Executives representing more than 60% of the WCIRB's regular membership met this month in Oakland for the 100th Annual Meeting of the WCIRB. At the meeting, the WCIRB membership elected new insurer members to the Governing Committee and Classification and Rating Committee to fill vacancies created by expiring terms.
WCIRB President and CEO Bill Mudge opened the meeting by highlighting some of the WCIRB’s recent accomplishments and by providing an update on the status of its multi-year transformation effort:
"In the four years since we began our strategic transformation, we have launched over 100 major initiatives dedicated to getting us ready to meet the challenges of our next century. As always, our focus is on becoming more agile, modern and easier to do business with. We continue to develop innovative new products and services that expand access to information and provide insight into system cost drivers. Our forward-looking outreach and education program spans the entire state as it reaches the system’s stakeholders. And we have invested in our leadership team to make sure we are thinking big, taking on the toughest challenges, and delivering value to our members."
Turning toward 2016, Mr. Mudge outlined plans for several initiatives that are part of the organization’s continuing transformative agenda. Included were game-changing initiatives around "big data," new technologies designed to speed the flow of data between the WCIRB and its members, a transformation of the inspection report and classification inspection process, and a continued evolution of the WCIRB’s various online services designed to expand real-time, self-service access to data.
Following Mr. Mudge's remarks, members voted on the nominees to fill vacancies on the Governing Committee and Classification and Rating Committee. Committee members elected at the meeting will serve three-year terms expiring at the Annual Meeting in 2019. Hartford Accident and Indemnity Company was re-elected, and Preferred Employers Insurance Company was elected to the Governing Committee. National Union Fire Insurance Co. of Pittsburgh PA was re-elected and Pacific Compensation Insurance Company was elected to the Classification and Rating Committee.
On behalf of the membership, Mr. Mudge thanked outgoing committee members and recognized their service and support of the WCIRB’s mission ...
WCIRB President and CEO Bill Mudge opened the meeting by highlighting some of the WCIRB’s recent accomplishments and by providing an update on the status of its multi-year transformation effort:
"In the four years since we began our strategic transformation, we have launched over 100 major initiatives dedicated to getting us ready to meet the challenges of our next century. As always, our focus is on becoming more agile, modern and easier to do business with. We continue to develop innovative new products and services that expand access to information and provide insight into system cost drivers. Our forward-looking outreach and education program spans the entire state as it reaches the system’s stakeholders. And we have invested in our leadership team to make sure we are thinking big, taking on the toughest challenges, and delivering value to our members."
Turning toward 2016, Mr. Mudge outlined plans for several initiatives that are part of the organization’s continuing transformative agenda. Included were game-changing initiatives around "big data," new technologies designed to speed the flow of data between the WCIRB and its members, a transformation of the inspection report and classification inspection process, and a continued evolution of the WCIRB’s various online services designed to expand real-time, self-service access to data.
Following Mr. Mudge's remarks, members voted on the nominees to fill vacancies on the Governing Committee and Classification and Rating Committee. Committee members elected at the meeting will serve three-year terms expiring at the Annual Meeting in 2019. Hartford Accident and Indemnity Company was re-elected, and Preferred Employers Insurance Company was elected to the Governing Committee. National Union Fire Insurance Co. of Pittsburgh PA was re-elected and Pacific Compensation Insurance Company was elected to the Classification and Rating Committee.
On behalf of the membership, Mr. Mudge thanked outgoing committee members and recognized their service and support of the WCIRB’s mission ...
A federal judge in California granted the United States’ motion to dismiss portions of CIGA's complaint regarding Medicare payments, holding that California’s insurance codes are preempted by federal law in the case of California Insurance Guarantee Association v. Sylvia Mathews Burwell, et al., No. 15-cv-1113, C.D. Calif..
CIGA is currently paying several claims under various workers’ compensation policies issued by now-insolvent insurers. Some of these claimants also received payments from Medicare for items and services that were otherwise covered by these policies. Where Medicare pays benefits for a loss that is also covered by another insurer, the Medicare Secondary Payer statute, 42 U.S.C. § 1395y, designates Medicare as the "secondary payer" and generally requires those other insurance plans (called "primary plans") to reimburse Medicare for all benefits it paid. Concluding that the workers’ compensation policies were "primary plans" within the meaning of the statute, the United States demanded that CIGA reimburse it for the Medicare benefits paid to these claimants. CIGA refused, prompting the United States to commence collection proceedings.
CIGA filed a declaratory and injunctive relief action against Defendants Sylvia Mathews Burwell, United States Department of Health and Human Services, and the Centers for Medicare and Medicaid Services contending that it was not required to reimburse the United States for Medicare benefits paid to individuals whose losses may also be covered by CIGA.
The United States argued that claims made by the United States could never be defeated by a state-imposed time limit, CIGA argued that the California Guarantee Act is a state law that regulates the business of insurance, and thus supersedes any general federal law allowing claims to be filed outside the Guarantee Act’s filing deadline. In reply, the United States argued that McCarran-Ferguson does not apply because (1) the Guarantee Act’s claims filing statute does not regulate the "business of insurance," and (2) that the Medicare Secondary Payer statute is at any rate a federal statute that specifically regulates the business of insurance.
Ultimately, the California District Court for the Central District of California held that the McCarran-Ferguson Act did not subject the United States to California’s claims filing deadline because the Act was never intended to waive the federal government’s sovereign immunity. CIGA’s claims against the United States were dismissed to the extent that they were based on the United States’ failure to file timely proofs of claim under California’s Guarantee Act.
The Court cited the familiar rule that "[w]hen the United States becomes entitled to a claim, acting in its governmental capacity and asserts its claim in that right, it cannot be deemed to have abdicated its governmental authority so as to become subject to a state statute putting a time limit upon enforcement." United States v. Summerlin, 310 U.S. 414, 417 (1940); see also Bresson v. C.I.R., 213 F.3d 1173, 1176 (9th Cir. 2000). This common law rule has its origins in the concept of sovereign immunity; just as the states cannot sue the federal government without its consent, the states cannot enact laws that purport to bind the federal government without its consent ...
CIGA is currently paying several claims under various workers’ compensation policies issued by now-insolvent insurers. Some of these claimants also received payments from Medicare for items and services that were otherwise covered by these policies. Where Medicare pays benefits for a loss that is also covered by another insurer, the Medicare Secondary Payer statute, 42 U.S.C. § 1395y, designates Medicare as the "secondary payer" and generally requires those other insurance plans (called "primary plans") to reimburse Medicare for all benefits it paid. Concluding that the workers’ compensation policies were "primary plans" within the meaning of the statute, the United States demanded that CIGA reimburse it for the Medicare benefits paid to these claimants. CIGA refused, prompting the United States to commence collection proceedings.
CIGA filed a declaratory and injunctive relief action against Defendants Sylvia Mathews Burwell, United States Department of Health and Human Services, and the Centers for Medicare and Medicaid Services contending that it was not required to reimburse the United States for Medicare benefits paid to individuals whose losses may also be covered by CIGA.
The United States argued that claims made by the United States could never be defeated by a state-imposed time limit, CIGA argued that the California Guarantee Act is a state law that regulates the business of insurance, and thus supersedes any general federal law allowing claims to be filed outside the Guarantee Act’s filing deadline. In reply, the United States argued that McCarran-Ferguson does not apply because (1) the Guarantee Act’s claims filing statute does not regulate the "business of insurance," and (2) that the Medicare Secondary Payer statute is at any rate a federal statute that specifically regulates the business of insurance.
Ultimately, the California District Court for the Central District of California held that the McCarran-Ferguson Act did not subject the United States to California’s claims filing deadline because the Act was never intended to waive the federal government’s sovereign immunity. CIGA’s claims against the United States were dismissed to the extent that they were based on the United States’ failure to file timely proofs of claim under California’s Guarantee Act.
The Court cited the familiar rule that "[w]hen the United States becomes entitled to a claim, acting in its governmental capacity and asserts its claim in that right, it cannot be deemed to have abdicated its governmental authority so as to become subject to a state statute putting a time limit upon enforcement." United States v. Summerlin, 310 U.S. 414, 417 (1940); see also Bresson v. C.I.R., 213 F.3d 1173, 1176 (9th Cir. 2000). This common law rule has its origins in the concept of sovereign immunity; just as the states cannot sue the federal government without its consent, the states cannot enact laws that purport to bind the federal government without its consent ...
The Food and Drug Administration issued a draft guidance intended to support the pharmaceutical industry in its development of generic versions of approved opioids with abuse-deterrent formulations (ADF) while ensuring that generic ADF opioids are no less abuse-deterrent than the brand-name drug. These actions are among a number of steps the agency recently outlined to reassess its approach to opioid medications. The recently announced action plan is focused on policies aimed at reversing the epidemic, while still providing patients in pain access to effective relief.
The agency is encouraging industry efforts to develop pain medicines that are more difficult to abuse. Abuse-deterrent properties make certain types of abuse, such as crushing a tablet in order to snort the contents or dissolving a capsule in order to inject its contents, more difficult or less rewarding. It does not mean the product is impossible to abuse or that these properties necessarily prevent addiction, overdose or death - notably, the FDA has not approved an opioid product with properties that are expected to deter abuse if the product is swallowed whole.
To better understand the real-world impact of ADF therapies and continue to support innovation in this space, the FDA has required all sponsors of brand name products with approved abuse-deterrent labeling to conduct long-term epidemiological studies to assess their effectiveness in reducing abuse in practice. While the FDA recognizes that the ADFs are not failsafe and more data are needed, ADF opioids do have properties expected to deter abuse compared to non-ADFs. Given the lower cost, on average, of generic products, encouraging access to generic forms of ADF opioids is an important step toward balancing the need to reduce opioid abuse with helping to ensure access to appropriate treatment for patients in pain.
The draft guidance for generic abuse-deterrent opioids follows the agency’s final guidance for brand name opioids, "Abuse-Deterrent Opioids - Evaluation and Labeling," which was issued April 2015 as the first step to provide a framework for what studies were needed to test a product’s ability to deter abuse.
To encourage additional input from outside experts and the public, the agency will also hold a public meeting later this year to discuss the draft guidance on generic ADF products and a broad range of issues related to the use of abuse-deterrent technology as one tool to reduce prescription opioid abuse. The FDA will take this feedback into consideration when developing the final guidance on this topic ...
