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Hundreds of thousands of dollars have been fraudulently taken in two separate schemes that targeted California Employment Development Department unemployment insurance benefits that were intended for Californians hit hardest by the ongoing COVID-19 pandemic shutdown.

A federal grand jury in Fresno returned an indictment involving a prison-based scheme out of the Central California Women’s Facility (CCWF) in Chowchilla.

Inmate Sholanda Thomas, 36, and parolee Christina Smith, 37, were indicted for conspiracy to commit mail fraud and aggravated identity theft charges for the submission of several fraudulent EDD unemployment insurance claims in Thomas’ and other CCWF inmates’ names.

Recorded jail calls and emails show that Thomas and others engaged in "bundling," that is, they obtained the names, dates of birth, and social security numbers for inmates at CCWF and relayed that information to Smith to submit the fraudulent claims. The claims were submitted shortly thereafter, and the benefits were loaded onto debit cards that were mailed to the addresses provided.

The underlying applications for the claims falsely stated that the inmates had worked within the prescribed period as hairstylists, barbers, and other occupations, and that they were available to work, which was not true because they were incarcerated. The claims would have been denied if accurate answers had been given. EDD and the United States have suffered a loss of over $200,000 as a result of the fraud.

Thomas and Smith used the proceeds for their own benefit, which included Smith keeping Thomas’ share in a shoebox pending Thomas’ release from prison, and Smith getting plastic surgery.

In the second scheme, Andrea M. Gervais, 43, of Roseville - a former Employment Development Department employee - allegedly participated in a mail fraud scheme involving approximately 100 fraudulent Pandemic Unemployment Assistance (PUA) claims in the names of persons other than Gervais.

According to the criminal complaint, at least 12 of the 100 claims were processed for payment, and over $200,000 in PUA benefits were paid out to Gervais’s Roseville address in the form of Bank of America debit cards. The total value of all fraudulent PUA claims from her residence was at least $2 million.

The investigation began when investigators discovered a PUA claim using the identity of a sitting United States Senator for approximately $21,000. This fraudulent claim was processed for payment, and Gervais received a PUA debit card in the United States Senator’s name. Investigators further discovered that Bank of America ATM cameras captured Gervais on multiple occasions withdrawing cash from at least seven of the PUA debit cards, and at least one captured transaction showed Gervais using the debit card issued to the United States Senator.

If convicted, Thomas and Smith face a maximum statutory penalty of 20 years in prison for conspiracy to commit mail fraud, and a mandatory and additional two-year prison sentence if convicted of aggravated identity theft. If convicted,

Gervais faces a maximum statutory penalty of 20 years in prison for mail fraud.
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/ 2020 News, Daily News
Jorge Gerardo Maldonado, 55, of Sacramento, was charged with three felony counts of insurance fraud after allegedly underreporting payroll and employees to illegally save on workers’ compensation insurance premiums, resulting in a $687,560 loss to three insurance carriers.

After one of the victim insurance companies suspected Maldonado of fraud, the California Department of Insurance launched an investigation into his Sacramento cleaning company Pro-Care Building Maintenance (Pro-Care). It found that Maldonado underreported payroll and committed premium fraud. Maldonado has owned Pro-Care since 2014.

On July 10, 2016, a Pro-Care employee was injured while on the job and a workers’ compensation insurance claim was filed with one of the company’s insurance carriers. During a review of the claim, it was found that Pro-Care underreported payroll and failed to report the end of policy payroll to the insurance company as the policy required.

The Department’s investigation further discovered that Maldonado failed to report payroll and employees of Pro-Care to three insurance carriers from 2017 through 2019. The alleged unreported payroll was over $5 million.

Maldonado self-surrendered to the Sacramento County Jail on Wednesday, December 23, 2020.

The case is being prosecuted by the Sacramento County District Attorney’s Office ...
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/ 2020 News, Daily News
In 2008, Charter Communications hired Anthony Lave as a "broadband tech." Approximately two years after he was hired, Lave injured his back while working. He filed a workers’ compensation claim and, although he continued to work, Lave ultimately received a permanent disability rating of 30 percent.

Years later, in 2014, Lave asked for time off, claiming he needed to take his wife to a medical appointment. Lave’s supervisor failed to respond for over a week. Frustrated with the lack of a response, Lave complained to a human resources employee but eventually abandoned his request for time off. This occurred again a few days later.

Lave claimed that his relationship with his supervisor worsened after Lave bypassed him and went to human resources regarding his leave requests. Lave testified that his supervisor would stare him down, and disciplined him for minor infractions, and continued to delay his responses to Lave’s leave requests.

Later, Lave’s preexisting back injury flared up in early 2015, leading him to take one day of sick leave. When he returned, the same supervisor issue a "milestone" to Lave for taking a sick day off. A "milestone" was the documentation Charter used to memorialize employee discipline. Lave complained to another human resources employee and then, days later, filed a formal complaint against his supervisor. The local human resources department would "handle the situation."

