The Division of Workers’ Compensation (DWC) has suspended three more medical providers from participating in California’s workers’ compensation system, bringing the total number of providers suspended this year to 49.
DWC Acting Administrative Director George Parisotto issued Orders of Suspension against the following providers:
1) Samuel H. Albert of Tustin, psychiatrist, pled guilty in the U.S. District Court for the Central District of California on June 20, 2016 to conspiracy to commit health care fraud. Albert had submitted over $4.2 million in fraudulent claims to the Federal Office of Workers’ Compensation Programs.
2) Barry Julian Broomberg of San Diego, physician and owner of La Jolla Medical Associates, pled guilty in the U.S. District Court for the Southern District of California on September 4, 2013 to visa fraud, and surrendered his Physician’s and Surgeon’s Certificate on September 9, 2014. Broomberg knowingly made false statements under penalty of perjury on visa applicants’ Report of Medical Examination and Vaccination Record forms (United States Citizenship and Immigration Services Form I-693) without performing the required tests and examinations.
3) Robert E. Brizendine of San Diego, psychologist, surrendered his Psychologist’s License to the California Board of Psychology on March 20, 2014.
New law requires the division’s Administrative Director to suspend any medical provider, physician or practitioner from participating in the workers’ compensation system in circumstances as described above ...
DWC Acting Administrative Director George Parisotto issued Orders of Suspension against the following providers:
1) Samuel H. Albert of Tustin, psychiatrist, pled guilty in the U.S. District Court for the Central District of California on June 20, 2016 to conspiracy to commit health care fraud. Albert had submitted over $4.2 million in fraudulent claims to the Federal Office of Workers’ Compensation Programs.
2) Barry Julian Broomberg of San Diego, physician and owner of La Jolla Medical Associates, pled guilty in the U.S. District Court for the Southern District of California on September 4, 2013 to visa fraud, and surrendered his Physician’s and Surgeon’s Certificate on September 9, 2014. Broomberg knowingly made false statements under penalty of perjury on visa applicants’ Report of Medical Examination and Vaccination Record forms (United States Citizenship and Immigration Services Form I-693) without performing the required tests and examinations.
3) Robert E. Brizendine of San Diego, psychologist, surrendered his Psychologist’s License to the California Board of Psychology on March 20, 2014.
New law requires the division’s Administrative Director to suspend any medical provider, physician or practitioner from participating in the workers’ compensation system in circumstances as described above ...
The Division of Workers’ Compensation (DWC) has posted an adjustment to the inpatient hospital section of the Official Medical Fee Schedule (OMFS) to conform to changes in the 2018 Medicare payment system as required by Labor Code section 5307.1.
The effective date of the changes is December 1, 2017. Further information and adjustments to the inpatient hospital section of the Official Medical Fee Schedule can be found on the DWC website’s OMFS page.
The Medicare FY18 update to the inpatient prospective payment system was published on August 14, 2017 in the Federal Register (Vol. 82 FR 37990) and is entitled "Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2018 Rates; Quality reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Program Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Provider-Based Status of Indian Health Services and Tribal Facilities and Organizations; Costs Reporting and Provider Requirements; Agreement Termination Notices" (CMS-1677-F).
Corrections to the final rule were published on October 4, 2017, in the Federal Register (Vol. 82 FR 46138, CMS-1677-CN - Final rule; correction). These documents are available online.
...
The effective date of the changes is December 1, 2017. Further information and adjustments to the inpatient hospital section of the Official Medical Fee Schedule can be found on the DWC website’s OMFS page.
The Medicare FY18 update to the inpatient prospective payment system was published on August 14, 2017 in the Federal Register (Vol. 82 FR 37990) and is entitled "Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2018 Rates; Quality reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Program Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Provider-Based Status of Indian Health Services and Tribal Facilities and Organizations; Costs Reporting and Provider Requirements; Agreement Termination Notices" (CMS-1677-F).
Corrections to the final rule were published on October 4, 2017, in the Federal Register (Vol. 82 FR 46138, CMS-1677-CN - Final rule; correction). These documents are available online.
...
A Rancho Mirage cosmetic surgeon who has been on the run for four months after pleading guilty in a scheme that duped health insurance companies into paying tens of millions of dollars for procedures that were not medically necessary was sentenced in absentia to 20 years in federal prison.
Dr. David M. Morrow, 72, a former Rancho Mirage resident whose current whereabouts are unknown, was sentenced by United States District Judge Josephine L. Staton. Judge Staton imposed the sentence after Morrow pleaded guilty last year to conspiracy to commit mail fraud and filing a false tax return.
Judge Staton noted that Morrow’s "greed knew no bounds," and that he showed an "utter disregard for patients’ well-being and safety." As part of the sentencing, Judge Staton found that the intended loss from Morrow’s scheme was $44,265,211.
"This defendant was a successful doctor who owned a medical clinic and multiple valuable residences, yet he engaged in a scheme designed to steal tens of millions of dollars from insurance companies by tricking them into paying for cosmetic surgery," said Acting United States Attorney Sandra R. Brown. "After admitting guilt, he went on the lam in the hopes of avoiding the punishment that was sure to come. When he is taken into custody - and he will definitely be captured - he will serve the lengthy sentence he deserves as a result of his greed and fraud."
Morrow, a dermatologist-turned-cosmetic-surgeon who was the owner of the Morrow Institute (TMI) in Rancho Mirage, specifically admitted that he submitted millions of dollars in claims for procedures that he certified were "medically necessary" - but in fact were cosmetic procedures. In some cases, according to court documents, patients underwent procedures they did not want in exchange for promises from Morrow that he would perform the cosmetic procedures that they really wanted.
When he pleaded guilty in March 2016, Morrow admitted participating in a health care fraud scheme, which included submitting altered documents to private insurance companies that claimed various procedures were "medically necessary" to induce insurers to pay for them. The guilty pleas followed a grand jury indictment two years ago that alleged Morrow, his wife, and TMI lured patients to the Coachella Valley surgery center with promises that cosmetic procedures would be paid for by their union or PPO health insurance plans. The victim health insurance companies included Anthem Blue Cross, Blue Cross/Blue Shield of California, Blue Cross/Blue Shield of Massachusetts, Regional Employer/Employee Partnership for Benefits, formerly known as Riverside Employer/Employee Partnership (REEP), and Cigna.
Some of the insurance companies refused to pay for patients who were employed by public entities. According to prosecutors, the Morrows then made claims against those entities, demanding more than $15 million from the California Highway Patrol, Desert Sands Unified School District, Palm Springs Unified School District and the city of Palm Springs.
Morrow and his wife are believed to have fled in May 2017. Prior to becoming fugitives, they failed to report to court officials, among other things, the sale of their $9.45 million home in Beverly Hills. Last month, prosecutors filed notice with the court that Morrow had breached his plea agreement by becoming a fugitive.
Charges against Morrow’s wife, Linda Morrow, 65, are currently pending.
The investigation into the Morrows and TMI was conducted by the Federal Bureau of Investigation, IRS - Criminal Investigation, and the California Department of Insurance ...
Dr. David M. Morrow, 72, a former Rancho Mirage resident whose current whereabouts are unknown, was sentenced by United States District Judge Josephine L. Staton. Judge Staton imposed the sentence after Morrow pleaded guilty last year to conspiracy to commit mail fraud and filing a false tax return.
Judge Staton noted that Morrow’s "greed knew no bounds," and that he showed an "utter disregard for patients’ well-being and safety." As part of the sentencing, Judge Staton found that the intended loss from Morrow’s scheme was $44,265,211.
"This defendant was a successful doctor who owned a medical clinic and multiple valuable residences, yet he engaged in a scheme designed to steal tens of millions of dollars from insurance companies by tricking them into paying for cosmetic surgery," said Acting United States Attorney Sandra R. Brown. "After admitting guilt, he went on the lam in the hopes of avoiding the punishment that was sure to come. When he is taken into custody - and he will definitely be captured - he will serve the lengthy sentence he deserves as a result of his greed and fraud."
Morrow, a dermatologist-turned-cosmetic-surgeon who was the owner of the Morrow Institute (TMI) in Rancho Mirage, specifically admitted that he submitted millions of dollars in claims for procedures that he certified were "medically necessary" - but in fact were cosmetic procedures. In some cases, according to court documents, patients underwent procedures they did not want in exchange for promises from Morrow that he would perform the cosmetic procedures that they really wanted.
When he pleaded guilty in March 2016, Morrow admitted participating in a health care fraud scheme, which included submitting altered documents to private insurance companies that claimed various procedures were "medically necessary" to induce insurers to pay for them. The guilty pleas followed a grand jury indictment two years ago that alleged Morrow, his wife, and TMI lured patients to the Coachella Valley surgery center with promises that cosmetic procedures would be paid for by their union or PPO health insurance plans. The victim health insurance companies included Anthem Blue Cross, Blue Cross/Blue Shield of California, Blue Cross/Blue Shield of Massachusetts, Regional Employer/Employee Partnership for Benefits, formerly known as Riverside Employer/Employee Partnership (REEP), and Cigna.
Some of the insurance companies refused to pay for patients who were employed by public entities. According to prosecutors, the Morrows then made claims against those entities, demanding more than $15 million from the California Highway Patrol, Desert Sands Unified School District, Palm Springs Unified School District and the city of Palm Springs.
Morrow and his wife are believed to have fled in May 2017. Prior to becoming fugitives, they failed to report to court officials, among other things, the sale of their $9.45 million home in Beverly Hills. Last month, prosecutors filed notice with the court that Morrow had breached his plea agreement by becoming a fugitive.
Charges against Morrow’s wife, Linda Morrow, 65, are currently pending.
The investigation into the Morrows and TMI was conducted by the Federal Bureau of Investigation, IRS - Criminal Investigation, and the California Department of Insurance ...
United States Attorney Phillip A. Talbert announced that Christina Hernandez, 39, of Las Vegas, Nevada, pleaded guilty on October 10, to embezzlement from a health care benefits program.
According to the plea agreement, Hernandez was a provider relations specialist at the Fresno County Department of Behavioral Health, which was responsible for administering mental health service benefits for Fresno County’s Medi-Cal beneficiaries.
As a provider relations specialist, Hernandez was responsible for reviewing and approving claim forms from private mental health care providers who provide services to Medi-Cal beneficiaries in Fresno County.
To steal funds from Fresno County, Hernandez submitted claim forms for medical services that were never provided. She then took the payment checks for those fake services and cashed the checks at check-cashing stores in Fresno for her personal benefit.
In addition, Hernandez stole payment checks written to doctors for actual medical services provided. She also cashed those checks at convenience stores in Fresno for her personal benefit In total, Hernandez stole approximately $98,560 from the Fresno County Department of Behavioral Services.
Hernandez is scheduled to be sentenced by U.S. District Judge Dale A. Drozd on January 8, 2018. Hernandez faces a maximum statutory penalty of ten years in prison and a $250,000 fine. Any sentence, however, will be determined at the discretion of the court after consideration of any applicable statutory factors and the Federal Sentencing Guidelines, which take into account a number of variables.