The agency is encouraging industry efforts to develop pain medicines that are more difficult to abuse. Abuse-deterrent properties make certain types of abuse, such as crushing a tablet in order to snort the contents or dissolving a capsule in order to inject its contents, more difficult or less rewarding. It does not mean the product is impossible to abuse or that these properties necessarily prevent addiction, overdose or death - notably, the FDA has not approved an opioid product with properties that are expected to deter abuse if the product is swallowed whole.
To better understand the real-world impact of ADF therapies and continue to support innovation in this space, the FDA has required all sponsors of brand name products with approved abuse-deterrent labeling to conduct long-term epidemiological studies to assess their effectiveness in reducing abuse in practice. While the FDA recognizes that the ADFs are not failsafe and more data are needed, ADF opioids do have properties expected to deter abuse compared to non-ADFs. Given the lower cost, on average, of generic products, encouraging access to generic forms of ADF opioids is an important step toward balancing the need to reduce opioid abuse with helping to ensure access to appropriate treatment for patients in pain.
The draft guidance for generic abuse-deterrent opioids follows the agency’s final guidance for brand name opioids, "Abuse-Deterrent Opioids - Evaluation and Labeling," which was issued April 2015 as the first step to provide a framework for what studies were needed to test a product’s ability to deter abuse.
To encourage additional input from outside experts and the public, the agency will also hold a public meeting later this year to discuss the draft guidance on generic ADF products and a broad range of issues related to the use of abuse-deterrent technology as one tool to reduce prescription opioid abuse. The FDA will take this feedback into consideration when developing the final guidance on this topic ...
Roza Lopez sustained a cumulative injury while employed as a grocery clerk by Superior Center Concepts. Two insurers, Care West Pegasus Modesto (Care West) and Ullico Casualty Company (Ullico), were jointly and severally liable for claims arising from this injury. In a compromise and release agreement, they settled the employee’s claims and the insurers stipulated they would "pay, adjust, or litigate all liens of record," and would "share equally for liability for med-legal charges," and would allocate 52 percent of liability for the treatment charges to Care West and 48 percent to Ullico.
When Ullico became insolvent and was liquidated, responsibility for third party claims against it was assumed by the California Insurance Guarantee Association (CIGA), which the Legislature established in 1969 to protect against loss to insureds "arising from the failure of an insolvent insurer to discharge its obligations under its insurance policies." CIGA moved to be dismissed from the instant workers’ compensation cases on the ground that it was authorized to pay only "covered claims," from which the Legislature expressly excluded any "claim to the extent it is covered by any other insurance." CIGA argued Care West’s policy constituted "other insurance" that covered third party claims. The Workers’ Compensation Appeals Board denied CIGA’s motion on the ground that the Care West/Ullico agreement limited Care West’s liability to roughly half of any third party claims, thereby rendering Care West’s insurance unavailable as to the remaining half.
The Court of Appeal summarily denied the petition for review filed by CIGA, but the Supreme Court granted review and remanded the case with directions to hear the matter on the merits. After review of the record, the Court of Appeal ruled that the order denying CIGA’s petition for reconsideration be annulled and the matter is remanded to the Appeals Board with directions to enter an order dismissing CIGA from these proceedings in the published case of CIGA v Workers' Compensation Appeals Board.
The Appeals Board argued that the approved compromise and release was a final judgment that may not be relitigated, and after entry of that judgment Care West’s and Ullico’s liability was no longer joint and several. The Court of Appeal disagreed. "The argument reflects a basic misunderstanding of the nature of "several" liability, which is not, strictly speaking, a rule of liability at all - it is a rule of joinder." Several liability has nothing to do with, and cannot be changed by, apportionment of an obligation between promissors."
The Court concluded that the Care West/Ullico compromise and release agreement did not relieve Care West of its several liability for third party claims.The judgment merely apportioned liability; it did not change the joint and several nature of the now-apportioned liability ...
When Ullico became insolvent and was liquidated, responsibility for third party claims against it was assumed by the California Insurance Guarantee Association (CIGA), which the Legislature established in 1969 to protect against loss to insureds "arising from the failure of an insolvent insurer to discharge its obligations under its insurance policies." CIGA moved to be dismissed from the instant workers’ compensation cases on the ground that it was authorized to pay only "covered claims," from which the Legislature expressly excluded any "claim to the extent it is covered by any other insurance." CIGA argued Care West’s policy constituted "other insurance" that covered third party claims. The Workers’ Compensation Appeals Board denied CIGA’s motion on the ground that the Care West/Ullico agreement limited Care West’s liability to roughly half of any third party claims, thereby rendering Care West’s insurance unavailable as to the remaining half.
The Court of Appeal summarily denied the petition for review filed by CIGA, but the Supreme Court granted review and remanded the case with directions to hear the matter on the merits. After review of the record, the Court of Appeal ruled that the order denying CIGA’s petition for reconsideration be annulled and the matter is remanded to the Appeals Board with directions to enter an order dismissing CIGA from these proceedings in the published case of CIGA v Workers' Compensation Appeals Board.
The Appeals Board argued that the approved compromise and release was a final judgment that may not be relitigated, and after entry of that judgment Care West’s and Ullico’s liability was no longer joint and several. The Court of Appeal disagreed. "The argument reflects a basic misunderstanding of the nature of "several" liability, which is not, strictly speaking, a rule of liability at all - it is a rule of joinder." Several liability has nothing to do with, and cannot be changed by, apportionment of an obligation between promissors."
The Court concluded that the Care West/Ullico compromise and release agreement did not relieve Care West of its several liability for third party claims.The judgment merely apportioned liability; it did not change the joint and several nature of the now-apportioned liability ...
The owner of a uninsured San Jose auto repair shop and her manager have been charged with felony fraud after they denied that an employee who had lost three fingers in a workplace accident even worked for them. The cover-up by Sarb Collision Center owner, Sarbjeet Takhar, and her manager, Narindelpal Singh, both 43, delayed the injured employee from receiving any workers compensation benefits for months.
The two defendants have been charged with making a false statement to prevent a worker from receiving workers’ compensation benefits, making a false statement for reducing the insurance premium of a workers’ compensation insurance policy, and failure to obtain workers’ compensation insurance.
If convicted of all charges, Singh faces a maximum of seven years incarceration. Takhar faces a maximum of eight years incarceration. Both defendants would be ordered to pay full restitution.
The crimes came to light earlier this year after the injured worker tried to obtain benefits from the Uninsured Employers Benefit Trust Fund (UEBTF). Takhar, whose business was uninsured at the time of the injury, repeatedly denied at administrative hearings that the injured worker was her employee. The UEBTF is a special fund used to pay the claims of employees who are injured while working for an uninsured employer. UEBTF pays the injured worker and attempts to recover all benefits disbursed from the uninsured employer.
Subsequent to the accident, both Takhar and Singh obtained workers’ compensation insurance, but lied in the application by denying that the company had any work-related injuries within three years.
"The Santa Clara County District Attorney’s Office is committed to proactively pursue workers' compensation insurance fraud to protect workers and promote fair businesses competition," Deputy District Attorney Christopher Kwok said. "The Office conducts regular enforcement actions to ensure every employer who has employees carries workers’ compensation insurance." ...
The two defendants have been charged with making a false statement to prevent a worker from receiving workers’ compensation benefits, making a false statement for reducing the insurance premium of a workers’ compensation insurance policy, and failure to obtain workers’ compensation insurance.
If convicted of all charges, Singh faces a maximum of seven years incarceration. Takhar faces a maximum of eight years incarceration. Both defendants would be ordered to pay full restitution.
The crimes came to light earlier this year after the injured worker tried to obtain benefits from the Uninsured Employers Benefit Trust Fund (UEBTF). Takhar, whose business was uninsured at the time of the injury, repeatedly denied at administrative hearings that the injured worker was her employee. The UEBTF is a special fund used to pay the claims of employees who are injured while working for an uninsured employer. UEBTF pays the injured worker and attempts to recover all benefits disbursed from the uninsured employer.
Subsequent to the accident, both Takhar and Singh obtained workers’ compensation insurance, but lied in the application by denying that the company had any work-related injuries within three years.
"The Santa Clara County District Attorney’s Office is committed to proactively pursue workers' compensation insurance fraud to protect workers and promote fair businesses competition," Deputy District Attorney Christopher Kwok said. "The Office conducts regular enforcement actions to ensure every employer who has employees carries workers’ compensation insurance." ...
A Rancho Mirage cosmetic surgeon pleaded guilty to a scheme to defraud health insurance companies by submitting bills for more than $3.4 million for procedures that he claimed were "medically necessary" but in fact were cosmetic procedures such as "tummy tucks", "nose jobs" and breast augmentations.
In a plea agreement filed in United States District Court, Dr. David M. Morrow, 71, of Rancho Mirage, a cosmetic surgeon and dermatologist who was the owner of the Morrow Institute (TMI) in Rancho Mirage, admitted that he participated in a scheme to obtain money from insurance companies by false or fraudulent pretences, which included submitting altered documents to the insurance companies. Morrow admitted that cosmetic surgeries were billed to insurance companies under the pretence that the procedures were "medically necessary" so that insurers would pay for them.
Morrow also pleaded guilty to one count of filing a false tax return for 2008. Morrow admitted that he failed to report to more than $100,000 of income on his 2008 tax return and more than $1.5 million on his 2009 tax return.
Morrow, his wife, and TMI were charged in this case last fall when a federal grand jury returned a 27-count indictment that outlined a scheme in which patients were lured to the Coachella Valley surgery center with promises that cosmetic procedures would be paid for by their union or PPO health insurance plans. The victim health insurance companies included Anthem Blue Cross, Blue Cross/Blue Shield of California, Blue Cross/Blue Shield of Massachusetts, Regional Employer/Employee Partnership for Benefits, formerly known as Riverside Employer/Employee Partnership (REEP), and Cigna.
To trick insurance companies into paying for the cosmetic procedures, Morrow and others at TMI completely fabricated diagnoses such as a "hernia" in the patients’ official medical records. According to the indictment, they also fabricated test results and symptoms on medical records to cover up the actual medical procedures being performed - tummy tucks were fraudulently billed as hernia repair or abdominal reconstruction surgeries, rhinoplasties ("nose jobs") were fraudulently billed as deviated septum repair surgeries, and breast lifts and augmentations were fraudulently billed as "tuberous breast deformity." A document filed as part of Morrow’s plea agreement shows that TMI billed insurance as much as $150,750 for a single cosmetic procedure.
