Doreen Dahl sustained a cumulative industrial injury in 2005 (pre SB 863) to her neck and right shoulder while employed by Contra Costa County as a medical records technician. She was 49 years old and had worked for the county for over 8 years. Dahl's vocational experts noted that she has a bachelor’s degree from CSU Hayward and a felony conviction for possession and sale of methamphetamine.
The WPI resulted in a rating of 59 percent disability. However, Dahl sought to rebut the scheduled rating through a vocational expert (Jeffrey Malmuth), and the County sought to counter that with its own expert (Ira Cohen). The WCJ initially awarded the 59% disability pursuant to the Schedule but it was was rejected on reconsideration. The WCJ then assigned Dahl a disability of 79 percent. The WCAB affirmed an increase based upon the Olgivie case in the second award. In doing so, the WCAB again concluded that "complete lack of amenability to vocational rehabilitation" is not "necessary before a LeBoeuf analysis may be properly applied."
The Court of Appeal rejected the WCAB methodology in the published case of Contra Costa County v WCAB (Dahl) holding "When it devised this new methodology, the WCAB acted in excess of its authority."
There are three methods to rebut the scheduled rating: 1) a factual error in the application of a formula or the preparation of the schedule, 2) when the injury impairs rehabilitation, and for that reason, the employee’s diminished future earning capacity is greater than the scheduled rating or 3) when a claimant can demonstrate that the nature or severity of the injury is not captured within the sampling of disabled workers used to compute the adjustment factor. The second method however requires that the diminished future earnings is directly attributable to the employee’s work-related injury, and not due to nonindustrial factors such as general economic conditions, illiteracy, proficiency in speaking English, or an employee’s lack of education. This case involved application of the second method.
Under the second method, the WCAB held that Dahl could rebut the scheduled rating by showing the injury impaired her amenability to rehabilitation, even where there was less than total permanent disability. The Court of Appeal responded by saying "We are skeptical of WCAB’s conclusion that an employee may invoke the second Ogilvie rebuttal method where the inability to rehabilitate results in less than a 100-percent permanent disability." However the Court did not decide the case on that basis. Instead it concluded "There is no evidence that the injury even limited her rehabilitation prospects."
"In sum, we find WCAB’s approach in this case flies in the face of Ogilvie and the 2004 amendments to the workers’ compensation scheme. Under the 2004 amendments, a claimant’s scheduled rating is presumptively correct. Ogilvie confirmed the Legislature meant what it said, and that claimants may not rebut their disability rating merely by offering an alternative calculation of their diminished future earning capacity." ...
The WPI resulted in a rating of 59 percent disability. However, Dahl sought to rebut the scheduled rating through a vocational expert (Jeffrey Malmuth), and the County sought to counter that with its own expert (Ira Cohen). The WCJ initially awarded the 59% disability pursuant to the Schedule but it was was rejected on reconsideration. The WCJ then assigned Dahl a disability of 79 percent. The WCAB affirmed an increase based upon the Olgivie case in the second award. In doing so, the WCAB again concluded that "complete lack of amenability to vocational rehabilitation" is not "necessary before a LeBoeuf analysis may be properly applied."
The Court of Appeal rejected the WCAB methodology in the published case of Contra Costa County v WCAB (Dahl) holding "When it devised this new methodology, the WCAB acted in excess of its authority."
There are three methods to rebut the scheduled rating: 1) a factual error in the application of a formula or the preparation of the schedule, 2) when the injury impairs rehabilitation, and for that reason, the employee’s diminished future earning capacity is greater than the scheduled rating or 3) when a claimant can demonstrate that the nature or severity of the injury is not captured within the sampling of disabled workers used to compute the adjustment factor. The second method however requires that the diminished future earnings is directly attributable to the employee’s work-related injury, and not due to nonindustrial factors such as general economic conditions, illiteracy, proficiency in speaking English, or an employee’s lack of education. This case involved application of the second method.
Under the second method, the WCAB held that Dahl could rebut the scheduled rating by showing the injury impaired her amenability to rehabilitation, even where there was less than total permanent disability. The Court of Appeal responded by saying "We are skeptical of WCAB’s conclusion that an employee may invoke the second Ogilvie rebuttal method where the inability to rehabilitate results in less than a 100-percent permanent disability." However the Court did not decide the case on that basis. Instead it concluded "There is no evidence that the injury even limited her rehabilitation prospects."
"In sum, we find WCAB’s approach in this case flies in the face of Ogilvie and the 2004 amendments to the workers’ compensation scheme. Under the 2004 amendments, a claimant’s scheduled rating is presumptively correct. Ogilvie confirmed the Legislature meant what it said, and that claimants may not rebut their disability rating merely by offering an alternative calculation of their diminished future earning capacity." ...
Cal/OSHA’s criminal investigation into the December 2012 falling death of a 51-year-old carpenter in San Francisco resulted in manslaughter charges by the San Francisco District Attorney against the worker’s employer and foreman. Salvador William Versaggi of Sonoma, owner of Versaggi Construction, along with foreman John Fitt of Sebastopol pleaded not guilty on to the manslaughter charges and two counts of violation of the labor code.
On December 26, 2012, 51 year old Jose Plancarte was assigned to lower a window frame opening in the main stairwell of a residential construction site at 40 Edgehill Way in San Francisco. Plancarte had worked as a carpenter for Versaggi’s company, Versaggi Construction, for 20 years. He built a nailed-bracket scaffold and used two scaffold planks to access the window located more than 18 feet above ground. Plancarte was not wearing fall protection and the scaffold did not have guardrails. He was found unresponsive at the base of the stairwell, having fallen 18.5 feet to the concrete basement floor. Plancarte was transported to San Francisco General Hospital, where he later died from his injuries.
Cal/OSHA’s investigation determined that Versaggi Construction had failed to provide fall protection training to its workers at the site, and that foreman Jim Fitt was aware that Plancarte had cobbled together a prohibited type of scaffolding in direct violation to the employer’s own safety program.
Cal/OSHA’s civil investigation resulted in the issuance of four citations with penalties totaling $25,870 on March 29, 2013, including two citations for serious violations ...
On December 26, 2012, 51 year old Jose Plancarte was assigned to lower a window frame opening in the main stairwell of a residential construction site at 40 Edgehill Way in San Francisco. Plancarte had worked as a carpenter for Versaggi’s company, Versaggi Construction, for 20 years. He built a nailed-bracket scaffold and used two scaffold planks to access the window located more than 18 feet above ground. Plancarte was not wearing fall protection and the scaffold did not have guardrails. He was found unresponsive at the base of the stairwell, having fallen 18.5 feet to the concrete basement floor. Plancarte was transported to San Francisco General Hospital, where he later died from his injuries.
Cal/OSHA’s investigation determined that Versaggi Construction had failed to provide fall protection training to its workers at the site, and that foreman Jim Fitt was aware that Plancarte had cobbled together a prohibited type of scaffolding in direct violation to the employer’s own safety program.
Cal/OSHA’s civil investigation resulted in the issuance of four citations with penalties totaling $25,870 on March 29, 2013, including two citations for serious violations ...
Senate Bill 863 in part was designed to combat an acute "lien crisis" in the workers’ compensation system by imposing a $100 "activation fee" on liens filed prior to January 1, 2013. Angelotti Chiropractic and others sued in federal court challenging the constitutionality of these provisions claiming that SB 863 violates the Takings Clause, the Due Process Clause, and the Equal Protection Clause of the United States Constitution.
The trial court issued a preliminary injunction in plaintiffs’ favor as to the Equal Protection claim, but not as to the other claims. Defendants appealed the district court’s issuance of the preliminary injunction and its denial of the motion to dismiss the Equal Protection claim. The 9th Circuit Court of Appeal reversed last June, and vacated the injunction in the published case of Angelotti Chiropractic Inc. v Christine Baker.
The panel held that the district court properly dismissed the Takings Clause claim because the economic impact of SB 863 and its interference with plaintiffs’ expectations was not sufficiently severe to constitute a taking. The panel further concluded that the lien activation fee did not burden any substantive due process right to court access and also rejected plaintiffs’ claim that the retroactive nature of the lien activation fee violated the Due Process Clause.
The lien claimants file a petition for rehearing in the 9th Circuit Court of Appeal. According to the latest status report filed in the underlying federal action, there is not yet any ruling on the petition.