Lave then reopened his workers' compensation claim, and required time off by Charter's own physician. He returned to work, but was suspended in less than a month because of a customer complaint. Lave filed another complaint with human resources, claiming his suspension was in retaliation for taking time off work. Lave never received a response to his complaint and was later terminated from employment.

Lave filed this lawsuit against Charter, alleging he was retaliated against based on his disability related to his back injury; for taking time off to accompany his wife to her medical appointment; for taking sick leave; for taking medical leave; and for filing complaints arising from his disability accommodation and leave requests.

A jury awarded him $575,000. And a post judgment awarded $400,800 in attorney fees, rather than the requested amount of $1,064,062.70. The judgment was affirmed in the unpublished case of Lave v Charter Communications.

The court of appeal found that the trial court correctly excluded evidence that Charter did not produce during discovery.

With regard to the remaining issues over the jury verdict, the court found that "Charter fails to undermine the jury’s ultimate finding in Lave’s favor and award of damages." ...
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/ 2020 News, Daily News
Cal/OSHA has cited eight more employers for not protecting workers from COVID-19 during inspections at meat processing facilities across the state.

The inspections were opened upon learning of a COVID-19 fatality and several illnesses, and after receiving complaints. The employers cited failed to take required steps to prevent COVID-19 infection in the workplace such as safe physical distancing procedures or proper face covering usage for workers in production areas.

"Enforcement of COVID-19 protections at meatpacking and food processing facilities has been a priority of Cal/OSHA given the high rates of positive cases and alarming number of deaths among food processing workers," said Cal/OSHA Chief Doug Parker. "These citations represent a portion of our enforcement efforts in these industries. More citations will be issued when violations are identified and inspections are closed."

On November 12, Cal/OSHA cited Smithfield Foods, Inc. in Vernon $58,100 in proposed penalties for multiple COVID-19 related violations, including two serious in nature, and its staffing firm CitiStaff Solutions was also cited $46,695 for two serious violations. Both employers failed to ensure that workers used face coverings properly in production areas and during breaks, and failed to provide effective training and instruction on how the virus is spread and how to disinfect areas properly. The investigators determined that Smithfield Foods, Inc. failed to adequately address at least 300 COVID-19 illnesses (including three that required hospitalization) amongst its employees and contracted workers hired by CitiStaff Solutions. Smithfield Foods, Inc. further failed to report serious COVID-19 illnesses to Cal/OSHA.

Central Valley Meat Co. was cited for not informing employees of possible exposure when coworkers were infected with COVID-19 and for failing to provide face coverings and ensure their proper use. Cal/OSHA opened a complaint-initiated inspection at the facility in Hanford on April 29 and identified violations in the employer’s training procedures and response to COVID-19 hazards. Citations were issued on December 11 with $50,000 in proposed penalties for two violations classified as serious.

In June, Cal/OSHA became aware that several One World Beef Packer employees were hospitalized for complications related to COVID-19, including one employee who died. When Cal/OSHA inspected the Brawley facility, investigators noted that workers in the production lines and quality assurance area were not provided protective barriers and were working too close to each other. Furthermore, the employer failed to report the serious illnesses and fatality within the eight-hour time limit as required by law. Cal/OSHA cited One World Beef Packer $23,000 on December 11 for one serious violation and a regulatory violation for failing to report the serious illnesses.

After reports of outbreaks, Cal/OSHA opened inspections at meat processing plants in Vernon last June and July as part of a targeted enforcement effort. An onsite inspection at California Farms Meat Company confirmed the employer did not implement physical distancing procedures or install barriers in the production area, where workers separated chicken by hand and operated machines within close distance of each other. Cal/OSHA cited the employer $11,700 in proposed penalties on December 14 for the serious violation.

In July, Cal/OSHA opened inspections with CLW Foods and its staffing firms California Enterprises Employment and HR Staffing Solutions in Vernon. The employers were cited on December 14 for multiple violations, including some categorized as serious for failing to address COVID-19 hazards by training employees and ensuring proper physical distancing procedures on conveyor lines, in the production area and when employees took breaks. CLW Foods and California Enterprise Employment were also cited for failing to report serious COVID-19 illnesses to Cal/OSHA.
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/ 2020 News, Daily News
The Internal Revenue Service just announced that the standard mileage rate for business miles will decrease to 56.0 cents per mile as of January 1, 2021, down 1.5 cents from the rate of 57.5 cents per mile for 2020.

As a result, the California Workers’ Compensation Institute reports that effective for travel on or after January 1, 2021, the rate that California workers’ compensation claims administrators pay injured workers for travel related to medical care or evaluation of their injuries will also decrease to 56.0 cents per mile.

The new workers’ compensation medical mileage rate will apply for 2021 travel dates, regardless of the date of injury on the claim, but for 2020 travel dates claims administrators should continue to pay 57.5 cents per mile.

California Labor Code §4600 (e)(2), working in conjunction with Government Code §19820 and Department of Personnel Administration (DPA) regulations, requires claims administrators to reimburse injured workers for such expenses at the rate adopted by the Director of the DPA for non-represented (excluded) state employees, which is tied to the IRS published mileage rate.

