Four class-action lawsuits have been filed in California federal court on behalf of small business owners who are feeling hopeless and terrified after four major banks rejected their Paycheck Protection Program (PPP) loan applications.
Congress passed the CARES Act in response to the COVID-19 pandemic, which allocated $349 billion in emergency funds for the small business loan program known as the Paycheck Protection Program. The program, which launched on April 3, was intended to provide loans of up to two-and-a-half times a business owner’s monthly payroll.
The loan program ran out of funds on April 16, leaving most of the small business applicants empty handed.
The lawsuits claim the nation’s four largest lenders involved in the paycheck protection program, JPMorgan, Bank of America, Wells Fargo and US Bank, rigged the loan process to benefit their bottom line.
According to the complaints, instead of a "first-come, first-served basis," the banks processed the biggest loan amounts first, because it increased the banks’ origination fees while leaving more than 90% of the small businesses owners who applied for loans out of luck once the funds depleted. An origination fee is the compensation a lender receives for processing a new application.
To make matters worse, the banks allegedly concealed from the public that they were reshuffling the PPP applications received and prioritizing the applications that would make the banks the most money.
The lawsuits allege that as a result of their deceptive lending prioritization practices, giving preference to larger "small businesses" over true small businesses, banks received nearly $6 billion in fees while hundreds of thousands of loan applicants got nothing.
The four banks have either denied the allegations, or failed to respond to media requests for a response.
A similar action is pending against Bank of America in Baltimore, for allegedly giving its lending clients a higher priority and denying or limiting access to the Paycheck Protection Program to its depository clients and other small firms. The law firm noted that the bank updated its policy on April 4 by letting depository-only customers apply for PPP loans after the filing of a class action compliant.
However, the law firm said the bank added another requirement: Depository-only clients couldn’t have a credit card or loan with another bank.
The Baltimore firm claims that "Nothing in the CARES Act authorizes or permits defendants to pick and choose who would gain access to or benefit from the federally backed lending program,"
Senators Marco Rubio (R.-Fla.) and Ben Cardin (D.-Md.) have already chastised BOA for imposing criteria not found in the law and selectively choosing who can apply ...
Congress passed the CARES Act in response to the COVID-19 pandemic, which allocated $349 billion in emergency funds for the small business loan program known as the Paycheck Protection Program. The program, which launched on April 3, was intended to provide loans of up to two-and-a-half times a business owner’s monthly payroll.
The loan program ran out of funds on April 16, leaving most of the small business applicants empty handed.
The lawsuits claim the nation’s four largest lenders involved in the paycheck protection program, JPMorgan, Bank of America, Wells Fargo and US Bank, rigged the loan process to benefit their bottom line.
According to the complaints, instead of a "first-come, first-served basis," the banks processed the biggest loan amounts first, because it increased the banks’ origination fees while leaving more than 90% of the small businesses owners who applied for loans out of luck once the funds depleted. An origination fee is the compensation a lender receives for processing a new application.
To make matters worse, the banks allegedly concealed from the public that they were reshuffling the PPP applications received and prioritizing the applications that would make the banks the most money.
The lawsuits allege that as a result of their deceptive lending prioritization practices, giving preference to larger "small businesses" over true small businesses, banks received nearly $6 billion in fees while hundreds of thousands of loan applicants got nothing.
The four banks have either denied the allegations, or failed to respond to media requests for a response.
A similar action is pending against Bank of America in Baltimore, for allegedly giving its lending clients a higher priority and denying or limiting access to the Paycheck Protection Program to its depository clients and other small firms. The law firm noted that the bank updated its policy on April 4 by letting depository-only customers apply for PPP loans after the filing of a class action compliant.
However, the law firm said the bank added another requirement: Depository-only clients couldn’t have a credit card or loan with another bank.
The Baltimore firm claims that "Nothing in the CARES Act authorizes or permits defendants to pick and choose who would gain access to or benefit from the federally backed lending program,"
Senators Marco Rubio (R.-Fla.) and Ben Cardin (D.-Md.) have already chastised BOA for imposing criteria not found in the law and selectively choosing who can apply ...
Some blood tests being marketed to tell people if they have had the new coronavirus are a "disaster", Roche Chief Executive Severin Schwan said on Wednesday as he prepares to launch the drugmaker’s own antibody test next month.
Countries around the world hope such blood tests - meant to show whether people exposed to the disease have developed antibodies thought to offer some immunity - will guide efforts to restart their economies and keep healthcare workers safe.
An erroneous false-positive result could lead to the mistaken conclusion that someone has immunity. In developing its test, Schwan said, Roche scrutinised some existing products for reliability before rejecting them.
"It’s a disaster. These tests are not worth anything, or have very little use," Schwan told reporters on a conference call. "Some of these companies, I tell you, this is ethically very questionable to get out with this stuff."
Schwan said there were about 100 such tests on offer, including finger-prick assays that offer a quick result. The Basel-based company declined to specify which rival tests it had studied, but said it was not referring to tests from established testing companies.
Roche also makes separate tests to determine if a person has an active coronavirus infection, with a sample taken via a swab from nasal passages.
By contrast, Roche’s planned antibody test relies on intravenous blood draws taken by a nurse or a doctor.
Schwan did not release figures for its test’s "specificity", or how many false-positives can be expected, but promised it would be reliable because Roche had successfully found the antibody produced by the body after exposure to the novel virus.
Abbott Laboratories also said last week it would begin shipping a new coronavirus blood test similar to Roche’s by June. Like Roche’s test, Abbott’s assay would be launched under the U.S. Food and Drug Administration’s recently relaxed rules for coronavirus tests.
...
Countries around the world hope such blood tests - meant to show whether people exposed to the disease have developed antibodies thought to offer some immunity - will guide efforts to restart their economies and keep healthcare workers safe.
An erroneous false-positive result could lead to the mistaken conclusion that someone has immunity. In developing its test, Schwan said, Roche scrutinised some existing products for reliability before rejecting them.
"It’s a disaster. These tests are not worth anything, or have very little use," Schwan told reporters on a conference call. "Some of these companies, I tell you, this is ethically very questionable to get out with this stuff."
Schwan said there were about 100 such tests on offer, including finger-prick assays that offer a quick result. The Basel-based company declined to specify which rival tests it had studied, but said it was not referring to tests from established testing companies.
Roche also makes separate tests to determine if a person has an active coronavirus infection, with a sample taken via a swab from nasal passages.
By contrast, Roche’s planned antibody test relies on intravenous blood draws taken by a nurse or a doctor.
Schwan did not release figures for its test’s "specificity", or how many false-positives can be expected, but promised it would be reliable because Roche had successfully found the antibody produced by the body after exposure to the novel virus.
Abbott Laboratories also said last week it would begin shipping a new coronavirus blood test similar to Roche’s by June. Like Roche’s test, Abbott’s assay would be launched under the U.S. Food and Drug Administration’s recently relaxed rules for coronavirus tests.
...
In the new panel decision of Harris v Numac Company, SCIF, SIBTF the WCAB went to great lengths elaborating on the requirements for SIBTF eligibility.
In 2005, George Harris fell ill with pneumonia after working on an AC unit in wet and cold weather. He was later diagnosed with stage II sarcoidosis.
On April 3, 2015, Harris filed an Application for Subsequent Injuries Fund Benefits, claiming he had a 2003 pre-existing disability to his back.
On April 23, 2015, the WCJ issued a Findings of Fact, Awards and Order finding that applicant sustained industrial injury on January 8, 2015 to his lungs/pulmonary, skin (sarcoidosis) and psyche, which caused 65% permanent disability.
The parties then went to trial on the following two issues: (1) SIBTF, and (2) the statute of limitations.
The WCJ issued a Findings and Award finding that applicant's current injury resulted in 48% permanent disability when considered alone and without adjustment to applicant's occupation or age. The WCJ concluded that 48% permanent disability satisfied the 35% threshold under section 4751, subdivision (b), and proceeded to add 38% from a prior permanent disability rating from applicant's 1999 and 2003 back injuries. This addition resulted in 86% permanent disability, from which the WCJ then added 34%, which is the non-industrial portion of applicant's current respiratory disorder that the WCJ reasoned was pre-existing.
As a result, the WCJ found that applicant's combined pre-existing and current disabilities resulted in 100% permanent disability.
SIBTF's Petition for Reconsideration raises three issues: (1) whether applicant's prior 34% lung impairment is labor disabling, (2) whether the WCJ improperly added the prior disabilities to the current disability, and (3) whether applicant's SIBTF claim is barred by the statute of limitations.
Based on Ferguson and Escobedo, the WCAB concluded that applicant's sarcoidosis was not labor disabling prior to his industrial pneumonia. Applicant was asymptomatic and had no disability prior to the pneumonia. "This recognizes that the patient apparently had dormant sarcoidosis of non-industrial origin which was not symptomatic and causing no disability prior to the pneumonia, which had an industrial component, and that the patient had no disability prior to the reactivation of sarcoidosis precipitated by the episode of pneumonia."
Thus, the WCJ erred in adding the 34% non-industrial dormant sarcoidosis in calculating applicant's combined disability for purposes of SIBTF's benefits.
However, the WCJ incorrectly determined the permanent disabilities that must be added for SIBTF benefit entitlement. It is derived by adding the 65% subsequent permanent disability, consisting of the three current impairments of respiratory disorder, contact dermatitis and arousal, and the 38% of pre-existing permanent disability in applicant's back, resulting in 100% permanent disability.
There is no statutory time limit to apply for SIBTF benefits. It must be filed within a reasonable time after learning from the board's findings on the issue of permanent disability that the Fund has probable liability ...
In 2005, George Harris fell ill with pneumonia after working on an AC unit in wet and cold weather. He was later diagnosed with stage II sarcoidosis.
On April 3, 2015, Harris filed an Application for Subsequent Injuries Fund Benefits, claiming he had a 2003 pre-existing disability to his back.
On April 23, 2015, the WCJ issued a Findings of Fact, Awards and Order finding that applicant sustained industrial injury on January 8, 2015 to his lungs/pulmonary, skin (sarcoidosis) and psyche, which caused 65% permanent disability.
The parties then went to trial on the following two issues: (1) SIBTF, and (2) the statute of limitations.
The WCJ issued a Findings and Award finding that applicant's current injury resulted in 48% permanent disability when considered alone and without adjustment to applicant's occupation or age. The WCJ concluded that 48% permanent disability satisfied the 35% threshold under section 4751, subdivision (b), and proceeded to add 38% from a prior permanent disability rating from applicant's 1999 and 2003 back injuries. This addition resulted in 86% permanent disability, from which the WCJ then added 34%, which is the non-industrial portion of applicant's current respiratory disorder that the WCJ reasoned was pre-existing.