The California Society Of Industrial Medicine (CSIMS) is the association exclusively representing the private physician practicing occupational medicine in California. In the aftermath of the Angelotti decision, and apparently assuming that the petition for rehearing will be denied, has announced a new website, www.lienactivation.com, to assist lien holders to identify unresolved liens.
According to its website "Pending final resolution of the Angelotti litigation, all unresolved liens filed prior to January 1, 2013 are subject to a $100 lien activation fee. This website will enable you to quickly and easily identify all of your unactivated liens and receive a detailed list via email. It doesn't matter how or when your liens were filed, or if the name of the lien claimant was misspelled at the time of filing. You can find them all using our simple Lien Finder search tool." ...
The trial court issued a preliminary injunction in plaintiffs’ favor as to the Equal Protection claim, but not as to the other claims. Defendants appealed the district court’s issuance of the preliminary injunction and its denial of the motion to dismiss the Equal Protection claim. The 9th Circuit Court of Appeal reversed last June, and vacated the injunction in the published case of Angelotti Chiropractic Inc. v Christine Baker.
The panel held that the district court properly dismissed the Takings Clause claim because the economic impact of SB 863 and its interference with plaintiffs’ expectations was not sufficiently severe to constitute a taking. The panel further concluded that the lien activation fee did not burden any substantive due process right to court access and also rejected plaintiffs’ claim that the retroactive nature of the lien activation fee violated the Due Process Clause.
The lien claimants file a petition for rehearing in the 9th Circuit Court of Appeal. According to the latest status report filed in the underlying federal action, there is not yet any ruling on the petition.
The California Society Of Industrial Medicine (CSIMS) is the association exclusively representing the private physician practicing occupational medicine in California. In the aftermath of the Angelotti decision, and apparently assuming that the petition for rehearing will be denied, has announced a new website, www.lienactivation.com, to assist lien holders to identify unresolved liens.
According to its website "Pending final resolution of the Angelotti litigation, all unresolved liens filed prior to January 1, 2013 are subject to a $100 lien activation fee. This website will enable you to quickly and easily identify all of your unactivated liens and receive a detailed list via email. It doesn't matter how or when your liens were filed, or if the name of the lien claimant was misspelled at the time of filing. You can find them all using our simple Lien Finder search tool." ...
The California Department of Insurance together with the University of California San Francisco (UCSF) and Consumer Reports, announced the launch of California Healthcare Compare, a web-based tool that offers quality and price information in a consumer-focused, easy-to-use website. The tool is now available at HealthcareCompare.insurance.ca.gov and at ConsumerReports.org/CAHealthcareCompare. The California Department of Insurance obtained federal Affordable Care Act grant funds to enhance transparency in healthcare pricing. The CDI then partnered with UCSF and Consumer Reports to create California Healthcare Compare.
California Healthcare Compare allows consumers to compare hospital and medical group quality in the areas of maternity care, hip and knee replacement, back pain, colon cancer screening, and diabetes to help consumers make informed decisions about where to seek care. The site also reveals estimated regional costs for more than 100 different medical procedures or conditions ranging from appendicitis to prostate cancer, illustrating dramatic price differences depending on where you seek care. To enhance consumers' knowledge of the healthcare system, Consumer Reports provides expert tips and advice on how to navigate the healthcare system.
"Consumer Reports sought out and incorporated feedback from thousands of consumers on issues of navigation and usability, resulting in a tool that makes complex data on quality and cost easy to digest," said Doris Peter, PhD, Director of the Consumer Reports Health Ratings Center. "Choosing a doctor or hospital shouldn't be guesswork. By increasing cost and quality transparency in California, the tool gives consumers decision-making power that will ultimately drive marketplace change."
"This website would not be possible in most states, because the information simply isn't available," said R. Adams Dudley, MD, Director of UCSF's Center for Healthcare Value. "Because of the advocacy of California consumer and business groups and the vision of California's insurers and providers, we have much more information about quality of care than most states."
"We know there is wide variation in cost and quality across the state, and this program now allows each of us to better evaluate the doctors and hospitals available to us before we decide where to get care. It's a key step in the long journey to increased transparency for California consumers," added David Lansky, Chief Executive Officer of the Pacific Business Group on Health ...
California Healthcare Compare allows consumers to compare hospital and medical group quality in the areas of maternity care, hip and knee replacement, back pain, colon cancer screening, and diabetes to help consumers make informed decisions about where to seek care. The site also reveals estimated regional costs for more than 100 different medical procedures or conditions ranging from appendicitis to prostate cancer, illustrating dramatic price differences depending on where you seek care. To enhance consumers' knowledge of the healthcare system, Consumer Reports provides expert tips and advice on how to navigate the healthcare system.
"Consumer Reports sought out and incorporated feedback from thousands of consumers on issues of navigation and usability, resulting in a tool that makes complex data on quality and cost easy to digest," said Doris Peter, PhD, Director of the Consumer Reports Health Ratings Center. "Choosing a doctor or hospital shouldn't be guesswork. By increasing cost and quality transparency in California, the tool gives consumers decision-making power that will ultimately drive marketplace change."
"This website would not be possible in most states, because the information simply isn't available," said R. Adams Dudley, MD, Director of UCSF's Center for Healthcare Value. "Because of the advocacy of California consumer and business groups and the vision of California's insurers and providers, we have much more information about quality of care than most states."
"We know there is wide variation in cost and quality across the state, and this program now allows each of us to better evaluate the doctors and hospitals available to us before we decide where to get care. It's a key step in the long journey to increased transparency for California consumers," added David Lansky, Chief Executive Officer of the Pacific Business Group on Health ...
Getting the right diagnosis is a key aspect of health care -- it provides an explanation of a patient's health problem and informs subsequent health care decisions. A new report published this month by the Institute of Medicine, Improving Diagnosis in Health Care, is a a continuation of the landmark Institute of Medicine reports To Err is Human: Building a Safer Health System (2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (2001) finds that diagnosis -- and, in particular, the occurrence of diagnostic errors -- has been largely unappreciated in efforts to improve the quality and safety of health care. The result of this inattention is significant: the committee concluded that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences.
According to the report, diagnostic errors cause about 10 percent of patient deaths. Studies of patient medical records also suggest that 6 percent to 17 percent of "adverse events," or harms that occur to patients during a hospital stay, resulted from diagnostic errors. And in the current hospital culture, many doctors are not aware of the errors they make. "Diagnostic errors persist throughout all settings of care and continue to harm an unacceptable number of patients."
The report says that diagnostic errors stem from many causes, including inadequate collaboration and communication among clinicians, patients, and their families; a health care work system that is not well designed to support the diagnostic process; limited feedback to clinicians about diagnostic performance; and a culture that discourages transparency and disclosure of diagnostic errors, which in turn may impede attempts to learn from these events and improve diagnosis.
Collecting such data is challenging because many healthcare settings discourage the disclosure of diagnostic errors, the report said. To address such problems, the committee concluded that improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The committee’s recommendations contribute to the growing momentum for change in this crucial area of health care quality and safety ...
According to the report, diagnostic errors cause about 10 percent of patient deaths. Studies of patient medical records also suggest that 6 percent to 17 percent of "adverse events," or harms that occur to patients during a hospital stay, resulted from diagnostic errors. And in the current hospital culture, many doctors are not aware of the errors they make. "Diagnostic errors persist throughout all settings of care and continue to harm an unacceptable number of patients."
The report says that diagnostic errors stem from many causes, including inadequate collaboration and communication among clinicians, patients, and their families; a health care work system that is not well designed to support the diagnostic process; limited feedback to clinicians about diagnostic performance; and a culture that discourages transparency and disclosure of diagnostic errors, which in turn may impede attempts to learn from these events and improve diagnosis.
Collecting such data is challenging because many healthcare settings discourage the disclosure of diagnostic errors, the report said. To address such problems, the committee concluded that improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The committee’s recommendations contribute to the growing momentum for change in this crucial area of health care quality and safety ...
People may happily, and safely, forgo in-person doctors' visits after surgery by opting instead for talking with their surgeons by phone or video, suggests a small study of U.S. veterans. According to the summary in Reuters Health, most patients preferred the virtual visits and the doctors didn't miss any infections that popped up after surgery, the researchers report in JAMA Surgery.
"These kinds of methods are really important in the climate we’re in now," said lead author Dr. Michael Vella, of Vanderbilt University Medical Center in Nashville. "So I think anything you can do to save money, see more patients and improve access to care is really important." There is interest in so-called telehealth to increase access to healthcare while also decreasing the costs associated with traveling to office visits, Vella and his colleagues write.
