see a higher experience mod, while businesses that are better than average are likely to see a decrease in their experience mod ...
SB 626 which was introduced last year by state Senator Jim Beall would have rolled back some of the key workers’ compensation reforms contained in SB 863.
The California Chamber of Commerce characterized SB 626 as "A California Chamber of Commerce-opposed "job killer" bill that severely undercuts the workers’ compensation reform deal agreed to by labor unions and employers in 2012 and would result in dramatic cost increases to California employers." The Chamber goes on to state that "SB 626 distorts the entire balance of the deal and would decimate provisions anticipated to deliver hundreds of millions of dollars of costs savings, which were promised to be redirected to injured workers in the form of higher benefits. Already, important cost-saving reforms under SB 863 have been placed in doubt as a result of litigation from system vendors. Additionally, full regulatory implementation has not been completed, creating uncertainty over whether the savings will materialize. Meanwhile, California employers continue to see their workers’ compensation costs increase, due to higher medical treatment costs and an increase in the rate of claims filed."
Specifically, the bill would eliminate a cornerstone cost-saving provision contained in SB 863 - independent medical review (IMR). Under SB 626, IMR decisions would be fully appealable to the WCAB taking medical necessity decisions away from physicians and putting them back in the hands of judges. It would also result in treatment delays for injured workers. The projected savings associated with IMR are estimated at around $400 million. It would repeal a provision in SB 863 that eliminates impairment ratings for psychiatric add-ons in some, but not all, cases. Numerous data-driven analyses demonstrated applicant attorneys had abused this add-on to artificially inflate permanent disability ratings. It would repeal a provision in SB 863 that prohibits a chiropractor from being a primary treating physician once the maximum number of chiropractic treatments has been received. It also unnecessarily limits utilization review and Independent Medical Review by requiring that the reviewing physician hold the same license as the physician requesting treatment. Current law requires reviewers to be competent to evaluate the specific clinical issues involved in the medical treatment and utilize relevant, evidence-based medical treatment guidelines, which are not state-specific.
A Senate Labor and Industrial Relations Committee hearing on SB 626 was set for January 15, 2014. This hearing would have been the first step in obtaining passage this legislative year. However, Senator Beall removed the bill from the Committee agenda fearing that it would not obtain enough votes to successfully win Committee approval. Thus, at this point, it would seem the SB 626 may have suffered an early death in 2014 ...
The California Chamber of Commerce characterized SB 626 as "A California Chamber of Commerce-opposed "job killer" bill that severely undercuts the workers’ compensation reform deal agreed to by labor unions and employers in 2012 and would result in dramatic cost increases to California employers." The Chamber goes on to state that "SB 626 distorts the entire balance of the deal and would decimate provisions anticipated to deliver hundreds of millions of dollars of costs savings, which were promised to be redirected to injured workers in the form of higher benefits. Already, important cost-saving reforms under SB 863 have been placed in doubt as a result of litigation from system vendors. Additionally, full regulatory implementation has not been completed, creating uncertainty over whether the savings will materialize. Meanwhile, California employers continue to see their workers’ compensation costs increase, due to higher medical treatment costs and an increase in the rate of claims filed."
Specifically, the bill would eliminate a cornerstone cost-saving provision contained in SB 863 - independent medical review (IMR). Under SB 626, IMR decisions would be fully appealable to the WCAB taking medical necessity decisions away from physicians and putting them back in the hands of judges. It would also result in treatment delays for injured workers. The projected savings associated with IMR are estimated at around $400 million. It would repeal a provision in SB 863 that eliminates impairment ratings for psychiatric add-ons in some, but not all, cases. Numerous data-driven analyses demonstrated applicant attorneys had abused this add-on to artificially inflate permanent disability ratings. It would repeal a provision in SB 863 that prohibits a chiropractor from being a primary treating physician once the maximum number of chiropractic treatments has been received. It also unnecessarily limits utilization review and Independent Medical Review by requiring that the reviewing physician hold the same license as the physician requesting treatment. Current law requires reviewers to be competent to evaluate the specific clinical issues involved in the medical treatment and utilize relevant, evidence-based medical treatment guidelines, which are not state-specific.
A Senate Labor and Industrial Relations Committee hearing on SB 626 was set for January 15, 2014. This hearing would have been the first step in obtaining passage this legislative year. However, Senator Beall removed the bill from the Committee agenda fearing that it would not obtain enough votes to successfully win Committee approval. Thus, at this point, it would seem the SB 626 may have suffered an early death in 2014 ...
A North Hollywood woman who worked in the health care industry pleaded guilty this week to federal charges for orchestrating a scheme that submitted nearly $25 million in fraudulent bills to Medicare for services and supplies, including power wheelchairs and diagnostic tests that were medically unnecessary and sometimes were never provided.
Susanna Artsruni, 46, who formerly owned a durable medical equipment (DME) company and worked at a number of medical clinics in Los Angeles, pleaded guilty before United States District Judge Margaret M. Morrow. Artsruni, to one count of health care fraud and one count of money laundering.
In a plea agreement filed last year, Artsruni admitted that she defrauded Medicare in a number of ways. In one part of the scheme, Artsruni had physicians’ assistants at three Los Angeles medical clinics sign prescriptions and orders for medically unnecessary DME and diagnostic tests that were later referred to other Medicare providers that billed for the equipment and tests. Artsruni also caused the three clinics to bill Medicare for medically unnecessary services. Further, Artsruni fraudulently billed Medicare on behalf of her own DME supply company, Midvalley Medical Supply in Van Nuys, for medically unnecessary DME based on referrals from one of the three medical clinics. In total, Artsruni caused more than $24.8 million in fraudulent claims to be submitted to Medicare, which paid more than $9.2 million on the bogus bills.
Artsruni also admitted that she wrote checks totaling more than $35,000 from the Midvalley bank account to three corporations that had no connection to the medical industry and apparently had not provided any legitimate business services to Midvalley. Artrsuni admitted that she wrote these checks to conceal the nature of the funds as the proceeds of health care fraud and used the three corporations to launder these funds.
At the time that she worked at two of the clinics and wrote one of the checks to launder the proceeds of her fraud, Artsruni was free on bond in another health care fraud case (United States v. Artsruni, CR08-209-CAS). Although the terms of her pre-trial release in the 2008 case dictated that she not commit crimes and forbid her from working at medical facilities, Artsruni concealed her activities from her pre-trial services officer and engaged in the fraudulent conduct that led to most of the losses suffered by Medicare in the second case.
As a result of her guilty pleas, Artsruni faces a statutory maximum sentence of 30 years in federal prison. Judge Morrow is scheduled to sentence Artsruni on April 14. A second defendant in the case, Erasmus Kotey, a physician’s assistant who worked with Artsruni in a medical clinic on North Vermont Avenue in Los Angeles, is scheduled to go on trial before Judge Morrow on April 8.
