A medical doctor who fled the United States nearly 15 years ago and faked his own death to avoid prosecution in a healthcare fraud case was sentenced to 29 months in federal prison for fleeing justice.
Tigran Svadjian, 58, a naturalized U.S. citizen originally from Armenia who was residing in Newport Beach prior to fleeing the country in September 2002, was sentenced late this afternoon by United States District Judge Michael W. Fitzgerald.
Svadjian pleaded guilty in November to one count of unlawful flight to avoid prosecution.
In a case filed in 2002 in United States District Court in Sacramento, Svadjian, who operated medical clinics in Los Angeles and Fresno, had agreed to plead guilty in a $2.4 million scheme to defraud Medi-Cal by submitting bills for tests that had not been performed, in many cases because the “patients” were dead. After being ordered to appear in federal court in the Eastern District of California for an arraignment in that case, he fled to Russia, leaving behind his wife and son.
On October 24, 2002, the United States Embassy in Moscow received notification that Svadjian had died of pneumonia and that his body had been cremated. Relying on this false information, the Embassy then issued a report documenting the death, and Svadjian’s defense counsel submitted that report to federal prosecutors.
When he pleaded guilty, Svadjian admitted that he paid a Russian police officer in 2002 to submit an official report about his death to the United States Embassy. Soon after, Svadjian obtained a fraudulent Russian passport in a different name and relocated to Hurghada, Egypt, where he occasionally worked as a scuba instructor.
In January 2013, after lengthy and unsuccessful attempts to locate Svadjian or to obtain further confirmation of his death, prosecutors in the Eastern District of California dismissed the healthcare fraud case.
Svadjian was taken into custody by Egyptian authorities on August 1 - nearly 14 years after he fled the United States. Svadjian had been deported to Egypt by Ukrainian authorities after they determined he was travelling on a fraudulent Lithuanian passport. Egyptian authorities discovered in his residence an old United States passport with his true name.
Svadjian "did not simply flee from prosecution," prosecutors wrote in a sentencing memorandum filed with the court. "Instead, defendant planned and implemented a sophisticated, fraudulent scheme that involved bribing foreign officials, using false statements to mislead U.S. State Department officials into creating a false death certificate, and submitting that false certificate to federal prosecutors. Defendant then hid from U.S. authorities through the use of false identities for approximately 15 years. He abandoned his wife, son, and parents, and started a whole new life without them because he did not want to spend time in prison." ...
Tigran Svadjian, 58, a naturalized U.S. citizen originally from Armenia who was residing in Newport Beach prior to fleeing the country in September 2002, was sentenced late this afternoon by United States District Judge Michael W. Fitzgerald.
Svadjian pleaded guilty in November to one count of unlawful flight to avoid prosecution.
In a case filed in 2002 in United States District Court in Sacramento, Svadjian, who operated medical clinics in Los Angeles and Fresno, had agreed to plead guilty in a $2.4 million scheme to defraud Medi-Cal by submitting bills for tests that had not been performed, in many cases because the “patients” were dead. After being ordered to appear in federal court in the Eastern District of California for an arraignment in that case, he fled to Russia, leaving behind his wife and son.
On October 24, 2002, the United States Embassy in Moscow received notification that Svadjian had died of pneumonia and that his body had been cremated. Relying on this false information, the Embassy then issued a report documenting the death, and Svadjian’s defense counsel submitted that report to federal prosecutors.
When he pleaded guilty, Svadjian admitted that he paid a Russian police officer in 2002 to submit an official report about his death to the United States Embassy. Soon after, Svadjian obtained a fraudulent Russian passport in a different name and relocated to Hurghada, Egypt, where he occasionally worked as a scuba instructor.
In January 2013, after lengthy and unsuccessful attempts to locate Svadjian or to obtain further confirmation of his death, prosecutors in the Eastern District of California dismissed the healthcare fraud case.
Svadjian was taken into custody by Egyptian authorities on August 1 - nearly 14 years after he fled the United States. Svadjian had been deported to Egypt by Ukrainian authorities after they determined he was travelling on a fraudulent Lithuanian passport. Egyptian authorities discovered in his residence an old United States passport with his true name.
Svadjian "did not simply flee from prosecution," prosecutors wrote in a sentencing memorandum filed with the court. "Instead, defendant planned and implemented a sophisticated, fraudulent scheme that involved bribing foreign officials, using false statements to mislead U.S. State Department officials into creating a false death certificate, and submitting that false certificate to federal prosecutors. Defendant then hid from U.S. authorities through the use of false identities for approximately 15 years. He abandoned his wife, son, and parents, and started a whole new life without them because he did not want to spend time in prison." ...
A common antibiotic called doxycycline can disrupt the formation of negative thoughts and fears in the brain and may prove useful in treating or preventing post traumatic stress disorder (PTSD), according to research by British and Swiss scientists.
In a specially designed trial involving 76 healthy volunteers who were given either the drug or a placebo dummy pill, those who were on doxycycline had a 60 percent lower fear response than those who were not.
The article in Reuters Health reports that the scientists said the antibiotic works in this way because it blocks certain proteins outside nerve cells, called matrix enzymes, which our brains need to form memories.
"We have demonstrated a proof-of-principle for an entirely new treatment strategy for PTSD," said Dominik Bach, a professor at University College London and the University of Zurich, who co-led the research team.
In the trial, volunteers were given either doxycycline or a placebo and put in front of a computer. The screen would flash either blue or red, and one of the colors was associated with a 50 percent chance of getting a painful electric shock. After 160 flashes with colors in random order, participants learnt to associate the 'bad' color with the shock.
A week later, under no medication, the volunteers repeated the experiment. This time there were no electric shocks, but a loud sound played after either color was shown.
Fear responses were measured by tracking eye blinks, as this is an instinctive response to sudden threats. The fear memory was calculated by subtracting the baseline startle response – to the sound on the 'good' color – from the response to the sound when the 'bad' color was showing.
While the fear response was 60 percent lower in those who had doxycycline in the first session, the researchers found that, importantly, other cognitive measures - including sensory memory and attention - were not affected.
"When we talk about reducing fear memory, we're not talking about deleting the memory of what actually happened," Bach said in a statement about the findings.
"The participants may not forget that they received a shock when the screen was red, but they 'forget' to be instinctively scared when they next see a red screen.
"Learning to fear threats is an important ability ... helping us to avoid dangers. (But) over-prediction of threat can cause tremendous suffering and distress in anxiety disorders such as PTSD."
PTSD is caused by an overactive fear memory and includes a broad range of psychological symptoms that can develop after someone goes through a traumatic event.
Bach said he and his team would now like to explore doxycycline's potential effects further, including in a phenomenon called "reconsolidation" of fear memories - an approach to helping people with PTSD - in which memories and associations can be changed after an event when the patient experiences or imagines similar situations ...
In a specially designed trial involving 76 healthy volunteers who were given either the drug or a placebo dummy pill, those who were on doxycycline had a 60 percent lower fear response than those who were not.
The article in Reuters Health reports that the scientists said the antibiotic works in this way because it blocks certain proteins outside nerve cells, called matrix enzymes, which our brains need to form memories.
"We have demonstrated a proof-of-principle for an entirely new treatment strategy for PTSD," said Dominik Bach, a professor at University College London and the University of Zurich, who co-led the research team.
In the trial, volunteers were given either doxycycline or a placebo and put in front of a computer. The screen would flash either blue or red, and one of the colors was associated with a 50 percent chance of getting a painful electric shock. After 160 flashes with colors in random order, participants learnt to associate the 'bad' color with the shock.
A week later, under no medication, the volunteers repeated the experiment. This time there were no electric shocks, but a loud sound played after either color was shown.
Fear responses were measured by tracking eye blinks, as this is an instinctive response to sudden threats. The fear memory was calculated by subtracting the baseline startle response – to the sound on the 'good' color – from the response to the sound when the 'bad' color was showing.
While the fear response was 60 percent lower in those who had doxycycline in the first session, the researchers found that, importantly, other cognitive measures - including sensory memory and attention - were not affected.
"When we talk about reducing fear memory, we're not talking about deleting the memory of what actually happened," Bach said in a statement about the findings.
"The participants may not forget that they received a shock when the screen was red, but they 'forget' to be instinctively scared when they next see a red screen.
"Learning to fear threats is an important ability ... helping us to avoid dangers. (But) over-prediction of threat can cause tremendous suffering and distress in anxiety disorders such as PTSD."
PTSD is caused by an overactive fear memory and includes a broad range of psychological symptoms that can develop after someone goes through a traumatic event.
Bach said he and his team would now like to explore doxycycline's potential effects further, including in a phenomenon called "reconsolidation" of fear memories - an approach to helping people with PTSD - in which memories and associations can be changed after an event when the patient experiences or imagines similar situations ...
The Justice Department has joined a California whistleblower’s lawsuit that accuses insurance giant UnitedHealth Group of fraud in its popular Medicare Advantage health plans.
Justice officials filed legal papers to intervene in the suit, first brought by whistleblower James Swoben in 2009, on Friday in federal court in Los Angeles. On Monday, they sought a court order to combine Swoben’s case with that of another whistleblower.
According to the report by Salon.com, Swoben has accused the insurer of "gaming" the Medicare Advantage payment system by "making patients look sicker than they are," said his attorney, William K. Hanagami. Hanagami said the combined cases could prove to be among the "larger frauds" ever against Medicare, with damages that he speculates could top $1 billion.
UnitedHealth spokesman Matt Burns denied any wrongdoing by the company. "We are honored to serve millions of seniors through Medicare Advantage, proud of the access to quality health care we provided, and confident we complied with program rules," he wrote in an email.
Medicare Advantage is a popular alternative to traditional Medicare. The privately run health plans have enrolled more than 18 million elderly and people with disabilities - about a third of those eligible for Medicare - at a cost to taxpayers of more than $150 billion a year.
Although the plans generally enjoy strong support in Congress, they have been the target of at least a half-dozen whistleblower lawsuits alleging patterns of overbilling and fraud. In most of the prior cases, Justice Department officials have decided not to intervene, which often limits the financial recovery by the government and also by whistleblowers, who can be awarded a portion of recovered funds. A decision to intervene means that the Justice Department is taking over investigating the case, greatly raising the stakes.
"This is a very big development and sends a strong signal that the Trump administration is very serious when it comes to fighting fraud in the health care arena," said Patrick Burns, associate director of Taxpayers Against Fraud in Washington, a nonprofit supported by whistleblowers and their lawyers. Burns said the "winners here are going to be American taxpayers."
"This is not one company engaged in episodic bad behavior, but a lucrative business plan that appears to be national in scope," Burns said.
On Monday, the government said it wants to consolidate the Swoben case with another whistleblower action filed in 2011 by former UnitedHealth executive Benjamin Poehling and unsealed in March by a federal judge. Poehling also has alleged that the insurer generated hundreds of millions of dollars or more in overpayments.
When Congress created the current Medicare Advantage program in 2003, it expected to pay higher rates for sicker patients than for people in good health using a formula called a risk score.
But overspending tied to inflated risk scores has repeatedly been cited by government auditors, including the Government Accountability Office. A series of articles published in 2014 by the Center for Public Integrity found that these improper payments have cost taxpayers tens of billions of dollars.
"If the goal of fraud is to artificially increase risk scores and you do that wholesale, that results in some rather significant dollars," Hanagami said.
David Lipschutz, senior policy attorney for the Center for Medicare Advocacy, a nonprofit offering legal assistance and other resources for those eligible for Medicare, said his group is "deeply concerned by ongoing improper payments" to Medicare Advantage health plans.
