Independent pharmacists across Ventura County have filed a lawsuit against OptumRx, alleging the company manipulated drug pricing to enable lower reimbursement rates paid to small drugstores and plunging businesses underwater.
OptumRx, one of the biggest operations of its kind in the United States and part of the UnitedHealth network, sets payment rates as the pharmacy benefit manager for the Gold Coast Health Plan. The publicly funded Gold Coast organization provides Medi-Cal insurance to nearly 200,000 low-income Ventura County residents.
The pharmacists allege the company used contracts negotiated with agents of pharmacies to force the businesses into accepting payment that often fell below costs. OptumRx threatened people who pushed back with expulsion from the network, the complaint stated.
The lawsuit alleges unfair trade practices, breach of contract and violation of California law. It was filed by 18 companies and individuals in Ventura County Superior Court.
The litigation also targets three pharmacy services administration organizations - operated by Cardinal Health, Arete Pharmacy Network and AmerisourceBergen - that worked as middlemen between the pharmacies and OptumRx.
Leaders of OptumRx have repeatedly defended their pricing in a drama that dates back to last summer, shortly after the company assumed its role as Gold Coast’s pharmacy benefit manager.
"OptumRx’s role is to ensure consumers and health plan payers have convenient access to affordable prescription medications, and we will continue to work to help lower health care costs for Gold Coast Health Plan and California taxpayers," said OptumRx spokesman Drew Krejci in a statement Thursday. "We believe this lawsuit is without merit and will vigorously defend ourselves."
Pharmacists have crowded meetings of the Ventura County Medi-Cal Managed Care Commission for months, complaining about below-market rates they say shut down the Medical Plaza Pharmacy in Fillmore and put many others in jeopardy. The commission governs Gold Coast.
An independent consultant reviewed the rates and told the commission in April that the reimbursement paid by OptumRx is comparable to payment in similar Medicaid plans in California and elsewhere. After a closed-door discussion, commissioners announced they would not try to force the pharmacy benefit manager to raise the rates.
The lawsuit alleges OptumRx won the Gold Coast contract because it offered price guarantees and met the guarantees by obtaining secret rebates from drug makers and then manipulating pricing.
OptumRx also used something called the "maximum allowable cost" list to force reimbursement down, pharmacists claim. The so-called MAC list helps set the reimbursement rate and is supposed to be influenced by prices different distributors ask for the same generic medication. The pharmacists allege OptumRx ignored market prices and made up its own maximum allowable cost "based on thin air."
It is "a moving target moved at Optum’s whim," the lawsuit stated. It alleged OptumRx also kept its MAC price for generic drugs secret and violated state law by not making decisions on appeals by pharmacists within seven business days ...
OptumRx, one of the biggest operations of its kind in the United States and part of the UnitedHealth network, sets payment rates as the pharmacy benefit manager for the Gold Coast Health Plan. The publicly funded Gold Coast organization provides Medi-Cal insurance to nearly 200,000 low-income Ventura County residents.
The pharmacists allege the company used contracts negotiated with agents of pharmacies to force the businesses into accepting payment that often fell below costs. OptumRx threatened people who pushed back with expulsion from the network, the complaint stated.
The lawsuit alleges unfair trade practices, breach of contract and violation of California law. It was filed by 18 companies and individuals in Ventura County Superior Court.
The litigation also targets three pharmacy services administration organizations - operated by Cardinal Health, Arete Pharmacy Network and AmerisourceBergen - that worked as middlemen between the pharmacies and OptumRx.
Leaders of OptumRx have repeatedly defended their pricing in a drama that dates back to last summer, shortly after the company assumed its role as Gold Coast’s pharmacy benefit manager.
"OptumRx’s role is to ensure consumers and health plan payers have convenient access to affordable prescription medications, and we will continue to work to help lower health care costs for Gold Coast Health Plan and California taxpayers," said OptumRx spokesman Drew Krejci in a statement Thursday. "We believe this lawsuit is without merit and will vigorously defend ourselves."
Pharmacists have crowded meetings of the Ventura County Medi-Cal Managed Care Commission for months, complaining about below-market rates they say shut down the Medical Plaza Pharmacy in Fillmore and put many others in jeopardy. The commission governs Gold Coast.
An independent consultant reviewed the rates and told the commission in April that the reimbursement paid by OptumRx is comparable to payment in similar Medicaid plans in California and elsewhere. After a closed-door discussion, commissioners announced they would not try to force the pharmacy benefit manager to raise the rates.
The lawsuit alleges OptumRx won the Gold Coast contract because it offered price guarantees and met the guarantees by obtaining secret rebates from drug makers and then manipulating pricing.
OptumRx also used something called the "maximum allowable cost" list to force reimbursement down, pharmacists claim. The so-called MAC list helps set the reimbursement rate and is supposed to be influenced by prices different distributors ask for the same generic medication. The pharmacists allege OptumRx ignored market prices and made up its own maximum allowable cost "based on thin air."
It is "a moving target moved at Optum’s whim," the lawsuit stated. It alleged OptumRx also kept its MAC price for generic drugs secret and violated state law by not making decisions on appeals by pharmacists within seven business days ...
A federal grand jury indicted Dr. George David, a Freemont Psychiatrist, and Linda Nguyen with conspiracy to commit mail fraud and substantive mail fraud.
According to the indictment filed January 29, 2019, and unsealed in February, David, 78, and Nguyen, 66, of Union City, engaged in a scheme to defraud California’s State Disability Insurance (SDI) program.
The SDI program is designed to provide partial wage replacement benefits to eligible California workers who are unable to work due to a non-work-related illness, injury, or pregnancy.
To receive SDI benefits, a claimant must file a claim for benefits supported by a Physician/Practitioner Certification attesting to the claimant’s disability.
According to the indictment, David provided fraudulent Physician/Practitioner Certifications to support fraudulent SDI applications for non-disabled claimants. In addition, the indictment alleges that Nguyen facilitated the fraud by assisting non-disabled persons with the execution and submission of fraudulent documents.
The indictment further alleges that Nguyen charged the non-disabled persons for processing their fraudulent applications. In sum, the defendants each were charged with one count of conspiracy to commit mail fraud, in violation of 18 U.S.C. § 1349, and one count of substantive mail fraud, in violation of 18 U.S.C. § 1341.
The defendants were arrested and made their initial appearances before U.S. Magistrate Judge Donna M. Ryu. Both defendants were released on bond. Magistrate Judge Ryu scheduled David’s and Nguyen’s next appearances for February 8 and February 15, 2019, respectively, for arraignment and identification of counsel.
If found guilty, the defendants face a maximum statutory sentence of 20 years in prison for each count in the indictment. However, any sentence following conviction would be imposed by the court after consideration of the U.S. Sentencing Guidelines and the federal statute governing the imposition of a sentence, 18 U.S.C. § 3553.
Special Assistant U.S. Attorney Christopher Vieira is prosecuting the case with the assistance of Kimberly Richardson. The prosecution is the result of an investigation by the FBI and Social Security Administration Office of the Inspector General ...
According to the indictment filed January 29, 2019, and unsealed in February, David, 78, and Nguyen, 66, of Union City, engaged in a scheme to defraud California’s State Disability Insurance (SDI) program.
The SDI program is designed to provide partial wage replacement benefits to eligible California workers who are unable to work due to a non-work-related illness, injury, or pregnancy.
To receive SDI benefits, a claimant must file a claim for benefits supported by a Physician/Practitioner Certification attesting to the claimant’s disability.
According to the indictment, David provided fraudulent Physician/Practitioner Certifications to support fraudulent SDI applications for non-disabled claimants. In addition, the indictment alleges that Nguyen facilitated the fraud by assisting non-disabled persons with the execution and submission of fraudulent documents.
The indictment further alleges that Nguyen charged the non-disabled persons for processing their fraudulent applications. In sum, the defendants each were charged with one count of conspiracy to commit mail fraud, in violation of 18 U.S.C. § 1349, and one count of substantive mail fraud, in violation of 18 U.S.C. § 1341.
The defendants were arrested and made their initial appearances before U.S. Magistrate Judge Donna M. Ryu. Both defendants were released on bond. Magistrate Judge Ryu scheduled David’s and Nguyen’s next appearances for February 8 and February 15, 2019, respectively, for arraignment and identification of counsel.
If found guilty, the defendants face a maximum statutory sentence of 20 years in prison for each count in the indictment. However, any sentence following conviction would be imposed by the court after consideration of the U.S. Sentencing Guidelines and the federal statute governing the imposition of a sentence, 18 U.S.C. § 3553.
Special Assistant U.S. Attorney Christopher Vieira is prosecuting the case with the assistance of Kimberly Richardson. The prosecution is the result of an investigation by the FBI and Social Security Administration Office of the Inspector General ...
Johnson & Johnson said on Thursday it will start adding the price of its medicines to television commercials by next month, becoming the first drugmaker to heed a call by U.S. President Donald Trump for price transparency of drugs advertised directly to consumers on TV.
The healthcare conglomerate said it will include both the list price of a product - the price before any rebates or discounts to insurers or pharmacy benefit managers - as well as potential out-of-pocket costs that patients will pay.
The move, announced in a statement on J&J’s website, won swift praise from U.S. Health and Human Services Secretary Alex Azar. Last May, Azar’s office released a blueprint for reducing the cost of drug prices, which included a proposal to require disclosure of list prices in TV ads for drugs.
"We commend Johnson & Johnson for recognizing the value of informing consumers about list prices and for doing so voluntarily. We call on other manufacturers to follow their lead," Azar said in a statement.
Trump made lowering the cost of prescription drugs for U.S. consumers a central issue of the 2016 presidential campaign and emphasized it again in his State of the Union Address this week.
Ads for the blood thinner Xarelto, J&J’s most widely prescribed medicine, will be the first television spot to include pricing information, the company said. The treatment used to prevent blood clots costs about $450 to $540 a month.
Congress has increased its scrutiny of U.S. drug pricing since Democrats took over control of the House of Representatives in January, while pressure is also coming from the Republican-led Senate.