As a result, the WCJ found that applicant's combined pre-existing and current disabilities resulted in 100% permanent disability.
SIBTF's Petition for Reconsideration raises three issues: (1) whether applicant's prior 34% lung impairment is labor disabling, (2) whether the WCJ improperly added the prior disabilities to the current disability, and (3) whether applicant's SIBTF claim is barred by the statute of limitations.
Based on Ferguson and Escobedo, the WCAB concluded that applicant's sarcoidosis was not labor disabling prior to his industrial pneumonia. Applicant was asymptomatic and had no disability prior to the pneumonia. "This recognizes that the patient apparently had dormant sarcoidosis of non-industrial origin which was not symptomatic and causing no disability prior to the pneumonia, which had an industrial component, and that the patient had no disability prior to the reactivation of sarcoidosis precipitated by the episode of pneumonia."
Thus, the WCJ erred in adding the 34% non-industrial dormant sarcoidosis in calculating applicant's combined disability for purposes of SIBTF's benefits.
However, the WCJ incorrectly determined the permanent disabilities that must be added for SIBTF benefit entitlement. It is derived by adding the 65% subsequent permanent disability, consisting of the three current impairments of respiratory disorder, contact dermatitis and arousal, and the 38% of pre-existing permanent disability in applicant's back, resulting in 100% permanent disability.
There is no statutory time limit to apply for SIBTF benefits. It must be filed within a reasonable time after learning from the board's findings on the issue of permanent disability that the Fund has probable liability ...
Thomas Hasson sustained an industrial cumulative trauma injury to his lumbar spine and bilateral hips as a result of working 18 years as a stock clerk for Ann Taylor, a job that required repetitive strenuous lifting and bending.
The injury to his lumbar spine and bilateral hips caused marked limitations in his ability to return to the open labor market. The record establishes that applicant's 2014 right hip arthroplasty was not successful, as applicant's right hip pain subsequently increased. Two and a half years post arthroplasty, applicant was described by Dr. Knight as being in "moderate to severe pain in the right hip with limited range of motion," and was "quite limited in this ability to do prolonged walking, standing or other activities." He concluded applicant was "incapable of returning to work as a result of his ongoing pain."
Applicant obtained a vocational evaluation from Mr. Frank Diaz, who found that as a consequence of the disability from his cumulative trauma injury, applicant was not amenable to vocational rehabilitation and had lost his ability to return to the labor market.
The WCJ determined that applicant is permanently totally disabled, based upon substantial evidence in the record that establishes that applicant is unable to benefit from vocational rehabilitation or return to full time employment in the labor market.
The WCAB affirmed the WCJ's determination and denied defendant's Petition for Reconsideration in the panel decision of Hasson v Ann Taylor and Travelers Insurance Co.
The issue on reconsideration is whether the vocational evidence constitutes substantial evidence to support the conclusion that applicant was permanently totally disabled due to his inability to benefit from vocational rehabilitation, per Ogilvie v. Workers' Comp. Appeals Bd.; Contra Costa County v. Workers' Comp. Appeals Bd. (Dahl) and LeBoeuf v. Workers' Comp. Appeals Ed.
In Dahl, the Court of Appeal held that to rebut the scheduled rating, applicant must prove that the industrial injury precludes vocational rehabilitation, writing in pertinent part as follows: The first step in any LeBoeef analysis is to determine whether a work-related injury precludes the claimant from taking advantage of vocational rehabilitation and participating in the labor force. This necessarily requires an individualized approach .. . It is this individualized assessment of whether industrial factors preclude the employee's rehabilitation that Ogilvie approved as a method for rebutting the Schedule. (Dahl, 80 Cal.Comp.Cases at 1128.)
The vocational evidence the WCJ relied upon, the reporting of Mr. Diaz, indicates that applicant is not amenable to vocational rehabilitation and that Dr. Knight's and Dr. Rovner's work restrictions preclude applicant from returning to full time employment. Mr. Diaz's "individualized assessment" of the vocational factors affecting applicant's ability to return to work shows that the medical restrictions do preclude applicant from gainful employment. We find his analysis of applicant's vocational limitations to constitute substantial evidence to support the WCJ's determination.
This WCAB panel seems again to have sidestepped the Court of Appeal published decision in Department of Corrections and Rehabilitation v. Workers’ Compensation Appeals Board (Fitzpatrick (2018) 27 Cal. App. 5th 607 [238 Cal. Rptr.3d 224, 83 Cal. Comp. Cases 1680] although it was cited in the Opinion .
The Court of Appeal in Fitzpatrick rejected a 100 percent disability award that did not first rate a case using the AMA Guides, and then follow the steps outlined in the 2005 Rating Schedule, and then a rational why some other scheme should be used instead ...
The injury to his lumbar spine and bilateral hips caused marked limitations in his ability to return to the open labor market. The record establishes that applicant's 2014 right hip arthroplasty was not successful, as applicant's right hip pain subsequently increased. Two and a half years post arthroplasty, applicant was described by Dr. Knight as being in "moderate to severe pain in the right hip with limited range of motion," and was "quite limited in this ability to do prolonged walking, standing or other activities." He concluded applicant was "incapable of returning to work as a result of his ongoing pain."
Applicant obtained a vocational evaluation from Mr. Frank Diaz, who found that as a consequence of the disability from his cumulative trauma injury, applicant was not amenable to vocational rehabilitation and had lost his ability to return to the labor market.
The WCJ determined that applicant is permanently totally disabled, based upon substantial evidence in the record that establishes that applicant is unable to benefit from vocational rehabilitation or return to full time employment in the labor market.
The WCAB affirmed the WCJ's determination and denied defendant's Petition for Reconsideration in the panel decision of Hasson v Ann Taylor and Travelers Insurance Co.
The issue on reconsideration is whether the vocational evidence constitutes substantial evidence to support the conclusion that applicant was permanently totally disabled due to his inability to benefit from vocational rehabilitation, per Ogilvie v. Workers' Comp. Appeals Bd.; Contra Costa County v. Workers' Comp. Appeals Bd. (Dahl) and LeBoeuf v. Workers' Comp. Appeals Ed.
In Dahl, the Court of Appeal held that to rebut the scheduled rating, applicant must prove that the industrial injury precludes vocational rehabilitation, writing in pertinent part as follows: The first step in any LeBoeef analysis is to determine whether a work-related injury precludes the claimant from taking advantage of vocational rehabilitation and participating in the labor force. This necessarily requires an individualized approach .. . It is this individualized assessment of whether industrial factors preclude the employee's rehabilitation that Ogilvie approved as a method for rebutting the Schedule. (Dahl, 80 Cal.Comp.Cases at 1128.)
The vocational evidence the WCJ relied upon, the reporting of Mr. Diaz, indicates that applicant is not amenable to vocational rehabilitation and that Dr. Knight's and Dr. Rovner's work restrictions preclude applicant from returning to full time employment. Mr. Diaz's "individualized assessment" of the vocational factors affecting applicant's ability to return to work shows that the medical restrictions do preclude applicant from gainful employment. We find his analysis of applicant's vocational limitations to constitute substantial evidence to support the WCJ's determination.
This WCAB panel seems again to have sidestepped the Court of Appeal published decision in Department of Corrections and Rehabilitation v. Workers’ Compensation Appeals Board (Fitzpatrick (2018) 27 Cal. App. 5th 607 [238 Cal. Rptr.3d 224, 83 Cal. Comp. Cases 1680] although it was cited in the Opinion .
The Court of Appeal in Fitzpatrick rejected a 100 percent disability award that did not first rate a case using the AMA Guides, and then follow the steps outlined in the 2005 Rating Schedule, and then a rational why some other scheme should be used instead ...
The Claims Journal reports that data from the California Division of Workers’ Compensation as of Thursday April 16, 1,527 claims coded for COVID-19 on claims notices had been filed, according to agency spokeswoman Erika Monterroza.
Some experts say that COVID-19 claims that require admission to an intensive care unit will likely run into the six figures for medical costs alone. What’s more, employers will be taking full responsibility for whatever complications arise from a coronavirus infection far into the future.
According to Science Magazine, the lack of oxygen and widespread inflammation caused by COVID-19 can damage kidneys, liver, heart, brain and other organs. Studies show that severe pneumonia caused by other diseases sometimes lead to scarring that causes long-term breathing problems. Pneumonia also increases the risk of future illnesses, including heart attack, stroke and kidney disease.
In one study of 138 patients hospitalized in Wuhan, China due to pneumonia from COVID-19, 20 percent suffered acute respiratory distress syndrome.
A separate study published by the New England Journal of Medicine in 2011 found that of 109 survivors of ARDS, 51% suffered physician-diagnosed depression, anxiety or both. Perhaps more relevant to workers’ comp, that study found that just 77 percent of the 83 patients who survived throughout the study period had returned to work five years after being treated. The study found that only 39% of patients were able to walk the distance expected for their age group in six minutes five years later, suggesting a high degree of physical impairment.
The governors of Kentucky, Arkansas, North Dakota and Florida and state regulators in Illinois, Washington, Michigan and Missouri have issued executive orders or amended rules to expand eligibility for workers’ compensation.
Most of those decrees ease the path for benefits only for healthcare workers and first responders, but an emergency order by the Illinois Workers’ Compensation Commission creates a presumption that work is the cause of COVID-19 if contracted by any “frontline worker” identified in Gov. J.B. Pritzker’s March 20 stay-at-home order. That includes workers at grocery stores, laundries, banks and hardware stores, among other businesses.
Kentucky Gov. Beshear issued a similarly broad executive order that created a COVID-19 presumption for workers in grocery stores, child-care centers, domestic violence shelters and rape crisis centers, in addition to first responders and healthcare workers.
In the meantime state legislators are also pushing to expand benefits for COVID-19. Earlier this month, Alaska Gov. Mike Dunleavy (R), Wisconsin Gov. Tony Evers (D) and Minnesota Gov. Tim Walz (D) signed into law bills that create a COVID-19 presumptions for first responders and some healthcare workers.
Bills to create presumptions for COVID-19 have been introduced in the New York, New Jersey, Pennsylvania, Ohio and Utah state legislatures ...
Some experts say that COVID-19 claims that require admission to an intensive care unit will likely run into the six figures for medical costs alone. What’s more, employers will be taking full responsibility for whatever complications arise from a coronavirus infection far into the future.
According to Science Magazine, the lack of oxygen and widespread inflammation caused by COVID-19 can damage kidneys, liver, heart, brain and other organs. Studies show that severe pneumonia caused by other diseases sometimes lead to scarring that causes long-term breathing problems. Pneumonia also increases the risk of future illnesses, including heart attack, stroke and kidney disease.
In one study of 138 patients hospitalized in Wuhan, China due to pneumonia from COVID-19, 20 percent suffered acute respiratory distress syndrome.