The case against Artsruni and Kotey is the product of an investigation by the Federal Bureau of Investigation; the U.S. Department of Health and Human Services, Office of Inspector General; and IRS-Criminal Investigation ...
Susanna Artsruni, 46, who formerly owned a durable medical equipment (DME) company and worked at a number of medical clinics in Los Angeles, pleaded guilty before United States District Judge Margaret M. Morrow. Artsruni, to one count of health care fraud and one count of money laundering.
In a plea agreement filed last year, Artsruni admitted that she defrauded Medicare in a number of ways. In one part of the scheme, Artsruni had physicians’ assistants at three Los Angeles medical clinics sign prescriptions and orders for medically unnecessary DME and diagnostic tests that were later referred to other Medicare providers that billed for the equipment and tests. Artsruni also caused the three clinics to bill Medicare for medically unnecessary services. Further, Artsruni fraudulently billed Medicare on behalf of her own DME supply company, Midvalley Medical Supply in Van Nuys, for medically unnecessary DME based on referrals from one of the three medical clinics. In total, Artsruni caused more than $24.8 million in fraudulent claims to be submitted to Medicare, which paid more than $9.2 million on the bogus bills.
Artsruni also admitted that she wrote checks totaling more than $35,000 from the Midvalley bank account to three corporations that had no connection to the medical industry and apparently had not provided any legitimate business services to Midvalley. Artrsuni admitted that she wrote these checks to conceal the nature of the funds as the proceeds of health care fraud and used the three corporations to launder these funds.
At the time that she worked at two of the clinics and wrote one of the checks to launder the proceeds of her fraud, Artsruni was free on bond in another health care fraud case (United States v. Artsruni, CR08-209-CAS). Although the terms of her pre-trial release in the 2008 case dictated that she not commit crimes and forbid her from working at medical facilities, Artsruni concealed her activities from her pre-trial services officer and engaged in the fraudulent conduct that led to most of the losses suffered by Medicare in the second case.
As a result of her guilty pleas, Artsruni faces a statutory maximum sentence of 30 years in federal prison. Judge Morrow is scheduled to sentence Artsruni on April 14. A second defendant in the case, Erasmus Kotey, a physician’s assistant who worked with Artsruni in a medical clinic on North Vermont Avenue in Los Angeles, is scheduled to go on trial before Judge Morrow on April 8.
The case against Artsruni and Kotey is the product of an investigation by the Federal Bureau of Investigation; the U.S. Department of Health and Human Services, Office of Inspector General; and IRS-Criminal Investigation ...
ABC News reports that federal prosecutors filed a record number of health care fraud cases last fiscal year, perhaps reflecting the greater emphasis the government has placed on combating the crime costing taxpayers billions of dollars per year. According to Justice Department statistics obtained through a Freedom of Information Act request by a Syracuse University-based nonprofit group that tracks federal spending, staffing and enforcement activities, prosecutors pursued 377 new federal health care fraud cases in the fiscal year that ended in October. That was 3 percent more than the previous year and 7.7 percent more than five years ago.
Southern Illinois led the nation on a per-capita basis in such cases filed, with the government pursuing 10.1 prosecutions per 1 million people, which was more than eight times the national average.
The latest numbers, while not necessarily showing that the white-collar crime is on the rise, may reflect a greater emphasis by authorities, predominantly the FBI and the Department of Health and Human Services, to root out the wrongdoing, said Susan Long, who is an associated professor of managerial statistics at the school and the co-director of the nonprofit, the Transactional Records Access Clearinghouse. "Clearly the numbers suggest this is an area the (Obama) administration is not ignoring," Long said Wednesday.
An illustration of the anti-fraud push came last May, when 89 people in eight cities - including 14 doctors and nurses - were charged for their alleged roles in separate Medicare scams that collectively billed the taxpayer-funded program for roughly $223 million in bogus charges. Because such fraud is believed to cost the Medicare program between $60 billion and $90 billion each year, Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius partnered in 2009 to increase enforcement by allocating more money and staff and creating strike forces in fraud hot spots around the country.
Medicare fraud has morphed into complex schemes over the years, moving from medical equipment and HIV infusion fraud to ambulance scams as crooks try to stay a step ahead of authorities. The scammers have also grown more sophisticated using recruiters who are paid kickbacks for finding patients, while doctors, nurses and company owners coordinate to appear to deliver medical services that they are not.
For decades, Medicare has operated under a pay-and-chase system, paying providers first and investigating suspicious claims later. Federal authorities are using new technology designed to flag suspicious claims before they are paid, but the system still is relatively new.
While "frankly surprised" by his office's distinction as the per-capita leader in health-care fraud prosecutions, southern Illinois U.S. Attorney Stephen Wigginton said every U.S. attorney enjoys discretion in prioritizing which crime issues to combat, taking into account regional demographics and Holder's desires. But Wigginton said he placed special emphasis on going after health-care defrauders since he began overseeing his district more than three years ago. Since then, Wigginton's office has increased such investigations each year. Last year, more than 30 people were indicted for allegedly scamming a Medicaid program meant to allow individuals to stay in their homes instead of entering a nursing home. "I think we're very focused and strategic," said Wigginton, whose office also has taken a lead nationally in cracking down on fraudulent time-share marketing and the St. Louis region's increasing struggles with heroin use ...
Southern Illinois led the nation on a per-capita basis in such cases filed, with the government pursuing 10.1 prosecutions per 1 million people, which was more than eight times the national average.
The latest numbers, while not necessarily showing that the white-collar crime is on the rise, may reflect a greater emphasis by authorities, predominantly the FBI and the Department of Health and Human Services, to root out the wrongdoing, said Susan Long, who is an associated professor of managerial statistics at the school and the co-director of the nonprofit, the Transactional Records Access Clearinghouse. "Clearly the numbers suggest this is an area the (Obama) administration is not ignoring," Long said Wednesday.
An illustration of the anti-fraud push came last May, when 89 people in eight cities - including 14 doctors and nurses - were charged for their alleged roles in separate Medicare scams that collectively billed the taxpayer-funded program for roughly $223 million in bogus charges. Because such fraud is believed to cost the Medicare program between $60 billion and $90 billion each year, Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius partnered in 2009 to increase enforcement by allocating more money and staff and creating strike forces in fraud hot spots around the country.
Medicare fraud has morphed into complex schemes over the years, moving from medical equipment and HIV infusion fraud to ambulance scams as crooks try to stay a step ahead of authorities. The scammers have also grown more sophisticated using recruiters who are paid kickbacks for finding patients, while doctors, nurses and company owners coordinate to appear to deliver medical services that they are not.
For decades, Medicare has operated under a pay-and-chase system, paying providers first and investigating suspicious claims later. Federal authorities are using new technology designed to flag suspicious claims before they are paid, but the system still is relatively new.