This case was the product of an investigation by the Federal Bureau of Investigation and the Fresno County Sheriff’s Office. Assistant United States Attorney Grant B. Rabenn is prosecuting the case.
...
According to the plea agreement, Hernandez was a provider relations specialist at the Fresno County Department of Behavioral Health, which was responsible for administering mental health service benefits for Fresno County’s Medi-Cal beneficiaries.
As a provider relations specialist, Hernandez was responsible for reviewing and approving claim forms from private mental health care providers who provide services to Medi-Cal beneficiaries in Fresno County.
To steal funds from Fresno County, Hernandez submitted claim forms for medical services that were never provided. She then took the payment checks for those fake services and cashed the checks at check-cashing stores in Fresno for her personal benefit.
In addition, Hernandez stole payment checks written to doctors for actual medical services provided. She also cashed those checks at convenience stores in Fresno for her personal benefit In total, Hernandez stole approximately $98,560 from the Fresno County Department of Behavioral Services.
Hernandez is scheduled to be sentenced by U.S. District Judge Dale A. Drozd on January 8, 2018. Hernandez faces a maximum statutory penalty of ten years in prison and a $250,000 fine. Any sentence, however, will be determined at the discretion of the court after consideration of any applicable statutory factors and the Federal Sentencing Guidelines, which take into account a number of variables.
This case was the product of an investigation by the Federal Bureau of Investigation and the Fresno County Sheriff’s Office. Assistant United States Attorney Grant B. Rabenn is prosecuting the case.
...
Anna Nicole Smith was an American model, actress and television personality. On February 8, 2007, Smith was found dead at the Seminole Hard Rock Hotel and Casino in Hollywood, Florida. Broward County Medical Examiner and Forensic Pathologist Dr. Joshua Perper announced that Smith died of "combined drug intoxication" with the sleeping medication chloral hydrate as the "major component."
The sedative chloral hydrate that became increasingly lethal when combined with other prescription drugs in her system, specifically four benzodiazepines: Klonopin (Clonazepam), Ativan (Lorazepam), Serax (Oxazepam), and Valium (Diazepam). Furthermore, she had taken Benadryl (Diphenhydramine) and Topamax (Topiramate), an anticonvulsant AMPA/Kainate antagonist, which likely contributed to the sedative effect of chloral hydrate and the benzodiazepines.
Dr. Perper claimed that Dr. Khristine Elaine Eroshevich, an Encino psychiatrist had issued 11 prescriptions to Smith. Eroshevich was with Smith when she checked into the Florida hotel, where she later died. More than 600 pills - including about 450 muscle relaxants - were missing from prescriptions that were no more than five weeks old.
Eroshevich was charged in California and initially convicted of two felonies in the drug trial involving the treatment of Smith. One charge was later thrown out and the other was reduced to a misdemeanor (Health and Safety Code 11173(A) unlawful prescribing. The case has even been the subject of a California Supreme Court Decision in People v Eroshevich which reviewed the issue of double jeopardy as applied to an order for retrial in her case.
Khristine Erosevich M.D. was a 1975 graduate of Ohio State University College of Medicine. She became licensed as a physician and surgeon in California in 1978. A Second Amended Accusation was filed before the Medical Board in 2011 seeking the revocation of her license or other relief. The Sixth Cause for Discipline cited the Anna Nichole Smith criminal case number BA 353907 as grounds for discipline. Other Causes alleged that "she engaged in dishonest acts by making false statements in a psychiatric report and billing statement regarding a workers compensation claimant."
On March 12, 2012 the Medical Board ordered approval of her stipulation in which "Respondent admits the truth of each and every charge and allegation in the First and Sixth Causes for Discipline in Second Amended Accusation No. 17-2009-197998." On March 17, 2016, after a hearing, an ALJ ruled "The petition of Khristine Elaine Eroshevich, M.D. for termination of probation is granted. Physician's and Surgeon's Certificate Number C 37980 is fully restored.
On September 8, 2017 the DWC notified Eroshevich of its intention to suspend her from participation in the worker's compensation system pursuant to labor code 139.21 for the reasons stated above, as well as her suspension from the Medi-Cal program. On September 18 she requested a hearing, and a hearing before the WCAB was set for October 10.
On October 6, 2017 Eroshevich filed a federal lawsuit against officials of the DIR. She alleges that the remaining misdemeanor count "was ordered set aside, a plea of not guilty was entered, and it was also dismissed by the Superior Court." Thus it could not be used as grounds for her suspension.
With regard to the other reasons for suspension "Plaintiff has never applied or participated in the federal Medicare program and hence was not suspended from that program." Her petition for reinstatement in the Medi-Cal program is currently pending before the Director of the California Department of Health Care Services. She claims it would be unfair for her to have a hearing on her suspension at the WCAB on October 10 before that petition has been decide.
She alleges a number of constitutional challenges to the law as well, including the prohibition against ex post facto laws contained in by the United States and the California Constitutions. The case has been re-assigned to federal Judge Wu (the same federal judge involved in prior lien claimant constitutional challenges to workers' compensation law). She also filed an ex parte application for a temporary restraining order seeking an order enjoining the scheduled suspension hearing from going forward on October 10, 2017. On October 6, Judge Wu denied her request. He set a status conference for October 12 to "discuss further proceedings." ...
The sedative chloral hydrate that became increasingly lethal when combined with other prescription drugs in her system, specifically four benzodiazepines: Klonopin (Clonazepam), Ativan (Lorazepam), Serax (Oxazepam), and Valium (Diazepam). Furthermore, she had taken Benadryl (Diphenhydramine) and Topamax (Topiramate), an anticonvulsant AMPA/Kainate antagonist, which likely contributed to the sedative effect of chloral hydrate and the benzodiazepines.
Dr. Perper claimed that Dr. Khristine Elaine Eroshevich, an Encino psychiatrist had issued 11 prescriptions to Smith. Eroshevich was with Smith when she checked into the Florida hotel, where she later died. More than 600 pills - including about 450 muscle relaxants - were missing from prescriptions that were no more than five weeks old.
Eroshevich was charged in California and initially convicted of two felonies in the drug trial involving the treatment of Smith. One charge was later thrown out and the other was reduced to a misdemeanor (Health and Safety Code 11173(A) unlawful prescribing. The case has even been the subject of a California Supreme Court Decision in People v Eroshevich which reviewed the issue of double jeopardy as applied to an order for retrial in her case.
Khristine Erosevich M.D. was a 1975 graduate of Ohio State University College of Medicine. She became licensed as a physician and surgeon in California in 1978. A Second Amended Accusation was filed before the Medical Board in 2011 seeking the revocation of her license or other relief. The Sixth Cause for Discipline cited the Anna Nichole Smith criminal case number BA 353907 as grounds for discipline. Other Causes alleged that "she engaged in dishonest acts by making false statements in a psychiatric report and billing statement regarding a workers compensation claimant."
On March 12, 2012 the Medical Board ordered approval of her stipulation in which "Respondent admits the truth of each and every charge and allegation in the First and Sixth Causes for Discipline in Second Amended Accusation No. 17-2009-197998." On March 17, 2016, after a hearing, an ALJ ruled "The petition of Khristine Elaine Eroshevich, M.D. for termination of probation is granted. Physician's and Surgeon's Certificate Number C 37980 is fully restored.
On September 8, 2017 the DWC notified Eroshevich of its intention to suspend her from participation in the worker's compensation system pursuant to labor code 139.21 for the reasons stated above, as well as her suspension from the Medi-Cal program. On September 18 she requested a hearing, and a hearing before the WCAB was set for October 10.
On October 6, 2017 Eroshevich filed a federal lawsuit against officials of the DIR. She alleges that the remaining misdemeanor count "was ordered set aside, a plea of not guilty was entered, and it was also dismissed by the Superior Court." Thus it could not be used as grounds for her suspension.
With regard to the other reasons for suspension "Plaintiff has never applied or participated in the federal Medicare program and hence was not suspended from that program." Her petition for reinstatement in the Medi-Cal program is currently pending before the Director of the California Department of Health Care Services. She claims it would be unfair for her to have a hearing on her suspension at the WCAB on October 10 before that petition has been decide.
She alleges a number of constitutional challenges to the law as well, including the prohibition against ex post facto laws contained in by the United States and the California Constitutions. The case has been re-assigned to federal Judge Wu (the same federal judge involved in prior lien claimant constitutional challenges to workers' compensation law). She also filed an ex parte application for a temporary restraining order seeking an order enjoining the scheduled suspension hearing from going forward on October 10, 2017. On October 6, Judge Wu denied her request. He set a status conference for October 12 to "discuss further proceedings." ...
Eduardo Anguizola M.D claims in his federal lawsuit that Labor Code 4615 - the automatic lien stay law - violates his constitutional rights. Before submission of his request for an injunction, Governor Brown signed AB 1422 into law which was adverse to his federal claim. The parties were given additional time to brief the implications of the new law. The California Attorney General has now filed what is the final scheduled written response.
The AG said "Plaintiffs most recent brief makes clear that they are asking this Court to void Section 4615 in its entirety, an outcome that would enable criminally-charged lien claimants to continue collecting on their liens unabated while criminal charges against them are pending."
The brief further points out that AB 1422, recently passed by the Legislature and signed by the Governor "confirms that lien claimants may raise any disputes concerning the applicability of the automatic stay to specific liens using existing workers’ compensation procedures. It also confirms that the Legislature never intended to strip the Workers’ Compensation Appeal Board ("WCAB") or workers’ compensation administrative law judges ("WCALJs") of jurisdiction to determine whether a lien falls into the category of liens subject to the stay. AB 1422 thus verifies Defendants’ interpretation of the statute and the showing that has been made on this motion in support of that interpretation. The amendment to the statute should resolve any lingering concern as to whether lien claimants have access to process and procedures in order to dispute whether the provisions of Section 4615 apply to their liens."
"The effect of this new language on Plaintiffs’ preliminary injunction motion is substantial. It specifically addresses the procedural due process issues about which the Court has expressed concerns by confirming that nothing in Section 4615 precludes the appeals board from determining whether the automatic stay applies to a specific lien (i.e., whether that lien falls within the category of liens subject to the automatic stay)."
"This Court has previously determined that 'the statutory language [of Section 4615] is ambiguous.' Aug. 31, 2017 Tentative Ruling at 5. Where 'a statute is ambiguous . . . a subsequent expression of the Legislature as to the intent of the prior statute, although not binding on the court, may properly be used in determining the effect of a prior act.' "
"AB 1422 illuminates the original intent of Section 4615. It clarifies that in enacting Section 4615, the Legislature intended for workers’ compensation judges and the WCAB to maintain jurisdiction to determine within the pre-existing workers’ compensation procedures whether the Section 4615 stay applies to a particular lien. Because AB 1422 was passed within a year of Section 4615, it carries great weight in the analysis of the Legislature’s intent in enacting Section 4615. Even though AB 1422 will not go into effect until January 1, 2018, it offers clarification to the WCAB and WCALJs charged with administering Section 4615, and there is no reason to think that they will ignore or act contrary to the amendment. In fact, the amendment confirms instructions received from Chief Judge Levy (see Dkt. 42-1 at ¶ 9) and eliminates any doubt as to whether WCALJs have jurisdiction to consider the applicability of the stay."