A separate study published by the New England Journal of Medicine in 2011 found that of 109 survivors of ARDS, 51% suffered physician-diagnosed depression, anxiety or both. Perhaps more relevant to workers’ comp, that study found that just 77 percent of the 83 patients who survived throughout the study period had returned to work five years after being treated. The study found that only 39% of patients were able to walk the distance expected for their age group in six minutes five years later, suggesting a high degree of physical impairment.
The governors of Kentucky, Arkansas, North Dakota and Florida and state regulators in Illinois, Washington, Michigan and Missouri have issued executive orders or amended rules to expand eligibility for workers’ compensation.
Most of those decrees ease the path for benefits only for healthcare workers and first responders, but an emergency order by the Illinois Workers’ Compensation Commission creates a presumption that work is the cause of COVID-19 if contracted by any “frontline worker” identified in Gov. J.B. Pritzker’s March 20 stay-at-home order. That includes workers at grocery stores, laundries, banks and hardware stores, among other businesses.
Kentucky Gov. Beshear issued a similarly broad executive order that created a COVID-19 presumption for workers in grocery stores, child-care centers, domestic violence shelters and rape crisis centers, in addition to first responders and healthcare workers.
In the meantime state legislators are also pushing to expand benefits for COVID-19. Earlier this month, Alaska Gov. Mike Dunleavy (R), Wisconsin Gov. Tony Evers (D) and Minnesota Gov. Tim Walz (D) signed into law bills that create a COVID-19 presumptions for first responders and some healthcare workers.
Bills to create presumptions for COVID-19 have been introduced in the New York, New Jersey, Pennsylvania, Ohio and Utah state legislatures ...
State Compensation Insurance Fund announced another series of actions designed to support policyholders and workers affected by the COVID-19 crisis.
These actions include:
-- Doubling the size of the Essential Business Support Fund announced earlier this week to $50 million. In the four days since the fund was announced, State Fund has received over 700 applications for COVID-19 workplace safety support funds. The first several payments, all at the maximum $10,000 reimbursement, were sent to qualified applicants today.
-- Creating a new, $50-million Returning California to Work COVID-19 Safety Protocol Fund. This fund will operate in a similar way to the Essential Business Support Fund but is designed to help businesses that were not deemed essential by Governor Newsom’s executive order after he removes statewide stay-at-home restrictions. The fund will provide grants to qualified policyholders to help defray the costs of safety-related expenses, planned or already incurred, related to protecting their workforces from COVID-19. Individual grants can total up to $10,000 or two times the policyholder’s premium, whichever is less. Applications for this fund will be made available at StateFundCA.com after statewide stay-at-home restrictions are lifted.
-- Effective immediately, accepting any claim by an essential worker - as defined by Governor Newsom’s Executive Order N-33-20 - for a diagnosed case of COVID-19 regardless of whether or not that worker can demonstrate the virus was contracted during the course of employment. The diagnosis must include a confirmed positive test for COVID-19 and must occur during the period of time between when the Governor issued his stay-at-home order and before that order is lifted. This action effectively replaces the Essential Worker Support Fund announced earlier this week as all employees who would have been covered under that fund are now entitled to full workers’ compensation benefits. State Fund currently estimates these added benefits will require approximately $90 million in addition to the previously committed funds for a total of $115 million. State Fund will still provide temporary disability benefits to any covered essential worker who must self-quarantine if they are not covered by another source.
"We are doing everything we can to provide our customers and injured workers with the support they need to make it through the COVID-19 crisis," said State Fund President & CEO Vern Steiner. "We have worked hard to be in a position where we can help, and we’re proud to stand with the essential workers who are risking their lives every day to hold our communities together." More information about State Fund’s actions in response to the COVID-19 pandemic can be found at StateFundCA.com ...
These actions include:
-- Doubling the size of the Essential Business Support Fund announced earlier this week to $50 million. In the four days since the fund was announced, State Fund has received over 700 applications for COVID-19 workplace safety support funds. The first several payments, all at the maximum $10,000 reimbursement, were sent to qualified applicants today.
-- Creating a new, $50-million Returning California to Work COVID-19 Safety Protocol Fund. This fund will operate in a similar way to the Essential Business Support Fund but is designed to help businesses that were not deemed essential by Governor Newsom’s executive order after he removes statewide stay-at-home restrictions. The fund will provide grants to qualified policyholders to help defray the costs of safety-related expenses, planned or already incurred, related to protecting their workforces from COVID-19. Individual grants can total up to $10,000 or two times the policyholder’s premium, whichever is less. Applications for this fund will be made available at StateFundCA.com after statewide stay-at-home restrictions are lifted.
-- Effective immediately, accepting any claim by an essential worker - as defined by Governor Newsom’s Executive Order N-33-20 - for a diagnosed case of COVID-19 regardless of whether or not that worker can demonstrate the virus was contracted during the course of employment. The diagnosis must include a confirmed positive test for COVID-19 and must occur during the period of time between when the Governor issued his stay-at-home order and before that order is lifted. This action effectively replaces the Essential Worker Support Fund announced earlier this week as all employees who would have been covered under that fund are now entitled to full workers’ compensation benefits. State Fund currently estimates these added benefits will require approximately $90 million in addition to the previously committed funds for a total of $115 million. State Fund will still provide temporary disability benefits to any covered essential worker who must self-quarantine if they are not covered by another source.
"We are doing everything we can to provide our customers and injured workers with the support they need to make it through the COVID-19 crisis," said State Fund President & CEO Vern Steiner. "We have worked hard to be in a position where we can help, and we’re proud to stand with the essential workers who are risking their lives every day to hold our communities together." More information about State Fund’s actions in response to the COVID-19 pandemic can be found at StateFundCA.com ...
Dr. Jennings Ryan Staley, a licensed physician and the operator of Skinny Beach Med Spa in San Diego, was charged with mail fraud in connection with the sale of what he described as a "100%" cure for COVID-19 that he said would render customers immune to the virus for at least six weeks.
FBI Agents began investigating this COVID-19 related fraud immediately upon receiving a tip from the public and shortly thereafter introduced an undercover agent. FBI Agents also executed a search warrant at the business of Skinny Beach Med Spa located in Carmel Valley. Skinny Beach Med Spa, offered a range of beauty-related services such as botox, hair removal, and fat transfer.
In late March, Skinny Beach allegedly began sending emails advertising "COVID-19 treatment packs," described as a "concierge medicine experience" priced at $3,995 for a family of four, that included among other things access to Dr. Staley, the medications hydroxychloroquine and azithromycin, and "anti-anxiety treatments to help you avoid panic if needed and help you sleep."
In a recorded call in which Dr. Staley was selling his services to a would-be customer - in fact, the undercover FBI agent - Dr. Staley described the medication he was offering as "an amazing cure" and a "miracle cure" that would cure COVID-19 "100%." He added that if you take the medication without having the disease, "you’re immune for at least 6 weeks."
Staley referred to medication he offered as a "magic bullet," and said, "It’s preventative and curative. It’s hard to believe, it’s almost too good to be true. But it’s a remarkable clinical phenomenon."
Staley also stated, "I’ve never seen anything like this in medicine, just so you know. Really, I can’t think of anything. That, you’ve got a disease that literally disappears in hours."
Dr. Staley was interviewed a week later by the FBI as part of the overt investigation. When Dr. Staley was asked by agents whether Skinny Beach has told patients that the treatments are a 100% effective cure for COVID-19, Dr. Staley said, "No, that would be foolish. We would never say anything like that." He also told the FBI that it was "not definitive" that the medication he offered cures COVID-19.
As set out in the complaint, Dr. Staley also offered the would-be customer Xanax (alprazolam) - a Schedule IV controlled substance - as part of his concierge package, and shipped the drug without conducting any sort of medical examination. He claimed that his broker was smuggling hydroxychloroquine from China to make his own pills, and had concealed the shipment from customs authorities by describing it as sweet potato extract. Shipping records confirmed that Dr. Staley was indeed importing a shipment of "yam extract," scheduled to arrive in the U.S. in a matter of days.
"The sale of false cures, especially by a medical professional, will be vigorously investigated by the FBI," said Omer Meisel, the Acting Special Agent in Charge of the FBI’s San Diego Field Office. "The FBI is using a variety of tools to identify anyone who exploits the current crisis with fraudulent scams or a variety of cyber schemes - and is proactively warning the public about products claiming to save lives, before losing their money or creating false hope. Scammers seeking to profit by exploiting fear and uncertainty during this COVID-19 pandemic will be brought to justice.” ...
FBI Agents began investigating this COVID-19 related fraud immediately upon receiving a tip from the public and shortly thereafter introduced an undercover agent. FBI Agents also executed a search warrant at the business of Skinny Beach Med Spa located in Carmel Valley. Skinny Beach Med Spa, offered a range of beauty-related services such as botox, hair removal, and fat transfer.
In late March, Skinny Beach allegedly began sending emails advertising "COVID-19 treatment packs," described as a "concierge medicine experience" priced at $3,995 for a family of four, that included among other things access to Dr. Staley, the medications hydroxychloroquine and azithromycin, and "anti-anxiety treatments to help you avoid panic if needed and help you sleep."
In a recorded call in which Dr. Staley was selling his services to a would-be customer - in fact, the undercover FBI agent - Dr. Staley described the medication he was offering as "an amazing cure" and a "miracle cure" that would cure COVID-19 "100%." He added that if you take the medication without having the disease, "you’re immune for at least 6 weeks."
Staley referred to medication he offered as a "magic bullet," and said, "It’s preventative and curative. It’s hard to believe, it’s almost too good to be true. But it’s a remarkable clinical phenomenon."
Staley also stated, "I’ve never seen anything like this in medicine, just so you know. Really, I can’t think of anything. That, you’ve got a disease that literally disappears in hours."
Dr. Staley was interviewed a week later by the FBI as part of the overt investigation. When Dr. Staley was asked by agents whether Skinny Beach has told patients that the treatments are a 100% effective cure for COVID-19, Dr. Staley said, "No, that would be foolish. We would never say anything like that." He also told the FBI that it was "not definitive" that the medication he offered cures COVID-19.
As set out in the complaint, Dr. Staley also offered the would-be customer Xanax (alprazolam) - a Schedule IV controlled substance - as part of his concierge package, and shipped the drug without conducting any sort of medical examination. He claimed that his broker was smuggling hydroxychloroquine from China to make his own pills, and had concealed the shipment from customs authorities by describing it as sweet potato extract. Shipping records confirmed that Dr. Staley was indeed importing a shipment of "yam extract," scheduled to arrive in the U.S. in a matter of days.