Republican Senator Chuck Grassley, chairman of the Senate Finance Committee, and Democratic Senator Ron Wyden, ranking member of the committee, on Monday invited executives from seven pharmaceutical companies, including J&J, to testify at a Feb. 26 hearing on rising drug prices ...
The healthcare conglomerate said it will include both the list price of a product - the price before any rebates or discounts to insurers or pharmacy benefit managers - as well as potential out-of-pocket costs that patients will pay.
The move, announced in a statement on J&J’s website, won swift praise from U.S. Health and Human Services Secretary Alex Azar. Last May, Azar’s office released a blueprint for reducing the cost of drug prices, which included a proposal to require disclosure of list prices in TV ads for drugs.
"We commend Johnson & Johnson for recognizing the value of informing consumers about list prices and for doing so voluntarily. We call on other manufacturers to follow their lead," Azar said in a statement.
Trump made lowering the cost of prescription drugs for U.S. consumers a central issue of the 2016 presidential campaign and emphasized it again in his State of the Union Address this week.
Ads for the blood thinner Xarelto, J&J’s most widely prescribed medicine, will be the first television spot to include pricing information, the company said. The treatment used to prevent blood clots costs about $450 to $540 a month.
Congress has increased its scrutiny of U.S. drug pricing since Democrats took over control of the House of Representatives in January, while pressure is also coming from the Republican-led Senate.
Republican Senator Chuck Grassley, chairman of the Senate Finance Committee, and Democratic Senator Ron Wyden, ranking member of the committee, on Monday invited executives from seven pharmaceutical companies, including J&J, to testify at a Feb. 26 hearing on rising drug prices ...
As the first company to offer telehealth in the workers’ compensation space, there was no roadmap to follow. Since adding telehealth services in 2015, CorVel has now completed 10,000 virtual visits. With this significant milestone, David Lupinsky, CorVel's Vice President of Medical Review Services reported on a few of the lessons the company learned:
In order to make telehealth equally efficacious to the brick and mortar visit, it needed to offer the same features patients have come to expect, value, and appreciate. Immediate access to medical services such as physical therapy, diagnostics imaging, pharmacotherapy, and durable medical equipment are essential to a successful telehealth offering.
Telehealth physicians have prescribed medications, ordered vaccines, requested durable medical equipment, and scheduled short term physical therapy and diagnostic imaging when clinically appropriate.
Brick and mortar evaluations take 4+ hours on average, factoring travel and wait times, while virtual visits last an average 30 minutes from start to finish. And though it is customary for injured employees to wait 1-2 days for the claim to be completely set up before receiving treatment, telehealth provides appropriate clinical care within minutes of the injury. Moreover, all claims data obtained through virtual visits is loaded into CareMC, its claims management technology, making the information immediately and easily accessible for all constituents.
Interdisciplinary care is defined by its multi-specialty shared relationships and common goals. While it’s appropriate to have multiple team members and providers working on a claim, CorVel has learned the importance of working towards a shared goal of providing timely, appropriate care for injured workers.
To ensure consistent protocols and concordance with each case, it has a dedicated medical director who oversees telehealth physicians and maintains communication with the nursing director. Communication between the claims intake department (FNOL), triage nurse, and treating telehealth physician significantly reduces duplication of services and thus patient wait times, patient frustration, and coding errors.
As a result of an integrated and shared database, all data captured by its 24/7 nurse triage and telehealth services can be accessed by both its FNOL intake team and our adjusters in real time. This is crucial to minimizing talk time, ensuring consistency, and maximizing the patient experience.
With telehealth becoming more popular in "mainstream healthcare", it is now an expectation for injured employees. Since patients expect a telehealth platform to provide these services, it’s essential they be delivered in a coordinated fashion with updated clinical notes available to the providers on follow up visits to maintain an equal or superior standard of care to brick and mortar outcomes.
Healthcare is evolving and at the core of its change is data and artificial intelligence (AI). At CorVel, it has utilized AI with the Edge, its completely modernized claims management portal. The Edge takes claims data from a variety of sources, including bill review and pharmacy, to identify potential risk for certain claims and push out telehealth visits to mitigate the risk.
The real cost of a "minor" injury can significantly change when viewed in the context of medications, psychosocial factors, testing, and opioids. Automatic identification of these proprietary factors can elevate this case to higher acuity and a telehealth visit can be pushed out to the patient for a collaborative and holistic approach to care that can be implemented while working in tandem with other treating physician already involved in the patient’s care.
Being able to integrate this data into its claims management platform has allowed CorVel to prevent many minor injuries from becoming expensive claims. Read Corvel's recent white paper, Breaking Down Barriers, to learn more about its approach to telehealth in performance-based networks ...
In order to make telehealth equally efficacious to the brick and mortar visit, it needed to offer the same features patients have come to expect, value, and appreciate. Immediate access to medical services such as physical therapy, diagnostics imaging, pharmacotherapy, and durable medical equipment are essential to a successful telehealth offering.
Telehealth physicians have prescribed medications, ordered vaccines, requested durable medical equipment, and scheduled short term physical therapy and diagnostic imaging when clinically appropriate.
Brick and mortar evaluations take 4+ hours on average, factoring travel and wait times, while virtual visits last an average 30 minutes from start to finish. And though it is customary for injured employees to wait 1-2 days for the claim to be completely set up before receiving treatment, telehealth provides appropriate clinical care within minutes of the injury. Moreover, all claims data obtained through virtual visits is loaded into CareMC, its claims management technology, making the information immediately and easily accessible for all constituents.
Interdisciplinary care is defined by its multi-specialty shared relationships and common goals. While it’s appropriate to have multiple team members and providers working on a claim, CorVel has learned the importance of working towards a shared goal of providing timely, appropriate care for injured workers.
To ensure consistent protocols and concordance with each case, it has a dedicated medical director who oversees telehealth physicians and maintains communication with the nursing director. Communication between the claims intake department (FNOL), triage nurse, and treating telehealth physician significantly reduces duplication of services and thus patient wait times, patient frustration, and coding errors.
As a result of an integrated and shared database, all data captured by its 24/7 nurse triage and telehealth services can be accessed by both its FNOL intake team and our adjusters in real time. This is crucial to minimizing talk time, ensuring consistency, and maximizing the patient experience.
With telehealth becoming more popular in "mainstream healthcare", it is now an expectation for injured employees. Since patients expect a telehealth platform to provide these services, it’s essential they be delivered in a coordinated fashion with updated clinical notes available to the providers on follow up visits to maintain an equal or superior standard of care to brick and mortar outcomes.
Healthcare is evolving and at the core of its change is data and artificial intelligence (AI). At CorVel, it has utilized AI with the Edge, its completely modernized claims management portal. The Edge takes claims data from a variety of sources, including bill review and pharmacy, to identify potential risk for certain claims and push out telehealth visits to mitigate the risk.
The real cost of a "minor" injury can significantly change when viewed in the context of medications, psychosocial factors, testing, and opioids. Automatic identification of these proprietary factors can elevate this case to higher acuity and a telehealth visit can be pushed out to the patient for a collaborative and holistic approach to care that can be implemented while working in tandem with other treating physician already involved in the patient’s care.
Being able to integrate this data into its claims management platform has allowed CorVel to prevent many minor injuries from becoming expensive claims. Read Corvel's recent white paper, Breaking Down Barriers, to learn more about its approach to telehealth in performance-based networks ...
Last week the Department of Health and Human Services proposed a rule to end the industry-wide system of after-market discounts called rebates that pharmacy benefit managers (PBMs) receive from drugmakers, a practice that has been under increased scrutiny.
If finalized, the rule would change a system that has been in place for decades and that has been criticized for obfuscating the real price of prescription medicines.
Now CEOs from Novartis and Eli Lilly have backed US government proposals to cut out "middlemen" in the health system, who have inflated the costs of their medicines. Novartis’ Vas Narasimhan, and Eli Lilly’s David Ricks backed the proposals to end rebates paid to pharmacy benefit managers and health insurers that push up the prices of their diabetes medicines.
While the justification for the rebates is that they pay for improvements elsewhere in the US healthcare system, big pharma companies argue they don’t benefit as they have to push up prices to maintain profit margins. Critics also say that patients do not benefit either, as in the US they may have to cover part or all of their medicine costs, depending on their health insurance arrangements.
The administration of president Donald Trump in January proposed a rule that would end the rebate system, or pass savings to patients.
In an interview with Reuters, Novartis said it pays almost 50% of gross revenues in the US into rebates. The Novartis CEO added: "If you return those rebates to patients, so patients pay less out of pocket, I think that is something that makes a lot of sense and will correct a distortion in the marketplace."
But he also said efforts to link US prices to those in other countries are "destructive", adding that in some cases US prices are cheaper.
"There are situations where prices in the US are certainly higher than the prices in Europe, but there are many situations, as well, where they are very comparable,” he said. “It’s difficult to make blanket statements, like this is always happening."
Eli Lilly’s chief executive David Ricks, in a quarterly conference call with analysts, said the proposals are a "win for patients, lowering their out-of-pocket costs at the pharmacy with the greatest benefit realized by patients taking more highly-rebated products such as insulin."
Rival diabetes drug manufacturers Sanofi and Novo Nordisk have also backed the proposals to cut rebates ...
If finalized, the rule would change a system that has been in place for decades and that has been criticized for obfuscating the real price of prescription medicines.
Now CEOs from Novartis and Eli Lilly have backed US government proposals to cut out "middlemen" in the health system, who have inflated the costs of their medicines. Novartis’ Vas Narasimhan, and Eli Lilly’s David Ricks backed the proposals to end rebates paid to pharmacy benefit managers and health insurers that push up the prices of their diabetes medicines.
While the justification for the rebates is that they pay for improvements elsewhere in the US healthcare system, big pharma companies argue they don’t benefit as they have to push up prices to maintain profit margins. Critics also say that patients do not benefit either, as in the US they may have to cover part or all of their medicine costs, depending on their health insurance arrangements.
The administration of president Donald Trump in January proposed a rule that would end the rebate system, or pass savings to patients.