In its December 22 news release the IRS announced that as of January 1, 2021, the standard mileage rate will drop to 56.0 cents per business mile driven.

The IRS bases the standard mileage rate on an annual study of the fixed and variable costs of operating an automobile, which includes the cost of gasoline and depreciation.

There have been multiple mileage rate changes over the past decade, so the California Division of Workers’ Compensation has posted downloadable mileage-expense forms on the forms section of its website (DWC Forms (ca.gov) which show applicable rates based on travel date.

A new form with the 2021 rate will be posted shortly, but should not be used until reimbursements are made for 2021 travel.

Given the upcoming holidays, however, claims organizations should alert their staff and programmers as soon as possible that the medical mileage rate will decrease to 56.0 cents per mile for travel on or after January 1, 2021 ...
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/ 2020 News, Daily News
The California Division of Workers’ Compensation announced dates for its 28th annual educational conference. The conference will take place on a virtual platform from March 24-26, 2021.

Sessions will also be available to view on demand through April 9, 2021.

The largest workers' compensation educational event in the state is usually held in March in both Northern and Southern California, although it will be online-only during the COVID-19 pandemic.

Speakers from the Division of Workers' Compensation and the private sector will address the most current topics and issues confronting claims administrators, medical providers, attorneys, rehabilitation counselors and others involved in workers' compensation.

The program will include valuable information for anyone with a professional interest in California workers’ compensation, a virtual exhibit hall featuring service providers, and sponsorship opportunities.

Continuing education credits will be offered for California adjusters and attorneys, HR professionals and rehabilitation providers, as well as DWC QME credits.

Additional information regarding the agenda, registration fees and instructions will be sent by email in late January 2021.

Questions or Concerns? Please contact the DWC at DWCEvents@dir.ca.gov ...
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/ 2020 News, Daily News
In November, gig companies including Uber, Lyft, DoorDash, and Instacart helped pass California’s Proposition 22, effectively writing their own labor law. Now the companies plan to bring similar legislation elsewhere.

Last month, the companies launched a group called the App-Based Work Alliance to support their agenda. Industry-supported bills in the works in New York state and Illinois would, like the California ballot measure, deny gig workers status as employees, and the workers’ compensation, paid family leave, sick pay, unemployment insurance, and minimum wage guarantees that come with it.

But the bills could give gig workers the right to form something resembling a union, allowing workers to bargain with multiple employers to create wage floors and standards. US workers in trucking, auto manufacturing, and grocery stores have participated in types of industry-wide bargaining, though the arrangement is more common in Europe.

The California Proposition 22, was written by gig companies, who then poured $205 million into supporting it, the most expensive campaign in the state’s history. Proposition 22 is near-irreversible - the law needs a "supermajority" of seven-eighths of the state’s legislature to be changed.

At the same time, gig companies invested in bringing the Proposition 22 fight elsewhere. Lyft stood up a political action committee called Illinoisans for Independent Work that spent at least $660,000 on ad buys and political contributions in local elections. In August, Uber released a white paper laying out its plans for "Independent Contractor+," a new employment category it hopes to promote across the country.

Now New York, a less-than-traditional gig market in many ways, is set to be among the first states where a post-Proposition 22 battle might play out.

A constellation of gig companies and allies introduced the New York Coalition for Independent Work, which describes its mission as "protecting self-employed, app-based contractors’ independence and flexibility while also working to provide them with needed benefits." But the state’s relatively labor-friendly climate means that gig companies will have to tread carefully - and that a pitched battle is likely ahead.

In statements, spokespeople for Uber, Instacart, and DoorDash said the companies would work with legislators to protect flexible work schedules for their gig workers, something they have said would be impossible if they were forced to treat the workers as employees.

DoorDash vice president of communications and policy Liz Jarvis-Shean said the company wants to work with state and federal lawmakers "to help create a new portable, proportional, and flexible framework that embraces today’s modern workforce." Uber spokesperson Matthew Wing said the company supports state laws to require "all gig economy companies - including ours - to provide new benefits and protections to all independent workers."

Back in California, drivers say plenty of organizing can happen without official bargaining rights or recognition from the gig companies. Moore, the Rideshare Drivers United organizer, says her organization is now focused on recouping unemployment insurance for drivers for the months before Proposition 22 went into effect, when, she says, drivers legally should have been treated as employees. "We’re not going away," she says ...
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/ 2020 News, Daily News
Pharmaceutical companies are holding out hope that the mRNA technology used to develop breakthrough Covid-19 vaccines is flexible enough to provide for seasonal shots in case immunity gained from initial vaccination is short-lived.

The first Covid-19 vaccine approved for use in the U.S., Pfizer and BioNTech’s shot was purportedly 95% effective in preventing symptomatic coronavirus infections in a large study group. Positive study results have also been released for Moderna’s vaccine, which secured an emergency use authorization by the Food and Drug Administration on Dec. 18.

The jury is still out on how long the immunity induced by these rapidly developed mRNA vaccines will last.

Despite the encouraging clinical trial results, Pfizer is being cautious about speculating on the durability of immune response elicited by mRNA vaccines.