Morrow faces a statutory maximum sentence of 20 years of in federal prison for the conspiracy count and three years of imprisonment for filing the false tax return. Morrow is scheduled to be sentenced by United States District Judge Josephine L. Staton on September 23. Morrow has also agreed to pay full restitution to the victims. Charges against Morrow’s wife, Linda Morrow, 63, are currently pending ...
In a plea agreement filed in United States District Court, Dr. David M. Morrow, 71, of Rancho Mirage, a cosmetic surgeon and dermatologist who was the owner of the Morrow Institute (TMI) in Rancho Mirage, admitted that he participated in a scheme to obtain money from insurance companies by false or fraudulent pretences, which included submitting altered documents to the insurance companies. Morrow admitted that cosmetic surgeries were billed to insurance companies under the pretence that the procedures were "medically necessary" so that insurers would pay for them.
Morrow also pleaded guilty to one count of filing a false tax return for 2008. Morrow admitted that he failed to report to more than $100,000 of income on his 2008 tax return and more than $1.5 million on his 2009 tax return.
Morrow, his wife, and TMI were charged in this case last fall when a federal grand jury returned a 27-count indictment that outlined a scheme in which patients were lured to the Coachella Valley surgery center with promises that cosmetic procedures would be paid for by their union or PPO health insurance plans. The victim health insurance companies included Anthem Blue Cross, Blue Cross/Blue Shield of California, Blue Cross/Blue Shield of Massachusetts, Regional Employer/Employee Partnership for Benefits, formerly known as Riverside Employer/Employee Partnership (REEP), and Cigna.
To trick insurance companies into paying for the cosmetic procedures, Morrow and others at TMI completely fabricated diagnoses such as a "hernia" in the patients’ official medical records. According to the indictment, they also fabricated test results and symptoms on medical records to cover up the actual medical procedures being performed - tummy tucks were fraudulently billed as hernia repair or abdominal reconstruction surgeries, rhinoplasties ("nose jobs") were fraudulently billed as deviated septum repair surgeries, and breast lifts and augmentations were fraudulently billed as "tuberous breast deformity." A document filed as part of Morrow’s plea agreement shows that TMI billed insurance as much as $150,750 for a single cosmetic procedure.
Morrow faces a statutory maximum sentence of 20 years of in federal prison for the conspiracy count and three years of imprisonment for filing the false tax return. Morrow is scheduled to be sentenced by United States District Judge Josephine L. Staton on September 23. Morrow has also agreed to pay full restitution to the victims. Charges against Morrow’s wife, Linda Morrow, 63, are currently pending ...
Khoa Tan Huynh, owner of the Script Life Pharmacy in Clovis has agreed to pay the United States $200,000 to settle civil claims for statutory violations occurring at the pharmacy,
According to the settlement agreement, in June 2013, an audit revealed multiple violations of the Controlled Substances Act (CSA). The government contends that between June 6, 2011, and December 31, 2012, Script Life Pharmacy accepted and filled prescriptions that lacked required information, including the prescribers’ DEA registration numbers and signatures. In addition, the audit demonstrated shortages of several controlled substances, along with overages of several others.
"Abuse of prescription drugs is a significant societal problem. Pharmacies must take great care to ensure that controlled substances do not end up in the wrong hands. This settlement underscores the federal commitment to holding accountable dispensaries of controlled substances," said U.S. Attorney Wagner.
The Controlled Substances Act (CSA) authorizes the Drug Enforcement Administration (DEA) to regulate controlled substances to create a "closed" system of distribution that provides the legitimate drug industry with a unified approach to narcotic and dangerous drug control. The CSA establishes a classification system for all controlled substances, including prescription medications, based upon the potential for abuse, dependence profile, and medicinal value of the drugs. The CSA and its implementing regulations mandate that prescriptions for controlled substances include certain critical information and require pharmacies to maintain certain records and inventories of these controlled substances; these controls allow the DEA to protect the distribution system and prevent drug diversion and abuse.
This case was prosecuted by Assistant United States Attorney Catherine Swann and results from an investigatory audit by the DEA Fresno Diversion Group ...
According to the settlement agreement, in June 2013, an audit revealed multiple violations of the Controlled Substances Act (CSA). The government contends that between June 6, 2011, and December 31, 2012, Script Life Pharmacy accepted and filled prescriptions that lacked required information, including the prescribers’ DEA registration numbers and signatures. In addition, the audit demonstrated shortages of several controlled substances, along with overages of several others.
"Abuse of prescription drugs is a significant societal problem. Pharmacies must take great care to ensure that controlled substances do not end up in the wrong hands. This settlement underscores the federal commitment to holding accountable dispensaries of controlled substances," said U.S. Attorney Wagner.
The Controlled Substances Act (CSA) authorizes the Drug Enforcement Administration (DEA) to regulate controlled substances to create a "closed" system of distribution that provides the legitimate drug industry with a unified approach to narcotic and dangerous drug control. The CSA establishes a classification system for all controlled substances, including prescription medications, based upon the potential for abuse, dependence profile, and medicinal value of the drugs. The CSA and its implementing regulations mandate that prescriptions for controlled substances include certain critical information and require pharmacies to maintain certain records and inventories of these controlled substances; these controls allow the DEA to protect the distribution system and prevent drug diversion and abuse.
This case was prosecuted by Assistant United States Attorney Catherine Swann and results from an investigatory audit by the DEA Fresno Diversion Group ...
Joint replacements and surgical implants are an integral part of medical care for injured workers. Many devices cost tens of thousands of dollars. While consumers spend hours agonizing over product features and benefits for home appliances or automobiles, often little or no time is spent deciding what surgical product will be selected by a physician to be placed in the patient, and more importantly why was that product selected over any other. Indeed, looking back at the data in a claim file for these cases, can we even identify the manufacturer of a product that was used in a surgery after the fact? Perhaps this jury verdict last week will illustrate why shopping for medical implants might be worth the time and effort.
Reuters Health reports that Johnson & Johnson and its DePuy unit were ordered by a Texas federal jury on Thursday to pay about $500 million to five plaintiffs who said they were injured by Pinnacle metal-on-metal hip implants. Following a two-month trial, jurors deliberated for a week before finding that the Pinnacle hips were defectively designed, and that the companies failed to warn the public about their risks. Jurors awarded about $140 million in total compensatory damages and about $360 million in punitive damages.
A J&J spokeswoman said the company will appeal. John Beisner, a lawyer for the company, said he expected the verdict to be a "pyrrhic victory for plaintiffs' counsel" that could be slashed significantly. Appeals courts often reduce massive personal-injury verdicts, and Texas law limits the amount of punitive damages that can be awarded to plaintiffs. Beisner estimated that punitive damages could be reduced to as little as $10 million. Lanier said plaintiffs would address the issue in post-trial proceedings.
The verdict came in the second federal trial involving the Pinnacle device. J&J was cleared of liability in the first trial, which ended in 2014.Verdicts in these early trials are not binding on the rest of the litigation, but are used to help gauge the value of the remaining claims. More than 8,000 Pinnacle lawsuits have been consolidated in Texas federal court.
All five plaintiffs are Texas residents who were implanted with metal-on-metal Pinnacle hip devices. They said design flaws caused the devices to fail more frequently and quickly than expected, leading to injuries including tissue death, bone erosion and high levels of metal in their blood. Plaintiffs said J&J and DePuy described the metal-on-metal hips as long-lasting, durable and safe despite being aware of the risks, and aggressively promoted them for use in younger, more active patients. J&J has said that it researched and marketed the devices responsibly.
DePuy stopped selling the metal-on-metal version of the Pinnacle devices in 2013. That year, it paid $2.5 billion to settle more than 7,000 lawsuits over a separate metal-on-metal hip device, the ASR, which was recalled in 2010 ...
Reuters Health reports that Johnson & Johnson and its DePuy unit were ordered by a Texas federal jury on Thursday to pay about $500 million to five plaintiffs who said they were injured by Pinnacle metal-on-metal hip implants. Following a two-month trial, jurors deliberated for a week before finding that the Pinnacle hips were defectively designed, and that the companies failed to warn the public about their risks. Jurors awarded about $140 million in total compensatory damages and about $360 million in punitive damages.
A J&J spokeswoman said the company will appeal. John Beisner, a lawyer for the company, said he expected the verdict to be a "pyrrhic victory for plaintiffs' counsel" that could be slashed significantly. Appeals courts often reduce massive personal-injury verdicts, and Texas law limits the amount of punitive damages that can be awarded to plaintiffs. Beisner estimated that punitive damages could be reduced to as little as $10 million. Lanier said plaintiffs would address the issue in post-trial proceedings.
The verdict came in the second federal trial involving the Pinnacle device. J&J was cleared of liability in the first trial, which ended in 2014.Verdicts in these early trials are not binding on the rest of the litigation, but are used to help gauge the value of the remaining claims. More than 8,000 Pinnacle lawsuits have been consolidated in Texas federal court.
All five plaintiffs are Texas residents who were implanted with metal-on-metal Pinnacle hip devices. They said design flaws caused the devices to fail more frequently and quickly than expected, leading to injuries including tissue death, bone erosion and high levels of metal in their blood. Plaintiffs said J&J and DePuy described the metal-on-metal hips as long-lasting, durable and safe despite being aware of the risks, and aggressively promoted them for use in younger, more active patients. J&J has said that it researched and marketed the devices responsibly.
DePuy stopped selling the metal-on-metal version of the Pinnacle devices in 2013. That year, it paid $2.5 billion to settle more than 7,000 lawsuits over a separate metal-on-metal hip device, the ASR, which was recalled in 2010 ...
The Commission on Health and Safety and Workers’ Compensation (CHSWC) has released its twenty-first Annual Report of its activities to improve vital programs affecting nearly all Californians. The 313 page 2015 Annual Report presents information about the health and safety and workers’ compensation systems in California and makes recommendations to improve their operations. CHSWC, created by the workers' compensation reform legislation of 1993, is charged with examining the health and safety and workers' compensation systems in California and recommending administrative or legislative modifications to improve its operations.
Senate Bill (SB) 863, the workers’ compensation reform legislation passed in 2012, incorporated many of CHSWC’s previous recommendations for statutory improvements in the workers’ compensation system, and the Division of Workers’ Compensation (DWC) is carrying out many of the commission’s recommendations for administrative improvements.