In an interview with Reuters, Novartis said it pays almost 50% of gross revenues in the US into rebates. The Novartis CEO added: "If you return those rebates to patients, so patients pay less out of pocket, I think that is something that makes a lot of sense and will correct a distortion in the marketplace."
But he also said efforts to link US prices to those in other countries are "destructive", adding that in some cases US prices are cheaper.
"There are situations where prices in the US are certainly higher than the prices in Europe, but there are many situations, as well, where they are very comparable,” he said. “It’s difficult to make blanket statements, like this is always happening."
Eli Lilly’s chief executive David Ricks, in a quarterly conference call with analysts, said the proposals are a "win for patients, lowering their out-of-pocket costs at the pharmacy with the greatest benefit realized by patients taking more highly-rebated products such as insulin."
Rival diabetes drug manufacturers Sanofi and Novo Nordisk have also backed the proposals to cut rebates ...
The San Francisco Chronicle reports that three women who say they were sexually assaulted by an Oakland doctor who reviewed their cases for workers’ compensation claims have sued the state of California and several insurance providers, alleging the agencies were aware of the doctor’s abuse and continued sending patients to him anyway.
The women, who are not identified in the complaint, were required to see Dr. John Warbritton after being injured while at work and filing for workers’ compensation with the state. They each said they reported the alleged abuse by Warbritton and were told they would have to continue seeing him for their claims to proceed.
Warbritton was a QME, and an orthopedic specialist in the East Bay since 1982 but lost his medical license in April 2017, after two of the women accused him of sexual misconduct. Warbritton voluntarily gave up his license.
At the time, Warbritton’s license was already suspended because of charges filed against him in 2016 for transporting child pornography images on his phone and a laptop while flying from Thailand to San Francisco. Warbritton pleaded guilty to the child pornography charges and was sentenced to seven years in prison in September 2018.
The new complaint, filed Jan. 22 in Alameda County Superior Court, alleges that Warbritton’s history of abuse toward female patients was so well known that the agencies that worked with him should be held accountable. The complaint is filed as a class action, and attorney Waukeen McCoy said he expects more women to join the case as it becomes public.
Three insurance providers also are named as defendants: Travelers Indemnity Company in Hartford, Conn.; JT2 Integrated Resources in Oakland; and York Risk Services Group in Jersey City, N.J. Officials from those companies did not respond to requests for comment on the complaint.
Warbritton was suspended as a QME in February 2018, 10 months after he lost his medical license and while the child pornography charges were under investigation.
All of the women said they reported being molested by Warbritton to their lawyers, and in some cases to other doctors treating them and to the insurance providers. One woman said in an interview that her attorney had heard similar complaints about Warbritton before.
In the complaint, the women describe multiple incidents of inappropriate language and touching. All of the women said he touched them on the breast, thigh or between the legs in an inappropriate way. They say Warbritton made comments about their bodies and their undergarments. They say he talked about his sex life and made references to having sex with employees when they were underage ...
The women, who are not identified in the complaint, were required to see Dr. John Warbritton after being injured while at work and filing for workers’ compensation with the state. They each said they reported the alleged abuse by Warbritton and were told they would have to continue seeing him for their claims to proceed.
Warbritton was a QME, and an orthopedic specialist in the East Bay since 1982 but lost his medical license in April 2017, after two of the women accused him of sexual misconduct. Warbritton voluntarily gave up his license.
At the time, Warbritton’s license was already suspended because of charges filed against him in 2016 for transporting child pornography images on his phone and a laptop while flying from Thailand to San Francisco. Warbritton pleaded guilty to the child pornography charges and was sentenced to seven years in prison in September 2018.
The new complaint, filed Jan. 22 in Alameda County Superior Court, alleges that Warbritton’s history of abuse toward female patients was so well known that the agencies that worked with him should be held accountable. The complaint is filed as a class action, and attorney Waukeen McCoy said he expects more women to join the case as it becomes public.
Three insurance providers also are named as defendants: Travelers Indemnity Company in Hartford, Conn.; JT2 Integrated Resources in Oakland; and York Risk Services Group in Jersey City, N.J. Officials from those companies did not respond to requests for comment on the complaint.
Warbritton was suspended as a QME in February 2018, 10 months after he lost his medical license and while the child pornography charges were under investigation.
All of the women said they reported being molested by Warbritton to their lawyers, and in some cases to other doctors treating them and to the insurance providers. One woman said in an interview that her attorney had heard similar complaints about Warbritton before.
In the complaint, the women describe multiple incidents of inappropriate language and touching. All of the women said he touched them on the breast, thigh or between the legs in an inappropriate way. They say Warbritton made comments about their bodies and their undergarments. They say he talked about his sex life and made references to having sex with employees when they were underage ...
The Division of Workers’ Compensation announced that medical providers who treat injured California workers can now have free online access to the State’s Medical Treatment Utilization Schedule (MTUS) guidelines.
"Medical providers in California should ensure that treatment decisions for injured workers are based on the best available evidence," said George Parisotto, DWC Administrative Director. "By providing these guidelines free of charge, we are removing barriers that we expect will improve quality of care and reduce friction in the utilization review process."
Licensed healthcare providers who treat California injured workers can use MDGuidelines: CA MTUS-ACOEM Edition to quickly search the latest evidence-based recommendations incorporated into the State’s MTUS. Providers who perform qualified medical evaluations, utilization review or independent medical review can also register to use the online tool free of charge.
The MTUS, a set of regulations based on the principles of evidence-based medicine, has adopted treatment guidelines developed by the American College of Occupational and Environmental Medicine (ACOEM). In most cases, medical treatment that is reasonable and necessary to cure or relieve an injured worker from the effects of injury means treatment that is based upon the ACOEM treatment guidelines. Providers must register in order to gain access to the site administered by the Reed Group. The site includes online training webinars and instructions. Users can email MTUS@reedgroup.com for more information.
The Division of Workers’ Compensation monitors the administration of workers’ compensation claims, and provides administrative and judicial services to assist in resolving disputes that arise in connection with claims for workers' compensation benefits ...
"Medical providers in California should ensure that treatment decisions for injured workers are based on the best available evidence," said George Parisotto, DWC Administrative Director. "By providing these guidelines free of charge, we are removing barriers that we expect will improve quality of care and reduce friction in the utilization review process."
Licensed healthcare providers who treat California injured workers can use MDGuidelines: CA MTUS-ACOEM Edition to quickly search the latest evidence-based recommendations incorporated into the State’s MTUS. Providers who perform qualified medical evaluations, utilization review or independent medical review can also register to use the online tool free of charge.
The MTUS, a set of regulations based on the principles of evidence-based medicine, has adopted treatment guidelines developed by the American College of Occupational and Environmental Medicine (ACOEM). In most cases, medical treatment that is reasonable and necessary to cure or relieve an injured worker from the effects of injury means treatment that is based upon the ACOEM treatment guidelines. Providers must register in order to gain access to the site administered by the Reed Group. The site includes online training webinars and instructions. Users can email MTUS@reedgroup.com for more information.
The Division of Workers’ Compensation monitors the administration of workers’ compensation claims, and provides administrative and judicial services to assist in resolving disputes that arise in connection with claims for workers' compensation benefits ...
In a unanimous opinion decided this January, the United States Supreme Court continued its expansive reading of the Federal Arbitration Act and arbitration provisions, rebuffing an effort by some to erect an additional hurdle that would interfere with an employers’ ability to enforce arbitration agreements. The case is Henry Schein Inc. v. Archer and White Sales Inc.
By rejecting the "wholly groundless" exception that courts had used to "spot-check" whether a claim of arbitrability was plausible before compelling arbitration, all lower federal courts must now compel arbitration in all cases where the parties have agreed to delegate the issue of "who decides what is arbitrable" to an arbitrator.
The Court’s decision - the first authored by Justice Brett Kavanaugh - extinguishes a conflict among various circuit courts of appeal and provides uniform guidance to employers who use arbitration agreements throughout the country. Employers should familiarize themselves with the ruling in order to ensure that their dispute resolution plans are fully compliant and in line with this decision.
In keeping with its recent interest in defining the contours of the FAA, the Court accepted the case to clear up the conflict among the circuit courts. A unanimous Court reiterated that it meant what it said in the 2009 Rent-A-Center, West Inc. v Jackson case and that the parties are certainly free to delegate issues of arbitrability to an arbitrator: "The FAA does not contain a ‘wholly groundless’ exception, and we are not at liberty to rewrite the statute passed by Congress and signed by the President." The Court went further and confirmed it saw no reason to "engraft our own exceptions onto the statutory text."
There’s a double dose of good news for employers in the Henry Schein ruling. First off, the decision clears up conflicting case law in the various circuits, and employers now know there is a uniform interpretation as to the enforceability of parties’ delegations of arbitrability to an arbitrator. Second, the decision sweeps aside a possible hurdle that might have otherwise existed in trying to enforce an arbitration agreement with employees.
However, liberal legislators are very unhappy with the broad rights to arbitrate agreements. Congress has once again proposed legislation that would seek to ban mandatory workplace arbitration of employment claims, despite a string of United States Supreme Court decisions upholding arbitration and class/collective action waivers as a lawful and appropriate mechanism to resolve workplace disputes.
H.R. 7109, the Restoring Justice for Workers Act, was introduced by Representative Jerrold Nadler, D-N.Y., and Representative Bobby Scott, D-Va., with 58 Democratic co-sponsors. Similar legislation is expected to be introduced in the Senate by Senator Patty Murray, D-Wash, with eight Democratic co-sponsors. The proposed legislation would overturn the U.S. Supreme Court’s decision in Epic Systems, and would amend the National Labor Relations Act to specifically prohibit class and collective action waivers under a new "Section 8(a)(6)." ...
By rejecting the "wholly groundless" exception that courts had used to "spot-check" whether a claim of arbitrability was plausible before compelling arbitration, all lower federal courts must now compel arbitration in all cases where the parties have agreed to delegate the issue of "who decides what is arbitrable" to an arbitrator.