"We don’t know how the virus will change, and we also don’t know how durable the protective effect of any vaccination will be," the company said in a statement.

Pfizer said that if it turns out that the induced immunity lasts only a few months, mRNA vaccines are suitable for repeated administration as booster shots.

If a mutation in the Covid-19 virus affects Pfizer’s vaccine effectiveness, the company said, mRNA technology will enable "rapid development" of adjustments. The technology also allows for a fast production process without the need for complex mammalian cell systems used in traditional vaccine production, the company said.

Multiple other Covid-19 vaccine candidates using a variety of technologies are under development by other large pharmaceutical companies. Viral-vector vaccines, one from Johnson & Johnson, and another from a partnership between AstraZeneca and Oxford University, are in late-stage clinical trials.

Dr. Marc Hellerstein, a biochemistry lab head at the University of California, Berkeley, said researchers will be focused next year on determining which vaccine produces the longest-lived immune response against Covid-19. Of particular importance is the immune response of T cells including CD8+ cells, immune system agents that kill off virus-infected cells in the body, Hellerstein explained.
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/ 2020 News, Daily News
Randy Rosen M.D., an Orange County surgeon and jail inmate accused in a $29 million insurance fraud scheme who is facing decades behind bars, was temporarily set free ahead of the weekend after testing positive for coronavirus to the criticism of local officials.

Rosen, who was involved in a civil federal lawsuit involving a health care fraud scheme at a Long Beach hospital that was settled in 2017, was was indicted in this new case along with co-defendant Liza Vismanos

Vismanos owns the Wellness Wave surgical center in Beverly Hills and the Lotus Labs medical laboratory in Los Alamitos. Rosen/Vismanos entered into a fraud scheme specifically targeting patients from addiction recovery rehabs to bill their private medical insurance carriers primarily for two types of procedures; a non-FDA approved Naltrexone implant and Cortisone injections.

Rosen and Visamanos were first arrested back on June 30 on a combined 144 counts including money laundering, submitting fraudulent insurance claims and withholding material facts on insurance claims.

CBS Los Angeles reports that District Attorney Todd Spitzer called the release of 57-year-old Rosen - who is being monitored by an electronic bracelet - unfair.

Rosen’s attorney argued before a judge that Rosen "is at substantial risk of poor outcome (of the coronavirus) because of his multiple co-morbidities for his current COVID-19 infection which requires medical follow-up."

Rosen faces a maximum sentence of 84 years in state prison if convicted as charged, while Visamanos faces 36 years.

After Rosen’s positive COVID-19 test, he has been released, and now Spitzer is calling him a flight risk and questioned whether he would leave the country.

"If I knew I had an out for 30 days and money available and the means to get the heck of out this country, quite frankly I think I’d probably take the opportunity," Spitzer said. "Whether we see him back again is the big question." ...
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/ 2020 News, Daily News
Congress is poised to include a ban on "surprise" medical bills as part of its massive year-end spending package that lawmakers are expected to vote on Monday.

In a joint statement Sunday night, House Speaker Nancy Pelosi and Senate Minority Leader Chuck Schumer confirmed that "bipartisan, bicameral legislation that will end surprise billing for emergency and scheduled care" will be part of $1.4 trillion spending bill, which also includes an additional $900 billion in coronavirus relief money.

The long sought-after legislation will protect insured patients from receiving expensive medical bills when they inadvertently receive out-of-network care. Americans of all stripes support the effort: A survey published Friday by the Kaiser Family Foundation found that 80% of adults support abolishing the practice.

Although lawmakers in both parties had been pushing for a plan to fix the issue for years -- with the support President Trump, who had made it a key campaign priority -- the effort drew fierce opposition from powerful lobbying groups representing the health care industry, who questioned how much the insurer would have to pay the doctor once the patient was removed from the equation.

A previously announced deal called for health insurers and providers to negotiate most billing disputes or bring their complaints to a mediator. The final legislation moves even further in favor of doctors and hospitals by preventing the arbiter from using the lower payment rates paid by Medicaid and Medicare programs, according to Politico, which obtained a copy of the bill summary.

Lawmakers also diluted a measure that would have required health insurers to disclose information to employers about their drug costs and rebates through their contracts with middlemen known as pharmacy benefit managers. The legislation now calls for insurers to submit more general information on medical costs and prescription drug spending, according to Politico.

Rep. Richard Neal, chairman of the House Ways and Means Committee, called the proposal a "win for patients and their families that will improve America's health care system."

An earlier clash between Neal, who had previously blocked proposals to stop surprise medical billing, and three other committees - House Energy and Commerce, House Education and Labor and Senate Health, Education, Labor and Pensions - threatened to derail the reform efforts. After securing changes that were friendlier to doctors and hospitals, however, Neal agreed to support the proposal ...
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/ 2020 News, Daily News
Governor, Gavin Newsom, declared a state of emergency in response to the spread of the novel coronavirus, and issued Executive Order N-33-20 which required all Californians to stay home with certain limited exceptions.

