The Santa Clara County District Attorney’s Office has charged a San Jose police officer with using his private security company to commit insurance fraud, tax evasion, wage theft, and about $18 million in money laundering.
Robert Foster, 47, the Morgan Hill owner of Atlas Private Security, self-surrendered and will be arraigned on November 30th, at the Hall of Justice in San Jose on felony charges. Foster’s wife and eight other company employees are being charged with four counts of felony conspiracy to commit insurance fraud, unemployment insurance fraud, money laundering, and wage theft, and 39 additional felonies, including extortion and a white-collar crime enhancement. They face prison time, if convicted.
The officer and his co-defendants allegedly reduced insurance premiums and taxes by reporting false and inaccurate payroll, underreporting headcount, paying employees off-the-books, and underreporting employee injuries. In one case, an employee was allegedly threatened with deportation if she continued to speak attorneys about her rights under worker’s compensation laws after suffering a workplace injury.
The six-month investigation was spearheaded by the Santa Clara County District Attorney’s Office Bureau of Investigation in close collaboration with the California Department of Insurance, Employment Development Department, California Department of Justice Bureau of Medical Fraud and Elder Abuse and United States Department of Labor.
The probe showed that Foster allegedly hid approximately $8.09 million in payroll over three years, avoided approximately $578,716.56 in tax liability and $560,293.15 in insurance premiums.
To carry on their fraud scheme, the Atlas officials allegedly laundered approximately $18.20 million. The co-conspirators used and traded on Foster’s position as an active-duty San Jose Police Officer and self-described expert in lie detection to further their business interests. Yet, Foster allegedly failed to disclose to SJPD that he owned and operated Atlas or that such ownership could result in ethical conflicts.
The arrest comes just days after District Attorney Jeff Rosen announced a series of social justice reforms that included creating a Workers Exploitation Task Force that will investigate cases such as this one.
"This Office will root out and prosecute anyone - whether they wear a badge or not - taking criminal advantage of workers," District Attorney Rosen said. "Our new task force will protect and heal the victims of labor trafficking, wage theft and illegal exploitation and raise awareness about how these insidious crimes are attacks on our communities of color."
...
Robert Foster, 47, the Morgan Hill owner of Atlas Private Security, self-surrendered and will be arraigned on November 30th, at the Hall of Justice in San Jose on felony charges. Foster’s wife and eight other company employees are being charged with four counts of felony conspiracy to commit insurance fraud, unemployment insurance fraud, money laundering, and wage theft, and 39 additional felonies, including extortion and a white-collar crime enhancement. They face prison time, if convicted.
The officer and his co-defendants allegedly reduced insurance premiums and taxes by reporting false and inaccurate payroll, underreporting headcount, paying employees off-the-books, and underreporting employee injuries. In one case, an employee was allegedly threatened with deportation if she continued to speak attorneys about her rights under worker’s compensation laws after suffering a workplace injury.
The six-month investigation was spearheaded by the Santa Clara County District Attorney’s Office Bureau of Investigation in close collaboration with the California Department of Insurance, Employment Development Department, California Department of Justice Bureau of Medical Fraud and Elder Abuse and United States Department of Labor.
The probe showed that Foster allegedly hid approximately $8.09 million in payroll over three years, avoided approximately $578,716.56 in tax liability and $560,293.15 in insurance premiums.
To carry on their fraud scheme, the Atlas officials allegedly laundered approximately $18.20 million. The co-conspirators used and traded on Foster’s position as an active-duty San Jose Police Officer and self-described expert in lie detection to further their business interests. Yet, Foster allegedly failed to disclose to SJPD that he owned and operated Atlas or that such ownership could result in ethical conflicts.
The arrest comes just days after District Attorney Jeff Rosen announced a series of social justice reforms that included creating a Workers Exploitation Task Force that will investigate cases such as this one.
"This Office will root out and prosecute anyone - whether they wear a badge or not - taking criminal advantage of workers," District Attorney Rosen said. "Our new task force will protect and heal the victims of labor trafficking, wage theft and illegal exploitation and raise awareness about how these insidious crimes are attacks on our communities of color."
...
Marlene Cavalcanti, 40, pleaded guilty to two felony counts of insurance fraud and identity theft after falsifying documents to receive an additional $10,590 on her workers’ compensation claim.
Cavalcanti, employed as an executive assistant, reportedly fell at work and sustained injuries. As a result of her subsequent workers’ compensation claim, Cavalcanti received more than $42,000 in total temporary disability payments in addition to her medical treatment.
An investigation by the Department of Insurance revealed after being placed on disability, Cavalcanti ceased medical treatment and began working for another company. During this time, she submitted multiple fictitious doctors reports in an attempt to continue to receive disability payments from the workers’ compensation insurance company.
When confronted by detectives, Cavalcanti ultimately admitted to the fraudulent documents and forged doctors’ signatures.
During the investigation, department detectives discovered Cavalcanti attempted to file a new workers’ compensation claim at a different insurance company with her new employer.
The new workers’ compensation claim dates and injuries were similar and overlapped with her initial claim. The investigation by detectives prevented payment on this subsequent fraudulent claim and the insurance company incurred no loss.
"The Marin County District Attorney’s Office will continue to partner with the California Department of Insurance to investigate and prosecute workers’ compensation fraud in every form. Whether it is claimant fraud as in the case of Ms. Cavalcanti, which drive up premiums for employers, or businesses who seek to gain an unfair advantage by underinsuring their employees, workers’ compensation fraud remains a priority for our office," said Deputy District Attorney Sean Kensinger.
Cavalcanti is expected back in court September 9, 2020 for sentencing. The Marin County District Attorney’s Office prosecuted this case ...
Cavalcanti, employed as an executive assistant, reportedly fell at work and sustained injuries. As a result of her subsequent workers’ compensation claim, Cavalcanti received more than $42,000 in total temporary disability payments in addition to her medical treatment.
An investigation by the Department of Insurance revealed after being placed on disability, Cavalcanti ceased medical treatment and began working for another company. During this time, she submitted multiple fictitious doctors reports in an attempt to continue to receive disability payments from the workers’ compensation insurance company.
When confronted by detectives, Cavalcanti ultimately admitted to the fraudulent documents and forged doctors’ signatures.
During the investigation, department detectives discovered Cavalcanti attempted to file a new workers’ compensation claim at a different insurance company with her new employer.
The new workers’ compensation claim dates and injuries were similar and overlapped with her initial claim. The investigation by detectives prevented payment on this subsequent fraudulent claim and the insurance company incurred no loss.
"The Marin County District Attorney’s Office will continue to partner with the California Department of Insurance to investigate and prosecute workers’ compensation fraud in every form. Whether it is claimant fraud as in the case of Ms. Cavalcanti, which drive up premiums for employers, or businesses who seek to gain an unfair advantage by underinsuring their employees, workers’ compensation fraud remains a priority for our office," said Deputy District Attorney Sean Kensinger.
Cavalcanti is expected back in court September 9, 2020 for sentencing. The Marin County District Attorney’s Office prosecuted this case ...
U.S. News announced the 2020-2021 list of Best Hospitals in the country.
It analyzed data from nearly 5,000 medical centers and survey responses from more than 30,000 physicians to rank hospitals in 16 adult specialties including cancer, cardiology, diabetes, rheumatology and more. Survival rates, patient experience, specialized staff and advanced technologies were among the factors weighed.
Nationally, only 134 hospitals ranked in at least one of the specialties in 2020-2021. The Honor Roll recognizes 20 hospitals for their exceptional care for complex cases across these specialties, as well as recognizes hospitals by state, metro and regional areas for their work in ten more widely performed procedures and conditions, including hip and knee replacement, cancer surgery, heart bypass and more.
With a specialty score of 100/100, Hospital for Special Surgery (HSS) in New York topped the annual Best Hospitals for Orthopedics rankings, which included 1,683 orthopedic hospitals nationwide.
Mayo Clinic Rochester, Cedars-Sinai Medical Center, NYU Langone Orthopedic Hospital and Rush University Medical Center rounded out the top five Best Hospitals for Orthopedics.
However, overall, California hospitals had a respectable showing on the Orthopedic Hospital list, with seven hospitals ranking in the top 30.
#3 - Cedars-Sinai Medical Center,Los Angeles,
#7 - Santa Monica UCLA Medical Center and Orthopedic Hospital
#10 - Scripps La Jolla Hospitals
#12 - Stanford Health Care - Stanford Hospital
#15 - UCSF Medical Center
#26 - John Muir Health - Walnut Creek
#30 - Keck Medical Center of USC ...
It analyzed data from nearly 5,000 medical centers and survey responses from more than 30,000 physicians to rank hospitals in 16 adult specialties including cancer, cardiology, diabetes, rheumatology and more. Survival rates, patient experience, specialized staff and advanced technologies were among the factors weighed.
Nationally, only 134 hospitals ranked in at least one of the specialties in 2020-2021. The Honor Roll recognizes 20 hospitals for their exceptional care for complex cases across these specialties, as well as recognizes hospitals by state, metro and regional areas for their work in ten more widely performed procedures and conditions, including hip and knee replacement, cancer surgery, heart bypass and more.
With a specialty score of 100/100, Hospital for Special Surgery (HSS) in New York topped the annual Best Hospitals for Orthopedics rankings, which included 1,683 orthopedic hospitals nationwide.
Mayo Clinic Rochester, Cedars-Sinai Medical Center, NYU Langone Orthopedic Hospital and Rush University Medical Center rounded out the top five Best Hospitals for Orthopedics.
However, overall, California hospitals had a respectable showing on the Orthopedic Hospital list, with seven hospitals ranking in the top 30.
#3 - Cedars-Sinai Medical Center,Los Angeles,
#7 - Santa Monica UCLA Medical Center and Orthopedic Hospital
#10 - Scripps La Jolla Hospitals
#12 - Stanford Health Care - Stanford Hospital
#15 - UCSF Medical Center
#26 - John Muir Health - Walnut Creek
#30 - Keck Medical Center of USC ...
Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 added mandatory reporting requirements with respect to Medicare beneficiaries who have coverage under group health plan arrangements as well as for Medicare beneficiaries who receive settlements, judgments, awards or other payment from workers’ compensation, which is referred to as Non-Group Health Plan or NGHP insurance.