While "frankly surprised" by his office's distinction as the per-capita leader in health-care fraud prosecutions, southern Illinois U.S. Attorney Stephen Wigginton said every U.S. attorney enjoys discretion in prioritizing which crime issues to combat, taking into account regional demographics and Holder's desires. But Wigginton said he placed special emphasis on going after health-care defrauders since he began overseeing his district more than three years ago. Since then, Wigginton's office has increased such investigations each year. Last year, more than 30 people were indicted for allegedly scamming a Medicaid program meant to allow individuals to stay in their homes instead of entering a nursing home. "I think we're very focused and strategic," said Wigginton, whose office also has taken a lead nationally in cracking down on fraudulent time-share marketing and the St. Louis region's increasing struggles with heroin use ...
Chronic low back pain often goes hand in hand with obesity. A new study published in the journal Pain and summarized by Reuters Health hints that changes in the brain's reward systems could be one reason why. The finding follows earlier research that showed people with chronic low back pain often have changes in the areas of the brain that are associated with food and pleasure. "Patients who suffer from chronic low back pain might be at risk of overeating, especially from the highly palatable energy dense food," Dr. Paul Geha told Reuters Health in an email. "I would advise them to stay away from a diet rich in such foods (such as fries, pudding etc.) and develop habits of eating from healthier choices."
Geha led the new study at the Yale University School of Medicine in New Haven, Connecticut. He and his colleagues recruited 18 people with chronic low back pain and 19 healthy participants to serve as a comparison group. The participants were first instructed to taste and rate how much they liked four samples of pudding that were made with different amounts of fat. The procedure was repeated with orange-flavored drinks that contained various amounts of sugar. Participants returned on a different day and were told to eat as much of their favorite pudding as they liked. Then they rated how full they felt.
During the first session, people in both groups rated the puddings similarly for flavor, but those with back pain didn't like them as much as the healthy participants did. The pain-free participants rated the puddings between "like moderately" and "like very much" and the back pain patients rated them between "like slightly" and "like moderately." People in both groups liked the orange drinks about the same.
On the return visit, the researchers found that healthy participants who liked the pudding more ended up eating more of it. But that wasn't the case among people with back pain. Healthy people also reported feeling less hungry when they ate more calories of pudding - but again, that association didn't occur among back pain patients, the researchers reported in Pain.
Geha said people with chronic back pain might not be able to derive as much pleasure from eating as others. "Chronic low back pain is very common in the U.S.," Dr. Naum Shaparin told Reuters Health in an email. "Low back pain, in general, is one of the most common reasons for a doctor's visit, both in the office and the emergency department."
Shaparin is the director of Pain Service at Montefiore Medical Center in Bronx, New York, and was not involved in the new study.
He said people with back pain are often asked about nausea, anxiety and a range of other health problems - but not about satiety and pleasure derived from food. The theory, he said, has always been that these patients gain weight as a result of a lack of physical activity related to their pain. "This study, however, proposes the argument that chronic low back pain affects a patient's relationship with food such that the patient's pleasure from eating is decreased and the patient's ability to know when to stop eating is also decreased, thereby leading to overeating and weight gain," Shaparin said ...
Geha led the new study at the Yale University School of Medicine in New Haven, Connecticut. He and his colleagues recruited 18 people with chronic low back pain and 19 healthy participants to serve as a comparison group. The participants were first instructed to taste and rate how much they liked four samples of pudding that were made with different amounts of fat. The procedure was repeated with orange-flavored drinks that contained various amounts of sugar. Participants returned on a different day and were told to eat as much of their favorite pudding as they liked. Then they rated how full they felt.
During the first session, people in both groups rated the puddings similarly for flavor, but those with back pain didn't like them as much as the healthy participants did. The pain-free participants rated the puddings between "like moderately" and "like very much" and the back pain patients rated them between "like slightly" and "like moderately." People in both groups liked the orange drinks about the same.
On the return visit, the researchers found that healthy participants who liked the pudding more ended up eating more of it. But that wasn't the case among people with back pain. Healthy people also reported feeling less hungry when they ate more calories of pudding - but again, that association didn't occur among back pain patients, the researchers reported in Pain.
Geha said people with chronic back pain might not be able to derive as much pleasure from eating as others. "Chronic low back pain is very common in the U.S.," Dr. Naum Shaparin told Reuters Health in an email. "Low back pain, in general, is one of the most common reasons for a doctor's visit, both in the office and the emergency department."
Shaparin is the director of Pain Service at Montefiore Medical Center in Bronx, New York, and was not involved in the new study.
He said people with back pain are often asked about nausea, anxiety and a range of other health problems - but not about satiety and pleasure derived from food. The theory, he said, has always been that these patients gain weight as a result of a lack of physical activity related to their pain. "This study, however, proposes the argument that chronic low back pain affects a patient's relationship with food such that the patient's pleasure from eating is decreased and the patient's ability to know when to stop eating is also decreased, thereby leading to overeating and weight gain," Shaparin said ...
The judge presiding in the proposed $765 million settlement between the N.F.L. and more than 4,500 retired players who sued the league and accused it of hiding the dangers of concussions has raised significant questions about whether there will be enough money to pay for all of the payouts, medical tests and treatment. Judge Anita B. Brody of the United States District Court for the Eastern District of Pennsylvania rejected the proposed settlement because the league and the plaintiffs’ lawyers had not produced enough evidence to persuade her that $765 million would cover the potential costs for 18,000 retirees over the 65-year life of the agreement. "I am primarily concerned that not all retired N.F.L. football players who ultimately receive a qualifying diagnosis or their related claimants will be paid," Brody wrote.
The lawyers for the players have said that economists and actuaries have said there will be sufficient money available.
"Unfortunately, no such analyses were provided to me in support of the plaintiffs’ motion," Brody said. "In the absence of additional supporting evidence, I have concerns about the fairness, reasonableness and adequacy of the settlement."
The judge’s ruling will probably force the plaintiffs’ lawyers and the N.F.L. to provide documents proving that there will be enough money to pay for the retired players’ claims. If the judge remains unconvinced, the league and the lawyers could increase the size of the settlement, change the amount of the payouts or limit who might be eligible. Even if the league and the lawyers for the players convince the judge that there will be enough money to go around, her ruling on Tuesday will undoubtedly delay when players may get paid. The proposed settlement that the judge reviewed, which was released last week, was to form the basis for mailings sent to retired players. The players would then have several months to approve the settlement, or opt out of it.
None of this means the settlement is off, however. There are tweaks that can be made and, as Christopher Seeger, co-lead counsel for the plaintiffs said in a statement, "analysis from economists, acutaries and medical experts" will prove that the settlement will take care of the players in question.