The two whistleblower complaints allege that UnitedHealth has had a practice of asking the government to reimburse it for underpayments, but did not report claims for which it had received too much money, despite knowing some these claims had inflated risk scores.
The Justice Department has said it also is investigating risk-score payments to other Medicare Advantage insurers, but has not said whether it plans to take action against any of them ...
Justice officials filed legal papers to intervene in the suit, first brought by whistleblower James Swoben in 2009, on Friday in federal court in Los Angeles. On Monday, they sought a court order to combine Swoben’s case with that of another whistleblower.
According to the report by Salon.com, Swoben has accused the insurer of "gaming" the Medicare Advantage payment system by "making patients look sicker than they are," said his attorney, William K. Hanagami. Hanagami said the combined cases could prove to be among the "larger frauds" ever against Medicare, with damages that he speculates could top $1 billion.
UnitedHealth spokesman Matt Burns denied any wrongdoing by the company. "We are honored to serve millions of seniors through Medicare Advantage, proud of the access to quality health care we provided, and confident we complied with program rules," he wrote in an email.
Medicare Advantage is a popular alternative to traditional Medicare. The privately run health plans have enrolled more than 18 million elderly and people with disabilities - about a third of those eligible for Medicare - at a cost to taxpayers of more than $150 billion a year.
Although the plans generally enjoy strong support in Congress, they have been the target of at least a half-dozen whistleblower lawsuits alleging patterns of overbilling and fraud. In most of the prior cases, Justice Department officials have decided not to intervene, which often limits the financial recovery by the government and also by whistleblowers, who can be awarded a portion of recovered funds. A decision to intervene means that the Justice Department is taking over investigating the case, greatly raising the stakes.
"This is a very big development and sends a strong signal that the Trump administration is very serious when it comes to fighting fraud in the health care arena," said Patrick Burns, associate director of Taxpayers Against Fraud in Washington, a nonprofit supported by whistleblowers and their lawyers. Burns said the "winners here are going to be American taxpayers."
"This is not one company engaged in episodic bad behavior, but a lucrative business plan that appears to be national in scope," Burns said.
On Monday, the government said it wants to consolidate the Swoben case with another whistleblower action filed in 2011 by former UnitedHealth executive Benjamin Poehling and unsealed in March by a federal judge. Poehling also has alleged that the insurer generated hundreds of millions of dollars or more in overpayments.
When Congress created the current Medicare Advantage program in 2003, it expected to pay higher rates for sicker patients than for people in good health using a formula called a risk score.
But overspending tied to inflated risk scores has repeatedly been cited by government auditors, including the Government Accountability Office. A series of articles published in 2014 by the Center for Public Integrity found that these improper payments have cost taxpayers tens of billions of dollars.
"If the goal of fraud is to artificially increase risk scores and you do that wholesale, that results in some rather significant dollars," Hanagami said.
David Lipschutz, senior policy attorney for the Center for Medicare Advocacy, a nonprofit offering legal assistance and other resources for those eligible for Medicare, said his group is "deeply concerned by ongoing improper payments" to Medicare Advantage health plans.
The two whistleblower complaints allege that UnitedHealth has had a practice of asking the government to reimburse it for underpayments, but did not report claims for which it had received too much money, despite knowing some these claims had inflated risk scores.
The Justice Department has said it also is investigating risk-score payments to other Medicare Advantage insurers, but has not said whether it plans to take action against any of them ...
The California Department of Insurance announced that CastlePoint National Insurance Company, the California insurance company affiliate of the defunct Tower Group, has been ordered into formal liquidation, paving the way for protection of CastlePoint's policyholders through the national system of insurance guaranty associations.
The filing on March 30, 2017, of an Order of Liquidation by the San Francisco Superior Court effective April 1, was the final judicial stage of a planned and complex process of winding up a group of financially impaired insurers that wrote insurance across the country.
The CDI started the process in January 2016 when it took the lead in convincing insurance commissioners in six other states to redomicile all of the insurers within the Tower Insurance Group to California so that the companies could be consolidated into CastlePoint National to achieve an orderly conservation and liquidation of the companies.
In July the CDI Commissioner implemented the second phase of the plan, by asking the Court to order CastlePoint into conservation and appoint him as Conservator of the company. As Conservator, the Commissioner developed and implemented a multi-stage Conservation & Liquidation Plan that infused $200 million in liquid assets into CastlePoint and locked in the resources required to ensure the uninterrupted administration and payment of CastlePoint's policyholder claims during the conservation phase. The final phase of the plan is the entry of a liquidation order.
"The liquidation order for CastlePoint was an essential step in our efforts to protect CastlePoint's policyholders across the country," said Commissioner Jones. "The order triggers the legal obligation of the national network of insurance guaranty associations to step up to pay CastlePoint's insurance claims in a timely and fair manner. It's never good when an insurance company fails, but through careful planning and execution we have provided CastlePoint's policyholders with the maximum protection available under the law."
All CastlePoint claims continued to be adjusted and paid throughout the eight-month conservation phase of this process. During the final stage of conservation, the CDI prepared for a seamless transition into liquidation by arranging for pre-funding of all workers' compensation indemnity (or wage replacement) benefits for the next 60 to 90 days. This pre-funding process ensures that there will be no interruption or avoidable delay in payments to the injured workers while they recover from workplace injuries.
The Order of Liquidation also sets a deadline for filing any and all claims against CastlePoint. The Court has set this "claims bar date" as December 31, 2017. All claims against CastlePoint must be filed by that date or they will be deemed barred and forever waived. Notice of the claims bar date, along with a proof of claim form and instructions, will be distributed by the Commissioner's Conservation & Liquidation Office in the coming weeks. Information may also be found at the CLO's website www.CACLO.org ...
The filing on March 30, 2017, of an Order of Liquidation by the San Francisco Superior Court effective April 1, was the final judicial stage of a planned and complex process of winding up a group of financially impaired insurers that wrote insurance across the country.
The CDI started the process in January 2016 when it took the lead in convincing insurance commissioners in six other states to redomicile all of the insurers within the Tower Insurance Group to California so that the companies could be consolidated into CastlePoint National to achieve an orderly conservation and liquidation of the companies.
In July the CDI Commissioner implemented the second phase of the plan, by asking the Court to order CastlePoint into conservation and appoint him as Conservator of the company. As Conservator, the Commissioner developed and implemented a multi-stage Conservation & Liquidation Plan that infused $200 million in liquid assets into CastlePoint and locked in the resources required to ensure the uninterrupted administration and payment of CastlePoint's policyholder claims during the conservation phase. The final phase of the plan is the entry of a liquidation order.
"The liquidation order for CastlePoint was an essential step in our efforts to protect CastlePoint's policyholders across the country," said Commissioner Jones. "The order triggers the legal obligation of the national network of insurance guaranty associations to step up to pay CastlePoint's insurance claims in a timely and fair manner. It's never good when an insurance company fails, but through careful planning and execution we have provided CastlePoint's policyholders with the maximum protection available under the law."
All CastlePoint claims continued to be adjusted and paid throughout the eight-month conservation phase of this process. During the final stage of conservation, the CDI prepared for a seamless transition into liquidation by arranging for pre-funding of all workers' compensation indemnity (or wage replacement) benefits for the next 60 to 90 days. This pre-funding process ensures that there will be no interruption or avoidable delay in payments to the injured workers while they recover from workplace injuries.
The Order of Liquidation also sets a deadline for filing any and all claims against CastlePoint. The Court has set this "claims bar date" as December 31, 2017. All claims against CastlePoint must be filed by that date or they will be deemed barred and forever waived. Notice of the claims bar date, along with a proof of claim form and instructions, will be distributed by the Commissioner's Conservation & Liquidation Office in the coming weeks. Information may also be found at the CLO's website www.CACLO.org ...
Mallinckrodt Pharmaceuticals, based in Staines-upon-Thames, England, with its U.S. headquarters in St. Louis, Missouri, produces specialty pharmaceutical products, including generic drugs and imaging agents. Key generic specialty products include Hydrocodone API and tablets and Oxycodone API and tablets
As of 1988, Mallinckrodt was the only company in the US that is allowed to receive cocaine, which it has used to make cocaine hydrochloride, a prescription drug used in hospitals as a local anesthetic by eye and ear, nose and throat doctors.
To combat an escalating opioid epidemic, the Drug Enforcement Administration trained its sights in 2011 on Mallinckrodt Pharmaceuticals. It was the first time the DEA had targeted a manufacturer of opioids for alleged violations of laws designed to prevent diversion of legal narcotics to the black market. And it would become the largest prescription-drug case the agency has pursued.
Ultimately, the DEA and federal prosecutors would contend that the company ignored its responsibility to report suspicious orders as 500 million of its pills ended up in Florida between 2008 and 2012 - 66 percent of all oxycodone sold in the state. Government investigators alleged in internal documents that the company’s lack of due diligence could have resulted in nearly 44,000 federal violations and exposed it to $2.3 billion in fines, according to confidential government records and emails obtained by The Washington Post.
But six years later, after four investigations that spanned five states, the Washington Post reports that the government has taken no legal action against Mallinckrodt. Instead, the company has reached a tentative settlement with federal prosecutors, according to sources familiar with the discussions. Under the proposal, which remains confidential, Mallinckrodt would agree to pay a $35 million fine and admit no wrongdoing.
"Mallinckrodt’s response was that ‘everyone knew what was going on in Florida but they had no duty to report it," according to an internal summary of the case prepared by federal prosecutors and obtained by The Post.
The case shows how difficult it is for the government to hold a drug manufacturer responsible for the damage done by its product. DEA investigators appalled by rising overdose deaths said they worked for years to build the biggest case of their careers only to watch it falter on uncertain legal territory and in the face of stiff resistance from the company.
The drug company said that the agreement in principle is subject to additional review and approval by the U.S. Justice Department and U.S. Drug Enforcement Administration and will not have a material effect on Mallinckrodt's financial condition. In a statement, a Mallinckrodt spokesman said the company has worked hard to fight drug diversion.
The U.S. attorney’s office in Detroit, which is handling the case, issued a statement. "Our office works diligently to use all the legal tools available to us to hold corporations responsible for their actions," acting U.S. attorney Daniel Lemisch said. "This is particularly true in a highly regulated industry such as the manufacture of opioids. As this case is still in settlement negotiations, we cannot comment on the specifics of the matter." ...
As of 1988, Mallinckrodt was the only company in the US that is allowed to receive cocaine, which it has used to make cocaine hydrochloride, a prescription drug used in hospitals as a local anesthetic by eye and ear, nose and throat doctors.
To combat an escalating opioid epidemic, the Drug Enforcement Administration trained its sights in 2011 on Mallinckrodt Pharmaceuticals. It was the first time the DEA had targeted a manufacturer of opioids for alleged violations of laws designed to prevent diversion of legal narcotics to the black market. And it would become the largest prescription-drug case the agency has pursued.
Ultimately, the DEA and federal prosecutors would contend that the company ignored its responsibility to report suspicious orders as 500 million of its pills ended up in Florida between 2008 and 2012 - 66 percent of all oxycodone sold in the state. Government investigators alleged in internal documents that the company’s lack of due diligence could have resulted in nearly 44,000 federal violations and exposed it to $2.3 billion in fines, according to confidential government records and emails obtained by The Washington Post.
But six years later, after four investigations that spanned five states, the Washington Post reports that the government has taken no legal action against Mallinckrodt. Instead, the company has reached a tentative settlement with federal prosecutors, according to sources familiar with the discussions. Under the proposal, which remains confidential, Mallinckrodt would agree to pay a $35 million fine and admit no wrongdoing.