The purpose of Section 111 reporting is to enable CMS to pay appropriately for Medicare-covered items and services furnished to Medicare beneficiaries. Workers’ compensation claim information helps CMS determine when other insurance coverage is primary to Medicare, meaning that it should pay for the items and services first before Medicare considers its payment responsibilities.
Reporting is accomplished by either the submission of an electronic file of liability, no-fault, and workers’ compensation claim information, where the injured party is a Medicare beneficiary, or by entry of this claim information directly into a secure Web portal, depending on the volume of data to be submitted.
Upon receipt of this information, CMS checks whether the injured party associated with the claim report is a Medicare beneficiary, and determines if the other insurance is primary to Medicare. CMS then uses this information in the Medicare claims payment process and, if Medicare paid first when it should not have, uses it to seek repayment from the other insurer or the Medicare beneficiary.
The Centers for Medicare and Medicaid Services (CMS) has released a notice announcing it will be holding a webinar for Section 111 non-group health plan (NGHP) reporting on August 13, 2020, at 1:00 p.m. ET.
The agency released a new Section 111 NGHP User Guide in June, which contained a reminder regarding the $750 low dollar reporting threshold, incorporated its recent alert addressing no-fault and med-pay reporting, and provided several other technical update changes. This User Guide is the primary source for Section 111 reporting requirements.
Those interested in attending CMS’s webinar, please see CMS’s notice for further details and webinar registration information.
Please note that for this webinar you will need to access the webinar link and dial in using the information above to access the visual and audio portion of the presentation. Due to the number of participants please dial in at least 15 minutes prior to the start of the presentation ...
The purpose of Section 111 reporting is to enable CMS to pay appropriately for Medicare-covered items and services furnished to Medicare beneficiaries. Workers’ compensation claim information helps CMS determine when other insurance coverage is primary to Medicare, meaning that it should pay for the items and services first before Medicare considers its payment responsibilities.
Reporting is accomplished by either the submission of an electronic file of liability, no-fault, and workers’ compensation claim information, where the injured party is a Medicare beneficiary, or by entry of this claim information directly into a secure Web portal, depending on the volume of data to be submitted.
Upon receipt of this information, CMS checks whether the injured party associated with the claim report is a Medicare beneficiary, and determines if the other insurance is primary to Medicare. CMS then uses this information in the Medicare claims payment process and, if Medicare paid first when it should not have, uses it to seek repayment from the other insurer or the Medicare beneficiary.
The Centers for Medicare and Medicaid Services (CMS) has released a notice announcing it will be holding a webinar for Section 111 non-group health plan (NGHP) reporting on August 13, 2020, at 1:00 p.m. ET.
The agency released a new Section 111 NGHP User Guide in June, which contained a reminder regarding the $750 low dollar reporting threshold, incorporated its recent alert addressing no-fault and med-pay reporting, and provided several other technical update changes. This User Guide is the primary source for Section 111 reporting requirements.
Those interested in attending CMS’s webinar, please see CMS’s notice for further details and webinar registration information.
Please note that for this webinar you will need to access the webinar link and dial in using the information above to access the visual and audio portion of the presentation. Due to the number of participants please dial in at least 15 minutes prior to the start of the presentation ...
Millions of workers have been uprooted by COVID-19 and been thrown into a "new normal" of working from home offices. To further complicate things, many individuals were provided with only a laptop and little, if any, education on setting up an ergonomically correct workstation.
As a result, many home office - based workers potentially face suboptimal working conditions. Workers across the nation have converted their basements, spare rooms, dining room tables or bedrooms into makeshift offices.
Kermit Davis, PhD, an expert in office ergonomics at the University of Cincinnati College of Medicine, conducted an ergonomic assessment of employees at the University of Cincinnati sending out an email survey to 4,500 faculty and staff after the coronavirus pandemic prompted the university to join many other employers across the nation in sending workers home to continue operations.
The survey had 843 people complete it. As part of the study, 41 employees sent Davis photos of workers at home workstations for ergonomic review. This subset showed some trends and offered a glimpse into what many who work from home are encountering. The survey’s findings were recently published in the scholarly journal Ergonomics in Design.
Davis says the ergonomic evaluations of the home workstations identified many issues that could be adversely affecting the workers. Many chairs were the wrong height with about 41% too low and 2% too high. Fifty-three percent of workers had armrests on their chairs, but 32% did not use them and for 18% of workers the armrests were improperly adjusted, the study found.
Davis says not using the armrests causes contact stress on forearms when rested on the hard front edge of work surfaces and strain across the upper back as the arms need support. Also, support of the back of the chair was not used by 69% and often without any lumbar support for 73% of survey participants. That meant many individuals did not have proper support of their lower back, maintaining the lumbar curvature.
The position of a computer monitor was often too low or off to the side. Three quarters of monitors were laptops, which were too low relative to the workers’ eye height, the study found. External monitors were also routinely set up too low in 52% of participants or too high in 4%. Another common issue with the monitors was the lack of the primary screens centered in front of the workers occurring in 31% of workers and resulting in twisting of the neck and/or back to view the monitor, according to the study.
Here are a few tips that might be helpful for the homebound office worker:
-- Place a pillow on your seat to elevate the seat height.
-- Place a pillow or rolled up towel behind your back to provide lumbar and back support.
-- Wrap armrests when they are low and not adjustable.
-- Move your chair closer to the desk or table to encourage having the back against the back of the seat.
-- If a laptop is too low, place a lap desk or large pillow under the laptop to raise the monitor when using it on the lap.
-- Use an external keyboard and mouse, along with raising the laptop monitor by placing a stack of books or a box under the laptop when using a laptop on a desk.
-- An appropriate standing workstation should have the top of the monitor at eye height and directly in front, keyboard at a height so that forearms are parallel to the ground (approximately 90° elbow angle), and a soft or rounded front edge to the working surface.
-- If obtaining a new chair or identifying an appropriate sitting workstation at home is not possible, rotating between a poor sitting workstation and a standing workstation would be the next best practice. There are many simple, makeshift standing workstations available in the home, including implementing the use of an ironing board, a kitchen counter, the top of a piano, a clothes basket placed upside down on a table or desk or a large box under the laptop ...
As a result, many home office - based workers potentially face suboptimal working conditions. Workers across the nation have converted their basements, spare rooms, dining room tables or bedrooms into makeshift offices.
Kermit Davis, PhD, an expert in office ergonomics at the University of Cincinnati College of Medicine, conducted an ergonomic assessment of employees at the University of Cincinnati sending out an email survey to 4,500 faculty and staff after the coronavirus pandemic prompted the university to join many other employers across the nation in sending workers home to continue operations.
The survey had 843 people complete it. As part of the study, 41 employees sent Davis photos of workers at home workstations for ergonomic review. This subset showed some trends and offered a glimpse into what many who work from home are encountering. The survey’s findings were recently published in the scholarly journal Ergonomics in Design.
Davis says the ergonomic evaluations of the home workstations identified many issues that could be adversely affecting the workers. Many chairs were the wrong height with about 41% too low and 2% too high. Fifty-three percent of workers had armrests on their chairs, but 32% did not use them and for 18% of workers the armrests were improperly adjusted, the study found.
Davis says not using the armrests causes contact stress on forearms when rested on the hard front edge of work surfaces and strain across the upper back as the arms need support. Also, support of the back of the chair was not used by 69% and often without any lumbar support for 73% of survey participants. That meant many individuals did not have proper support of their lower back, maintaining the lumbar curvature.
The position of a computer monitor was often too low or off to the side. Three quarters of monitors were laptops, which were too low relative to the workers’ eye height, the study found. External monitors were also routinely set up too low in 52% of participants or too high in 4%. Another common issue with the monitors was the lack of the primary screens centered in front of the workers occurring in 31% of workers and resulting in twisting of the neck and/or back to view the monitor, according to the study.
Here are a few tips that might be helpful for the homebound office worker:
-- Place a pillow on your seat to elevate the seat height.
-- Place a pillow or rolled up towel behind your back to provide lumbar and back support.
-- Wrap armrests when they are low and not adjustable.
-- Move your chair closer to the desk or table to encourage having the back against the back of the seat.
-- If a laptop is too low, place a lap desk or large pillow under the laptop to raise the monitor when using it on the lap.
-- Use an external keyboard and mouse, along with raising the laptop monitor by placing a stack of books or a box under the laptop when using a laptop on a desk.
-- An appropriate standing workstation should have the top of the monitor at eye height and directly in front, keyboard at a height so that forearms are parallel to the ground (approximately 90° elbow angle), and a soft or rounded front edge to the working surface.
-- If obtaining a new chair or identifying an appropriate sitting workstation at home is not possible, rotating between a poor sitting workstation and a standing workstation would be the next best practice. There are many simple, makeshift standing workstations available in the home, including implementing the use of an ironing board, a kitchen counter, the top of a piano, a clothes basket placed upside down on a table or desk or a large box under the laptop ...
KJL Consultants Inc., doing business as Luke’s Yreka Drug, and owner Lucas Walsh have agreed to pay $200,000 to resolve allegations that the pharmacy committed multiple violations of the Controlled Substances Act’s strict recordkeeping requirements.
The pharmacy permanently ceased operations in December 2018, and a key term of the settlement agreement included the pharmacy’s surrender of its DEA registration for cause.
The settlement relates to a DEA administrative audit and inspection of Luke’s Yreka Drug in September 2016 during which the DEA identified more than 150 Controlled Substances Act violations including failing to maintain the archived DEA-E-222 form for orders of controlled substances from a distributor, to properly document the quantity and/or date of controlled substances received from a distributor, and to conduct a complete and accurate biennial inventory.
"To prevent diversion of opioids and other dangerous drugs and avoid harm to the public from abuse of these powerful substances, it is critical that all pharmacies, whether they be large national chains or small local stores like Luke’s, ensure that their drug transactions are properly documented, tracked and inventoried," U.S. Attorney Scott said.
"This settlement emphasizes the importance of proper and diligent recordkeeping and the significant penalties to pharmacies that fail to do so."
This settlement resulted from joint efforts of the U.S. Attorney’s Office for the Eastern District of California and the DEA. It was handled by Assistant U.S. Attorney Lynn Trinka Ernce ...
The pharmacy permanently ceased operations in December 2018, and a key term of the settlement agreement included the pharmacy’s surrender of its DEA registration for cause.
