A federal grand jury has indicted San Francisco acupuncturist Haichao Huang, charging him with health care fraud and making false statements relating to health care billing.
Huang, was a health care provider who offered acupuncture, physical therapy, massage, and other services at his office in San Francisco.
The indictment alleges that Huang submitted claims for reimbursement to his patients’ health insurance plans, claiming that he provided reimbursable services and treatments when, in fact, he knew that the billings were false and not properly reimbursable.
The indictment gives three examples of the ways in which Huang allegedly submitted billings for reimbursement. First, Huang submitted requests for reimbursement for acupuncture and other treatments when, in fact, the patient had received either much shorter periods of treatment or no treatment at all.
Second, after a patient reached the limit of acupuncture sessions allowed by the relevant insurance plan, Huang billed the plan for other types of treatments and services that were not provided in order to continue receiving improper reimbursements.
Third, Huang submitted claims for services rendered on days when the patient beneficiaries were not seen and received no services at all - including days when Huang was not in California.
Huang is charged with six counts of health care fraud, in violation of 18 U.S.C. § 1347, and one count of false statement relating to health care matters, in violation of 18 U.S.C. § 1035(a)(2).
If convicted, the defendant faces a maximum sentence of 10 years in prison and $250,000 for each violation of 18 U.S.C. § 371. The defendant faces five years in prison and a fine of $250,000 if convicted of the violation of 18 U.S.C. § 1035(a)(2).
Huang pleaded not guilty and was released on bond. Huang’s first appearance before a district court judge is scheduled for March 22, 2019, before the Hon. Susan Illston, U.S. District Judge.
This prosecution is the result of investigations by the Office of Personnel Management Office of Inspector General and the Department of Labor Office of Inspector General, with assistance from the San Mateo County District Attorney’s Office ...
Huang, was a health care provider who offered acupuncture, physical therapy, massage, and other services at his office in San Francisco.
The indictment alleges that Huang submitted claims for reimbursement to his patients’ health insurance plans, claiming that he provided reimbursable services and treatments when, in fact, he knew that the billings were false and not properly reimbursable.
The indictment gives three examples of the ways in which Huang allegedly submitted billings for reimbursement. First, Huang submitted requests for reimbursement for acupuncture and other treatments when, in fact, the patient had received either much shorter periods of treatment or no treatment at all.
Second, after a patient reached the limit of acupuncture sessions allowed by the relevant insurance plan, Huang billed the plan for other types of treatments and services that were not provided in order to continue receiving improper reimbursements.
Third, Huang submitted claims for services rendered on days when the patient beneficiaries were not seen and received no services at all - including days when Huang was not in California.
Huang is charged with six counts of health care fraud, in violation of 18 U.S.C. § 1347, and one count of false statement relating to health care matters, in violation of 18 U.S.C. § 1035(a)(2).
If convicted, the defendant faces a maximum sentence of 10 years in prison and $250,000 for each violation of 18 U.S.C. § 371. The defendant faces five years in prison and a fine of $250,000 if convicted of the violation of 18 U.S.C. § 1035(a)(2).
Huang pleaded not guilty and was released on bond. Huang’s first appearance before a district court judge is scheduled for March 22, 2019, before the Hon. Susan Illston, U.S. District Judge.
This prosecution is the result of investigations by the Office of Personnel Management Office of Inspector General and the Department of Labor Office of Inspector General, with assistance from the San Mateo County District Attorney’s Office ...
Trial proceeded in the case of Ana Villanueva v Teva Foods, Travelers Insurance Company on December 12, 2018 on the issue of whether the lien of Firstline Health, Inc., should be subject to an automatic stay pursuant to Labor Code section 4615.
The WCJ found that applicant claimed an injury arising out of and in the course of her employment on October 11, 2012; that criminally charged providers Munir Uwaydah, M.D., and Paul Turley controlled Firstline pursuant to Labor Code section 139.21(a)(3); and, that Firstline’s Exhibit 73 is not admissible as it was not listed on the pre-trial conference statement.
The WCJ thus ordered that the lien of Firstline in this case is subject to a stay pursuant to section 4615.
Firstline filed a Petition for Reconsideration contending that as of October 11, 2010, David Johnson, M.D., was the sole owner and officer of Firstline and thus "controlled" Firstline pursuant to section 139.21(a)(3); that Dr. Johnson is not currently charged with any crime; and, thus, there are no grounds to impose a section 4615 stay against its lien in this case.
Defendant did not file an answer to Firstline’s Petition for Reconsideration.
The WCJ filed a Report recommending that Firstline’s Petition for Reconsideration be denied because defendant’s evidence indicates that Dr. Uwaydah exercised absolute control over Firstline despite the fraudulent identification of other individuals as owners, officers or directors of Firstline in official documents, which was done in order to hide Dr. Uwaydah’s ownership and control of Firstline from creditors, investigators, government agencies and law enforcement.
Mr. Turley states that Firstline was created to take over the fraudulent activities of Frontline, and that Dr. Uwaydah exercised the same absolute control over Firstline as he had over Frontline, even though others - including Dr. Johnson - were identified as owners, officers or directors:
Uwaydah fled the United States to Lebanon in June of 2010...In the Fall of 2010, Turley traveled to Lebanon to confer with Uwaydah and to discuss how to keep the Frontline Business operating without Uwaydah’s presence, and without his name being connected to the business.
Uwaydah told Turley that there was close to a billion dollars in receivables from Frontline and Firstline
Dr. Uwaydah’s control extends to the current criminal defense in this case. He has paid millions of dollars for the attorneys for the defendants, including defending Turley.
The WCAB on reconsideration said it concurs with the conclusion of the WCJ that defendant’s evidence, namely defendant’s Exhibit C, the "Factual Statement of Paul Turley dated 12/3/18" appears to establish prima facie grounds to impose a section 4615 stay against Firstline’s lien based on Dr. Uwaydah’s de facto ownership and control of Firstline." The ruling is posted to its website as a "Significant Panel Decision."
"However, the Turley Statement was produced on the eve of trial and thus, lien claimant did not have sufficient notice or opportunity to rebut the Turley Statement."
Lien claimant objected that the Turley Statement was part of a plea arrangement in his criminal case wherein he pled guilty and got credit for time-served in exchange for his execution of this statement.
The Petition for Reconsideration, was granted, and the WCAB rescinded the F&O and returned this case to the trial level for further proceedings consistent with this decision. Firstline is thus afforded an opportunity to rebut the Turley Statement ...
The WCJ found that applicant claimed an injury arising out of and in the course of her employment on October 11, 2012; that criminally charged providers Munir Uwaydah, M.D., and Paul Turley controlled Firstline pursuant to Labor Code section 139.21(a)(3); and, that Firstline’s Exhibit 73 is not admissible as it was not listed on the pre-trial conference statement.
The WCJ thus ordered that the lien of Firstline in this case is subject to a stay pursuant to section 4615.
Firstline filed a Petition for Reconsideration contending that as of October 11, 2010, David Johnson, M.D., was the sole owner and officer of Firstline and thus "controlled" Firstline pursuant to section 139.21(a)(3); that Dr. Johnson is not currently charged with any crime; and, thus, there are no grounds to impose a section 4615 stay against its lien in this case.
Defendant did not file an answer to Firstline’s Petition for Reconsideration.
The WCJ filed a Report recommending that Firstline’s Petition for Reconsideration be denied because defendant’s evidence indicates that Dr. Uwaydah exercised absolute control over Firstline despite the fraudulent identification of other individuals as owners, officers or directors of Firstline in official documents, which was done in order to hide Dr. Uwaydah’s ownership and control of Firstline from creditors, investigators, government agencies and law enforcement.
Mr. Turley states that Firstline was created to take over the fraudulent activities of Frontline, and that Dr. Uwaydah exercised the same absolute control over Firstline as he had over Frontline, even though others - including Dr. Johnson - were identified as owners, officers or directors:
Uwaydah fled the United States to Lebanon in June of 2010...In the Fall of 2010, Turley traveled to Lebanon to confer with Uwaydah and to discuss how to keep the Frontline Business operating without Uwaydah’s presence, and without his name being connected to the business.
Uwaydah told Turley that there was close to a billion dollars in receivables from Frontline and Firstline
Dr. Uwaydah’s control extends to the current criminal defense in this case. He has paid millions of dollars for the attorneys for the defendants, including defending Turley.
The WCAB on reconsideration said it concurs with the conclusion of the WCJ that defendant’s evidence, namely defendant’s Exhibit C, the "Factual Statement of Paul Turley dated 12/3/18" appears to establish prima facie grounds to impose a section 4615 stay against Firstline’s lien based on Dr. Uwaydah’s de facto ownership and control of Firstline." The ruling is posted to its website as a "Significant Panel Decision."
"However, the Turley Statement was produced on the eve of trial and thus, lien claimant did not have sufficient notice or opportunity to rebut the Turley Statement."
Lien claimant objected that the Turley Statement was part of a plea arrangement in his criminal case wherein he pled guilty and got credit for time-served in exchange for his execution of this statement.
The Petition for Reconsideration, was granted, and the WCAB rescinded the F&O and returned this case to the trial level for further proceedings consistent with this decision. Firstline is thus afforded an opportunity to rebut the Turley Statement ...
Andrew Panaggio suffered a workrelated injury to his lower back in 1991. A permanent impairment award was approved in 1996, and in 1997 he received a lump-sum settlement.
Panaggio continues to suffer ongoing pain as a result of his injury and has experienced negative side effects from taking prescribed opiates. In 2016, the New Hampshire Department of Health and Human Services determined that Panaggio qualified as a patient in the therapeutic cannabis program, and issued him a New Hampshire cannabis registry identification card.
Panaggio purchased medical marijuana and submitted his receipt to the workers’ compensation insurance carrier for reimbursement. The carrier, CNA Insurance Company, denied payment on the ground that "medical marijuana is not reasonable/necessary or causally related" to his injury. A hearing officer and the board agreed with the denial.