Judge Wu will hold another hearing in federal court on October 19, and will likely rule on the request for a preliminary injunction shortly thereafter ...
The AG said "Plaintiffs most recent brief makes clear that they are asking this Court to void Section 4615 in its entirety, an outcome that would enable criminally-charged lien claimants to continue collecting on their liens unabated while criminal charges against them are pending."
The brief further points out that AB 1422, recently passed by the Legislature and signed by the Governor "confirms that lien claimants may raise any disputes concerning the applicability of the automatic stay to specific liens using existing workers’ compensation procedures. It also confirms that the Legislature never intended to strip the Workers’ Compensation Appeal Board ("WCAB") or workers’ compensation administrative law judges ("WCALJs") of jurisdiction to determine whether a lien falls into the category of liens subject to the stay. AB 1422 thus verifies Defendants’ interpretation of the statute and the showing that has been made on this motion in support of that interpretation. The amendment to the statute should resolve any lingering concern as to whether lien claimants have access to process and procedures in order to dispute whether the provisions of Section 4615 apply to their liens."
"The effect of this new language on Plaintiffs’ preliminary injunction motion is substantial. It specifically addresses the procedural due process issues about which the Court has expressed concerns by confirming that nothing in Section 4615 precludes the appeals board from determining whether the automatic stay applies to a specific lien (i.e., whether that lien falls within the category of liens subject to the automatic stay)."
"This Court has previously determined that 'the statutory language [of Section 4615] is ambiguous.' Aug. 31, 2017 Tentative Ruling at 5. Where 'a statute is ambiguous . . . a subsequent expression of the Legislature as to the intent of the prior statute, although not binding on the court, may properly be used in determining the effect of a prior act.' "
"AB 1422 illuminates the original intent of Section 4615. It clarifies that in enacting Section 4615, the Legislature intended for workers’ compensation judges and the WCAB to maintain jurisdiction to determine within the pre-existing workers’ compensation procedures whether the Section 4615 stay applies to a particular lien. Because AB 1422 was passed within a year of Section 4615, it carries great weight in the analysis of the Legislature’s intent in enacting Section 4615. Even though AB 1422 will not go into effect until January 1, 2018, it offers clarification to the WCAB and WCALJs charged with administering Section 4615, and there is no reason to think that they will ignore or act contrary to the amendment. In fact, the amendment confirms instructions received from Chief Judge Levy (see Dkt. 42-1 at ¶ 9) and eliminates any doubt as to whether WCALJs have jurisdiction to consider the applicability of the stay."
Judge Wu will hold another hearing in federal court on October 19, and will likely rule on the request for a preliminary injunction shortly thereafter ...
Governor Jerry Brown signed SB 17, state legislation requiring drug companies to report certain price hikes for prescription medicines in a move that could set a model for other states to follow.
The law, which aims to provide more transparency around pharmaceutical and biotech company pricing methods for their medicines, requires drug manufacturers to give a 60-day notice if prices are raised more than 16 percent over a two-year period.
It also requires drug manufacturers to notify state purchasers (CalPERS, Medi-Cal, Department of Corrections and Rehabilitation, and Department of General Services), health plans and insurers, and PBMs at least 90 days prior to the planned effective date, of an increase in the WAC of a prescription drug, as specified.
The law also requires health plans and insurers to file annual reports outlining how drug costs affect healthcare premiums in California. Health plans and insurers that report rate information in the small and large group markets, beginning October 1, 2018, for example must annually report to regulators
- the 25 most frequently prescribed drugs,
- the 25 most costly drugs by total annual spending; and,
- the 25 drugs with the highest year-over-year increase in total annual spending.
And health plans that report as part of the large group process among other things must report
- the percentage of the premium attributable to prescription drug costs for the prior year for each category of prescription drugs;
- the year-over-year increase, as a percentage, in per-member, per-month total health plan spending for each category of prescription drugs;
- the year-over-year increase in per-member, per-month costs for drug prices compared to other components of the health care premium;
- the specialty tier formulary list; the percentage of the premium attributable to prescription drugs administered in a doctor's office that are covered under the medical benefit as separate from the pharmacy benefit, if available;
- and, information on its use of a pharmacy benefit manager (PBM), if any, including its name and which components of the prescription drug coverage are managed by the PBM.
The bill has been opposed by drugmakers, who argue that wholesale price increases do not reflect the actual prices paid for medicines after discounts and rebates.
Biotechnology Innovation Organization (BIO), the leading biotech industry trade group, issued a statement condemning the bill and arguing that it would not serve its intended purpose. "This law will neither provide meaningful information to patients nor lower prescription drug costs," the group said, adding that the law "seriously jeopardizes the future of California’s leadership in this innovative industry." California is home to hundreds of biotechnology companies.
PhRMA condemned the law in a press release that claimed "California’s latest bill falls short of offering patients, providers or policymakers any meaningful improvements on medicine access, affordability or coverage. Rather, it calls for mounds of red tape and government reports that look only at the list price of a prescription drug rather than considering actual patient spending after negotiated discounts and rebates."
Pharmaceutical companies have so far dodged stricter federal oversight despite growing public and political outrage over pricing practices for both branded and some generic medicines.
But states, struggling to cover rising healthcare costs, have been addressing the issue rather than wait for federal help. At least 176 bills on pharmaceutical pricing and payment have been introduced this year in 36 states, according to the National Conference of State Legislatures.
A new Maryland law takes aims at egregious price hikes on generic versions of older off-patent drugs that are supposed to be far cheaper than the original branded medicines after some companies took massive increases on generic drugs not facing competition from other distributors.
Amid the furor some drugmakers, including Allergan Plc and AbbVie Inc, have voluntarily pledged one annual price increase of under 10 percent on branded prescription medicines. It had been common industry practice to raise prices twice a year, often by double-digit percentages.
However, even annual price hikes of 9 percent over a two-year period would put a company in the crosshairs of the new California legislation ...
The law, which aims to provide more transparency around pharmaceutical and biotech company pricing methods for their medicines, requires drug manufacturers to give a 60-day notice if prices are raised more than 16 percent over a two-year period.
It also requires drug manufacturers to notify state purchasers (CalPERS, Medi-Cal, Department of Corrections and Rehabilitation, and Department of General Services), health plans and insurers, and PBMs at least 90 days prior to the planned effective date, of an increase in the WAC of a prescription drug, as specified.
The law also requires health plans and insurers to file annual reports outlining how drug costs affect healthcare premiums in California. Health plans and insurers that report rate information in the small and large group markets, beginning October 1, 2018, for example must annually report to regulators
- the 25 most frequently prescribed drugs,
- the 25 most costly drugs by total annual spending; and,
- the 25 drugs with the highest year-over-year increase in total annual spending.
And health plans that report as part of the large group process among other things must report
- the percentage of the premium attributable to prescription drug costs for the prior year for each category of prescription drugs;
- the year-over-year increase, as a percentage, in per-member, per-month total health plan spending for each category of prescription drugs;
- the year-over-year increase in per-member, per-month costs for drug prices compared to other components of the health care premium;
- the specialty tier formulary list; the percentage of the premium attributable to prescription drugs administered in a doctor's office that are covered under the medical benefit as separate from the pharmacy benefit, if available;
- and, information on its use of a pharmacy benefit manager (PBM), if any, including its name and which components of the prescription drug coverage are managed by the PBM.
The bill has been opposed by drugmakers, who argue that wholesale price increases do not reflect the actual prices paid for medicines after discounts and rebates.
Biotechnology Innovation Organization (BIO), the leading biotech industry trade group, issued a statement condemning the bill and arguing that it would not serve its intended purpose. "This law will neither provide meaningful information to patients nor lower prescription drug costs," the group said, adding that the law "seriously jeopardizes the future of California’s leadership in this innovative industry." California is home to hundreds of biotechnology companies.
PhRMA condemned the law in a press release that claimed "California’s latest bill falls short of offering patients, providers or policymakers any meaningful improvements on medicine access, affordability or coverage. Rather, it calls for mounds of red tape and government reports that look only at the list price of a prescription drug rather than considering actual patient spending after negotiated discounts and rebates."
Pharmaceutical companies have so far dodged stricter federal oversight despite growing public and political outrage over pricing practices for both branded and some generic medicines.
But states, struggling to cover rising healthcare costs, have been addressing the issue rather than wait for federal help. At least 176 bills on pharmaceutical pricing and payment have been introduced this year in 36 states, according to the National Conference of State Legislatures.
A new Maryland law takes aims at egregious price hikes on generic versions of older off-patent drugs that are supposed to be far cheaper than the original branded medicines after some companies took massive increases on generic drugs not facing competition from other distributors.
Amid the furor some drugmakers, including Allergan Plc and AbbVie Inc, have voluntarily pledged one annual price increase of under 10 percent on branded prescription medicines. It had been common industry practice to raise prices twice a year, often by double-digit percentages.
However, even annual price hikes of 9 percent over a two-year period would put a company in the crosshairs of the new California legislation ...
United States Attorney Phillip A. Talbert announced that Raul Oropeza Lopez, 50, and Ana Maria Oropeza, 43, both of Delano, California, pleaded guilty to mail fraud.
According to court documents, Raul Oropeza Lopez obtained social security numbers, names, and other personal identifying information of U.S. citizens and legal residents and then fraudulently used such information to provide undocumented workers with false identities required to work in the United States as farm laborers.
Then, when the undocumented workers were laid off at the end of the growing season, Lopez and his wife filed fraudulent unemployment insurance claims in the names of the assumed identities, fraudulently relying on the work performed by the undocumented workers to claim unemployment insurance benefits for the Lopezes’ benefit.
Over a period of six years, Lopez and his wife submitted more than 520 fraudulent unemployment insurance claims on behalf of over 70 individuals, collecting at least $1.3 million.
The defendants are scheduled to be sentenced by Judge Lawrence J. O'Neill on January 29, 2018. Each defendant faces a maximum statutory penalty of 20 years in prison and a $250,000 fine. The actual sentence, however, will be determined at the discretion of the court after consideration of any applicable statutory factors and the Federal Sentencing Guidelines, which take into account a number of variables.
This case was the product of a joint investigation by the U.S. Department of Labor, Office of Inspector General; Homeland Security Investigations; Social Security Administration, Office of Inspector General; the Bureau of Alcohol, Tobacco, Firearms and Explosives; U.S. Postal Inspection Service; and the California Employment Development Department, Criminal Investigations Division.
Assistant United States Attorney Mark J. McKeon is prosecuting the case ...
According to court documents, Raul Oropeza Lopez obtained social security numbers, names, and other personal identifying information of U.S. citizens and legal residents and then fraudulently used such information to provide undocumented workers with false identities required to work in the United States as farm laborers.