Past research has found that telehealth visits may be useful in the treatment of chronic conditions and after surgery, but less is known about patients preferences for these types of visits, they add.
For the new study, the study team evaluated data collected over several months in 2014 from 23 veterans, all but one of them men, who were seen three times after a simple operation that would require only a night or so in the hospital. One visit was via video, the second was via telephone and the third was an in-person office visit. The researchers found that no post-operation infections were missed during the video or telephone visits. "The veterans were very good at describing their wounds," Vella said. "There was one patient who thought they were having problems, we brought them into clinic and there was an infection."
Overall, 69 percent of the participants said they preferred a telehealth visit over the traditional in-office visit. Those who preferred the telehealth visit tended to live farther away from the hospital than those who would rather come into the office. "I think (the study) challenges the paradigm that we need to see all patients back for visits," Vella said.
He cautioned that the study was small, and they can't say telehealth visits won't miss problems. The study also can't assess how telehealth visits would work for patients who have undergone more complex surgeries ...
"These kinds of methods are really important in the climate we’re in now," said lead author Dr. Michael Vella, of Vanderbilt University Medical Center in Nashville. "So I think anything you can do to save money, see more patients and improve access to care is really important." There is interest in so-called telehealth to increase access to healthcare while also decreasing the costs associated with traveling to office visits, Vella and his colleagues write.
Past research has found that telehealth visits may be useful in the treatment of chronic conditions and after surgery, but less is known about patients preferences for these types of visits, they add.
For the new study, the study team evaluated data collected over several months in 2014 from 23 veterans, all but one of them men, who were seen three times after a simple operation that would require only a night or so in the hospital. One visit was via video, the second was via telephone and the third was an in-person office visit. The researchers found that no post-operation infections were missed during the video or telephone visits. "The veterans were very good at describing their wounds," Vella said. "There was one patient who thought they were having problems, we brought them into clinic and there was an infection."
Overall, 69 percent of the participants said they preferred a telehealth visit over the traditional in-office visit. Those who preferred the telehealth visit tended to live farther away from the hospital than those who would rather come into the office. "I think (the study) challenges the paradigm that we need to see all patients back for visits," Vella said.
He cautioned that the study was small, and they can't say telehealth visits won't miss problems. The study also can't assess how telehealth visits would work for patients who have undergone more complex surgeries ...
Chipotle Mexican Grill implemented a Shoes For Crews program in which employees were permitted to buy shoes directly from Shoes For Crews or through a payroll deduction. This is considered a safety program or good safety practice by workers’ compensation carriers. Based on its employees wearing SFC shoes, Chipotle obtained a reduction in its workers’ compensation premiums. Shoes For Crews also extended warranties to Chipotle to cover certain medical expenses in slip and fall related workers’ compensation cases. At one point, Shoes For Crews paid $25,000 to offset the cost of medical bills arising from injuries sustained by Chipotle employees.
Ashante Lewings filed a class action against her employer claiming this program violated a statute which prohibits employers from receiving a contribution from an employee, directly or indirectly, to cover any part of the cost of workers’ compensation.
Chipotle demurred arguing that labor code sections 3751 and 3752 do not prohibit safe workplace programs that are voluntary, nor do they prohibit third party warranty reimbursements. The trial court sustained the demurrer without leave to amend and the class action was dismissed. The court of appeal reversed in the unpublished case of Lewings v. Chipotle Mexican Grill, Inc.
The primary issue is whether Chipotle violated Labor Code section 3751, a statute which prohibits employers from receiving a contribution from an employee, directly or indirectly, to cover any part of the cost of workers’ compensation. The court noted that "Any time Chipotle is self-insured, the warranties directly cover the cost of compensation by paying medical expenses. Any time Chipotle has workers’ compensation insurance, the warranties indirectly cover the cost of compensation by defraying increases in insurance premiums and replacing lost dividends."
When the employees purchased SFC shoes, they indirectly contributed to the cost of compensation because their purchases resulted in Chipotle receiving warranties from Shoes For Crews designed to offset workers’ compensation medical expenses ...
Ashante Lewings filed a class action against her employer claiming this program violated a statute which prohibits employers from receiving a contribution from an employee, directly or indirectly, to cover any part of the cost of workers’ compensation.
Chipotle demurred arguing that labor code sections 3751 and 3752 do not prohibit safe workplace programs that are voluntary, nor do they prohibit third party warranty reimbursements. The trial court sustained the demurrer without leave to amend and the class action was dismissed. The court of appeal reversed in the unpublished case of Lewings v. Chipotle Mexican Grill, Inc.
The primary issue is whether Chipotle violated Labor Code section 3751, a statute which prohibits employers from receiving a contribution from an employee, directly or indirectly, to cover any part of the cost of workers’ compensation. The court noted that "Any time Chipotle is self-insured, the warranties directly cover the cost of compensation by paying medical expenses. Any time Chipotle has workers’ compensation insurance, the warranties indirectly cover the cost of compensation by defraying increases in insurance premiums and replacing lost dividends."
When the employees purchased SFC shoes, they indirectly contributed to the cost of compensation because their purchases resulted in Chipotle receiving warranties from Shoes For Crews designed to offset workers’ compensation medical expenses ...
The reputation of the biopharmaceutical industry continues to be battered by claims of illegal detailing of drugs or questionable sales and marketing practices. And now a new twist from the hands of Martin Shkreli, the CEO of Turing Pharmaceuticals and a former hedge fund manager. He raised the price of a 60 year old generic drug Daraprim acquired by his company in August from $13.50 to $750 a tablet, overnight.
According to the report in Forbes, Shkreli’s actions are being viewed as typical drug company behavior and yet another example of the industry’s price gouging. Daraprim was originally discovered, developed and manufactured by GlaxoSmithKline (GSK). The Daraprim patent expired decades ago and the drug is now generic, thus allowing others to make it.
However, it is a small product and no real competition has arisen. In 2010, GSK sold the marketing rights for Daraprim to CorePharma. Sales of Daraprim were less than $1 million in 2010 based on a price of about $1/pill. CorePharma raised the price to $13.50, which itself is surprising. But given the importance of the drug and the modest number of prescriptions per year (about 12,700), there was little complaint. However, a series of deals brought Daraprim to Turing Pharmaceuticals and the price was immediately increased to $750 a pill.
Turing’s price increase is not an isolated example. Although some price increases have been caused by shortages, others have resulted from a business strategy of buying old neglected drugs and turning them into high-priced "specialty drugs."
Cycloserine, a drug used to treat dangerous multidrug-resistant tuberculosis, was just increased in price to $10,800 for 30 pills from $500 after its acquisition by Rodelis Therapeutics. Scott Spencer, general manager of Rodelis, said the company needed to invest to make sure the supply of the drug remained reliable. He said the company provided the drug free to certain needy patients.
Valeant Pharmaceuticals acquired two heart drugs, Isuprel and Nitropress, from Marathon Pharmaceuticals and promptly raised their prices by 525 percent and 212 percent respectively. Marathon had acquired the drugs from another company in 2013 and had quintupled their prices. Another drug, Doxycycline, an antibiotic, went from $20 a bottle in October 2013 to $1,849 by April 2014.
This is not the first time the 32-year-old Shkreli has been the center of controversy. In 2011, Mr. Shkreli started another company, Retrophin, which also acquired old neglected drugs and sharply raised their prices. Retrophin’s board fired Mr. Shkreli a year ago. Last month, it filed a complaint in Federal District Court in Manhattan, accusing him of using Retrophin as a personal piggy bank to pay back angry investors in his hedge fund. Shkreli has denied the accusations. He has filed for arbitration against his old company, which he says owes him at least $25 million in severance ...
According to the report in Forbes, Shkreli’s actions are being viewed as typical drug company behavior and yet another example of the industry’s price gouging. Daraprim was originally discovered, developed and manufactured by GlaxoSmithKline (GSK). The Daraprim patent expired decades ago and the drug is now generic, thus allowing others to make it.
However, it is a small product and no real competition has arisen. In 2010, GSK sold the marketing rights for Daraprim to CorePharma. Sales of Daraprim were less than $1 million in 2010 based on a price of about $1/pill. CorePharma raised the price to $13.50, which itself is surprising. But given the importance of the drug and the modest number of prescriptions per year (about 12,700), there was little complaint. However, a series of deals brought Daraprim to Turing Pharmaceuticals and the price was immediately increased to $750 a pill.