"The sale of false cures, especially by a medical professional, will be vigorously investigated by the FBI," said Omer Meisel, the Acting Special Agent in Charge of the FBI’s San Diego Field Office. "The FBI is using a variety of tools to identify anyone who exploits the current crisis with fraudulent scams or a variety of cyber schemes - and is proactively warning the public about products claiming to save lives, before losing their money or creating false hope. Scammers seeking to profit by exploiting fear and uncertainty during this COVID-19 pandemic will be brought to justice.” ...
The operator of a Los Angeles company is facing federal charges for his alleged participation in a massive telemedicine health care fraud scheme that reached the southern part of Georgia, the U.S. Department of Justice announced Thursday.
Scott M. Hirsch, who ran JI Medical, a durable medical equipment company formerly based in the Miracle Mile area of Los Angeles, is accused of conspiring to pay kickbacks in exchange for obtaining orders that the company would then bill to Medicare, according to the DOJ.
As part of the scheme, federal prosecutors allege, the physicians receiving kickbacks from JI Medical knowingly signed false medical records describing telephonic "consultations" of Medicare patients.
Hirsch is the 22nd defendant charged in Georgia as part of an investigation that uncovered more than $410 million in alleged phony claims to Medicare, according to the DOJ.
"Telemedicine is an important tool for legitimate providers - but paying kickbacks is not part of telemedicine and will not be tolerated under any circumstances," said Bobby L. Christine, the U.S. attorney for the Southern District of Georgia.
"While many of our prosecutors and law enforcement partners may be working remotely during the COVID-19 pandemic, this office continues to work day and night to bring bad actors to justice," Christine said.
Previous charges in the case were brought against eight physicians, two nurse practitioners, two operators of telemedicine companies and two brokers of patient data, according to the DOJ ...
Scott M. Hirsch, who ran JI Medical, a durable medical equipment company formerly based in the Miracle Mile area of Los Angeles, is accused of conspiring to pay kickbacks in exchange for obtaining orders that the company would then bill to Medicare, according to the DOJ.
As part of the scheme, federal prosecutors allege, the physicians receiving kickbacks from JI Medical knowingly signed false medical records describing telephonic "consultations" of Medicare patients.
Hirsch is the 22nd defendant charged in Georgia as part of an investigation that uncovered more than $410 million in alleged phony claims to Medicare, according to the DOJ.
"Telemedicine is an important tool for legitimate providers - but paying kickbacks is not part of telemedicine and will not be tolerated under any circumstances," said Bobby L. Christine, the U.S. attorney for the Southern District of Georgia.
"While many of our prosecutors and law enforcement partners may be working remotely during the COVID-19 pandemic, this office continues to work day and night to bring bad actors to justice," Christine said.
Previous charges in the case were brought against eight physicians, two nurse practitioners, two operators of telemedicine companies and two brokers of patient data, according to the DOJ ...
The Press Democrat reports that law enforcement, firefighters and other first responders are raising alarms about the unique threat posed by the novel coronavirus to their health - and the need to protect personnel who get sick.
Some states have changed regulations to provide swifter access to workers’ compensation coverage for essential workers in the community during the coronavirus pandemic. These employee- funded benefits can cover lost wages, additional sick leave, job protections and death benefits.
Not yet in California, where lawmakers and Gov. Gavin Newsom have not taken up the issue, leaving each claim to be evaluated on a case- by-case by employers and insurance carriers.
Nine Santa Rosa police officers and one Sonoma County sheriff’s lieutenant have so far tested positive for the coronavirus, including longtime Santa Rosa Detective Marylou Armer, who died March 31 of complications from COVID-19, a respiratory disease caused by the disease. One Santa Rosa firefighter has tested positive for the virus.
The state must act - and soon - to assure these front-line workers don’t have to worry about lost wages, benefits and time away from work if they get sick, said Stephen Bussell, president of the Santa Rosa Police Officers’ Association. "We definitely have a higher risk level than the general public," Bussell said.
Employees seeking workers’ compensation generally must prove they acquired the illness or got hurt on the job in order for their claims to be approved. There are exceptions for law enforcement and firefighters in California. State law provides automatic workers’ compensation eligibility if they get diseases like tuberculosis, cancer and pneumonia.
Those are just some of the ailments on a list of conditions that, if acquired while employed, allow police and firefighters to receive workers’ compensation benefits without having to document where they got sick or injured. Last year, that list was expanded to include post-traumatic stress syndrome, a change made to acknowledge the heavy and growing toll of wildfires.
"That gets them treatment and paid time-off faster," said Laura Rosenthal, a Santa Rosa attorney who specializes in workers’ comp claims for law enforcement.
As a new disease, COVID-19 is not included on the list of conditions that make it easier for police officers and firefighters to file a workers’ comp claim.
But those employees who develop pneumonia while battling COVID-19 may have an easier time accessing workers’ compensation benefits because the lung infection is part of the state exemption, Rosenthal said.
No such protections for any workplace-acquired diseases or injuries exist yet for nurses or health care workers. Rosenthal said she hopes the pandemic pushes the state to consider adding protections for health care workers.
"You have law enforcement transporting an individual with a staph infection to the hospital, and he’s covered if he gets it," Rosenthal said. "But the minute you drop them off at hospital, the workers there don’t get the same protection."
Bussell said the Santa Rosa Police Department has so far been supportive of employees with coronavirus who are filing workers’ compensation claims, but it’s no easy task to document where they got it. Officers are in the community on patrol and various assignments, they often take individuals to hospitals and are in a variety of settings where they may come in close contact with people carrying the virus.
"Right now we’re doing our best to document exposures. It’s challenging to document it and be accurate," Bussell said. "But the likelihood that it happened at work is greater than not." ...
Some states have changed regulations to provide swifter access to workers’ compensation coverage for essential workers in the community during the coronavirus pandemic. These employee- funded benefits can cover lost wages, additional sick leave, job protections and death benefits.
Not yet in California, where lawmakers and Gov. Gavin Newsom have not taken up the issue, leaving each claim to be evaluated on a case- by-case by employers and insurance carriers.
Nine Santa Rosa police officers and one Sonoma County sheriff’s lieutenant have so far tested positive for the coronavirus, including longtime Santa Rosa Detective Marylou Armer, who died March 31 of complications from COVID-19, a respiratory disease caused by the disease. One Santa Rosa firefighter has tested positive for the virus.
The state must act - and soon - to assure these front-line workers don’t have to worry about lost wages, benefits and time away from work if they get sick, said Stephen Bussell, president of the Santa Rosa Police Officers’ Association. "We definitely have a higher risk level than the general public," Bussell said.
Employees seeking workers’ compensation generally must prove they acquired the illness or got hurt on the job in order for their claims to be approved. There are exceptions for law enforcement and firefighters in California. State law provides automatic workers’ compensation eligibility if they get diseases like tuberculosis, cancer and pneumonia.
Those are just some of the ailments on a list of conditions that, if acquired while employed, allow police and firefighters to receive workers’ compensation benefits without having to document where they got sick or injured. Last year, that list was expanded to include post-traumatic stress syndrome, a change made to acknowledge the heavy and growing toll of wildfires.
"That gets them treatment and paid time-off faster," said Laura Rosenthal, a Santa Rosa attorney who specializes in workers’ comp claims for law enforcement.
As a new disease, COVID-19 is not included on the list of conditions that make it easier for police officers and firefighters to file a workers’ comp claim.
But those employees who develop pneumonia while battling COVID-19 may have an easier time accessing workers’ compensation benefits because the lung infection is part of the state exemption, Rosenthal said.
No such protections for any workplace-acquired diseases or injuries exist yet for nurses or health care workers. Rosenthal said she hopes the pandemic pushes the state to consider adding protections for health care workers.
"You have law enforcement transporting an individual with a staph infection to the hospital, and he’s covered if he gets it," Rosenthal said. "But the minute you drop them off at hospital, the workers there don’t get the same protection."
Bussell said the Santa Rosa Police Department has so far been supportive of employees with coronavirus who are filing workers’ compensation claims, but it’s no easy task to document where they got it. Officers are in the community on patrol and various assignments, they often take individuals to hospitals and are in a variety of settings where they may come in close contact with people carrying the virus.
"Right now we’re doing our best to document exposures. It’s challenging to document it and be accurate," Bussell said. "But the likelihood that it happened at work is greater than not." ...
South Korean health officials are investigating several possible explanations for a small but growing number of recovered coronavirus patients who later test positive for the virus again. Among the main possibilities are re-infection, a relapse, or inconsistent tests, experts say.
South Korea had reported 141 such cases as of Thursday, according to the Korea Centers for Disease Control and Prevention (KCDC).
Although re-infection would be the most concerning scenario because of its implications for developing immunity in a population, both the KCDC and many experts say this is unlikely.
Instead, the KCDC says it is leaning toward some kind of relapse or "re-activation" in the virus.
A relapse could mean that parts of the virus go into some kind of dormant state for a time, or that some patients may have certain conditions or weak immunity that makes them susceptible to the virus reviving in their system, experts said.
A recent study by doctors in China and the United States suggested the new coronavirus can damage T lymphocytes, also known as T cells, which play a central role the body’s immune system and ability to battle infections.
Kim Jeong-ki, a virologist at the Korea University College of Pharmacy, compared a relapse after treatment to a spring that snaps back after being pressed down. "When you press down a spring it becomes smaller, then when you take your hands off, the spring pops up," he said.
Even if the patients are found to have relapsed rather than to have been re-infected, it could signal new challenges for containing the spread of the virus.
"South Korean health authorities still haven’t found cases where the ‘reactivated’ patients spread the virus to third parties, but if such infectiousness is proven, that would be a huge problem," said Seol Dai-wu, an expert in vaccine development and a professor at Chung-Ang University.
Patients in South Korea are considered clear of the virus when they have tested negative twice in a 48-hour period.
While the RT-PCR tests used in South Korea are considered generally accurate, experts said that there are ways they could return false or inconsistent results for a small number of cases.
"RT-PCR tests boast an accuracy of 95%. This means that there still can be 2-5% of those cases that are detected false negative or false positive cases," Kim said. Remnants of the virus could remain at levels too low to be detected by a given test, Seol said.
On the other hand, the tests may also be so sensitive that they are picking up small, potentially harmless levels of the virus, leading to new positive results even though the person has recovered, Kwon Jun-wook, deputy director of KCDC said at a briefing on Tuesday.
The tests could also be compromised if the necessary samples are not collected properly, said Eom Joong-sik, professor of infectious diseases at Gachon University Gil Medical Centre ...
South Korea had reported 141 such cases as of Thursday, according to the Korea Centers for Disease Control and Prevention (KCDC).
Although re-infection would be the most concerning scenario because of its implications for developing immunity in a population, both the KCDC and many experts say this is unlikely.
Instead, the KCDC says it is leaning toward some kind of relapse or "re-activation" in the virus.