"We are confident that the settlement will be approved after the Court conducts its due diligence on the fairness and adequacy of the proposed agreement," Christopher Seeger, co-lead counsel for the plaintiffs, said in a statement. "Analysis from economists, actuaries and medical experts will confirm that the programs established by the settlement will be sufficiently funded to meet their obligations for all eligible retired players. We look forward to working with the Court and Special Master to address their concerns, as they rightfully ensure all class members are protected.
"We believe this is an extraordinary settlement for retired NFL players and their families, and have received overwhelming support as they have learned about its benefits. We look forward to finalizing this agreement so they can soon begin taking advantage of its benefits."
Florida-based lawyer Sia Nejad, who specializes in insurance defense, says this rejection is a matter of wanting the NFL to "show its work." "At this point, it seems that Judge Brody is doubting that the $765 million is sufficient to cover the players and that some of the parameters to qualify for portions of the settlement monies are too narrow or restrictive. Bottom line, she wants the lawyers to 'show their work' because she's doubting the fairness of the agreement." ...
The lawyers for the players have said that economists and actuaries have said there will be sufficient money available.
"Unfortunately, no such analyses were provided to me in support of the plaintiffs’ motion," Brody said. "In the absence of additional supporting evidence, I have concerns about the fairness, reasonableness and adequacy of the settlement."
The judge’s ruling will probably force the plaintiffs’ lawyers and the N.F.L. to provide documents proving that there will be enough money to pay for the retired players’ claims. If the judge remains unconvinced, the league and the lawyers could increase the size of the settlement, change the amount of the payouts or limit who might be eligible. Even if the league and the lawyers for the players convince the judge that there will be enough money to go around, her ruling on Tuesday will undoubtedly delay when players may get paid. The proposed settlement that the judge reviewed, which was released last week, was to form the basis for mailings sent to retired players. The players would then have several months to approve the settlement, or opt out of it.
None of this means the settlement is off, however. There are tweaks that can be made and, as Christopher Seeger, co-lead counsel for the plaintiffs said in a statement, "analysis from economists, acutaries and medical experts" will prove that the settlement will take care of the players in question.
"We are confident that the settlement will be approved after the Court conducts its due diligence on the fairness and adequacy of the proposed agreement," Christopher Seeger, co-lead counsel for the plaintiffs, said in a statement. "Analysis from economists, actuaries and medical experts will confirm that the programs established by the settlement will be sufficiently funded to meet their obligations for all eligible retired players. We look forward to working with the Court and Special Master to address their concerns, as they rightfully ensure all class members are protected.
"We believe this is an extraordinary settlement for retired NFL players and their families, and have received overwhelming support as they have learned about its benefits. We look forward to finalizing this agreement so they can soon begin taking advantage of its benefits."
Florida-based lawyer Sia Nejad, who specializes in insurance defense, says this rejection is a matter of wanting the NFL to "show its work." "At this point, it seems that Judge Brody is doubting that the $765 million is sufficient to cover the players and that some of the parameters to qualify for portions of the settlement monies are too narrow or restrictive. Bottom line, she wants the lawyers to 'show their work' because she's doubting the fairness of the agreement." ...
Lumbar disc surgery is one of the most commonly performed operations in the United States, although rates vary considerably in different regions. Past studies have suggested that surgery provides faster pain relief and recovery for patients with herniated discs, compared to nonsurgical treatment. However, it has been difficult to determine the true effects of surgery - especially because of the high number of patients who cross over from nonsurgical treatment to surgery. This tends to underestimate the true benefits of surgery.
For patients with herniated discs in the lower (lumbar) spine, surgery leads to greater long-term improvement in pain, functioning, and disability compared to nonsurgical treatment, concludes an eight year follow-up study in the journal Spine. "Carefully selected patients who underwent surgery for a lumbar disc herniation achieved greater improvement than non-operatively treated patients," according to lead author Dr. Jon D. Lurie of Dartmouth-Hitchcock Medical Center and the Geisel School of Medicine and colleagues. The results add to the evidence for surgical treatment of herniated discs - but also show that nonsurgical treatment can provide lasting benefits for some patients. The study has been posted ahead of print on the journal website; it will be published in the January issue of Spine.
The researchers analyzed data from the Spine Patient Outcomes Research Trial (SPORT), one of the largest clinical trials of surgery for spinal disorders. In SPORT, patients meeting strict criteria for herniated discs in the lumbar spine underwent surgery or nonsurgical treatment such as physical therapy, exercise, and pain-relieving medications. Patients with herniated discs experience back pain, leg pain (sciatica), and other symptoms caused by pressure on the spinal nerve roots. The current analysis included eight-year follow-up data on 1,244 patients treated at 13 spine clinics across the United States. About 500 patients were randomly assigned to surgery (a procedure called discectomy) or nonsurgical treatment, although patients were allowed to "cross over" to the other treatment. For the remaining patients, decisions as to surgery or nonsurgical treatment were left up to the patients and their doctors. Standard measures of pain, physical functioning, and disability were compared between groups.
Consistent with previous data from SPORT, patients assigned to surgery tended to have better outcomes. However, because many patients did not actually undergo their assigned treatment, the differences based on "intention to treat" were not statistically significant. When outcomes were compared for patients who actually underwent surgery versus nonsurgical treatment, significant differences emerged. On a 100-point pain scale, pain scores averaged about 11 points lower in the surgery group. Measures of physical functioning and disability showed similar differences. Surgery also led to greater improvement in some additional outcomes, including the bothersomeness of sciatica symptoms, patient satisfaction, and self-rated improvement.
While average outcome scores were better with surgery, many patients had significant improvement with nonsurgical treatment. After eight years, about one-third of patients who were clinically indicated for surgery have chosen not to have operative treatment.
SPORT Principal Investigator Dr. James N. Weinstein said this is significant and shows the important role that shared decision making plays in the process: "Every patient in the SPORT study went through shared decision-making, during which they reviewed objective information about the risks and benefits of their treatment options. This allowed them to make an informed choice, in line with their own values. That about a third of these patients have continued to be satisfied with their choice is in large part due, I believe, to their being active participants in the initial decision-making process" Weinstein said.
The long-term follow-up results from SPORT show that, for patients with confirmed herniated lumbar discs, "[S]urgery was superior to non-operative treatment in relieving symptoms and improving function." Dr Lurie and coauthors note that the peak benefits are achieved within six months after surgery and persist through eight years.
However, many patients treated without surgery "also showed substantial improvements over time," the researchers write. They add that patients who crossed over to surgery were more likely to be dissatisfied with their symptoms, felt like their symptoms were getting worse, and had initially worse physical function and disability ...