"Mallinckrodt’s response was that ‘everyone knew what was going on in Florida but they had no duty to report it," according to an internal summary of the case prepared by federal prosecutors and obtained by The Post.
The case shows how difficult it is for the government to hold a drug manufacturer responsible for the damage done by its product. DEA investigators appalled by rising overdose deaths said they worked for years to build the biggest case of their careers only to watch it falter on uncertain legal territory and in the face of stiff resistance from the company.
The drug company said that the agreement in principle is subject to additional review and approval by the U.S. Justice Department and U.S. Drug Enforcement Administration and will not have a material effect on Mallinckrodt's financial condition. In a statement, a Mallinckrodt spokesman said the company has worked hard to fight drug diversion.
The U.S. attorney’s office in Detroit, which is handling the case, issued a statement. "Our office works diligently to use all the legal tools available to us to hold corporations responsible for their actions," acting U.S. attorney Daniel Lemisch said. "This is particularly true in a highly regulated industry such as the manufacture of opioids. As this case is still in settlement negotiations, we cannot comment on the specifics of the matter." ...
On January 17, 2017, a group of compliance professionals and staff from the Department of Health and Human Services, Office of Inspector General (OIG) met to discuss ways to measure the effectiveness of compliance programs. individual compliance program metrics.
Following this meeting, The OIG published guidelines on how healthcare organizations can measure the effectiveness of their healthcare fraud compliance programs.
The resource guide explains how healthcare organizations of all sizes can measure different components of their compliance program. The guide covers how organizations can evaluate standards and policies, administration, stakeholder screening and assessments, training, internal reporting system monitoring, non-compliance discipline, and investigations and remedial measures.
"The purpose of this list is to give healthcare organizations as many ideas as possible, be broad enough to help any type of organization, and let the organization choose which ones best suit its needs," the federal watchdog wrote. "This is not a ‘checklist’ to be applied wholesale to assess a compliance program."
Rather than use all the healthcare fraud compliance guidelines, OIG recommends that organizations select a small sample of guidelines to implement in a year. Leaders should choose measures based on the organization’s risk areas, size, resources, and industry segment.
"Any attempt to use this as a standard or a certification is discouraged by those who worked on this project; one size truly does not fit all," the resource guide stated.
The 54 page resource guide started by identifying improvement strategies for healthcare organizations to use to align their compliance program with healthcare fraud prevention laws. Healthcare organizations should develop and maintain the following standards for an effective compliance program:
Each one of these topics is covered in greater detail in the guideline. Having a compliance program in place may prevent healthcare fraud and abuse cases, but healthcare organizations should ensure their program is effective by regularly auditing the program and any internal reporting systems.
OIG suggested that organizations aim to audit their compliance program on an annual basis and use each year’s results to analyze and benchmark their performance. The audit process should ensure that the program and any related systems check for healthcare fraud violations based on updated laws and regulations.
Healthcare organizations may also want to consider using a third party to complete a compliance program audit.
Additionally, the federal watchdog recommended that healthcare organizations develop an internal reporting system for employees to identify potential violations. The system should ensure anonymity and confidentiality for reporting and be easily accessible to all employees in the organization ...
Following this meeting, The OIG published guidelines on how healthcare organizations can measure the effectiveness of their healthcare fraud compliance programs.
The resource guide explains how healthcare organizations of all sizes can measure different components of their compliance program. The guide covers how organizations can evaluate standards and policies, administration, stakeholder screening and assessments, training, internal reporting system monitoring, non-compliance discipline, and investigations and remedial measures.
"The purpose of this list is to give healthcare organizations as many ideas as possible, be broad enough to help any type of organization, and let the organization choose which ones best suit its needs," the federal watchdog wrote. "This is not a ‘checklist’ to be applied wholesale to assess a compliance program."
Rather than use all the healthcare fraud compliance guidelines, OIG recommends that organizations select a small sample of guidelines to implement in a year. Leaders should choose measures based on the organization’s risk areas, size, resources, and industry segment.
"Any attempt to use this as a standard or a certification is discouraged by those who worked on this project; one size truly does not fit all," the resource guide stated.
The 54 page resource guide started by identifying improvement strategies for healthcare organizations to use to align their compliance program with healthcare fraud prevention laws. Healthcare organizations should develop and maintain the following standards for an effective compliance program:
- Appropriate coding policies and procedures
- Adequate overpayment policies and procedures
- Updated compliance plan
- Non-retribution and/or non-retaliation policies
- Internal and external compliance audit standards and procedures
- Record retention policy
- Healthcare stakeholder interaction policies, such as how hospitals and physicians, pharmaceutical and medical device representatives, and vendors should engage with each other
- Gift and gratuity acceptance policy
- Standards accountability standards, including how the organization handles incentives, sanctions, and disciplinary policies for employees at all levels
- Compliance Department operations manual
- Code of conduct
Each one of these topics is covered in greater detail in the guideline. Having a compliance program in place may prevent healthcare fraud and abuse cases, but healthcare organizations should ensure their program is effective by regularly auditing the program and any internal reporting systems.
OIG suggested that organizations aim to audit their compliance program on an annual basis and use each year’s results to analyze and benchmark their performance. The audit process should ensure that the program and any related systems check for healthcare fraud violations based on updated laws and regulations.
Healthcare organizations may also want to consider using a third party to complete a compliance program audit.
Additionally, the federal watchdog recommended that healthcare organizations develop an internal reporting system for employees to identify potential violations. The system should ensure anonymity and confidentiality for reporting and be easily accessible to all employees in the organization ...
According to a 2016 Workers' Compensation Benchmarking Study survey, national claims leaders rank psychosocial issues as the number one barrier to successful claim outcomes.
A new white paper shows how claims advocacy principles at The Hartford, CNA, Nationwide, and Albertsons Companies are taming the effects of psychosocial issues and coaching injured workers to recovery and claim resolution. In order to understand these findings, it is important to take a brief look at what "psychosocial" is and, perhaps more importantly, what it is not.
The Hartford’s medical director, Dr. Marcos Iglesias, says that the "psych" part does not mean psychiatric issues, such as schizophrenia, personality disorders, or major depressive disorders. Instead, he points out, "we are talking about behavioral issues, the way we think, feel, and act. An example is fear of physical movement as it may worsen one’s impairment or cause pain, or fear of judgment by coworkers."
The Hartford’s text mining has found the presence of "fear" in claim notes was more predictive of poor outcomes than a lumbar fusion surgery. Similar findings were recently cited by both Lockton and the Workers’ Compensation Research Institute (WCRI) which independently report that workers who express fear are at greater risk of poor outcomes.
There is no shortage of studies demonstrating the dramatic impact of psychosocial roadblocks and just how hard they are to manage. Lockton’s study directly links worker fears with high litigation rates. Another from the Journal of Occupational and Environmental Medicine found that injured workers with emotional distress, such as pain catastrophizing and activity avoidance, were seven times less likely than those in the low-risk group to return to work within three months.
Other conditions, behaviors, and predicaments include obesity, hard feelings about coworkers, troubled home life, the lack of temporary modified work assignments, limited English proficiency, and - most commonly noted - poor coping skills. Additionally, being out of work can lead to problems such as increased smoking, alcohol abuse, illicit drug use, and risky sexual behavior. Suicide rates have been observed to increase by a factor of six.
The national medical director for Albertson Companies uses a modified Linton tool for screening injured workers for psychosocial comorbidities. Approximately nine percent of screened workers receive specialist intervention, which is usually performed by a network of psychologists who provide health coaching consistent with cognitive behavioral therapy principles. This intervention method is short in duration and focuses on active problem-solving with the patient.
Albertson's medical director cautions that, with the long-tail nature of workers’ compensation claims, it will take three or four years before the strategy’s impact can be effectively measured in claim outcomes, but she is optimistic. Her tentative estimate is duration of disability and medical spending will decline by 20 percent.
When peeling back the psychosocial onion, one can see how adversarial, compliance, and task-driven claim styles are 1) ill-suited for addressing fears, beliefs, perceptions, and poor coping skills and 2) less likely to effectively address these roadblocks due to the disruption they pose to workflows and task timelines.
This short report - "How to Overcome Psychosocial Roadblocks: Claims Advocacy's Biggest Opportunity" - examines key best practices, skill sets, and training approaches organizations are using to screen for, intervene in, and effectively address psychosocial factors. Rooted in advocacy, these strategies treat the injured worker as a whole person to proactively resolve non-medical barriers to timely recovery ...
A new white paper shows how claims advocacy principles at The Hartford, CNA, Nationwide, and Albertsons Companies are taming the effects of psychosocial issues and coaching injured workers to recovery and claim resolution. In order to understand these findings, it is important to take a brief look at what "psychosocial" is and, perhaps more importantly, what it is not.
The Hartford’s medical director, Dr. Marcos Iglesias, says that the "psych" part does not mean psychiatric issues, such as schizophrenia, personality disorders, or major depressive disorders. Instead, he points out, "we are talking about behavioral issues, the way we think, feel, and act. An example is fear of physical movement as it may worsen one’s impairment or cause pain, or fear of judgment by coworkers."
The Hartford’s text mining has found the presence of "fear" in claim notes was more predictive of poor outcomes than a lumbar fusion surgery. Similar findings were recently cited by both Lockton and the Workers’ Compensation Research Institute (WCRI) which independently report that workers who express fear are at greater risk of poor outcomes.
There is no shortage of studies demonstrating the dramatic impact of psychosocial roadblocks and just how hard they are to manage. Lockton’s study directly links worker fears with high litigation rates. Another from the Journal of Occupational and Environmental Medicine found that injured workers with emotional distress, such as pain catastrophizing and activity avoidance, were seven times less likely than those in the low-risk group to return to work within three months.
Other conditions, behaviors, and predicaments include obesity, hard feelings about coworkers, troubled home life, the lack of temporary modified work assignments, limited English proficiency, and - most commonly noted - poor coping skills. Additionally, being out of work can lead to problems such as increased smoking, alcohol abuse, illicit drug use, and risky sexual behavior. Suicide rates have been observed to increase by a factor of six.
The national medical director for Albertson Companies uses a modified Linton tool for screening injured workers for psychosocial comorbidities. Approximately nine percent of screened workers receive specialist intervention, which is usually performed by a network of psychologists who provide health coaching consistent with cognitive behavioral therapy principles. This intervention method is short in duration and focuses on active problem-solving with the patient.
Albertson's medical director cautions that, with the long-tail nature of workers’ compensation claims, it will take three or four years before the strategy’s impact can be effectively measured in claim outcomes, but she is optimistic. Her tentative estimate is duration of disability and medical spending will decline by 20 percent.
When peeling back the psychosocial onion, one can see how adversarial, compliance, and task-driven claim styles are 1) ill-suited for addressing fears, beliefs, perceptions, and poor coping skills and 2) less likely to effectively address these roadblocks due to the disruption they pose to workflows and task timelines.
This short report - "How to Overcome Psychosocial Roadblocks: Claims Advocacy's Biggest Opportunity" - examines key best practices, skill sets, and training approaches organizations are using to screen for, intervene in, and effectively address psychosocial factors. Rooted in advocacy, these strategies treat the injured worker as a whole person to proactively resolve non-medical barriers to timely recovery ...
The owner of what the District Attorney’s office is calling a "now-defunct landscaping company" has been arrested and now faces felony charges for workers' compensation premium fraud.
Deputy District Attorney Vonda Tracey with the Insurance Fraud Unit said, that Jorge Rojas Sanchez, 49, had numerous paid employees working for his company known as Tao Landscaping."