The Court’s decision - the first authored by Justice Brett Kavanaugh - extinguishes a conflict among various circuit courts of appeal and provides uniform guidance to employers who use arbitration agreements throughout the country. Employers should familiarize themselves with the ruling in order to ensure that their dispute resolution plans are fully compliant and in line with this decision.
In keeping with its recent interest in defining the contours of the FAA, the Court accepted the case to clear up the conflict among the circuit courts. A unanimous Court reiterated that it meant what it said in the 2009 Rent-A-Center, West Inc. v Jackson case and that the parties are certainly free to delegate issues of arbitrability to an arbitrator: "The FAA does not contain a ‘wholly groundless’ exception, and we are not at liberty to rewrite the statute passed by Congress and signed by the President." The Court went further and confirmed it saw no reason to "engraft our own exceptions onto the statutory text."
There’s a double dose of good news for employers in the Henry Schein ruling. First off, the decision clears up conflicting case law in the various circuits, and employers now know there is a uniform interpretation as to the enforceability of parties’ delegations of arbitrability to an arbitrator. Second, the decision sweeps aside a possible hurdle that might have otherwise existed in trying to enforce an arbitration agreement with employees.
However, liberal legislators are very unhappy with the broad rights to arbitrate agreements. Congress has once again proposed legislation that would seek to ban mandatory workplace arbitration of employment claims, despite a string of United States Supreme Court decisions upholding arbitration and class/collective action waivers as a lawful and appropriate mechanism to resolve workplace disputes.
H.R. 7109, the Restoring Justice for Workers Act, was introduced by Representative Jerrold Nadler, D-N.Y., and Representative Bobby Scott, D-Va., with 58 Democratic co-sponsors. Similar legislation is expected to be introduced in the Senate by Senator Patty Murray, D-Wash, with eight Democratic co-sponsors. The proposed legislation would overturn the U.S. Supreme Court’s decision in Epic Systems, and would amend the National Labor Relations Act to specifically prohibit class and collective action waivers under a new "Section 8(a)(6)." ...
Decisions made by UR physicians are justified by evidence based medicine, which is derived from scientific medical studies. A new study will help rule out compounded pain creams in most cases.
The new study reported by Reuters Health and published in the Annals of Internal Medicine suggests that compounded pain creams are no better for chronic pain than topical treatments that contain no medicine at all..The current study focused on pain creams made from medicines that are often prescribed for pain in pill form such as muscle relaxants, anticonvulsants and non-steroidal anti-inflammatory (NSAID) drugs.
In this study, researchers randomly assigned 399 patients with different types of chronic pain to receive either a compounded cream containing an analgesic or a placebo cream without any medicine.
After one month, 36 percent of patients who used pain creams and 28 percent who got placebo creams reported less pain than they had at the start, a difference that was too small to rule out the possibility that it was due to chance.
"We know from other studies that some of the agents (lidocaine, non-steroidal anti-inflammatory drugs) may be effective for certain types of acute and chronic pain, so it is surprising that the difference here did not reach statistical significance in any of the pain types," said senior study author Dr. Steven Cohen, a pain researcher at Walter Reed National Military Medical Center in Bethesda, Maryland, and Johns Hopkins Medicine in Baltimore.
"This matters because compounded pain creams are much more expensive than prescribed (lidocaine, diclofenac) or over-the-counter (capsaicin) pain creams, but they didn’t provide meaningful benefit compared to placebo cream," Cohen said by email.
All of the patients in the current study were treated at pain clinics at Walter Reed and had one of three types of pain syndromes. Within these three groups, patients were randomly chosen to receive either a compounded cream or a placebo cream.
One third of the patients had neuropathic pain, which happens due to nerve damage and includes phantom limb pain experienced by amputees. Patients in this group who got compounded creams received anticonvulsants.
Another third had so-called nociceptive pain, the most common kind that is often due to an injury or infection, not nerve damage. Patients in this group who got compounded creams received muscle relaxants and NSAIDs.
And one third had "mixed" pain caused by a variety of things; many of the compounded creams were similar to drugs provided for nerve damage or nociceptive pain.
When patients rated their pain levels on a 10-point scale, with 10 being the most painful, the average pain reductions reported by both compounded-cream users and the placebo group after a month were nearly identical. The difference between groups was 0.1 points for neuropathic pain and 0.3 points for both nociceptive and mixed pain ...
The new study reported by Reuters Health and published in the Annals of Internal Medicine suggests that compounded pain creams are no better for chronic pain than topical treatments that contain no medicine at all..The current study focused on pain creams made from medicines that are often prescribed for pain in pill form such as muscle relaxants, anticonvulsants and non-steroidal anti-inflammatory (NSAID) drugs.
In this study, researchers randomly assigned 399 patients with different types of chronic pain to receive either a compounded cream containing an analgesic or a placebo cream without any medicine.
After one month, 36 percent of patients who used pain creams and 28 percent who got placebo creams reported less pain than they had at the start, a difference that was too small to rule out the possibility that it was due to chance.
"We know from other studies that some of the agents (lidocaine, non-steroidal anti-inflammatory drugs) may be effective for certain types of acute and chronic pain, so it is surprising that the difference here did not reach statistical significance in any of the pain types," said senior study author Dr. Steven Cohen, a pain researcher at Walter Reed National Military Medical Center in Bethesda, Maryland, and Johns Hopkins Medicine in Baltimore.
"This matters because compounded pain creams are much more expensive than prescribed (lidocaine, diclofenac) or over-the-counter (capsaicin) pain creams, but they didn’t provide meaningful benefit compared to placebo cream," Cohen said by email.
All of the patients in the current study were treated at pain clinics at Walter Reed and had one of three types of pain syndromes. Within these three groups, patients were randomly chosen to receive either a compounded cream or a placebo cream.
One third of the patients had neuropathic pain, which happens due to nerve damage and includes phantom limb pain experienced by amputees. Patients in this group who got compounded creams received anticonvulsants.
Another third had so-called nociceptive pain, the most common kind that is often due to an injury or infection, not nerve damage. Patients in this group who got compounded creams received muscle relaxants and NSAIDs.
And one third had "mixed" pain caused by a variety of things; many of the compounded creams were similar to drugs provided for nerve damage or nociceptive pain.
When patients rated their pain levels on a 10-point scale, with 10 being the most painful, the average pain reductions reported by both compounded-cream users and the placebo group after a month were nearly identical. The difference between groups was 0.1 points for neuropathic pain and 0.3 points for both nociceptive and mixed pain ...
The Orange County District Attorney’s Office obtained a $1.6 million judgment in the civil case against a plastics manufacturer for willfully endangering employees by maintaining hazardous work environment.
Beginning in 2007, Solus Industrial Innovations operated a plastics manufacturing plant in Rancho Santa Margarita. Solus willfully, knowingly, and intentionally maintained an unsafe and hazardous work environment for their employees.
When the business relocated certain operations from Pennsylvania to Orange County in 2007, the defendants intentionally discarded a commercial boiler to avoid the cost and permitting requirements of proper installation. Solus instead purchased and installed an inexpensive residential water heater, knowing that it was not equipped to function at a commercial level.
In March 2009, the water heater exploded, senselessly killing two employees.
The Division of Occupational Safety and Health investigated and "determined the explosion had been caused by a failed safety valve and the lack of ‘any other suitable safety features on the heater due to ‘manipulation and misuse’ because Solus used a residential water heater instead of a commercial one."
In March 2012, the OCDA filed a criminal suit against Solus’s plant manager and its maintenance supervisor for felony violations of Labor Code section 6425 subdivision (a) for knowingly operating an unsafe work environment, which resulted in the death of two employees.
The OCDA also filed the present civil action against Solus and its successor corporations.
The first cause of action "allege[d] that Solus’s failure to comply with workplace safety standards amount[ed] to an unlawful, unfair and fraudulent business practice under Business and Professions Code section 17200, and the district attorney request[ed] imposition of civil penalties as a consequence of that practice, in the amount of up to $2,500 per day, per employee, for the period from November 29, 2007, through March 19, 2009."
The second was a claim that Solus "made numerous false and misleading representations concerning its commitment to workplace safety and its compliance with all applicable workplace safety standards, and as a result of those false and misleading statements, Solus was allegedly able to retain employees and customers in violation of Business and Professions Code section 17500." The district attorney requested imposition of civil penalties in the same amount for the same period.
On Jan. 29, 2019, the defendants were ordered to pay $1.6 million, $1.5 million of which will go toward civil penalties and $100,000 for additional victim restitution.
Deputy District Attorney Kelly Ernby of the OCDA’s Environmental Protection Unit is the assigned prosecutor on the case ...
Beginning in 2007, Solus Industrial Innovations operated a plastics manufacturing plant in Rancho Santa Margarita. Solus willfully, knowingly, and intentionally maintained an unsafe and hazardous work environment for their employees.
When the business relocated certain operations from Pennsylvania to Orange County in 2007, the defendants intentionally discarded a commercial boiler to avoid the cost and permitting requirements of proper installation. Solus instead purchased and installed an inexpensive residential water heater, knowing that it was not equipped to function at a commercial level.
In March 2009, the water heater exploded, senselessly killing two employees.
The Division of Occupational Safety and Health investigated and "determined the explosion had been caused by a failed safety valve and the lack of ‘any other suitable safety features on the heater due to ‘manipulation and misuse’ because Solus used a residential water heater instead of a commercial one."
In March 2012, the OCDA filed a criminal suit against Solus’s plant manager and its maintenance supervisor for felony violations of Labor Code section 6425 subdivision (a) for knowingly operating an unsafe work environment, which resulted in the death of two employees.
The OCDA also filed the present civil action against Solus and its successor corporations.
The first cause of action "allege[d] that Solus’s failure to comply with workplace safety standards amount[ed] to an unlawful, unfair and fraudulent business practice under Business and Professions Code section 17200, and the district attorney request[ed] imposition of civil penalties as a consequence of that practice, in the amount of up to $2,500 per day, per employee, for the period from November 29, 2007, through March 19, 2009."