But not all of past CHSWC recommendations have had success. Suggestions have been made to integrate workers’ compensation medical care with the general medical care provided to patients by group health insurers in order to improve the quality and coordination of care, reduce overall medical expenditure and administrative costs, and derive other efficiencies in care. Research also supports the contention that an integrated 24-hour care system has the potential to create medical cost savings as well as shorten the duration of disability for workers. So far this ongoing annual suggestion has been a non-starter.
CHSWC continues to report unrelenting systemic fraud. By misreporting payroll costs, some employers avoid the higher premiums they would incur with accurate reporting of their payroll. Employers can also misreport total payroll or the number of workers in specific high-risk, high-premium occupation classifications by reporting them in lower-risk, lower-premium occupations. An earlier study by CHSWC found that between $15 billion and $68 billion of payroll is underreported annually.
Although most California businesses comply with laws regarding health, safety, and workers’ compensation, some businesses do not and thus operate in the "underground economy." Such businesses may not have all their employees on the official company payroll or may not report wages paid to employees that reflect their real job duties. The underground economy costs the state economy an estimated $8.5 billion to $10 billion in tax revenues every year.
CHSWC identified an ongoing problem with the definition of first aid. Injuries that do not require treatment beyond first aid do not necessitate an employer report of injury for worker’s compensation or a Cal/OSHA log. The definitions of first aid for those two purposes are different, however, leading to some uncertainty about when a minor injury is reportable. Even criminal evasion of workers’ compensation obligations can hide behind that uncertainty. Employers have identified the conflicting definitions as a barrier to compliance, and prosecutors have identified the conflicting definitions as a barrier to prosecution of willful violations. The definition of first aid is pertinent only to reporting requirements, so a change in the definition would not change an injured workers’ right to receive treatment.
Information about CHSWC and the 2015 Annual Report is available on the CHSWC website ...
Senate Bill (SB) 863, the workers’ compensation reform legislation passed in 2012, incorporated many of CHSWC’s previous recommendations for statutory improvements in the workers’ compensation system, and the Division of Workers’ Compensation (DWC) is carrying out many of the commission’s recommendations for administrative improvements.
But not all of past CHSWC recommendations have had success. Suggestions have been made to integrate workers’ compensation medical care with the general medical care provided to patients by group health insurers in order to improve the quality and coordination of care, reduce overall medical expenditure and administrative costs, and derive other efficiencies in care. Research also supports the contention that an integrated 24-hour care system has the potential to create medical cost savings as well as shorten the duration of disability for workers. So far this ongoing annual suggestion has been a non-starter.
CHSWC continues to report unrelenting systemic fraud. By misreporting payroll costs, some employers avoid the higher premiums they would incur with accurate reporting of their payroll. Employers can also misreport total payroll or the number of workers in specific high-risk, high-premium occupation classifications by reporting them in lower-risk, lower-premium occupations. An earlier study by CHSWC found that between $15 billion and $68 billion of payroll is underreported annually.
Although most California businesses comply with laws regarding health, safety, and workers’ compensation, some businesses do not and thus operate in the "underground economy." Such businesses may not have all their employees on the official company payroll or may not report wages paid to employees that reflect their real job duties. The underground economy costs the state economy an estimated $8.5 billion to $10 billion in tax revenues every year.
CHSWC identified an ongoing problem with the definition of first aid. Injuries that do not require treatment beyond first aid do not necessitate an employer report of injury for worker’s compensation or a Cal/OSHA log. The definitions of first aid for those two purposes are different, however, leading to some uncertainty about when a minor injury is reportable. Even criminal evasion of workers’ compensation obligations can hide behind that uncertainty. Employers have identified the conflicting definitions as a barrier to compliance, and prosecutors have identified the conflicting definitions as a barrier to prosecution of willful violations. The definition of first aid is pertinent only to reporting requirements, so a change in the definition would not change an injured workers’ right to receive treatment.
Information about CHSWC and the 2015 Annual Report is available on the CHSWC website ...
"Americans should never believe, even incorrectly, that one’s criminal activity will go unpunished simply because it was committed on behalf of a corporation." This was the pronouncement made by Deputy Attorney General Sally Yates a day after she issued new guidance to Department of Justice attorneys outlining the importance of individual accountability in DOJ prosecutions. The Department of Justice has thus increased the risk in medical fraud cases. The Yates Memo announced an official DOJ initiative to hold individuals responsible for corporate misdeeds, both criminal and civil. By having the Justice Department’s number two official instruct prosecutors to target individual business people for criminal prosecution and civil sanctions, DOJ is upping the ante in white collar enforcement.
The Yates Memo is the latest in a line of similar pronouncements that began in 1999 when then-Deputy Attorney General Eric Holder penned a similar memo titled "Bringing Criminal Charges Against Corporations." The principles stated in the Holder Memo continued to evolve through several subsequent memos from later Deputy Attorneys General (Thompson Memo (2003), McNulty Memo (2006), Filip Memo (2008)), and were eventually "codified" in the U.S. Attorney’s Manual ("USAM") as the Principles of Federal Prosecution of Business Organizations (USAM § 9-28.000).
The "Principles" are a detailed framework that federal prosecutors are supposed to rely on in assessing whether and what charges to bring against a corporation in a criminal case. They also provide corporations and their counsel tools for considering important issues such as cooperation and remediation. The "Principles" and other sections of the USAM are being revised to incorporate the Yates Memo’s dictates on individual accountability for corporate wrongdoing.
The notion of targeting individuals for prosecution has been a stated goal expressed by numerous DOJ officials in recent years. It should not be news to anyone inside or outside a corporation that federal prosecutors are being asked to identify and prosecute individual executives and managers for their roles in corporate misconduct. However, the Yates Memo provides a telling insight into DOJ’s current policy objective: reach the highest-level business leaders through cooperation deals with lower-ranking executives.
While this shift in policy appears to be a response to repeated criticism that too many individuals evaded punishment for wrongdoing related to the financial crisis and a related push to improve integrity within the banking sector, it will have significant implications for healthcare providers and their employees. Recognizing the challenges required to go back and pursue individuals after the conclusion of a case originally aimed at corporate liability, DOJ attorneys have now been instructed to focus on individuals from the start of an investigation. Once a case is underway, the inquiry into individual misconduct will proceed in tandem with the broader corporate investigation.
Only in the rarest of circumstances will the DOJ now release individuals from civil or criminal liability when resolving a matter with a corporation. Any decision to conclude a corporate case, without simultaneously settling individual liability, will require the DOJ attorney to demonstrate, to his/her supervisor, a clear plan for resolving any related individual cases promptly and before the statute of limitations expires. Further, if the decision is made not to proceed against individuals, the justification for such a decision must be memorialized and approved by the relevant U.S. Attorney or Assistant Attorney General overseeing the investigation ...
The Yates Memo is the latest in a line of similar pronouncements that began in 1999 when then-Deputy Attorney General Eric Holder penned a similar memo titled "Bringing Criminal Charges Against Corporations." The principles stated in the Holder Memo continued to evolve through several subsequent memos from later Deputy Attorneys General (Thompson Memo (2003), McNulty Memo (2006), Filip Memo (2008)), and were eventually "codified" in the U.S. Attorney’s Manual ("USAM") as the Principles of Federal Prosecution of Business Organizations (USAM § 9-28.000).
The "Principles" are a detailed framework that federal prosecutors are supposed to rely on in assessing whether and what charges to bring against a corporation in a criminal case. They also provide corporations and their counsel tools for considering important issues such as cooperation and remediation. The "Principles" and other sections of the USAM are being revised to incorporate the Yates Memo’s dictates on individual accountability for corporate wrongdoing.
The notion of targeting individuals for prosecution has been a stated goal expressed by numerous DOJ officials in recent years. It should not be news to anyone inside or outside a corporation that federal prosecutors are being asked to identify and prosecute individual executives and managers for their roles in corporate misconduct. However, the Yates Memo provides a telling insight into DOJ’s current policy objective: reach the highest-level business leaders through cooperation deals with lower-ranking executives.
While this shift in policy appears to be a response to repeated criticism that too many individuals evaded punishment for wrongdoing related to the financial crisis and a related push to improve integrity within the banking sector, it will have significant implications for healthcare providers and their employees. Recognizing the challenges required to go back and pursue individuals after the conclusion of a case originally aimed at corporate liability, DOJ attorneys have now been instructed to focus on individuals from the start of an investigation. Once a case is underway, the inquiry into individual misconduct will proceed in tandem with the broader corporate investigation.
Only in the rarest of circumstances will the DOJ now release individuals from civil or criminal liability when resolving a matter with a corporation. Any decision to conclude a corporate case, without simultaneously settling individual liability, will require the DOJ attorney to demonstrate, to his/her supervisor, a clear plan for resolving any related individual cases promptly and before the statute of limitations expires. Further, if the decision is made not to proceed against individuals, the justification for such a decision must be memorialized and approved by the relevant U.S. Attorney or Assistant Attorney General overseeing the investigation ...
For many consumers seeking construction or home repair services, online advertising services have become their go-to source to "hire the right pro," as one popular website proclaims. However, they’ve also become a place where unlicensed contractors unqualified to perform construction services lurk, a recent Contractors State License Board (CSLB) sting operation in Napa showed. Of the 12 people cited on illegal contracting charges during the March 9-10 operation, eight were contacted through online advertising sites that exercise little to no control over unlicensed contractors.
Although California-licensed contractors do advertise on these online sites, CSLB Registrar Cindi Christenson said consumers need to be aware that unlicensed operators post their ads or list themselves on consumer services websites, often right next to legitimate contractors. Most of these sites operate on a buyer beware principle, with no warnings posted about California contractor law requirements.
"It’s vital that consumers check CSLB’s website and make sure they’re considering a reputable contractor in order to avoid serious risks," Christenson said. "In all advertising, including websites, licensed contractors are required to list their license number, and unlicensed contractors, by law, must declare that they are not licensed."
The Napa sting took place at a single-family home near Alston Park. Investigators with CSLB’s Statewide Investigative Fraud Team (SWIFT) posed as the homeowners seeking bids on improvement projects such as laminate flooring, concrete work, fencing, painting, and landscaping. Napa County District Attorney’s Office investigators lent assistance.
Six persons who came to the house and turned in bids were cited for contracting without a state license (Business and Professions Code (BPC) section (§) 7028) on the sting’s first day. Six received misdemeanor citations for that offense on the operation’s second day, March 10.
Most of the bids for the work were far in excess of what’s legally allowable before a state contractor license is required. The limit is $500 for construction-related materials and/or labor. Most of those cited submitted quotes that were in the $3,000-$5,000 range, the highest for interior painting and a stretch of fencing.