Then, when the undocumented workers were laid off at the end of the growing season, Lopez and his wife filed fraudulent unemployment insurance claims in the names of the assumed identities, fraudulently relying on the work performed by the undocumented workers to claim unemployment insurance benefits for the Lopezes’ benefit.
Over a period of six years, Lopez and his wife submitted more than 520 fraudulent unemployment insurance claims on behalf of over 70 individuals, collecting at least $1.3 million.
The defendants are scheduled to be sentenced by Judge Lawrence J. O'Neill on January 29, 2018. Each defendant faces a maximum statutory penalty of 20 years in prison and a $250,000 fine. The actual sentence, however, will be determined at the discretion of the court after consideration of any applicable statutory factors and the Federal Sentencing Guidelines, which take into account a number of variables.
This case was the product of a joint investigation by the U.S. Department of Labor, Office of Inspector General; Homeland Security Investigations; Social Security Administration, Office of Inspector General; the Bureau of Alcohol, Tobacco, Firearms and Explosives; U.S. Postal Inspection Service; and the California Employment Development Department, Criminal Investigations Division.
Assistant United States Attorney Mark J. McKeon is prosecuting the case ...
The Court of Appeal ruled that "In specified circumstances, a worker who engages in criminal fraud in attempting to recover workers' compensation benefits and is convicted of doing so is thereafter barred from recovering benefits growing out of the fraud. However, in given circumstances where, independent of any fraud, a worker is able to establish his or her entitlement to benefits, benefits may be awarded."
In 2006, while working at Pearson Ford, Leopoldo Hernandez accidentally slammed the trunk of a car on his left hand and crushed one of his fingers. He applied for and received workers' compensation benefits.
Dr. Byron King, an orthopedic AME, had some difficulty in examining Hernandez's left arm and hand; in particular, although Hernandez complained about his inability to use his left hand and arm, he would not permit Dr. King to perform grip or pinch strength tests on the hand..
Subsequently, Hernandez was examined three times by Dr. Walter Strauser, a pain specialist who had been treating Hernandez. On each of his visits, Hernandez wore a sling on his left arm and complained of continuing severe pain and an inability to use his left arm and hand.
Video surveillance was conducted following each of the three visits to Dr. Strauser in early 2010. Following each visit, Hernandez was observed taking off his sling, using his left hand to get in and out of his truck or a car, using his left hand to steer his truck or car, and on one occasion stopping at a grocery store and using his left hand to carry a bag of groceries.
Hernandez's also saw Dr. Greg M. Balourdas, acting as Hernandez's primary physician. As he did when he was examined by Dr. Strauser, Hernandez appeared wearing a sling on his left arm. Following his visit to Dr. Balourdas, Hernandez was observed once again taking off his sling, driving his car and stopping at an appliance store where, using both hands, he lifted a washing machine into the back of the car he was driving.
After AME King was made aware of the surveillance, Hernandez appeared for another exam, more cooperative than before. King performed a number of objective tests and concluded that his hand was severely compromised, and had suffered a 38 percent impairment. He said the videos were not very helpful in making any diagnosis because "it was difficult to identify any actual finger motions of the left hand other than using the left hand and thumb to hold and move objects."
In March 2011, Hernandez was charged with four counts of violating Insurance Code section 1871.4 ; three counts were based on his three visits in 2010 to Dr. Strauser and one count was based on his 2010 visit to Dr. Balourdas. Hernandez was also charged with insurance fraud within the meaning of Penal Code section 550 subdivision (b)(3). On May 10, 2012, Hernandez pled guilty to one count of violating Insurance Code section 1871.4, based on his May 2010 visit to Dr. Strauser. He was placed on summary probation and required to pay $9,000 in restitution.
In 2016, a WCJ, relying on Dr. King's conclusions found that Hernandez suffered a 70 percent permanent disability. The WCAB denied reconsideration, and the Court of Appeal affirmed in the unpublished case of Pearson Ford v WCAB.
The main issue on appeal was the employer's argument that any award to Hernandez for the injury is barred by Labor Code section 1871.5. which provides ""Any person convicted of workers' compensation fraud pursuant to Section 1871.4 . . . shall be ineligible to receive or retain any compensation, as defined in Section 3207[ ] of the Labor Code, where that compensation was owed or received as a result of a violation of Section 1871.4 . . . for which the recipient of the compensation was convicted."
The leading case interpreting section 1871.4 is Tensfeldt v. Workers Compensation Appeals Board (1998) 66 Cal.App.4th 116. The court in Tensfeldt took pains to expressly limit the scope of its holding so that section 1871.5 would not be used as an automatic or broad prohibition on the payment of benefits which were not directly connected to a worker's fraudulent misrepresentation.
Here, the WCJ found Hernandez met the three requirements set forth in Tensfeldt, and the WCAB adopted those findings. The WCJ found that Hernandez suffered a compensable injury, there was substantial medical evidence supporting an award which did not stem from his fraudulent statements, and his credibility had not been so damaged as to make him unbelievable concerning the underlying compensation case ...
In 2006, while working at Pearson Ford, Leopoldo Hernandez accidentally slammed the trunk of a car on his left hand and crushed one of his fingers. He applied for and received workers' compensation benefits.
Dr. Byron King, an orthopedic AME, had some difficulty in examining Hernandez's left arm and hand; in particular, although Hernandez complained about his inability to use his left hand and arm, he would not permit Dr. King to perform grip or pinch strength tests on the hand..
Subsequently, Hernandez was examined three times by Dr. Walter Strauser, a pain specialist who had been treating Hernandez. On each of his visits, Hernandez wore a sling on his left arm and complained of continuing severe pain and an inability to use his left arm and hand.
Video surveillance was conducted following each of the three visits to Dr. Strauser in early 2010. Following each visit, Hernandez was observed taking off his sling, using his left hand to get in and out of his truck or a car, using his left hand to steer his truck or car, and on one occasion stopping at a grocery store and using his left hand to carry a bag of groceries.
Hernandez's also saw Dr. Greg M. Balourdas, acting as Hernandez's primary physician. As he did when he was examined by Dr. Strauser, Hernandez appeared wearing a sling on his left arm. Following his visit to Dr. Balourdas, Hernandez was observed once again taking off his sling, driving his car and stopping at an appliance store where, using both hands, he lifted a washing machine into the back of the car he was driving.
After AME King was made aware of the surveillance, Hernandez appeared for another exam, more cooperative than before. King performed a number of objective tests and concluded that his hand was severely compromised, and had suffered a 38 percent impairment. He said the videos were not very helpful in making any diagnosis because "it was difficult to identify any actual finger motions of the left hand other than using the left hand and thumb to hold and move objects."
In March 2011, Hernandez was charged with four counts of violating Insurance Code section 1871.4 ; three counts were based on his three visits in 2010 to Dr. Strauser and one count was based on his 2010 visit to Dr. Balourdas. Hernandez was also charged with insurance fraud within the meaning of Penal Code section 550 subdivision (b)(3). On May 10, 2012, Hernandez pled guilty to one count of violating Insurance Code section 1871.4, based on his May 2010 visit to Dr. Strauser. He was placed on summary probation and required to pay $9,000 in restitution.
In 2016, a WCJ, relying on Dr. King's conclusions found that Hernandez suffered a 70 percent permanent disability. The WCAB denied reconsideration, and the Court of Appeal affirmed in the unpublished case of Pearson Ford v WCAB.
The main issue on appeal was the employer's argument that any award to Hernandez for the injury is barred by Labor Code section 1871.5. which provides ""Any person convicted of workers' compensation fraud pursuant to Section 1871.4 . . . shall be ineligible to receive or retain any compensation, as defined in Section 3207[ ] of the Labor Code, where that compensation was owed or received as a result of a violation of Section 1871.4 . . . for which the recipient of the compensation was convicted."
The leading case interpreting section 1871.4 is Tensfeldt v. Workers Compensation Appeals Board (1998) 66 Cal.App.4th 116. The court in Tensfeldt took pains to expressly limit the scope of its holding so that section 1871.5 would not be used as an automatic or broad prohibition on the payment of benefits which were not directly connected to a worker's fraudulent misrepresentation.
Here, the WCJ found Hernandez met the three requirements set forth in Tensfeldt, and the WCAB adopted those findings. The WCJ found that Hernandez suffered a compensable injury, there was substantial medical evidence supporting an award which did not stem from his fraudulent statements, and his credibility had not been so damaged as to make him unbelievable concerning the underlying compensation case ...
Amazon is in the final stages of figuring out its strategy to get into the multibillion-dollar prescription drug market.
The company will decide before Thanksgiving whether to move into selling prescription drugs online, according to an email from Amazon viewed by CNBC and a source familiar with the situation. If it decides to make that move, it will start expanding its senior team with drug supply chain experts.
Amazon typically spends years researching opportunities before it telegraphs its intentions. The opportunity to sell drugs online is alluring given its market size -- analysts have estimated the U.S. prescription drug market at $560 billion per year. Amazon is well aware of the complexities, say sources familiar with the company's thinking.
Amazon declined to comment.
In the past year, Amazon has ramped up its hiring and consulted with dozens of people about a potential move into the pharmacy market. The consumables team, which includes groceries, kicked off the research, with the division's vice president, Eric French, taking the lead.
It brought on Mark Lyons from Premera Blue Cross to build an internal pharmacy benefits manager for its own employees, say multiple people familiar. According to one of the people, it's possible that the push into the broader drug supply chain hinges on its success with this effort.
In May, the company kicked off its search for a general manager to lead its pharmacy push, externally dubbed "healthcare."
Analyst firm Leerink has separately reported that Amazon will get into the pharmacy management space and expects an announcement within the next year or two.
Goldman Sachs published a report on the topic in August of this year, speculating that Amazon will ultimately look to improve price transparency for consumers and reduce out-of-pocket costs.
Amazon already has a business selling medical supplies online, such as gauze and thermometers. It also has a health team called 1492, which is focused on both hardware and software projects, like developing health applications for the Echo and Dash Wand. Its cloud service, Amazon Web Services, continues to dominate the health and life sciences market ...
The company will decide before Thanksgiving whether to move into selling prescription drugs online, according to an email from Amazon viewed by CNBC and a source familiar with the situation. If it decides to make that move, it will start expanding its senior team with drug supply chain experts.
Amazon typically spends years researching opportunities before it telegraphs its intentions. The opportunity to sell drugs online is alluring given its market size -- analysts have estimated the U.S. prescription drug market at $560 billion per year. Amazon is well aware of the complexities, say sources familiar with the company's thinking.
Amazon declined to comment.
In the past year, Amazon has ramped up its hiring and consulted with dozens of people about a potential move into the pharmacy market. The consumables team, which includes groceries, kicked off the research, with the division's vice president, Eric French, taking the lead.
It brought on Mark Lyons from Premera Blue Cross to build an internal pharmacy benefits manager for its own employees, say multiple people familiar. According to one of the people, it's possible that the push into the broader drug supply chain hinges on its success with this effort.