Turing’s price increase is not an isolated example. Although some price increases have been caused by shortages, others have resulted from a business strategy of buying old neglected drugs and turning them into high-priced "specialty drugs."
Cycloserine, a drug used to treat dangerous multidrug-resistant tuberculosis, was just increased in price to $10,800 for 30 pills from $500 after its acquisition by Rodelis Therapeutics. Scott Spencer, general manager of Rodelis, said the company needed to invest to make sure the supply of the drug remained reliable. He said the company provided the drug free to certain needy patients.
Valeant Pharmaceuticals acquired two heart drugs, Isuprel and Nitropress, from Marathon Pharmaceuticals and promptly raised their prices by 525 percent and 212 percent respectively. Marathon had acquired the drugs from another company in 2013 and had quintupled their prices. Another drug, Doxycycline, an antibiotic, went from $20 a bottle in October 2013 to $1,849 by April 2014.
This is not the first time the 32-year-old Shkreli has been the center of controversy. In 2011, Mr. Shkreli started another company, Retrophin, which also acquired old neglected drugs and sharply raised their prices. Retrophin’s board fired Mr. Shkreli a year ago. Last month, it filed a complaint in Federal District Court in Manhattan, accusing him of using Retrophin as a personal piggy bank to pay back angry investors in his hedge fund. Shkreli has denied the accusations. He has filed for arbitration against his old company, which he says owes him at least $25 million in severance ...
Lario Melendrez worked for Ameron International Corporation in Pasadena for 24 years and was exposed to asbestos while manufacturing pipe products for the company. He died in 2011 of asbestos-related mesothelioma. His wife and children filed a wrongful death lawsuit against Ameron and argued that Mr. Melendrez was exposed to asbestos at work and through waste or scrap pipe that Ameron permitted him to take home for personal projects, such as making flower pots and part of a patio. Ameron argued that workers comp was the exclusive remedy for Mr. Melendrez's family.
The Superior Court agreed with the employer and granted summary judgment finding that Mr. Melendrez's death was work-related and the exclusive remedy applied. The family appealed, and the court of appeal sustained the dismissal in the published case of Melendrez v Ameron International Corporation.
The appeals court agreed that although a triable issue of fact exists whether Melendrez’s exposure to asbestos at home arose out of and in the course of his employment with Ameron, that issue is not material to the viability of Ameron’s defense of workers’ compensation exclusivity. "It is undisputed that Melendrez’s exposure to asbestos in his employment with Ameron substantially contributed to his mesothelioma. Therefore, under the contributing cause standard applicable in workers’ compensation law, his mesothelioma is covered by workers’ compensation, and his separate exposure at home does not create a separate injury outside workers’ compensation coverage. Thus, plaintiffs’ lawsuit is barred by workers’ compensation exclusivity."
The court also upheld an award of $80,719 to be paid by Mr. Melendrez's family to Ameron for costs and fees as a result of their rejection of a CCP 998 offer to allow judgment in the lower court trial ...
The Superior Court agreed with the employer and granted summary judgment finding that Mr. Melendrez's death was work-related and the exclusive remedy applied. The family appealed, and the court of appeal sustained the dismissal in the published case of Melendrez v Ameron International Corporation.
The appeals court agreed that although a triable issue of fact exists whether Melendrez’s exposure to asbestos at home arose out of and in the course of his employment with Ameron, that issue is not material to the viability of Ameron’s defense of workers’ compensation exclusivity. "It is undisputed that Melendrez’s exposure to asbestos in his employment with Ameron substantially contributed to his mesothelioma. Therefore, under the contributing cause standard applicable in workers’ compensation law, his mesothelioma is covered by workers’ compensation, and his separate exposure at home does not create a separate injury outside workers’ compensation coverage. Thus, plaintiffs’ lawsuit is barred by workers’ compensation exclusivity."
The court also upheld an award of $80,719 to be paid by Mr. Melendrez's family to Ameron for costs and fees as a result of their rejection of a CCP 998 offer to allow judgment in the lower court trial ...
In the unpublished case of Hallmark Marketing Corp. v. WCAB and Gannon, Carol Ann Gannon sustained an industrial injury in December 2000 affecting her low back, neck, and bilateral carpal tunnels while working for Hallmark Marketing Corporation. Permanent disability was evaluated using the 1997 disability rating schedule. She has motion segment loss at two lumbar spine levels after two surgical fusions, one in 2004 and the other in 2007 and has a "failed back syndrome with chronic pain."
The AME reported that Gannon "would be unable to sustain six to eight hours of work every day in a constructive, productive and consistent fashion. [She] would be able to work out of her home [(which actually means, in her home)] probably six to eight hours a day where she would be able to rest and take breaks and ‘spread’ the workday into a longer period. . . . [She] would be able on certain days to probably work between four and six hours a day, but other days not, and therefore I would consider that [she] is probably 100% disabled solely based on her orthopedic condition . . . ."
The WCJ disagreed with the rater’s conclusion that an industrial injury that limits the employee-applicant to working only from home is necessarily 100% permanent disability (termed a "sheltered workshop" or "sheltered workplace" by the DEU rater). The WCJ, instead, applied the following legal standard: An injured employee is 100% permanently disabled if having to work from home is necessitated by limitations that also render the employee unable to compete in the open labor market and awarded total disability. On reconsideration the WCAB did not adopt the WCJ's legal standard but affirmed the 100% award based on the DEU rationale.
The Court of Appeal reversed finding that the WCJ used the correct standard. "The applicant has the initial burden, under this standard, to show that she can work only from home in work that is not generally available; if the applicant meets this burden, the burden shifts to the employer to establish the applicant’s ability to compete in the open labor market (i.e., to show there is work available that the applicant can perform)." ...
The AME reported that Gannon "would be unable to sustain six to eight hours of work every day in a constructive, productive and consistent fashion. [She] would be able to work out of her home [(which actually means, in her home)] probably six to eight hours a day where she would be able to rest and take breaks and ‘spread’ the workday into a longer period. . . . [She] would be able on certain days to probably work between four and six hours a day, but other days not, and therefore I would consider that [she] is probably 100% disabled solely based on her orthopedic condition . . . ."
The WCJ disagreed with the rater’s conclusion that an industrial injury that limits the employee-applicant to working only from home is necessarily 100% permanent disability (termed a "sheltered workshop" or "sheltered workplace" by the DEU rater). The WCJ, instead, applied the following legal standard: An injured employee is 100% permanently disabled if having to work from home is necessitated by limitations that also render the employee unable to compete in the open labor market and awarded total disability. On reconsideration the WCAB did not adopt the WCJ's legal standard but affirmed the 100% award based on the DEU rationale.
The Court of Appeal reversed finding that the WCJ used the correct standard. "The applicant has the initial burden, under this standard, to show that she can work only from home in work that is not generally available; if the applicant meets this burden, the burden shifts to the employer to establish the applicant’s ability to compete in the open labor market (i.e., to show there is work available that the applicant can perform)." ...
A federal grand jury indicted 54 year old Oakland resident Daniel Rush for taking illegal payments as a union employee, honest services fraud, attempted extortion, and money laundering. According to the indictment, Rush is alleged to have used his position as a union organizer with the United Food and Commercial Workers (UFCW) to obtain money and other things of value over a five year period.
Rush was an organizing coordinator of the medical cannabis division of the UFCW. The indictment further charges Rush with taking kickbacks from Marc Terbeek, an Oakland workers compensation attorney, in exchange for arranging for the attorney to represent clients in worker’s compensation matters. Rush was an officer and director of an advocacy organization for the working poor. Rush directed the organization’s referral of worker’s compensation clients to the attorney. In exchange, the attorney provided Rush with a credit card on which Rush charged thousands of dollars of personal expenses which ultimately were paid by the attorney.
Rush also is charged with attempted extortion. Rush was a member of the Berkeley Medical Cannabis Commission, which is a commission of the City of Berkeley organized to facilitate the appropriate licensing and regulation of medical marijuana in the city. Rush demanded a well-compensated job from a prospective medical marijuana dispensary in exchange for his influence as a member of the commission.
In addition, the indictment alleges that Rush engaged in a conspiracy to commit money laundering and financial structuring, as well as substantive money laundering. The indictment and FBI agent’s affidavit filed in the case explain that Rush took a loan totaling $600,000 in cash from a person engaged in the marijuana business. Rush and the attorney engaged in a series of structuring transactions designed to obscure the origin of the money. Over the ensuing years, Rush required the attorney to fund interest payments on the loan and, when Rush ultimately was not able to repay the loan, he offered favorable union benefits in exchange for forgiveness of the loan.