The locally owned San Jose business did not come into question until one of its employees had cut off part of his finger with a saw. The cut was so severe that the employee needed surgery to repair his severed finger.
Once at the hospital, medical staff questioned the employee and found out that he did not have workman’s compensation through his employment with the company. San Jose Police on duty at the hospital were able to take a statement, which led to an investigation into the allegations.
During the course of a two-year investigation after the 2015 accident, it was soon discovered that Sanchez obtained Worker’s Compensation Insurance in 2012 under false pretences. The insurance company estimates the loss in premiums totaled more than $30,000.
Sanchez faces up to 5 years incarceration if convicted and may be ordered to pay full restitution. Sanchez was released on his own recognizance and will be arraigned on April 26.
The insurance premium is based on the nature of the business, safety record, and the employees’ wages or payroll as reported by the employer. To report Workers’ Compensation Insurance Fraud, call the Santa Clara County Workers’ Compensation Insurance Fraud Hotline at (408) 792-2466 ...
Deputy District Attorney Vonda Tracey with the Insurance Fraud Unit said, that Jorge Rojas Sanchez, 49, had numerous paid employees working for his company known as Tao Landscaping."
The locally owned San Jose business did not come into question until one of its employees had cut off part of his finger with a saw. The cut was so severe that the employee needed surgery to repair his severed finger.
Once at the hospital, medical staff questioned the employee and found out that he did not have workman’s compensation through his employment with the company. San Jose Police on duty at the hospital were able to take a statement, which led to an investigation into the allegations.
During the course of a two-year investigation after the 2015 accident, it was soon discovered that Sanchez obtained Worker’s Compensation Insurance in 2012 under false pretences. The insurance company estimates the loss in premiums totaled more than $30,000.
Sanchez faces up to 5 years incarceration if convicted and may be ordered to pay full restitution. Sanchez was released on his own recognizance and will be arraigned on April 26.
The insurance premium is based on the nature of the business, safety record, and the employees’ wages or payroll as reported by the employer. To report Workers’ Compensation Insurance Fraud, call the Santa Clara County Workers’ Compensation Insurance Fraud Hotline at (408) 792-2466 ...
Pete Romo worked as a firefighter for three different fire departments. He was a volunteer firefighter for Marinwood from 1989 to 1991 and the San Antonio Volunteer Fire District in Sonoma County from 2002 to 2006. From 2006 through trial of his WCAB case, he was employed full time as a paid firefighter for the City of Mill Valley. While working for Mill Valley, Romo was diagnosed with prostate cancer.
Romo filed a claim for workers’ compensation benefits with each of the three fire departments for which he had worked. Mill Valley and San Antonio stipulated that the statutory presumption that cancer suffered while employed as a firefighter arises out of the employment would apply to them if the elements set forth in labor code section 3212.1 were proven.
Marinwood contested the application of the presumption. It was established in the 1950s as an all-volunteer fire department. By the 1980s, it had a paid fire chief and two paid professional firefighters for each shift. At the time Romo was a volunteer firefighter there, Marinwood had a total of seven paid firefighters and 24 volunteer firefighters.
The WCJ concluded that Romo was "an active volunteer firefighting member of [Marinwood] from mid-1989 to early 1991 within the meaning of Labor Code sections 3212.1 and 3361" and that he "is entitled to the extension of the presumption under Labor Code section 3212.1, since he is within 120 months of the ‘last date actually worked in the specified capacity.’ " The WCAB denied Marinwood’s Petition for Reconsideration.
The Court of Appeal affirmed the WCAB in the published decision of Marinwood Community Services v WCAB (Ramos)
Section 3352 excludes certain categories of persons from the term "[e]mployee" as used in the workers’ compensation statutes. Subdivision (i) of that section generally excludes volunteers. Section 3361 is a nuanced exception to this exclusion for "Each member registered as an active firefighting member of any regularly organized volunteer fire department..." Marinwood contends it is not (and was not when Romo was a volunteer firefighter there) a "regularly organized volunteer fire department" within the meaning of section 3361.
The Court of Appeal concluded that the language "volunteer fire department" in section 3361 is ambiguous in regard to whether it extends to a department comprised predominantly, but not exclusively, of volunteers. "The WCAB’s interpretation of section 3361 is reasonable, and we give it weight. Its interpretation is consistent with the purpose of the statutory scheme."
Marinwood next contends the WCAB misconstrued section 3212.1 presumption terms that it "shall be extended to a member following termination of service for a period of three calendar months for each full year of the requisite service, but not to exceed 120 months in any circumstance, commencing with the last date actually worked in the specified capacity." Marinwood argues the above-quoted sentence should be applied separately to each employer for whom a firefighter worked.
The WCJ and WCAB interpreted the language in subdivision (d) "last date actually worked in the specified capacity" to mean the last day worked in the capacity of a firefighter for any employer. The Court of Appeal agreed and concluded that "the WCAB’s interpretation of section 3212.1 in this and other cases furthers the purpose of the cancer presumption." ...
Romo filed a claim for workers’ compensation benefits with each of the three fire departments for which he had worked. Mill Valley and San Antonio stipulated that the statutory presumption that cancer suffered while employed as a firefighter arises out of the employment would apply to them if the elements set forth in labor code section 3212.1 were proven.
Marinwood contested the application of the presumption. It was established in the 1950s as an all-volunteer fire department. By the 1980s, it had a paid fire chief and two paid professional firefighters for each shift. At the time Romo was a volunteer firefighter there, Marinwood had a total of seven paid firefighters and 24 volunteer firefighters.
The WCJ concluded that Romo was "an active volunteer firefighting member of [Marinwood] from mid-1989 to early 1991 within the meaning of Labor Code sections 3212.1 and 3361" and that he "is entitled to the extension of the presumption under Labor Code section 3212.1, since he is within 120 months of the ‘last date actually worked in the specified capacity.’ " The WCAB denied Marinwood’s Petition for Reconsideration.
The Court of Appeal affirmed the WCAB in the published decision of Marinwood Community Services v WCAB (Ramos)
Section 3352 excludes certain categories of persons from the term "[e]mployee" as used in the workers’ compensation statutes. Subdivision (i) of that section generally excludes volunteers. Section 3361 is a nuanced exception to this exclusion for "Each member registered as an active firefighting member of any regularly organized volunteer fire department..." Marinwood contends it is not (and was not when Romo was a volunteer firefighter there) a "regularly organized volunteer fire department" within the meaning of section 3361.
The Court of Appeal concluded that the language "volunteer fire department" in section 3361 is ambiguous in regard to whether it extends to a department comprised predominantly, but not exclusively, of volunteers. "The WCAB’s interpretation of section 3361 is reasonable, and we give it weight. Its interpretation is consistent with the purpose of the statutory scheme."
Marinwood next contends the WCAB misconstrued section 3212.1 presumption terms that it "shall be extended to a member following termination of service for a period of three calendar months for each full year of the requisite service, but not to exceed 120 months in any circumstance, commencing with the last date actually worked in the specified capacity." Marinwood argues the above-quoted sentence should be applied separately to each employer for whom a firefighter worked.
The WCJ and WCAB interpreted the language in subdivision (d) "last date actually worked in the specified capacity" to mean the last day worked in the capacity of a firefighter for any employer. The Court of Appeal agreed and concluded that "the WCAB’s interpretation of section 3212.1 in this and other cases furthers the purpose of the cancer presumption." ...
A Riverside woman was arraigned Wednesday on 52 felonies related to workers’ compensation insurance fraud that resulted in a loss of more than $540,000 to two insurance companies.
Joanne Trealoff, age 60, is charged with providing a false statement to reduce workers’ compensation rates (Insurance Code section 11760 (A)) and failure to disclose facts regarding insurance benefits (Penal Code section 550 (B)(3)).
Trealoff is the owner of Eclipse Recreational Vehicles Inc, a manufacturer of toy haulers and travel trailers located in the city of Riverside.
Trealoff appeared in Riverside Superior Court and entered not guilty pleas to all 52 counts. She now has a felony settlement conference scheduled for June 7, 2017, at 8:30 a.m. in Dept. 63 at the Hall of Justice in Riverside.
Two other people have been charged in this case but, as of this news release, had not been arrested subsequent to arrest warrants that have been issued. They are David Armando Torres, of Yucaipa; and Sylvia Leon, of Duarte.
Torres is the owner of Employer Support Group, a workers’ compensation consulting firm located in Montclair, and Leon is an employee of that business. Torres and Leon have each been charged with 51 felonies, 50 counts of failure to disclose facts regarding insurance benefits (Penal Code section 550 (B)(3)) and one count of unlawful transaction of insurance business (Insurance Code section 700)
Based on the investigation in this case, it is alleged that Trealoff misclassified an estimated 15 to 20 percent of the approximately 200 employees at Eclipse and failed to report more than 50 injuries to employees. The charged crimes happened over the years 2012 to 2016. It is alleged that Torres and Leon, through their company, assisted Trealoff in not lawfully reporting industrial injuries to insurance companies.
The charged crimes resulted in more than $540,000 in losses to Everest National Insurance Company and Security National Insurance Company.
The case was investigated by the Inland Empire Premium Fraud Task Force composed of investigators from the California Department of Insurance, the Riverside County DA’s Office, the San Bernardino DA’s Office, the state Employment Development Department and the state Franchise Tax Board.
The case, RIF1700031, is being prosecuted by Deputy District Attorney Courtney Breaux of the DA’s Insurance Fraud Team ...
Joanne Trealoff, age 60, is charged with providing a false statement to reduce workers’ compensation rates (Insurance Code section 11760 (A)) and failure to disclose facts regarding insurance benefits (Penal Code section 550 (B)(3)).
Trealoff is the owner of Eclipse Recreational Vehicles Inc, a manufacturer of toy haulers and travel trailers located in the city of Riverside.
Trealoff appeared in Riverside Superior Court and entered not guilty pleas to all 52 counts. She now has a felony settlement conference scheduled for June 7, 2017, at 8:30 a.m. in Dept. 63 at the Hall of Justice in Riverside.
Two other people have been charged in this case but, as of this news release, had not been arrested subsequent to arrest warrants that have been issued. They are David Armando Torres, of Yucaipa; and Sylvia Leon, of Duarte.
Torres is the owner of Employer Support Group, a workers’ compensation consulting firm located in Montclair, and Leon is an employee of that business. Torres and Leon have each been charged with 51 felonies, 50 counts of failure to disclose facts regarding insurance benefits (Penal Code section 550 (B)(3)) and one count of unlawful transaction of insurance business (Insurance Code section 700)
Based on the investigation in this case, it is alleged that Trealoff misclassified an estimated 15 to 20 percent of the approximately 200 employees at Eclipse and failed to report more than 50 injuries to employees. The charged crimes happened over the years 2012 to 2016. It is alleged that Torres and Leon, through their company, assisted Trealoff in not lawfully reporting industrial injuries to insurance companies.
The charged crimes resulted in more than $540,000 in losses to Everest National Insurance Company and Security National Insurance Company.
The case was investigated by the Inland Empire Premium Fraud Task Force composed of investigators from the California Department of Insurance, the Riverside County DA’s Office, the San Bernardino DA’s Office, the state Employment Development Department and the state Franchise Tax Board.
The case, RIF1700031, is being prosecuted by Deputy District Attorney Courtney Breaux of the DA’s Insurance Fraud Team ...
Daniel Ramirez sustained an injury to his lower leg and ankle in the course of his job as an office assistant for the State Department of Health Care Services. The claims were administered by the State Compensation Insurance Fund.