In May, the company kicked off its search for a general manager to lead its pharmacy push, externally dubbed "healthcare."
Analyst firm Leerink has separately reported that Amazon will get into the pharmacy management space and expects an announcement within the next year or two.
Goldman Sachs published a report on the topic in August of this year, speculating that Amazon will ultimately look to improve price transparency for consumers and reduce out-of-pocket costs.
Amazon already has a business selling medical supplies online, such as gauze and thermometers. It also has a health team called 1492, which is focused on both hardware and software projects, like developing health applications for the Echo and Dash Wand. Its cloud service, Amazon Web Services, continues to dominate the health and life sciences market ...
The risk of double damages claimed against California workers compensation carriers may be increasing for failure to reimburse Medicare Advantage Plans for medical care of an injured worker when a claim is settled.
Hartford Casualty Insurance Company is the target of a new complaint recently filed in the United States District Court, Western District of Washington (Seattle) by Humana Health Plan.
Humana, as a Medicare Advantage Plan (MAP) is seeking a declaratory judgment as to Hartford’s obligation to reimburse conditional payments made before settlement of its claim, as well as a private cause of action pursuant to 42 USC 1395y(b)(3)(A) for the recovery of double damages for the alleged failure to reimburse Humana.
If Humana ultimately prevails and Hartford appeals to the Ninth Circuit Court of Appeals, precedent may be set determining that MAPs have the same recovery rights as traditional Medicare (a right to double damages for failure to reimburse MAP conditional payments within 60 days of issuance of the settlement check) in the largest Circuit in the United States including California.
These states would be added to the growing list of the 3rd and 11th Circuits from the In Re Avandia and Western Heritage litigation which has now established this double damages private cause of action right for MAPs in the states of: Pennsylvania, Delaware, New Jersey, Alabama, Georgia and Florida.
The Medicare beneficiary in this test case was injured in a car accident. The Enrollee received medical treatment related to the collision which was paid for by Humana totaling at least $161,853.14 in conditional payments. On February 19, 2015 Humana sent Hartford a written notice of its right to recovery of the conditional payments pursuant to the Medicare Secondary Payer Act (MSP).
Later in 2015 Hartford entered into a settlement with Enrollee. Enrollee was responsible for reimbursing Humana within 60 days of the Hartford’s payment of the settlement amount; however, Enrollee did not reimburse Humana.
Even though Hartford had already paid Enrollee the settlement funds, Humana alleges that the Hartford remains responsible to ensure that Humana was reimbursed pursuant to 42 CFR 411.24(i)(1).
The issue of a MAP’s ability to bring a double damages private cause of action was brought to the Ninth Circuit Court of Appeals in Parra v. PacifiCare of Arizona back in 2012. The MAP in Parra was unsuccessful in its double damages pursuit and simply awarded a contractual right of recovery.The Parra court determined that double damages was not available, because the carrier had already interpleaded the funds to the Court, and at that point had no control over such funds. The MAP had a remedy by exercising its recovery directly against the beneficiary from that fund.
However, this new complaint filed by Humana may establish MSP double damages if the allegations that Hartford ignored Humana’s request for reimbursement holds true.
Thus far, Circuit Courts and District Courts nationwide tend to be favoring MAPs having the same rights to recovery as Medicare. Further, the circumstances and legalities behind this complaint are quite simple: Hartford was on notice of Humana’s claim for recovery and did not respond/reimburse. Despite Hartford already having paid Enrollee, Humana purport to have a solid legal basis to pursue recovery from Hartford pursuant to 42 CFR 411.24(i)(1) ...
Hartford Casualty Insurance Company is the target of a new complaint recently filed in the United States District Court, Western District of Washington (Seattle) by Humana Health Plan.
Humana, as a Medicare Advantage Plan (MAP) is seeking a declaratory judgment as to Hartford’s obligation to reimburse conditional payments made before settlement of its claim, as well as a private cause of action pursuant to 42 USC 1395y(b)(3)(A) for the recovery of double damages for the alleged failure to reimburse Humana.
If Humana ultimately prevails and Hartford appeals to the Ninth Circuit Court of Appeals, precedent may be set determining that MAPs have the same recovery rights as traditional Medicare (a right to double damages for failure to reimburse MAP conditional payments within 60 days of issuance of the settlement check) in the largest Circuit in the United States including California.
These states would be added to the growing list of the 3rd and 11th Circuits from the In Re Avandia and Western Heritage litigation which has now established this double damages private cause of action right for MAPs in the states of: Pennsylvania, Delaware, New Jersey, Alabama, Georgia and Florida.
The Medicare beneficiary in this test case was injured in a car accident. The Enrollee received medical treatment related to the collision which was paid for by Humana totaling at least $161,853.14 in conditional payments. On February 19, 2015 Humana sent Hartford a written notice of its right to recovery of the conditional payments pursuant to the Medicare Secondary Payer Act (MSP).
Later in 2015 Hartford entered into a settlement with Enrollee. Enrollee was responsible for reimbursing Humana within 60 days of the Hartford’s payment of the settlement amount; however, Enrollee did not reimburse Humana.
Even though Hartford had already paid Enrollee the settlement funds, Humana alleges that the Hartford remains responsible to ensure that Humana was reimbursed pursuant to 42 CFR 411.24(i)(1).
The issue of a MAP’s ability to bring a double damages private cause of action was brought to the Ninth Circuit Court of Appeals in Parra v. PacifiCare of Arizona back in 2012. The MAP in Parra was unsuccessful in its double damages pursuit and simply awarded a contractual right of recovery.The Parra court determined that double damages was not available, because the carrier had already interpleaded the funds to the Court, and at that point had no control over such funds. The MAP had a remedy by exercising its recovery directly against the beneficiary from that fund.
However, this new complaint filed by Humana may establish MSP double damages if the allegations that Hartford ignored Humana’s request for reimbursement holds true.
Thus far, Circuit Courts and District Courts nationwide tend to be favoring MAPs having the same rights to recovery as Medicare. Further, the circumstances and legalities behind this complaint are quite simple: Hartford was on notice of Humana’s claim for recovery and did not respond/reimburse. Despite Hartford already having paid Enrollee, Humana purport to have a solid legal basis to pursue recovery from Hartford pursuant to 42 CFR 411.24(i)(1) ...
The Division of Workers’ Compensation (DWC) has suspended eight more medical providers from participating in California’s workers’ compensation system, bringing the total number of providers suspended this year to 46.
DWC Acting Administrative Director George Parisotto issued Orders of Suspension against the following providers:
- Abraham Khorshad of Beverly Hills, investor in Aspen Medical Resources and co-conspirator with Jeffrey Campau and Landen Mirallegro, who were suspended from the workers’ compensation system last month. Khorshad and his codefendants pled guilty in Orange County Superior Court on May 5 to medical insurance fraud for their involvement in an overbilling scheme in which they defrauded insurance companies of more than $70 million. The three providers agreed to pay more than $8 million in restitution to several insurers and selfinsured employers, and to voluntarily dismiss liens of nearly $140 million.
- Joseff Sales of Buena Park, physical therapist, and Danniel Goyena of Whittier, physical therapist assistant, pled guilty in federal court on November 17, 2015 for paying illegal kickbacks as part of a Medicare fraud scheme. Both providers were co-owners and operators of Rehab, Inc., Rehab Dynamics, Inc. and Innovation Physical Therapy, Inc. They surrendered their licenses and were each sentenced to 51 months in federal prison. The pair were ordered to pay restitution of up to $7.9 million.
- Edgar Pogosian (also known as Edgar Hakobyan) of Glendale was found guilty in federal court on February 26, 2016 for money laundering and conspiring to commit money laundering. He took part in a health care fraud scheme to bill Medicare for equipment and tests that were not medically necessary and sometimes were not provided. He received 150 checks and laundered over $700,000 in health care fraud proceeds. Pogosian was sentenced to 18 months in federal prison.
- Timothy Martin of Benicia, osteopathic physician and surgeon, had his medical certificate revoked on June 1, 2015 by the Medical Board of California.
- Alex Abbassi of Tarzana, surrendered his physician and surgeon’s certificate on August 31, 2015 to the Medical Board of California.
- Nicole Hlava of Palo Alto, surrendered her medical license on August 11, 2016 to the Medical Board of California.
- Maher Abadir of Modesto, surrendered his medical license on May 20, 2016 to the Medical Board of California.
AB 1244 (Gray and Daly), which went into effect January 1, introduced new changes to the workers’ compensation system and requires the division’s Administrative Director to suspend any medical provider, physician or practitioner from participating in the workers’ compensation system for various reasons ...
DWC Acting Administrative Director George Parisotto issued Orders of Suspension against the following providers:
- Abraham Khorshad of Beverly Hills, investor in Aspen Medical Resources and co-conspirator with Jeffrey Campau and Landen Mirallegro, who were suspended from the workers’ compensation system last month. Khorshad and his codefendants pled guilty in Orange County Superior Court on May 5 to medical insurance fraud for their involvement in an overbilling scheme in which they defrauded insurance companies of more than $70 million. The three providers agreed to pay more than $8 million in restitution to several insurers and selfinsured employers, and to voluntarily dismiss liens of nearly $140 million.
- Joseff Sales of Buena Park, physical therapist, and Danniel Goyena of Whittier, physical therapist assistant, pled guilty in federal court on November 17, 2015 for paying illegal kickbacks as part of a Medicare fraud scheme. Both providers were co-owners and operators of Rehab, Inc., Rehab Dynamics, Inc. and Innovation Physical Therapy, Inc. They surrendered their licenses and were each sentenced to 51 months in federal prison. The pair were ordered to pay restitution of up to $7.9 million.
- Edgar Pogosian (also known as Edgar Hakobyan) of Glendale was found guilty in federal court on February 26, 2016 for money laundering and conspiring to commit money laundering. He took part in a health care fraud scheme to bill Medicare for equipment and tests that were not medically necessary and sometimes were not provided. He received 150 checks and laundered over $700,000 in health care fraud proceeds. Pogosian was sentenced to 18 months in federal prison.
- Timothy Martin of Benicia, osteopathic physician and surgeon, had his medical certificate revoked on June 1, 2015 by the Medical Board of California.
- Alex Abbassi of Tarzana, surrendered his physician and surgeon’s certificate on August 31, 2015 to the Medical Board of California.
- Nicole Hlava of Palo Alto, surrendered her medical license on August 11, 2016 to the Medical Board of California.
- Maher Abadir of Modesto, surrendered his medical license on May 20, 2016 to the Medical Board of California.
AB 1244 (Gray and Daly), which went into effect January 1, introduced new changes to the workers’ compensation system and requires the division’s Administrative Director to suspend any medical provider, physician or practitioner from participating in the workers’ compensation system for various reasons ...
Ramiro Zapata Jimenez was injured on May 19, 2003 at work. He filed a timely workers’ compensation claim on August 1, 2003 naming Luis Aragon, an uninsured contractor, as the employer. Zapata sustained injury to his head, brain, right knee, internal system, and urinary tract and is totally and permanently disabled.