For patients with herniated discs in the lower (lumbar) spine, surgery leads to greater long-term improvement in pain, functioning, and disability compared to nonsurgical treatment, concludes an eight year follow-up study in the journal Spine. "Carefully selected patients who underwent surgery for a lumbar disc herniation achieved greater improvement than non-operatively treated patients," according to lead author Dr. Jon D. Lurie of Dartmouth-Hitchcock Medical Center and the Geisel School of Medicine and colleagues. The results add to the evidence for surgical treatment of herniated discs - but also show that nonsurgical treatment can provide lasting benefits for some patients. The study has been posted ahead of print on the journal website; it will be published in the January issue of Spine.
The researchers analyzed data from the Spine Patient Outcomes Research Trial (SPORT), one of the largest clinical trials of surgery for spinal disorders. In SPORT, patients meeting strict criteria for herniated discs in the lumbar spine underwent surgery or nonsurgical treatment such as physical therapy, exercise, and pain-relieving medications. Patients with herniated discs experience back pain, leg pain (sciatica), and other symptoms caused by pressure on the spinal nerve roots. The current analysis included eight-year follow-up data on 1,244 patients treated at 13 spine clinics across the United States. About 500 patients were randomly assigned to surgery (a procedure called discectomy) or nonsurgical treatment, although patients were allowed to "cross over" to the other treatment. For the remaining patients, decisions as to surgery or nonsurgical treatment were left up to the patients and their doctors. Standard measures of pain, physical functioning, and disability were compared between groups.
Consistent with previous data from SPORT, patients assigned to surgery tended to have better outcomes. However, because many patients did not actually undergo their assigned treatment, the differences based on "intention to treat" were not statistically significant. When outcomes were compared for patients who actually underwent surgery versus nonsurgical treatment, significant differences emerged. On a 100-point pain scale, pain scores averaged about 11 points lower in the surgery group. Measures of physical functioning and disability showed similar differences. Surgery also led to greater improvement in some additional outcomes, including the bothersomeness of sciatica symptoms, patient satisfaction, and self-rated improvement.
While average outcome scores were better with surgery, many patients had significant improvement with nonsurgical treatment. After eight years, about one-third of patients who were clinically indicated for surgery have chosen not to have operative treatment.
SPORT Principal Investigator Dr. James N. Weinstein said this is significant and shows the important role that shared decision making plays in the process: "Every patient in the SPORT study went through shared decision-making, during which they reviewed objective information about the risks and benefits of their treatment options. This allowed them to make an informed choice, in line with their own values. That about a third of these patients have continued to be satisfied with their choice is in large part due, I believe, to their being active participants in the initial decision-making process" Weinstein said.
The long-term follow-up results from SPORT show that, for patients with confirmed herniated lumbar discs, "[S]urgery was superior to non-operative treatment in relieving symptoms and improving function." Dr Lurie and coauthors note that the peak benefits are achieved within six months after surgery and persist through eight years.
However, many patients treated without surgery "also showed substantial improvements over time," the researchers write. They add that patients who crossed over to surgery were more likely to be dissatisfied with their symptoms, felt like their symptoms were getting worse, and had initially worse physical function and disability ...
In forecasting serious asbestos-related claims, some of the country’s largest insurers and consultants appear to be ignoring relevant changes in medical knowledge, demographics and even social media. As a third wave of costly asbestos-related claims strikes the nation in the years ahead, many insurers will be swamped with "unexpected" reserve charges, according to "A Third Wave in Asbestos Liabilities Lies Ahead," a new study by Assured Research, a New Jersey-based firm that analyzes the property/casualty insurance industry.
"In studying asbestos-related claims, we’re seeing evidence of outdated actuarial models," explains Assured president William Wilt. "Since they’re based on 30-year-old epidemiological and demographic data, they can’t accurately forecast asbestos-related claims. Some insurers also seem to be ignoring advances in medical knowledge and diagnosis - and the changing behaviors of consumers and personal injury lawyers."
The first wave of claims came from asbestos miners and millers; the second from people who handled asbestos regularly, such as plumbers, shipbuilders and carpenters. The third wave will be dominated by lung cancer claims which are ostensibly lower quality than those of mesothelioma because the cancer was predominantly caused by smoking rather than asbestos. Nevertheless, large numbers of even lower-quality claims could raise pressure on defendants anxious to settle and minimize nuisance suits. Moreover, recent literature illustrates researchers’ rising awareness of the malignant synergies between asbestos and smoking. Further, researchers are finding that short but intense exposures to asbestos can lead to asbestos illnesses.
"Medical evidence is mounting," says Wilt, "that there is no ‘lower limit’ below which asbestos fibers cannot cause mesothelioma. Meanwhile, the people most likely to make asbestos claims are living longer - long enough, in some cases, to be diagnosed with asbestos-related disease."
Asbestosis may be easier to diagnose today, thanks to high-resolution CT-scans, but Assured Research believes the third wave will be dominated by lung cancer claims. Personal injury lawyers are finding it easier than ever to prospect for new claimants, while a new recommendation from the U.S. Preventive Services Task Force recommends annual CT scans for all current and formers (heavy) smokers between the ages of 55 and 80 - some 10 million people.
"We believe this third wave will be aided by the growing prevalence of social media sites such as Google and YouTube which have lowered the cost of prospecting for claimants by lawyers," says co-author and Managing Director Alan Zimmermann. "If you need convincing, type the name of any well-known asbestos law firm into a search engine and see how fast they come back to you with offers of direct conversations."
"The confluence of outdated actuarial models, shifts in life expectancies, medical knowledge, social media, and now recommended screening," Wilt says, "can’t be good news for insurers that are funding higher than expected claims on a pay-as-you-go basis." ...
"In studying asbestos-related claims, we’re seeing evidence of outdated actuarial models," explains Assured president William Wilt. "Since they’re based on 30-year-old epidemiological and demographic data, they can’t accurately forecast asbestos-related claims. Some insurers also seem to be ignoring advances in medical knowledge and diagnosis - and the changing behaviors of consumers and personal injury lawyers."
The first wave of claims came from asbestos miners and millers; the second from people who handled asbestos regularly, such as plumbers, shipbuilders and carpenters. The third wave will be dominated by lung cancer claims which are ostensibly lower quality than those of mesothelioma because the cancer was predominantly caused by smoking rather than asbestos. Nevertheless, large numbers of even lower-quality claims could raise pressure on defendants anxious to settle and minimize nuisance suits. Moreover, recent literature illustrates researchers’ rising awareness of the malignant synergies between asbestos and smoking. Further, researchers are finding that short but intense exposures to asbestos can lead to asbestos illnesses.
"Medical evidence is mounting," says Wilt, "that there is no ‘lower limit’ below which asbestos fibers cannot cause mesothelioma. Meanwhile, the people most likely to make asbestos claims are living longer - long enough, in some cases, to be diagnosed with asbestos-related disease."