A majority of the board upheld the carrier’s refusal to reimburse Panaggio. It noted that the statutory language of the Cannabis law states that "[n]othing in this chapter shall be construed to require . . . [a]ny health insurance provider, health care plan, or medical assistance program to be liable for any claim for reimbursement for the therapeutic use of cannabis. And concluded that "the carrier is not able to provide medical marijuana" because such reimbursement is "not legal under state or federal law."
The Supreme Court of New Hampshire disagreed, and reversed in the case of Appeal of Andrew Panaggio.
It noted that statutes in other jurisdictions expressly prohibit workers’ compensation insurance carriers from reimbursing claimants for the cost of medical marijuana. See, e.g., Fla. Stat. § 381.986(15) (2017) (providing in Florida’s Medical Use of Marijuana statute that "[m]arijuana . . . is not reimbursable under" Florida’s Workers’ Compensation Law); Mich. Comp. Laws § 418.315a (2014) (providing in the Michigan Worker’s Disability Compensation Act that "[n]otwithstanding" the requirement that an employer "shall furnish, or cause to be furnished, to an employee who receives a personal injury arising out of and in the course of employment, reasonable medical . . . treatment," an employer "is not required to reimburse or cause to be reimbursed charges for medical marihuana treatment").
But "Had the legislature intended to bar patients in the therapeutic cannabis program from receiving reimbursement under RSA 281-A:23, I, it easily could have done so, and we will not add language that the legislature did not see fit to include."
"Because the board’s order fails to sufficiently articulate the law that supports the board’s legal conclusion and fails to provide an adequate explanation of its reasoning regarding federal law, it is impossible for us to discern the basis for the board’s decision sufficient for us to conduct meaningful review."
The case was remanded to the board for a determination of the issue of the federal criminal issues in the first instance ...
Panaggio continues to suffer ongoing pain as a result of his injury and has experienced negative side effects from taking prescribed opiates. In 2016, the New Hampshire Department of Health and Human Services determined that Panaggio qualified as a patient in the therapeutic cannabis program, and issued him a New Hampshire cannabis registry identification card.
Panaggio purchased medical marijuana and submitted his receipt to the workers’ compensation insurance carrier for reimbursement. The carrier, CNA Insurance Company, denied payment on the ground that "medical marijuana is not reasonable/necessary or causally related" to his injury. A hearing officer and the board agreed with the denial.
A majority of the board upheld the carrier’s refusal to reimburse Panaggio. It noted that the statutory language of the Cannabis law states that "[n]othing in this chapter shall be construed to require . . . [a]ny health insurance provider, health care plan, or medical assistance program to be liable for any claim for reimbursement for the therapeutic use of cannabis. And concluded that "the carrier is not able to provide medical marijuana" because such reimbursement is "not legal under state or federal law."
The Supreme Court of New Hampshire disagreed, and reversed in the case of Appeal of Andrew Panaggio.
It noted that statutes in other jurisdictions expressly prohibit workers’ compensation insurance carriers from reimbursing claimants for the cost of medical marijuana. See, e.g., Fla. Stat. § 381.986(15) (2017) (providing in Florida’s Medical Use of Marijuana statute that "[m]arijuana . . . is not reimbursable under" Florida’s Workers’ Compensation Law); Mich. Comp. Laws § 418.315a (2014) (providing in the Michigan Worker’s Disability Compensation Act that "[n]otwithstanding" the requirement that an employer "shall furnish, or cause to be furnished, to an employee who receives a personal injury arising out of and in the course of employment, reasonable medical . . . treatment," an employer "is not required to reimburse or cause to be reimbursed charges for medical marihuana treatment").
But "Had the legislature intended to bar patients in the therapeutic cannabis program from receiving reimbursement under RSA 281-A:23, I, it easily could have done so, and we will not add language that the legislature did not see fit to include."
"Because the board’s order fails to sufficiently articulate the law that supports the board’s legal conclusion and fails to provide an adequate explanation of its reasoning regarding federal law, it is impossible for us to discern the basis for the board’s decision sufficient for us to conduct meaningful review."
The case was remanded to the board for a determination of the issue of the federal criminal issues in the first instance ...
In a radiation-proof room at the Erasmus Medical Center in Rotterdam, Emar Thomasa sits behind shielded glass as he carefully measures and mixes lutetium octreotate, an intravenous treatment for certain types of cancer.
The Dutch hospital has been offering it to patients for more than a decade at 16,000 euros ($18,000) for one course of treatments. Drug firm Novartis, which in 2018 acquired rights to sell it in Europe, is asking more than five times that for its proprietary version, Lutathera.
Thomasa is part of a protest against high drug prices launched by an unlikely group of rebels: Dutch pharmacies.
Three - Erasmus, Amsterdam’s University Medical Center (UMC) and the Transvaal Pharmacy in The Hague - have vowed to bypass drug company products and make treatments for a handful of rare diseases themselves, exercising their right to "compound" medicines.
The dispute is part of a growing global backlash against high drug prices, from the United States and Canada to Japan, and campaigners said it was being closely watched by health experts elsewhere.
Compounding is the ancient practice of preparing medicines for individual patients. Pharmacists are trained to compound, though nowadays most medicines are made by industrial producers.
UMC received a 5-million-euro grant last month to expand its compounding program. It plans to use the money to set up a center to swap know-how with pharmacies at home and abroad.
The worldwide push against high drug prices has seen the Trump administration in the United States declare bringing down prescription prices a top priority.
The Dutch pharmacies, whose production is on a small scale, acknowledge they may face legal challenges from the drug industry. However, such a case could set a precedent for other European countries.
Pharmacies retain the right under European and American law to prepare medicines for individual patients. Common examples including making lower dosage versions for children or liquid versions for people with difficulty swallowing.
However, in the United States, for-profit compounding pharmacies have tested the limits of what they are allowed to do in recent years, including mixing medicines in large quantities. In some cases, that has prompted legal conflicts with drugmakers.
Official scrutiny of the practice increased after the 2012 deaths in Massachusetts, which led to U.S. lawmakers requiring bulk compounding facilities to register with the Food and Drug Administration (FDA) and meet quality and labeling standards - still not as stringent as full FDA drug approval.
The first two drugs targeted by Dutch pharmacies are Novartis’s Lutathera and a drug called CDCA, registered in Europe by Leadiant.
Novartis boss Narasimhan said he was worried by developments in the Netherlands. "The Netherlands’ characterization that the local medicine that is made in the hospitals is the same as what we’ve done from a regulatory, full-development standpoint, particularly given (the Dutch) will house the European Medicines Agency, I think is troubling," he told Reuters in an interview ...
The Dutch hospital has been offering it to patients for more than a decade at 16,000 euros ($18,000) for one course of treatments. Drug firm Novartis, which in 2018 acquired rights to sell it in Europe, is asking more than five times that for its proprietary version, Lutathera.
Thomasa is part of a protest against high drug prices launched by an unlikely group of rebels: Dutch pharmacies.
Three - Erasmus, Amsterdam’s University Medical Center (UMC) and the Transvaal Pharmacy in The Hague - have vowed to bypass drug company products and make treatments for a handful of rare diseases themselves, exercising their right to "compound" medicines.
The dispute is part of a growing global backlash against high drug prices, from the United States and Canada to Japan, and campaigners said it was being closely watched by health experts elsewhere.
Compounding is the ancient practice of preparing medicines for individual patients. Pharmacists are trained to compound, though nowadays most medicines are made by industrial producers.
UMC received a 5-million-euro grant last month to expand its compounding program. It plans to use the money to set up a center to swap know-how with pharmacies at home and abroad.
The worldwide push against high drug prices has seen the Trump administration in the United States declare bringing down prescription prices a top priority.
The Dutch pharmacies, whose production is on a small scale, acknowledge they may face legal challenges from the drug industry. However, such a case could set a precedent for other European countries.
Pharmacies retain the right under European and American law to prepare medicines for individual patients. Common examples including making lower dosage versions for children or liquid versions for people with difficulty swallowing.
However, in the United States, for-profit compounding pharmacies have tested the limits of what they are allowed to do in recent years, including mixing medicines in large quantities. In some cases, that has prompted legal conflicts with drugmakers.
Official scrutiny of the practice increased after the 2012 deaths in Massachusetts, which led to U.S. lawmakers requiring bulk compounding facilities to register with the Food and Drug Administration (FDA) and meet quality and labeling standards - still not as stringent as full FDA drug approval.
The first two drugs targeted by Dutch pharmacies are Novartis’s Lutathera and a drug called CDCA, registered in Europe by Leadiant.
Novartis boss Narasimhan said he was worried by developments in the Netherlands. "The Netherlands’ characterization that the local medicine that is made in the hospitals is the same as what we’ve done from a regulatory, full-development standpoint, particularly given (the Dutch) will house the European Medicines Agency, I think is troubling," he told Reuters in an interview ...
According to the American Orthopedic Society Sports Medicine, worldwide, more than 4 million people get arthroscopic knee surgery each year.
During the operation, a surgeon makes a small incision in the knee and inserts a tiny camera called an arthroscope to view the inside of the joint, locate and diagnose the problem, and guide repairs. Sometimes surgeons remove all of the meniscus, the cartilage that works as a cushion between the shin and thigh bones, and other times they only remove part of it.
While this is minimally invasive, it’s not risk-free. Patients receive anesthesia, which in any surgery may lead to complications such as allergic reactions or breathing difficulties. In addition, this specific procedure might potentially damage the knee or trigger blood clots in the leg.
A review of past studies published in the British Journal of Sport Medicine by researchers, and reviewed by Reuters Health, suggests that many middle-aged and older adults with torn cartilage and pain in their knee are not likely to benefit from arthroscopic surgery.
Researchers analyzed 10 previous clinical trials that randomly offered some patients knee surgery and others nonsurgical options including exercise or medication. Overall, knee surgery was no better than these alternatives for improving physical function, and resulted in only a small reduction in pain.
In the current analysis, all of the trial participants who got knee operations had a partial meniscectomy, removing only some of this cartilage.
For all types of patients - including people with and without arthritis pain - surgery was slightly better than physical therapy at reducing pain after 6 to 12 months, an analysis of five trials with a total of 943 patients found.