A relapse could mean that parts of the virus go into some kind of dormant state for a time, or that some patients may have certain conditions or weak immunity that makes them susceptible to the virus reviving in their system, experts said.
A recent study by doctors in China and the United States suggested the new coronavirus can damage T lymphocytes, also known as T cells, which play a central role the body’s immune system and ability to battle infections.
Kim Jeong-ki, a virologist at the Korea University College of Pharmacy, compared a relapse after treatment to a spring that snaps back after being pressed down. "When you press down a spring it becomes smaller, then when you take your hands off, the spring pops up," he said.
Even if the patients are found to have relapsed rather than to have been re-infected, it could signal new challenges for containing the spread of the virus.
"South Korean health authorities still haven’t found cases where the ‘reactivated’ patients spread the virus to third parties, but if such infectiousness is proven, that would be a huge problem," said Seol Dai-wu, an expert in vaccine development and a professor at Chung-Ang University.
Patients in South Korea are considered clear of the virus when they have tested negative twice in a 48-hour period.
While the RT-PCR tests used in South Korea are considered generally accurate, experts said that there are ways they could return false or inconsistent results for a small number of cases.
"RT-PCR tests boast an accuracy of 95%. This means that there still can be 2-5% of those cases that are detected false negative or false positive cases," Kim said. Remnants of the virus could remain at levels too low to be detected by a given test, Seol said.
On the other hand, the tests may also be so sensitive that they are picking up small, potentially harmless levels of the virus, leading to new positive results even though the person has recovered, Kwon Jun-wook, deputy director of KCDC said at a briefing on Tuesday.
The tests could also be compromised if the necessary samples are not collected properly, said Eom Joong-sik, professor of infectious diseases at Gachon University Gil Medical Centre ...
The WCIRB’s Classification and Rating Committee is considering three rule changes that WCIRB staff are recommending in response to the impact of the coronavirus disease 2019 (COVID-19) pandemic on California employers and workers. The Committee is considering changes that, if approved by the Insurance Commissioner, would:
Exclude Payments to Employees Who Continue to Be Paid While Not Working
The Committee will review a proposal to exclude from reported payroll the payments made to employees who are continuing to be paid while not engaged in any work activities. This exclusion would apply while California’s stay-at-home order is in place and for up to 30 days thereafter if the employee continues not to work. Excluding this payroll recognizes the extraordinary circumstances resulting from the stay-at-home order and the fact that employees not engaged in work activities have virtually no work-related exposure. Allow Assignment of Classification 8810 for Temporary Change in Duties
The Committee will review a proposal to allow the assignment of Classification 8810, Clerical Office Employees, to the payroll of employees whose job duties, during California’s stay-at-home order, meet the definition of a Clerical Office Employee. This provision would apply while California’s stay-at-home order is in place and for up to 30 days thereafter if the employee continues to meet the definition of a Clerical Office Employee, but does not apply to the payroll of employees whose payroll is otherwise assignable to a standard classification that specifically includes Clerical Office Employees.
Exclude COVID-19 Claims from Experience Rating
The Committee will review a proposal to exclude claims with a diagnosis of COVID-19 and an accident date on or after December 1, 2019 from the experience rating calculations of individual employers. Since the occurrence of COVID-19 workers’ compensation claims are unlikely to be a strong predictor of future claim costs incurred by an employer, their inclusion in an experience modification calculation would not meet the intended goal of experience rating.
This is a high-level summary of the proposed regulatory changes. Details regarding the proposed changes and the full agenda, including the teleconference login information, are available on the Committee Documents page in the Filings and Plans section of the WCIRB’s website ...
Exclude Payments to Employees Who Continue to Be Paid While Not Working
The Committee will review a proposal to exclude from reported payroll the payments made to employees who are continuing to be paid while not engaged in any work activities. This exclusion would apply while California’s stay-at-home order is in place and for up to 30 days thereafter if the employee continues not to work. Excluding this payroll recognizes the extraordinary circumstances resulting from the stay-at-home order and the fact that employees not engaged in work activities have virtually no work-related exposure. Allow Assignment of Classification 8810 for Temporary Change in Duties
The Committee will review a proposal to allow the assignment of Classification 8810, Clerical Office Employees, to the payroll of employees whose job duties, during California’s stay-at-home order, meet the definition of a Clerical Office Employee. This provision would apply while California’s stay-at-home order is in place and for up to 30 days thereafter if the employee continues to meet the definition of a Clerical Office Employee, but does not apply to the payroll of employees whose payroll is otherwise assignable to a standard classification that specifically includes Clerical Office Employees.
Exclude COVID-19 Claims from Experience Rating
The Committee will review a proposal to exclude claims with a diagnosis of COVID-19 and an accident date on or after December 1, 2019 from the experience rating calculations of individual employers. Since the occurrence of COVID-19 workers’ compensation claims are unlikely to be a strong predictor of future claim costs incurred by an employer, their inclusion in an experience modification calculation would not meet the intended goal of experience rating.
This is a high-level summary of the proposed regulatory changes. Details regarding the proposed changes and the full agenda, including the teleconference login information, are available on the Committee Documents page in the Filings and Plans section of the WCIRB’s website ...
Health Strategy Associates has published the key findings of "The Impact of COVID-19 on Workers’ Compensation" survey. HSA Principal Joe Paduda interviewed 15 workers’ compensation insurance carriers, third-party payers, government entities, and other self-insured employers over a seven-day period ending April 6.
"I wanted to gather information to help payers learn from each other so they could adapt more quickly to this fluid and entirely unforeseen event," Paduda said.
Among the initial impacts raised were:
-- Declining payrolls
-- Access-to-care issues
-- Spike in demand for telemedicine, telerehab and other telehealth services
-- Delayed return to work
-- Transitioning employees to work from home (WFH)
-- Determining which COVID-19-related claims should be accepted -- Dealing with WFH claims
Respondents noted the challenge of shifting operations from managing injury-related claims to disease-related ones. Prior to the pandemic, roughly 95 percent of claims resulted from injuries and investigating them was usually straightforward.
"With COVID-19, you need to try to figure out where the exposure occurred. Could it have happened outside the workplace? Adjusters need to ask about travel, family health, potential contact with infected people, and determine whether to test or not," Paduda said.
"States have different presumption standards, and some link COVID-19 to specific occupation types," he added.
Paduda will conduct a second survey on the impact of COVID-19 on workers’ compensation in a few weeks. He plans to expand the types of respondents to include managed care organizations and others that support workers’ compensation payers as well as payers. Anyone interested in participating can email jpaduda@healthstrategyassoc.com. While the full report is available only to respondents, an abstract can be found at https://tinyurl.com/HSACOVIDsurvey.
Based near Syracuse in Skaneateles, New York, Health Strategy Associates consults with insurers, employers, medical management companies, health care providers, and venture capitalists ...
"I wanted to gather information to help payers learn from each other so they could adapt more quickly to this fluid and entirely unforeseen event," Paduda said.
Among the initial impacts raised were:
-- Declining payrolls
-- Access-to-care issues
-- Spike in demand for telemedicine, telerehab and other telehealth services
-- Delayed return to work
-- Transitioning employees to work from home (WFH)
-- Determining which COVID-19-related claims should be accepted -- Dealing with WFH claims
Respondents noted the challenge of shifting operations from managing injury-related claims to disease-related ones. Prior to the pandemic, roughly 95 percent of claims resulted from injuries and investigating them was usually straightforward.
"With COVID-19, you need to try to figure out where the exposure occurred. Could it have happened outside the workplace? Adjusters need to ask about travel, family health, potential contact with infected people, and determine whether to test or not," Paduda said.
"States have different presumption standards, and some link COVID-19 to specific occupation types," he added.
Paduda will conduct a second survey on the impact of COVID-19 on workers’ compensation in a few weeks. He plans to expand the types of respondents to include managed care organizations and others that support workers’ compensation payers as well as payers. Anyone interested in participating can email jpaduda@healthstrategyassoc.com. While the full report is available only to respondents, an abstract can be found at https://tinyurl.com/HSACOVIDsurvey.
Based near Syracuse in Skaneateles, New York, Health Strategy Associates consults with insurers, employers, medical management companies, health care providers, and venture capitalists ...
Anthony Dennis sustained an injury in 2013 to his right wrist while working as an inmate for the California Department of Corrections and Rehabilitation. The parties stipulated to an award in 2017. This did not include his claim for a SJDB voucher. Prior to the stipulation, defendant sent Dennis a Notice of Offer of Regular, Modified, or Alternative Work. The Notice also stated "SUBJECT TO APPLICANT VERIFYING THEY ARE LAWFULLY QUALIFIED TO ACCEPT EMPLOYMENT AS AN INMATE LABORER, YOU HAVE VOLUNTARILY TERMINATED YOUR EMPLOYMENT DUE TO YOUR RELEASE FROM PRISON AND ARE NO LONGER AVAILABLE FOR EMPLOYMENT[sic]." Dennis filed a Request for Dispute Resolution Before Administrative Director, to resolve the issue of entitlement to a SJDB voucher. the AD did not issue a determination, and pursuant to the Rules, the request was therefore deemed denied. Dennis then filed a DOR with the Sacramento District Office asking it to adjudicate his claim to this benefit. The WCAB rescinded the Award, and substituted a new Finding that applicant is entitled to a SJDB voucher. It concluded that the WCAB maintains exclusive jurisdiction to adjudicate SJDB disputes irrespective of AD Rule 10133.54, which provides that the parties may request a dispute resolution with the Administrative Director before appealing the Administrative Director’s decision to the WCAB. The Defendant, newly aggrieved, sought reconsideration of the new decision, which the WCAB granted. In the tentative En Banc decision it concluded that AD Rule 10133.54 exceeds the authority granted in sections 4658.5(c) and 4658.7(h), which authorizes the Administrative Director to adopt regulations for the administration of the supplemental job displacement benefits program. Neither statute authorizes the Administrative Director to adjudicate SJDB disputes. It went on to note that it was "cognizant that employment in a prison setting is unique in that inmate workers cannot return to an inmate job once they are released from prison, making it impossible for a prison employer to make a bona fide job offer. Our review of statutes and case law, however, leads us to conclude that an employer’s inability to offer regular, modified, or alternative work does not release an employer from the statutory obligation to provide a SJDB voucher." In concluding, the WCAB issued its notice of intent to issue a decision after affording the Administrative Director 30 days to file a response to this Notice of Intention. The Administrative Director responded contending that: (1) it has the adjudicatory authority to resolve disputes over the SJDB and that its dispute resolution process is valid; (2) its dispute resolution process is voluntary and does not usurp the jurisdiction of the WCAB; and (3) the WCAB cannot invalidate AD Rule 10133.54 because the issue is not ripe since applicant did not properly file his Request for Dispute Resolution Before Administrative Director. Nothing in the Administrative Director’s Response changed the views as expressed in the Notice of Intention. Its. final En Bank decision of Dennis v Department of Corrections, the WCAB provided a thorough and detailed iustification of this position ...