An additional misdemeanor charge of illegal advertising (BPC §7027.1) was lodged against 10 of the 12 suspects. State law requires unlicensed contractors to state in all advertising that they are not licensed.
CSLB regularly stages sting operations throughout the state to crack down on unlicensed contracting, which feeds a multi-billion-dollar underground economy in California, endangers the public, and creates unfair business competition for licensed, law-abiding contractors.
Those receiving citations were ordered to appear for arraignment May 26, 2016, in Napa County Superior Court, 1111 Third Street, Napa, CA 94559 ...
Although California-licensed contractors do advertise on these online sites, CSLB Registrar Cindi Christenson said consumers need to be aware that unlicensed operators post their ads or list themselves on consumer services websites, often right next to legitimate contractors. Most of these sites operate on a buyer beware principle, with no warnings posted about California contractor law requirements.
"It’s vital that consumers check CSLB’s website and make sure they’re considering a reputable contractor in order to avoid serious risks," Christenson said. "In all advertising, including websites, licensed contractors are required to list their license number, and unlicensed contractors, by law, must declare that they are not licensed."
The Napa sting took place at a single-family home near Alston Park. Investigators with CSLB’s Statewide Investigative Fraud Team (SWIFT) posed as the homeowners seeking bids on improvement projects such as laminate flooring, concrete work, fencing, painting, and landscaping. Napa County District Attorney’s Office investigators lent assistance.
Six persons who came to the house and turned in bids were cited for contracting without a state license (Business and Professions Code (BPC) section (§) 7028) on the sting’s first day. Six received misdemeanor citations for that offense on the operation’s second day, March 10.
Most of the bids for the work were far in excess of what’s legally allowable before a state contractor license is required. The limit is $500 for construction-related materials and/or labor. Most of those cited submitted quotes that were in the $3,000-$5,000 range, the highest for interior painting and a stretch of fencing.
An additional misdemeanor charge of illegal advertising (BPC §7027.1) was lodged against 10 of the 12 suspects. State law requires unlicensed contractors to state in all advertising that they are not licensed.
CSLB regularly stages sting operations throughout the state to crack down on unlicensed contracting, which feeds a multi-billion-dollar underground economy in California, endangers the public, and creates unfair business competition for licensed, law-abiding contractors.
Those receiving citations were ordered to appear for arraignment May 26, 2016, in Napa County Superior Court, 1111 Third Street, Napa, CA 94559 ...
Orthopaedic care for patients living in remote areas may be managed through phone or email, allowing patients to receive treatment without traveling to a larger, urban hospital for care, according to a study presented at the 2016 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS). The study also found that remote care may provide significant savings in time, missed work, and health care and transportation costs for residents living in rural areas.
Orthopaedic surgeons at a McGill University Health Centre in Montreal used commercial, encrypted email and phone calls to communicate with primary care physicians in six towns in the northern area of Quebec about their patients, who primarily suffered from bone fractures, injuries which typically require travel to a larger hospital for care. The towns are part of a geographic area surrounding the hospital which spans 375,291 square miles (972,000 square kilometers), including areas where medical services are extremely limited.
The retrospective study, using data from January 2008 to June 2013, found that out of 921 email consults, 731 patients were able to receive treatment from their local doctor with the guidance of an orthopaedic surgeon at McGill.
"These results show that you don't need an expensive, elaborate system to clinically manage patients with more common conditions," said Adam Cota, MD, lead study author and now an orthopaedic trauma fellow at OrthoIndy at St. Vincent Indianapolis.
Researchers used a basic email system, requiring virtually no start-up costs or dedicated personnel. In contrast, sophisticated telehealth communication systems have higher operating costs. Dr. Cota noted that the email application meets Canada's requirements for protecting patient information.
For patients, receiving proper orthopaedic treatment and care near their home eliminates the need to travel, take time off from work, or pay for child care and other related expenses. In addition, the study estimated a savings of nearly $3.7 million ($5.5 million in Canadian dollars) over the study timeframe in medical transportation, which in Canada, is provided free of charge from rural areas.
"We feel that these results will be important for planning and enhancing delivery of orthopaedic care in remote communities," said Dr. Cota, "and a low-cost referral system like this can result in significant savings by the patient and/or insurance or government provider." ...
Orthopaedic surgeons at a McGill University Health Centre in Montreal used commercial, encrypted email and phone calls to communicate with primary care physicians in six towns in the northern area of Quebec about their patients, who primarily suffered from bone fractures, injuries which typically require travel to a larger hospital for care. The towns are part of a geographic area surrounding the hospital which spans 375,291 square miles (972,000 square kilometers), including areas where medical services are extremely limited.
The retrospective study, using data from January 2008 to June 2013, found that out of 921 email consults, 731 patients were able to receive treatment from their local doctor with the guidance of an orthopaedic surgeon at McGill.
"These results show that you don't need an expensive, elaborate system to clinically manage patients with more common conditions," said Adam Cota, MD, lead study author and now an orthopaedic trauma fellow at OrthoIndy at St. Vincent Indianapolis.
Researchers used a basic email system, requiring virtually no start-up costs or dedicated personnel. In contrast, sophisticated telehealth communication systems have higher operating costs. Dr. Cota noted that the email application meets Canada's requirements for protecting patient information.
For patients, receiving proper orthopaedic treatment and care near their home eliminates the need to travel, take time off from work, or pay for child care and other related expenses. In addition, the study estimated a savings of nearly $3.7 million ($5.5 million in Canadian dollars) over the study timeframe in medical transportation, which in Canada, is provided free of charge from rural areas.
"We feel that these results will be important for planning and enhancing delivery of orthopaedic care in remote communities," said Dr. Cota, "and a low-cost referral system like this can result in significant savings by the patient and/or insurance or government provider." ...
According to a study at Hospital for Special Surgery (HSS) in New York City, if all patients scheduled for knee replacement were directed to high-volume hospitals for the surgery, it could save the U.S. healthcare system between $2.5 and $4 billion annually by the year 2030. "Numerous studies have shown lower complication rates and better outcomes in hospitals that do a high number of knee replacements compared to low-volume hospitals. And this new study was designed to determine whether the lower rate of complications, hospital readmissions and revision surgeries translated into cost savings.
The researchers found that knee replacement surgery at higher-volume hospitals is less costly over a patient's lifetime and provides better outcomes, and if all knee replacements were performed at these hospitals, it could save between $15 and $23 million annually in New York State alone. With the number of procedures growing at a rapid rate nationwide, this could potentially translate into annual cost savings to society of up to $4 billion by 2030.
The study, "Cost-Effectiveness of Total Knee Arthroplasty at High Volume Hospitals," was presented at the annual meeting of the American Academy of Orthopaedic Surgeons (AAOS) on March 4, in Orlando, Florida.
"Regionalization of knee replacement surgery to high-volume hospitals has been proposed as a means for reducing escalating health care expenditures in the United States, especially given the large and growing demand for the procedure," said Stephen Lyman, PhD, study author and director of the Healthcare Research Institute at HSS.
"This is the first study to include a younger patient population in addition to Medicare patients in a cost-effectiveness analysis of total knee replacement. This is important because patients under 65 now account for about 50 percent of those having the procedure," said Douglas Padgett, MD, chief of the Adult Reconstruction and Joint Replacement Service at HSS. "The list of complications included in our study was also much more comprehensive than those in previous analyses."
Researchers compared the cost-effectiveness of elective knee replacement over a patient's lifetime in low-, medium-, high-, and very high-volume hospitals utilizing data from the New York Statewide Planning and Research Cooperative System (SPARCS) from 1997-2014.
Total knee replacement in the younger patients at very high-volume hospitals was associated with the lowest lifetime costs and the greatest benefits. Hospitals performing the most knee replacements showed significantly greater cost-effectiveness than all other hospital categories. In the Medicare group, results were similar; however, the cost savings of very high-volume centers relative to the other categories was more modest than in the younger patient group.
"Based on current trends, 2.8 million patients will be eligible to regionalize to very high-volume hospitals annually by the year 2030," Dr. Burket noted. "While regionalization may not be feasible for all patients, many low-volume hospitals are located in or near a metropolitan area with a high-volume hospital. Policy initiatives aiding to guide patients to higher-volume hospitals when available will not only reduce their risk for complications and improve outcomes, but will also considerably reduce the large financial burden knee replacement surgery places on our healthcare system. " ...
The researchers found that knee replacement surgery at higher-volume hospitals is less costly over a patient's lifetime and provides better outcomes, and if all knee replacements were performed at these hospitals, it could save between $15 and $23 million annually in New York State alone. With the number of procedures growing at a rapid rate nationwide, this could potentially translate into annual cost savings to society of up to $4 billion by 2030.
The study, "Cost-Effectiveness of Total Knee Arthroplasty at High Volume Hospitals," was presented at the annual meeting of the American Academy of Orthopaedic Surgeons (AAOS) on March 4, in Orlando, Florida.
"Regionalization of knee replacement surgery to high-volume hospitals has been proposed as a means for reducing escalating health care expenditures in the United States, especially given the large and growing demand for the procedure," said Stephen Lyman, PhD, study author and director of the Healthcare Research Institute at HSS.
"This is the first study to include a younger patient population in addition to Medicare patients in a cost-effectiveness analysis of total knee replacement. This is important because patients under 65 now account for about 50 percent of those having the procedure," said Douglas Padgett, MD, chief of the Adult Reconstruction and Joint Replacement Service at HSS. "The list of complications included in our study was also much more comprehensive than those in previous analyses."
Researchers compared the cost-effectiveness of elective knee replacement over a patient's lifetime in low-, medium-, high-, and very high-volume hospitals utilizing data from the New York Statewide Planning and Research Cooperative System (SPARCS) from 1997-2014.
Total knee replacement in the younger patients at very high-volume hospitals was associated with the lowest lifetime costs and the greatest benefits. Hospitals performing the most knee replacements showed significantly greater cost-effectiveness than all other hospital categories. In the Medicare group, results were similar; however, the cost savings of very high-volume centers relative to the other categories was more modest than in the younger patient group.
"Based on current trends, 2.8 million patients will be eligible to regionalize to very high-volume hospitals annually by the year 2030," Dr. Burket noted. "While regionalization may not be feasible for all patients, many low-volume hospitals are located in or near a metropolitan area with a high-volume hospital. Policy initiatives aiding to guide patients to higher-volume hospitals when available will not only reduce their risk for complications and improve outcomes, but will also considerably reduce the large financial burden knee replacement surgery places on our healthcare system. " ...