The DWC temporarily closed the district offices for filing to protect the health and safety of staff and the community. The district offices reopened for filing effective April 13, 2020, but limited filings to e-filing via the Electronic Adjudication Management System (EAMS), JET filing or by mail. The DWC has continued to conduct hearings via teleconference or video, but does not currently permit filing of walk-through documents.

The California Department of Public Health issued a Regional Stay At Home Order applicable based on a region’s intensive care unit (ICU) capacity on December 3.

And as a result, the WCAB in it's December 15, en bank decision, ordered suspension of WCAB Rule 10789(c) regarding the required timeframes for assignment of walk-through cases.This suspension is applicable to all district offices in the State.

This rule states that certain documents "may be submitted on a walk-through basis" including the following: (1) Compromise and Releases; (2) Stipulations with Request for Award; (3) Petitions for attorney’s fees for representation of the applicant at a deposition; (4) Petitions to compel attendance at a medical examination or deposition; and (5) Petitions for Costs pursuant to rule 10545.

The rule also provides that "Each district office shall have a designee of the presiding workers’ compensation judge available to assign walk-through cases from 8:00 a.m. to 11:00 a.m. and 1:00 p.m. to 4:00 p.m. on court days."

The order of suspension of WCAB Rule 10789(c) will provide the district offices with the ability to schedule timeframes for walk-through of documents as appropriate for their capacity under these circumstances.

WCAB Rule 10789(a) is permissive and the documents that may be submitted on a walk-through basis may therefore be further restricted by the district offices at the discretion of the presiding workers’ compensation judges.

The presiding workers’ compensation judge has full responsibility for assignment of cases to the workers’ compensation judges in each district office. This includes the authority to decline to assign a document submitted on a walk-through basis.

The presiding workers’ compensation judges are empowered to prioritize which documents may be assigned on a walk-through basis to expedite resolution of claims and to account for limited capacity in their respective offices in determining whether to permit a document to be assigned as a walk-through.

This order will remain in effect until further notice ...
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/ 2020 News, Daily News
Mitchell International, Inc., released its fourth quarter Industry Trends Report for 2020. In this report, industry experts from across Mitchell predict and analyze the key trends that will impact 2021, providing insights that can help guide planning for organizations across the industry.

In 2020, the workers’ compensation industry has faced no shortage of challenges - treatment gaps, delays in elective surgeries, the shift to work-from-home, an onslaught of emergency regulations and more. In 2021, the industries will continue to face pandemic-related challenges that will require adaptations and focus to address.

One of the major issues the workers’ compensation industry has faced during the pandemic is access to care. Across the country, hospitals, medical offices and other sites of service limited or delayed elective surgeries and treatments, leaving gaps in care for many workers’ compensation claims. These trends are expected to continue through the pandemic in line with state COVID-19 rules and restrictions.

The shifting workforce will be the biggest trend to watch in 2021. Much of the U.S. workforce has shifted to work from home, with many workers expected to stay remote even after the pandemic ends. For the workers’ compensation industry, this will pose a challenge when it comes to worker safety, as the risks are different in a home environment compared to an office.

They also anticipate that next year, claims organizations will lean into automating the end-to-end claims process more than ever, that telemedicine will undergo both innovation and additional regulatory and security scrutiny and that we will see increases in certain types of workers’ compensation claims like ergonomic injuries and growing COVID-19 illness claims.

For adjusters and other claim handlers, the biggest game changer will be having a clear understanding that telemedicine, telehealth, telerehab and others are acceptable forms of treatment.

Mitchell experts also caution that in 2021 we may see continuing concerns in the pharmacy system, including escalating drug costs and a growing opioid crisis that has led to an estimated 18% increase in overdoses in 2020, though mostly from synthetic drugs.

Fraud, which costs $30 billion each year, should also remain top of mind right now for carriers, since the changes caused by the pandemic have altered previous patterns, making fraud harder to detect.

The also expect in 2021 that Congress is going to do something to reconcile the difference between where the states are at and where the federal government is at when it comes to marijuana. The federal government might allow states to regulate marijuana similar to alcohol, allowing each state to decide the right policy ...
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/ 2020 News, Daily News
The U.S. Supreme Court published its decision in Rutledge v. Pharmaceutical Care Management Association. The question presented was whether ERISA preempts Arkansas Act 900, an Arkansas law that regulates the price at which pharmacy benefit managers (PBMs) reimburse pharmacies for the cost of drugs covered by prescription drug plans.

PCMA, the Pharmaceutical Care Management Association, which represents some of the largest PBMs in the country, challenged Arkansas Act 900 by arguing that the Act is preempted by ERISA. The Supreme Court reversed the judgment of the U.S. Court of Appeals for the Eight Circuit, ruling that Act 900 was not preempted by ERISA.

The Opinion reasoned that Arkansas Act 900’s requirements were too far away from ERISA and ERISA plans to have an "impermissible connection" with ERISA plans, even though the law has an indirect effect on what ERISA plans pay for prescription drugs. "State regulations that merely increase the costs or alter incentives for ERISA plans without forcing plans to adopt any particular scheme of substantive coverage are not preempted by ERISA," Justice Sotomayor wrote, citing earlier Supreme Court opinions.