Ramirez settled his case by stipulations providing him with further medical treatment for the injury. The treatment included a gym/swim membership, and, over the course of about one and a half years.
His physician prescribed another 12 sessions of acupuncture. The utilization review recommended that the requested treatment be denied. Ramirez appealed the utilization review denial under the independent medical review process. IMR upheld the UR decision.
Ramirez appealed the decision of the independent medical review to the Board. The grounds for the appeal were that the independent medical reviewer "may have been subject to a material conflict of interest that is in violation of Section 139.5," and the "determination may have been the result of bias on the basis of race, national origin, ethnic group identification, religion, age, sex, sexual orientation, color, or disability."
Ramirez wanted discovery to determine whether the doctor performing the independent medical review was biased or had a conflict of interest. He also raised constitutional violations regarding the UR/IMR process which were beyond the jurisdiction of the WCAB. The appeal was taken off calendar pending resolution of the constitutional issues.
Ramirez filed a petition for writ of review with the Court of Appeal. His constitutional challenges were rejected in the published case of Ramirez v WCAB.
The Court concluded that the Board had no jurisdiction to review a utilization review that was alleged to be defective for failure to follow the medical treatment utilization schedule. Whether the utilization review followed the medical treatment utilization schedule is directly related to a determination of medical necessity. By statute, a review of a determination of medical necessity is limited to the medical professionals performing the independent medical review.
On the constitutional challenges, the Court affirmed the prior decision of Stevens v. Workers’ Comp. Appeals Bd. (2015) 241 Cal.App.4th 1074 on these issues ...
Ramirez settled his case by stipulations providing him with further medical treatment for the injury. The treatment included a gym/swim membership, and, over the course of about one and a half years.
His physician prescribed another 12 sessions of acupuncture. The utilization review recommended that the requested treatment be denied. Ramirez appealed the utilization review denial under the independent medical review process. IMR upheld the UR decision.
Ramirez appealed the decision of the independent medical review to the Board. The grounds for the appeal were that the independent medical reviewer "may have been subject to a material conflict of interest that is in violation of Section 139.5," and the "determination may have been the result of bias on the basis of race, national origin, ethnic group identification, religion, age, sex, sexual orientation, color, or disability."
Ramirez wanted discovery to determine whether the doctor performing the independent medical review was biased or had a conflict of interest. He also raised constitutional violations regarding the UR/IMR process which were beyond the jurisdiction of the WCAB. The appeal was taken off calendar pending resolution of the constitutional issues.
Ramirez filed a petition for writ of review with the Court of Appeal. His constitutional challenges were rejected in the published case of Ramirez v WCAB.
The Court concluded that the Board had no jurisdiction to review a utilization review that was alleged to be defective for failure to follow the medical treatment utilization schedule. Whether the utilization review followed the medical treatment utilization schedule is directly related to a determination of medical necessity. By statute, a review of a determination of medical necessity is limited to the medical professionals performing the independent medical review.
On the constitutional challenges, the Court affirmed the prior decision of Stevens v. Workers’ Comp. Appeals Bd. (2015) 241 Cal.App.4th 1074 on these issues ...
Russell Madson worked as a truck driver for Michael J. Cavaletto Ranches when he was involved in a motor vehicle accident on May 17, 2013. He sustained an accepted industrial injury to his head, neck, shoulders, and nervous system. However, he also alleged injury to psyche.
Madson is claustrophobic. He was pinned and crushed in the cab upside down for approximately 35 to 40 minutes. (Ibid.) He could only take shallow breaths. He was afraid that the truck would catch fire because the engine was still running and the truck had two full tanks of fuel. (Ibid.) He had to be freed from the wreckage using the ''.jaws of life." He described the event as "horrific."
A QME performed an evaluation and assigned him a GAF score of 58 and determined that 95% of his psychological impairment was caused by "the motor vehicle accident of May 17, 2013" and assigned 5% to outside stressors. This was equivalent to 35% for the psychiatric component after apportionment and adjustments in the rating string.
His injury occurred in 2013, which is subject to section 4660.l(c) and limits the compensability of permanent disability resulting from certain physical injuries with exceptions. Once of which is being a victim of a "violent act."
The WCJ did not award applicant psychiatric disability, opining on the definition of "violent act'' as follows: "In the undersigned's opinion as unfortunate as the applicant's vehicle accident was, the undersigned believes that the better and more reasonable interpretation of the statute is that there has to be at least some volitional act set in force by a human being with at least if not intent something more than mere negligence to bring the violent act exception into play. There is no evidence of that and accordingly, applicant is not entitled to receive permanent disability indemnity for his psychiatric claim."
The sole issue on reconsideration is whether applicant's psychiatric pennanent disability is ratable pursuant to section 4660.l(c).3 Applicant alleges that the motor vehicle accident constituted a "violent act" and thus an exception to the statute. Applicant further alleges that his injury does not arise out of the physical injury, but instead is directly caused by the accident itself and thus, section 4660. I is not applicable in this case. Applicant.
The WCAB rescinded the October 13, 2016 F&A and substitute a new Findings and Award, which includes an award of psychiatric impairment, which arose directly from the events of employment in the panel decision of Madson v Michael J. Cavaletto.
"Section 4660.1( c ) does not preclude increases in impairment ratings when the psyche injury arises directly from the events of employment. (See City of Los Angeles v. Workers' Comp. Appeals Bd.(Montenegro) (2016), 81 Cal.Comp.Cases 611 (writ den.) [holding that impairment caused by sexual dysfunction arising directly from the industrial injury is not precluded under section 4660.l(c)].)"
"The QME clearly opined that the traumatic stress that resulted in applicant's psychiatric disorder was the industrial accident itself and not the compensable physical injury. Thus, the preclusion of psychiatric impairment under section 4660.l(c) does not apply to applicant's injury." ...
Madson is claustrophobic. He was pinned and crushed in the cab upside down for approximately 35 to 40 minutes. (Ibid.) He could only take shallow breaths. He was afraid that the truck would catch fire because the engine was still running and the truck had two full tanks of fuel. (Ibid.) He had to be freed from the wreckage using the ''.jaws of life." He described the event as "horrific."
A QME performed an evaluation and assigned him a GAF score of 58 and determined that 95% of his psychological impairment was caused by "the motor vehicle accident of May 17, 2013" and assigned 5% to outside stressors. This was equivalent to 35% for the psychiatric component after apportionment and adjustments in the rating string.
His injury occurred in 2013, which is subject to section 4660.l(c) and limits the compensability of permanent disability resulting from certain physical injuries with exceptions. Once of which is being a victim of a "violent act."
The WCJ did not award applicant psychiatric disability, opining on the definition of "violent act'' as follows: "In the undersigned's opinion as unfortunate as the applicant's vehicle accident was, the undersigned believes that the better and more reasonable interpretation of the statute is that there has to be at least some volitional act set in force by a human being with at least if not intent something more than mere negligence to bring the violent act exception into play. There is no evidence of that and accordingly, applicant is not entitled to receive permanent disability indemnity for his psychiatric claim."
The sole issue on reconsideration is whether applicant's psychiatric pennanent disability is ratable pursuant to section 4660.l(c).3 Applicant alleges that the motor vehicle accident constituted a "violent act" and thus an exception to the statute. Applicant further alleges that his injury does not arise out of the physical injury, but instead is directly caused by the accident itself and thus, section 4660. I is not applicable in this case. Applicant.
The WCAB rescinded the October 13, 2016 F&A and substitute a new Findings and Award, which includes an award of psychiatric impairment, which arose directly from the events of employment in the panel decision of Madson v Michael J. Cavaletto.
"Section 4660.1( c ) does not preclude increases in impairment ratings when the psyche injury arises directly from the events of employment. (See City of Los Angeles v. Workers' Comp. Appeals Bd.(Montenegro) (2016), 81 Cal.Comp.Cases 611 (writ den.) [holding that impairment caused by sexual dysfunction arising directly from the industrial injury is not precluded under section 4660.l(c)].)"
"The QME clearly opined that the traumatic stress that resulted in applicant's psychiatric disorder was the industrial accident itself and not the compensable physical injury. Thus, the preclusion of psychiatric impairment under section 4660.l(c) does not apply to applicant's injury." ...
Safety violations citations issued to staffing firm Barrett Business Services following a September 28, 2011 carbon monoxide warehouse incident in Anaheim that sent eight temporary workers to the hospital were upheld by the Occupational Safety and Health Appeals Board (OSHAB).
For months prior to the incident, the workers contracted by Barrett Business Services to package fruits and nuts in L&L Foods’ warehouse in Anaheim had complained to their supervisor that they were experiencing headaches, nausea and other health issues caused by forklifts operating in an enclosed area with poor ventilation. Neither the Ontario-based staffing company nor host employer L&L Foods took any action.
On the day of the incident, a forklift driver became ill and was hospitalized for carbon monoxide (CO) poisoning, while seven other workers were taken to the hospital for treatment.
Cal/OSHA tested the facility and found the workers were exposed to CO levels of 250-350 parts per million, which exceeded the ceiling limit of 200 parts per million. Following an investigation, Cal/OSHA issued citations in 2012 to both Barrett Business Services and L&L Foods for numerous safety violations, including willful violations for failing to take action on known hazards.
Both employers filed appeals protesting the citations; L&L Foods settled its case on April 22, 2013. Following a lengthy appeal process that started in 2013, an administrative law judge last April denied Barrett’s appeal and imposed total civil penalties of $80,050.
Barrett objected to the appeal decision and on August 29, 2016, filed a petition for reconsideration with the Appeals Board.
The Board rendered its decision last December, citing evidence gained from Cal/OSHA’s investigation that the employer did not properly train its employees, disregarded workers’ reports of health hazards and failed to monitor the worksite.
The evidence revealed that L&L Foods had sealed all of the vents at the facility to prevent vermin from entering the establishment. Barrett did not assess the safety conditions for the enclosed environment, failed to control the increased carbon monoxide levels in the workplace and continually disregarded worker’s reports of headaches and nausea from the fumes.
The citations issued included three violations for one general, one willful general and one willful serious category violation. A willful violation is cited when the employer is aware of the law and violates it nevertheless, or when the employer is aware of the hazardous condition and takes no reasonable steps to address it.
A serious violation is cited when there is a realistic possibility that death or serious harm could result from the actual hazard created by the violation.
A general violation is cited when an accident or occupational illness resulting from violation of a standard would probably not cause death or serious physical harm, but would have a direct or immediate relationship to the safety or health of employees ...
For months prior to the incident, the workers contracted by Barrett Business Services to package fruits and nuts in L&L Foods’ warehouse in Anaheim had complained to their supervisor that they were experiencing headaches, nausea and other health issues caused by forklifts operating in an enclosed area with poor ventilation. Neither the Ontario-based staffing company nor host employer L&L Foods took any action.
On the day of the incident, a forklift driver became ill and was hospitalized for carbon monoxide (CO) poisoning, while seven other workers were taken to the hospital for treatment.
Cal/OSHA tested the facility and found the workers were exposed to CO levels of 250-350 parts per million, which exceeded the ceiling limit of 200 parts per million. Following an investigation, Cal/OSHA issued citations in 2012 to both Barrett Business Services and L&L Foods for numerous safety violations, including willful violations for failing to take action on known hazards.
Both employers filed appeals protesting the citations; L&L Foods settled its case on April 22, 2013. Following a lengthy appeal process that started in 2013, an administrative law judge last April denied Barrett’s appeal and imposed total civil penalties of $80,050.