Aragon was refurbishing an apartment complex located in Long Beach for the owner of the complex, Marco Bolanos. Aragon was a licensed contractor but his workers’ compensation insurance had lapsed on April 9, 2002. Aragon filed for bankruptcy in 2011.
Bolanos did not recall whether he asked Aragon if he had workers’ compensation insurance when Bolanos hired Aragon to refurbish the apartment complex. Bolanos did not inquire with the Contractors State License Board about the status of Aragon’s license.
On August 26, 2003, Zapata’s counsel sent a letter to Bolanos notifying him of Zapata’s injury. This letter was Bolanos’ first notice of Zapata’s accident and injury. Bolanos did not reply to the letter and did not at any time after the accident provide a claim form to Zapata.
Upon confirming Aragon’s uninsured status from the Workers’ Compensation Insurance Rating Bureau on August 28, 2003, Zapata joined the UEBTF as a defendant on February 26, 2004.
The WCJ, on the UEBTF’s motion, joined Bolanos as a party defendant on June 17, 2009, six years after the accident occurred. Bolanos raised the statute of limitations and laches as defenses.
Zapata also sued Bolanos in a civil action in 2011, represented by the same attorney who represented him in the workers’ compensation proceeding. The Superior Court sustained Bolanos’s demurrer without leave to amend in 2012 based on the statute of limitations.
The WCJ issued findings and an award on July 31, 2015 and found Bolanos to be the ultimate employer of Zapata because Aragon was both uninsured and unlicensed by operation of law. The WCJ rejected the statute of limitations defense. The Workers’ Compensation Appeal Board in a split decision, held that the statute of limitations was tolled. The Court of Appeal reversed in the unpublished opinion of Bolanos v WCAB.
Labor Code 5405 provides that a workers’ compensation claim must be filed one year after the date of injury. A new defendant cannot be added after the statute of limitations has run. (McGee Street Productions v. Workers’ Comp. Appeals Bd. (2003) 108 Cal.App.4th 717, 724-725 (McGee).) "The general rule is well settled that, when new parties are brought in by amendment, the statute of limitations continues to run in their favor until thus made parties. The suit cannot be considered as having been commenced against them until they are made parties." (Ingram v. Department of Industrial Relations (1930) 208 Cal. 633, 643; see also McGee, supra, 108 Cal.App.4th at pp. 724-726.)
The statute of limitations is tolled if the employee is unaware of his right to file a workers’ compensation claim. Zapata was not ignorant of his right to apply for benefits under the workers’ compensation laws for this injury, as demonstrated by his filing a workers’ compensation claim on August 1, 2003. After that date, there was no need for a claim form and "notice of potential eligibility for benefits." (Kaiser Foundation Hospitals, supra, 39 Cal.3d at pp. 64-65, § 5401.) Nor was there any reason for tolling the statute of limitations after that date ...
Aragon was refurbishing an apartment complex located in Long Beach for the owner of the complex, Marco Bolanos. Aragon was a licensed contractor but his workers’ compensation insurance had lapsed on April 9, 2002. Aragon filed for bankruptcy in 2011.
Bolanos did not recall whether he asked Aragon if he had workers’ compensation insurance when Bolanos hired Aragon to refurbish the apartment complex. Bolanos did not inquire with the Contractors State License Board about the status of Aragon’s license.
On August 26, 2003, Zapata’s counsel sent a letter to Bolanos notifying him of Zapata’s injury. This letter was Bolanos’ first notice of Zapata’s accident and injury. Bolanos did not reply to the letter and did not at any time after the accident provide a claim form to Zapata.
Upon confirming Aragon’s uninsured status from the Workers’ Compensation Insurance Rating Bureau on August 28, 2003, Zapata joined the UEBTF as a defendant on February 26, 2004.
The WCJ, on the UEBTF’s motion, joined Bolanos as a party defendant on June 17, 2009, six years after the accident occurred. Bolanos raised the statute of limitations and laches as defenses.
Zapata also sued Bolanos in a civil action in 2011, represented by the same attorney who represented him in the workers’ compensation proceeding. The Superior Court sustained Bolanos’s demurrer without leave to amend in 2012 based on the statute of limitations.
The WCJ issued findings and an award on July 31, 2015 and found Bolanos to be the ultimate employer of Zapata because Aragon was both uninsured and unlicensed by operation of law. The WCJ rejected the statute of limitations defense. The Workers’ Compensation Appeal Board in a split decision, held that the statute of limitations was tolled. The Court of Appeal reversed in the unpublished opinion of Bolanos v WCAB.
Labor Code 5405 provides that a workers’ compensation claim must be filed one year after the date of injury. A new defendant cannot be added after the statute of limitations has run. (McGee Street Productions v. Workers’ Comp. Appeals Bd. (2003) 108 Cal.App.4th 717, 724-725 (McGee).) "The general rule is well settled that, when new parties are brought in by amendment, the statute of limitations continues to run in their favor until thus made parties. The suit cannot be considered as having been commenced against them until they are made parties." (Ingram v. Department of Industrial Relations (1930) 208 Cal. 633, 643; see also McGee, supra, 108 Cal.App.4th at pp. 724-726.)
The statute of limitations is tolled if the employee is unaware of his right to file a workers’ compensation claim. Zapata was not ignorant of his right to apply for benefits under the workers’ compensation laws for this injury, as demonstrated by his filing a workers’ compensation claim on August 1, 2003. After that date, there was no need for a claim form and "notice of potential eligibility for benefits." (Kaiser Foundation Hospitals, supra, 39 Cal.3d at pp. 64-65, § 5401.) Nor was there any reason for tolling the statute of limitations after that date ...
Cigna has taken a multi-faceted approach to reducing opioid use among its customers by 25 percent by 2019. The company’s covered drug lists are regularly evaluated. As a result of a recent review, the brand OxyContin will no longer be covered as a preferred option on Cigna's group commercial drug lists effective January 1, 2018.
Cigna is in the process of notifying customers with current OxyContin prescriptions and their doctors of the upcoming change so that they have time to discuss treatment options and covered oxycodone clinical alternatives.
Individuals who have started using OxyContin for hospice care or cancer treatments will continue to have the medication covered in 2018. As with other medications that are not on covered drug lists, Cigna will consider approving coverage for OxyContin if a customer’s doctor feels that treatment using OxyContin is medically necessary.
Cigna has signed a value-based contract with Collegium Pharmaceutical for the drug Xtampza® ER, an oxycodone equivalent with abuse deterrent properties. Xtampza ER's abuse deterrent platform allows the product to maintain its extended release profile even when cut, crushed, chewed or otherwise manipulated.
Under the terms of the contract, Collegium is financially accountable if the average daily dosage strengths of Xtampza ER prescribed for Cigna customers exceed a specific threshold. If the threshold is exceeded, Collegium will reduce the cost of the medication for many of Cigna's benefit plans.
Linking financial terms to dosage metrics may encourage more education to prevent overprescribing. The contract is effective January 1, 2018 for Cigna's commercial business.
"While drug companies don’t control prescriptions, they can help influence patient and doctor conversations by educating people about their medications. The insights we obtain from the metrics in the new value-based contract will help us continue to evolve our opioid management strategies to assist our customers and their doctors," says Jon Maesner, PharmD, Cigna's chief pharmacy officer ...
Cigna is in the process of notifying customers with current OxyContin prescriptions and their doctors of the upcoming change so that they have time to discuss treatment options and covered oxycodone clinical alternatives.
Individuals who have started using OxyContin for hospice care or cancer treatments will continue to have the medication covered in 2018. As with other medications that are not on covered drug lists, Cigna will consider approving coverage for OxyContin if a customer’s doctor feels that treatment using OxyContin is medically necessary.
Cigna has signed a value-based contract with Collegium Pharmaceutical for the drug Xtampza® ER, an oxycodone equivalent with abuse deterrent properties. Xtampza ER's abuse deterrent platform allows the product to maintain its extended release profile even when cut, crushed, chewed or otherwise manipulated.
Under the terms of the contract, Collegium is financially accountable if the average daily dosage strengths of Xtampza ER prescribed for Cigna customers exceed a specific threshold. If the threshold is exceeded, Collegium will reduce the cost of the medication for many of Cigna's benefit plans.
Linking financial terms to dosage metrics may encourage more education to prevent overprescribing. The contract is effective January 1, 2018 for Cigna's commercial business.
"While drug companies don’t control prescriptions, they can help influence patient and doctor conversations by educating people about their medications. The insights we obtain from the metrics in the new value-based contract will help us continue to evolve our opioid management strategies to assist our customers and their doctors," says Jon Maesner, PharmD, Cigna's chief pharmacy officer ...
Dr. Eduardo Anguizola, who is facing multiple counts of insurance fraud filed by Orange County prosecutors, is one the plaintiffs who claims Labor Code 4615 - the automatic lien stay law - violates the procedural component of the due process clause because it immediately stays all liens without notice or a hearing. His motion in federal court for a preliminary injunction halting the implementation of the new law has been pending since early this year.
As the Anguizola case headed for its final hearing on September 28, Governor Brown signed AB 1422 into law. According to the Governor's signing memo he said "I am signing AB 1422 which is clean-up legislation to last year's workers' compensation anti-fraud bills, AB 1244 and SB 1160. Those measures established new requirements and authority to help prevent and reduce fraud in the workers' compensation system. Specifically, they require the suspension of medical providers who have been convicted of crimes involving fraud or abuse. They also require placing a stay on any liens filed by providers charged with such crimes (pending disposition of the charges)."
AB 1422 contains a new LC 4615 subsection (e) which reads "The automatic stay required by this section shall not preclude the appeals board from inquiring into and determining within a workers’ compensation proceeding whether a lien is stayed pursuant to subdivision (a) or whether a lien claimant is controlled by a physician, practitioner, or provider."
The DIR filed a "Notice of New Law" in federal court the day before the September 28, hearing set before Judge Wu which would have been the final hearing before his ruling. Accordingly, Judge Wu continued the September 28 hearing to October 19, and provided the parties with a briefing schedule to discuss the impact of AB 1422, the newly passed law.
In the "final" closing brief just filed in support of a preliminary injunction, attorneys for the lien claimants respond to the new law saying that they are making "a facial constitutional attack on a statute, which cannot be cured by a hastily passed amendment."
They go on to claim that "Recognizing the deficiencies in their evidence, the State appears to have corralled the Legislature into intervening by rushing through 'amended' legislation in the hopes of making an end run around this litigation, accompanied with a signing message directed to this Court."
They go on to argue that "the California Legislature’s recent amendment to Section 4615 does not repair the law’s constitutional defects. Indeed, the amendment merely serves to highlight those defects while doing nothing to ameliorate the Due Process and Sixth Amendment quagmire created by the law. Its language establishes no right to a hearing, which is required under both the Due Process Clause and the Supreme Court’s interpretation of the Sixth Amendment."