The Court’s Opinion is a strict preemption analysis and does not cite to, or reference, the many amicus briefs filed in the case or the political debate surrounding Arkansas Act 900, other than to reiterate the express legislative intent in enacting Arkansas Act 900.

PBMs typically use a "maximum allowable cost" list to determine how much pharmacies should be reimbursed. Trade groups for rural and independent pharmacies have argued that PBM’s strategies in reimbursement rates of maximum allowable costs are unfair and can be lower than the pharmacies’ cost to purchase the drug.

Conversely, other trade groups in support of PCMA, state that PBMs have expertise in ensuring efficiency and cost reduction, and that drug prices are largely established by drug manufacturers.

According to America’s Health Insurance Plans, Inc. (AHIP), PBMs provide incentives to pharmacies to offer low-cost generic drugs and to be more efficient with their drug purchasing. AHIP also claims that PBMs have the expertise in pharmaceutical manufacturing and distribution systems, and that the compliance costs of managing different state regulations make work in this area prohibitively expensive.

The Court’s Opinion may lead to further state regulation of PBMs.

A statement from PCMA expressed disappointment and urged states to proceed cautiously: "We are disappointed in the Court’s decision that will result in the unraveling of federal protections under . . . ERISA," and "As states across the country consider this outcome, we would encourage they proceed with caution and avoid any regulations around prescription drug benefits that will result in higher health care cost for consumers and employers." ...
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/ 2020 News, Daily News
A Riverside County woman pleaded guilty to a federal criminal charge for fraudulently obtaining more than $500,000 in COVID-related unemployment benefits for herself.

Cara Marie Kirk-Connell, 32, of Menifee, pleaded guilty to a single-count information charging her with use of an unauthorized access device.

Kirk-Connell knowingly used approximately 50 unauthorized access devices. Specifically, she used stolen personal identifiable information, such as dates of birth and Social Security numbers, to apply for unemployment insurance benefits in the names of other people.

Based upon Kirk-Connell’s false and fraudulent applications, she obtained from the California Employment Development Department (EDD) multiple debit cards that contained more than $500,000 in COVID-related unemployment benefits to which she was not entitled, the plea agreement states.

Kirk-Connell admitted she knew people who access the "dark web" to purchase stolen identities that she used to then file fraudulent claims with EDD. She further admitted to watching YouTube videos that instructed viewers on how to commit EDD fraud.

When Murietta police arrested Kirk-Connell on September 11 during a traffic stop, she possessed eight EDD debit cards in other people’s names and, the day before her arrest, Kirk-Connell used fraudulently obtained EDD debit cards to withdraw more than $1,000 in cash. When federal law enforcement arrested Kirk-Connell on October 9, she possessed in her purse four EDD debit cards in victims’ names, four additional debit cards in victims’ names in her car trunk, and approximately $10,000 in cash, according to the plea agreement.

EDD records showed that the cards and identities that Kirk-Connell possessed had been used to apply for and authorize approximately $534,149 in COVID-related unemployment benefits from California’s EDD program, of which nearly $270,000 had already been spent, according to an affidavit filed with a criminal complaint in this case.

The California EDD distributes unemployment benefits under the Coronavirus Aid, Relief, and Economic Security Act, passed by Congress in March. The CARES Act expanded unemployment benefits to cover those who were previously ineligible, including business owners, self-employed workers, and independent contractors, who were put out of business or significantly reduced their services because of the COVID-19 pandemic.

She is scheduled for an April 9, 2021 sentencing hearing, at which time Kirk-Connell will face a statutory maximum sentence of 10 years in federal prison.
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/ 2020 News, Daily News
Jacob Lopez, was an employee of the Los Angeles County Metropolitan Transportation Authority. In February 2014 Lopez went on medical leave and submitted a doctor’s note stating he was "to remain totally disabled from work," because of pain in his back that could not be resolved by ergonomics at work.

When Lopez was ready to come back to work, the Authority did not allow him to return to his position as a transit security lieutenant because his doctor said Lopez had certain physical restrictions.

Lopez sought disability benefits from the California Public Employees’ Retirement System (CalPERS). In his application to CalPERS Lopez claimed that he had "cumulative trauma" to his back and hands, anxiety, and depressive symptoms; that he had lifting, sitting, and standing restrictions and that he was unable to perform his job.

He also filed a workers’ compensation claim against the Authority, claiming he suffered hand, back, and psychological injuries.

In September 2015 CalPERS approved Lopez’s application for disability retirement benefits, finding Lopez was "substantially incapacitated from the performance of [his] usual duties as a Transit Security Lieutenant . . . based upon [his] orthopedic (low back, bilateral hands) condition." In December 2016 the Workers’ Compensation Appeals Board approved a settlement between Lopez and the Authority for $65,000.

Lopez then filed a civil action, alleging the Authority violated provisions of the Fair Employment and Housing Act (FEHA) that prohibit disability discrimination and that require employers to engage in good faith in the interactive process to find reasonable accommodations.