The settlement relates to a DEA administrative audit and inspection of Luke’s Yreka Drug in September 2016 during which the DEA identified more than 150 Controlled Substances Act violations including failing to maintain the archived DEA-E-222 form for orders of controlled substances from a distributor, to properly document the quantity and/or date of controlled substances received from a distributor, and to conduct a complete and accurate biennial inventory.
"To prevent diversion of opioids and other dangerous drugs and avoid harm to the public from abuse of these powerful substances, it is critical that all pharmacies, whether they be large national chains or small local stores like Luke’s, ensure that their drug transactions are properly documented, tracked and inventoried," U.S. Attorney Scott said.
"This settlement emphasizes the importance of proper and diligent recordkeeping and the significant penalties to pharmacies that fail to do so."
This settlement resulted from joint efforts of the U.S. Attorney’s Office for the Eastern District of California and the DEA. It was handled by Assistant U.S. Attorney Lynn Trinka Ernce ...
Maurosan Milhomem pleaded no contest to six felonies related to his complex fraud schemes of insurance premium fraud and payroll tax fraud. He also admitted a white collar crime enhancement that he caused the loss of more than $500,000.
Milhomem is the owner of Viking Pavers, Inc., a construction company based out of Point Richmond, California. The successful resolution to this criminal case was a result of a joint investigation by the Fraud Division of the California Department of Insurance, Criminal Investigation Division of the Employment Development Department, and the Contra Costa County District Attorney's Office.
The Contractors’ State Licensing Board and Department of Industrial Relations previously issued Viking Pavers, Inc. civil citations in 2017. Investigators from the Board and Marin County District Attorney’s Office discovered a subcontractor work crew operating for the company without a license and without worker compensation insurance under the name FF Services during a random job site inspection.
The Business and Professions Code does not permit construction companies to subcontract construction work unless the crews have their own license. This is because licensed subcontractors are required to have their own bond and workers compensation insurance to protect homeowners and employees.
The District Attorney’s Office learned of the fraud after employees of Viking Pavers were involved in a vehicle accident. The employees were never reported during premium audits as employees or subcontractors. These audits help confirm if an employer is following the law and ensure the appropriate classifications for their employees and subcontractors.
The investigation by the Contra Costa County District Attorney’s Office revealed that Viking Pavers continued to use FF Services as an unlicensed subcontractor after the civil citations and throughout 2018. The company re-routed the payments off the books to avoid detection during required audits. Forensic accountants traced payments to FF Services and other unlicensed and uninsured work crews, initially through a check cashing service in Richmond, California, and then through the bank accounts of a newly created a shell company. A subsequent search warrant at the business resulted in the seizure of over $80,000 in cash.
Milhomem will serve 364 days in county jail and is eligible to serve the sentence through electronic home detention. In addition, he will serve five years of formal probation. He is ordered to pay $1,109,603 to Markel Corporation for the underpayment of workers’ compensation insurance premium, $808,455.34 to the Employment Development Department for the underpayment of tax liability and $312,000 to Berkshire Hathaway for the underpayment of workers’ compensation insurance premium.
The Court ordered the seized cash forfeited as criminal restitution pursuant to the plea agreement ...
Milhomem is the owner of Viking Pavers, Inc., a construction company based out of Point Richmond, California. The successful resolution to this criminal case was a result of a joint investigation by the Fraud Division of the California Department of Insurance, Criminal Investigation Division of the Employment Development Department, and the Contra Costa County District Attorney's Office.
The Contractors’ State Licensing Board and Department of Industrial Relations previously issued Viking Pavers, Inc. civil citations in 2017. Investigators from the Board and Marin County District Attorney’s Office discovered a subcontractor work crew operating for the company without a license and without worker compensation insurance under the name FF Services during a random job site inspection.
The Business and Professions Code does not permit construction companies to subcontract construction work unless the crews have their own license. This is because licensed subcontractors are required to have their own bond and workers compensation insurance to protect homeowners and employees.
The District Attorney’s Office learned of the fraud after employees of Viking Pavers were involved in a vehicle accident. The employees were never reported during premium audits as employees or subcontractors. These audits help confirm if an employer is following the law and ensure the appropriate classifications for their employees and subcontractors.
The investigation by the Contra Costa County District Attorney’s Office revealed that Viking Pavers continued to use FF Services as an unlicensed subcontractor after the civil citations and throughout 2018. The company re-routed the payments off the books to avoid detection during required audits. Forensic accountants traced payments to FF Services and other unlicensed and uninsured work crews, initially through a check cashing service in Richmond, California, and then through the bank accounts of a newly created a shell company. A subsequent search warrant at the business resulted in the seizure of over $80,000 in cash.
Milhomem will serve 364 days in county jail and is eligible to serve the sentence through electronic home detention. In addition, he will serve five years of formal probation. He is ordered to pay $1,109,603 to Markel Corporation for the underpayment of workers’ compensation insurance premium, $808,455.34 to the Employment Development Department for the underpayment of tax liability and $312,000 to Berkshire Hathaway for the underpayment of workers’ compensation insurance premium.
The Court ordered the seized cash forfeited as criminal restitution pursuant to the plea agreement ...
About 4,000 federal employees have filed workers’ compensation claims with the Labor Department due to COVID-19. 60 people have filed death claims. Labor projects COVID-19 claims among federal employees may reach 6,000 in the coming weeks.
As part of Phase 1 of the Office of Inspector General’s Pandemic Oversight Response Plan, a new report published this month presents the results of its audit of the Office of Workers’ Compensation Programs’ (OWCP) initial response to the pandemic.
It conducted a performance audit to answer the following question: To what extent has COVID-19 affected OWCP’s ability to process and adjudicate claims, and what has OWCP done to address challenges encountered?
The department’s inspector general says the division that handles federal employee claims is anticipating a strain in resources due to demand and social distancing mandates. It has alternative staffing plans if COVID-19 compensation claims continue to surge. Labor says it’s accepted over 1,600 federal employees claims so far. Over 2,300 are unadjudicated.
It found that most OWCP programs are experiencing or expecting delays and resource management issues as a result of increasing claims or social distancing mandates brought on by the pandemic. In response, the programs are tracking delays, providing guidance, extending deadlines, and taking additional actions as needed.
Specifically:The Division of Federal Employees' Compensation (DFEC) is expecting a potential strain on resources and claims processing delays. To address these potential challenges, DFEC developed a contingency plan, issued new procedures for handling COVID-19 claims, and created a COVID-19 Task Force to oversee claims development and adjudication.
The Division of Coal Mine Workers’ Compensation (DCMWC) is experiencing challenges in its ability to process claims timely because a significant number of approved physicians have temporarily suspended pulmonary examinations, which are required for a coal miner’s claim to be processed. These delays are creating a backlog that could strain resources when physicians resume claimant examinations. DCMWC is tracking the delays and has taken steps to assist claimants, including publishing guidance on its website and extending deadlines.
The Division of Energy Employees Occupational Illness Compensation (DEEOIC) is experiencing delays in obtaining required information from certain Department of Energy facilities and physicians who have closed or limited operations during the pandemic. DEEOIC is tracking a small number of impacted claims and allowing for extensions in these cases.
The Division of Longshore and Harbor Workers' Compensation (DLHWC) has not experienced, nor is it expecting, any significant impact from the COVID-19 pandemic ...
As part of Phase 1 of the Office of Inspector General’s Pandemic Oversight Response Plan, a new report published this month presents the results of its audit of the Office of Workers’ Compensation Programs’ (OWCP) initial response to the pandemic.
It conducted a performance audit to answer the following question: To what extent has COVID-19 affected OWCP’s ability to process and adjudicate claims, and what has OWCP done to address challenges encountered?
The department’s inspector general says the division that handles federal employee claims is anticipating a strain in resources due to demand and social distancing mandates. It has alternative staffing plans if COVID-19 compensation claims continue to surge. Labor says it’s accepted over 1,600 federal employees claims so far. Over 2,300 are unadjudicated.
It found that most OWCP programs are experiencing or expecting delays and resource management issues as a result of increasing claims or social distancing mandates brought on by the pandemic. In response, the programs are tracking delays, providing guidance, extending deadlines, and taking additional actions as needed.
Specifically:The Division of Federal Employees' Compensation (DFEC) is expecting a potential strain on resources and claims processing delays. To address these potential challenges, DFEC developed a contingency plan, issued new procedures for handling COVID-19 claims, and created a COVID-19 Task Force to oversee claims development and adjudication.
The Division of Coal Mine Workers’ Compensation (DCMWC) is experiencing challenges in its ability to process claims timely because a significant number of approved physicians have temporarily suspended pulmonary examinations, which are required for a coal miner’s claim to be processed. These delays are creating a backlog that could strain resources when physicians resume claimant examinations. DCMWC is tracking the delays and has taken steps to assist claimants, including publishing guidance on its website and extending deadlines.
The Division of Energy Employees Occupational Illness Compensation (DEEOIC) is experiencing delays in obtaining required information from certain Department of Energy facilities and physicians who have closed or limited operations during the pandemic. DEEOIC is tracking a small number of impacted claims and allowing for extensions in these cases.
The Division of Longshore and Harbor Workers' Compensation (DLHWC) has not experienced, nor is it expecting, any significant impact from the COVID-19 pandemic ...
On September 30, 2008, Patrick Sauceda was injured while working as a teacher for the Fresno Unified School District. He injured his head, left eye, and left knee following a physical attack by a student. The case was resolved by a Stipulations with Request for Award on December 13, 2010.
He then filed a Petition for Increased Benefits for Serious and Willful Misconduct of Employer. He alleges thad his industrial injury was the result of being assaulted by a special education student who had been previously identified and known to the School District to be a person with propensities for causing serious injury to others and who had stated on more than one occasion that he intended to kill or cause serious injury to Mr. Sauceda.
He claimed that the special education program manager, Nancy Miser, "was advised that a specific student in applicant's classroom had a prior history of physically attacking two different teachers on separate occasions at a previous school [and] that this student had made specific threats that he intended to kill or seriously injury applicant," but Ms. Miser refused a request to move the student to "another emotionally disturbed program on another campus," stating that "applicant would have to find a way to deal with the student."
The classroom had no radio or telephone for use in case of emergency.
The WCJ awarded Serious and Willful Misconduct benefits. Reconsideration was denied in the split panel decision of Sauceda v Fresno Unified School District.
Labor Code section 4553, a finding of liability is appropriate where the employer 1) knew of the dangerous condition; 2) knew that the probable consequences of the continuance of that condition would involve serious injury to an employee; and 3) deliberately failed to take corrective action.