They support the argument by saying "Notably, subsection (e) does not provide any stayed lien claimant with the right to a hearing. It merely states that the stay 'shall not preclude the appeals board' from 'inquiring into and determining' whether a lien is stayed. Id. The statute appears to give the appeals board (not workers’ compensation judges) the limited ability to consider the narrow issue of whether the lien falls within the scope of Section 4615 and therefore, whether the appeals board is required to treat it as automatically stayed."
"Notably, it does not require the appeals board to allow a lien claimant to be heard on this issue, or even to consider any protest raised by a lien claimant - it merely gives the appeals board permission to consider such a grievance."
They go on to conclude that "In other words, new subsection (e) gives lien claimants no right at all to a hearing, even when it is abundantly clear that a lien claimant should not have been on the published list, the secret list, the double-secret list, or any other list that might be available to the appeals board. Although the appeals board can choose to hear what the lien claimant has to say, there is no direction that the appeals board must make an inquiry and determine whether the law applies. This does not suffice to protect lien claimants’ due process rights."
The DIR will file their response by October 10, and Judge Wu will hold another hearing in federal court on October 19 ...
As the Anguizola case headed for its final hearing on September 28, Governor Brown signed AB 1422 into law. According to the Governor's signing memo he said "I am signing AB 1422 which is clean-up legislation to last year's workers' compensation anti-fraud bills, AB 1244 and SB 1160. Those measures established new requirements and authority to help prevent and reduce fraud in the workers' compensation system. Specifically, they require the suspension of medical providers who have been convicted of crimes involving fraud or abuse. They also require placing a stay on any liens filed by providers charged with such crimes (pending disposition of the charges)."
AB 1422 contains a new LC 4615 subsection (e) which reads "The automatic stay required by this section shall not preclude the appeals board from inquiring into and determining within a workers’ compensation proceeding whether a lien is stayed pursuant to subdivision (a) or whether a lien claimant is controlled by a physician, practitioner, or provider."
The DIR filed a "Notice of New Law" in federal court the day before the September 28, hearing set before Judge Wu which would have been the final hearing before his ruling. Accordingly, Judge Wu continued the September 28 hearing to October 19, and provided the parties with a briefing schedule to discuss the impact of AB 1422, the newly passed law.
In the "final" closing brief just filed in support of a preliminary injunction, attorneys for the lien claimants respond to the new law saying that they are making "a facial constitutional attack on a statute, which cannot be cured by a hastily passed amendment."
They go on to claim that "Recognizing the deficiencies in their evidence, the State appears to have corralled the Legislature into intervening by rushing through 'amended' legislation in the hopes of making an end run around this litigation, accompanied with a signing message directed to this Court."
They go on to argue that "the California Legislature’s recent amendment to Section 4615 does not repair the law’s constitutional defects. Indeed, the amendment merely serves to highlight those defects while doing nothing to ameliorate the Due Process and Sixth Amendment quagmire created by the law. Its language establishes no right to a hearing, which is required under both the Due Process Clause and the Supreme Court’s interpretation of the Sixth Amendment."
They support the argument by saying "Notably, subsection (e) does not provide any stayed lien claimant with the right to a hearing. It merely states that the stay 'shall not preclude the appeals board' from 'inquiring into and determining' whether a lien is stayed. Id. The statute appears to give the appeals board (not workers’ compensation judges) the limited ability to consider the narrow issue of whether the lien falls within the scope of Section 4615 and therefore, whether the appeals board is required to treat it as automatically stayed."
"Notably, it does not require the appeals board to allow a lien claimant to be heard on this issue, or even to consider any protest raised by a lien claimant - it merely gives the appeals board permission to consider such a grievance."
They go on to conclude that "In other words, new subsection (e) gives lien claimants no right at all to a hearing, even when it is abundantly clear that a lien claimant should not have been on the published list, the secret list, the double-secret list, or any other list that might be available to the appeals board. Although the appeals board can choose to hear what the lien claimant has to say, there is no direction that the appeals board must make an inquiry and determine whether the law applies. This does not suffice to protect lien claimants’ due process rights."
The DIR will file their response by October 10, and Judge Wu will hold another hearing in federal court on October 19 ...
The Department of Industrial Relations’ Division of Workers’ Compensation (DWC) announced that it will this week lift the notation in its Electronic Adjudication Management System (EAMS) that indicates all liens with Labor Code section 4903.05(c) declarations filed on July 2 and July 3 were dismissed.
Under this Labor Code provision, a Senate Bill 1160 mandate to combat workers’ compensation fraud, all lien claimants who filed a lien between January 1, 2013 and December 31, 2016, and paid a filing fee, were required to file the "Supplemental Lien Form and 4903.05(c) Declaration" form by July 1, 2017. The declarations confirm that the liens are valid and appropriately filed.
A total of 2,794 liens with declarations filed on July 2 and 3 were administratively designated as dismissed for failure to comply with the July 1 filing deadline. Because July 1 fell on a weekend, workers’ compensation administrative law judges will adjudicate the timeliness of lien declarations filed on July 2 and July 3 on a case-by-case basis. DWC’s reversal of the dismissal notation is not a decision or order on the timeliness of the declarations, and shall not be construed as such.
Liens with declarations filed after July 3 and liens where no declaration was filed will remain dismissed by operation of law under Labor Code section 4903.05(c)(3) ...
Under this Labor Code provision, a Senate Bill 1160 mandate to combat workers’ compensation fraud, all lien claimants who filed a lien between January 1, 2013 and December 31, 2016, and paid a filing fee, were required to file the "Supplemental Lien Form and 4903.05(c) Declaration" form by July 1, 2017. The declarations confirm that the liens are valid and appropriately filed.
A total of 2,794 liens with declarations filed on July 2 and 3 were administratively designated as dismissed for failure to comply with the July 1 filing deadline. Because July 1 fell on a weekend, workers’ compensation administrative law judges will adjudicate the timeliness of lien declarations filed on July 2 and July 3 on a case-by-case basis. DWC’s reversal of the dismissal notation is not a decision or order on the timeliness of the declarations, and shall not be construed as such.
Liens with declarations filed after July 3 and liens where no declaration was filed will remain dismissed by operation of law under Labor Code section 4903.05(c)(3) ...
Belinda Go sustained industrial injury to her neck while working for Sutter Solano Medical Center as a registered nurse in 2013.
On May 7, 2015, one of her treating physicians, Christopher Neuberger, M.D. submitted a request for authorization (RFA) for cervical spine surgery and related treatment and services. The RFA was submitted by defendant to its UR provider, which denied authorization. Applicant obtained IMR pursuant to Labor Code section 4610.5, but the UR denial was upheld in a July 22, 2015 IMR determination.
On September 11, 2015, her condition was found to be permanent and stationary following the UR denial by her primary treating physician. A consulting physician said that her neck disability caused 5% whole person impairment (WPI), which rated 7% permanent disability after apportionment of 20% to nonindustrial factors.
Belinda Go returned to work for a period of time until March 22, 2016, and experienced increased symptoms during that time. On March 28, 2016, she followed Dr. Nueberger's recommendation for cervical spine surgery and self-procured it from Jason Huffman, M.D.
On August 1, 2016, applicant was evaluated by PQME Dr. Zwerin, who found that applicant's condition became permanent and stationary on July 28, 2016, four months after the surgery. Dr. Zwerin further determined that as a result of the unauthorized surgery, applicant's neck disability caused 17% WPI and that 20% of the permanent disability is properly apportioned to nonindustrial factors.
Defendant disputed the determination of Dr. Zwerin and argued that because authorization for the cervical spine surgery was denied through the UR and IMR processes that it has no liability for permanent or temporary disability that the surgery caused. Defendant further contends that the pre-surgery reporting of Dr. Cohen should be followed to award 7% permanent disability.
The WCJ found that applicant was entitled to temporary disability indemnity for a period of time following the cervical spine surgery, and finding that the industrial injury caused 23% permanent disability after apportionment, as opined by PQME Dr. Zwerin. The defendant's petition for reconsideration was denied in the panel decision of Go v Sutter Solano Medial Center.
After reviewing several conflicting panel decisions on this issue, this panel concluded that "An employee is entitled to unapportioned compensation for permanent disability caused by reasonable medical treatment of the industrial injury. (See, Hikida v. Workers' Comp. Appeals Bd. (2017) 12 Cal.App.5th 1249 [82 Cal.Comp.Cases 679] [2017 Cal. App. LEXIS 572].) In that the UR and IMR statutes are silent on the question of temporary disability indemnity, an employee is not precluded from claiming it even if the disability results from reasonable medical treatment that is self-procured pursuant to section 4605." ...
On May 7, 2015, one of her treating physicians, Christopher Neuberger, M.D. submitted a request for authorization (RFA) for cervical spine surgery and related treatment and services. The RFA was submitted by defendant to its UR provider, which denied authorization. Applicant obtained IMR pursuant to Labor Code section 4610.5, but the UR denial was upheld in a July 22, 2015 IMR determination.
On September 11, 2015, her condition was found to be permanent and stationary following the UR denial by her primary treating physician. A consulting physician said that her neck disability caused 5% whole person impairment (WPI), which rated 7% permanent disability after apportionment of 20% to nonindustrial factors.
Belinda Go returned to work for a period of time until March 22, 2016, and experienced increased symptoms during that time. On March 28, 2016, she followed Dr. Nueberger's recommendation for cervical spine surgery and self-procured it from Jason Huffman, M.D.
On August 1, 2016, applicant was evaluated by PQME Dr. Zwerin, who found that applicant's condition became permanent and stationary on July 28, 2016, four months after the surgery. Dr. Zwerin further determined that as a result of the unauthorized surgery, applicant's neck disability caused 17% WPI and that 20% of the permanent disability is properly apportioned to nonindustrial factors.
Defendant disputed the determination of Dr. Zwerin and argued that because authorization for the cervical spine surgery was denied through the UR and IMR processes that it has no liability for permanent or temporary disability that the surgery caused. Defendant further contends that the pre-surgery reporting of Dr. Cohen should be followed to award 7% permanent disability.
The WCJ found that applicant was entitled to temporary disability indemnity for a period of time following the cervical spine surgery, and finding that the industrial injury caused 23% permanent disability after apportionment, as opined by PQME Dr. Zwerin. The defendant's petition for reconsideration was denied in the panel decision of Go v Sutter Solano Medial Center.
After reviewing several conflicting panel decisions on this issue, this panel concluded that "An employee is entitled to unapportioned compensation for permanent disability caused by reasonable medical treatment of the industrial injury. (See, Hikida v. Workers' Comp. Appeals Bd. (2017) 12 Cal.App.5th 1249 [82 Cal.Comp.Cases 679] [2017 Cal. App. LEXIS 572].) In that the UR and IMR statutes are silent on the question of temporary disability indemnity, an employee is not precluded from claiming it even if the disability results from reasonable medical treatment that is self-procured pursuant to section 4605." ...