The trial court granted the Authority’s motion for summary judgment, ruling Lopez could not prevail on either of his two causes of action, in part because he was judicially estopped from asserting he could have performed the duties of his prior position. The court of appeal affirmed the dismissal in the unpublished case of Lopez v Los Angeles County Metropolitan etc.

The trial court ruled that, because Lopez stated in his disability application with CalPERS and in his Workers’ Compensation Appeals Board proceeding that he could not work as a transit security lieutenant, and because Lopez received benefits from CalPERS and settled his workers’ compensation claim, he was judicially estopped from contending he could perform the essential functions of the position.

Several courts have held that, to prevail on a cause of action for failure to engage in good faith in the interactive process, the plaintiff must identify a reasonable accommodation that was available at the time the interactive process (should have) occurred and that the defendant employer could have offered.

Lopez never argued he needed an accommodation, reasonable or otherwise, to return to his position as a transit security lieutenant ...
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/ 2020 News, Daily News
Residents of Los Angeles, California, and Henderson, Nevada, and 16 pharmacies scattered between California, Texas, Wyoming, Arizona and Nevada, pled guilty to charges of healthcare fraud, conspiracy to commit fraud, and/or conspiracy to violate the federal anti-kickback statutes.

Those pleading guilty included brothers Mehran David Kohanbash, and Joseph Kohan and their nephew, Nima Rodefshalom.

In addition guilty pleas included pharmacies Insure Nutrition, Inc., Affordable Pharmacy, Inc., ASC Pharmaceutical, LLC, DQD Enterprise Corporation, DTST Ventures, LLC, Econo Pharmacy, Inc., Emerson Pharmacy, Inc., Genorex Pharmaceutical, LLC, Nutrition Plus, Inc., Pharmatek Pharmacy, Inc., Premier Med Services, Inc., Rexford Pharmacy, Inc., Specialty Pharmacy Management of America, Inc., Solutech Pharmaceuticals, LLC, Village Drug & Compounding, Inc., and Vitamed LLC.

The three individual defendants together with the defendant pharmacies engaged in a series of interconnected actions that resulted in misleading advertising associated with supplying what were described to the Court as nutritional shakes.

The defendants secured the patients’ insurance information which in turn resulted in the defendants soliciting the patients to appeal to their respective physicians to prescribe what were described for the Court as High Yield (expensive) medications.

These medications were often compounded, meaning that one or more of the pharmacies mixed together preexisting medications or substances to provide a new or different product.

It was a part of the scheme(s) involved in the guilty pleas that the defendants conspired to promote these medications that often yielded extremely high profits, by manipulating the collection of co pays on various medications to make it appear that co pays were being collected when in fact they were not.

Sentencing is scheduled for April 7-8, 2020 for the individual defendants. Sentencing for the defendant pharmacies has not been scheduled.

For each individual defendant, the law provides for a maximum total sentence of 35 years in prison, a fine of $750,000, or both.

The three defendants and the 16 corporations agreed to forfeiture, restitution, fines and civil penalties amounting to more than $60,000,000 ...
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/ 2020 News, Daily News
Escondido pain clinic doctor, and board-certified physiatrist, Bradley Chesler, M.D., has paid the United States $153,000 to resolve allegations that he overprescribed opioids.

Dr. Chesler is listed as a Qualified Medical Evaluator by the DWC in the specialties of Pain Medicine and Physical Medicine and Rehabilitation. His QME office address is 1955 Citracado Pkwy, in Escondido.

This settlement stems from the investigation into whether Dr. Chesler illegally prescribed opioids to his patients in violation of the Controlled Substances Act.

Pursuant to the Controlled Substances Act, doctors may write prescriptions for opioids only for a legitimate medical purpose while acting in the usual course of their professional practice.

Federal investigators alleged that from January 1, 2014 to August 31, 2019, Dr. Chesler wrote opioid prescriptions that violated the Controlled Substances Act, which included prescriptions for fentanyl, hydromorphone, methadone, and oxycodone.

Dr. Chesler allegedly prescribed opioids while he concurrently prescribed benzodiazepines, and he prescribed to some patients a combination of at least one opioid, one benzodiazepine, and one muscle relaxant.

Drug abusers colloquially refer to the opioid, benzodiazepine, and muscle relaxant combination as the "Trinity" because of its rapid euphoric effects. These drug combinations are known to increase the risk of abuse, addiction, and overdose.

Chesler prescribed large quantities of opioids to his patients that reached high daily Morphine Milligram Equivalent (MME) levels (sometimes even exceeding 180 MME). The United States further alleged that Dr. Chesler failed to properly address aberrant urine drug test results when prescribing opioids.

Public health experts have long warned health care providers that overdose risk is elevated in patients receiving medically prescribed opioids, particularly those receiving high dosages. Among other things, tracking MMEs advances better practices for pain management by reinforcing the need for providers to consider alternatives to using high-dosage opioids to treat pain, and to appropriately justify decisions to use opioids at dosages that place patients at high risk of addiction, abuse, and overdose.