The case is being prosecuted by the Special Prosecutions and National Security Unit of the U.S. Attorney’s Office in San Francisco and investigated by the FBI ...
Rush was an organizing coordinator of the medical cannabis division of the UFCW. The indictment further charges Rush with taking kickbacks from Marc Terbeek, an Oakland workers compensation attorney, in exchange for arranging for the attorney to represent clients in worker’s compensation matters. Rush was an officer and director of an advocacy organization for the working poor. Rush directed the organization’s referral of worker’s compensation clients to the attorney. In exchange, the attorney provided Rush with a credit card on which Rush charged thousands of dollars of personal expenses which ultimately were paid by the attorney.
Rush also is charged with attempted extortion. Rush was a member of the Berkeley Medical Cannabis Commission, which is a commission of the City of Berkeley organized to facilitate the appropriate licensing and regulation of medical marijuana in the city. Rush demanded a well-compensated job from a prospective medical marijuana dispensary in exchange for his influence as a member of the commission.
In addition, the indictment alleges that Rush engaged in a conspiracy to commit money laundering and financial structuring, as well as substantive money laundering. The indictment and FBI agent’s affidavit filed in the case explain that Rush took a loan totaling $600,000 in cash from a person engaged in the marijuana business. Rush and the attorney engaged in a series of structuring transactions designed to obscure the origin of the money. Over the ensuing years, Rush required the attorney to fund interest payments on the loan and, when Rush ultimately was not able to repay the loan, he offered favorable union benefits in exchange for forgiveness of the loan.
The case is being prosecuted by the Special Prosecutions and National Security Unit of the U.S. Attorney’s Office in San Francisco and investigated by the FBI ...
The San Francisco-based company ZenPayroll has offered a cloud-based system to automate tax calculations and payroll payments. Its web-based services are already used by more than 20,000 small businesses. The company has now changed its name to Gusto, and is competing in the workers' compensation insurance marketplace. When it was still ZenPayroll, the company's sights were set on helping the six million US-based small businesses - places like florists, churches, and salons - that have, in the past, done payroll by hand. But the company also announced that it will also be rolling out health benefits and workers’ compensation to these businesses.
Over the past few months, Gusto has quietly tested health benefits and workers’ compensation products. Now, it will offer both services to existing and new accounts, starting in California. That shift will put the San Francisco-based company in head-to-head competition with Zenefits, the powerful online health insurance broker. Traditionally, the two startups have been partners: Zenefits uses payroll data from the likes of ADP and ZenPayroll to manage its plans, but wants to reduce that dependency. As of late June, Zenefits claimed more than 10,000 accounts. Last year, it generated around $20 million in revenue and as of May its valuation was around $4.5 billion. CEO Parker Conrad told Fortune sales could quintuple this year.
So far, Gusto has raised approximately $86.1 million, including a massive $60 million round from Google Capital last April. As a side note, Google Capital just put $32.5 million into another disruptive insurance startup, Oscar Health. There are also plenty of other companies seeking a piece of the action, including those hoping to empower existing insurance brokers with cloud software, such as EaseCentral and Maxwell Health ...
Over the past few months, Gusto has quietly tested health benefits and workers’ compensation products. Now, it will offer both services to existing and new accounts, starting in California. That shift will put the San Francisco-based company in head-to-head competition with Zenefits, the powerful online health insurance broker. Traditionally, the two startups have been partners: Zenefits uses payroll data from the likes of ADP and ZenPayroll to manage its plans, but wants to reduce that dependency. As of late June, Zenefits claimed more than 10,000 accounts. Last year, it generated around $20 million in revenue and as of May its valuation was around $4.5 billion. CEO Parker Conrad told Fortune sales could quintuple this year.
So far, Gusto has raised approximately $86.1 million, including a massive $60 million round from Google Capital last April. As a side note, Google Capital just put $32.5 million into another disruptive insurance startup, Oscar Health. There are also plenty of other companies seeking a piece of the action, including those hoping to empower existing insurance brokers with cloud software, such as EaseCentral and Maxwell Health ...
Joann Matute claimed cumulative industrial injury to her psyche, fibromyalgia, carpal tunnel syndrome, allergies and rheumatoid arthritis while employed as a teacher for the Los Angeles Unified School District. She was awarded 37% permanent disability and future medical treatment for rheumatoid arthritis, fibromyalgia and psychiatric injuries.
On July 7, 2014, Pamela Stitt, M.D. issued a prescription for 24-hour home health care services. On August 23, 2014, defendant served applicant with a letter finding that the requested services were not medically necessary. On September 4, 2014, applicant filed a request for IMR. On November 6, 2014, Maximus Federal Services, Inc., issued a Final Determination Letter upholding the UR denial. On December 10, 2014, applicant filed an appeal of the IMR determination. December 10 was 34 days after the November 6, 2014 date of the Final Determination Letter.
The WCJ found that a five day extension for service by mail pursuant to Code of Civil Procedure [C.C.P.] section 1013(a) did not apply to applicant’s IMR appeal and issued the Findings and Order dismissing the IMR appeal as untimely. The WCAB in the case of Matute v LAUSD reversed and held that:
(1) The term "mailing" contained in section 4610.6(h) is equivalent to and means "service by mail" and (2) The 30-day period to file a timely appeal from an IMR determination under section 4610.6(h) is extended by five days pursuant to the provisions of section 5316 and C.C.P. section 1013(a).
There is no specific mention of "service" in section 4610.6(h). Thus, the issue presented is whether the "mailing" of the written IMR determination to the employee or employer is equivalent to and means service by mail. WCAB Rule 10957.1(c) specifically mentions "service by mail" as the trigger for responding to an IMR determination. This rule reflects the intended meaning of "mailing" in light of the relevant case law. The 30-day period to file an appeal of an IMR determination pursuant to section 4610.6(h) is extended by five days pursuant to the provisions of section 5316 and C.C.P. section 1013(a) ...
On July 7, 2014, Pamela Stitt, M.D. issued a prescription for 24-hour home health care services. On August 23, 2014, defendant served applicant with a letter finding that the requested services were not medically necessary. On September 4, 2014, applicant filed a request for IMR. On November 6, 2014, Maximus Federal Services, Inc., issued a Final Determination Letter upholding the UR denial. On December 10, 2014, applicant filed an appeal of the IMR determination. December 10 was 34 days after the November 6, 2014 date of the Final Determination Letter.
The WCJ found that a five day extension for service by mail pursuant to Code of Civil Procedure [C.C.P.] section 1013(a) did not apply to applicant’s IMR appeal and issued the Findings and Order dismissing the IMR appeal as untimely. The WCAB in the case of Matute v LAUSD reversed and held that:
(1) The term "mailing" contained in section 4610.6(h) is equivalent to and means "service by mail" and (2) The 30-day period to file a timely appeal from an IMR determination under section 4610.6(h) is extended by five days pursuant to the provisions of section 5316 and C.C.P. section 1013(a).
There is no specific mention of "service" in section 4610.6(h). Thus, the issue presented is whether the "mailing" of the written IMR determination to the employee or employer is equivalent to and means service by mail. WCAB Rule 10957.1(c) specifically mentions "service by mail" as the trigger for responding to an IMR determination. This rule reflects the intended meaning of "mailing" in light of the relevant case law. The 30-day period to file an appeal of an IMR determination pursuant to section 4610.6(h) is extended by five days pursuant to the provisions of section 5316 and C.C.P. section 1013(a) ...
The California Legislature passed A.B. 1124, which would establish an evidence-based closed drug formulary for Workers' Compensation by July 1, 2017 if signed by the Governor. Notwithstanding this legislation, the DWC has already commenced public hearings on a drug formulary believing that it has authority to adopt one without further legislation.
An article in Business Insurance reports that California insurance experts are optimistic that a new workers compensation prescription drug formulary will help injured workers and reduce comp costs in the state, but the legislation could face hurdles from claimants who need to be weaned from banned drugs or want to continue using them off-label.
The formulary "takes a significant step forward in improving the state workers compensation system as it will assist in injured workers' medical outcomes, decrease system bureaucracy and provide for savings," Steve Suchil, Western region assistant vice president of state affairs at the American Insurance Association, said Wednesday in a statement.