"Here, it is undisputed that defendant knew of the dangerous condition. Defendant has admitted to knowing that the student assailant had a prior history of physically attacking two different teachers on separate occasions at a previous school and that this student had made specific threats that he intended to kill or seriously injury applicant."
Applicant has amply shown that defendant deliberately failed to take corrective action. Defendant has made no attempt to deny that, when presented with the evidence from the student assailant's file, the administrative team at applicant's place of work declined to take any action to remove the student assailant from applicant's classroom ...
He then filed a Petition for Increased Benefits for Serious and Willful Misconduct of Employer. He alleges thad his industrial injury was the result of being assaulted by a special education student who had been previously identified and known to the School District to be a person with propensities for causing serious injury to others and who had stated on more than one occasion that he intended to kill or cause serious injury to Mr. Sauceda.
He claimed that the special education program manager, Nancy Miser, "was advised that a specific student in applicant's classroom had a prior history of physically attacking two different teachers on separate occasions at a previous school [and] that this student had made specific threats that he intended to kill or seriously injury applicant," but Ms. Miser refused a request to move the student to "another emotionally disturbed program on another campus," stating that "applicant would have to find a way to deal with the student."
The classroom had no radio or telephone for use in case of emergency.
The WCJ awarded Serious and Willful Misconduct benefits. Reconsideration was denied in the split panel decision of Sauceda v Fresno Unified School District.
Labor Code section 4553, a finding of liability is appropriate where the employer 1) knew of the dangerous condition; 2) knew that the probable consequences of the continuance of that condition would involve serious injury to an employee; and 3) deliberately failed to take corrective action.
"Here, it is undisputed that defendant knew of the dangerous condition. Defendant has admitted to knowing that the student assailant had a prior history of physically attacking two different teachers on separate occasions at a previous school and that this student had made specific threats that he intended to kill or seriously injury applicant."
Applicant has amply shown that defendant deliberately failed to take corrective action. Defendant has made no attempt to deny that, when presented with the evidence from the student assailant's file, the administrative team at applicant's place of work declined to take any action to remove the student assailant from applicant's classroom ...
Six former National Football League (NFL) players have been charged in a superseding indictment in the Eastern District of Kentucky for their alleged roles in a nationwide fraud on a health care benefit program for retired NFL players.
Darrell Reid, 38, of Farmingdale New Jersey, Antwan Odom, 38, of Irvington, Alabama, Anthony Montgomery, 36, of Cleveland, Ohio, Clinton Portis, 38, of Fort Mill, South Carolina, Tamarick Vanover, 46, of Tallahassee, Florida, and Robert McCune, 41, of Riverdale, Georgia, were charged in the superseding indictment. Each of the defendants was charged with one count of conspiracy to commit health care fraud and wire fraud. Reid, Odom, Montgomery, and Portis were also each charged with one count of wire fraud and one count of health care fraud. Vanover was also charged with two counts of wire fraud and two counts of health care fraud. And McCune was also charged with 10 counts of wire fraud, 12 counts of health care fraud, and three counts of aggravated identity theft.
McCune and 11 other former NFL players, including Portis and Vanover, were previously charged in the Eastern District of Kentucky in December 2019 for their alleged roles in the fraud. The alleged fraud targeted the Gene Upshaw NFL Player Health Reimbursement Account Plan, which was established pursuant to the 2006 collective bargaining agreement and provided for tax-free reimbursement of out-of-pocket medical care expenses that were not covered by insurance and that were incurred by former players, their wives and their dependents – up to a maximum of $350,000 per player. According to the charging documents, over $3.9 million in false and fraudulent claims were submitted to the Plan, and the Plan paid out over $3.4 million on those claims between June 2017 and December 2018.
Since the initial charges were announced, seven of the defendants have entered guilty pleas. Correll Buckhalter, James Butler, Joseph Horn, Etric Pruitt, Ceandris Brown, John Eubanks and Donald "Reche" Caldwell, who passed away in June, each pleaded guilty to conspiracy to commit health care fraud.
On June 22, 2020, Brown was sentenced for his role in the scheme to a term of incarceration of 12 months and one day. Sentencing for the remaining defendants is pending.
The superseding indictment adds Reid, Odom, and Montgomery as defendants for their roles in the scheme, and it adds additional charges against McCune: three counts of aggravated identity theft for McCune’s unlawful use of the identity of other persons as part of this scheme; and two counts of health care fraud for a scheme whereby McCune allegedly submitted or caused the submission of false and fraudulent claims to the Plan on his own behalf.
The superseding indictment alleges that the scheme to defraud involved the submission of false and fraudulent claims to the Plan for expensive medical equipment - typically between $40,000 and $50,000 for each claim - that was never purchased or received. The expensive medical equipment described on the false and fraudulent claims included hyperbaric oxygen chambers, cryotherapy machines, ultrasound machines designed for use by a doctor’s office to conduct women’s health examinations and electromagnetic therapy devices designed for use on horses.
The superseding indictment further alleges that McCune, Vanover, and others recruited other players into the scheme by offering to submit or cause the submission of these false and fraudulent claims in exchange for kickbacks and bribes that ranged from a few thousand dollars to $10,000 or more per claim submitted. As part of the scheme, the defendants allegedly fabricated supporting documentation for the claims, including invoices, prescriptions and letters of medical necessity ...
Darrell Reid, 38, of Farmingdale New Jersey, Antwan Odom, 38, of Irvington, Alabama, Anthony Montgomery, 36, of Cleveland, Ohio, Clinton Portis, 38, of Fort Mill, South Carolina, Tamarick Vanover, 46, of Tallahassee, Florida, and Robert McCune, 41, of Riverdale, Georgia, were charged in the superseding indictment. Each of the defendants was charged with one count of conspiracy to commit health care fraud and wire fraud. Reid, Odom, Montgomery, and Portis were also each charged with one count of wire fraud and one count of health care fraud. Vanover was also charged with two counts of wire fraud and two counts of health care fraud. And McCune was also charged with 10 counts of wire fraud, 12 counts of health care fraud, and three counts of aggravated identity theft.
McCune and 11 other former NFL players, including Portis and Vanover, were previously charged in the Eastern District of Kentucky in December 2019 for their alleged roles in the fraud. The alleged fraud targeted the Gene Upshaw NFL Player Health Reimbursement Account Plan, which was established pursuant to the 2006 collective bargaining agreement and provided for tax-free reimbursement of out-of-pocket medical care expenses that were not covered by insurance and that were incurred by former players, their wives and their dependents – up to a maximum of $350,000 per player. According to the charging documents, over $3.9 million in false and fraudulent claims were submitted to the Plan, and the Plan paid out over $3.4 million on those claims between June 2017 and December 2018.
Since the initial charges were announced, seven of the defendants have entered guilty pleas. Correll Buckhalter, James Butler, Joseph Horn, Etric Pruitt, Ceandris Brown, John Eubanks and Donald "Reche" Caldwell, who passed away in June, each pleaded guilty to conspiracy to commit health care fraud.
On June 22, 2020, Brown was sentenced for his role in the scheme to a term of incarceration of 12 months and one day. Sentencing for the remaining defendants is pending.
The superseding indictment adds Reid, Odom, and Montgomery as defendants for their roles in the scheme, and it adds additional charges against McCune: three counts of aggravated identity theft for McCune’s unlawful use of the identity of other persons as part of this scheme; and two counts of health care fraud for a scheme whereby McCune allegedly submitted or caused the submission of false and fraudulent claims to the Plan on his own behalf.
The superseding indictment alleges that the scheme to defraud involved the submission of false and fraudulent claims to the Plan for expensive medical equipment - typically between $40,000 and $50,000 for each claim - that was never purchased or received. The expensive medical equipment described on the false and fraudulent claims included hyperbaric oxygen chambers, cryotherapy machines, ultrasound machines designed for use by a doctor’s office to conduct women’s health examinations and electromagnetic therapy devices designed for use on horses.
The superseding indictment further alleges that McCune, Vanover, and others recruited other players into the scheme by offering to submit or cause the submission of these false and fraudulent claims in exchange for kickbacks and bribes that ranged from a few thousand dollars to $10,000 or more per claim submitted. As part of the scheme, the defendants allegedly fabricated supporting documentation for the claims, including invoices, prescriptions and letters of medical necessity ...
San Diego-based clinical laboratory Progenity, Inc. admitted that it submitted fraudulent bills to TRICARE, the Department of Defense health care benefit program that covers military service members and their dependents, and to the Federal Health Care Employee Benefits Program (FEHBP), for clinical tests that it knew were not covered or properly payable by either program.
In addition, Progenity, formerly known as Ascendant MDx, Inc., and previously headquartered in Carlsbad, California, admitted that it offered improper incentives to patients and doctors to use its laboratory services.
To account for its fraud, Progenity has agreed to pay a total of $49 million in civil settlements in federal courts in the Southern District of California (SDCA) and the Southern District of New York (SDNY), as well as to multiple states.
Progenity offered noninvasive prenatal testing ("NIPT") to pregnant women. NIPT refers to a category of genetic tests that screen for fetal chromosomal abnormalities, through analysis of fetal DNA present in a pregnant woman’s blood.
This form of genetic testing, however, did not have FDA approval and was considered by TRICARE as a "laboratory-developed test." As a result, TRICARE did not cover NIPT tests for its beneficiaries.
Therefore, in order to get reimbursed by TRICARE, Progenity falsely and fraudulently used a medical billing code that TRICARE covered, but that Progenity knew did not accurately reflect that the NIPT test.
The U.S. Attorney’s Office for SDCA launched both a criminal probe into Progenity’s fraudulent billing practices and a civil investigation of the false claims Progenity had submitted to TRICARE and the FEHBP. Separately, SDNY initiated its own investigation into misconduct by Progenity relating to the improper incentives provided to patients and doctors to use its laboratory services. SDNY also coordinated with multiple state Attorneys General to investigate Progenity’s miscoding of NIPT to Medicaid programs in New York and several other states.
Progenity’s settlement agreement requires the company to pay $16.4 million to settle the SDCA civil matter, $19,449,316 to settle the SDNY civil matter, and $13,150,684 to settle the state civil allegations.