DEA Special Agent in Charge John Callery said, "Although 99 percent of medical professionals abide by DEA guidance and federal law, we will investigate those who put illicit profits before their oaths and bring them to justice." ...
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/ 2020 News, Daily News
The Division of Workers’ Compensation (DWC) has been working since the start of the COVID-19 crisis to provide critical services while keeping employees safe.

To that end, DWC has implemented multiple options for virtual hearings, including a call-in option on April 3 and a video option for trials that are usually heard at DWC district offices on August 12.

DWC has maintained a limited staff in its 24 district offices during this crisis and has not been accepting any walk-in requests or walk-in filings.

Increasing infection rates have resulted in the closure of many state offices throughout California. While DWC will continue to maintain all critical functions in its district offices, including holding all remote hearings and processing documents, it will have limited staff during the next three weeks to process documents.

This might result in extended processing times for documents that are mailed to the district offices.

DWC strongly encourages all parties to e-file or JET file documents to reduce processing times. For documents that are subject to a statute of limitations and cannot be otherwise e-filed or JET filed the parties may file those documents via e-mail as instructed in the Newsline dated April 23 and the WCAB en banc order of April 6.

DWC previously posted instructions on its website on how to file settlement documents in EAMS. Parties should review those instructions. If you are not already an e-filer and would like to become one please go to DWC’s EAMS page to learn how or send a request to EFORMS@dir.ca.gov for more information.

These recommendations also apply to the DWC Subsequent Injury Benefit Trust Fund Unit, which is also experiencing delay times for processing documents due to the reduction in staff during the COVID-19 crisis. Parties are strongly encouraged to file their documents electronically ...
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/ 2020 News, Daily News
The National Council on Compensation Insurance (NCCI) is undertaking several activities to better understand the impacts of the COVID-19 pandemic on the Workers Compensation system. One action is monitoring several medical data-related metrics, which were developed to provide insight into the effect of COVID-19 on several aspects of the medical system as it relates to WC.

These metrics track quarterly results over time, allowing it to compare the data before the onset of the pandemic and workers compensation medical experience thereafter. Looking at the first two quarters of 2020, it identified general demographics and cost characteristics of claims having COVID-19 medical treatments.

In it's recent article NCCI shares some of the aggregated-multi-state results for these metrics including data from the first and second quarter of 2020.

Some of the conclusions of the report show:

-- Hospitalization and intensive care unit (ICU) treatment are key cost indicators of COVID-19 claims.
-- Overall active claim volume decreased during 2Q20.
-- Increased use of telemedicine in 2Q20, to varying degrees across states.
-- Evaluation and management and physical medicine show a decrease in the utilization of in-person services in 2Q20.
-- The share of claims with surgery has remained steady, but the decreased intensity of surgery procedures seems to reflect a change in injuries or surgery mix.
-- Drug share of medical costs took an upward turn, in part driven by increased utilization of opioids.

While it is too early to fully assess the impact that the COVID-19 pandemic will have on the WC system, NCCI is beginning to identify the medical aspects of the system that are likely to be affected.

Furthermore, the measures of the potential indirect impact of the pandemic on medical services provided to all injured workers in the first two quarters of 2020, at first blush, do not show evidence of substantial disruption.

As data emerges, future updates to these metrics will be available on NCCI.com. A medical data dashboard will include state-specific results, allowing the user to compare a state’s experience to a multi-state benchmark ...
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/ 2020 News, Daily News
The annual summary of public self-insured data issued on December 6 by the Office of Self-Insurance Plans (OSIP) offers the first look at the workers' comp experience of cities, counties, and other public self-insured entities for the 12 months ending June 30 of this year, including the first 6 months of the pandemic.

The new report shows California's public self-insured work force declined by 1 percent to 2.09 million workers last year, with wages and salaries for those workers totaling $137.2 billion. The public self-insured employers reported 108,080 claims last year, 7,437 fewer than in the FY 2018/2019 initial report, which was by far the biggest decline in the past decade.

While claim volume fell 6.4% compared to the prior year, medical-only claims accounted for nearly all of that decline.

Meanwhile, average indemnity payments per claim rose 16.9%, more than offsetting a 3.7% decline in average medical payments, so even though there were fewer claims, total paid benefits increased for the sixth year in a row, edging up by $2.2 million to a record $414.9 million for the fiscal year ending June 30.

The first report data on incurred losses (paid amounts plus reserves for future payments) show a somewhat different pattern for public self-insured claim costs.

Aggregate incurred losses on the FY 2019/2020 claims totaled $1.33 billion, 2.8% less than the first report total from the prior year. The 6.4% decline in public self-insured claim volume in the initial report accounted for much of the one-year decline in total incurred, while a 1.8% decline in average incurred medical also contributed a small amount, though it did not offset the 11.0% increase in average incurred indemnity, which led to a 3.9% increase in the average incurred loss per claim, which hit a record $12,309.

OSIP also compiles private self-insured claims data, which is reported on a calendar year basis rather than on a fiscal year basis, so the private self-insured data, which was posted in June, now lags the private self-insured data by 6 months. The next report on private self-insured experience should be released next summer ...
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/ 2020 News, Daily News
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