In light of the COVID-19 public health emergency and the Executive Orders issued by Governor Newsom, the Division of Workers’ Compensation (DWC) has posted an order adjusting the Physician Services / Non-Physician Practitioner Services Fee Schedule to adopt changes that will encourage expanded use of telehealth during the COVID-19 public health emergency.
The changes are based upon Medicare’s public health emergency Physician Fee Schedule interim revisions, which adopt an expanded list of services that may be provided through telehealth, and which modify the "Place of Service" code for telehealth.
Adoption of the Medicare telehealth code list will encourage the expanded use of telehealth by identifying services which may be provided through telehealth where medically appropriate and identified by modifier 95. The adoption of the Place of Service code revision will encourage use of telehealth by equalizing the payment for a service whether provided in a physician’s office or through telehealth using real time audio and video telecommunications.
DWC encourages the provision of medical treatment by telehealth in lieu of in-person visits whenever medically appropriate, in order to protect patients and health care providers and to support the crucial effort to slow the community spread of the COVID-19 virus. Increased use of telehealth for workers’ compensation treatment is in alignment with the goals of the Governor’s "stay at home" Executive Order, and Executive Order regarding telehealth services.
The DWC order and revised regulation text, effective for services rendered on or after April 15, 2020, can be found on the Physician and Non-Physician Practitioner fee schedule web page ...
The changes are based upon Medicare’s public health emergency Physician Fee Schedule interim revisions, which adopt an expanded list of services that may be provided through telehealth, and which modify the "Place of Service" code for telehealth.
Adoption of the Medicare telehealth code list will encourage the expanded use of telehealth by identifying services which may be provided through telehealth where medically appropriate and identified by modifier 95. The adoption of the Place of Service code revision will encourage use of telehealth by equalizing the payment for a service whether provided in a physician’s office or through telehealth using real time audio and video telecommunications.
DWC encourages the provision of medical treatment by telehealth in lieu of in-person visits whenever medically appropriate, in order to protect patients and health care providers and to support the crucial effort to slow the community spread of the COVID-19 virus. Increased use of telehealth for workers’ compensation treatment is in alignment with the goals of the Governor’s "stay at home" Executive Order, and Executive Order regarding telehealth services.
The DWC order and revised regulation text, effective for services rendered on or after April 15, 2020, can be found on the Physician and Non-Physician Practitioner fee schedule web page ...
The FBI uncovered an international coronavirus-fueled fraud scheme after more than 39 million masks promised to a powerful California union representing health-care workers were never delivered to hospitals and other medical groups in the state, according to a report published Saturday.
Service Employees International Union-United Healthcare Workers West announced on March 26 it had identified a distributor overseas who was willing to sell 39 million critically needed N95 masks, a press release said. The union said it secured the deal after 48 hours calling leads and potential suppliers to help find personal protective equipment for health-care workers on the front lines of the crisis.
An unidentified businessman in Pittsburgh reportedly was helping the union contact a broker in Australia and a distributor in Kuwait on WhatsApp to secure the deal, U.S. Attorney Scott Brady of the Western District of Pennsylvania told the Los Angeles Times.
"We believe we disrupted fraud," Brady said. "We are seeing fraud in every variation, but mostly in respect to N95 masks. We have an anxious public, and resources are strained."
As part of the deal, Kaiser Permanente said they planned to purchase 6 million masks. Sutter Health officials also placed an order for 2 million masks, the Times reported.
Meanwhile, SEIU 121RN, Southern California’s Union of Registered Nurses, launched an online petition accusing hospitals who did not agree to take part in the deal of "putting bottom line profits over your safety."
The FBI initially began to track the deal to determine if the 39 million masks should be intercepted for the Federal Emergency Management Agency under the Defense Production Act. That’s when the investigators found fraud had been committed.
Kaiser Permanente said the seller had "repeatedly failed to provide reliable information about where we could verify and inspect the shipment." Brady added that the broker in Australia told the middleman in Pittsburgh there was a warehouse in Georgia filled with 2 million of the masks.
The FBI found no such warehouse with the alleged stockpile. Meanwhile, the seller demanded a 40 percent payment upfront and planned to send Kaiser Permanente details on how to send the funds.
"We learned shortly afterward that the supplier never had possession of the masks," a Kaiser spokesman Marc Brown said in an emailed statement to the Times. "We are cooperating with federal law enforcement in their investigation of suspected fraud in this case."
Neither the union nor the Pittsburgh businessman are under investigation and appear to have been fooled by the international scammers, Brady said. No money was exchanged as part of the deal.
SEIU initially said the stockpile of masks available for purchase was made by American manufacturer 3M. But, 3M told federal investigators the company manufactured only 20 million masks last year, signaling that the stockpile overseas was likely counterfeit if it existed at all.
"As far as we knew, he had legitimate masks," Steve Trossman, spokesman for SEIU-UHW, said of the supplier. "The people who were going to purchase those masks were going to fully vet it and check it out and do their due diligence."
Union officials were "trying to save the lives of health-care workers and patients" and "were proud of having made that attempt," Trossman told the Times ...
Service Employees International Union-United Healthcare Workers West announced on March 26 it had identified a distributor overseas who was willing to sell 39 million critically needed N95 masks, a press release said. The union said it secured the deal after 48 hours calling leads and potential suppliers to help find personal protective equipment for health-care workers on the front lines of the crisis.
An unidentified businessman in Pittsburgh reportedly was helping the union contact a broker in Australia and a distributor in Kuwait on WhatsApp to secure the deal, U.S. Attorney Scott Brady of the Western District of Pennsylvania told the Los Angeles Times.
"We believe we disrupted fraud," Brady said. "We are seeing fraud in every variation, but mostly in respect to N95 masks. We have an anxious public, and resources are strained."
As part of the deal, Kaiser Permanente said they planned to purchase 6 million masks. Sutter Health officials also placed an order for 2 million masks, the Times reported.
Meanwhile, SEIU 121RN, Southern California’s Union of Registered Nurses, launched an online petition accusing hospitals who did not agree to take part in the deal of "putting bottom line profits over your safety."
The FBI initially began to track the deal to determine if the 39 million masks should be intercepted for the Federal Emergency Management Agency under the Defense Production Act. That’s when the investigators found fraud had been committed.
Kaiser Permanente said the seller had "repeatedly failed to provide reliable information about where we could verify and inspect the shipment." Brady added that the broker in Australia told the middleman in Pittsburgh there was a warehouse in Georgia filled with 2 million of the masks.
The FBI found no such warehouse with the alleged stockpile. Meanwhile, the seller demanded a 40 percent payment upfront and planned to send Kaiser Permanente details on how to send the funds.
"We learned shortly afterward that the supplier never had possession of the masks," a Kaiser spokesman Marc Brown said in an emailed statement to the Times. "We are cooperating with federal law enforcement in their investigation of suspected fraud in this case."
Neither the union nor the Pittsburgh businessman are under investigation and appear to have been fooled by the international scammers, Brady said. No money was exchanged as part of the deal.
SEIU initially said the stockpile of masks available for purchase was made by American manufacturer 3M. But, 3M told federal investigators the company manufactured only 20 million masks last year, signaling that the stockpile overseas was likely counterfeit if it existed at all.
"As far as we knew, he had legitimate masks," Steve Trossman, spokesman for SEIU-UHW, said of the supplier. "The people who were going to purchase those masks were going to fully vet it and check it out and do their due diligence."
Union officials were "trying to save the lives of health-care workers and patients" and "were proud of having made that attempt," Trossman told the Times ...
On April 3, 2020, Cerity Insurance Company, a direct to small business workers’ compensation carrier, launched their fully automated online purchasing platform in the state of California.
Small businesses can now take advantage of the lower prices and affordable billing options provided through direct purchase. This increases the number of states served by Cerity to thirty-nine, with two additional states scheduled to launch later this quarter.
The company received written approval to sell in California on April 2, and launched the next day. Tracey Berg, President of Cerity said "Our team moves quickly. Every piece of our tech stack is modern and scalable, which guarantees we can move faster and offer more features than traditional agents and carriers."
Cerity Services, Inc. is a subsidiary of Employers Holdings Inc. (NYSE:EIG), an industry veteran, with over 100 years of experience in workers’ compensation.
Berg added "Businesses across the U.S. are facing unprecedented challenges. We're excited to bring our digital insurance platform to California businesses during this critical time as our products directly reduce business expenses and increase billing flexibility. Cerity offers complete protection at an affordable price, with a team of licensed agents and 24/7 online access to important policy documents,"
Cerity also recently released two new products designed to help small business owners.
The first, PayGoTM, is a fully automated pay-as-you-go billing solution that works with all major payroll platforms. Unlike traditional workers’ comp plans that require annual payroll estimations, large up-front fees, and painful year-end audits, PayGo relies on real-time payroll calculations, resulting in more accurate monthly payments that adjust automatically to a changing small business. With no money down, cash flow advantages, and automated payment processing, PayGo has rapidly grown in popularity with small to medium sized businesses.
The second, PIXTM, or Partner Insurance Exchange, is available to business professionals, affiliate platforms, and associations who work with and advise their clients and members. Enrolled partners gain access to Cerity’s Business Growth EngineTM, a suite of tools designed to quickly and easily educate their clients about the benefits of Cerity.
These tools enable partners to offer a digital workers’ compensation option for their clients and members, with Cerity serving as the licensed agent. "Payroll and accounting professionals are in a unique position to educate their clients and help them save money on insurance, but most are not licensed," said Dennis Dix, SVP, Chief Operating Officer at Cerity. "We currently fill that void for independent payroll providers and are excited to expand our PIX program to affiliations, associations, and franchises to help them continue to add value and grow membership."
...
Small businesses can now take advantage of the lower prices and affordable billing options provided through direct purchase. This increases the number of states served by Cerity to thirty-nine, with two additional states scheduled to launch later this quarter.
The company received written approval to sell in California on April 2, and launched the next day. Tracey Berg, President of Cerity said "Our team moves quickly. Every piece of our tech stack is modern and scalable, which guarantees we can move faster and offer more features than traditional agents and carriers."
Cerity Services, Inc. is a subsidiary of Employers Holdings Inc. (NYSE:EIG), an industry veteran, with over 100 years of experience in workers’ compensation.
Berg added "Businesses across the U.S. are facing unprecedented challenges. We're excited to bring our digital insurance platform to California businesses during this critical time as our products directly reduce business expenses and increase billing flexibility. Cerity offers complete protection at an affordable price, with a team of licensed agents and 24/7 online access to important policy documents,"
Cerity also recently released two new products designed to help small business owners.