The civil settlements were based on an ability-to-pay, payment-over-time basis, following an analysis of financial condition submissions made by Progenity. In light of Progenity’s remedial efforts, cooperation with the investigation, and payment of restitution to TRICARE and the FEHBP, the criminal investigation was resolved via a non-prosecution agreement, requiring that Progenity admit its misconduct and be subject to additional terms and conditions for up to a 24-month period ...
In addition, Progenity, formerly known as Ascendant MDx, Inc., and previously headquartered in Carlsbad, California, admitted that it offered improper incentives to patients and doctors to use its laboratory services.
To account for its fraud, Progenity has agreed to pay a total of $49 million in civil settlements in federal courts in the Southern District of California (SDCA) and the Southern District of New York (SDNY), as well as to multiple states.
Progenity offered noninvasive prenatal testing ("NIPT") to pregnant women. NIPT refers to a category of genetic tests that screen for fetal chromosomal abnormalities, through analysis of fetal DNA present in a pregnant woman’s blood.
This form of genetic testing, however, did not have FDA approval and was considered by TRICARE as a "laboratory-developed test." As a result, TRICARE did not cover NIPT tests for its beneficiaries.
Therefore, in order to get reimbursed by TRICARE, Progenity falsely and fraudulently used a medical billing code that TRICARE covered, but that Progenity knew did not accurately reflect that the NIPT test.
The U.S. Attorney’s Office for SDCA launched both a criminal probe into Progenity’s fraudulent billing practices and a civil investigation of the false claims Progenity had submitted to TRICARE and the FEHBP. Separately, SDNY initiated its own investigation into misconduct by Progenity relating to the improper incentives provided to patients and doctors to use its laboratory services. SDNY also coordinated with multiple state Attorneys General to investigate Progenity’s miscoding of NIPT to Medicaid programs in New York and several other states.
Progenity’s settlement agreement requires the company to pay $16.4 million to settle the SDCA civil matter, $19,449,316 to settle the SDNY civil matter, and $13,150,684 to settle the state civil allegations.
The civil settlements were based on an ability-to-pay, payment-over-time basis, following an analysis of financial condition submissions made by Progenity. In light of Progenity’s remedial efforts, cooperation with the investigation, and payment of restitution to TRICARE and the FEHBP, the criminal investigation was resolved via a non-prosecution agreement, requiring that Progenity admit its misconduct and be subject to additional terms and conditions for up to a 24-month period ...
With many of California's workplaces facing significant changes fueled by the COVID-19 pandemic, state lawmakers are considering whether labor laws also need to evolve.
Legislators have proposed expanding workers' compensation eligibility so that more employees will be covered if they are diagnosed with COVID-19, increasing the number of sick days for food service workers and requiring employers to pay a portion of utility and internet bills for teleworkers.
MSN reports that Gov. Gavin Newsom said that he plans to work "hand in glove" with the Legislature to expand workplace protections, including guaranteeing COVID-19-related sick leave, easing workers' compensation claim requirements, enforcing labor laws and ensuring employers are reporting outbreaks.
Assemblywoman Lorena Gonzalez (D-San Diego) and state Sen. Jerry Hill (D-San Mateo) both have bills to ease restrictions on workers' compensation so more employees have access to the benefit. Talks are underway to combine Gonzalez's bill with Hill's legislation, Senate Bill 1159, the lawmakers said.
SB 1159 would add coronavirus-related illness or death to the list of on-the-job injuries covered under the state's workers' compensation program while removing a requirement that workers prove they contracted the virus on the job. Instead, employers would have to prove that COVID-19 wasn't contracted in the workplace.
Newsom included a similar measure for essential workers in a May 6 executive order - a big win for labor unions. However, that executive order only eased the burden of proof for workers with COVID-19 before July 5.
As currently written, Gonzalez's bill, AB 196, would go a step further than Hill's legislation by creating a presumption that essential workers who contract COVID-19 were infected while on the job, with no ability for the employer to contest that finding.
Among the other workplace bills the Legislature will consider in the coming weeks is AB 3216 by Assemblyman Ash Kalra (D-San Jose), which would make it an unlawful employment practice to refuse a request for up to 12 weeks of job-protected leave from a worker who needs to care for a child whose school or daycare has closed due to a state, local or federal public health emergency.
Assembly Bill 1492 by Assemblywoman Tasha Boerner Horvath (D-Encinitas) would ease workplace restrictions dictating when employees must take meal and rest breaks during the day - a proposal intended to provide more flexibility in working from home - while requiring employers to pay for an additional hour of work if the employer requires workers to skip those breaks. The bill also would require an employer to pay for equipment needed to work from home and a portion of the worker's home internet and utility bills.
Senate Bill 729 by state Sen. Anthony Portantino (D-La Cañada Flintridge) would require employers to provide an additional 80 hours of paid COVID-19 sick leave to full-time food sector workers during a declared local or state emergency.
Lawmakers have until Aug. 31 to send bills to Gov. Newsom before adjourning for the year.
...
Legislators have proposed expanding workers' compensation eligibility so that more employees will be covered if they are diagnosed with COVID-19, increasing the number of sick days for food service workers and requiring employers to pay a portion of utility and internet bills for teleworkers.
MSN reports that Gov. Gavin Newsom said that he plans to work "hand in glove" with the Legislature to expand workplace protections, including guaranteeing COVID-19-related sick leave, easing workers' compensation claim requirements, enforcing labor laws and ensuring employers are reporting outbreaks.
Assemblywoman Lorena Gonzalez (D-San Diego) and state Sen. Jerry Hill (D-San Mateo) both have bills to ease restrictions on workers' compensation so more employees have access to the benefit. Talks are underway to combine Gonzalez's bill with Hill's legislation, Senate Bill 1159, the lawmakers said.
SB 1159 would add coronavirus-related illness or death to the list of on-the-job injuries covered under the state's workers' compensation program while removing a requirement that workers prove they contracted the virus on the job. Instead, employers would have to prove that COVID-19 wasn't contracted in the workplace.
Newsom included a similar measure for essential workers in a May 6 executive order - a big win for labor unions. However, that executive order only eased the burden of proof for workers with COVID-19 before July 5.
As currently written, Gonzalez's bill, AB 196, would go a step further than Hill's legislation by creating a presumption that essential workers who contract COVID-19 were infected while on the job, with no ability for the employer to contest that finding.
Among the other workplace bills the Legislature will consider in the coming weeks is AB 3216 by Assemblyman Ash Kalra (D-San Jose), which would make it an unlawful employment practice to refuse a request for up to 12 weeks of job-protected leave from a worker who needs to care for a child whose school or daycare has closed due to a state, local or federal public health emergency.
Assembly Bill 1492 by Assemblywoman Tasha Boerner Horvath (D-Encinitas) would ease workplace restrictions dictating when employees must take meal and rest breaks during the day - a proposal intended to provide more flexibility in working from home - while requiring employers to pay for an additional hour of work if the employer requires workers to skip those breaks. The bill also would require an employer to pay for equipment needed to work from home and a portion of the worker's home internet and utility bills.
Senate Bill 729 by state Sen. Anthony Portantino (D-La Cañada Flintridge) would require employers to provide an additional 80 hours of paid COVID-19 sick leave to full-time food sector workers during a declared local or state emergency.
Lawmakers have until Aug. 31 to send bills to Gov. Newsom before adjourning for the year.
...
In an opinion out of the United States District Court for the District of New Jersey, Osterbye v. United States, 2020 U.S. Dist. LEXIS 116591 , the Court denied Defendant Selective Insurance’s Motion to Dismiss Plaintiff’s suit and allegations that Defendant failed to reimburse Medicare for Osterbye’s medical expenses under the Medicare Secondary Payer Act (MSP) private cause of action pursuant to 42 USC § 1395y(b)(3)(A).
Plaintiffs’ decedent, Anna May Osterbye, a Medicare beneficiary, was injured in a fire at her home allegedly caused by the negligence of a plumbing contractor, insured by the Defendant. Osterbye.
The claim resulted in a settlement in the amount of $740,000 including $13,562.90 that Medicare estimated for reimbursement of conditional payments. On April 29, 2013, the Plaintiffs executed a Release.
After Plaintiffs reimbursed $13,562.90 to Medicare, Medicare issued a final demand letter for an additional amount of $118,071.28 on June 4, 2013. The Plaintiffs then proceeded to exhaust administrative appeals with Medicare. On June 26, 2019, the Medicare Appeals council dismissed Plaintiffs’ request for review.
On August 28, 2019, Plaintiffs elevated the dispute to the United States District Court. Defendant’s Motion to Dismiss asserted two main arguments 1) The statute of limitations time-bars Plaintiff’s MSP claim and 2) Dismissal is appropriate based upon the settlement agreement and release.
With respect to the statute of limitations defense, administrative remedies were not exhausted until June 26, 2019- over 6 years after the settlement and release were executed. Plaintiffs were unable to seek judicial review on their MSP claim until all administrative remedies were exhausted. It was not apparent on the face of Plaintiffs’ Complaint that Plaintiffs’ MSP private cause of action is time-barred and denied the Motion to dismiss on the statute of limitations defense.
Defendant argued that the Court should dismiss Plaintiff’s claims by enforcing the Release Plaintiffs executed on April 29, 2013. The Court ultimately determined that whether the Plaintiffs’ Release should be nullified based on mutual mistake turns on a factual inquiry that was better left for a later time.
The ultimate outcome of this case is yet to be determined; however, there are several clear warning signals and reminders found within this case. Relying on an initial Conditional Payment Letter, and not a Final Demand amount can leave a primary payer open to significant exposure. Understanding the Conditional Payment Recovery process also includes understanding the inner workings of the Medicare Administrative Appeals process, and the associated delay ...
Plaintiffs’ decedent, Anna May Osterbye, a Medicare beneficiary, was injured in a fire at her home allegedly caused by the negligence of a plumbing contractor, insured by the Defendant. Osterbye.
The claim resulted in a settlement in the amount of $740,000 including $13,562.90 that Medicare estimated for reimbursement of conditional payments. On April 29, 2013, the Plaintiffs executed a Release.
After Plaintiffs reimbursed $13,562.90 to Medicare, Medicare issued a final demand letter for an additional amount of $118,071.28 on June 4, 2013. The Plaintiffs then proceeded to exhaust administrative appeals with Medicare. On June 26, 2019, the Medicare Appeals council dismissed Plaintiffs’ request for review.