Asbestosis may be easier to diagnose today, thanks to high-resolution CT-scans, but Assured Research believes the third wave will be dominated by lung cancer claims. Personal injury lawyers are finding it easier than ever to prospect for new claimants, while a new recommendation from the U.S. Preventive Services Task Force recommends annual CT scans for all current and formers (heavy) smokers between the ages of 55 and 80 - some 10 million people.
"We believe this third wave will be aided by the growing prevalence of social media sites such as Google and YouTube which have lowered the cost of prospecting for claimants by lawyers," says co-author and Managing Director Alan Zimmermann. "If you need convincing, type the name of any well-known asbestos law firm into a search engine and see how fast they come back to you with offers of direct conversations."
"The confluence of outdated actuarial models, shifts in life expectancies, medical knowledge, social media, and now recommended screening," Wilt says, "can’t be good news for insurers that are funding higher than expected claims on a pay-as-you-go basis." ...
National Nurses United, with close to 185,000 members in every state, is the largest union and professional association of registered nurses in U.S. history. A report from NNU claims that an epidemic of sky-rocketing medical costs has afflicted our country and grown to obscene proportions. Medical bills are bloated with waste, redundancy, profiteering, fraud and outrageous over-billing. Much is wrong with the process of pricing and providing health care.
The latest in this medical cost saga comes from new data released last week. In a news release, NNU revealed that fourteen hospitals in the United States are charging more than ten times their costs for treatment. Specifically, for every $100 one of these hospitals spends, the charge on the corresponding bill is nearly $1,200. NNU's key findings note that the top 100 most expensive U.S. hospitals have "a charge to cost ratio of 765 percent and higher -- more than double the national average of 331 percent." They found that despite the enactment of "Obamacare" -- the Affordable Care Act -- overall hospital charges experienced their largest increase in 16 years. For-profit hospitals continue to be the worst offenders with average charges of 503 percent of their costs compared to publically-run hospitals ("...including federal, state, county, city, or district operated hospitals, with public budgets and boards that meet in public...") which show more restraint in pricing. The average charge ratios for these hospitals are 235 percent of their costs.
NNU claims that the needless complications of the vast medical marketplace have provided far too many opportunities for profiteering. Numerous examples of hospital visit bills feature enormous overcharges on simple supplies such as over-the-counter painkillers, gauze, bandages and even the markers used to prep patients for surgery. That's not to mention the cost of more advanced procedures and the use of advanced medical equipment which are billed at several times their actual cost. These charges have resulted in many hundreds of millions of dollars in overcharges.
When pressed for answers, many hospital representatives are quick to defer to factors out of their control. It's the cost of providing care they might say, or perhaps infer that other vague aspects of running the business of medical treatment add up and are factored into these massive charges. Cost allocations mix treatment costs with research budgets, cash reserves, and just plain accounting gimmicks. These excuses shouldn't fly in the United States. Few in the medical industry will acknowledge the troubling trend. One thing is undeniably certain however -- the medical marketplace is not suffering for profits. Health-care in the United States is a nearly 3 trillion dollar a year industry replete with excessive profits for many hospitals, medical supply companies, pharmaceutical companies, labs and health insurance vendors.
The U.S. spends more on health care than the next ten countries combined -- most of which cover almost all of their citizens.The United States spends $8,233 per person, per year according to a 2012 figure from the Organization for Economic Co-operation and Development (OECD). The average expenditure of the thirty three other developed nations OECD tracked is just $3,268 per person. It gets worse. Harvard's Malcolm Sparrow, the leading expert on health care billing fraud and abuse, conservatively estimates that 10 percent of all health care expenditure in the United States is lost to computerized billing fraud. That's $270 billion dollars a year! ...
The latest in this medical cost saga comes from new data released last week. In a news release, NNU revealed that fourteen hospitals in the United States are charging more than ten times their costs for treatment. Specifically, for every $100 one of these hospitals spends, the charge on the corresponding bill is nearly $1,200. NNU's key findings note that the top 100 most expensive U.S. hospitals have "a charge to cost ratio of 765 percent and higher -- more than double the national average of 331 percent." They found that despite the enactment of "Obamacare" -- the Affordable Care Act -- overall hospital charges experienced their largest increase in 16 years. For-profit hospitals continue to be the worst offenders with average charges of 503 percent of their costs compared to publically-run hospitals ("...including federal, state, county, city, or district operated hospitals, with public budgets and boards that meet in public...") which show more restraint in pricing. The average charge ratios for these hospitals are 235 percent of their costs.
NNU claims that the needless complications of the vast medical marketplace have provided far too many opportunities for profiteering. Numerous examples of hospital visit bills feature enormous overcharges on simple supplies such as over-the-counter painkillers, gauze, bandages and even the markers used to prep patients for surgery. That's not to mention the cost of more advanced procedures and the use of advanced medical equipment which are billed at several times their actual cost. These charges have resulted in many hundreds of millions of dollars in overcharges.
When pressed for answers, many hospital representatives are quick to defer to factors out of their control. It's the cost of providing care they might say, or perhaps infer that other vague aspects of running the business of medical treatment add up and are factored into these massive charges. Cost allocations mix treatment costs with research budgets, cash reserves, and just plain accounting gimmicks. These excuses shouldn't fly in the United States. Few in the medical industry will acknowledge the troubling trend. One thing is undeniably certain however -- the medical marketplace is not suffering for profits. Health-care in the United States is a nearly 3 trillion dollar a year industry replete with excessive profits for many hospitals, medical supply companies, pharmaceutical companies, labs and health insurance vendors.
The U.S. spends more on health care than the next ten countries combined -- most of which cover almost all of their citizens.The United States spends $8,233 per person, per year according to a 2012 figure from the Organization for Economic Co-operation and Development (OECD). The average expenditure of the thirty three other developed nations OECD tracked is just $3,268 per person. It gets worse. Harvard's Malcolm Sparrow, the leading expert on health care billing fraud and abuse, conservatively estimates that 10 percent of all health care expenditure in the United States is lost to computerized billing fraud. That's $270 billion dollars a year! ...
In 2003, the Legislature reformed the workers’ compensation medical care delivery system by repealing the PTP’s presumption of correctness and implementing an objective standard of care determined by evidence-based medicine guidelines. The result was the creation of a Medical Treatment Utilization Schedule (MTUS), a dynamic series of medical treatment guidelines designed to create a "standard of care" by which proposed medical treatment would be evaluated.
In late 2012, another round of reforms began to take shape in the form of Senate Bill 863. The inability of the adversarial and judicial systems in workers’ compensation to effectively implement the standard of medical care intended by the prior reforms through the adoption of the Medical Utilization Treatment Schedule and utilization review led to the creation of a new medical dispute resolution process: independent medical review. A common principle of both UR and IMR is the process of evaluating requests for medical tests and treatments for medical necessity, efficacy, and appropriateness.