Barrett objected to the appeal decision and on August 29, 2016, filed a petition for reconsideration with the Appeals Board.
The Board rendered its decision last December, citing evidence gained from Cal/OSHA’s investigation that the employer did not properly train its employees, disregarded workers’ reports of health hazards and failed to monitor the worksite.
The evidence revealed that L&L Foods had sealed all of the vents at the facility to prevent vermin from entering the establishment. Barrett did not assess the safety conditions for the enclosed environment, failed to control the increased carbon monoxide levels in the workplace and continually disregarded worker’s reports of headaches and nausea from the fumes.
The citations issued included three violations for one general, one willful general and one willful serious category violation. A willful violation is cited when the employer is aware of the law and violates it nevertheless, or when the employer is aware of the hazardous condition and takes no reasonable steps to address it.
A serious violation is cited when there is a realistic possibility that death or serious harm could result from the actual hazard created by the violation.
A general violation is cited when an accident or occupational illness resulting from violation of a standard would probably not cause death or serious physical harm, but would have a direct or immediate relationship to the safety or health of employees ...
A Los Angeles Superior Court jury has ruled in favor of a disabled, minimum wage worker deemed wrongfully terminated by high-end jeans manufacturer, Citizens of Humanity.
Employers are typically aware of the penalties that can be imposed under Labor Code section 132a for discriminating against an injured worker, and take necessary measures to avoid the risks of such claims.
But, in addition to the 132a risk, employers face discrimination claims under the Americans with Disabilities Act (ADA), and the California equivalent known as the Fair Employment Housing Act (FEHA).
Digging deeper into the risks, at a lower level is the garden variety wrongful termination claim. A recent Los Angeles jury verdict serves as a grim reminder that legacy wrongful termination claims are alive and well.
According to court documents (Case No: BC521900), the jury found with clear and convincing evidence that ‘Citizens of Humanity’ acted with malice, fraud, and oppression when they fired an employee who had suffered an industrial injury.
61 year old Noe Abarca was born and raised with eight brothers and sisters in a small hut made of rocks, hay, and cardboard in Guerro, Mexico.
He moved to the US in 1981 and became a permanent resident and worked in the garment industry for the past 30 years. He raised six daughters; five have gone on to UCLA, UC-Berkley, UCSD, USC and CSUN, his youngest is 11-years old.
Mr. Abarca, worked as a quality control inspector for six years when his doctor placed him on a work restriction due to a long-term shoulder injury sustained by lifting boxes over the years. The day the restriction ended, the company fired Mr. Abarca.
The jury concluded that the Director of Human Resources fraudulently stated on the workers compensation form that ‘Citizens of Humanity’ had first learned of the injury on the day of Mr. Abarca’s termination. Damages amounting to $650,000 were awarded, with a significant $550,000 designated punitive damages.
Managing risks of liability arising out of employment law claims becomes a more complex task every year. The Floyd Skeren & Kelly annual Employment Law Conference provides a great opportunity to learn more about these risks. More than 300 people are expected to attend the Seventh Annual Employment Law Conference on April 28th at the Disneyland Hotel ...
Employers are typically aware of the penalties that can be imposed under Labor Code section 132a for discriminating against an injured worker, and take necessary measures to avoid the risks of such claims.
But, in addition to the 132a risk, employers face discrimination claims under the Americans with Disabilities Act (ADA), and the California equivalent known as the Fair Employment Housing Act (FEHA).
Digging deeper into the risks, at a lower level is the garden variety wrongful termination claim. A recent Los Angeles jury verdict serves as a grim reminder that legacy wrongful termination claims are alive and well.
According to court documents (Case No: BC521900), the jury found with clear and convincing evidence that ‘Citizens of Humanity’ acted with malice, fraud, and oppression when they fired an employee who had suffered an industrial injury.
61 year old Noe Abarca was born and raised with eight brothers and sisters in a small hut made of rocks, hay, and cardboard in Guerro, Mexico.
He moved to the US in 1981 and became a permanent resident and worked in the garment industry for the past 30 years. He raised six daughters; five have gone on to UCLA, UC-Berkley, UCSD, USC and CSUN, his youngest is 11-years old.
Mr. Abarca, worked as a quality control inspector for six years when his doctor placed him on a work restriction due to a long-term shoulder injury sustained by lifting boxes over the years. The day the restriction ended, the company fired Mr. Abarca.
The jury concluded that the Director of Human Resources fraudulently stated on the workers compensation form that ‘Citizens of Humanity’ had first learned of the injury on the day of Mr. Abarca’s termination. Damages amounting to $650,000 were awarded, with a significant $550,000 designated punitive damages.
Managing risks of liability arising out of employment law claims becomes a more complex task every year. The Floyd Skeren & Kelly annual Employment Law Conference provides a great opportunity to learn more about these risks. More than 300 people are expected to attend the Seventh Annual Employment Law Conference on April 28th at the Disneyland Hotel ...
Peter Sylves was employed by the County as a deputy sheriff. He took a service retirement and then worked for the Pauma Police Department on a reservation belonging to the Pauma Band of Luiseno Indians.
He filed an application for adjudication of claim on July 16, 2014. He claimed a continuous trauma for "hypertension, GERDS [gastroesophageal reflux disease], left shoulder, low back and both knees."
After a hearing, the WCJ issued his findings of fact. Under the heading titled "Statute of Limitations," he found: "Pursuant to Labor Code section 5500.5, applicant’s continuous trauma is limited to the last year of injurious exposure, even if it is with the Pauma Tribal Police." The WCJ found that Sylves’s knee and left shoulder injuries, his GERDS, and his sleep disorder were not compensable injuries arising in and out of employment. However, he also found that Sylves’s hypertension and back injury were compensable and arose from employment with the County.
Both parties requested reconsideration. An opinion and decision after reconsideration found "substantial medical evidence support[ing] industrial injury to [Sylves’s] left shoulder, bilateral knees, GERD and sleep disorder."
With respect to the statute of limitations, the WCAB explained that the time in which to file a claim did not begin to run until a doctor told him the symptoms for which he had been receiving treatment were industrially related; since medical confirmation did not occur until 2013, Sylves’s 2014 application was timely. The WCAB further found that section 5500.5 "is not a Statute of Limitations but provides for a supplemental proceeding in which multiple defendants have an opportunity to apportion liability." Finally, it agreed with Sylves that section 5500.5 cannot limit liability to the Pauma Police Department in this case because the WCAB lacks jurisdiction over the tribe.
The Court of Appeal granted review in the published case of County of Riverside v WCAB and Peter Sylves in order to provide better clarity regarding the application of section 5500.5. It affirmed the WCAB decision after reconsideration.
Limiting the liability of the defendants in a workers’ compensation case is not the same as prescribing the time in which that case can be filed. Since neither the language nor the history of section 5500.5 evidences a concern with the limitations period for filing an application for workers’ compensation benefits, the court rejected the County’s suggestion that the WCAB violated section 5500.5(a) when it found Sylves’s claims to be timely. Section 5500.5(a) does not relate to the statute of limitations for filing an application for adjudication of benefits.
Section 5500.5(a) provides that "In the event that none of the employers during [last year] of occupational disease or cumulative injury are insured for workers’ compensation coverage or an approved alternative thereof, liability shall be imposed upon the last year of employment exposing the employee to the hazards of the occupational disease or cumulative injury for which an employer is insured for workers’ compensation coverage or an approved alternative thereof."
The WCAB lacks jurisdiction over federally recognized Indian tribes. The fact that the Pauma Police Department is not subject to the WCAB’s jurisdiction means the department was not "insured for workers’ compensation coverage or an approved alternative thereof." Consequently, liability is imposed on the next employer in line that had workers’ compensation insurance. In this case, that employer is the County ...
He filed an application for adjudication of claim on July 16, 2014. He claimed a continuous trauma for "hypertension, GERDS [gastroesophageal reflux disease], left shoulder, low back and both knees."
After a hearing, the WCJ issued his findings of fact. Under the heading titled "Statute of Limitations," he found: "Pursuant to Labor Code section 5500.5, applicant’s continuous trauma is limited to the last year of injurious exposure, even if it is with the Pauma Tribal Police." The WCJ found that Sylves’s knee and left shoulder injuries, his GERDS, and his sleep disorder were not compensable injuries arising in and out of employment. However, he also found that Sylves’s hypertension and back injury were compensable and arose from employment with the County.
Both parties requested reconsideration. An opinion and decision after reconsideration found "substantial medical evidence support[ing] industrial injury to [Sylves’s] left shoulder, bilateral knees, GERD and sleep disorder."
With respect to the statute of limitations, the WCAB explained that the time in which to file a claim did not begin to run until a doctor told him the symptoms for which he had been receiving treatment were industrially related; since medical confirmation did not occur until 2013, Sylves’s 2014 application was timely. The WCAB further found that section 5500.5 "is not a Statute of Limitations but provides for a supplemental proceeding in which multiple defendants have an opportunity to apportion liability." Finally, it agreed with Sylves that section 5500.5 cannot limit liability to the Pauma Police Department in this case because the WCAB lacks jurisdiction over the tribe.
The Court of Appeal granted review in the published case of County of Riverside v WCAB and Peter Sylves in order to provide better clarity regarding the application of section 5500.5. It affirmed the WCAB decision after reconsideration.
Limiting the liability of the defendants in a workers’ compensation case is not the same as prescribing the time in which that case can be filed. Since neither the language nor the history of section 5500.5 evidences a concern with the limitations period for filing an application for workers’ compensation benefits, the court rejected the County’s suggestion that the WCAB violated section 5500.5(a) when it found Sylves’s claims to be timely. Section 5500.5(a) does not relate to the statute of limitations for filing an application for adjudication of benefits.
Section 5500.5(a) provides that "In the event that none of the employers during [last year] of occupational disease or cumulative injury are insured for workers’ compensation coverage or an approved alternative thereof, liability shall be imposed upon the last year of employment exposing the employee to the hazards of the occupational disease or cumulative injury for which an employer is insured for workers’ compensation coverage or an approved alternative thereof."
The WCAB lacks jurisdiction over federally recognized Indian tribes. The fact that the Pauma Police Department is not subject to the WCAB’s jurisdiction means the department was not "insured for workers’ compensation coverage or an approved alternative thereof." Consequently, liability is imposed on the next employer in line that had workers’ compensation insurance. In this case, that employer is the County ...
Europe's medicines regulator has recommended the suspension of more than 300 generic drug approvals and drug applications due to "unreliable" tests conducted by Indian contract research firm Micro Therapeutic Research Labs.
The decision, announced by the European Medicines Agency (EMA) on its website, is the latest blow for India's drug-testing industry, which has run into a series of problems with international regulators in recent years.
Nobody at the Chennai-based company was immediately available to comment.
A contract research organization (CRO) is an organization that provides support to the pharmaceutical, biotechnology, and medical device industries in the form of research services outsourced on a contract basis. ... CROs range from large, international full-service organizations to small, niche specialty groups.
According to the report in Reuters Health, the EMA said European officials had been investigating Micro Therapeutic's compliance with good clinical practice after Austrian and Dutch authorities raised concerns in February 2016.
"The inspections identified several concerns at the company’s sites regarding misrepresentation of study data and deficiencies in documentation and data handling," the agency said.
However, there is no evidence of harm or lack of effectiveness of the medicines, which include generic versions of many common prescription pharmaceuticals, including blood pressure tablets and painkillers.
The EMA's recommendation on the suspension of the medicines tested by Micro Therapeutic will now be sent to the European Commission for a legally binding decision valid throughout the European Union.