On August 28, 2019, Plaintiffs elevated the dispute to the United States District Court. Defendant’s Motion to Dismiss asserted two main arguments 1) The statute of limitations time-bars Plaintiff’s MSP claim and 2) Dismissal is appropriate based upon the settlement agreement and release.
With respect to the statute of limitations defense, administrative remedies were not exhausted until June 26, 2019- over 6 years after the settlement and release were executed. Plaintiffs were unable to seek judicial review on their MSP claim until all administrative remedies were exhausted. It was not apparent on the face of Plaintiffs’ Complaint that Plaintiffs’ MSP private cause of action is time-barred and denied the Motion to dismiss on the statute of limitations defense.
Defendant argued that the Court should dismiss Plaintiff’s claims by enforcing the Release Plaintiffs executed on April 29, 2013. The Court ultimately determined that whether the Plaintiffs’ Release should be nullified based on mutual mistake turns on a factual inquiry that was better left for a later time.
The ultimate outcome of this case is yet to be determined; however, there are several clear warning signals and reminders found within this case. Relying on an initial Conditional Payment Letter, and not a Final Demand amount can leave a primary payer open to significant exposure. Understanding the Conditional Payment Recovery process also includes understanding the inner workings of the Medicare Administrative Appeals process, and the associated delay ...
The CDC has recommended wearing a mask to reduce spread of the SARS-CoV-2 virus, although surgical and N95 type masks should be reserved for healthcare settings due to limited supply. Studies and meta-analyses have backed reduced transmission of the virus with the lower-grade masks and supported multi-layer versions as more protective.
In a surrogate-marker study of protection against COVID-19 spread led by Raina MacIntyre, MBBS, PhD, of the Kirby Institute at UNSW Sydney in Australia, high-speed video capture of droplet dispersal and aerosolization showed the result when a healthy volunteer coughed, sneezed, and talked while wearing a range of masks.
MacIntyre's study used the CDC's directions for a single-layer, "quick cut T-shirt face covering (no-sew method)" and a two-layer mask following the agency's method for sewing one. The cloth used was made of 175 g/m2 cotton fabric with a thread count of 170 TPI, close to what's used in quality T-shirts.
"From the captured video it can be observed that, for speaking, a single-layer cloth face covering reduced the droplet spread but a double-layer covering performed better," they reported in a case study in Thorax. "Even a single-layer face covering is better than no face covering."
For coughing and sneezing, though, a double-layer cloth face covering was significantly better at reducing the droplet spread. A three-ply surgical mask performed best of all for every type of respiratory emission, the group noted.
A recent study in JAMA showed a decline in healthcare workers testing positive for SARS-CoV-19 after implementing universal masking of patients. CDC leaders pointed to it as "practical, timely, and compelling evidence that community-wide face covering is another means to help control the national COVID-19 crisis," which they suggested is "a civic duty, a small sacrifice reliant on a highly effective low-tech solution that can help turn the tide favorably in national and global efforts against COVID-19."
Meanwhile, a group at Duke University in Durham, North Carolina, offered some suggestions for overcoming resistance to mask wearing.
"The way we communicate is going to be very critical here," noted Gavan Fitzsimons, MBA, PhD, a consumer behavior expert there, and "using a term like 'selfish,' I think, is going to lead people who are already digging in to dig in even harder."
Communicating benefits rather than threats may also help, said Lavanya Vasudevan, PhD, MPH, of Duke's Center for Health Policy and Inequalities Research ...
In a surrogate-marker study of protection against COVID-19 spread led by Raina MacIntyre, MBBS, PhD, of the Kirby Institute at UNSW Sydney in Australia, high-speed video capture of droplet dispersal and aerosolization showed the result when a healthy volunteer coughed, sneezed, and talked while wearing a range of masks.
MacIntyre's study used the CDC's directions for a single-layer, "quick cut T-shirt face covering (no-sew method)" and a two-layer mask following the agency's method for sewing one. The cloth used was made of 175 g/m2 cotton fabric with a thread count of 170 TPI, close to what's used in quality T-shirts.
"From the captured video it can be observed that, for speaking, a single-layer cloth face covering reduced the droplet spread but a double-layer covering performed better," they reported in a case study in Thorax. "Even a single-layer face covering is better than no face covering."
For coughing and sneezing, though, a double-layer cloth face covering was significantly better at reducing the droplet spread. A three-ply surgical mask performed best of all for every type of respiratory emission, the group noted.
A recent study in JAMA showed a decline in healthcare workers testing positive for SARS-CoV-19 after implementing universal masking of patients. CDC leaders pointed to it as "practical, timely, and compelling evidence that community-wide face covering is another means to help control the national COVID-19 crisis," which they suggested is "a civic duty, a small sacrifice reliant on a highly effective low-tech solution that can help turn the tide favorably in national and global efforts against COVID-19."
Meanwhile, a group at Duke University in Durham, North Carolina, offered some suggestions for overcoming resistance to mask wearing.
"The way we communicate is going to be very critical here," noted Gavan Fitzsimons, MBA, PhD, a consumer behavior expert there, and "using a term like 'selfish,' I think, is going to lead people who are already digging in to dig in even harder."
Communicating benefits rather than threats may also help, said Lavanya Vasudevan, PhD, MPH, of Duke's Center for Health Policy and Inequalities Research ...
Several legal experts say workplace safety rules may clash with federal protections for individual rights if employees resist potential employer efforts to require them to take a prospective COVID-19 vaccine, but safety considerations will likely carry more weight in court.
According to the report in Business Insurance, "When there is a vaccine, it will be a gamechanger, but it will raise issues," said Dennis Brown, managing shareholder in the San Jose, California, office of Littler Mendelson P.C., which represents employers.
"Because COVID-19 is highly contagious and dangerous for some people - there will be a big rush by employers to require vaccinations, and part of that is driven by fear," he said. "Employers will be under tremendous pressure to require the vaccine."
Yet Mr. Brown and other employment law attorneys say they are bracing for challenges to vaccine requirements.
Employers may require vaccines to comply with regulations such as the U.S. Occupational Safety and Health Administration’s general duty clause, which calls for employers to provide safe work sites. But they also face requirements to comply with legal exemptions for individuals on the basis of health or religion.
Title VII of the Civil Rights Act, for example, bars employment discrimination on the basis of religion, among other things, and the Americans with Disabilities Act states that a disabled person can be exempt from receiving a mandatory vaccination under certain conditions.
"The Title VII and ADA disability accommodations are not new to employers, but this context is new," said Casey Denson, a New Orleans-based employment law attorney for her own firm, Casey Denson Law LLC, which represents employees. She said there’s no legal precedence concerning vaccine exemptions for COVID-19, so it’s unclear how courts will rule.
Mr. Brown said courts are "less hospitable" to religious exemptions than to medical concerns "as a general rule" and that the pandemic could further tip the scales away from accepting personal religious exemptions in favor of protecting all workers and businesses. Overall, in health care settings, exemptions almost never stand as "the balancing test you go through between individual liberty and public health and safety tilts heavily to public safety," he said.
How the EEOC guidance would pertain to a COVID-19 vaccine remains to be seen, Ms. Denson said.
"It’s going to depend on the type of business you have, whether you are interacting with coworkers, customers or older individuals" shown to be at risk for COVID-19 complications, she said. "Even though we have legal frameworks for decisions on vaccines it’s going to be a complicated decision."
"We will have to see how things play out," said David Kurtz, Boston-based partner with Constangy, Brooks, Smith & Prophete LLP, which represents employers.
"When it came to influenza vaccines, the EEOC said employers should consider encouraging people to get vaccines but not force them. (COVID-19) will absolutely shake things up. One of the things that is so unusual with COVID-19 is when people have the flu they know it; when it comes to COVID-19 you hear that people are asymptomatic. That’s part of the problem employers are facing."
Samuel Burgess, Syracuse, New York-based senior counsel with Bond, Schoeneck & King PLLC, said courts will likely side with employers seeking to protect their entire workforce through compulsory vaccinations.
"We’ve seen this in the schools context with the measles and the flu shot requirements in the health care setting, and how courts aim to look at protection for the public and the greater good," he said ...
According to the report in Business Insurance, "When there is a vaccine, it will be a gamechanger, but it will raise issues," said Dennis Brown, managing shareholder in the San Jose, California, office of Littler Mendelson P.C., which represents employers.
"Because COVID-19 is highly contagious and dangerous for some people - there will be a big rush by employers to require vaccinations, and part of that is driven by fear," he said. "Employers will be under tremendous pressure to require the vaccine."
Yet Mr. Brown and other employment law attorneys say they are bracing for challenges to vaccine requirements.
Employers may require vaccines to comply with regulations such as the U.S. Occupational Safety and Health Administration’s general duty clause, which calls for employers to provide safe work sites. But they also face requirements to comply with legal exemptions for individuals on the basis of health or religion.
Title VII of the Civil Rights Act, for example, bars employment discrimination on the basis of religion, among other things, and the Americans with Disabilities Act states that a disabled person can be exempt from receiving a mandatory vaccination under certain conditions.
"The Title VII and ADA disability accommodations are not new to employers, but this context is new," said Casey Denson, a New Orleans-based employment law attorney for her own firm, Casey Denson Law LLC, which represents employees. She said there’s no legal precedence concerning vaccine exemptions for COVID-19, so it’s unclear how courts will rule.
Mr. Brown said courts are "less hospitable" to religious exemptions than to medical concerns "as a general rule" and that the pandemic could further tip the scales away from accepting personal religious exemptions in favor of protecting all workers and businesses. Overall, in health care settings, exemptions almost never stand as "the balancing test you go through between individual liberty and public health and safety tilts heavily to public safety," he said.
How the EEOC guidance would pertain to a COVID-19 vaccine remains to be seen, Ms. Denson said.
"It’s going to depend on the type of business you have, whether you are interacting with coworkers, customers or older individuals" shown to be at risk for COVID-19 complications, she said. "Even though we have legal frameworks for decisions on vaccines it’s going to be a complicated decision."
"We will have to see how things play out," said David Kurtz, Boston-based partner with Constangy, Brooks, Smith & Prophete LLP, which represents employers.
"When it came to influenza vaccines, the EEOC said employers should consider encouraging people to get vaccines but not force them. (COVID-19) will absolutely shake things up. One of the things that is so unusual with COVID-19 is when people have the flu they know it; when it comes to COVID-19 you hear that people are asymptomatic. That’s part of the problem employers are facing."