Mark Sektnan, president of the Sacramento-based Association of California Insurance Cos., said the proposal could help curb opioid addiction and ensure injured workers receive appropriate medications. "We need to be very careful about ensuring that we provide the correct drug at the right time to that injured worker so they can do what they need to do, which is get back to work," Mr. Sektnan said.
While California's formulary has received positive reactions, experts say there also could be some pushback. Mr. Sektnan said California insurance regulators have discussed limiting the off-label use of medications for conditions that aren't Food and Drug Administration-approved for such drugs. For instance, injured workers would have difficulty getting prescriptions for some powerful opioids that are indicated for treating end-stage cancer pain, Mr. Sektnan said.
The formulary could include a process for claimants who want to continue taking medications for off-label uses. Speakers also cautioned that patients already on medications need a robust and carefully managed transition process - a provision in the bill requires a yet-to-be-determined transition period. However, Mr. Eichler advised against adopting transition rules from the plan Texas implemented in 2011, which used a two-year phase-in for legacy claims. "It doesn't take two years to wean a patient," Mr. Eichler said. "My personal recommendation is to go with one year for legacy claims. You need to protect injured workers with the best protocols possible."
A major concern voiced by several participants during the public meeting was the need to ensure that the formulary is consistent with the state's medical treatment utilization schedule, which provides guidelines for utilization review, a framework to evaluate and treat injured workers; and information for providers on understanding which evidence-based treatments have been effective ...
An article in Business Insurance reports that California insurance experts are optimistic that a new workers compensation prescription drug formulary will help injured workers and reduce comp costs in the state, but the legislation could face hurdles from claimants who need to be weaned from banned drugs or want to continue using them off-label.
The formulary "takes a significant step forward in improving the state workers compensation system as it will assist in injured workers' medical outcomes, decrease system bureaucracy and provide for savings," Steve Suchil, Western region assistant vice president of state affairs at the American Insurance Association, said Wednesday in a statement.
Mark Sektnan, president of the Sacramento-based Association of California Insurance Cos., said the proposal could help curb opioid addiction and ensure injured workers receive appropriate medications. "We need to be very careful about ensuring that we provide the correct drug at the right time to that injured worker so they can do what they need to do, which is get back to work," Mr. Sektnan said.
While California's formulary has received positive reactions, experts say there also could be some pushback. Mr. Sektnan said California insurance regulators have discussed limiting the off-label use of medications for conditions that aren't Food and Drug Administration-approved for such drugs. For instance, injured workers would have difficulty getting prescriptions for some powerful opioids that are indicated for treating end-stage cancer pain, Mr. Sektnan said.
The formulary could include a process for claimants who want to continue taking medications for off-label uses. Speakers also cautioned that patients already on medications need a robust and carefully managed transition process - a provision in the bill requires a yet-to-be-determined transition period. However, Mr. Eichler advised against adopting transition rules from the plan Texas implemented in 2011, which used a two-year phase-in for legacy claims. "It doesn't take two years to wean a patient," Mr. Eichler said. "My personal recommendation is to go with one year for legacy claims. You need to protect injured workers with the best protocols possible."
A major concern voiced by several participants during the public meeting was the need to ensure that the formulary is consistent with the state's medical treatment utilization schedule, which provides guidelines for utilization review, a framework to evaluate and treat injured workers; and information for providers on understanding which evidence-based treatments have been effective ...
SB 863 placed limits on the ability to claim permanent disability for psychiatric injury, sleep disorder or sexual disorder, if it is the result of a physical injury. Before the new law, these claims were referred to as AMA Guides "add-on" cases. A recent case may answer questions about the use of a PQME with a specialty in those areas in add-on cases.
Shari Hernandez, a bank teller for Fremont Bank, claims to have sustained a specific injury to her knee, and cumulative trauma injury to her left leg and foot. Both Applications were amended to include claim of injury to psyche, stomach and internal organs.
The parties later decided to utilize Joel Renbaum, M.D., as an orthopedic AME. Applicant petitioned for assignment of an additional panel in psychiatry, and an Order to that effect was issued by a WCJ. It is from this Order that Defendant petitioned for removal.
Defendant relied on Labor Code Section 4660.l(c)(l), which it quotes as follows: "'there shall be no increases in impairment ratings for sleep dysfunction, sexual dysfunction or psychiatric disorder, or any combination thereof arising out of a compensable physical injury' for injuries occurring on or after 1/1/13." Defendant goes on, "Therefore, a medical legal evaluation in the specialty of psychiatry is inappropriate."
The WCAB denied removal in the case of Hernandez v. Fremont Bank. The WCJ pointed out that the second sentence of 4660. l(c)(l), states, "Nothing in this section shall limit the ability of an injured employee to obtain treatment for sleep dysfunction, sexual dysfunction, or psychiatric disorder, if any, that are a consequence of an industrial injury."
The appropriate procedure to resolve a dispute over injury is to utilize the panel Qualified Medical Evaluator mechanism (or agree to an AME). The fact that compensation for a permanent psychiatric impairment is not available to this injured worker does not deprive her of her potential right to medical care or, for that matter, temporary disability indemnity on a psychiatric basis ...
Shari Hernandez, a bank teller for Fremont Bank, claims to have sustained a specific injury to her knee, and cumulative trauma injury to her left leg and foot. Both Applications were amended to include claim of injury to psyche, stomach and internal organs.
The parties later decided to utilize Joel Renbaum, M.D., as an orthopedic AME. Applicant petitioned for assignment of an additional panel in psychiatry, and an Order to that effect was issued by a WCJ. It is from this Order that Defendant petitioned for removal.
Defendant relied on Labor Code Section 4660.l(c)(l), which it quotes as follows: "'there shall be no increases in impairment ratings for sleep dysfunction, sexual dysfunction or psychiatric disorder, or any combination thereof arising out of a compensable physical injury' for injuries occurring on or after 1/1/13." Defendant goes on, "Therefore, a medical legal evaluation in the specialty of psychiatry is inappropriate."
The WCAB denied removal in the case of Hernandez v. Fremont Bank. The WCJ pointed out that the second sentence of 4660. l(c)(l), states, "Nothing in this section shall limit the ability of an injured employee to obtain treatment for sleep dysfunction, sexual dysfunction, or psychiatric disorder, if any, that are a consequence of an industrial injury."
The appropriate procedure to resolve a dispute over injury is to utilize the panel Qualified Medical Evaluator mechanism (or agree to an AME). The fact that compensation for a permanent psychiatric impairment is not available to this injured worker does not deprive her of her potential right to medical care or, for that matter, temporary disability indemnity on a psychiatric basis ...
The Division of Workers’ Compensation (DWC) has posted an order adjusting the Official Medical Fee Schedule (OMFS) to conform to changes in the Medicare payment system as required by Labor Code section 5307.1.
The Physician and Non-Physician Practitioner Fee Schedule Update Order adopts the following Medicare changes:
1) National Correct Coding Initiative Medically Unlikely Edits October 1, 2015 quarterly update
2) National Correct Coding Initiative Physician/Practitioner Services CCI Edits October 1, 2015 quarterly update
3) CMS’ Medicare National Physician Fee Schedule Relative Value File (RVU file) RVU15D October 1, 2015 quarterly update
The order adopting the OMFS adjustments is effective for services rendered on or after October 1, 2015 and can be found on the DWC website ...
The Physician and Non-Physician Practitioner Fee Schedule Update Order adopts the following Medicare changes:
1) National Correct Coding Initiative Medically Unlikely Edits October 1, 2015 quarterly update
2) National Correct Coding Initiative Physician/Practitioner Services CCI Edits October 1, 2015 quarterly update
3) CMS’ Medicare National Physician Fee Schedule Relative Value File (RVU file) RVU15D October 1, 2015 quarterly update
The order adopting the OMFS adjustments is effective for services rendered on or after October 1, 2015 and can be found on the DWC website ...
Los Angeles County District Attorney Jackie Lacey announced that two criminal Grand Jury indictments were unsealed charging an orthopedic surgeon, his personal attorney and a cadre of assistants with operating one of the largest insurance fraud scams in state history.
Dr. Munir Uwaydah, his personal lawyer and his former office manager were among the 15 named in two indictments totaling 132 felony counts. Uwaydah was arrested in Germany and is awaiting extradition back to the United States.