Drug tests carried out at Indian contract research organizations (CROs) have been key in getting a huge array of generic medicines approved for sale around the world over many years.
In 2015, Europe banned around 700 medicines that had been approved based on clinical trial data provided by GVK Biosciences, then India’s largest CRO. Other smaller Indian CROs have also been found to have fallen short of required standards.
In the wake of such trial data scandals, many large drugmakers have been shifting more critical trials back to the United States and Europe over the last three years, according to consultants and industry executives ...
The decision, announced by the European Medicines Agency (EMA) on its website, is the latest blow for India's drug-testing industry, which has run into a series of problems with international regulators in recent years.
Nobody at the Chennai-based company was immediately available to comment.
A contract research organization (CRO) is an organization that provides support to the pharmaceutical, biotechnology, and medical device industries in the form of research services outsourced on a contract basis. ... CROs range from large, international full-service organizations to small, niche specialty groups.
According to the report in Reuters Health, the EMA said European officials had been investigating Micro Therapeutic's compliance with good clinical practice after Austrian and Dutch authorities raised concerns in February 2016.
"The inspections identified several concerns at the company’s sites regarding misrepresentation of study data and deficiencies in documentation and data handling," the agency said.
However, there is no evidence of harm or lack of effectiveness of the medicines, which include generic versions of many common prescription pharmaceuticals, including blood pressure tablets and painkillers.
The EMA's recommendation on the suspension of the medicines tested by Micro Therapeutic will now be sent to the European Commission for a legally binding decision valid throughout the European Union.
Drug tests carried out at Indian contract research organizations (CROs) have been key in getting a huge array of generic medicines approved for sale around the world over many years.
In 2015, Europe banned around 700 medicines that had been approved based on clinical trial data provided by GVK Biosciences, then India’s largest CRO. Other smaller Indian CROs have also been found to have fallen short of required standards.
In the wake of such trial data scandals, many large drugmakers have been shifting more critical trials back to the United States and Europe over the last three years, according to consultants and industry executives ...
A legal battle has pitted a major national insurer and its pharmacy benefit manager (PBM) against each other in dueling legal actions in litigation that seeks class action status that could include tens of thousands of claimants.
Anthem is one of the nation’s largest health insurers with more than 38 million members. Express Scripts handled more than 175 million claims for Anthem in 2015 alone, according to the complaint.
The saga starts when Anthem sued Express Scripts last March, accusing it of excessive pricing and operational failures. It also sought the right to terminate its 10-year contract with Express Scripts, which began in 2009.
Express Scripts was contracted as Anthem’s exclusive provider of PBM services for Anthem-administered health insurance plans for a ten year period. Part of the agreement was a "periodic pricing review" to ensure that Anthem was receiving competitive benchmark pricing for drugs. However, when Anthem engaged Health Strategy, LLC. as a private consultant to conduct a comprehensive market analysis Anthem discovered that Express Scripts did not provide competitive benchmark pricing.
Based on the Health Strategy’s analysis, ESI’s current pricing to Anthem exceeded competitive benchmark pricing by more than $3 billion annually, and $13 billion over the remaining term of the Agreement. This was the basis of the March Anthem v Express Scripts litigation.
In its counterclaims against Anthem, Express Scripts said the insurer rejected several proposals to renegotiate prices. In addition, Express Scripts’ legal document says Anthem was offered a choice of "less money up front but lower pricing" or a bigger upfront payment "with higher pricing for Express Scripts’ services."
It chose the higher prices over the course of the contract in exchange $4.6 billion more in upfront fees, according to the PBM’s counterclaim. That money, Express Scripts’ documents allege, was then used by Anthem to buy back its own stock, rather than passing it along to health plan members. The stock buyback "applied upward pressure to Anthem’s stock price, thereby enriching shareholders and management," the filing alleges.
Two months later, two health plan participants sued both companies under the Employee Retirement Income Security Act challenging Express Scripts' alleged overbilling.
Express Scripts Inc. and Anthem Inc. are accused in a proposed class action of breaching their ERISA fiduciary duties by entering into the 10-year, multibillion-dollar prescription-drug agreement that caused plan participants to overpay for benefits ( Burnett v. Express Scripts, Inc. , S.D.N.Y., No. 1:16-cv-04948, complaint filed 6/24/16 ). "This action seeks to recover losses suffered by the plaintiffs...who overpaid and continue to overpay for the portions of the costs of prescription drugs...they are responsible for paying as plan participants," says the lawsuit.
Express Scripts spokesman David Whitrap said the firm denies "the allegations and will defend ourselves vigorously." Anthem, too, denied the allegations and said it would fight the charges. However, the "denied" allegations echo those in Anthem’s March lawsuit against Express Scripts, and counterclaims filed shortly thereafter by Express Scripts against Anthem.
The court has not yet decided if the suit will have class action status.
The federal judge has dismissed two of the six counterclaims that Express Scripts raised in Anthem $15 billion lawsuit. In a decision recently made public, U.S. District Judge Edgardo Ramos in Manhattan dismissed Express Scripts' claim that Anthem breached an implied covenant of good faith and fair dealing, saying it duplicated a breach of contract claim. He also dismissed an unjust enrichment claim filed by Express Scripts.
Express Scripts has contracts with insurers and other administrators of workers' compensation benefits in California. It is unclear if any of Anthem's allegations apply to any of the California workers' compensation pharmacy benefit contracts ...
Anthem is one of the nation’s largest health insurers with more than 38 million members. Express Scripts handled more than 175 million claims for Anthem in 2015 alone, according to the complaint.
The saga starts when Anthem sued Express Scripts last March, accusing it of excessive pricing and operational failures. It also sought the right to terminate its 10-year contract with Express Scripts, which began in 2009.
Express Scripts was contracted as Anthem’s exclusive provider of PBM services for Anthem-administered health insurance plans for a ten year period. Part of the agreement was a "periodic pricing review" to ensure that Anthem was receiving competitive benchmark pricing for drugs. However, when Anthem engaged Health Strategy, LLC. as a private consultant to conduct a comprehensive market analysis Anthem discovered that Express Scripts did not provide competitive benchmark pricing.
Based on the Health Strategy’s analysis, ESI’s current pricing to Anthem exceeded competitive benchmark pricing by more than $3 billion annually, and $13 billion over the remaining term of the Agreement. This was the basis of the March Anthem v Express Scripts litigation.
In its counterclaims against Anthem, Express Scripts said the insurer rejected several proposals to renegotiate prices. In addition, Express Scripts’ legal document says Anthem was offered a choice of "less money up front but lower pricing" or a bigger upfront payment "with higher pricing for Express Scripts’ services."
It chose the higher prices over the course of the contract in exchange $4.6 billion more in upfront fees, according to the PBM’s counterclaim. That money, Express Scripts’ documents allege, was then used by Anthem to buy back its own stock, rather than passing it along to health plan members. The stock buyback "applied upward pressure to Anthem’s stock price, thereby enriching shareholders and management," the filing alleges.
Two months later, two health plan participants sued both companies under the Employee Retirement Income Security Act challenging Express Scripts' alleged overbilling.
Express Scripts Inc. and Anthem Inc. are accused in a proposed class action of breaching their ERISA fiduciary duties by entering into the 10-year, multibillion-dollar prescription-drug agreement that caused plan participants to overpay for benefits ( Burnett v. Express Scripts, Inc. , S.D.N.Y., No. 1:16-cv-04948, complaint filed 6/24/16 ). "This action seeks to recover losses suffered by the plaintiffs...who overpaid and continue to overpay for the portions of the costs of prescription drugs...they are responsible for paying as plan participants," says the lawsuit.
Express Scripts spokesman David Whitrap said the firm denies "the allegations and will defend ourselves vigorously." Anthem, too, denied the allegations and said it would fight the charges. However, the "denied" allegations echo those in Anthem’s March lawsuit against Express Scripts, and counterclaims filed shortly thereafter by Express Scripts against Anthem.
The court has not yet decided if the suit will have class action status.
The federal judge has dismissed two of the six counterclaims that Express Scripts raised in Anthem $15 billion lawsuit. In a decision recently made public, U.S. District Judge Edgardo Ramos in Manhattan dismissed Express Scripts' claim that Anthem breached an implied covenant of good faith and fair dealing, saying it duplicated a breach of contract claim. He also dismissed an unjust enrichment claim filed by Express Scripts.
Express Scripts has contracts with insurers and other administrators of workers' compensation benefits in California. It is unclear if any of Anthem's allegations apply to any of the California workers' compensation pharmacy benefit contracts ...
The biggest marijuana market for now is the United States, with estimates that it will surpass $20 billion by 2020. And the workers' compensation industry is carefully watching the evolving trend, which some say will soon reach its doorstep. The momentum is increasing with billions of dollars now pushing the momentum to yet higher levels of energy.
But importing cannabis to the United States is illegal under federal law. The only way to get around the ban is to receive approval from the U.S. Food and Drug Administration (FDA).
Britain's GW Pharmaceuticals' Epidiolex - an experimental cannabis-based drug to treat epilepsy - could be the first to get the green light.
"The medical cannabis industry is much larger than the U.S.," said Matthew Ginder, whose Florida-based law firm represents cannabis businesses, including in Israel. Growing acceptance of medical marijuana creates opportunities in countries that have legalized medical marijuana but have not developed the infrastructure, he said.
Canada, for instance, exports medical cannabis to Australia, Croatia and Chile.
And now Reuters Health reports that Israel, a leader in marijuana research and health technology, is attracting international investment as it tries to position itself as a cutting-edge exporter in the rapidly-growing market for medical-grade cannabis.
With estimates that the global market for medical marijuana could reach $50 billion by 2025, the Israeli government is set to allow the local industry to start exporting and projects annual revenues in the hundreds of millions of dollars.
Medical cannabis is a relatively new field with no universal clinical standard. Israel aims to fill the void by combining its expertise in agriculture, technology and cannabis-based medicine, said Yuval Landschaft, head of the health ministry's medical cannabis unit (IMCA).
"In the United States, for example, they use recreational marijuana for medical use - that's like making chicken soup when you have a cold," Landschaft told Reuters. "We're the ones making the antibiotics."
The strategy is to create medical-grade cannabis with quality and efficacy ensured along the entire supply chain from cultivation to manufacture and distribution.
In contrast to the United States, which is currently the biggest legal marijuana market, authorities in Israel are liberal in their support of research and development.
Licensed marijuana growers work with scientific institutions in clinical trials toward the development of cannabis strains that treat a variety of illnesses and disorders.
There are about 120 studies ongoing in Israel, including clinical trials looking at the effects of cannabis on autism, epilepsy, psoriasis and tinnitus.
The health ministry wants to share its acquired knowledge and train doctors from abroad. Talks are underway with Australia, Germany, Brazil and others, Landschaft said.
The government gave the go-ahead in February to legislation that would allow export.
More than 500 Israeli companies have applied for licenses to grow, manufacture and export cannabis products, according to government officials, and some are already capitalizing on the booming U.S. market.
In the past year, U.S. and other firms have invested about $100 million to license Israeli medical marijuana patents, cannabis agro-tech startups and firms developing delivery devices such as inhalers, said Saul Kaye, chief executive of iCAN, a private cannabis research hub in Israel.
Kaye expects investment to grow ten-fold and reach $1 billion over the next two years.
Tikun Olam, Israel's largest grower, has partnered with U.S. companies to cultivate marijuana in four U.S. states, chief executive Aharon Lutzky said. Pending government approval, it hopes to export to Europe and South America ...