Samuel Burgess, Syracuse, New York-based senior counsel with Bond, Schoeneck & King PLLC, said courts will likely side with employers seeking to protect their entire workforce through compulsory vaccinations.
"We’ve seen this in the schools context with the measles and the flu shot requirements in the health care setting, and how courts aim to look at protection for the public and the greater good," he said ...
Although California employers may face a presumption of compensability in COVID-19 claims, ongoing research may provide opportunities to dispute the presumption.
South Korean epidemiologists have found that people were more likely to contract the new coronavirus from members of their own households than from contacts outside the home.
A study published in the U.S. Centers for Disease Control and Prevention (CDC) on July 16, and summarized by Reuters, looked in detail at 5,706 "index patients" who had tested positive for the coronavirus and more than 59,000 people who came into contact with them.
The findings showed that less than 2% of patients’ non-household contacts had caught the virus, while nearly 12% of patients’ household contacts had contracted the disease.
By age group, the infection rate within the household was higher when the first confirmed cases were teenagers or people in their 60s and 70s.
"This is probably because these age groups are more likely to be in close contact with family members as the group is in more need of protection or support," Jeong Eun-kyeong, director of the Korea Centers for Disease Control and Prevention (KCDC) and one of the authors of the study, told a briefing.
Children aged nine and under were least likely to be the index patient, said Dr. Choe Young-june, a Hallym University College of Medicine assistant professor who co-led the work, although he noted that the sample size of 29 was small compared to the 1,695 20-to-29-year-olds studied.
Children with COVID-19 were also more likely to be asymptomatic than adults, which made it harder to identify index cases within that group.
"The difference in age group has no huge significance when it comes to contracting COVID-19. Children could be less likely to transmit the virus, but our data is not enough to confirm this hypothesis," said Choe.
Data for the study was collected between Jan. 20 and March 27, when the new coronavirus was spreading exponentially and as daily infections in South Korea reached their peak.
KCDC has reported 45 new infections as of Monday, bringing the country’s total cases to 13,816 with 296 deaths ...
South Korean epidemiologists have found that people were more likely to contract the new coronavirus from members of their own households than from contacts outside the home.
A study published in the U.S. Centers for Disease Control and Prevention (CDC) on July 16, and summarized by Reuters, looked in detail at 5,706 "index patients" who had tested positive for the coronavirus and more than 59,000 people who came into contact with them.
The findings showed that less than 2% of patients’ non-household contacts had caught the virus, while nearly 12% of patients’ household contacts had contracted the disease.
By age group, the infection rate within the household was higher when the first confirmed cases were teenagers or people in their 60s and 70s.
"This is probably because these age groups are more likely to be in close contact with family members as the group is in more need of protection or support," Jeong Eun-kyeong, director of the Korea Centers for Disease Control and Prevention (KCDC) and one of the authors of the study, told a briefing.
Children aged nine and under were least likely to be the index patient, said Dr. Choe Young-june, a Hallym University College of Medicine assistant professor who co-led the work, although he noted that the sample size of 29 was small compared to the 1,695 20-to-29-year-olds studied.
Children with COVID-19 were also more likely to be asymptomatic than adults, which made it harder to identify index cases within that group.
"The difference in age group has no huge significance when it comes to contracting COVID-19. Children could be less likely to transmit the virus, but our data is not enough to confirm this hypothesis," said Choe.
Data for the study was collected between Jan. 20 and March 27, when the new coronavirus was spreading exponentially and as daily infections in South Korea reached their peak.
KCDC has reported 45 new infections as of Monday, bringing the country’s total cases to 13,816 with 296 deaths ...
According to an American Medical Association report, physician employment has grown 13 percent since 2012, with the percent of employed physicians surpassing their cohorts in physician-owned practices for the first time in 2018. A new report suggests that this phenomena will be accelerating.
More than half of independent physicians reported they are worried about their practices surviving the COVID-19 pandemic indicating there may be a sharp uptick in future partnerships and consolidation, the new report found.
Consulting firm McKinsey & Co. surveyed physicians nationally in both 2019 and, again, six weeks into the pandemic, to understand physician sentiment. Nearly half of the physicians surveyed in the six weeks after the pandemic was declared said they had less than four weeks cash on hand.
Nearly seven in ten (68%) of those who were looking for partners listed financial support as the primary driver, the report said.
"While autonomy has remained a priority for physicians, respondents indicated that they will consider partnerships or joining a health system as a result of financial uncertainty resulting from the COVID-19 pandemic," authors Kyle Gibler, M.D., Omar Kattan, M.D., Rupal Malani, M.D., and Laura Medford-Davis, M.D., wrote in the report..
For example, more than half (54%) of large independent practice docs and 30% of small independent practice physicians said the pandemic "has shown me the benefits of working for a large practice outweigh the benefits of working in a smaller practice."
Four in 10 physicians who responded said they are now more likely to pursue employment as a result of COVID-19.
Meanwhile, more than a quarter of independents are considering selling their practice or partnering with a larger entity due to COVID-19.
In 2019, 75% of responding physicians said they preferred to join an independent physician group while 41% said they preferred to join a hospital or health system. After COVID-19, nearly 90% of respondents said they preferred to join an independent group while 28% preferred to join a health system.
However, the report said, 26% of physicians who joined a practice or health system reported "buyer’s remorse," stating that they were interested in returning to self-employment.
"As health systems explore the next chapter of physician acquisition, our research in the healthcare sectors suggests all parties should deepen their understanding of physicians’ needs," the authors wrote. "Clear communication between health systems and physicians on the expectations and benefits of alignment, including the implications for physicians, their teams, and their patients, will be important considerations in building longer-term successful relationships." ...
More than half of independent physicians reported they are worried about their practices surviving the COVID-19 pandemic indicating there may be a sharp uptick in future partnerships and consolidation, the new report found.
Consulting firm McKinsey & Co. surveyed physicians nationally in both 2019 and, again, six weeks into the pandemic, to understand physician sentiment. Nearly half of the physicians surveyed in the six weeks after the pandemic was declared said they had less than four weeks cash on hand.
Nearly seven in ten (68%) of those who were looking for partners listed financial support as the primary driver, the report said.
"While autonomy has remained a priority for physicians, respondents indicated that they will consider partnerships or joining a health system as a result of financial uncertainty resulting from the COVID-19 pandemic," authors Kyle Gibler, M.D., Omar Kattan, M.D., Rupal Malani, M.D., and Laura Medford-Davis, M.D., wrote in the report..
For example, more than half (54%) of large independent practice docs and 30% of small independent practice physicians said the pandemic "has shown me the benefits of working for a large practice outweigh the benefits of working in a smaller practice."
Four in 10 physicians who responded said they are now more likely to pursue employment as a result of COVID-19.
Meanwhile, more than a quarter of independents are considering selling their practice or partnering with a larger entity due to COVID-19.
In 2019, 75% of responding physicians said they preferred to join an independent physician group while 41% said they preferred to join a hospital or health system. After COVID-19, nearly 90% of respondents said they preferred to join an independent group while 28% preferred to join a health system.
However, the report said, 26% of physicians who joined a practice or health system reported "buyer’s remorse," stating that they were interested in returning to self-employment.
"As health systems explore the next chapter of physician acquisition, our research in the healthcare sectors suggests all parties should deepen their understanding of physicians’ needs," the authors wrote. "Clear communication between health systems and physicians on the expectations and benefits of alignment, including the implications for physicians, their teams, and their patients, will be important considerations in building longer-term successful relationships." ...
Division of Workers’ Compensation (DWC) Administrative Director George Parisotto has appointed Jill A. Dulich to serve as a member of the Workers’ Compensation Ethics Advisory Committee. The appointment is effective July 1, 2020.
Jill A. Dulich will fill the position of a member of the public representing self-insured employers, previously held by Jim Zelko.
Dulich has been the Claims and Operations Manager for the California Self-Insurers’ Security Fund. In her role, she oversees the third party administrators that manage the claims that have been assigned to the Security Fund due to the default of a self-insured employer, as well as manages the daily administrative operations of the Fund. She also serves as the Executive Director for the National Council of Self-Insurers and for the California Self-Insurers Association.
Jim Zelko has been reappointed to the Committee, but in the position of a member of the public outside the workers’ compensation community in light of his recent retirement from Kaiser Foundation Health Plan.
The Ethics Advisory Committee, established in 1995 by Title 8, California Code of Regulations, section 9722, reviews all ethics complaints from the public against workers' compensation administrative law judges.
The committee reviews all complaints without learning the names of complainants or judges, and then makes recommendations to the DWC Administrative Director and the Chief Judge. The members meet quarterly and serve without compensation.
The committee includes the following members: a member of the public representing organized labor; a member of the public representing insurers; a member of the public representing self-insured employers; an attorney who formerly practiced before the Workers' Compensation Appeals Board and who usually represented insurers or employers; an attorney who formerly practiced before the Workers' Compensation Appeals Board and who usually represented applicants; a presiding judge; a workers’ compensation administrative law judge (WCALJ) or retired WCALJ; and two members of the public outside the workers' compensation community.
A judicial ethics complaint form and instructions can be found on the forms page of the DWC website ...
Jill A. Dulich will fill the position of a member of the public representing self-insured employers, previously held by Jim Zelko.
Dulich has been the Claims and Operations Manager for the California Self-Insurers’ Security Fund. In her role, she oversees the third party administrators that manage the claims that have been assigned to the Security Fund due to the default of a self-insured employer, as well as manages the daily administrative operations of the Fund. She also serves as the Executive Director for the National Council of Self-Insurers and for the California Self-Insurers Association.
Jim Zelko has been reappointed to the Committee, but in the position of a member of the public outside the workers’ compensation community in light of his recent retirement from Kaiser Foundation Health Plan.
The Ethics Advisory Committee, established in 1995 by Title 8, California Code of Regulations, section 9722, reviews all ethics complaints from the public against workers' compensation administrative law judges.
The committee reviews all complaints without learning the names of complainants or judges, and then makes recommendations to the DWC Administrative Director and the Chief Judge. The members meet quarterly and serve without compensation.
The committee includes the following members: a member of the public representing organized labor; a member of the public representing insurers; a member of the public representing self-insured employers; an attorney who formerly practiced before the Workers' Compensation Appeals Board and who usually represented insurers or employers; an attorney who formerly practiced before the Workers' Compensation Appeals Board and who usually represented applicants; a presiding judge; a workers’ compensation administrative law judge (WCALJ) or retired WCALJ; and two members of the public outside the workers' compensation community.