However, when researchers looked just at a subset of patients without knee pain from arthritis in their knee, surgery did appear moderately better than physical therapy for reducing pain from the tear.
In three trials of 402 patients without arthritis pain, surgery had a small to moderate advantage in knee pain improvement after 6 to 12 months over physical therapy.
Two trials with 244 patients without arthritis pain also found surgery associated with a moderate to much larger improvement in quality of life than nonsurgical treatment.
"Surgery does not work for everyone but in selected cases we show that surgery should be available to patients," said lead study author Simon Abram of the University of Oxford in the UK.
"In most circumstances, patients should try physiotherapy first," Abram said by email. "If this does not improve symptoms, knee surgery may be beneficial, especially in patients without osteoarthritis and with specific symptoms." ...
During the operation, a surgeon makes a small incision in the knee and inserts a tiny camera called an arthroscope to view the inside of the joint, locate and diagnose the problem, and guide repairs. Sometimes surgeons remove all of the meniscus, the cartilage that works as a cushion between the shin and thigh bones, and other times they only remove part of it.
While this is minimally invasive, it’s not risk-free. Patients receive anesthesia, which in any surgery may lead to complications such as allergic reactions or breathing difficulties. In addition, this specific procedure might potentially damage the knee or trigger blood clots in the leg.
A review of past studies published in the British Journal of Sport Medicine by researchers, and reviewed by Reuters Health, suggests that many middle-aged and older adults with torn cartilage and pain in their knee are not likely to benefit from arthroscopic surgery.
Researchers analyzed 10 previous clinical trials that randomly offered some patients knee surgery and others nonsurgical options including exercise or medication. Overall, knee surgery was no better than these alternatives for improving physical function, and resulted in only a small reduction in pain.
In the current analysis, all of the trial participants who got knee operations had a partial meniscectomy, removing only some of this cartilage.
For all types of patients - including people with and without arthritis pain - surgery was slightly better than physical therapy at reducing pain after 6 to 12 months, an analysis of five trials with a total of 943 patients found.
However, when researchers looked just at a subset of patients without knee pain from arthritis in their knee, surgery did appear moderately better than physical therapy for reducing pain from the tear.
In three trials of 402 patients without arthritis pain, surgery had a small to moderate advantage in knee pain improvement after 6 to 12 months over physical therapy.
Two trials with 244 patients without arthritis pain also found surgery associated with a moderate to much larger improvement in quality of life than nonsurgical treatment.
"Surgery does not work for everyone but in selected cases we show that surgery should be available to patients," said lead study author Simon Abram of the University of Oxford in the UK.
"In most circumstances, patients should try physiotherapy first," Abram said by email. "If this does not improve symptoms, knee surgery may be beneficial, especially in patients without osteoarthritis and with specific symptoms." ...
Paris-based Shift Technology has raised another $60 million funding round, and announced a new contract with CNA. Shift Technology claims to have a 70% hit rate in detecting fraudulent insurance claims.
Bessemer Venture Partners is leading the round and existing investors Accel, General Catalyst, Iris Capital and Elaia Partners are also participating.
This March it announced that it has entered into an agreement with CNA Financial Corporation, one of the largest commercial property and casualty insurance companies in the United States, to automate the carrier’s fraud detection capabilities. CNA is the first commercial insurer based in the United States to partner with Shift Technology to take advantage of FORCE, the company’s AI-native, SaaS-based fraud detection solution.
FORCE uses advanced artificial intelligence (AI) and data science to not only detect potentially fraudulent claims but also provide contextual guidance for investigation and resolution.
Unlike other technologies which rely heavily on the use of static business rules to identify those claims which may be non-meritorious, FORCE uses AI to analyze vast amounts of data from multiple sources. The result is a dynamically generated fraud score for each claim that indicates how suspicious the claim is, contributing factors, and how the claim could be investigated.
"CNA continues to focus on, and invest in, technology and analytics to advance claims," said Rob Thomas, Senior Vice President of Claim Analytics, Finance and Operations for CNA’s Worldwide P&C Claim unit. "By partnering with Shift Technology, CNA will optimize its special investigations efforts by focusing on the most suspicious cases with pre-identified paths for investigation."
There are 70 insurance companies around the world relying on its product, such as MACIF in France, Axa in Spain, and CNA and HyreCar in the U.S.
The startup has already grown quite a lot since its previous funding round. They now have 200 employees, and customers all around the globe. In addition to its headquarters in Paris, Shift Technology also has offices in Boston, London, Hong Kong, Madrid, Singapore and Zurich.
With today’s funding round, the company plans to hire more people in Boston, including data scientists and developers. The company is also developing an automated claim-processing solution ...
Bessemer Venture Partners is leading the round and existing investors Accel, General Catalyst, Iris Capital and Elaia Partners are also participating.
This March it announced that it has entered into an agreement with CNA Financial Corporation, one of the largest commercial property and casualty insurance companies in the United States, to automate the carrier’s fraud detection capabilities. CNA is the first commercial insurer based in the United States to partner with Shift Technology to take advantage of FORCE, the company’s AI-native, SaaS-based fraud detection solution.
FORCE uses advanced artificial intelligence (AI) and data science to not only detect potentially fraudulent claims but also provide contextual guidance for investigation and resolution.
Unlike other technologies which rely heavily on the use of static business rules to identify those claims which may be non-meritorious, FORCE uses AI to analyze vast amounts of data from multiple sources. The result is a dynamically generated fraud score for each claim that indicates how suspicious the claim is, contributing factors, and how the claim could be investigated.
"CNA continues to focus on, and invest in, technology and analytics to advance claims," said Rob Thomas, Senior Vice President of Claim Analytics, Finance and Operations for CNA’s Worldwide P&C Claim unit. "By partnering with Shift Technology, CNA will optimize its special investigations efforts by focusing on the most suspicious cases with pre-identified paths for investigation."
There are 70 insurance companies around the world relying on its product, such as MACIF in France, Axa in Spain, and CNA and HyreCar in the U.S.
The startup has already grown quite a lot since its previous funding round. They now have 200 employees, and customers all around the globe. In addition to its headquarters in Paris, Shift Technology also has offices in Boston, London, Hong Kong, Madrid, Singapore and Zurich.
With today’s funding round, the company plans to hire more people in Boston, including data scientists and developers. The company is also developing an automated claim-processing solution ...
Two men are facing charges based on the seizure of approximately 45 pounds of deadly fentanyl.
Luis Aponte, 48, of Hesperia, California, and Denny Diaz, 29, of Philadelphia, Pennsylvania, were charged by complaint with one count conspiracy to possess with intent to distribute 400 grams or more of fentanyl.
They appeared before U.S. Magistrate Judge Joseph Dickson in Newark federal court. The defendants were detained without bail.
Aponte on Friday drove a tractor trailer from California to a rest stop in Bloomsbury where he stayed, according to court documents. Agents from the Drug Enforcement Administration were following him.
On Saturday, Aponte got out of a truck with a backpack. Authorities saw Aponte remove a plastic bag from the backpack and put it behind the driver’s seat before driving off, according to court documents.
Both were later stopped in the Jeep by authorities where they searched it and discovered about 15 pounds of fentanyl in the plastic bagl, heroin and $17,000 in cash.
They arrested Diaz and Aponte, who later waived his Miranda rights and said he had more drugs in the tractor-trailer. Agents searched the truck cab and a refrigerator on board and found another 29 pounds of fentanyl and 11 pounds of heroin.
The count with which the defendants are charged carries a mandatory minimum sentence of 10 years in prison, a maximum of life in prison and a fine of up to $10 million.
They made their initial court appearances in Newark federal court. The government is represented by Assistant U.S. Attorney Andrew Macurdy of the U.S. Attorney’s Office Criminal Division in Newark ...
Luis Aponte, 48, of Hesperia, California, and Denny Diaz, 29, of Philadelphia, Pennsylvania, were charged by complaint with one count conspiracy to possess with intent to distribute 400 grams or more of fentanyl.
They appeared before U.S. Magistrate Judge Joseph Dickson in Newark federal court. The defendants were detained without bail.
Aponte on Friday drove a tractor trailer from California to a rest stop in Bloomsbury where he stayed, according to court documents. Agents from the Drug Enforcement Administration were following him.
On Saturday, Aponte got out of a truck with a backpack. Authorities saw Aponte remove a plastic bag from the backpack and put it behind the driver’s seat before driving off, according to court documents.
Both were later stopped in the Jeep by authorities where they searched it and discovered about 15 pounds of fentanyl in the plastic bagl, heroin and $17,000 in cash.
They arrested Diaz and Aponte, who later waived his Miranda rights and said he had more drugs in the tractor-trailer. Agents searched the truck cab and a refrigerator on board and found another 29 pounds of fentanyl and 11 pounds of heroin.
The count with which the defendants are charged carries a mandatory minimum sentence of 10 years in prison, a maximum of life in prison and a fine of up to $10 million.
They made their initial court appearances in Newark federal court. The government is represented by Assistant U.S. Attorney Andrew Macurdy of the U.S. Attorney’s Office Criminal Division in Newark ...
Jorge Orozco was a carpenter for Southland Framers. On September 7, 2001, he sustained and industrial injury to his back, neck, and head, and filed three claims for benefits.
His primary treating physician noted in 2012 that he was ambulating with a wheeled walker and that his wife was providing continuous home care services for him. He said "Patient requires home care assistance. He is a candidate at least eight hours a day, five days a week for home care assistance to assist with bathing, dressing, food preparation, laundering, and cleaning." The request was later increased to 12 hours a day.
On May 15, 2012, Anthem Workers' Compensation, and the PTP agreed that, as part of the UR process, "a relatively expedited RN evaluation should be done to assess the patient's needs."
On July 25, 2014, 26 months after this agreement, the nurse case manager performed the evaluation. She found applicant "requires maximum assistant with the majority of his activities of daily living." She recommended home health care assistance 12 hours per day, seven days a week to assist applicant with nutritional meal preparation, grocery shopping, grooming, hygiene, transfers into and out of the shower, bathing, dressing, transportation services and assistance in and out of vehicles, home cleaning, laundry, opening medication bottles, and verbal reminders to take medications.