The second was a claim that Solus "made numerous false and misleading representations concerning its commitment to workplace safety and its compliance with all applicable workplace safety standards, and as a result of those false and misleading statements, Solus was allegedly able to retain employees and customers in violation of Business and Professions Code section 17500." The district attorney requested imposition of civil penalties in the same amount for the same period.
On Jan. 29, 2019, the defendants were ordered to pay $1.6 million, $1.5 million of which will go toward civil penalties and $100,000 for additional victim restitution.
Deputy District Attorney Kelly Ernby of the OCDA’s Environmental Protection Unit is the assigned prosecutor on the case ...
Both the U.S. House of Representatives and the Senate have begun holding hearings this year on the rising costs of medicines. The government is intensifying its scrutiny of the pharmaceutical industry and rising prescription drug prices, a top voter concern and a priority of President Donald Trump’s administration.
U.S. Senator Bernie Sanders sent a letter to Catalyst Pharmaceuticals asking it to justify its decision to charge $375,000 annually for a medication that for years has been available to patients for free.
The drug, Firdapse, is used to treat Lambert-Eaton Myasthenic Syndrome (LEMS), a rare neuromuscular disorder, according to the letter, made available to Reuters by the senator’s office. The disorder affects about one in 100,000 people in the United States.
In the letter dated Feb. 4, Sanders asked Catalyst to lay out the financial and non-financial factors that led the company to set the list price at $375,000, and say how many patients would suffer or die as a result of the price and how much it was paying to purchase or produce the drug.
Catalyst declined to comment on Sanders’ letter. Its shares fell nearly 8 percent to $2.31
For years, patients have been able to get the same drug for free from Jacobus Pharmaceuticals, a small New Jersey-based drug company, which offered it through a U.S. Food and Drug Administration (FDA) program called "compassionate use." The program allows patients with rare diseases and conditions access to experimental drugs outside of a clinical trial when there is no viable alternative.
Florida-based Catalyst received FDA approval of Firdapse in November, along with exclusive rights to market the medication for several years. The company, which bought rights to the drug from a company called BioMarin in 2012, develops and commercializes drugs for rare diseases.
BioMarin and FDA did not immediately respond to requests for comment.
In December, Catalyst announced it would price Firdapse at $375,000 a year. "Catalyst’s decision to set the annual list price at $375,000 is not only a blatant fleecing of American taxpayers, but is also an immoral exploitation of patients who need this medication," Sanders wrote in his letter.
Democratic Representative Elijah Cummings, chairman of the House Oversight Committee, in January wrote to 12 pharmaceutical firms asking for detailed information on how they set drug prices.
Democratic Representatives Frank Pallone and Diana DeGette wrote to the heads of Eli Lilly and Co, Novo Nordisk and Sanofi SA, the long-time leading manufacturers of insulin, requesting information on why the drug’s price has skyrocketed in recent years.
...
U.S. Senator Bernie Sanders sent a letter to Catalyst Pharmaceuticals asking it to justify its decision to charge $375,000 annually for a medication that for years has been available to patients for free.
The drug, Firdapse, is used to treat Lambert-Eaton Myasthenic Syndrome (LEMS), a rare neuromuscular disorder, according to the letter, made available to Reuters by the senator’s office. The disorder affects about one in 100,000 people in the United States.
In the letter dated Feb. 4, Sanders asked Catalyst to lay out the financial and non-financial factors that led the company to set the list price at $375,000, and say how many patients would suffer or die as a result of the price and how much it was paying to purchase or produce the drug.
Catalyst declined to comment on Sanders’ letter. Its shares fell nearly 8 percent to $2.31
For years, patients have been able to get the same drug for free from Jacobus Pharmaceuticals, a small New Jersey-based drug company, which offered it through a U.S. Food and Drug Administration (FDA) program called "compassionate use." The program allows patients with rare diseases and conditions access to experimental drugs outside of a clinical trial when there is no viable alternative.
Florida-based Catalyst received FDA approval of Firdapse in November, along with exclusive rights to market the medication for several years. The company, which bought rights to the drug from a company called BioMarin in 2012, develops and commercializes drugs for rare diseases.
BioMarin and FDA did not immediately respond to requests for comment.
In December, Catalyst announced it would price Firdapse at $375,000 a year. "Catalyst’s decision to set the annual list price at $375,000 is not only a blatant fleecing of American taxpayers, but is also an immoral exploitation of patients who need this medication," Sanders wrote in his letter.
Democratic Representative Elijah Cummings, chairman of the House Oversight Committee, in January wrote to 12 pharmaceutical firms asking for detailed information on how they set drug prices.
Democratic Representatives Frank Pallone and Diana DeGette wrote to the heads of Eli Lilly and Co, Novo Nordisk and Sanofi SA, the long-time leading manufacturers of insulin, requesting information on why the drug’s price has skyrocketed in recent years.
...
A Ventura County man has been sentenced to 168 months in federal prison for participating in a massive fraud scheme that used dozens of nonexistent companies to collect nearly $5 million in unemployment benefits for phony employees who never performed any work at the fake entities.
Jack Benjamin Hessiani, a.k.a. "Jack Herrera," 40, of Camarillo, was sentenced today by United States District Judge John A. Kronstadt. Hessiani pleaded guilty in August 2018 to one count of mail fraud.
According to court documents, Hessiani created numerous fictitious businesses for the sole purpose of defrauding the Employment Development Department (EDD), the state agency that administers the federal unemployment insurance program in California.
After he and his co-schemers filed documents with EDD that showed made-up earnings for the fictitious workers, Hessiani and the co-schemers submitted claims for unemployment insurance benefits for laid-off "employees." In fact, many of the "employees" were people who had agreed to provide their personal identifying information in exchange for a portion of the unemployment insurance benefits. Some of the benefit portions would go to drug users who likely used the funds to enable future drug purchases, while others were poor students who later faced criminal exposure as a result of the actions of Hessiani and his co-schemers, court papers state.
The unemployment benefits were sent in the form of checks and debit cards to "mail drops" that Hessiani and the co-schemers established in the names of other individuals, according to court documents. After EDD began issuing unemployment benefits, Hessiani ensured that documents were filed that falsely stated that the laid-off "workers" were still unemployed, and he later sought "extended benefits" to obtain unemployment insurance benefits for the sham workers beyond the normal six-month period. These extended benefits were ultimately funded by the United States Treasury.
According to court documents, Hessiani and his co-schemers submitted approximately 725 unemployment insurance claims - including 521 original claims and 204 claims for extended benefits - in the names of 384 "employees." The investigation identified 43 fictitious companies based in Ventura County that were used to further the scheme, which caused EDD to suffer actual losses of $3.96 million and the United States Treasury to suffer actual losses of approximately $900,000. Hessiani enlarged his scheme by inducing the people whose names were already being used to obtain fraudulent benefits to “recruit” others who would be identified as additional false employees at the fictitious companies, and he paid referral fees for each new fake worker brought into the scheme.
Three other defendants in the case have pleaded guilty to criminal charges and are pending sentencing. They are Hessiani’s brother, James Manuel Herrera, 30, of Camarillo; Eduardo Josue Garcia, 27, of Camarillo; and Daniel Ayala-Mora, 29, formerly of Camarillo ...
Jack Benjamin Hessiani, a.k.a. "Jack Herrera," 40, of Camarillo, was sentenced today by United States District Judge John A. Kronstadt. Hessiani pleaded guilty in August 2018 to one count of mail fraud.
According to court documents, Hessiani created numerous fictitious businesses for the sole purpose of defrauding the Employment Development Department (EDD), the state agency that administers the federal unemployment insurance program in California.
After he and his co-schemers filed documents with EDD that showed made-up earnings for the fictitious workers, Hessiani and the co-schemers submitted claims for unemployment insurance benefits for laid-off "employees." In fact, many of the "employees" were people who had agreed to provide their personal identifying information in exchange for a portion of the unemployment insurance benefits. Some of the benefit portions would go to drug users who likely used the funds to enable future drug purchases, while others were poor students who later faced criminal exposure as a result of the actions of Hessiani and his co-schemers, court papers state.
The unemployment benefits were sent in the form of checks and debit cards to "mail drops" that Hessiani and the co-schemers established in the names of other individuals, according to court documents. After EDD began issuing unemployment benefits, Hessiani ensured that documents were filed that falsely stated that the laid-off "workers" were still unemployed, and he later sought "extended benefits" to obtain unemployment insurance benefits for the sham workers beyond the normal six-month period. These extended benefits were ultimately funded by the United States Treasury.
According to court documents, Hessiani and his co-schemers submitted approximately 725 unemployment insurance claims - including 521 original claims and 204 claims for extended benefits - in the names of 384 "employees." The investigation identified 43 fictitious companies based in Ventura County that were used to further the scheme, which caused EDD to suffer actual losses of $3.96 million and the United States Treasury to suffer actual losses of approximately $900,000. Hessiani enlarged his scheme by inducing the people whose names were already being used to obtain fraudulent benefits to “recruit” others who would be identified as additional false employees at the fictitious companies, and he paid referral fees for each new fake worker brought into the scheme.
Three other defendants in the case have pleaded guilty to criminal charges and are pending sentencing. They are Hessiani’s brother, James Manuel Herrera, 30, of Camarillo; Eduardo Josue Garcia, 27, of Camarillo; and Daniel Ayala-Mora, 29, formerly of Camarillo ...
Reuters Health reports that the Department of Health and Human Services proposed a rule to end the industry-wide system of after-market discounts called rebates that pharmacy benefit managers (PBMs) receive from drugmakers, a practice that has been under increased scrutiny.
If finalized, the rule would change a system that has been in place for decades and that has been criticized for obfuscating the real price of prescription medicines.
The administration of U.S. President Donald Trump has been promising to lower the cost of prescription drugs for consumers, who have seen their out-of-pocket expenses rise each year with higher list prices of pharmaceuticals.
The proposed rule from HHS would apply to companies like Cigna Corp’s Express Scripts and CVS Health Corp, as well as companies like Humana Inc that manage Medicare prescription drug benefits, and Medicaid managed care organizations.