And this week the CWCI published a report that compiled data on utilization review and independent medical review decisions from a variety of sources. According to the study, "due to the availability of the MTUS and other evidence-based medical guidelines, three out of four medical treatment requests are approved by claims adjusters without the need for additional oversight, with 25 percent of the treatment requests requiring elevated utilization review."
IMR upheld 78.9 percent of all reviewed elevated UR decisions, while overturning 21.1 percent, with a majority of the UR decisions upheld in all 14 medical service categories. As was the case in elevated UR, pharmacy-related IMR decisions were by far the most prevalent, accounting for one third of all IMR determinations. Of those pharmacy-related reviews, 78 percent upheld the UR decision, while 22 percent overturned the prior UR decision. Consultations, laboratory services, and tests and measurement had the highest percentage of overturned UR decisions following IMR (50 percent, 34.2 percent and 35.3 percent respectively). Among the high-volume IMR requests, durable medical equipment, which accounted for 1 out of 10 IMR determinations, had the lowest percentage of UR modifications (13.2 percent), while 85 percent of all IMR decisions on physical medicine upheld the UR determinations.
Physical medicine practitioners accounted for the largest proportion of the reviewers (43 percent), followed by occupational medicine specialists (20 percent), orthopedists (14 percent) and family practitioners/internal medicine specialists (10 percent). No other medical specialty accounted for more than 5 percent of the IMR reviewers.
Thus, the CWCI study concludes "The fact that only a small proportion of medical treatment requests are modified or denied shows that UR/IMR are serving as intended, as an exception process." Federal and group health plans typically use a shared risk model to balance supply and demand for medical services. Medicare, Medicaid and almost all group health programs use mandatory utilization review, along with supply-side controls such as fee schedules, closed provider panels, highly regulated pharmaceutical formularies, explicit limits on specific procedures and therapies and prohibitions on experimental procedures and equipment and demand-side controls such as co-payments and deductibles, contractually based limitations on services. Because cost controls such as co-payments and deductibles cannot be used in the workers’ compensation system, cost containment programs are typically limited to the use of fee schedules, medical treatment guidelines, partial limits on specific procedures and utilization review.
However, the study presents alarming data on opioid pain medication use. UR and IMR pharmaceutical reviews represent 43 and 25 percent of all decisions respectively. In terms of pharmaceutical control, a chronic pain management guideline was implemented within the MTUS in July 2009 for the purposes of providing better oversight controls on the use Schedule II and Schedule III opioids and other pain management therapies. Researchers found that between 2009 and 2012, Schedule II and Schedule III opioids have essentially remained at one quarter of all California workers’ compensation outpatient prescriptions and 30 percent of total prescription drug expenditures. This data compiled on UR and IMR decisions suggests that between one-third to one-half of the UR and IMR pharmacy reviews involved opioids or compound drug requests. The authors have also separately documented the high rate of Schedule II opioid prescriptions for minor back pain, strains of the extremities and mental health disturbances, a questionable use of these highly addictive and dangerous pain medications.
The sustained high rate of Schedule II and Schedule III opioids and the high rate of pharmacy-related UR and IMR decisions suggest an opportunity for stronger pharmaceutical utilization and cost controls. A forthcoming CWCI study will compare new trends in Schedule II and Schedule III opioid use in California workers’ compensation and compare California utilization and cost factors against an alternative closed formulary method used in other states ...
In late 2012, another round of reforms began to take shape in the form of Senate Bill 863. The inability of the adversarial and judicial systems in workers’ compensation to effectively implement the standard of medical care intended by the prior reforms through the adoption of the Medical Utilization Treatment Schedule and utilization review led to the creation of a new medical dispute resolution process: independent medical review. A common principle of both UR and IMR is the process of evaluating requests for medical tests and treatments for medical necessity, efficacy, and appropriateness.
And this week the CWCI published a report that compiled data on utilization review and independent medical review decisions from a variety of sources. According to the study, "due to the availability of the MTUS and other evidence-based medical guidelines, three out of four medical treatment requests are approved by claims adjusters without the need for additional oversight, with 25 percent of the treatment requests requiring elevated utilization review."
IMR upheld 78.9 percent of all reviewed elevated UR decisions, while overturning 21.1 percent, with a majority of the UR decisions upheld in all 14 medical service categories. As was the case in elevated UR, pharmacy-related IMR decisions were by far the most prevalent, accounting for one third of all IMR determinations. Of those pharmacy-related reviews, 78 percent upheld the UR decision, while 22 percent overturned the prior UR decision. Consultations, laboratory services, and tests and measurement had the highest percentage of overturned UR decisions following IMR (50 percent, 34.2 percent and 35.3 percent respectively). Among the high-volume IMR requests, durable medical equipment, which accounted for 1 out of 10 IMR determinations, had the lowest percentage of UR modifications (13.2 percent), while 85 percent of all IMR decisions on physical medicine upheld the UR determinations.
Physical medicine practitioners accounted for the largest proportion of the reviewers (43 percent), followed by occupational medicine specialists (20 percent), orthopedists (14 percent) and family practitioners/internal medicine specialists (10 percent). No other medical specialty accounted for more than 5 percent of the IMR reviewers.
Thus, the CWCI study concludes "The fact that only a small proportion of medical treatment requests are modified or denied shows that UR/IMR are serving as intended, as an exception process." Federal and group health plans typically use a shared risk model to balance supply and demand for medical services. Medicare, Medicaid and almost all group health programs use mandatory utilization review, along with supply-side controls such as fee schedules, closed provider panels, highly regulated pharmaceutical formularies, explicit limits on specific procedures and therapies and prohibitions on experimental procedures and equipment and demand-side controls such as co-payments and deductibles, contractually based limitations on services. Because cost controls such as co-payments and deductibles cannot be used in the workers’ compensation system, cost containment programs are typically limited to the use of fee schedules, medical treatment guidelines, partial limits on specific procedures and utilization review.
However, the study presents alarming data on opioid pain medication use. UR and IMR pharmaceutical reviews represent 43 and 25 percent of all decisions respectively. In terms of pharmaceutical control, a chronic pain management guideline was implemented within the MTUS in July 2009 for the purposes of providing better oversight controls on the use Schedule II and Schedule III opioids and other pain management therapies. Researchers found that between 2009 and 2012, Schedule II and Schedule III opioids have essentially remained at one quarter of all California workers’ compensation outpatient prescriptions and 30 percent of total prescription drug expenditures. This data compiled on UR and IMR decisions suggests that between one-third to one-half of the UR and IMR pharmacy reviews involved opioids or compound drug requests. The authors have also separately documented the high rate of Schedule II opioid prescriptions for minor back pain, strains of the extremities and mental health disturbances, a questionable use of these highly addictive and dangerous pain medications.