The first, PayGoTM, is a fully automated pay-as-you-go billing solution that works with all major payroll platforms. Unlike traditional workers’ comp plans that require annual payroll estimations, large up-front fees, and painful year-end audits, PayGo relies on real-time payroll calculations, resulting in more accurate monthly payments that adjust automatically to a changing small business. With no money down, cash flow advantages, and automated payment processing, PayGo has rapidly grown in popularity with small to medium sized businesses.
The second, PIXTM, or Partner Insurance Exchange, is available to business professionals, affiliate platforms, and associations who work with and advise their clients and members. Enrolled partners gain access to Cerity’s Business Growth EngineTM, a suite of tools designed to quickly and easily educate their clients about the benefits of Cerity.
These tools enable partners to offer a digital workers’ compensation option for their clients and members, with Cerity serving as the licensed agent. "Payroll and accounting professionals are in a unique position to educate their clients and help them save money on insurance, but most are not licensed," said Dennis Dix, SVP, Chief Operating Officer at Cerity. "We currently fill that void for independent payroll providers and are excited to expand our PIX program to affiliations, associations, and franchises to help them continue to add value and grow membership."
...
United States Attorney Michael Bailey and Arizona Attorney General Mark Brnovich launched a joint federal, state, and local task force to combat coronavirus-related fraud.
The COVID-19 Fraud Task Force brings together a dozen partners from across the state, with the goal of combining resources and information to better investigate and prosecute wrongdoers that seek to profit from the public health crisis.
Assistant United States Attorney Jim Knapp, recently appointed as the United States Attorney’s Office COVID-19 Fraud Coordinator, and Joseph Sciarrotta, Civil Division Chief for the Attorney General’s Office, are leading the Arizona COVID-19 Fraud Task Force. Other members include: Maricopa County Attorney’s Office, the Federal Bureau of Investigation, the Food and Drug Administration, the Internal Revenue Service Investigation Division, Health and Human Services, the United States Postal Inspection Service, the Treasury Inspector General for Tax Administration, the United States Secret Service, the United States Army Criminal Investigation Division, and the Defense Criminal Investigative Services.
In recent weeks, stories of fraud related to the coronavirus have increased across the nation. In times of uncertainty, consumers are often more vulnerable to scams as they seek answers and a sense of security. Fake texts, emails, and social media posts that might normally be ignored may now be enticing if they offer COVID-19 tests, miracle cures, medical products, or financial windfall.
On April 6, the Federal Trade Commission reported that it had received almost 12,000 consumer complaints related to COVID-19 in just three months. Well over half of those complaints were fraud-related, with a total loss to consumers of $8.39 million.
The Arizona Attorney General’s Office has also experienced a spike in COVID-19-related consumer fraud complaints. The office already sent cease-and-desist letters to local businesses (YiLo Superstore Dispensary and Prepper’s Discount) that were offering COVID-19-related products alleged to be in violation of the Arizona Consumer Fraud Act. To help keep Arizonans informed of the latest scams and to provide tips to consumers, the Attorney General’s Office recently launched a COVID-19 scam information page: www.AZAG.gov/COVID-19.
In light of these reports, consumers are urged to consider the following to protect yourself from COVID-19 fraud:
-- Do not respond to texts, emails, or calls requesting your personal information in exchange for a COVID-19 stimulus check. If you receive one of these requests, immediately report it to the hotline. COVID-19 economic impact checks will be delivered based on 2018 or 2019 tax return information, so no action is required for most people.
-- Ignore offers for a COVID-19 vaccine, cure, or treatment. Remember, if there is a medical breakthrough, you won’t hear about it for the first time through an email, online ad, or unsolicited sales pitch.
-- Research any charities or crowdfunding sites soliciting donations in connection with COVID-19 before giving. An organization may not be legitimate even if it uses words like “CDC” or “government” in its name.
-- Be cautious of purchasing personal protective equipment (PPE) from unknown third party vendors. Verify that the company is legitimate before ordering their products or sending money.
-- Never click on a link or open an email attachment from an unknown or unverified source. Links and attachments may be embedded with a virus that will infect your computer or mobile device. To better protect yourself against malware, make sure your anti-virus software is operating and up-to-date.
-- Do not be convinced by sales pitches for COVID-19 tests that promise to give results in as little as 24 hours. If an effective, quick-results test becomes widely available, you will find out through news sources and government reporting, not a sales pitch.
If you believe you have been a target of a coronavirus-related scam, or know someone else who has been, please report the fraud. Reports can be made to the Task Force at:
National Center for Disaster Fraud Hotline: 1-800-720-5721 or disaster@leo.gov
FBI’s IC3 (for internet related scams): www.IC3.gov ...
The COVID-19 Fraud Task Force brings together a dozen partners from across the state, with the goal of combining resources and information to better investigate and prosecute wrongdoers that seek to profit from the public health crisis.
Assistant United States Attorney Jim Knapp, recently appointed as the United States Attorney’s Office COVID-19 Fraud Coordinator, and Joseph Sciarrotta, Civil Division Chief for the Attorney General’s Office, are leading the Arizona COVID-19 Fraud Task Force. Other members include: Maricopa County Attorney’s Office, the Federal Bureau of Investigation, the Food and Drug Administration, the Internal Revenue Service Investigation Division, Health and Human Services, the United States Postal Inspection Service, the Treasury Inspector General for Tax Administration, the United States Secret Service, the United States Army Criminal Investigation Division, and the Defense Criminal Investigative Services.
In recent weeks, stories of fraud related to the coronavirus have increased across the nation. In times of uncertainty, consumers are often more vulnerable to scams as they seek answers and a sense of security. Fake texts, emails, and social media posts that might normally be ignored may now be enticing if they offer COVID-19 tests, miracle cures, medical products, or financial windfall.
On April 6, the Federal Trade Commission reported that it had received almost 12,000 consumer complaints related to COVID-19 in just three months. Well over half of those complaints were fraud-related, with a total loss to consumers of $8.39 million.
The Arizona Attorney General’s Office has also experienced a spike in COVID-19-related consumer fraud complaints. The office already sent cease-and-desist letters to local businesses (YiLo Superstore Dispensary and Prepper’s Discount) that were offering COVID-19-related products alleged to be in violation of the Arizona Consumer Fraud Act. To help keep Arizonans informed of the latest scams and to provide tips to consumers, the Attorney General’s Office recently launched a COVID-19 scam information page: www.AZAG.gov/COVID-19.
In light of these reports, consumers are urged to consider the following to protect yourself from COVID-19 fraud:
-- Do not respond to texts, emails, or calls requesting your personal information in exchange for a COVID-19 stimulus check. If you receive one of these requests, immediately report it to the hotline. COVID-19 economic impact checks will be delivered based on 2018 or 2019 tax return information, so no action is required for most people.
-- Ignore offers for a COVID-19 vaccine, cure, or treatment. Remember, if there is a medical breakthrough, you won’t hear about it for the first time through an email, online ad, or unsolicited sales pitch.
-- Research any charities or crowdfunding sites soliciting donations in connection with COVID-19 before giving. An organization may not be legitimate even if it uses words like “CDC” or “government” in its name.
-- Be cautious of purchasing personal protective equipment (PPE) from unknown third party vendors. Verify that the company is legitimate before ordering their products or sending money.
-- Never click on a link or open an email attachment from an unknown or unverified source. Links and attachments may be embedded with a virus that will infect your computer or mobile device. To better protect yourself against malware, make sure your anti-virus software is operating and up-to-date.
-- Do not be convinced by sales pitches for COVID-19 tests that promise to give results in as little as 24 hours. If an effective, quick-results test becomes widely available, you will find out through news sources and government reporting, not a sales pitch.
If you believe you have been a target of a coronavirus-related scam, or know someone else who has been, please report the fraud. Reports can be made to the Task Force at:
National Center for Disaster Fraud Hotline: 1-800-720-5721 or disaster@leo.gov
FBI’s IC3 (for internet related scams): www.IC3.gov ...
A national law firm with offices in the Bay Area, filed 4 class action lawsuits alleging United Behavioral Health and Cigna Behavioral Health, Inc. have both conspired for years with Viant, Inc. to perpetrate a fraud upon patients and out-of-network behavioral health providers who offered outpatient care.
The suits were filed in the U.S. District Court for the Northern District of California. Plaintiffs are seeking damages on behalf of nationwide classes of patients and providers. The suits are brought under federal and state laws including Employee Retirement Income Security Act (ERISA), the Racketeer Influenced and Corrupt Organizations Act (RICO), the Sherman Antitrust Act and California's Unfair Business Practices statute.
The alleged conspiracy affected the payments of reasonable and customary rates in healthcare and has resulted in below market payments to providers and hundreds of millions of dollars in total balance bills for patients across the country.
These allegedly illegally low payments violate the terms of patients' insurance plans and promises that were made to providers regarding rates for covered services.
Plaintiffs allege that the insurers used Viant as a middleman to systematically reduce payments for substance abuse and mental health treatment to less than 5% of what providers were actually owed.
Two of the cases are brought by patients against United and Viant and Cigna and Viant, respectively, and two are brought by behavioral health outpatient providers against the same defendants. Representative plaintiffs in the patient suits include health plan members from some of the most respected technology companies in Silicon Valley, including Apple, Inc., Tesla, Inc. and Inuit.
All of the behavioral health providers identified as plaintiffs in the suits are highly respected, licensed outpatient programs, and all accredited by the Joint Commission on Accreditation of Healthcare Organizations.
Lead Attorney Matt Lavin says of the case "Cigna and United's use of Viant to systematically underpay treatment costs for addicts and the mentally ill is, sadly, just today's example of insurers placing profits before behavioral health patients.
All the cases allege that the Viant scam rose to prominence after then NY Attorney General Andrew Cuomo put an end to the insurance companies' Ingenix underpayment racket in 2015. According to the complaints, Cigna and United replaced Ingenix with Viant to justify ripping off insurance customers by manipulating benefits by applying secret rates that are arbitrary, deceitful, self-serving, and harmful to patients, all in order to grow profits and steer patients to in-network providers who cost the insurers less.
The complaints can be found here: PRS, et. al. v. United, et al, case 3:20-cv-02249, PRS, et al. v. CIGNA, et. al., case 3:20-cv-02251, LD, et. al. v. United, et. al., case 5:20-cv-02254, and RJ v. Signa, et. al., case 5:20-cv-02255 ...
The suits were filed in the U.S. District Court for the Northern District of California. Plaintiffs are seeking damages on behalf of nationwide classes of patients and providers. The suits are brought under federal and state laws including Employee Retirement Income Security Act (ERISA), the Racketeer Influenced and Corrupt Organizations Act (RICO), the Sherman Antitrust Act and California's Unfair Business Practices statute.