"This proposal has the potential to be the most significant change in how Americans’ drugs are priced at the pharmacy counter," HHS Secretary Alex Azar said in a statement.
Eliminating rebates on prescription drug purchases is a key element of the Trump administration’s plan to lower prescription medicine costs. Trump made lowering drug prices a major priority during his 2016 presidential campaign.
PBMs administer drug benefits for employers and health plans and also run large mail-order pharmacies. Drugmakers say they are under pressure to provide rebates to the few PBMs that dominate the market in order to gain patient access to their products by having them included on preferred coverage lists.
Drugmakers say that PBMs do not pass on enough of those savings to patients - a contention the PBMs dispute - and that the rebates force them to raise the list price of medicines over time to preserve their profits. They argue that the net revenue they actually see has little relation to list prices.
The Pharmaceutical Care Management Association, the main PBM trade group, said eliminating rebates would drive up drug costs and out-of-pocket expenses for consumers. The group said drugmakers alone set prices.
But the Pharmaceutical Research and Manufacturers of America (PhRMA), the main U.S. lobbying group for drugmakers, said the proposal, if enacted, would "fix the misaligned incentives in the system."
The HHS proposal would allow rebates on prescription drugs to be offered directly to patients, and allow PBMs to establish fixed fee service arrangements with drugmakers that could replace lost revenue from rebates.
An anti-kickback law makes it illegal to pay an incentive for drugs or services that Medicare, Medicaid or other federal healthcare programs cover. The government has been considering removing the safe harbor protection for rebates from the anti-kickback law since last year ...
If finalized, the rule would change a system that has been in place for decades and that has been criticized for obfuscating the real price of prescription medicines.
The administration of U.S. President Donald Trump has been promising to lower the cost of prescription drugs for consumers, who have seen their out-of-pocket expenses rise each year with higher list prices of pharmaceuticals.
The proposed rule from HHS would apply to companies like Cigna Corp’s Express Scripts and CVS Health Corp, as well as companies like Humana Inc that manage Medicare prescription drug benefits, and Medicaid managed care organizations.
"This proposal has the potential to be the most significant change in how Americans’ drugs are priced at the pharmacy counter," HHS Secretary Alex Azar said in a statement.
Eliminating rebates on prescription drug purchases is a key element of the Trump administration’s plan to lower prescription medicine costs. Trump made lowering drug prices a major priority during his 2016 presidential campaign.
PBMs administer drug benefits for employers and health plans and also run large mail-order pharmacies. Drugmakers say they are under pressure to provide rebates to the few PBMs that dominate the market in order to gain patient access to their products by having them included on preferred coverage lists.
Drugmakers say that PBMs do not pass on enough of those savings to patients - a contention the PBMs dispute - and that the rebates force them to raise the list price of medicines over time to preserve their profits. They argue that the net revenue they actually see has little relation to list prices.
The Pharmaceutical Care Management Association, the main PBM trade group, said eliminating rebates would drive up drug costs and out-of-pocket expenses for consumers. The group said drugmakers alone set prices.
But the Pharmaceutical Research and Manufacturers of America (PhRMA), the main U.S. lobbying group for drugmakers, said the proposal, if enacted, would "fix the misaligned incentives in the system."
The HHS proposal would allow rebates on prescription drugs to be offered directly to patients, and allow PBMs to establish fixed fee service arrangements with drugmakers that could replace lost revenue from rebates.
An anti-kickback law makes it illegal to pay an incentive for drugs or services that Medicare, Medicaid or other federal healthcare programs cover. The government has been considering removing the safe harbor protection for rebates from the anti-kickback law since last year ...
The Division of Workers’ Compensation has posted the 2018 DWC Audit Unit annual report on its website. The annual report provides information on how claims administrators audited by the DWC performed and includes the Administrative Director’s ranking report for audits conducted in calendar year 2017.
The 2018 Audit Unit annual report details the results of audits conducted in 2017 and provides the name and location of each insurer, self-insured employer, and third-party administrator audited during that time.
The DWC Audit & Enforcement Unit completed 41 profile audit reviews (PAR audits). Of the PAR audits, 40 were routinely selected and there was 1 target audit, which would have been conducted based upon failure of a prior audit. The total number of PAR audit subjects included 5 insurance companies, 11 self-administered / self-insured employers, 21 third-party administrators (TPA), and 4 insurance companies / third-party administrators combined claims adjustinglocations.
Thirty-seven audit subjects (90%) met or exceeded the PAR 2017 performance standard and therefore had no penalty citations assessed in accordance with Labor Code section 129.5(c) and CCR, Title 8, Section 10107.1(c)(4). These audit subjects were, however, ordered to pay all unpaid compensation.
Four audit subjects (10%) failed to meet or exceed the PAR standard and their audits expanded into a full compliance audit of indemnity claims (FCA stage 1). One of these audit subjects (25% of those failing to meet or exceed the PAR standard) met or exceeded the FCA 2017 performance standard and therefore had penalty citations assessed for unpaid and late payment of indemnity in accordance pursuant to Labor Code section 129.5(c)(2) and CCR, Title 8, Sections 10107.1(d).
The remaining three of the four audit subjects (75% of those failing to meet or exceed the PAR standard) failed to meet or exceed the FCA 2017 performance standard and their audits expanded into full compliance audit of indemnity claims (FCA stage 2) and added a sample of denied claims to be audited. These audit subjects were assessed administrative penalties for all penalty citations in accordance with Labor Code section 129.5(c) and CCR, Title 8, Section 10107.1(d) and 10107.1(e).
The audit findings, by law, must detail the number of files audited, the number and type of violations cited, and the amount of an undisputed compensation found due and unpaid to the injured worker. The audit findings presented in this report are statistical and do not identify any individual injured worker. The Labor Code provides that contents of the claim files and the Audit Unit working papers are confidential.
The DWC Administrative Director's 2017 Audit Ranking Report is part of this annual report. The Ranking Report provides the performance ratings for the 41 audit subjects listed in order, from the best to worst performer.
Congratulations to Zenith Insurance Company - Pleasanton for having the best score in the Ranking Report. The ranking of the remaining 40 organizations are listed by name on the Ranking Report.
Performance of insurers, self-insured employers, and third party administrators subject to profile audit review and full compliance audit is rated in accordance with the performance standards set annually by the Administrative Director. The DWC Administrative Director’s 2018 Audit Ranking Report lists, in ascending order by performance rating, the administrators audited in calendar year 2017 ...
The 2018 Audit Unit annual report details the results of audits conducted in 2017 and provides the name and location of each insurer, self-insured employer, and third-party administrator audited during that time.
The DWC Audit & Enforcement Unit completed 41 profile audit reviews (PAR audits). Of the PAR audits, 40 were routinely selected and there was 1 target audit, which would have been conducted based upon failure of a prior audit. The total number of PAR audit subjects included 5 insurance companies, 11 self-administered / self-insured employers, 21 third-party administrators (TPA), and 4 insurance companies / third-party administrators combined claims adjustinglocations.
Thirty-seven audit subjects (90%) met or exceeded the PAR 2017 performance standard and therefore had no penalty citations assessed in accordance with Labor Code section 129.5(c) and CCR, Title 8, Section 10107.1(c)(4). These audit subjects were, however, ordered to pay all unpaid compensation.
Four audit subjects (10%) failed to meet or exceed the PAR standard and their audits expanded into a full compliance audit of indemnity claims (FCA stage 1). One of these audit subjects (25% of those failing to meet or exceed the PAR standard) met or exceeded the FCA 2017 performance standard and therefore had penalty citations assessed for unpaid and late payment of indemnity in accordance pursuant to Labor Code section 129.5(c)(2) and CCR, Title 8, Sections 10107.1(d).
The remaining three of the four audit subjects (75% of those failing to meet or exceed the PAR standard) failed to meet or exceed the FCA 2017 performance standard and their audits expanded into full compliance audit of indemnity claims (FCA stage 2) and added a sample of denied claims to be audited. These audit subjects were assessed administrative penalties for all penalty citations in accordance with Labor Code section 129.5(c) and CCR, Title 8, Section 10107.1(d) and 10107.1(e).
The audit findings, by law, must detail the number of files audited, the number and type of violations cited, and the amount of an undisputed compensation found due and unpaid to the injured worker. The audit findings presented in this report are statistical and do not identify any individual injured worker. The Labor Code provides that contents of the claim files and the Audit Unit working papers are confidential.
The DWC Administrative Director's 2017 Audit Ranking Report is part of this annual report. The Ranking Report provides the performance ratings for the 41 audit subjects listed in order, from the best to worst performer.
Congratulations to Zenith Insurance Company - Pleasanton for having the best score in the Ranking Report. The ranking of the remaining 40 organizations are listed by name on the Ranking Report.
Performance of insurers, self-insured employers, and third party administrators subject to profile audit review and full compliance audit is rated in accordance with the performance standards set annually by the Administrative Director. The DWC Administrative Director’s 2018 Audit Ranking Report lists, in ascending order by performance rating, the administrators audited in calendar year 2017 ...
A new report published by Fitch Ratings concludes that the the workers' compensation segment of the property/casualty (P/C) insurance business is a prime target for technology investment to maintain competitiveness and bolster performance.
"As the largest U.S. commercial lines segment, workers' compensation is a focal point for insurers' efforts to leverage new technologies to gain operating efficiency, reduce workplace injuries and improve claims outcomes," says Jim Auden, Managing Director at Fitch. "Insurers that lag in innovation face the risk of adverse selection in their underwriting portfolio and expense disadvantages--changes that make them more likely consolidation targets given recent market M&A activity."
Technology enhancements are a consistent theme in the insurance industry's history. Expanded ability to process, analyze and store large and more diverse volumes of data is creating greater modeling sophistication in risk segmentation and pricing. Data analytics in claims can help speed resolution, uncover fraudulent activity and predict high severity incidents. Further opportunities to improve modeling and risk management capabilities are emerging from the utilization of artificial intelligence (AI) and machine learning to more readily incorporate new information garnered from wearables, sensors and other connected devices into decision making.