The PTP reviewed nurse case manager's report and adopted its recommendations in his own October 13, 2014 report. On October 17 he submitted an RFA to the employer.
On December 9, 2014, the RFA was denied on the grounds that the Medicare Benefits Manual indicates "services should be part-time and not exceeding 28 hours per week, and authorization should not be made if these services are regularly performed by a member of the patient's household." The RFA was received on November 25, 2014, and the decision to deny was made on December 8, 2014.
The WCJ found that defendant did not conduct timely utilization review of the May 9, 2012 and November 25, 2014 requests for authorization (RFAs) for home health care services. The WCJ also found that defendant was liable for home health care services after May 1, 2012, up to 12 hours a day, seven days a week.
Defendant contended on reconsideration that the WCJ erred by awarding home health care services, arguing that she should not have found that the UR determination was untimely, among other arguments. The WCAB affirmed the WCJ's decision in the case of Orozco v Southland Framers, SCIF.
Here, the initial delay was timely. However, no UR determination issued within the statutory period, "14 days from the date of the medical treatment recommendation by the physician." (Former L.C. § 4610(g)(l).).
The RFA was received no later than November 25, 2014. Former AD Rule 9792.9.l(e)(3), in effect at the time of defendant's UR determination, provided in pertinent part, "[A] decision to modify, delay, or deny shall be communicated to the requesting physician within 24 hours of the decision, and shall be communicated to the requesting physician initially by telephone, facsimile, or electronic mail." (Former Cal. Code Regs., tit. 8, § 9792.9.l(e)(3).
The record reflects that defendant's UR notified the PTP of the determination on December 9, 2014, nine working days after receipt of the RFA on November 25, 2014, and four days after the statutory time period lapsed. Therefore, the Board has jurisdiction to determine the medical necessity of the requests for home health care services ...
His primary treating physician noted in 2012 that he was ambulating with a wheeled walker and that his wife was providing continuous home care services for him. He said "Patient requires home care assistance. He is a candidate at least eight hours a day, five days a week for home care assistance to assist with bathing, dressing, food preparation, laundering, and cleaning." The request was later increased to 12 hours a day.
On May 15, 2012, Anthem Workers' Compensation, and the PTP agreed that, as part of the UR process, "a relatively expedited RN evaluation should be done to assess the patient's needs."
On July 25, 2014, 26 months after this agreement, the nurse case manager performed the evaluation. She found applicant "requires maximum assistant with the majority of his activities of daily living." She recommended home health care assistance 12 hours per day, seven days a week to assist applicant with nutritional meal preparation, grocery shopping, grooming, hygiene, transfers into and out of the shower, bathing, dressing, transportation services and assistance in and out of vehicles, home cleaning, laundry, opening medication bottles, and verbal reminders to take medications.
The PTP reviewed nurse case manager's report and adopted its recommendations in his own October 13, 2014 report. On October 17 he submitted an RFA to the employer.
On December 9, 2014, the RFA was denied on the grounds that the Medicare Benefits Manual indicates "services should be part-time and not exceeding 28 hours per week, and authorization should not be made if these services are regularly performed by a member of the patient's household." The RFA was received on November 25, 2014, and the decision to deny was made on December 8, 2014.
The WCJ found that defendant did not conduct timely utilization review of the May 9, 2012 and November 25, 2014 requests for authorization (RFAs) for home health care services. The WCJ also found that defendant was liable for home health care services after May 1, 2012, up to 12 hours a day, seven days a week.
Defendant contended on reconsideration that the WCJ erred by awarding home health care services, arguing that she should not have found that the UR determination was untimely, among other arguments. The WCAB affirmed the WCJ's decision in the case of Orozco v Southland Framers, SCIF.
Here, the initial delay was timely. However, no UR determination issued within the statutory period, "14 days from the date of the medical treatment recommendation by the physician." (Former L.C. § 4610(g)(l).).
The RFA was received no later than November 25, 2014. Former AD Rule 9792.9.l(e)(3), in effect at the time of defendant's UR determination, provided in pertinent part, "[A] decision to modify, delay, or deny shall be communicated to the requesting physician within 24 hours of the decision, and shall be communicated to the requesting physician initially by telephone, facsimile, or electronic mail." (Former Cal. Code Regs., tit. 8, § 9792.9.l(e)(3).
The record reflects that defendant's UR notified the PTP of the determination on December 9, 2014, nine working days after receipt of the RFA on November 25, 2014, and four days after the statutory time period lapsed. Therefore, the Board has jurisdiction to determine the medical necessity of the requests for home health care services ...
Analysts at Research and Markets, predict that the global insurance market will reach $1.11 billion by 2023, fueled by growth in verticals like health, property, casualty, and life insurance.
Moreover, according to a recent analysis of CB Insights data by XL Innovate, over $1 billion has been invested in commercial insurance startups since 2015.
And FinTech Global estimates that deals totaled $2.5 billion in the first three quarters of 2018 - an 89.8 percent increase year-over-year.
Riding this wave is Pie Insurance, a Washington, D.C.-based workers’ compensation insurance provider that just announced it has raised $45 million in a series B funding round led by SVB Capital, with participation from Sirius Group, Greycroft, Moxley Holdings, Aspect Ventures, and Elefund. This follows an $11 million series A round in July and brings Pie’s total capital raised to $61 million.
CEO John Swigart, previously a senior executive at Esurance, says the fresh capital will be used to expand Pie’s geographic footprint and add new distribution sources.
Pie was founded in 2017 and operates as a managing general agency for Sirius America Insurance company. It sold its first insurance policy in March 2018 and claims to have generated nearly $10 million in written premiums from the "thousands" of small businesses among its customers.
It claims it saves those customers an average of 30 percent, thanks to a proprietary analytics backend that identifies risk, prices policies, and eliminates steps from the purchase process.
Is policies are available in 19 markets across the country: Arizona, Arkansas, California, Colorado, Georgia, Iowa, Illinois, Kansas, Kentucky, Louisiana, Maryland, Michigan, Nebraska, New Mexico, New York, North Carolina, Pennsylvania, Tennessee, and Texas ...
Moreover, according to a recent analysis of CB Insights data by XL Innovate, over $1 billion has been invested in commercial insurance startups since 2015.
And FinTech Global estimates that deals totaled $2.5 billion in the first three quarters of 2018 - an 89.8 percent increase year-over-year.
Riding this wave is Pie Insurance, a Washington, D.C.-based workers’ compensation insurance provider that just announced it has raised $45 million in a series B funding round led by SVB Capital, with participation from Sirius Group, Greycroft, Moxley Holdings, Aspect Ventures, and Elefund. This follows an $11 million series A round in July and brings Pie’s total capital raised to $61 million.
CEO John Swigart, previously a senior executive at Esurance, says the fresh capital will be used to expand Pie’s geographic footprint and add new distribution sources.
Pie was founded in 2017 and operates as a managing general agency for Sirius America Insurance company. It sold its first insurance policy in March 2018 and claims to have generated nearly $10 million in written premiums from the "thousands" of small businesses among its customers.
It claims it saves those customers an average of 30 percent, thanks to a proprietary analytics backend that identifies risk, prices policies, and eliminates steps from the purchase process.
Is policies are available in 19 markets across the country: Arizona, Arkansas, California, Colorado, Georgia, Iowa, Illinois, Kansas, Kentucky, Louisiana, Maryland, Michigan, Nebraska, New Mexico, New York, North Carolina, Pennsylvania, Tennessee, and Texas ...
Business Insurance reports that OxyContin maker Purdue Pharma LP is exploring filing for bankruptcy to address potentially significant liabilities from thousands of lawsuits alleging the drug manufacturer contributed to the deadly opioid crisis sweeping the United States, people familiar with the matter said Monday.
Purdue and its wealthy owners, the Sackler family, are under pressure to respond to mounting litigation accusing the pharmaceutical company of misleading doctors and patients about risks associated with prolonged use of its prescription opioids.
Purdue denies the allegations, arguing that the U.S. Food and Drug Administration-approved labels for its opioids carried warnings about the risk of abuse and misuse associated with the drugs.
Filing for Chapter 11 protection would halt the lawsuits and allow the drugmaker to negotiate legal claims with plaintiffs under the supervision of a U.S. bankruptcy judge, the sources said.
More than 1,000 lawsuits accusing Purdue and other opioid manufacturers of using deceptive practices to push addictive drugs that led to fatal overdoses are consolidated in an Ohio federal court.
A lesser-known opioid case: Oklahoma v. Purdue Pharma, is scheduled for trial in May in Norman, Oklahoma. The Oklahoma trial could presage many of the arguments the jury may be presented in the national case set in the fall on 2019.
The Oklahoma lawsuit seeks to hold Purdue and three other opioid-makers, Allergan, Cephalon and Janssen Pharmaceuticals, responsible for economic damages to the state and its residents stemming from the opioid addiction and overdose crisis.
The presiding judge in the Oklahoma case ruled that television cameras may be used in the courtroom, every detail of what promises to be a dramatic trial could be broadcast to the American public, potentially affecting the outcome of any future opioid trials.
A Purdue bankruptcy filing is not certain, the sources said. The Stamford, Connecticut, drugmaker has not made any final decisions and could instead continue fighting the lawsuits, they said.
Purdue tapped law firm Davis Polk & Wardwell LLP for restructuring advice, Reuters reported in August, fueling concerns among litigants including Oklahoma Attorney General Mike Hunter that the company might seek bankruptcy protection before the trial ...
Purdue and its wealthy owners, the Sackler family, are under pressure to respond to mounting litigation accusing the pharmaceutical company of misleading doctors and patients about risks associated with prolonged use of its prescription opioids.
Purdue denies the allegations, arguing that the U.S. Food and Drug Administration-approved labels for its opioids carried warnings about the risk of abuse and misuse associated with the drugs.
Filing for Chapter 11 protection would halt the lawsuits and allow the drugmaker to negotiate legal claims with plaintiffs under the supervision of a U.S. bankruptcy judge, the sources said.