The vast conspiracy outlined in the overt acts included fraudulently billing of more than $150 million to insurance companies including workers' compensation claims, and paying attorneys and marketers up to $10,000 a month each for illegal patient referrals, known as "capping." But the most serious charges outlined in the indictment involve Uwaydah and his staff deceiving nearly two dozen patients into having surgeries thinking they would be done by Uwaydah. In fact, the surgical procedures were performed by a physician’s assistant who never attended medical school, prosecutors said.
The physician’s assistant operated on patients while they were under general anesthesia and without Uwaydah present in the operating room, the indictment alleges. Prosecutors said in addition all 21 patients sustained lasting scars and many required additional surgeries and suffered physical and psychological trauma as a result of their experience in Uwaydah’s clinics.
A total of 102 people testified during two separate Grand Jury proceedings, one in February and the second in August. The 57-count indictment, BA425397, charges Uwaydah and 10 other defendants with one count each of conspiracy; 32 counts each of insurance fraud; 18 counts each of aggravated mayhem; and three counts each of capping or unlawful client referrals. Uwaydah, the physician’s assistant and three others are charged with three additional counts of aggravated mayhem involving patients. The 57-count indictment alleges all the surgeries were billed to insurance companies as if Uwaydah had performed the surgeries. As part of the fraud, the indictment alleges MRI and insurance authorization reports were routinely altered to justify surgeries, and some surgeries were performed with no medical justification.
In the 75-count indictment, BA435339, Uwaydah’s personal lawyer and three others are charged as coconspirators. Charges include conspiracy to commit insurance fraud, money laundering, illegal patient referrals and filing false tax returns. His personal attorney also is charged with one count of aggravated mayhem for her role in the alleged fraudulent surgery of a patient. If convicted, Uwaydah and 11 others face up to life in state prison.
In case BA425397, a 57-count indictment returned on Feb. 25, the 11 defendants are: Munir Uwaydah (dob 4/1/66): Alleged mastermind of fraud and owner of Frontline Medical. Awaiting extradition from Germany - Paul Turley (dob 11/12/62) of Granada Hills: A chiropractor and Uwaydah's business partner - Maria Turley (dob 3/4/67) of Granada Hills: Uwaydah's director of surgery and Paul Turley's wife - Marisa Schermbeck-Nelson (dob 11/29/76) of Redondo Beach: Uwaydah's personal assistant - Peter Nelson (dob 8/1/71) of Redondo Beach: Uwaydah's physician assistant and Marisa Schermbeck-Nelson's husband - David Johnson (dob 11/7/34) of Corona: Doctor who worked for Frontline - Leticia Alvarez Lemus (dob 2/9/77) of Corona: Office manager for Frontline - Jeff Stevens (dob 4/4/51) of Playa Del Rey: Uwaydah's business associate - Wendee Luke (dob 7/2/74) of Brea: Uwaydah's office manager for several of his companies - Kelly Park (dob 10/10/65) of Thousand Oaks: Uwaydah's office manager and personal assistant; - Ron Case (dob 4/11/76) of Camarillo: Billing manager for Frontline.
In BA435339, a 75-count indictment returned on Aug. 26, the four defendants are: Tatiana Torres Arnold (dob 1/6/70) of Encino: Uwaydah's personal attorney who held various positions for Uwaydah's companies - Terry Luke (dob 1/23/45) of Brea: Held various positions for Uwaydah's companies and defendant Wendee Luke's father - Tony Folgar (dob 11/24/57) of Sylmar: Paralegal for a law firm and Yolanda Groscost (dob 7/16/66) of Fountain Valley: Owner of YDG Marketing, a marketing firm ...
Dr. Munir Uwaydah, his personal lawyer and his former office manager were among the 15 named in two indictments totaling 132 felony counts. Uwaydah was arrested in Germany and is awaiting extradition back to the United States.
The vast conspiracy outlined in the overt acts included fraudulently billing of more than $150 million to insurance companies including workers' compensation claims, and paying attorneys and marketers up to $10,000 a month each for illegal patient referrals, known as "capping." But the most serious charges outlined in the indictment involve Uwaydah and his staff deceiving nearly two dozen patients into having surgeries thinking they would be done by Uwaydah. In fact, the surgical procedures were performed by a physician’s assistant who never attended medical school, prosecutors said.
The physician’s assistant operated on patients while they were under general anesthesia and without Uwaydah present in the operating room, the indictment alleges. Prosecutors said in addition all 21 patients sustained lasting scars and many required additional surgeries and suffered physical and psychological trauma as a result of their experience in Uwaydah’s clinics.
A total of 102 people testified during two separate Grand Jury proceedings, one in February and the second in August. The 57-count indictment, BA425397, charges Uwaydah and 10 other defendants with one count each of conspiracy; 32 counts each of insurance fraud; 18 counts each of aggravated mayhem; and three counts each of capping or unlawful client referrals. Uwaydah, the physician’s assistant and three others are charged with three additional counts of aggravated mayhem involving patients. The 57-count indictment alleges all the surgeries were billed to insurance companies as if Uwaydah had performed the surgeries. As part of the fraud, the indictment alleges MRI and insurance authorization reports were routinely altered to justify surgeries, and some surgeries were performed with no medical justification.
In the 75-count indictment, BA435339, Uwaydah’s personal lawyer and three others are charged as coconspirators. Charges include conspiracy to commit insurance fraud, money laundering, illegal patient referrals and filing false tax returns. His personal attorney also is charged with one count of aggravated mayhem for her role in the alleged fraudulent surgery of a patient. If convicted, Uwaydah and 11 others face up to life in state prison.
In case BA425397, a 57-count indictment returned on Feb. 25, the 11 defendants are: Munir Uwaydah (dob 4/1/66): Alleged mastermind of fraud and owner of Frontline Medical. Awaiting extradition from Germany - Paul Turley (dob 11/12/62) of Granada Hills: A chiropractor and Uwaydah's business partner - Maria Turley (dob 3/4/67) of Granada Hills: Uwaydah's director of surgery and Paul Turley's wife - Marisa Schermbeck-Nelson (dob 11/29/76) of Redondo Beach: Uwaydah's personal assistant - Peter Nelson (dob 8/1/71) of Redondo Beach: Uwaydah's physician assistant and Marisa Schermbeck-Nelson's husband - David Johnson (dob 11/7/34) of Corona: Doctor who worked for Frontline - Leticia Alvarez Lemus (dob 2/9/77) of Corona: Office manager for Frontline - Jeff Stevens (dob 4/4/51) of Playa Del Rey: Uwaydah's business associate - Wendee Luke (dob 7/2/74) of Brea: Uwaydah's office manager for several of his companies - Kelly Park (dob 10/10/65) of Thousand Oaks: Uwaydah's office manager and personal assistant; - Ron Case (dob 4/11/76) of Camarillo: Billing manager for Frontline.
In BA435339, a 75-count indictment returned on Aug. 26, the four defendants are: Tatiana Torres Arnold (dob 1/6/70) of Encino: Uwaydah's personal attorney who held various positions for Uwaydah's companies - Terry Luke (dob 1/23/45) of Brea: Held various positions for Uwaydah's companies and defendant Wendee Luke's father - Tony Folgar (dob 11/24/57) of Sylmar: Paralegal for a law firm and Yolanda Groscost (dob 7/16/66) of Fountain Valley: Owner of YDG Marketing, a marketing firm ...
Former state senator Leland Yee in plea agreement this summer admitted that he traded his political influence for bribes. Yee, among other things, admitted he agreed to influence legislation for would-be medical marijuana businesses in California, an NFL team owner trying to exempt pro athletes from the state's workers' compensation laws and a fictitious FBI concocted software firm seeking government technology contracts. He is scheduled to be sentenced on October 21.
Now six more defendants have entered guilty pleas in the case. George Nieh, Leslie Yun, Kevin Sui, Alan Chiu, Yat Wa Pau, and Andy Li all pleaded guilty to a broad range of charges alleged against them in a superseding indictment filed January 29, 2015. The indictment charged the defendants, Leland Yee, and 21 others with illegal conduct stemming from an alleged racketeering operation.
The guilty pleas bring to 10 the number of people who have pleaded guilty to one or more of the charges in the indictment. Unlike earlier pleas, these guilty pleas do not include an admission of guilt with respect to the charge that the defendants conspired to conduct the affairs of an enterprise through a pattern of racketeering activity, in violation of 18 U.S.C. § 1962(d) (RICO conspiracy); yet, the each defendant pleaded guilty one or more of the crimes alleged as part of the RICO conspiracy.