Although most workers' compensation underwriters are operating from a position of strength as 2018 represents a rare fourth-consecutive year of market underwriting profits, the business has also experienced historical instances of very large losses fueled by inadequate pricing and claims volatility. Success of insurers' technology initiatives is measured in part on generating steadier results over the long term.
Outside insurtech firms, mainly funded by venture capital and focused on providing technology solutions in many operational areas and across multiple business segments, represent a nimble force accelerating the pace of change.
In response, insurers are more actively investing in or creating strategic partnerships with insurtech firms to gain insight or are developing their own innovation labs to foster creative development. Insurers are seeing competition emerge from start-up underwriters and managing general agencies (MGA's) with direct, data driven on-line platforms including Next Insurance in small commercial lines and Pie Insurance in workers' compensation. Uncertainty remains as to whether these newer entrants can build a profitable business with sufficient operating scale.
...
"As the largest U.S. commercial lines segment, workers' compensation is a focal point for insurers' efforts to leverage new technologies to gain operating efficiency, reduce workplace injuries and improve claims outcomes," says Jim Auden, Managing Director at Fitch. "Insurers that lag in innovation face the risk of adverse selection in their underwriting portfolio and expense disadvantages--changes that make them more likely consolidation targets given recent market M&A activity."
Technology enhancements are a consistent theme in the insurance industry's history. Expanded ability to process, analyze and store large and more diverse volumes of data is creating greater modeling sophistication in risk segmentation and pricing. Data analytics in claims can help speed resolution, uncover fraudulent activity and predict high severity incidents. Further opportunities to improve modeling and risk management capabilities are emerging from the utilization of artificial intelligence (AI) and machine learning to more readily incorporate new information garnered from wearables, sensors and other connected devices into decision making.
Although most workers' compensation underwriters are operating from a position of strength as 2018 represents a rare fourth-consecutive year of market underwriting profits, the business has also experienced historical instances of very large losses fueled by inadequate pricing and claims volatility. Success of insurers' technology initiatives is measured in part on generating steadier results over the long term.
Outside insurtech firms, mainly funded by venture capital and focused on providing technology solutions in many operational areas and across multiple business segments, represent a nimble force accelerating the pace of change.
In response, insurers are more actively investing in or creating strategic partnerships with insurtech firms to gain insight or are developing their own innovation labs to foster creative development. Insurers are seeing competition emerge from start-up underwriters and managing general agencies (MGA's) with direct, data driven on-line platforms including Next Insurance in small commercial lines and Pie Insurance in workers' compensation. Uncertainty remains as to whether these newer entrants can build a profitable business with sufficient operating scale.
...
Sunrise Lee, an ex-stripper who became a regional sales director at Insys Therapeutics, gave a doctor a lap dance at a Chicago club as part of her marketing plan to convince the doctor to prescribe its addictive fentanyl spray.
Reuters reports that the testimony in federal court in Boston came in the first criminal trial of painkiller manufacturer executives over conduct that authorities say contributed to a U.S. opioid abuse epidemic that has killed tens of thousands of people a year.
Former Insys sales representative Holly Brown told jurors the incident with her boss, Sunrise Lee, took place after Insys began rewarding the doctor for prescribing its opioid product by paying him to speak at educational events about the drug.
That Illinois doctor, Paul Madison, is one of several whom prosecutors say Lee and four other former Insys executives and managers including wealthy founder and ex-chairman John Kapoor conspired to bribe to boost sales of the spray, Subsys.
Lee, Kapoor, Michael Gurry, Richard Simon and Joseph Rowan deny wrongdoing and have pleaded not guilty to racketeering conspiracy.
Drugmakers often retain doctors to speak at events with other clinicians about the benefits of their drugs, and defense lawyers argue the events were legal compensation for the doctors’ educational work.
Yet Brown said Madison’s events, held at a Chicago restaurant Kapoor owned, were attended by his friends instead of clinicians.
"The idea was these weren’t really meant to be educational programs but were meant to be rewards to physicians." Brown said.
After one dinner in mid-2012, Brown said she, Lee and Madison went to a club, where she witnessed Lee "sitting on his lap, kind of bouncing around."
Brown testified that at the time, Madison ran a "notorious" medical practice, which in a 2012 email shown to jurors she described as a "shady pill mill."
Prosecutors say Insys paid Madison at least $70,800 in speaker fees.
Madison was convicted in November of unrelated charges that he defrauded insurers into paying for unperformed chiropractic procedures. His lawyer did not respond to Reuters requests for comment.
...
Reuters reports that the testimony in federal court in Boston came in the first criminal trial of painkiller manufacturer executives over conduct that authorities say contributed to a U.S. opioid abuse epidemic that has killed tens of thousands of people a year.
Former Insys sales representative Holly Brown told jurors the incident with her boss, Sunrise Lee, took place after Insys began rewarding the doctor for prescribing its opioid product by paying him to speak at educational events about the drug.
That Illinois doctor, Paul Madison, is one of several whom prosecutors say Lee and four other former Insys executives and managers including wealthy founder and ex-chairman John Kapoor conspired to bribe to boost sales of the spray, Subsys.
Lee, Kapoor, Michael Gurry, Richard Simon and Joseph Rowan deny wrongdoing and have pleaded not guilty to racketeering conspiracy.
Drugmakers often retain doctors to speak at events with other clinicians about the benefits of their drugs, and defense lawyers argue the events were legal compensation for the doctors’ educational work.
Yet Brown said Madison’s events, held at a Chicago restaurant Kapoor owned, were attended by his friends instead of clinicians.
"The idea was these weren’t really meant to be educational programs but were meant to be rewards to physicians." Brown said.
After one dinner in mid-2012, Brown said she, Lee and Madison went to a club, where she witnessed Lee "sitting on his lap, kind of bouncing around."
Brown testified that at the time, Madison ran a "notorious" medical practice, which in a 2012 email shown to jurors she described as a "shady pill mill."
Prosecutors say Insys paid Madison at least $70,800 in speaker fees.
Madison was convicted in November of unrelated charges that he defrauded insurers into paying for unperformed chiropractic procedures. His lawyer did not respond to Reuters requests for comment.
...
Powerful committees in the U.S. Congress held hearings on Tuesday on insulin affordability and high prescription drug prices, an issue both chambers have said is a top priority for the year.
The House Oversight Committee, chaired by Democratic Representative Elijah Cummings, and the Senate Finance Committee, chaired by Republican Senator Chuck Grassley, brought in patient advocates and health policy experts to discuss the burden of high drug costs on consumers and sky-rocketing prices.
Both committees also focused on insulin, which those with type 1 diabetes and some with type 2 diabetes depend on.
High prescription drug costs have consistently polled as a top voter concern and have been a top priority of the administration of U.S. President Donald Trump.
It remains unclear whether Democrats, who control the U.S. House of Representatives, and Republicans, who control the U.S. Senate, will find a bipartisan way to address rising drug costs.
The annual cost of insulin for treating a type 1 diabetes patient in the United States nearly doubled from 2012 to 2016 to $5,705 from $2,864, according to a recent study.
Cummings earlier this month sent letters to 12 pharmaceutical companies asking for detailed information on their pricing practices. He focused on medicines whose costs rose the most over the last five years, including several diabetes medications.
Democrats in the Senate and House earlier this month, including Cummings, also introduced a series of bills aimed at bringing down drug costs. No Republicans have signed onto the legislation.
Ron Wyden, the ranking member of the Senate Finance Committee, said in a statement that the committee invited the heads of several large drug companies to testify on Tuesday, but none were willing to come ...
The House Oversight Committee, chaired by Democratic Representative Elijah Cummings, and the Senate Finance Committee, chaired by Republican Senator Chuck Grassley, brought in patient advocates and health policy experts to discuss the burden of high drug costs on consumers and sky-rocketing prices.
Both committees also focused on insulin, which those with type 1 diabetes and some with type 2 diabetes depend on.
High prescription drug costs have consistently polled as a top voter concern and have been a top priority of the administration of U.S. President Donald Trump.
It remains unclear whether Democrats, who control the U.S. House of Representatives, and Republicans, who control the U.S. Senate, will find a bipartisan way to address rising drug costs.
The annual cost of insulin for treating a type 1 diabetes patient in the United States nearly doubled from 2012 to 2016 to $5,705 from $2,864, according to a recent study.
Cummings earlier this month sent letters to 12 pharmaceutical companies asking for detailed information on their pricing practices. He focused on medicines whose costs rose the most over the last five years, including several diabetes medications.
Democrats in the Senate and House earlier this month, including Cummings, also introduced a series of bills aimed at bringing down drug costs. No Republicans have signed onto the legislation.
Ron Wyden, the ranking member of the Senate Finance Committee, said in a statement that the committee invited the heads of several large drug companies to testify on Tuesday, but none were willing to come ...
In three separate California state civil lawsuits, performers in the pornographic film industry sued Cybernet Entertainment, LLC for negligence, negligence per se, breach of the implied covenant of good faith and fair dealing, negligent supervision, and negligent hiring and/or retention.
They alleged, in essence, that Cybernet did not take adequate steps to protect its performers and prevent the spread of sexually transmitted diseases and HIV during pornographic shoots, causing injury. The plaintiffs alleged that Cybernet did not provide adequate personal protective equipment, such as condoms, to performers; did not test certain performers; and otherwise violated California regulations meant to prevent the spread of STDs and HIV in pornographic shoots.
The state-court plaintiffs’ causes of action for intentional/fraudulent misrepresentation and conspiracy to commit fraud alleged that Cybernet and others made various false representations concerning the safety of Cybernet shoots (e.g., that protection could be used on request) to the plaintiffs to induce them to participate in those shoots.
Cybernet Entertainment filed a third-party complaint in federal court against State Compensation Insurance Fund seeking a declaration that State Fund had a duty to defend Cybernet in the three state court actions filed against Cybernet under a Workers’ Compensation and Employer’s Liability Insurance Policy.