More than 1,000 lawsuits accusing Purdue and other opioid manufacturers of using deceptive practices to push addictive drugs that led to fatal overdoses are consolidated in an Ohio federal court.
A lesser-known opioid case: Oklahoma v. Purdue Pharma, is scheduled for trial in May in Norman, Oklahoma. The Oklahoma trial could presage many of the arguments the jury may be presented in the national case set in the fall on 2019.
The Oklahoma lawsuit seeks to hold Purdue and three other opioid-makers, Allergan, Cephalon and Janssen Pharmaceuticals, responsible for economic damages to the state and its residents stemming from the opioid addiction and overdose crisis.
The presiding judge in the Oklahoma case ruled that television cameras may be used in the courtroom, every detail of what promises to be a dramatic trial could be broadcast to the American public, potentially affecting the outcome of any future opioid trials.
A Purdue bankruptcy filing is not certain, the sources said. The Stamford, Connecticut, drugmaker has not made any final decisions and could instead continue fighting the lawsuits, they said.
Purdue tapped law firm Davis Polk & Wardwell LLP for restructuring advice, Reuters reported in August, fueling concerns among litigants including Oklahoma Attorney General Mike Hunter that the company might seek bankruptcy protection before the trial ...
45-year-old former pharmaceutical representative Holly Blakely, of San Antonio, TX, pleaded guilty for her role in an $8 million health care fraud scheme that netted her over $1 million.
The 30 count indictment filed in 2017, portrays her as one piece in a conspiracy targeted by a wide-ranging investigation of pharmacies that provide compound pain medication to military veterans and others with private insurance.Investigations of pharmacies that provide compound pain medication took place in at least four states.
Blakely was scheduled for trial in February. Instead she pleaded guilty to one conspiracy to commit wire fraud, health care fraud, bribery, and paying kickbacks. She now faces up to five years in federal prison. She remains on bond pending sentencing scheduled for June 13, 2019.
As part of her plea, Blakely admitted her role in a scheme to defraud health care benefit programs by paying over $400,000 in kickbacks and bribes to health care providers that prescribed compounded medications to individuals who did not need the medications.
She and her co-conspirators attempted to disguise the kickbacks and bribes to health care professionals by writing fictitious and back-dated "consulting agreements." In many instances, They submitted prescriptions to compounding pharmacies for patients that had never seen a medical professional.
Moreover, Blakely and her co-conspirators would occasionally forge the signature of a medical professional on prescriptions.
Blakely admitted that she conspired with two compounding pharmacies that would submit claims for reimbursement to health care benefit programs for compounded medications based on the prescriptions.
In exchange for her role in the conspiracy, the two compounding pharmacies paid Blakely approximately $1,147,885.14. Health care benefit programs reimbursed the two compounding pharmacies approximately $8,846,972.24 based on the claims submitted in connection with the compounded medications.
in 2015, the federal government reached a settlement with one of them, MediMix Specialty Pharmacy of Jacksonville, Florida, and a top-referring physician, Dr. Ankit Desai, for more than $3.7 million.
Under the deal, the parties resolved allegations that, from Jan. 1, 2009, until December 2014, Dr. Desai sent hundreds of prescriptions to MediMix. Desai was married to a vice president of MediMix ...
The 30 count indictment filed in 2017, portrays her as one piece in a conspiracy targeted by a wide-ranging investigation of pharmacies that provide compound pain medication to military veterans and others with private insurance.Investigations of pharmacies that provide compound pain medication took place in at least four states.
Blakely was scheduled for trial in February. Instead she pleaded guilty to one conspiracy to commit wire fraud, health care fraud, bribery, and paying kickbacks. She now faces up to five years in federal prison. She remains on bond pending sentencing scheduled for June 13, 2019.
As part of her plea, Blakely admitted her role in a scheme to defraud health care benefit programs by paying over $400,000 in kickbacks and bribes to health care providers that prescribed compounded medications to individuals who did not need the medications.
She and her co-conspirators attempted to disguise the kickbacks and bribes to health care professionals by writing fictitious and back-dated "consulting agreements." In many instances, They submitted prescriptions to compounding pharmacies for patients that had never seen a medical professional.
Moreover, Blakely and her co-conspirators would occasionally forge the signature of a medical professional on prescriptions.
Blakely admitted that she conspired with two compounding pharmacies that would submit claims for reimbursement to health care benefit programs for compounded medications based on the prescriptions.
In exchange for her role in the conspiracy, the two compounding pharmacies paid Blakely approximately $1,147,885.14. Health care benefit programs reimbursed the two compounding pharmacies approximately $8,846,972.24 based on the claims submitted in connection with the compounded medications.
in 2015, the federal government reached a settlement with one of them, MediMix Specialty Pharmacy of Jacksonville, Florida, and a top-referring physician, Dr. Ankit Desai, for more than $3.7 million.
Under the deal, the parties resolved allegations that, from Jan. 1, 2009, until December 2014, Dr. Desai sent hundreds of prescriptions to MediMix. Desai was married to a vice president of MediMix ...
The Supreme Court has ruled that payments to injured employees for lost wages by a railway company are taxable under the Railroad Retirement Tax Act (RRTA).
The opinion in BNSF Railway Co. vs. Loos by Justice Ruth Bader Ginsburg, in which six other justices joined, likens the payments to wages under the Social Security system.
Michael Loos sued BNSF Railway Co. under the Federal Employers’ Liability Act (FELA) for injuries he received while working at BNSF’s rail yard. A jury awarded him $126,212.78, with $30,000 of that amount ascribed to wages lost during the time Loos was unable to work.
BNSF claimed that the lost wages constituted "compensation" that is taxable under the Railroad Retirement Tax Act (RRTA) and asked to withhold $3,765 of the $30,000 to cover Loos’s share of the RRTA taxes.
The District Court and the Eighth Circuit rejected BNSF’s requested offset, holding that an award of damages compensating an injured railroad worker for lost wages is not taxable under the RRTA.
But the high court has now overturned those lower courts with this ruling that a railroad’s payment to an employee for working time lost due to an on-the-job injury is taxable "compensation" under the RRTA.
The RRTA is a self-sustaining retirement benefits system for railroad workers that is funded by a payroll tax on both railroads and their employees, referring to the railroad’s contribution as an "excise" tax and the employee’s share as an "income" tax. The Railroad Retirement Act (RRA) entitles railroad workers to various benefits.
Taxes under the RRTA and benefits under the RRA are measured by the employee’s "compensation," which both statutes define as "any form of money remuneration paid to an individual for services rendered as an employee."
According to the court, the railroad retirement system mirrors that of the Social Security system. The Federal Insurance Contributions Act (FICA) taxes employers and employees to fund benefits distributed pursuant to the Social Security Act (SSA). Tax and benefit amounts are determined by the worker’s "wages," the Social Security equivalent to "compensation." Both the FICA and the SSA define "wages" employing language resembling the RRTA and the RRA definitions of “compensation.”
Citing previous decisions, the court held that "compensation" under the RRTA "encompasses not simply pay for active service but also pay for periods of absence from active service" provided that the remuneration in question stems from the "employer-employee relationship."
Justice Gorsuch filed a dissenting opinion in which Justice Thomas joined ...
The opinion in BNSF Railway Co. vs. Loos by Justice Ruth Bader Ginsburg, in which six other justices joined, likens the payments to wages under the Social Security system.
Michael Loos sued BNSF Railway Co. under the Federal Employers’ Liability Act (FELA) for injuries he received while working at BNSF’s rail yard. A jury awarded him $126,212.78, with $30,000 of that amount ascribed to wages lost during the time Loos was unable to work.
BNSF claimed that the lost wages constituted "compensation" that is taxable under the Railroad Retirement Tax Act (RRTA) and asked to withhold $3,765 of the $30,000 to cover Loos’s share of the RRTA taxes.
The District Court and the Eighth Circuit rejected BNSF’s requested offset, holding that an award of damages compensating an injured railroad worker for lost wages is not taxable under the RRTA.
But the high court has now overturned those lower courts with this ruling that a railroad’s payment to an employee for working time lost due to an on-the-job injury is taxable "compensation" under the RRTA.
The RRTA is a self-sustaining retirement benefits system for railroad workers that is funded by a payroll tax on both railroads and their employees, referring to the railroad’s contribution as an "excise" tax and the employee’s share as an "income" tax. The Railroad Retirement Act (RRA) entitles railroad workers to various benefits.
Taxes under the RRTA and benefits under the RRA are measured by the employee’s "compensation," which both statutes define as "any form of money remuneration paid to an individual for services rendered as an employee."
According to the court, the railroad retirement system mirrors that of the Social Security system. The Federal Insurance Contributions Act (FICA) taxes employers and employees to fund benefits distributed pursuant to the Social Security Act (SSA). Tax and benefit amounts are determined by the worker’s "wages," the Social Security equivalent to "compensation." Both the FICA and the SSA define "wages" employing language resembling the RRTA and the RRA definitions of “compensation.”
Citing previous decisions, the court held that "compensation" under the RRTA "encompasses not simply pay for active service but also pay for periods of absence from active service" provided that the remuneration in question stems from the "employer-employee relationship."
Justice Gorsuch filed a dissenting opinion in which Justice Thomas joined ...
Reuters reports that Drugmaker Eli Lilly plans to sell a half-price version of its popular insulin injection Humalog, as it fends off criticism about rising drug prices in the United States.
Major drugmakers including Lilly, a leading producer of insulin, have come under fire from patients and lawmakers over the rising cost of the life-saving medication used to treat diabetes.
U.S. senators last week grilled executives from major drug companies, calling their pricing practices “morally repugnant”.
Lilly’s rebranded product will be called Insulin Lispro, while Humalog, which makes $3 billion in annual sales, will remain available for those wishing to access it through existing insurance plans.
The cost of insulin for treating type 1 diabetes in the United States has nearly doubled over a five-year period, leading some patients to put their own health at risk by rationing the medication.
The list price for Lilly’s authorized generic, to be sold only in the United States, will be $137.35 per vial.