The superseding indictment charged twenty-eight people in all. Eight of the defendants, including the six defendants who pleaded guilty, Raymond Chow, and Kongphet Chanthavong, are scheduled for trial on November 2, 2015, before U.S. District Judge Charles R. Breyer. The charges against the six defendants to which they have not pleaded guilty are still pending ...
Now six more defendants have entered guilty pleas in the case. George Nieh, Leslie Yun, Kevin Sui, Alan Chiu, Yat Wa Pau, and Andy Li all pleaded guilty to a broad range of charges alleged against them in a superseding indictment filed January 29, 2015. The indictment charged the defendants, Leland Yee, and 21 others with illegal conduct stemming from an alleged racketeering operation.
The guilty pleas bring to 10 the number of people who have pleaded guilty to one or more of the charges in the indictment. Unlike earlier pleas, these guilty pleas do not include an admission of guilt with respect to the charge that the defendants conspired to conduct the affairs of an enterprise through a pattern of racketeering activity, in violation of 18 U.S.C. § 1962(d) (RICO conspiracy); yet, the each defendant pleaded guilty one or more of the crimes alleged as part of the RICO conspiracy.
The superseding indictment charged twenty-eight people in all. Eight of the defendants, including the six defendants who pleaded guilty, Raymond Chow, and Kongphet Chanthavong, are scheduled for trial on November 2, 2015, before U.S. District Judge Charles R. Breyer. The charges against the six defendants to which they have not pleaded guilty are still pending ...
AB-1124 passed the California legislature yesterday, and now awaits the expected signature of Governor Brown in order to become law. According to the author, this bill gives the Administrative Director clear authority to establish a formulary. An effective formulary will control rising prescription drug costs in California's workers' compensation system, limit the over-prescribing of highly-addictive opioids, and ensure injured workers get the necessary treatment needed to get back to work.
Drug formularies have proven to be very effective at managing the cost of prescription drugs. Health plans have been using formularies in California for decades and they are commonly accepted as a useful cost control mechanism. They control costs by limiting the utilization of high priced drugs and reducing the price of drugs. Formularies are usually developed by companies known as pharmaceutical benefits managers (PBMs) who design formularies and manage prescription drug benefits for a contracting health plan. At the most basic level a formulary is a list of drugs that a health plan or insurer agrees to cover. However, formularies are not simply arbitrary limits on drug use. Formularies must be broad enough to provide drug treatment options when they are available, and formulary decisions are guided substantially by the scientific evidence regarding individual drugs. However, in most cases there are multiple drugs available to treat a given condition and formularies are constructed to drive treatment choices to the most cost-effective option.
This bill would require the DWC Administrative Director to establish a drug formulary, on or before July 1, 2017, as part of the medical treatment utilization schedule.The Administrative Director would be required to meet and consult with stakeholders, prior to the adoption of the formulary, and publish at least 2 interim reports on the Internet Web site of the DWC. The bill would require the Administrative Director to update the formulary at least on a quarterly basis to allow for the provision of all appropriate medications, including medications new to the market.The bill would require the Administrative Director to establish an independent pharmacy and therapeutics committee to review and consult with the Administrative Director in connection with updating the formulary.
The California Applicants Attorneys Association argued against the law claiming that establishing a formulary is just another in a long line of take-aways from injured workers. Business groups supported this bill and the California Labor Federation supports the concept of a formulary ...
Drug formularies have proven to be very effective at managing the cost of prescription drugs. Health plans have been using formularies in California for decades and they are commonly accepted as a useful cost control mechanism. They control costs by limiting the utilization of high priced drugs and reducing the price of drugs. Formularies are usually developed by companies known as pharmaceutical benefits managers (PBMs) who design formularies and manage prescription drug benefits for a contracting health plan. At the most basic level a formulary is a list of drugs that a health plan or insurer agrees to cover. However, formularies are not simply arbitrary limits on drug use. Formularies must be broad enough to provide drug treatment options when they are available, and formulary decisions are guided substantially by the scientific evidence regarding individual drugs. However, in most cases there are multiple drugs available to treat a given condition and formularies are constructed to drive treatment choices to the most cost-effective option.
This bill would require the DWC Administrative Director to establish a drug formulary, on or before July 1, 2017, as part of the medical treatment utilization schedule.The Administrative Director would be required to meet and consult with stakeholders, prior to the adoption of the formulary, and publish at least 2 interim reports on the Internet Web site of the DWC. The bill would require the Administrative Director to update the formulary at least on a quarterly basis to allow for the provision of all appropriate medications, including medications new to the market.The bill would require the Administrative Director to establish an independent pharmacy and therapeutics committee to review and consult with the Administrative Director in connection with updating the formulary.
The California Applicants Attorneys Association argued against the law claiming that establishing a formulary is just another in a long line of take-aways from injured workers. Business groups supported this bill and the California Labor Federation supports the concept of a formulary ...
Nearly 50 million American adults have significant chronic pain or severe pain, according to a new study prepared by National Institutes of Health’s National Center for Complementary and Integrative Health (NCCIH), which appears this month in The Journal of Pain, published by the American Pain Society.
Based on data from the 2012 National Health Interview Survey (NHIS), the study estimates that within a previous three-month period, 25 million U.S. adults had daily chronic pain, and 23 million more reported severe pain. Those with serious pain need and use more health care services and suffer greater disability then persons with less severe pain.
The annual NHIS study is conducted by the U.S. Centers for Disease Control and Prevention (CDC) and surveys tens of thousands of Americans about their overall health and illnesses. The 2012 NHIS studied asked participants about the frequency and intensity of pain experienced in the last 3 months.
The findings also showed that half of individuals with the most severe pain still rated their overall health as good or better, and there were associations between pain severity and race, ethnicity, language preference, gender, and age. Women, older individuals, and non-Hispanics were more likely to report any pain, but Asians less likely. Also, the study showed the impact of gender on pain is influenced by race and ethnicity.
In an NIH news release, Richard L. Nahin, Ph.D., M.P.H., lead epidemiologist for NCCIH and author of the analysis said: "This report begins to answer calls for better national data on the nature and extent of the pain problem. The experience of pain is subjective. It’s not surprising then that the data show varied responses to pain even in those with similar levels of pain. Continuing analyses of these data may help identify subpopulations that would benefit from additional pain treatment options."
Publication of the NIH study follows the recent "Pain Research Agenda for the 21st Century," published in December in The Journal of Pain, in which The American Pain Society identifies promising but underfunded approaches to develop new treatments and to help make currently used pain medications safer and more effective. However, APS believes breakthrough new treatments will not become available unless more resources are devoted to pain research. Its Pain Research Agenda states: "The most direct path to achieving dramatic advances in pain treatment is through substantially increased investment in pain research and education, which would enable the pursuit of an aggressive translational pain-research agenda." ...
Based on data from the 2012 National Health Interview Survey (NHIS), the study estimates that within a previous three-month period, 25 million U.S. adults had daily chronic pain, and 23 million more reported severe pain. Those with serious pain need and use more health care services and suffer greater disability then persons with less severe pain.
The annual NHIS study is conducted by the U.S. Centers for Disease Control and Prevention (CDC) and surveys tens of thousands of Americans about their overall health and illnesses. The 2012 NHIS studied asked participants about the frequency and intensity of pain experienced in the last 3 months.
The findings also showed that half of individuals with the most severe pain still rated their overall health as good or better, and there were associations between pain severity and race, ethnicity, language preference, gender, and age. Women, older individuals, and non-Hispanics were more likely to report any pain, but Asians less likely. Also, the study showed the impact of gender on pain is influenced by race and ethnicity.
In an NIH news release, Richard L. Nahin, Ph.D., M.P.H., lead epidemiologist for NCCIH and author of the analysis said: "This report begins to answer calls for better national data on the nature and extent of the pain problem. The experience of pain is subjective. It’s not surprising then that the data show varied responses to pain even in those with similar levels of pain. Continuing analyses of these data may help identify subpopulations that would benefit from additional pain treatment options."
Publication of the NIH study follows the recent "Pain Research Agenda for the 21st Century," published in December in The Journal of Pain, in which The American Pain Society identifies promising but underfunded approaches to develop new treatments and to help make currently used pain medications safer and more effective. However, APS believes breakthrough new treatments will not become available unless more resources are devoted to pain research. Its Pain Research Agenda states: "The most direct path to achieving dramatic advances in pain treatment is through substantially increased investment in pain research and education, which would enable the pursuit of an aggressive translational pain-research agenda." ...