But importing cannabis to the United States is illegal under federal law. The only way to get around the ban is to receive approval from the U.S. Food and Drug Administration (FDA).
Britain's GW Pharmaceuticals' Epidiolex - an experimental cannabis-based drug to treat epilepsy - could be the first to get the green light.
"The medical cannabis industry is much larger than the U.S.," said Matthew Ginder, whose Florida-based law firm represents cannabis businesses, including in Israel. Growing acceptance of medical marijuana creates opportunities in countries that have legalized medical marijuana but have not developed the infrastructure, he said.
Canada, for instance, exports medical cannabis to Australia, Croatia and Chile.
And now Reuters Health reports that Israel, a leader in marijuana research and health technology, is attracting international investment as it tries to position itself as a cutting-edge exporter in the rapidly-growing market for medical-grade cannabis.
With estimates that the global market for medical marijuana could reach $50 billion by 2025, the Israeli government is set to allow the local industry to start exporting and projects annual revenues in the hundreds of millions of dollars.
Medical cannabis is a relatively new field with no universal clinical standard. Israel aims to fill the void by combining its expertise in agriculture, technology and cannabis-based medicine, said Yuval Landschaft, head of the health ministry's medical cannabis unit (IMCA).
"In the United States, for example, they use recreational marijuana for medical use - that's like making chicken soup when you have a cold," Landschaft told Reuters. "We're the ones making the antibiotics."
The strategy is to create medical-grade cannabis with quality and efficacy ensured along the entire supply chain from cultivation to manufacture and distribution.
In contrast to the United States, which is currently the biggest legal marijuana market, authorities in Israel are liberal in their support of research and development.
Licensed marijuana growers work with scientific institutions in clinical trials toward the development of cannabis strains that treat a variety of illnesses and disorders.
There are about 120 studies ongoing in Israel, including clinical trials looking at the effects of cannabis on autism, epilepsy, psoriasis and tinnitus.
The health ministry wants to share its acquired knowledge and train doctors from abroad. Talks are underway with Australia, Germany, Brazil and others, Landschaft said.
The government gave the go-ahead in February to legislation that would allow export.
More than 500 Israeli companies have applied for licenses to grow, manufacture and export cannabis products, according to government officials, and some are already capitalizing on the booming U.S. market.
In the past year, U.S. and other firms have invested about $100 million to license Israeli medical marijuana patents, cannabis agro-tech startups and firms developing delivery devices such as inhalers, said Saul Kaye, chief executive of iCAN, a private cannabis research hub in Israel.
Kaye expects investment to grow ten-fold and reach $1 billion over the next two years.
Tikun Olam, Israel's largest grower, has partnered with U.S. companies to cultivate marijuana in four U.S. states, chief executive Aharon Lutzky said. Pending government approval, it hopes to export to Europe and South America ...
A Maine woman has filed suit in federal court against a California security services firm, saying the company retaliated against her when she complained about allegedly illegal acts being committed by one of its executives, Ousama Karawia.
Karawia was convicted in Los Angeles in 2012 for grand theft, insurance fraud and possession of an assault weapon for offenses committed at a security service he co-owned at the time that had provided security for sites in California and the Statue of Liberty in New York.
He was found guilty in 2012 of setting up a shell company to hide the true number of his employees as a way to avoid paying higher workers’ compensation premiums.
The trial court sentenced Karawia to five years in state prison on the fraud by misrepresentation count, suspended execution of that sentence, and placed him on probation for a period of five years on the condition that he serve 240 days in custody, which could be served by electronic monitoring.
According to the report in the Portland Press Herald, Pamela Treadwell, who worked for Vescom from 1988 until she resigned in March 2014, said in court documents that many of the problems began when Vescom, her employer, hired a man named Ousama Karawia to help with management of the firm.
Vescom is a part of Worldwide Sourcing Group, or WWSG, which also owns the security firms Vets Securing America, American Guard Service and Professional Building Maintenance, a property management company. The company says it is one of the largest privately owned security firms in the country.
Vescom had an office in Hampden Maine that has since been closed, and the company is now based in California. Treadwell’s lawsuit was filed in Maine state court and subsequently moved to the U.S. District Court in Portland because Vescom is located out of state.
According to the 2017 lawsuit, Karawia allegedly committed insurance fraud while at Vescom by getting a policy that covered employees of WWSG’s other companies at a low rate, but using Vescom’s claims history rather than the higher claims rate of the other companies.
Treadwell said in the lawsuit that she told the company’s owners that Karawia was getting kickbacks from the insurer and that having him involved in the company ran afoul of state licensing regulations that bar felons from having management positions in a security firm. Karawia had of course been convicted in the above California criminal case before he was hired at Vescom, and his appeal of his sentence was turned down by the California Court of Appeal in 2014.
After forwarding those concerns to the company’s owners, the lawsuit claims, Treadwell was shunned by the top management in the company and told she had to pay for insurance coverage for her husband on her employer-provided health care policy at a cost of $7,800 a year.
Finally, Karawia moved money out of the company’s payroll account, meaning that employees’ checks would bounce, according to the lawsuit. Treadwell said Karawia reminded her that as the company vice president, her name was on the checks, suggesting she might be liable if they bounced.
At that point, Treadwell said she resigned so as not to be implicated in the check-bouncing and accused of submitting false documents to state regulators ...
Karawia was convicted in Los Angeles in 2012 for grand theft, insurance fraud and possession of an assault weapon for offenses committed at a security service he co-owned at the time that had provided security for sites in California and the Statue of Liberty in New York.
He was found guilty in 2012 of setting up a shell company to hide the true number of his employees as a way to avoid paying higher workers’ compensation premiums.
The trial court sentenced Karawia to five years in state prison on the fraud by misrepresentation count, suspended execution of that sentence, and placed him on probation for a period of five years on the condition that he serve 240 days in custody, which could be served by electronic monitoring.
According to the report in the Portland Press Herald, Pamela Treadwell, who worked for Vescom from 1988 until she resigned in March 2014, said in court documents that many of the problems began when Vescom, her employer, hired a man named Ousama Karawia to help with management of the firm.
Vescom is a part of Worldwide Sourcing Group, or WWSG, which also owns the security firms Vets Securing America, American Guard Service and Professional Building Maintenance, a property management company. The company says it is one of the largest privately owned security firms in the country.
Vescom had an office in Hampden Maine that has since been closed, and the company is now based in California. Treadwell’s lawsuit was filed in Maine state court and subsequently moved to the U.S. District Court in Portland because Vescom is located out of state.
According to the 2017 lawsuit, Karawia allegedly committed insurance fraud while at Vescom by getting a policy that covered employees of WWSG’s other companies at a low rate, but using Vescom’s claims history rather than the higher claims rate of the other companies.
Treadwell said in the lawsuit that she told the company’s owners that Karawia was getting kickbacks from the insurer and that having him involved in the company ran afoul of state licensing regulations that bar felons from having management positions in a security firm. Karawia had of course been convicted in the above California criminal case before he was hired at Vescom, and his appeal of his sentence was turned down by the California Court of Appeal in 2014.
After forwarding those concerns to the company’s owners, the lawsuit claims, Treadwell was shunned by the top management in the company and told she had to pay for insurance coverage for her husband on her employer-provided health care policy at a cost of $7,800 a year.
Finally, Karawia moved money out of the company’s payroll account, meaning that employees’ checks would bounce, according to the lawsuit. Treadwell said Karawia reminded her that as the company vice president, her name was on the checks, suggesting she might be liable if they bounced.
At that point, Treadwell said she resigned so as not to be implicated in the check-bouncing and accused of submitting false documents to state regulators ...
A new study on the use of spinal fusion surgeries in California workers’ compensation finds that in 60% of all spinal fusion claims the initial report of injury was for a sprain or strain; a majority of the fusions occurred within two years of the injury; and as the claims aged, more than 20% involved at least one subsequent fusion surgery.
The analysis by the California Workers’ Compensation Institute (CWCI) is based on data from more than 18,266 California work injury claims from accident years (AY) 2000 through 2014 in which one or more spinal fusions were performed. Using claims data from the Institute’s Industry Research Information System database, CWCI Senior Research Associate Stacy L. Jones identified spinal fusion claim characteristics (cause and nature of injury, part of the spine that was fused and the number of spinal segments involved); patient demographics; the presence of comorbidities; and the average amounts paid in indemnity and medical benefits.
In addition the study measured the timing of the initial fusion and the presence and timing of any subsequent fusions; independent medical review outcomes for spinal fusion requests; utilization trends for MRIs, pre- and post-surgery physical therapy, and the level of pre- and post-surgical opioid use. Among the findings:
- Men accounted for more than 64% of the spinal fusion claims in each of the 15 years studied, and average amounts paid across the entire span were higher for males than females (15.5% more for temporary disability; 27.1% more for permanent disability; and 16% more for medical).
- 62% of the claims that involved a spinal fusion were initially reported as strain and sprains; followed by cumulative traumas (including mental stress), which comprised 14%.
- Lumbar fusions accounted for nearly half of the workers’ comp spinal fusions; while fusions involving additional vertebral segments (i.e., multiple-level fusions) represented 1/3 of all fusions.
- Mental health disorders were the leading comorbidity (noted in 37% of spinal fusion cases), while 29.9% involved circulatory problems, and 17.1% listed substance abuse as a comorbid condition.
- Loss payments on medical back diagnoses without spinal cord involvement averaged as much as $378,392 in AY 2003, or 6.7 times the average for similar claims without a spinal fusion.
The Institute has published a full report on the study, including additional results, background information, tables, and commentary as a CWCI Report to the Industry, "Spinal Fusion Claims in California Workers’ Compensation." CWCI members and subscribers may log on to the Research section to access the report, while others may purchase the report for $32 ...
The analysis by the California Workers’ Compensation Institute (CWCI) is based on data from more than 18,266 California work injury claims from accident years (AY) 2000 through 2014 in which one or more spinal fusions were performed. Using claims data from the Institute’s Industry Research Information System database, CWCI Senior Research Associate Stacy L. Jones identified spinal fusion claim characteristics (cause and nature of injury, part of the spine that was fused and the number of spinal segments involved); patient demographics; the presence of comorbidities; and the average amounts paid in indemnity and medical benefits.
In addition the study measured the timing of the initial fusion and the presence and timing of any subsequent fusions; independent medical review outcomes for spinal fusion requests; utilization trends for MRIs, pre- and post-surgery physical therapy, and the level of pre- and post-surgical opioid use. Among the findings:
- Men accounted for more than 64% of the spinal fusion claims in each of the 15 years studied, and average amounts paid across the entire span were higher for males than females (15.5% more for temporary disability; 27.1% more for permanent disability; and 16% more for medical).
- 62% of the claims that involved a spinal fusion were initially reported as strain and sprains; followed by cumulative traumas (including mental stress), which comprised 14%.
- Lumbar fusions accounted for nearly half of the workers’ comp spinal fusions; while fusions involving additional vertebral segments (i.e., multiple-level fusions) represented 1/3 of all fusions.
- Mental health disorders were the leading comorbidity (noted in 37% of spinal fusion cases), while 29.9% involved circulatory problems, and 17.1% listed substance abuse as a comorbid condition.
- Loss payments on medical back diagnoses without spinal cord involvement averaged as much as $378,392 in AY 2003, or 6.7 times the average for similar claims without a spinal fusion.
The Institute has published a full report on the study, including additional results, background information, tables, and commentary as a CWCI Report to the Industry, "Spinal Fusion Claims in California Workers’ Compensation." CWCI members and subscribers may log on to the Research section to access the report, while others may purchase the report for $32 ...