In 2014 an Orange County Grand Jury indicted 45-year-old Kareem Ahmed and 14 others, alleging he formulated topical creams and oversaw an extensive network of kickbacks that paid doctors and pharmacists more than $25 million to prescribe and distribute the products. Ahmed, president of Ontario company Landmark Medical Management, and the others faced a total of 44 counts on felony charges including conspiracy, trading rebates for patient referrals, insurance fraud and involuntary manslaughter, according to the original two grand jury indictments. The amounts individual doctors received between 2010 and 2013 allegedly ranged from $600,000 to more than $2.5 million. Among those Ahmed allegedly paid were Daniel Capen, M.D. (more than $2.5 million); Andrew Jarminski, M.D. (more than $1.9 million); pharmacist Michael Rudolph (more than $1 million); and Rahil Kahn, M.D. (more than $1 million), according to the indictment.
The grand jury was instructed that it had to unanimously find a defendant committed only a single act encompassed within the count to return a true bill on that count. After the grand jury found the indictments to be true, defendants demurred in the trial court, resulting in the People amending the indictments to add hundreds of new counts - a separate count for each victim - and adding an additional allegation in a single count of involuntary manslaughter.
The defendants moved to set aside the amended indictments on the ground the grand jury had not made separate findings as to each victim, but instead had been instructed to find only one act. Defendants posited that the amendments thus impermissibly changed the offenses charged by the grand jury in violation of Penal Code section 1009. As to the involuntary manslaughter count, the defendants contended the new allegation, embedded in the single charge of involuntary manslaughter, also impermissibly changed the offense charged by the grand jury. The court denied the motion.
The Court of Appeal reversed and remanded in the case of Kareem Ahmed v Superior Court.
The Court of Appeal ruled that "there is no logical basis upon which we can conclude that the grand jury made a finding as to each of the new counts in the amended indictment. The additional counts are new offenses, not shown to be found by the grand jury, and thus changed the offenses charged in violation of section 1009. Accordingly, the indictment was 'not found, endorsed, and presented as prescribed in' the Penal Code..... Based on our conclusion that adding multiple counts of insurance fraud changed the offense charged in violation of section 1009, we will grant the petition for writ of mandate setting aside most of the charges in the two indictments."
The trial court was ordered to issue a new order granting the motion with respect to all counts in the Charbonnet indictment except counts 1, 298, and 323, and all counts in the Ahmed indictment except count 1. The court is further directed to, at the prosecutor’s election, order the case resubmitted to a grand jury pursuant to sections 997, 998, and 1009. Count 1 is a conspiracy charge not addressed in this writ petition. Counts 298 and 323 repeated counts 30 and 33 from the original indictment, which alleged violations with respect to a single victim during a timeframe entirely within the statute of limitations.
The defendants had argued that the indictments alleged conduct outside the statute of limitations. In particular, defendants argued the statute of limitations for violations of section 549 and Business and Professions Code section 650 is three years (§ 801), and the statute of limitations for a violation of section 550 is four years (§§ 801.5, 803, subd. (c)(6)). With the indictments being filed on June 17, 2014, defendants argued they cannot be tried for conduct prior to June 17, 2011 and June 17, 2010, respectively.
At this point it is not clear how much of this major case remains. After remand the district attorney will have an opportunity to attempt to resurrect part of its case. It is not known at this time how successful this will be ...
The grand jury was instructed that it had to unanimously find a defendant committed only a single act encompassed within the count to return a true bill on that count. After the grand jury found the indictments to be true, defendants demurred in the trial court, resulting in the People amending the indictments to add hundreds of new counts - a separate count for each victim - and adding an additional allegation in a single count of involuntary manslaughter.
The defendants moved to set aside the amended indictments on the ground the grand jury had not made separate findings as to each victim, but instead had been instructed to find only one act. Defendants posited that the amendments thus impermissibly changed the offenses charged by the grand jury in violation of Penal Code section 1009. As to the involuntary manslaughter count, the defendants contended the new allegation, embedded in the single charge of involuntary manslaughter, also impermissibly changed the offense charged by the grand jury. The court denied the motion.
The Court of Appeal reversed and remanded in the case of Kareem Ahmed v Superior Court.
The Court of Appeal ruled that "there is no logical basis upon which we can conclude that the grand jury made a finding as to each of the new counts in the amended indictment. The additional counts are new offenses, not shown to be found by the grand jury, and thus changed the offenses charged in violation of section 1009. Accordingly, the indictment was 'not found, endorsed, and presented as prescribed in' the Penal Code..... Based on our conclusion that adding multiple counts of insurance fraud changed the offense charged in violation of section 1009, we will grant the petition for writ of mandate setting aside most of the charges in the two indictments."
The trial court was ordered to issue a new order granting the motion with respect to all counts in the Charbonnet indictment except counts 1, 298, and 323, and all counts in the Ahmed indictment except count 1. The court is further directed to, at the prosecutor’s election, order the case resubmitted to a grand jury pursuant to sections 997, 998, and 1009. Count 1 is a conspiracy charge not addressed in this writ petition. Counts 298 and 323 repeated counts 30 and 33 from the original indictment, which alleged violations with respect to a single victim during a timeframe entirely within the statute of limitations.
The defendants had argued that the indictments alleged conduct outside the statute of limitations. In particular, defendants argued the statute of limitations for violations of section 549 and Business and Professions Code section 650 is three years (§ 801), and the statute of limitations for a violation of section 550 is four years (§§ 801.5, 803, subd. (c)(6)). With the indictments being filed on June 17, 2014, defendants argued they cannot be tried for conduct prior to June 17, 2011 and June 17, 2010, respectively.
At this point it is not clear how much of this major case remains. After remand the district attorney will have an opportunity to attempt to resurrect part of its case. It is not known at this time how successful this will be ...
As part of the urgent response to the epidemic of overdose deaths, the Centers for Disease Control and Prevention (CDC) issued new recommendations for prescribing opioid medications for chronic pain, excluding cancer, palliative, and end-of-life care. The CDC Guideline for Prescribing Opioids for Chronic Pain, United States, 2016 will help primary care providers ensure the safest and most effective treatment for their patients.
While prescription opioids can be part of effective pain management, they have serious risks. The new guideline aims to improve the safety of prescribing and curtail the harms associated with opioids, including opioid use disorder and overdose. The guideline also focuses on increasing the use of other effective treatments available for chronic pain, such as nonopioid medications or physical therapy.
In developing the guideline, CDC followed a rigorous scientific process using the best available scientific evidence, consulting with experts, and listening to comments from the public and partners. CDC is dedicated to working with partners to improve the evidence base, and will refine recommendations as better evidence is available.
Among the 12 recommendations in the guideline, three principles are key to improving patient care:
1) Nonopioid therapy is preferred for chronic pain outside of active cancer, palliative, and end-of-life care.
2) When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose.
3) Providers should always exercise caution when prescribing opioids and monitor all patients closely.
Health and Human Services Secretary Sylvia Burwell has made addressing opioid misuse, dependence, and overdose a priority. Other work on this important issue is underway within HHS. The evidence-based HHS-wide opioid initiative focuses on three priority areas: informing opioid prescribing practices, increasing the use of naloxone (a rescue medication that can prevent death from overdose), and expanding access to and the use of Medication-Assisted Treatment to treat opioid use disorder.
At the same time, the DWC is in the process of developing its own Opioid Treatment Guideline. The last public hearing on the DWC Guideline was in September, and the first fifteen day comment period ended last December. However, the DWC Guideline outlines a philosophical difference by stating "A key difference between occupational and non-occupational guidelines is that a main goal of the former is the restoration of function to ensure early return to work."
It is clear that government at every level has recognized the opioid epidemic, and is responding with new Guideline initiatives. Time will tell if these efforts will be effective ...
While prescription opioids can be part of effective pain management, they have serious risks. The new guideline aims to improve the safety of prescribing and curtail the harms associated with opioids, including opioid use disorder and overdose. The guideline also focuses on increasing the use of other effective treatments available for chronic pain, such as nonopioid medications or physical therapy.
In developing the guideline, CDC followed a rigorous scientific process using the best available scientific evidence, consulting with experts, and listening to comments from the public and partners. CDC is dedicated to working with partners to improve the evidence base, and will refine recommendations as better evidence is available.
Among the 12 recommendations in the guideline, three principles are key to improving patient care:
1) Nonopioid therapy is preferred for chronic pain outside of active cancer, palliative, and end-of-life care.
2) When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose.
3) Providers should always exercise caution when prescribing opioids and monitor all patients closely.
Health and Human Services Secretary Sylvia Burwell has made addressing opioid misuse, dependence, and overdose a priority. Other work on this important issue is underway within HHS. The evidence-based HHS-wide opioid initiative focuses on three priority areas: informing opioid prescribing practices, increasing the use of naloxone (a rescue medication that can prevent death from overdose), and expanding access to and the use of Medication-Assisted Treatment to treat opioid use disorder.
At the same time, the DWC is in the process of developing its own Opioid Treatment Guideline. The last public hearing on the DWC Guideline was in September, and the first fifteen day comment period ended last December. However, the DWC Guideline outlines a philosophical difference by stating "A key difference between occupational and non-occupational guidelines is that a main goal of the former is the restoration of function to ensure early return to work."
It is clear that government at every level has recognized the opioid epidemic, and is responding with new Guideline initiatives. Time will tell if these efforts will be effective ...
NBC Sports reports that contracts being offered to new Los Angeles Rams players state that the laws of Missouri, not California, control the relationship. The NFL Players Association has in turn instructed all certified contract agents to reject that term as "inappropriate."
Critics says other language in the contract makes the purpose of this strategy clear. The Rams hope to nudge any workers’ compensation claims away from California and into Missouri.
From the contract: "The parties hereto acknowledge that this Player Contract has been negotiated and executed in Missouri; that should any dispute, claim or cause of action (collectively ‘dispute’) arise concerning rights or liabilities arising from the relationship between the Player and the Club, the parties hereto agree that the law governing such dispute shall be the law of the State of Missouri. Furthermore, the exclusive jurisdiction for resolving Workers’ Compensation related claims shall be the Division of Workers’ Compensation of Missouri, and the Missouri Workers’ Compensation Act shall govern."