Two senators last month launched an investigation into rising insulin prices, writing to Lilly and other leading manufacturers, asking them why the cost of the nearly 100-year-old medication had rapidly risen.
The price of Lilly’s Humalog rose from $35 to $234 per dose between 2001 and 2015, a 585 percent increase, the senators, Republican Chuck Grassley and Democrat Ron Wyden, had said.
Grassley on Monday called Lilly’s announcement "good news" in a Twitter post but added it was “only 1 piece of puzzle” and more needed to be done. Wyden said via email that Lilly’s move would be a part of the Senate Finance Committee’s investigation.
Meanwhile, Novo Nordisk and Sanofi SA, two other major insulin producers, told Reuters they were already taking steps to make insulin more affordable.
Novo said it was offering insulin at $25 per vial at many national pharmacy chains and had a program to help uninsured patients. Its insulin has a list price of $137.70 ...
Major drugmakers including Lilly, a leading producer of insulin, have come under fire from patients and lawmakers over the rising cost of the life-saving medication used to treat diabetes.
U.S. senators last week grilled executives from major drug companies, calling their pricing practices “morally repugnant”.
Lilly’s rebranded product will be called Insulin Lispro, while Humalog, which makes $3 billion in annual sales, will remain available for those wishing to access it through existing insurance plans.
The cost of insulin for treating type 1 diabetes in the United States has nearly doubled over a five-year period, leading some patients to put their own health at risk by rationing the medication.
The list price for Lilly’s authorized generic, to be sold only in the United States, will be $137.35 per vial.
Two senators last month launched an investigation into rising insulin prices, writing to Lilly and other leading manufacturers, asking them why the cost of the nearly 100-year-old medication had rapidly risen.
The price of Lilly’s Humalog rose from $35 to $234 per dose between 2001 and 2015, a 585 percent increase, the senators, Republican Chuck Grassley and Democrat Ron Wyden, had said.
Grassley on Monday called Lilly’s announcement "good news" in a Twitter post but added it was “only 1 piece of puzzle” and more needed to be done. Wyden said via email that Lilly’s move would be a part of the Senate Finance Committee’s investigation.
Meanwhile, Novo Nordisk and Sanofi SA, two other major insulin producers, told Reuters they were already taking steps to make insulin more affordable.
Novo said it was offering insulin at $25 per vial at many national pharmacy chains and had a program to help uninsured patients. Its insulin has a list price of $137.70 ...
Two recent California Department of Insurance investigations have led to the arrests of insurance agents who allegedly stole tens of thousands of dollars from clients and failed to place insurance coverage for those clients, exposing them to significant financial risk.
Maria Aquino, 34, of South Gate, was charged with multiple felony counts of embezzlement and theft for allegedly pocketing over $48,000 in clients’ insurance premium payments and failing to place insurance coverage for her clients between 2011 and 2018.
The premium payments collected by Aquino, while doing business as Kino Insurance and Tax Services, were never sent to insurance carriers.
Aquino falsified certificates of insurance for more than eight clients in order to hide her embezzlement. Aquino’s license was revoked on July 12, 2018.
In a separate case, Chih Ming Huang, also known as James Huang, 41, of Rowland Heights, was charged with multiple counts of embezzlement, theft and forgery after allegedly stealing nearly $14,000 dollars from more than three clients and also failing to place insurance coverage for his clients.
After receiving a complaint from Farmers Insurance, where Huang had been previously employed, the department found that between 2011 and 2013, Huang embezzled premium payments by placing coverage for clients then canceling the coverage without his clients’ knowledge.
Cancelling the coverage generated refund checks to his clients, which he received because he had changed their address on record to a location he controlled.
Huang then applied the refunds to policies in the names of his aliases and cancelled those polices to get refunds in his own name, which he deposited into his personal bank account. The department is taking immediate action against Huang’s license.
Both of these cases are being prosecuted by the Los Angeles County District Attorney’s Office. Aquino surrendered on February 27, 2019 to the Downey Police Department. Huang will surrender on March 4, 2019.
...
Maria Aquino, 34, of South Gate, was charged with multiple felony counts of embezzlement and theft for allegedly pocketing over $48,000 in clients’ insurance premium payments and failing to place insurance coverage for her clients between 2011 and 2018.
The premium payments collected by Aquino, while doing business as Kino Insurance and Tax Services, were never sent to insurance carriers.
Aquino falsified certificates of insurance for more than eight clients in order to hide her embezzlement. Aquino’s license was revoked on July 12, 2018.
In a separate case, Chih Ming Huang, also known as James Huang, 41, of Rowland Heights, was charged with multiple counts of embezzlement, theft and forgery after allegedly stealing nearly $14,000 dollars from more than three clients and also failing to place insurance coverage for his clients.
After receiving a complaint from Farmers Insurance, where Huang had been previously employed, the department found that between 2011 and 2013, Huang embezzled premium payments by placing coverage for clients then canceling the coverage without his clients’ knowledge.
Cancelling the coverage generated refund checks to his clients, which he received because he had changed their address on record to a location he controlled.
Huang then applied the refunds to policies in the names of his aliases and cancelled those polices to get refunds in his own name, which he deposited into his personal bank account. The department is taking immediate action against Huang’s license.
Both of these cases are being prosecuted by the Los Angeles County District Attorney’s Office. Aquino surrendered on February 27, 2019 to the Downey Police Department. Huang will surrender on March 4, 2019.
...
State Fund announced it has launched SafeAtWorkCA.com, a new online safety resource designed to help California employers protect their workers and build cultures of safety.
The new site features a variety of safety-related resources, including:
- - Workplace safety fundamentals customized for a variety of industries
- - Safety meeting topics and plans
- - Updates on legislative and regulatory changes that impact California businesses
- - State Fund’s 2019 in-person safety seminar schedule
"Our new online safety resources provide California employers and employees with the information and tools they need to better incorporate safety best practices into their everyday work," said Lauren Mayfield, senior vice president of Safety and Health Services at State Fund.
"By making it easier to find safety-related information and tools, we can help businesses make safety a priority before the job starts, and that leads to fewer on-the-job injuries and, ultimately, lower rates for our customers."
Employers can also ask their own workplace safety questions using the site’s "Ask the Expert" feature. When an employer asks a question, one of State Fund’s workplace safety experts will respond within 48 hours.
Visit SafeAtWorkCA.com for more information ...
The new site features a variety of safety-related resources, including:
- - Workplace safety fundamentals customized for a variety of industries
- - Safety meeting topics and plans
- - Updates on legislative and regulatory changes that impact California businesses
- - State Fund’s 2019 in-person safety seminar schedule
"Our new online safety resources provide California employers and employees with the information and tools they need to better incorporate safety best practices into their everyday work," said Lauren Mayfield, senior vice president of Safety and Health Services at State Fund.
"By making it easier to find safety-related information and tools, we can help businesses make safety a priority before the job starts, and that leads to fewer on-the-job injuries and, ultimately, lower rates for our customers."
Employers can also ask their own workplace safety questions using the site’s "Ask the Expert" feature. When an employer asks a question, one of State Fund’s workplace safety experts will respond within 48 hours.
Visit SafeAtWorkCA.com for more information ...
If traditional drug delivery were a type of painting, it might be akin to paintball. With good aim, a majority of the paint ends on the bullseye, but it also drips and splashes, carrying streams of paint across the target.
If the drug needs to enter the bloodstream and circulate throughout your body for treating disease wherever it may be, this paintball-like delivery system may work. But it won't work for targeted and precise drug delivery.
A more acute delivery approach would look more like "painting by numbers," a technique that would allow precise delivery of a certain amount of drugs to an exact location. Researchers at the James McKelvey School of Engineering and the School of Medicine at Washington University in St. Louis are developing the tools necessary for such a drug delivery system, which they call cavitation dose painting.
Their research was published online this week in Scientific Reports.
Using focused ultrasound with its contrast agent, microbubbles, to deliver drugs across the blood-brain barrier (FUS-BBBD), the research team, led by Hong Chen, assistant professor of biomedical engineering at McKelvey School of Engineering, and assistant professor of radiation oncology at the School of Medicine, was able to overcome some of the uncertainty of drug delivery.
This method takes advantage of the microbubbles expanding and contracting when they interact with the ultrasound, essentially pumping the intravenously-delivered drug to wherever the ultrasound is pointing.
To determine where and how much of the drugs were being delivered, the researchers used nanoparticles tagged with radio labels to represent drug particles, then used positron emission tomography (PET) imaging to track their whereabouts and concentrations. They could then create a detailed image, showing where the nanoparticles were going and in what concentrations.
There's one hitch, though. "The problem is, PET imaging is expensive and associated with radioactive exposure," Chen said.
So the team turned to passive cavitation imaging (PCI), an ultrasound imaging technique that has been under development by several groups for imaging the spatial distribution of microbubble cavitation, or the oscillation of microbubbles in the ultrasound field.
To determine whether PCI could also accurately determine the amount of drugs at a certain location, they correlated a PCI image with a PET image (which they knew can quantify the concentration of radioactive agents).
"We found there's pixel by pixel correlation between the ultrasound imaging and the PET imaging," said Yaoheng Yang, the lead author of this study and a second-year PhD student in the Department of Biomedical Engineering. The PCI image, therefore, can be used to predict where a drug goes and how much drug is there. Hence, she called the new technique cavitation dose painting.
Going forward, Chen believes this method could drastically change the way some drugs are delivered. Using cavitation dose painting in tandem with focused ultrasound will allow doctors to deliver precise amounts of drugs to specific locations, for example, targeting different areas of a tumor with exactitude.
"I think this cavitation dose painting technique in combination with focused ultrasound-enabled brain drug delivery opens new horizons in spatially targeted and modulated brain drug delivery," Chen said.
She has recently received a $1.6 million grant from the National Institutes of Health (NIH)'s National Institute of Biomedical Imaging and Bioengineering to work on combining intranasal drug delivery and focused ultrasound (FUSIN) with this research ...
If the drug needs to enter the bloodstream and circulate throughout your body for treating disease wherever it may be, this paintball-like delivery system may work. But it won't work for targeted and precise drug delivery.