The district court held that State Fund did not have a duty to defend Cybernet. Cybernet appealed. The ruling was affirmed in the unpublished case of Seneca Insurance Company Inc. v State Compensation Insurance Fund.
The court considered whether two policy exclusions bar coverage under the Employer’s Liability portion of the Policy for the claims asserted in the State Court Actions.
Exclusion 4 provides that coverage under the Employer’s Liability portion of the Policy does not extend to "any obligation imposed by a workers’ compensation . . . law." Exclusion 5 provides that coverage under the Employer’s Liability portion of the Policy does not extend to "damages or bodily injury intentionally caused or aggravated by" Cybernet.
The acts and injuries alleged in the negligence causes of action fall within the compensation bargain because the gravamen of each is that Cybernet did not maintain a safe workplace. The remedy for such workplace-safety claims is workers’ compensation.
Exclusion 5 bars coverage for the intentional tort claims.
Because either Exclusion 4 or Exclusion 5 bars coverage under the Employer’s Liability portion of the Policy for each of the causes of action alleged against Cybernet in the state court actions, State Fund did not have a duty to defend Cybernet in those actions ...
They alleged, in essence, that Cybernet did not take adequate steps to protect its performers and prevent the spread of sexually transmitted diseases and HIV during pornographic shoots, causing injury. The plaintiffs alleged that Cybernet did not provide adequate personal protective equipment, such as condoms, to performers; did not test certain performers; and otherwise violated California regulations meant to prevent the spread of STDs and HIV in pornographic shoots.
The state-court plaintiffs’ causes of action for intentional/fraudulent misrepresentation and conspiracy to commit fraud alleged that Cybernet and others made various false representations concerning the safety of Cybernet shoots (e.g., that protection could be used on request) to the plaintiffs to induce them to participate in those shoots.
Cybernet Entertainment filed a third-party complaint in federal court against State Compensation Insurance Fund seeking a declaration that State Fund had a duty to defend Cybernet in the three state court actions filed against Cybernet under a Workers’ Compensation and Employer’s Liability Insurance Policy.
The district court held that State Fund did not have a duty to defend Cybernet. Cybernet appealed. The ruling was affirmed in the unpublished case of Seneca Insurance Company Inc. v State Compensation Insurance Fund.
The court considered whether two policy exclusions bar coverage under the Employer’s Liability portion of the Policy for the claims asserted in the State Court Actions.
Exclusion 4 provides that coverage under the Employer’s Liability portion of the Policy does not extend to "any obligation imposed by a workers’ compensation . . . law." Exclusion 5 provides that coverage under the Employer’s Liability portion of the Policy does not extend to "damages or bodily injury intentionally caused or aggravated by" Cybernet.
The acts and injuries alleged in the negligence causes of action fall within the compensation bargain because the gravamen of each is that Cybernet did not maintain a safe workplace. The remedy for such workplace-safety claims is workers’ compensation.
Exclusion 5 bars coverage for the intentional tort claims.
Because either Exclusion 4 or Exclusion 5 bars coverage under the Employer’s Liability portion of the Policy for each of the causes of action alleged against Cybernet in the state court actions, State Fund did not have a duty to defend Cybernet in those actions ...
Aetna, a CVS Health business, announced the launch of Attain, a unique health experience designed by Aetna in collaboration with Apple.
Using an Apple Watch, the Attain app will provide Aetna members personalized goals, track their daily activity levels, recommend healthy actions, and ultimately reward them for taking these actions to improve their well-being. Reward opportunities include the ability for eligible users to earn their Apple Watch through their participation in the program.
This launch builds on the 2016 collaboration between Aetna and Apple in which 90 percent of participants reported a health benefit from their use of Apple Watch.
The Attain app claims to be the first of its kind - designed specifically to offer users a personalized experience that combines their health history with the power of the Apple Watch to help them achieve better health and well-being.
After users have joined Attain, they will have the additional option to share their Attain program data and health history with Apple, enabling Apple and Aetna to collaborate, and over time, continue to improve the Attain experience. Through analytics and machine learning, the collaboration will lead to new features for Attain, offering more personalized recommendations designed to give greater context and decrease barriers to health care.
The developers say user privacy and data security are at the heart of Attain. A completely voluntary program, members determine what information they want to share and can discontinue using Attain at any time. All Attain health data is encrypted on the device, in transit, and on Aetna and Apple's servers, where it will be stored in a highly secure environment using industry-leading practices fully in compliance with HIPAA.
Information from this program will not be used for underwriting, premium or coverage decisions.
Health history data is tightly regulated by the U.S. government, and Apple and Aetna had to enter into what is known as a business associate agreement in order for Aetna to share it with the Apple. Access to regulated data is necessary for some of the functions of the app, such as recommending age-appropriate exercise or a lower-cost option for scheduled lab tests or MRI imaging tests.
The Attain rewards platform builds off a program developed by Vitality Group, a model that has demonstrated that incentives linked to the Apple Watch are associated with increased, sustained activity. A recent study from RAND corporation found an average 34 percent increase in activity levels for participants using the rewards platform incorporated in Attain with Apple Watch, compared to those without these incentives - leading to an additional 4.8 days of activity per month.
Interested Aetna members are encouraged to sign up at www.AttainbyAetna.com to be notified when the App becomes available for download ...
Using an Apple Watch, the Attain app will provide Aetna members personalized goals, track their daily activity levels, recommend healthy actions, and ultimately reward them for taking these actions to improve their well-being. Reward opportunities include the ability for eligible users to earn their Apple Watch through their participation in the program.
This launch builds on the 2016 collaboration between Aetna and Apple in which 90 percent of participants reported a health benefit from their use of Apple Watch.
The Attain app claims to be the first of its kind - designed specifically to offer users a personalized experience that combines their health history with the power of the Apple Watch to help them achieve better health and well-being.
After users have joined Attain, they will have the additional option to share their Attain program data and health history with Apple, enabling Apple and Aetna to collaborate, and over time, continue to improve the Attain experience. Through analytics and machine learning, the collaboration will lead to new features for Attain, offering more personalized recommendations designed to give greater context and decrease barriers to health care.
The developers say user privacy and data security are at the heart of Attain. A completely voluntary program, members determine what information they want to share and can discontinue using Attain at any time. All Attain health data is encrypted on the device, in transit, and on Aetna and Apple's servers, where it will be stored in a highly secure environment using industry-leading practices fully in compliance with HIPAA.
Information from this program will not be used for underwriting, premium or coverage decisions.
Health history data is tightly regulated by the U.S. government, and Apple and Aetna had to enter into what is known as a business associate agreement in order for Aetna to share it with the Apple. Access to regulated data is necessary for some of the functions of the app, such as recommending age-appropriate exercise or a lower-cost option for scheduled lab tests or MRI imaging tests.
The Attain rewards platform builds off a program developed by Vitality Group, a model that has demonstrated that incentives linked to the Apple Watch are associated with increased, sustained activity. A recent study from RAND corporation found an average 34 percent increase in activity levels for participants using the rewards platform incorporated in Attain with Apple Watch, compared to those without these incentives - leading to an additional 4.8 days of activity per month.
Interested Aetna members are encouraged to sign up at www.AttainbyAetna.com to be notified when the App becomes available for download ...
The Tuolumne County District Attorney’s Office announced the conviction of a Social Services Department employee for workers’ compensation insurance fraud.
Janice Richardson was employed as a personal care assistant provider for Tuolumne County and reported an on the job injury in April of 2014.
The alleged injuries arose from a motor vehicle collision Richardson was involved in during her scheduled work hours and in the performance of her duties.
Richardson filed a workers’ compensation injury claim and as a result, received medical treatment and workers’ compensation benefits.
During a subsequent investigation, it was alleged Richardson presented false statements and material misrepresentations during a deposition before the Workers’ Compensation Appeals Board. Richardson misrepresented facts as it related to her physical abilities and limitations associated with her injury.
On June 25, 2018, Richardson pleaded no contest to Insurance Fraud, in violation of Penal Code section 550(b)(2), in that she unlawfully and knowingly made a statement containing false and misleading information in support of her claim to obtain workers’ compensation insurance benefits.
Richardson was sentenced to three years probation, ordered to pay a fine of $1,000.00 to the workers’ compensation fraud account and ordered to pay restitution in the amount of $27,500.00 to the County of Tuolumne for reimbursement of workers’ compensation benefits and investigation costs.
This case was a joint investigation by Probe Information Services, the Tuolumne County District Attorney’s Office and the Amador County District Attorney’s Workers’ Compensation Fraud Unit.
The Fraud Unit investigates insurance fraud cases in Amador, Tuolumne, Stanislaus and Calaveras Counties through a grant provided by the California Department of Insurance ...
Janice Richardson was employed as a personal care assistant provider for Tuolumne County and reported an on the job injury in April of 2014.
The alleged injuries arose from a motor vehicle collision Richardson was involved in during her scheduled work hours and in the performance of her duties.
Richardson filed a workers’ compensation injury claim and as a result, received medical treatment and workers’ compensation benefits.
During a subsequent investigation, it was alleged Richardson presented false statements and material misrepresentations during a deposition before the Workers’ Compensation Appeals Board. Richardson misrepresented facts as it related to her physical abilities and limitations associated with her injury.
On June 25, 2018, Richardson pleaded no contest to Insurance Fraud, in violation of Penal Code section 550(b)(2), in that she unlawfully and knowingly made a statement containing false and misleading information in support of her claim to obtain workers’ compensation insurance benefits.
Richardson was sentenced to three years probation, ordered to pay a fine of $1,000.00 to the workers’ compensation fraud account and ordered to pay restitution in the amount of $27,500.00 to the County of Tuolumne for reimbursement of workers’ compensation benefits and investigation costs.
This case was a joint investigation by Probe Information Services, the Tuolumne County District Attorney’s Office and the Amador County District Attorney’s Workers’ Compensation Fraud Unit.
The Fraud Unit investigates insurance fraud cases in Amador, Tuolumne, Stanislaus and Calaveras Counties through a grant provided by the California Department of Insurance ...