The NFLPA strongly disagrees. "We believe that any reference to the state of Missouri is inappropriate since the Rams have relocated to California as evidenced by the fact that they have changed their name on their website to the Los Angeles Rams, are prepared to hold off-season workouts and training camp in California, and will practice and play their home games in California in 2016," the union says in the memo to all agents.
The Rams, however, say that the use of such language is more geared toward player bonuses paid out in March as an effort to help players pay a lesser state income tax, according to the Los Angeles Daily News. Pro Football Talk offered another follow up on Sunday with the Rams offering further clarification that all deals will simply roll over into California when the team moves in April.
Forbes has yet to release its 2016 valuation of every NFL franchise, but the man in charge of putting them together told the Washington Post in January that upon moving back to Los Angeles, the Rams doubled their value. Michael Ozanian, Forbes's executive editor, said then that the Rams are now worth about $3 billion following the move to Los Angeles and the construction of their palatial new stadium in Inglewood. Assuming that value, the Rams would then trail only the Dallas Cowboys and New England Patriots in Forbes' rankings.
The team is planning to move out of Rams Park and St. Louis by the end of the month ...
Critics says other language in the contract makes the purpose of this strategy clear. The Rams hope to nudge any workers’ compensation claims away from California and into Missouri.
From the contract: "The parties hereto acknowledge that this Player Contract has been negotiated and executed in Missouri; that should any dispute, claim or cause of action (collectively ‘dispute’) arise concerning rights or liabilities arising from the relationship between the Player and the Club, the parties hereto agree that the law governing such dispute shall be the law of the State of Missouri. Furthermore, the exclusive jurisdiction for resolving Workers’ Compensation related claims shall be the Division of Workers’ Compensation of Missouri, and the Missouri Workers’ Compensation Act shall govern."
The NFLPA strongly disagrees. "We believe that any reference to the state of Missouri is inappropriate since the Rams have relocated to California as evidenced by the fact that they have changed their name on their website to the Los Angeles Rams, are prepared to hold off-season workouts and training camp in California, and will practice and play their home games in California in 2016," the union says in the memo to all agents.
The Rams, however, say that the use of such language is more geared toward player bonuses paid out in March as an effort to help players pay a lesser state income tax, according to the Los Angeles Daily News. Pro Football Talk offered another follow up on Sunday with the Rams offering further clarification that all deals will simply roll over into California when the team moves in April.
Forbes has yet to release its 2016 valuation of every NFL franchise, but the man in charge of putting them together told the Washington Post in January that upon moving back to Los Angeles, the Rams doubled their value. Michael Ozanian, Forbes's executive editor, said then that the Rams are now worth about $3 billion following the move to Los Angeles and the construction of their palatial new stadium in Inglewood. Assuming that value, the Rams would then trail only the Dallas Cowboys and New England Patriots in Forbes' rankings.
The team is planning to move out of Rams Park and St. Louis by the end of the month ...
The DWC Acting Administrative Director George Parisotto has appointed Jamie Spitzer, presiding workers’ compensation administrative law judge at the Anaheim DWC district office, and Neil Robinson, presiding administrative law judge of the Occupational Health and Safety Appeals Board (OSHAB), to serve as members of the Workers’ Compensation Ethics Advisory Committee.
The appointments are effective immediately.
Judge Spitzer will fill the position designated for a presiding workers’ compensation administrative law judge, replacing Marina del Rey Presiding Judge Paige Levy, who was named chief judge for DWC in February.
Judge Robinson will fill the position of a member of the public outside the workers’ compensation community, previously held by Alameda Superior Court Judge Alice Vilardi.
The ethics advisory committee, established in 1995 by Title 8, California Code of Regulations, section 9722, reviews all ethics complaints from the public against workers' compensation administrative law judges.
The committee reviews all complaints without learning the names of complainants or judges, and then makes recommendations to the administrative director and the DWC court administrator. The committee meets quarterly and members serve without compensation.
The regulation provides that the committee must include three members of the public representing organized labor; insurers and self-insured employers, an attorney who formerly practiced before the Workers' Compensation Appeals Board and who usually represented insurers or employers, an attorney who formerly practiced before the Workers' Compensation Appeals Board and who usually represented applicants, a presiding judge, a workers’ compensation administrative law judge (WCALJ) or retired WCALJ, and two members of the public outside the workers' compensation community.
A judicial ethics complaint form and instructions can be found on the DWC website ...
The appointments are effective immediately.
Judge Spitzer will fill the position designated for a presiding workers’ compensation administrative law judge, replacing Marina del Rey Presiding Judge Paige Levy, who was named chief judge for DWC in February.
Judge Robinson will fill the position of a member of the public outside the workers’ compensation community, previously held by Alameda Superior Court Judge Alice Vilardi.
The ethics advisory committee, established in 1995 by Title 8, California Code of Regulations, section 9722, reviews all ethics complaints from the public against workers' compensation administrative law judges.
The committee reviews all complaints without learning the names of complainants or judges, and then makes recommendations to the administrative director and the DWC court administrator. The committee meets quarterly and members serve without compensation.
The regulation provides that the committee must include three members of the public representing organized labor; insurers and self-insured employers, an attorney who formerly practiced before the Workers' Compensation Appeals Board and who usually represented insurers or employers, an attorney who formerly practiced before the Workers' Compensation Appeals Board and who usually represented applicants, a presiding judge, a workers’ compensation administrative law judge (WCALJ) or retired WCALJ, and two members of the public outside the workers' compensation community.
A judicial ethics complaint form and instructions can be found on the DWC website ...
The claim examiner's task of reserving for future medical care is becoming more complex by the day. It is hard to even imagine what medical science will have to offer injured workers even a few years down the road. For example, Vanderbilt University just announced that the FDA has given clearance to market and sell the powered lower-limb exoskeleton created by a team of Vanderbilt engineers and commercialized by the Parker Hannifin Corporation for both clinical and personal use in the United States.
Indego®, which allows people paralyzed below the waist to stand up and walk, is the result of an intensive, 10-year effort. The initial development was funded by a grant from the National Institute of Child Health and Human Development. In 2012 Parker, a global leader in motion and control technologies, purchased an exclusive license to market the design and has worked closely with the Vanderbilt group to develop a commercial version of the medical device.
Until recently "wearable robots" like Indego were the stuff of science fiction. In the last 15 years, however, advances in robotics, microelectronics, battery and electric motor technologies have made it practical to develop them to aid people with stroke and spinal cord injuries. The device acts like an external skeleton. It straps in tightly around the torso. Rigid supports are strapped to the legs and extend from the hip to the knee and from the knee to the foot. The hip and knee joints are driven by computer-controlled electric motors powered by advanced batteries. Patients use the powered apparatus with walkers or forearm crutches to maintain their balance.
"You can think of our exoskeleton as a Segway with legs. If the person wearing it leans forward, he moves forward. If he leans back and holds that position for a few seconds, he sits down. When he is sitting down, if he leans forward and holds that position for a few seconds, then he stands up" one of the engineers said.
Indego is the second exoskeleton to receive FDA certification for U.S. use. The first was a device produced by Rewalk Robotics Ltd. However, Indego’s clearance came after completion of the largest exoskeleton clinical trail conducted in the United States. According to the Parker news release, "Over the course of more than 1,200 individual sessions, study participants were able to use Indego to safely walk on a variety of indoor and outdoor surfaces and settings with no serious adverse events."
One of the design goals was to give users the maximum amount of personal freedom possible. One of his requirements, for example, was to allow the user to put the exoskeleton on and take it off while sitting in a wheelchair. As a result, the Indego is considerably lighter and less bulky than the other exoskeletons under development.
Beginning this summer, the scientists will head a four-year U.S. Department of Defense-funded study of the tangible economic and rehabilitation benefits of exoskeletons for people with spinal cord injuries. This will be performed at three medical centers: James Haley Veteran’s Hospital in Tampa (the first VA center in the country to use Indego), the Mayo Clinic in Rochester, Minnesota and the Vanderbilt University Medical Center.
People who use wheelchairs regularly can develop serious problems with their urinary, respiratory, cardiovascular and digestive systems, as well as getting osteoporosis, pressure sores, blood clots and other afflictions associated with lack of mobility. The risk for developing these conditions can be reduced considerably by regularly standing, moving and exercising their lower limbs. The study, which will involve 24 participants, is designed to determine whether regular use of the Indego will also reduce these conditions.
Indego has been available in Europe since November, when it received the CE Mark, the European Union’s equivalent of FDA approval. The initial price is $80,000. The next step is getting the device approved for health insurance reimbursement. This involves getting the Centers for Medicare and Medicaid Services (CMS) to approve a "rate code" for the exoskeleton: a numeric code that identifies the characteristics of patients who Medicare/Medicaid will reimburse for purchasing a given piece of medical equipment. Typically, the government will reimburse 80 percent of the cost of approved medical devices. In most cases private health insurance providers adopt the CMS code ...
Indego®, which allows people paralyzed below the waist to stand up and walk, is the result of an intensive, 10-year effort. The initial development was funded by a grant from the National Institute of Child Health and Human Development. In 2012 Parker, a global leader in motion and control technologies, purchased an exclusive license to market the design and has worked closely with the Vanderbilt group to develop a commercial version of the medical device.
Until recently "wearable robots" like Indego were the stuff of science fiction. In the last 15 years, however, advances in robotics, microelectronics, battery and electric motor technologies have made it practical to develop them to aid people with stroke and spinal cord injuries. The device acts like an external skeleton. It straps in tightly around the torso. Rigid supports are strapped to the legs and extend from the hip to the knee and from the knee to the foot. The hip and knee joints are driven by computer-controlled electric motors powered by advanced batteries. Patients use the powered apparatus with walkers or forearm crutches to maintain their balance.
"You can think of our exoskeleton as a Segway with legs. If the person wearing it leans forward, he moves forward. If he leans back and holds that position for a few seconds, he sits down. When he is sitting down, if he leans forward and holds that position for a few seconds, then he stands up" one of the engineers said.
Indego is the second exoskeleton to receive FDA certification for U.S. use. The first was a device produced by Rewalk Robotics Ltd. However, Indego’s clearance came after completion of the largest exoskeleton clinical trail conducted in the United States. According to the Parker news release, "Over the course of more than 1,200 individual sessions, study participants were able to use Indego to safely walk on a variety of indoor and outdoor surfaces and settings with no serious adverse events."
One of the design goals was to give users the maximum amount of personal freedom possible. One of his requirements, for example, was to allow the user to put the exoskeleton on and take it off while sitting in a wheelchair. As a result, the Indego is considerably lighter and less bulky than the other exoskeletons under development.