A more acute delivery approach would look more like "painting by numbers," a technique that would allow precise delivery of a certain amount of drugs to an exact location. Researchers at the James McKelvey School of Engineering and the School of Medicine at Washington University in St. Louis are developing the tools necessary for such a drug delivery system, which they call cavitation dose painting.
Their research was published online this week in Scientific Reports.
Using focused ultrasound with its contrast agent, microbubbles, to deliver drugs across the blood-brain barrier (FUS-BBBD), the research team, led by Hong Chen, assistant professor of biomedical engineering at McKelvey School of Engineering, and assistant professor of radiation oncology at the School of Medicine, was able to overcome some of the uncertainty of drug delivery.
This method takes advantage of the microbubbles expanding and contracting when they interact with the ultrasound, essentially pumping the intravenously-delivered drug to wherever the ultrasound is pointing.
To determine where and how much of the drugs were being delivered, the researchers used nanoparticles tagged with radio labels to represent drug particles, then used positron emission tomography (PET) imaging to track their whereabouts and concentrations. They could then create a detailed image, showing where the nanoparticles were going and in what concentrations.
There's one hitch, though. "The problem is, PET imaging is expensive and associated with radioactive exposure," Chen said.
So the team turned to passive cavitation imaging (PCI), an ultrasound imaging technique that has been under development by several groups for imaging the spatial distribution of microbubble cavitation, or the oscillation of microbubbles in the ultrasound field.
To determine whether PCI could also accurately determine the amount of drugs at a certain location, they correlated a PCI image with a PET image (which they knew can quantify the concentration of radioactive agents).
"We found there's pixel by pixel correlation between the ultrasound imaging and the PET imaging," said Yaoheng Yang, the lead author of this study and a second-year PhD student in the Department of Biomedical Engineering. The PCI image, therefore, can be used to predict where a drug goes and how much drug is there. Hence, she called the new technique cavitation dose painting.
Going forward, Chen believes this method could drastically change the way some drugs are delivered. Using cavitation dose painting in tandem with focused ultrasound will allow doctors to deliver precise amounts of drugs to specific locations, for example, targeting different areas of a tumor with exactitude.
"I think this cavitation dose painting technique in combination with focused ultrasound-enabled brain drug delivery opens new horizons in spatially targeted and modulated brain drug delivery," Chen said.
She has recently received a $1.6 million grant from the National Institutes of Health (NIH)'s National Institute of Biomedical Imaging and Bioengineering to work on combining intranasal drug delivery and focused ultrasound (FUSIN) with this research ...
Democratic Representative Pramila Jayapal from Washington state, has introduced a new bill that would transition the U.S. healthcare system to a single-payer "Medicare for All" program funded by the government in two years.
The legislation is the party’s most high-profile and ambitious single-payer proposal in the new Congress and has more than 100 co-sponsors, many from the party’s progressive flank.
Jayapal highlighted support from various labor unions and public interest groups on Wednesday. She also disputed the notion that House members from ideologically balanced districts would not support the plan. One congressman who won a swing district last year - Rep. Josh Harder of California - appeared with Jayapal to back her plan Wednesday.
It is unlikely to gain the support of any Republicans in the House or the Senate, who have derided single-payer healthcare as a socialist policy and oppose government interference in healthcare. It also remains unclear whether Democratic House Speaker Nancy Pelosi will bring the legislation up for a vote.
Medicare currently serves about 60 million Americans who are age 65 or older, or disabled. Jayapal’s legislation would eliminate the age threshold. The new Medicare would not require any beneficiaries to pay premiums or deductibles and would not charge patients co-pays or out-of-pocket costs after receiving care.
It does not include new or increased taxes or other additional revenues to pay for the healthcare overhaul. Jayapal said possible ways to pay for the bill include a tax on millionaires and billionaires, employer premiums and closing tax loopholes for the wealthy.
The idea of Medicare for All was first proposed by Independent Bernie Sanders as a single-payer system that would largely replace private insurance. It gained traction among Democrats running for congressional office in 2018, and is now a central campaign issue for party members vying for the 2020 presidential nomination.
The health industry has opposed single-payer proposals, saying they would ultimately lead to less access to care. Critics include the American Hospital Association and America’s Health Insurance Plans (AHIP), the health insurance industry’s biggest trade group ...
The legislation is the party’s most high-profile and ambitious single-payer proposal in the new Congress and has more than 100 co-sponsors, many from the party’s progressive flank.
Jayapal highlighted support from various labor unions and public interest groups on Wednesday. She also disputed the notion that House members from ideologically balanced districts would not support the plan. One congressman who won a swing district last year - Rep. Josh Harder of California - appeared with Jayapal to back her plan Wednesday.
It is unlikely to gain the support of any Republicans in the House or the Senate, who have derided single-payer healthcare as a socialist policy and oppose government interference in healthcare. It also remains unclear whether Democratic House Speaker Nancy Pelosi will bring the legislation up for a vote.
Medicare currently serves about 60 million Americans who are age 65 or older, or disabled. Jayapal’s legislation would eliminate the age threshold. The new Medicare would not require any beneficiaries to pay premiums or deductibles and would not charge patients co-pays or out-of-pocket costs after receiving care.
It does not include new or increased taxes or other additional revenues to pay for the healthcare overhaul. Jayapal said possible ways to pay for the bill include a tax on millionaires and billionaires, employer premiums and closing tax loopholes for the wealthy.
The idea of Medicare for All was first proposed by Independent Bernie Sanders as a single-payer system that would largely replace private insurance. It gained traction among Democrats running for congressional office in 2018, and is now a central campaign issue for party members vying for the 2020 presidential nomination.
The health industry has opposed single-payer proposals, saying they would ultimately lead to less access to care. Critics include the American Hospital Association and America’s Health Insurance Plans (AHIP), the health insurance industry’s biggest trade group ...
This month a slew of conspirators involved in a massive Workers’ Compensation kickback scheme were ordered to serve prison sentences and pay millions in financial penalties for their roles in the corrupt payment of millions of dollars to induce doctors and other medical professionals to refer hundreds of injured workers for medical treatments and services.
Defendant Fermin Iglesias and co-defendant Carlos Arguello operated a patient-capping enterprise, in which they found individuals who would file Workers’ Compensation claims against their employers. Iglesias and Arguello then sold, bartered and exchanged these applicants with others in the Workers’ Compensation industry, including attorneys, primary care physicians, and providers of medical goods and services.
Each of these entities had to "pay to play," and as the patient was referred throughout this corrupt system, money changed hands at each step.
Arguello operated several patient-recruitment entities, including one called Centro Legal. Through billboards, flyers, advertisements and business cards, Centro Legal recruited persons to seek workers' compensation benefits from their employers or former employers. When the injured worker called the 1-800 number on the billboard or card, he or she reached a call center, which might be located in another country. From there, Iglesias’ company, Providence Scheduling, took over brokering the patient to maximize the profit that could be extracted from him or her.
Centro Legal referred the newly-acquired patient to complicit Workers' Compensation attorneys, including, in San Diego, attorney Sean O’Keefe, who had one of the largest Workers’ Comp caseloads in the region. To get these new clients, the attorneys in the corrupt network were expected to comply with certain conditions.
First, they had to use Arguello’s copying service to fulfil document requests for all of the new client’s medical records. Next, they had to agree to designate as their client’s primary treating physician ("PTP") one of the complicit physicians within the corrupt network.
In exchange, the attorneys received compensation. For O'Keefe, the compensation took a variety of forms. One hospital administrator paid the salaries of two employees of O’Keefe’s law firm, as a kickback to O’Keefe for referring spinal surgeries to that hospital. In another variation, the kickback payments were disguised as payments for nonexistent legal services, for which O’Keefe generated phony "legal invoices" to cover up those obviously illegal payments.
The corrupt physician could serve as the patients' primary care physician in the Workers' Comp system. Iglesias required that the chiropractors prescribe a certain minimum quota of goods and services, on average, for each patient. If the chiropractor failed to live up to the quota, Iglesias would cut off the flow of new patients.
Dr. Steven Rigler was one of the chiropractors involved in the corrupt referral network. He had clinics in Calexico, San Diego, and Escondido.
Jennifer Louise White represented providers of other types of services, namely, Autonomic Nervous System ("ANS") studies and sleep studies. She worked with Alex Martinez and with providers of the ANS and sleep studies to pay nearly $200,000 in kickbacks to Rigler to refer patients for these services.
SENTENCES
Ronald Grusd, Los Angeles, CA - - 10 years, $1.3 million forfeiture, $250,000 fine
California Imaging Network Medical Group - - 5 years’ Probation, $500,000 fine
Willows Consulting Company - - 5 years’ Probation, $500,000 fine
Alex Martinez, El Centro, CA - - 37 months’ custody
Ruben Martinez, Murietta, CA - - 33 months’ custody
Line of Sight, Inc. - - 5 years’ Probation, $45,000 fine
Desert Blue Moon, Inc. - - 5 years’ Probation, $20,000 fine
Fermin Iglesias - - 60 months’ custody, $1,005,000 forfeiture
MedEx Solutions - - 5 years’ Probation, $500,000 fine
Meridian Medical Resources - - 5 years’ Probation, $500,000 fine
Miguel Morales - - 12 months 1 day custody, $140,000 forfeiture
Julian K. Garcia, National City, CA - - 33 months’ custody, $10,000 fine
Jennifer Louise White, Glendale, CA - - 24 months, $25,000 fine
Sean Enrique O’Keefe - - 13 months, $300,000 forfeiture
Steven J. Rigler - - 6 months, $150,000 forfeiture ...
Defendant Fermin Iglesias and co-defendant Carlos Arguello operated a patient-capping enterprise, in which they found individuals who would file Workers’ Compensation claims against their employers. Iglesias and Arguello then sold, bartered and exchanged these applicants with others in the Workers’ Compensation industry, including attorneys, primary care physicians, and providers of medical goods and services.
Each of these entities had to "pay to play," and as the patient was referred throughout this corrupt system, money changed hands at each step.