Federal prosecutors announced that the owner-operator of a Burbank medical clinic was sentenced to 37 months in federal prison on federal healthcare fraud charges for participating in a scheme to defraud Medicare by prescribing unnecessary services and equipment, which often were not even provided.
Knarik Vardumyan, 53, of Burbank, who formerly owned and operated the medical clinic, was sentenced by United States District Judge Dale S. Fischer who also ordered Vardumyan to pay $1,711,789 in restitution to the Centers for Medicare & Medicaid Services.
Vardumyan pleaded guilty in April to two counts of federal healthcare fraud.
According to court documents, Vardumyan admitted that she knowingly and unlawfully participated in a scheme to defraud Medicare by billing Medicare for "medically unnecessary office visits and diagnostic tests," and by arranging "for the issuance of . . . prescriptions and orders for medically unnecessary durable medical equipment" and "home health services."
Vardumyan further admitted, "many, if not all" of the people who visited her clinic "were brought . . . by co-schemers known as ‘marketers,’ who offered promises of free, medically unnecessary [equipment] or food" to those Medicare beneficiaries who were willing to attend Vardumyan’s clinic.
In documents filed in relation to thesentence, the government noted that Medicare paid $1,711,789 as a result of this fraudulent scheme, and that a 37-month term of imprisonment appropriately reflects the nature and circumstances of the offense, as well as the need for the sentence to "promote respect for the law and afford adequate deterrence against this kind of serious fraud against our healthcare system and the public fisc."
The case against Vardumyan was investigated by the Federal Bureau of Investigation and Assistant United States Attorneys Kristen Williams, Cathy J. Ostiller, and Julian André of the Major Frauds Section and prosecuted by Assistant United States Attorney Adam P. Schleifer ...
Knarik Vardumyan, 53, of Burbank, who formerly owned and operated the medical clinic, was sentenced by United States District Judge Dale S. Fischer who also ordered Vardumyan to pay $1,711,789 in restitution to the Centers for Medicare & Medicaid Services.
Vardumyan pleaded guilty in April to two counts of federal healthcare fraud.
According to court documents, Vardumyan admitted that she knowingly and unlawfully participated in a scheme to defraud Medicare by billing Medicare for "medically unnecessary office visits and diagnostic tests," and by arranging "for the issuance of . . . prescriptions and orders for medically unnecessary durable medical equipment" and "home health services."
Vardumyan further admitted, "many, if not all" of the people who visited her clinic "were brought . . . by co-schemers known as ‘marketers,’ who offered promises of free, medically unnecessary [equipment] or food" to those Medicare beneficiaries who were willing to attend Vardumyan’s clinic.
In documents filed in relation to thesentence, the government noted that Medicare paid $1,711,789 as a result of this fraudulent scheme, and that a 37-month term of imprisonment appropriately reflects the nature and circumstances of the offense, as well as the need for the sentence to "promote respect for the law and afford adequate deterrence against this kind of serious fraud against our healthcare system and the public fisc."
The case against Vardumyan was investigated by the Federal Bureau of Investigation and Assistant United States Attorneys Kristen Williams, Cathy J. Ostiller, and Julian André of the Major Frauds Section and prosecuted by Assistant United States Attorney Adam P. Schleifer ...
The U.S. Food and Drug Administration just announced a series of measures designed to speed to market generic versions of complex drugs in an effort to address the rising cost of pharmaceuticals.
The measures, announced in a blog post by Commissioner Scott Gottlieb, stray into an area that has not previously been the FDA’s purview: drug prices. The agency has typically made its decisions based on safety and efficacy without regard to cost.
Gottlieb said the measures are designed to increase competition in the market by enabling generic competition to complex drugs, something he has long argued for.
Earlier this year, he announced the Drug Competition Action Plan to advance new policies aimed at bringing more competition to the drug market. The goal was to improve access consumers have to the medicines that they need. Access to medicine is a matter of public health. "If consumers are priced out of the drugs they need, that’s a public health concern that FDA should address, within the scope of its mandate and authorities."
The plan has a number of different domains. Among them is a compilation of efforts to improve the efficiency of the generic drug approval process; and another is a group of policies aimed at closing loopholes that allow branded drug companies to game FDA rules in ways that forestall the generic competition that Congress intended.
One important group of policies is aimed at making it easier to bring generic competition to a category of branded drugs known as complex drugs. Thus the FDA announced a major new set of policies to advance these goals.
Complex drugs comprise high cost medicines like metered dose inhalers used to treat asthma, as well as some costly injectable drugs. These medicines generally have at least one feature that makes them harder to "genericize" under traditional approaches. As a consequence, these drugs can face less competition. In some cases, costly, branded drugs that are complex drugs have lost their exclusivity, but are subject to no generic competition.
The new policies just announced are aimed at ensuring that the FDA provides as much scientific and regulatory clarity as possible with respect to complex generic drugs. The new guidance provides information on requesting and conducting product development meetings, pre-submission meetings, and mid-review cycle meetings with FDA. These meetings will allow for enhanced communication between generic drug applicants and FDA early in the generic drug development process, allowing for more efficient generic drug development, review, and approval pathways.
The FDA commissioner says it will soon release other important policies aimed at spurring competition to complex drugs ...
The measures, announced in a blog post by Commissioner Scott Gottlieb, stray into an area that has not previously been the FDA’s purview: drug prices. The agency has typically made its decisions based on safety and efficacy without regard to cost.
Gottlieb said the measures are designed to increase competition in the market by enabling generic competition to complex drugs, something he has long argued for.
Earlier this year, he announced the Drug Competition Action Plan to advance new policies aimed at bringing more competition to the drug market. The goal was to improve access consumers have to the medicines that they need. Access to medicine is a matter of public health. "If consumers are priced out of the drugs they need, that’s a public health concern that FDA should address, within the scope of its mandate and authorities."
The plan has a number of different domains. Among them is a compilation of efforts to improve the efficiency of the generic drug approval process; and another is a group of policies aimed at closing loopholes that allow branded drug companies to game FDA rules in ways that forestall the generic competition that Congress intended.
One important group of policies is aimed at making it easier to bring generic competition to a category of branded drugs known as complex drugs. Thus the FDA announced a major new set of policies to advance these goals.
Complex drugs comprise high cost medicines like metered dose inhalers used to treat asthma, as well as some costly injectable drugs. These medicines generally have at least one feature that makes them harder to "genericize" under traditional approaches. As a consequence, these drugs can face less competition. In some cases, costly, branded drugs that are complex drugs have lost their exclusivity, but are subject to no generic competition.
The new policies just announced are aimed at ensuring that the FDA provides as much scientific and regulatory clarity as possible with respect to complex generic drugs. The new guidance provides information on requesting and conducting product development meetings, pre-submission meetings, and mid-review cycle meetings with FDA. These meetings will allow for enhanced communication between generic drug applicants and FDA early in the generic drug development process, allowing for more efficient generic drug development, review, and approval pathways.
The FDA commissioner says it will soon release other important policies aimed at spurring competition to complex drugs ...
A daily pill which halts the disabling bone loss caused by osteoarthritis is being hailed as a new dawn in the treatment of the disease. The new drug has excited scientists after trials showed that after just six months it reduced bone damage around knee joints and also maintained cartilage thickness. It is the first time a drug has been shown to tackle underlying bone structure changes in diseased joints. Current treatments have aimed only at helping patients manage pain symptoms.
The pan-European study was carried out over six months with 244 patients aged between 40 and 80 with osteoarthritis in the knee. "This drug heralds a new dawn in the treatment of this disease as it is the first evidence we have of a drug which can have a significant benefit on the structure of the bone."
Professor Conaghan, previously chairman of the National Institute for Health and Care Excellence group on the management of osteoarthritis, added: "We now need larger studies to replicate these findings, the results of which we hope will open up a new class of drug."
The treatment, known as M1V-711, is based on a molecule involved in the turnover of bone and cartilage in the joints. It works by interfering with the process that leads to joint breakdown. It was tested against patients given a placebo and after six months those receiving the treatment showed a 65 per cent reduction in bone loss.
Those on the dummy pills showed slight increases in bone loss. The drug, which was shown to have relatively few side effects, also halted cartilage loss, with those on low doses experiencing a 70 per cent reduction in cartilage thickness and those on higher doses showing a slight increase in cartilage thickness.
Experts hope over a longer period the results may be greater, and could have an impact on significantly reducing pain from the condition. The results of the trial are likely to be revealed next month at a conference in San Diego.
The news comes as experts call for an end to the widespread long-term use of painkillers such as paracetamol and antiinflammatories such as ibuprofen for osteo arthritis, following research showing they may be doing more harm than good.
Current guidance from Nice still recommends paracetamol and anti-infl ammatories as treatments for this disabling condition. However, in one large US study people who regularly took paracetamol over 12 years had a 35 per cent increased risk of a stroke or fatal heart attack. Other recent studies have linked long term use of anti-inflammatory drugs to an increased risk of stomach ulcers and kidney failure.
One of the UK’s leading experts on arthritis, Dr Rod Hughes, former president of rheumatology at The Royal Society of Medicine, said: "There are numerous side effects linked with anti-infl ammatory drugs and we need to look at safer longterm alternatives for those living with joint pain."
...
The pan-European study was carried out over six months with 244 patients aged between 40 and 80 with osteoarthritis in the knee. "This drug heralds a new dawn in the treatment of this disease as it is the first evidence we have of a drug which can have a significant benefit on the structure of the bone."
Professor Conaghan, previously chairman of the National Institute for Health and Care Excellence group on the management of osteoarthritis, added: "We now need larger studies to replicate these findings, the results of which we hope will open up a new class of drug."
The treatment, known as M1V-711, is based on a molecule involved in the turnover of bone and cartilage in the joints. It works by interfering with the process that leads to joint breakdown. It was tested against patients given a placebo and after six months those receiving the treatment showed a 65 per cent reduction in bone loss.
Those on the dummy pills showed slight increases in bone loss. The drug, which was shown to have relatively few side effects, also halted cartilage loss, with those on low doses experiencing a 70 per cent reduction in cartilage thickness and those on higher doses showing a slight increase in cartilage thickness.
Experts hope over a longer period the results may be greater, and could have an impact on significantly reducing pain from the condition. The results of the trial are likely to be revealed next month at a conference in San Diego.
The news comes as experts call for an end to the widespread long-term use of painkillers such as paracetamol and antiinflammatories such as ibuprofen for osteo arthritis, following research showing they may be doing more harm than good.
Current guidance from Nice still recommends paracetamol and anti-infl ammatories as treatments for this disabling condition. However, in one large US study people who regularly took paracetamol over 12 years had a 35 per cent increased risk of a stroke or fatal heart attack. Other recent studies have linked long term use of anti-inflammatory drugs to an increased risk of stomach ulcers and kidney failure.
One of the UK’s leading experts on arthritis, Dr Rod Hughes, former president of rheumatology at The Royal Society of Medicine, said: "There are numerous side effects linked with anti-infl ammatory drugs and we need to look at safer longterm alternatives for those living with joint pain."
...