Beginning this summer, the scientists will head a four-year U.S. Department of Defense-funded study of the tangible economic and rehabilitation benefits of exoskeletons for people with spinal cord injuries. This will be performed at three medical centers: James Haley Veteran’s Hospital in Tampa (the first VA center in the country to use Indego), the Mayo Clinic in Rochester, Minnesota and the Vanderbilt University Medical Center.
People who use wheelchairs regularly can develop serious problems with their urinary, respiratory, cardiovascular and digestive systems, as well as getting osteoporosis, pressure sores, blood clots and other afflictions associated with lack of mobility. The risk for developing these conditions can be reduced considerably by regularly standing, moving and exercising their lower limbs. The study, which will involve 24 participants, is designed to determine whether regular use of the Indego will also reduce these conditions.
Indego has been available in Europe since November, when it received the CE Mark, the European Union’s equivalent of FDA approval. The initial price is $80,000. The next step is getting the device approved for health insurance reimbursement. This involves getting the Centers for Medicare and Medicaid Services (CMS) to approve a "rate code" for the exoskeleton: a numeric code that identifies the characteristics of patients who Medicare/Medicaid will reimburse for purchasing a given piece of medical equipment. Typically, the government will reimburse 80 percent of the cost of approved medical devices. In most cases private health insurance providers adopt the CMS code ...
An article in The Telegraph says that the multi-billion dollar problem of fraud across the medical world has been officially acknowledged. Even Dubai has admitted that patients in the emirate may be "over-diagnosed" and detained in hospital longer than necessary. The director of the Dubai Health Authority, is launching a scheme to regulate services provided by private hospitals across the UAE. He said: "Sometimes people are kept longer than necessary in a hospital or an intensive-care unit. These kinds of things are daily issues that insurance members face and they need to be protected." Foreign nationals in Dubai, for whom insurance is mandatory, should welcome the development.
But medical fraud is far from uniquely a Middle Eastern practice. It is estimated to add 10 per cent to medical premiums across the globe. Countries with large expatriate communities head the list of offenders. People anxious about their health in a foreign country are easy targets. Insurers struggle against relatively borderline offenses, such as prescribing unwanted pain-killers, to over-diagnosis such as ordering unneeded MRI scans, to full-scale criminal activity by organized gangs.
InterGlobal, the insurer for expatriates, which won the 2012 industry award for unmasking criminal activity, can guarantee picking up a fraudulent claim every day, such is the extent of the problem. InterGlobal is now part of Aetna.The company played a key part in revealing a massive fraud in which a criminal ring is said to have submitted scores of bogus claims to numerous insurers over a 10-year period. The operation was fronted by a virtual hospital, non-existent consultants and a 24-hour switchboard. As Paul Weigall, InterGlobal's sales and marketing director, put it, the hospital was "just a telephone in the desert". He added: "A lot of insurers were caught out. We got on to the case and were only very lightly affected."
The Middle East was a major zone of concern, he said. China is often quoted as another hot spot. "You'll find a group of people who have built up a fabricated health care system, which will include hospitals, doctors and customers - making it very difficult for an insurer not to pay out on a claim that's submitted. Then we find that nothing of that actually exists.
"We've been invoiced by a hospital that gives an address, answers a phone when we ring and then we find that hospital doesn't exist. There are a number of people who are looking, on a very large basis, to defraud people. "However, there are also hospitals that overcharge. For example, you need 20 aspirin, they charge you for 200." ...
But medical fraud is far from uniquely a Middle Eastern practice. It is estimated to add 10 per cent to medical premiums across the globe. Countries with large expatriate communities head the list of offenders. People anxious about their health in a foreign country are easy targets. Insurers struggle against relatively borderline offenses, such as prescribing unwanted pain-killers, to over-diagnosis such as ordering unneeded MRI scans, to full-scale criminal activity by organized gangs.
InterGlobal, the insurer for expatriates, which won the 2012 industry award for unmasking criminal activity, can guarantee picking up a fraudulent claim every day, such is the extent of the problem. InterGlobal is now part of Aetna.The company played a key part in revealing a massive fraud in which a criminal ring is said to have submitted scores of bogus claims to numerous insurers over a 10-year period. The operation was fronted by a virtual hospital, non-existent consultants and a 24-hour switchboard. As Paul Weigall, InterGlobal's sales and marketing director, put it, the hospital was "just a telephone in the desert". He added: "A lot of insurers were caught out. We got on to the case and were only very lightly affected."
The Middle East was a major zone of concern, he said. China is often quoted as another hot spot. "You'll find a group of people who have built up a fabricated health care system, which will include hospitals, doctors and customers - making it very difficult for an insurer not to pay out on a claim that's submitted. Then we find that nothing of that actually exists.
"We've been invoiced by a hospital that gives an address, answers a phone when we ring and then we find that hospital doesn't exist. There are a number of people who are looking, on a very large basis, to defraud people. "However, there are also hospitals that overcharge. For example, you need 20 aspirin, they charge you for 200." ...
For years, Andrew F. Puzder, the CEO of CKE Restaurants, the parent company of the Carl's Jr. and Hardee's fast-food chains, has been telling the world that while the U.S. government makes life needlessly miserable for businesses, and California, where it has been headquartered, is exponentially worse.
This week, CKE announced that it is moving its headquarters to Nashville, Tennessee. In June 2013, Puzder told the Wall Street Journal that his chain would not expand in California because the state "is not interested in having businesses grow," noting among many other things that it takes 285 days to get a building permit after signing a lease. This means the chain has to pay rent for over nine months, plus the time needed to build, while not earning any revenues.
Puzder also wrote roughly 15 columns at Human Events in 2012, most of them bemoaning the sluggish U.S. economy and onerous U.S. government policies and regulations.
The company appears to have planned to move its headquarters to Nashville for years. This would explain why it has gone to the franchising model almost everywhere except Nashville. It can use its company-owned stores there to test new menu items and concepts before making them available to franchisees. CKE could have chosen any large metro area for this strategy, including the area surrounding its current California headquarters. But it did not. Nation's Restaurant News specifically notes that "Among the refranchised units are restaurants in Hardee’s headquarters city of St. Louis and in Santa Barbara County, Calif., where Carl’s Jr.’s home office in Carpinteria is located." Why did management clearly choose to go elsewhere? Among other things, Puzder told the Journal in 2013 that the Golden State's labor laws are intolerable.
And Car's Jr. joins a long list of California companies with an exit strategy. Some of them are big employers. In 2014, Toyota announced plans to move most of the 5,000 managers and employees from Toyota’s Torrance, Calif., headquarters to Plano Texas. Toyota has enjoyed a deep relationship with Texas through its $2.2-billion truck-assembly complex near San Antonio.
And remember many decades ago when General Motors had an assembly plant in Van Nuys. Southern California's long history as an auto manufacturing center ended in 1992 when a flame-red Chevrolet Camaro rolled off the assembly line, the last of 6.3 million vehicles built there over 45 years. The Van Nuys factory, which also made Pontiac Firebirds, was the last auto plant in Southern California. Its demise -announced to the plant's 2,600 workers - follows the closure in the early 1980s of a Ford Motor Co. plant in Pico Rivera and a GM plant in South Gate and the 1971 shutdown of a Chrysler Corp. plant in City of Commerce.
A recent published study of "California divestment events" - business decisions to shun the state paint a grim picture. These come in three types: companies that left the state entirely; companies that expanded in other states rather than in California; and a few companies that had planned to grow in the Golden State but changed their minds. The study found records of 1,510 divestment events occurring in California between 2008 and 2014, but that number is an incomplete accounting of the situation. "Experts in site selection generally agree that at least five events fail to become public knowledge for every one that does," giving rise to the conclusion that the real total is probably more than 9,000 divestment events for this period.
We can say goodbye to number 9001, the Carl's Jr. headquarters ...
This week, CKE announced that it is moving its headquarters to Nashville, Tennessee. In June 2013, Puzder told the Wall Street Journal that his chain would not expand in California because the state "is not interested in having businesses grow," noting among many other things that it takes 285 days to get a building permit after signing a lease. This means the chain has to pay rent for over nine months, plus the time needed to build, while not earning any revenues.
Puzder also wrote roughly 15 columns at Human Events in 2012, most of them bemoaning the sluggish U.S. economy and onerous U.S. government policies and regulations.
The company appears to have planned to move its headquarters to Nashville for years. This would explain why it has gone to the franchising model almost everywhere except Nashville. It can use its company-owned stores there to test new menu items and concepts before making them available to franchisees. CKE could have chosen any large metro area for this strategy, including the area surrounding its current California headquarters. But it did not. Nation's Restaurant News specifically notes that "Among the refranchised units are restaurants in Hardee’s headquarters city of St. Louis and in Santa Barbara County, Calif., where Carl’s Jr.’s home office in Carpinteria is located." Why did management clearly choose to go elsewhere? Among other things, Puzder told the Journal in 2013 that the Golden State's labor laws are intolerable.
And Car's Jr. joins a long list of California companies with an exit strategy. Some of them are big employers. In 2014, Toyota announced plans to move most of the 5,000 managers and employees from Toyota’s Torrance, Calif., headquarters to Plano Texas. Toyota has enjoyed a deep relationship with Texas through its $2.2-billion truck-assembly complex near San Antonio.
And remember many decades ago when General Motors had an assembly plant in Van Nuys. Southern California's long history as an auto manufacturing center ended in 1992 when a flame-red Chevrolet Camaro rolled off the assembly line, the last of 6.3 million vehicles built there over 45 years. The Van Nuys factory, which also made Pontiac Firebirds, was the last auto plant in Southern California. Its demise -announced to the plant's 2,600 workers - follows the closure in the early 1980s of a Ford Motor Co. plant in Pico Rivera and a GM plant in South Gate and the 1971 shutdown of a Chrysler Corp. plant in City of Commerce.
A recent published study of "California divestment events" - business decisions to shun the state paint a grim picture. These come in three types: companies that left the state entirely; companies that expanded in other states rather than in California; and a few companies that had planned to grow in the Golden State but changed their minds. The study found records of 1,510 divestment events occurring in California between 2008 and 2014, but that number is an incomplete accounting of the situation. "Experts in site selection generally agree that at least five events fail to become public knowledge for every one that does," giving rise to the conclusion that the real total is probably more than 9,000 divestment events for this period.
We can say goodbye to number 9001, the Carl's Jr. headquarters ...