The sustained high rate of Schedule II and Schedule III opioids and the high rate of pharmacy-related UR and IMR decisions suggest an opportunity for stronger pharmaceutical utilization and cost controls. A forthcoming CWCI study will compare new trends in Schedule II and Schedule III opioid use in California workers’ compensation and compare California utilization and cost factors against an alternative closed formulary method used in other states ...
A Santa Barbara physician was remanded into custody this week after he pleaded guilty to 11 federal drug trafficking charges for writing prescriptions for powerful painkillers for "patients" who were drug addicts.
Julio Gabriel Diaz, 65, who operated the Family Medical Clinic in Santa Barbara prior to his arrest two years ago, pleaded guilty to 10 counts of distributing controlled substances without a legitimate medical purpose and one count of distributing controlled substances to a minor (which, under federal law, is a person under 21).
Diaz pleaded guilty before United States District Judge Cormac J. Carney, who is scheduled to sentence the defendant on June 2. Diaz, who will be held in jail until his sentencing, faces a maximum statutory sentence of 200 years in federal prison and fines of up to $10 million.
"Dr. Diaz was, quite simply, acting as a common drug dealer," said United States Attorney André Birotte Jr. "The diversion of powerful painkillers from legitimate medical uses to the hands of drug abusers is a dangerous practice that fuels addiction and causes overdoses. Far too many of the illegal prescription drugs that find their way to street users come from doctors who, like Julio Diaz, choose to betray their Hippocratic oath."
In a plea agreement filed last year in United States District Court, Diaz admitted distributing narcotics such as oxycodone, methadone, hydrocodone, alprazolam, fentanyl and hydromorphone in 2009 and 2010. Diaz admitted that he distributed or dispensed the narcotics "while acting and intending to act outside the usual course of professional practice and without a legitimate medical purpose." Court documents previously filed in this case, as well as civil lawsuits, link Diaz to fatal drug overdoses. However, he was not specifically charged with causing any deaths, nor did he specifically admit causing any deaths during today’s hearing.
The investigation into Diaz was conducted by the Drug Enforcement Administration and the Santa Barbara Police Department, which received the assistance of the California Medical Board ...
Julio Gabriel Diaz, 65, who operated the Family Medical Clinic in Santa Barbara prior to his arrest two years ago, pleaded guilty to 10 counts of distributing controlled substances without a legitimate medical purpose and one count of distributing controlled substances to a minor (which, under federal law, is a person under 21).
Diaz pleaded guilty before United States District Judge Cormac J. Carney, who is scheduled to sentence the defendant on June 2. Diaz, who will be held in jail until his sentencing, faces a maximum statutory sentence of 200 years in federal prison and fines of up to $10 million.
"Dr. Diaz was, quite simply, acting as a common drug dealer," said United States Attorney André Birotte Jr. "The diversion of powerful painkillers from legitimate medical uses to the hands of drug abusers is a dangerous practice that fuels addiction and causes overdoses. Far too many of the illegal prescription drugs that find their way to street users come from doctors who, like Julio Diaz, choose to betray their Hippocratic oath."
In a plea agreement filed last year in United States District Court, Diaz admitted distributing narcotics such as oxycodone, methadone, hydrocodone, alprazolam, fentanyl and hydromorphone in 2009 and 2010. Diaz admitted that he distributed or dispensed the narcotics "while acting and intending to act outside the usual course of professional practice and without a legitimate medical purpose." Court documents previously filed in this case, as well as civil lawsuits, link Diaz to fatal drug overdoses. However, he was not specifically charged with causing any deaths, nor did he specifically admit causing any deaths during today’s hearing.
The investigation into Diaz was conducted by the Drug Enforcement Administration and the Santa Barbara Police Department, which received the assistance of the California Medical Board ...
American Financial Group, Inc. today announced that it has reached a definitive agreement to acquire Summit Holdings Southeast, Inc. and its related companies (together, "Summit"), from Liberty Mutual Insurance in an all-cash transaction. Based in Lakeland, FL, Summit is a leading provider of workers' compensation solutions in the Southeastern United States, with approximately $520 million of premium written. Following the transaction, Summit will continue to operate under the Summit brand as a member of AFG's Great American Insurance Group.
Under the terms of the transaction, AFG will pay Liberty Mutual Insurance an estimated $250 million at closing. The purchase price will be subject to adjustment between signing and closing for, among other things, changes in Summit's GAAP tangible book value. AFG's total capital investment in Summit will be approximately $400 million, inclusive of a capital contribution by AFG at closing. The transaction is expected to close in the first or second quarter of 2014, following customary regulatory approvals. AFG will not use any external financing in the acquisition.
Carl H. Lindner III, Co-Chief Executive Officer of AFG, commented, "Summit has an excellent long-term track record of underwriting outperformance. We value its underwriting discipline, talented management team and value-based service model. Their business model fits well with our Property and Casualty Group's strategic focus and complements our Great American Insurance Group specialty workers' compensation offerings available through our other specialty P&C businesses. We look forward to welcoming Carol Sipe, Summit Group's President and CEO, and her team to the AFG family."
American Financial Group is an insurance holding company, based in Cincinnati, Ohio with assets of approximately $40 billion. Through the operations of Great American Insurance Group, AFG is engaged primarily in property and casualty insurance, focusing on specialized commercial products for businesses, and in the sale of fixed and fixed-indexed annuities in the retail, financial institutions and education markets. Great American Insurance Group's roots go back to 1872 with the founding of its flagship company, Great American Insurance Company ...
Under the terms of the transaction, AFG will pay Liberty Mutual Insurance an estimated $250 million at closing. The purchase price will be subject to adjustment between signing and closing for, among other things, changes in Summit's GAAP tangible book value. AFG's total capital investment in Summit will be approximately $400 million, inclusive of a capital contribution by AFG at closing. The transaction is expected to close in the first or second quarter of 2014, following customary regulatory approvals. AFG will not use any external financing in the acquisition.
Carl H. Lindner III, Co-Chief Executive Officer of AFG, commented, "Summit has an excellent long-term track record of underwriting outperformance. We value its underwriting discipline, talented management team and value-based service model. Their business model fits well with our Property and Casualty Group's strategic focus and complements our Great American Insurance Group specialty workers' compensation offerings available through our other specialty P&C businesses. We look forward to welcoming Carol Sipe, Summit Group's President and CEO, and her team to the AFG family."
American Financial Group is an insurance holding company, based in Cincinnati, Ohio with assets of approximately $40 billion. Through the operations of Great American Insurance Group, AFG is engaged primarily in property and casualty insurance, focusing on specialized commercial products for businesses, and in the sale of fixed and fixed-indexed annuities in the retail, financial institutions and education markets. Great American Insurance Group's roots go back to 1872 with the founding of its flagship company, Great American Insurance Company ...