Arguello operated several patient-recruitment entities, including one called Centro Legal. Through billboards, flyers, advertisements and business cards, Centro Legal recruited persons to seek workers' compensation benefits from their employers or former employers. When the injured worker called the 1-800 number on the billboard or card, he or she reached a call center, which might be located in another country. From there, Iglesias’ company, Providence Scheduling, took over brokering the patient to maximize the profit that could be extracted from him or her.
Centro Legal referred the newly-acquired patient to complicit Workers' Compensation attorneys, including, in San Diego, attorney Sean O’Keefe, who had one of the largest Workers’ Comp caseloads in the region. To get these new clients, the attorneys in the corrupt network were expected to comply with certain conditions.
First, they had to use Arguello’s copying service to fulfil document requests for all of the new client’s medical records. Next, they had to agree to designate as their client’s primary treating physician ("PTP") one of the complicit physicians within the corrupt network.
In exchange, the attorneys received compensation. For O'Keefe, the compensation took a variety of forms. One hospital administrator paid the salaries of two employees of O’Keefe’s law firm, as a kickback to O’Keefe for referring spinal surgeries to that hospital. In another variation, the kickback payments were disguised as payments for nonexistent legal services, for which O’Keefe generated phony "legal invoices" to cover up those obviously illegal payments.
The corrupt physician could serve as the patients' primary care physician in the Workers' Comp system. Iglesias required that the chiropractors prescribe a certain minimum quota of goods and services, on average, for each patient. If the chiropractor failed to live up to the quota, Iglesias would cut off the flow of new patients.
Dr. Steven Rigler was one of the chiropractors involved in the corrupt referral network. He had clinics in Calexico, San Diego, and Escondido.
Jennifer Louise White represented providers of other types of services, namely, Autonomic Nervous System ("ANS") studies and sleep studies. She worked with Alex Martinez and with providers of the ANS and sleep studies to pay nearly $200,000 in kickbacks to Rigler to refer patients for these services.
SENTENCES
Ronald Grusd, Los Angeles, CA - - 10 years, $1.3 million forfeiture, $250,000 fine
California Imaging Network Medical Group - - 5 years’ Probation, $500,000 fine
Willows Consulting Company - - 5 years’ Probation, $500,000 fine
Alex Martinez, El Centro, CA - - 37 months’ custody
Ruben Martinez, Murietta, CA - - 33 months’ custody
Line of Sight, Inc. - - 5 years’ Probation, $45,000 fine
Desert Blue Moon, Inc. - - 5 years’ Probation, $20,000 fine
Fermin Iglesias - - 60 months’ custody, $1,005,000 forfeiture
MedEx Solutions - - 5 years’ Probation, $500,000 fine
Meridian Medical Resources - - 5 years’ Probation, $500,000 fine
Miguel Morales - - 12 months 1 day custody, $140,000 forfeiture
Julian K. Garcia, National City, CA - - 33 months’ custody, $10,000 fine
Jennifer Louise White, Glendale, CA - - 24 months, $25,000 fine
Sean Enrique O’Keefe - - 13 months, $300,000 forfeiture
Steven J. Rigler - - 6 months, $150,000 forfeiture ...
Cal/OSHA is reminding employers in California of the requirement to electronically submit by March 2 their Form 300A injury and illness data for calendar year 2018.
The federal Occupational Safety and Health Administration (OSHA) adopted the Improve Tracking of Workplace Injuries and Illnesses rule in 2016. This rule requires electronic submission of certain occupational injury and illness reports by covered employers with at least 250 employees and by smaller employers in high-risk industries.
Employers in California with establishments meeting one of the requirements below are required to electronically submit Form 300A data for those establishments:
- - All establishments with 250 or more employees, unless specifically exempted by section 14300.2 of title 8 of the California Code of Regulations.
- - ;Establishments with 20 to 249 employees in the specific industries listed in Appendix H of Cal/OSHA's emergency regulations.
For instructions on how to submit the data, follow the guidance on federal OSHA's Injury Tracking Application website.
The California Division of Occupational Safety and Health, or Cal/OSHA, is the division within the Department of Industrial Relations (DIR) that helps protect California’s workers from health and safety hazards on the job in almost every workplace. Cal/OSHA’s Consultation Services Branch provides free and voluntary assistance to employers to improve their safety and health programs. Employers should call (800) 963-9424 for assistance from Cal/OSHA Consultation Services.
...
The federal Occupational Safety and Health Administration (OSHA) adopted the Improve Tracking of Workplace Injuries and Illnesses rule in 2016. This rule requires electronic submission of certain occupational injury and illness reports by covered employers with at least 250 employees and by smaller employers in high-risk industries.
Employers in California with establishments meeting one of the requirements below are required to electronically submit Form 300A data for those establishments:
- - All establishments with 250 or more employees, unless specifically exempted by section 14300.2 of title 8 of the California Code of Regulations.
- - ;Establishments with 20 to 249 employees in the specific industries listed in Appendix H of Cal/OSHA's emergency regulations.
For instructions on how to submit the data, follow the guidance on federal OSHA's Injury Tracking Application website.
The California Division of Occupational Safety and Health, or Cal/OSHA, is the division within the Department of Industrial Relations (DIR) that helps protect California’s workers from health and safety hazards on the job in almost every workplace. Cal/OSHA’s Consultation Services Branch provides free and voluntary assistance to employers to improve their safety and health programs. Employers should call (800) 963-9424 for assistance from Cal/OSHA Consultation Services.
...
Christopher Devereux was employed as an attorney by State Compensation Insurance Fund. He sustained an admitted industrial injury in the form of hypertension, diabetes, heart, circulatory, and cognitive impairment, as a result of continuous trauma ending in 2015.
The cardiology QME reported that the cardiac impairment was separate and distinct from the cognitive impairment reported by the neuropsychology QME. Thus he said that the most accurate rating in this case would be to add the impairment ratings, and do not require the Combined Values Chart.
The QME went on to say "frankly, when we are dealing with mental impairments and physical impairments, in terms of the ultimate disability there often is not much the way of overlap. It is my perspective that these two impairments that are discrete and. in very different areas are best combined through a strict adding procedure than anything else. I do not hrave a basis to argue that they are synergistic to..any. significant-degree. That is, I would not argue that the actual disability is greater than the simple additive combining of the impairments.
The WCJ found applicant sustained 90% permanent disability by adding rather than combining the disabilities. The WCJ determined that applicant's combined permanent disability rating, from the WPI ratings of the two QMEs should be based upon adding the impairments rather than using the CVC, in view of the physicians' opinions that this was most appropriate in the absence of overlapping impairments.
The petition for reconsideration of this finding by the State Fund was denied in the panel decision of Devereux v. SCIF.
"The rating schedule provides that the CVC is "generally" used to combine multiple disabilities, but that other methodology may be used depending upon the relevant circumstances. It is the role of the medical expert to make a medical determination as to how to combine the separate impairments. One reason for using the CVC is to avoid combining impairments that lead to a rating greater than 100% permanent disability. However, this concern is not justified here, since applicant cannot receive a permanent disability award for a single injury greater than 100%".
"Multiple cases have held that this determination is best based upon the extent to which the impairments affect applicant's ability to perform activities of daily living. It is the opinions of the medical evaluators and not a rigid application of the CVC in the rating schedule that should prevail. (Athens Administrators v. Workers' Comp, Appeals Bd. (Kite) (2013) 78 Cal.Comp.Cases 213."
"It has been recognized that a disability rating, 'should reflect as accurately as possible an injured employee's diminished ability to compete in the open labor market.' (LeBoeuf. v. Workers' Comp. Appeals Bd, (1983) 34 Cal.3d 234,245-246 [48 Cal.Comp.Cases 587].) In this case, the WCJ reasonably concluded that the medical evaluators properly determined that adding the hypertension and cognitive impairment disabilities more accurately reflects applicant's entire permanent disability than results from using the CVC." ...
The cardiology QME reported that the cardiac impairment was separate and distinct from the cognitive impairment reported by the neuropsychology QME. Thus he said that the most accurate rating in this case would be to add the impairment ratings, and do not require the Combined Values Chart.
The QME went on to say "frankly, when we are dealing with mental impairments and physical impairments, in terms of the ultimate disability there often is not much the way of overlap. It is my perspective that these two impairments that are discrete and. in very different areas are best combined through a strict adding procedure than anything else. I do not hrave a basis to argue that they are synergistic to..any. significant-degree. That is, I would not argue that the actual disability is greater than the simple additive combining of the impairments.
The WCJ found applicant sustained 90% permanent disability by adding rather than combining the disabilities. The WCJ determined that applicant's combined permanent disability rating, from the WPI ratings of the two QMEs should be based upon adding the impairments rather than using the CVC, in view of the physicians' opinions that this was most appropriate in the absence of overlapping impairments.
The petition for reconsideration of this finding by the State Fund was denied in the panel decision of Devereux v. SCIF.
"The rating schedule provides that the CVC is "generally" used to combine multiple disabilities, but that other methodology may be used depending upon the relevant circumstances. It is the role of the medical expert to make a medical determination as to how to combine the separate impairments. One reason for using the CVC is to avoid combining impairments that lead to a rating greater than 100% permanent disability. However, this concern is not justified here, since applicant cannot receive a permanent disability award for a single injury greater than 100%".
"Multiple cases have held that this determination is best based upon the extent to which the impairments affect applicant's ability to perform activities of daily living. It is the opinions of the medical evaluators and not a rigid application of the CVC in the rating schedule that should prevail. (Athens Administrators v. Workers' Comp, Appeals Bd. (Kite) (2013) 78 Cal.Comp.Cases 213."
"It has been recognized that a disability rating, 'should reflect as accurately as possible an injured employee's diminished ability to compete in the open labor market.' (LeBoeuf. v. Workers' Comp. Appeals Bd, (1983) 34 Cal.3d 234,245-246 [48 Cal.Comp.Cases 587].) In this case, the WCJ reasonably concluded that the medical evaluators properly determined that adding the hypertension and cognitive impairment disabilities more accurately reflects applicant's entire permanent disability than results from using the CVC." ...