A judicial ethics complaint form and instructions can be found on the forms page of the DWC website ...
Amid ongoing scrutiny of its business practices, physician-staffing giant TeamHealth is now facing a California based class action suit accusing the company of fraudulent patient billing and racketeering.
TeamHealth, based in Knoxville, Tennessee, is one of the largest providers of outsourced clinical staffing and administrative services for hospital-based and freestanding emergency departments in the country.
The company, which was acquired by private equity firm Blackstone Group LP in 2017, operates within 47 states and runs about 3300 acute and post-acute facilities. TeamHealth contracts with hospitals to staff and manage various departments, including emergency, critical care, radiology, and anesthesiology services. The company currently controls about 17% of the emergency medicine market in the United States, according to the legal challenge.
The lawsuit, filed July 10 in US District Court for the Northern District of California, contends that TeamHealth vastly inflates the rates it charges patients and aggressively pursues debt collection if patients fail to pay the inflated prices. The complaint alleges TeamHealth is illegally engaging in the corporate practice of medicine and is avoiding state bans of this practice by operating a web of subsidiaries and purportedly independent organizations.
In a statement to Medscape Medical News, TeamHealth denied the claims and indicated that the company plans to aggressively fight the lawsuit.
"TeamHealth is confident that our billing practices and organizational structure are fully compliant with long established laws and precedents," TeamHealth said in an emailed statement. "TeamHealth maintains a long-standing practice against balance billing. We believe these claims are wholly without merit and we look forward to vigorously defending ourselves."
The class action suit claims that TeamHealth is practicing corporate medicine but is able to skirt state laws that prohibit the practice through a spectrum of so-called subsidiaries and "independent" contractors.
As director of the enterprise, TeamHealth controls the terms of its physicians' employment, all physician staffing decisions, and all the rates its physicians and practice groups charge patients, according to the suit. The complaint claims these rates are inflated far above what is reasonable and customary for the services provided.
The suit's lead plaintiff, Sia Fraser, claims she experienced just such inflated bills after an emergency department visit. Fraser was treated for emergency gallstone surgery by a physician in a TeamHealth-owned physician group in September 2019 at Tri-City Medical Center in Oceanside, California. TeamHealth billed Fraser $1082 for an hour of observation care during the visit, according to the suit. For the same hospital visit, TriCity Medical Center billed Fraser $63 per hour for observation care performed by hospital physicians.
Craig Briskin, an attorney for Fraser with the law firm Justice Catalyst Law, said his team intends to obtain substantial monetary relief for consumers in the case and aim to return fairness and common sense to medical billing.
The suit comes at the heels of growing skepticism about TeamHealth's practices. The company has come under fire in recent months for reportedly sending surprise bills to patients and slashing physicians' hours during the coronavirus health crisis, according to ProPublica. One analysis of the company's records by the news organization found that TeamHealth is substantially marking up medical bills to boost profits. Two TeamHealth affiliates in Texas, for instance, billed 7.7 times more than their actual costs for clinicians and support services, according to the June ProPublica report.
Most ER doctors are not employees of the hospital where they work. Historically they belonged to doctors’ practice groups. In recent years, wealthy private investors have bought out those practice groups and consolidated them into massive nationwide staffing firms like TeamHealth and its largest competitor, KKR-owned Envision Healthcare ...
TeamHealth, based in Knoxville, Tennessee, is one of the largest providers of outsourced clinical staffing and administrative services for hospital-based and freestanding emergency departments in the country.
The company, which was acquired by private equity firm Blackstone Group LP in 2017, operates within 47 states and runs about 3300 acute and post-acute facilities. TeamHealth contracts with hospitals to staff and manage various departments, including emergency, critical care, radiology, and anesthesiology services. The company currently controls about 17% of the emergency medicine market in the United States, according to the legal challenge.
The lawsuit, filed July 10 in US District Court for the Northern District of California, contends that TeamHealth vastly inflates the rates it charges patients and aggressively pursues debt collection if patients fail to pay the inflated prices. The complaint alleges TeamHealth is illegally engaging in the corporate practice of medicine and is avoiding state bans of this practice by operating a web of subsidiaries and purportedly independent organizations.
In a statement to Medscape Medical News, TeamHealth denied the claims and indicated that the company plans to aggressively fight the lawsuit.
"TeamHealth is confident that our billing practices and organizational structure are fully compliant with long established laws and precedents," TeamHealth said in an emailed statement. "TeamHealth maintains a long-standing practice against balance billing. We believe these claims are wholly without merit and we look forward to vigorously defending ourselves."
The class action suit claims that TeamHealth is practicing corporate medicine but is able to skirt state laws that prohibit the practice through a spectrum of so-called subsidiaries and "independent" contractors.
As director of the enterprise, TeamHealth controls the terms of its physicians' employment, all physician staffing decisions, and all the rates its physicians and practice groups charge patients, according to the suit. The complaint claims these rates are inflated far above what is reasonable and customary for the services provided.
The suit's lead plaintiff, Sia Fraser, claims she experienced just such inflated bills after an emergency department visit. Fraser was treated for emergency gallstone surgery by a physician in a TeamHealth-owned physician group in September 2019 at Tri-City Medical Center in Oceanside, California. TeamHealth billed Fraser $1082 for an hour of observation care during the visit, according to the suit. For the same hospital visit, TriCity Medical Center billed Fraser $63 per hour for observation care performed by hospital physicians.
Craig Briskin, an attorney for Fraser with the law firm Justice Catalyst Law, said his team intends to obtain substantial monetary relief for consumers in the case and aim to return fairness and common sense to medical billing.
The suit comes at the heels of growing skepticism about TeamHealth's practices. The company has come under fire in recent months for reportedly sending surprise bills to patients and slashing physicians' hours during the coronavirus health crisis, according to ProPublica. One analysis of the company's records by the news organization found that TeamHealth is substantially marking up medical bills to boost profits. Two TeamHealth affiliates in Texas, for instance, billed 7.7 times more than their actual costs for clinicians and support services, according to the June ProPublica report.
Most ER doctors are not employees of the hospital where they work. Historically they belonged to doctors’ practice groups. In recent years, wealthy private investors have bought out those practice groups and consolidated them into massive nationwide staffing firms like TeamHealth and its largest competitor, KKR-owned Envision Healthcare ...
As companies start planning their reopenings, business groups are pushing Congress to limit liability from potential lawsuits filed by workers and customers infected by the coronavirus.
President Donald Trump has floated shielding businesses from lawsuits. His top economic adviser Larry Kudlow said on CNBC last week that businesses shouldn't be held liable to trial lawyers "putting on false lawsuits that will probably be thrown out of court." He said the issue could require legislation, and Senate Majority Leader Mitch McConnell said that the issue would be a priority when lawmakers return.
New York Senator Daphne Jordan introduced legislation this month that would limit the civil liability of employers and employees over possible transmission of COVID-19 "caused by an act or omission while acting in good faith" and causing death or injury.
S.B. 8800, which is entitled "Get New York Back to Work act," would apply to a "Covered Entity" which is defined as one or more individuals, business trusts, legal representatives, corporations, companies, associations, firms, partnerships, societies, joint stock companies, universities, schools, not-for-profit organizations, religious organizations or any organized group of such entities.
If adopted, no Covered Entity shall be liable in any civil action for the spread or possible transmission of COVID-19 caused by an act or omission of such covered entity acting in good faith in the workplace.
The bill describes "good faith" as "making reasonable efforts to act in compliance" with applicable guidance from federal, state and local authorities, among other governing bodies.
The bill was referred to a rules committee and would go into effect 30 days after passage.
In addition to New York, at least 12 other states - including Alabama, Arkansas, Georgia, Iowa, Kansas, Louisiana, Mississippi, North Carolina, Ohio, Oklahoma, Utah, and Wyoming - have begun enacting such legislation to narrow the liability limits related to and stemming from COVID-19.
On June 26, 2020, the Georgia General Assembly passed Senate Bill 359, also known as the "Georgia COVID-19 Pandemic Business Safety Act." The Act, currently awaits final approval by Governor Brian Kemp pending his office’s legal review.
Although the various pieces of legislation may contain similarities, each law differs from state-to-state in a manner that leaves healthcare providers, businesses, and individuals vulnerable to differing rules and regulations related to COVID-19 liability across their respective footprints ...
President Donald Trump has floated shielding businesses from lawsuits. His top economic adviser Larry Kudlow said on CNBC last week that businesses shouldn't be held liable to trial lawyers "putting on false lawsuits that will probably be thrown out of court." He said the issue could require legislation, and Senate Majority Leader Mitch McConnell said that the issue would be a priority when lawmakers return.
New York Senator Daphne Jordan introduced legislation this month that would limit the civil liability of employers and employees over possible transmission of COVID-19 "caused by an act or omission while acting in good faith" and causing death or injury.
S.B. 8800, which is entitled "Get New York Back to Work act," would apply to a "Covered Entity" which is defined as one or more individuals, business trusts, legal representatives, corporations, companies, associations, firms, partnerships, societies, joint stock companies, universities, schools, not-for-profit organizations, religious organizations or any organized group of such entities.
If adopted, no Covered Entity shall be liable in any civil action for the spread or possible transmission of COVID-19 caused by an act or omission of such covered entity acting in good faith in the workplace.
The bill describes "good faith" as "making reasonable efforts to act in compliance" with applicable guidance from federal, state and local authorities, among other governing bodies.
The bill was referred to a rules committee and would go into effect 30 days after passage.
In addition to New York, at least 12 other states - including Alabama, Arkansas, Georgia, Iowa, Kansas, Louisiana, Mississippi, North Carolina, Ohio, Oklahoma, Utah, and Wyoming - have begun enacting such legislation to narrow the liability limits related to and stemming from COVID-19.
On June 26, 2020, the Georgia General Assembly passed Senate Bill 359, also known as the "Georgia COVID-19 Pandemic Business Safety Act." The Act, currently awaits final approval by Governor Brian Kemp pending his office’s legal review.
Although the various pieces of legislation may contain similarities, each law differs from state-to-state in a manner that leaves healthcare providers, businesses, and individuals vulnerable to differing rules and regulations related to COVID-19 liability across their respective footprints ...