The alleged conspiracy affected the payments of reasonable and customary rates in healthcare and has resulted in below market payments to providers and hundreds of millions of dollars in total balance bills for patients across the country.
These allegedly illegally low payments violate the terms of patients' insurance plans and promises that were made to providers regarding rates for covered services.
Plaintiffs allege that the insurers used Viant as a middleman to systematically reduce payments for substance abuse and mental health treatment to less than 5% of what providers were actually owed.
Two of the cases are brought by patients against United and Viant and Cigna and Viant, respectively, and two are brought by behavioral health outpatient providers against the same defendants. Representative plaintiffs in the patient suits include health plan members from some of the most respected technology companies in Silicon Valley, including Apple, Inc., Tesla, Inc. and Inuit.
All of the behavioral health providers identified as plaintiffs in the suits are highly respected, licensed outpatient programs, and all accredited by the Joint Commission on Accreditation of Healthcare Organizations.
Lead Attorney Matt Lavin says of the case "Cigna and United's use of Viant to systematically underpay treatment costs for addicts and the mentally ill is, sadly, just today's example of insurers placing profits before behavioral health patients.
All the cases allege that the Viant scam rose to prominence after then NY Attorney General Andrew Cuomo put an end to the insurance companies' Ingenix underpayment racket in 2015. According to the complaints, Cigna and United replaced Ingenix with Viant to justify ripping off insurance customers by manipulating benefits by applying secret rates that are arbitrary, deceitful, self-serving, and harmful to patients, all in order to grow profits and steer patients to in-network providers who cost the insurers less.
The complaints can be found here: PRS, et. al. v. United, et al, case 3:20-cv-02249, PRS, et al. v. CIGNA, et. al., case 3:20-cv-02251, LD, et. al. v. United, et. al., case 5:20-cv-02254, and RJ v. Signa, et. al., case 5:20-cv-02255 ...
The Workers’ Compensation Insurance Rating Bureau of California (WCIRB) Governing Committee recently met to review the WCIRB Actuarial Committee’s analysis of December 31, 2019 California workers’ compensation experience.
The indicated average July 1, 2020 advisory pure premium rate based on December 31, 2019 experience and the methodologies recommended by the Actuarial Committee was $1.53 per $100 of payroll, which is $0.01 above the average approved January 1, 2020 advisory pure premium rate of $1.52.
Given the minor indicated change in advisory pure premium rates and the exceptionally high level of uncertainty of the potential effects of the COVID-19 pandemic related to the impacts of the impending economic downturn on payrolls and claims costs, the potential slowdown in claims activity resulting from the statewide stay-at-home order and emerging claims arising from COVID-19 diagnoses, the Committee unanimously decided not to submit a July 1, 2020 filing.
The Committee also agreed that the potential impacts of the COVID-19 pandemic and payroll and claim cost level should be considered as part of the WCIRB’s January 1, 2021 pure premium rate filing, which is anticipated to be submitted to the Insurance Commissioner in August.
The Actuarial Committee’s analysis of December 31, 2019 experience is publicly available to all stakeholders as are the documents from the Committee meeting, including the agenda and materials presented at the meeting, on the Committee Documents page of the WCIRB website.
Also, on April 14, 2020, the Workers’ Compensation Insurance Rating Bureau of California’s Classification and Rating Committee will consider three rule changes that WCIRB staff are recommending in response to the impact of the coronavirus disease 2019 (COVID-19) pandemic on California employers and workers. The Committee will consider changes that, if approved by the Insurance Commissioner, would:
-- Exclude Payments to Employees Who Continue to Be Paid While Not Working
-- Allow Assignment of Classification 8810 for Temporary Change in Duties
-- Exclude COVID-19 Claims from Experience Rating
Details regarding the proposed changes and the full agenda, including the teleconference login information, are available on the Committee Documents page in the Filings and Plans section of the WCIRB’s website ...
The indicated average July 1, 2020 advisory pure premium rate based on December 31, 2019 experience and the methodologies recommended by the Actuarial Committee was $1.53 per $100 of payroll, which is $0.01 above the average approved January 1, 2020 advisory pure premium rate of $1.52.
Given the minor indicated change in advisory pure premium rates and the exceptionally high level of uncertainty of the potential effects of the COVID-19 pandemic related to the impacts of the impending economic downturn on payrolls and claims costs, the potential slowdown in claims activity resulting from the statewide stay-at-home order and emerging claims arising from COVID-19 diagnoses, the Committee unanimously decided not to submit a July 1, 2020 filing.
The Committee also agreed that the potential impacts of the COVID-19 pandemic and payroll and claim cost level should be considered as part of the WCIRB’s January 1, 2021 pure premium rate filing, which is anticipated to be submitted to the Insurance Commissioner in August.
The Actuarial Committee’s analysis of December 31, 2019 experience is publicly available to all stakeholders as are the documents from the Committee meeting, including the agenda and materials presented at the meeting, on the Committee Documents page of the WCIRB website.
Also, on April 14, 2020, the Workers’ Compensation Insurance Rating Bureau of California’s Classification and Rating Committee will consider three rule changes that WCIRB staff are recommending in response to the impact of the coronavirus disease 2019 (COVID-19) pandemic on California employers and workers. The Committee will consider changes that, if approved by the Insurance Commissioner, would:
-- Exclude Payments to Employees Who Continue to Be Paid While Not Working
-- Allow Assignment of Classification 8810 for Temporary Change in Duties
-- Exclude COVID-19 Claims from Experience Rating
Details regarding the proposed changes and the full agenda, including the teleconference login information, are available on the Committee Documents page in the Filings and Plans section of the WCIRB’s website ...
Attorneys representing parties in litigation have not had a clear understanding about possible liability for settling a workers' compensation or personal injury case without adequately dealing with Medicare issues. However, a new case filed by the United States against a plaintiff lawfirm in Texas may help to clear up any misunderstandings about attorney liability exposure.
Franco Signor reports that a lawsuit filed in in the United States District Court for the Southern District of Texas by the U.S. alleges that the plaintiff attorney in a personal injury action (Carrigan & Anderson, PLLC and Attorney Stephen P. Carrigan individually) failed to reimburse Medicare’s demand for conditional payments in full.
It is not unusual for U.S. Attorneys to file litigation against personal injury law firms for failure to comply with the Medicare Secondary Payer (MSP) act requirement to reimburse conditional payments. The instant case is different.
Here the personal injury attorney Defendants corresponded often with the Benefits Coordination & Recovery Contractor (BCRC) regarding Medicare conditional payments owed on behalf of their Medicare beneficiary client, Tomas R. Tijerina prior to settling the claim. Defendants did not agree with the amount demanded and sought state court protection in an Order that reduced Medicare’s conditional payments rather than undertake the administrative appeals process to dispute the conditional payment amount owed.
As alleged by the U.S. Attorney in the Complaint, on April 14, 2016, Defendants first notified the BCRC about Tijerina’s car accident on April 13, 2014. Additionally, on March 30, 2017, Defendants notified BCRC that Tijerina had settled his lawsuit with the responsible parties for $70,000.00. On April 10, 2017, BCRC sought to recover the Conditional Payments and sent Defendants an Initial Determination demanding reimbursement of $46,244.74 that the Medicare program paid for Tijerina’s medical expenses related to his lawsuit.
On April 19, 2017, Defendants filed a motion with the 278th Judicial District Court in Waller County, Texas, that challenged the Initial Determination by the Medicare program. The Defendants sent BCRC copies of their motion. On July 20, 2017, BCRC renewed its demand on behalf of Medicare for the full amount of $47,343.05, ignoring the State Court ruling.
On August 3, 2017, the Defendants without responding to BCRC’s Initial Determination or Demand Letter, sent BCRC a copy of an order issued by the 278th Judicial District Court in Waller County, Texas, that reduced the recovery of Medicare’s Conditional Payments by 90% to $4,700.00 and a check for $4,700.00. The District Court agreed with the Defendants assertion that the U.S. Supreme Court’s decision in Arkansas Dept. of Health v. Ahlborn applied, and that Medicare or the Centers for Medicare & Medicaid Services (CMS) is only entitled to the portion of the settlement that actually constitutes reimbursement for payments made. However, the District Court seemed to fail to realize the distinction between Medicaid and Medicare’s recovery rights, and that the underlying recovery in the Ahlborn decision pertained to Medicaid, and not Medicare (two distinct programs with distinct third-party recovery rights).
The lawsuit alleges that that to date, Medicare had not received additional payments to reimburse Medicare’s full conditional payment demand, and that the 278th Judicial District Court lacked subject matter jurisdiction to adjudicate a challenge to Medicare’s recovery of conditional payments. Further, the District Court’s order reducing or otherwise limiting Medicare’s recovery is void and unenforceable per the United States’ sovereign immunity. Lastly, the current amount alleged owed by Defendants to Medicare for its Conditional Payments is $53,445.93 ($42,643.05 principal, $10,802.88 interest).
Attorneys at Franco Signor claim that it is likely the U.S. Attorney will prevail in its lawsuit against Defendants and recover not only its full amount owed, plus interest. Historical case law has clearly established that responsible parties under the Medicare Secondary Payer Act (MSP) cannot avoid exhausting administrative remedies and go straight to Court to adjudicate conditional payment amounts. Further, the District Court’s application of Albhorn, a Medicaid decision to a Medicare claim for reimbursement, will likely be questioned upon further analysis by the Court in this lawsuit. What is surprising is that the U.S. Attorney’s office is seemingly refraining from seeking twice the amount claimed from the plaintiff attorney firm, although it could potentially amend its lawsuit.
The takeaway here is to always address conditional payments before settlement takes place. Disputing unrelated charges to the underlying case is easier before a determination in the form of a Demand is made by Medicare. Allowing plaintiff or their attorney to manage the matter creates exposure for the responsible party to potential claims ...
Franco Signor reports that a lawsuit filed in in the United States District Court for the Southern District of Texas by the U.S. alleges that the plaintiff attorney in a personal injury action (Carrigan & Anderson, PLLC and Attorney Stephen P. Carrigan individually) failed to reimburse Medicare’s demand for conditional payments in full.
It is not unusual for U.S. Attorneys to file litigation against personal injury law firms for failure to comply with the Medicare Secondary Payer (MSP) act requirement to reimburse conditional payments. The instant case is different.
Here the personal injury attorney Defendants corresponded often with the Benefits Coordination & Recovery Contractor (BCRC) regarding Medicare conditional payments owed on behalf of their Medicare beneficiary client, Tomas R. Tijerina prior to settling the claim. Defendants did not agree with the amount demanded and sought state court protection in an Order that reduced Medicare’s conditional payments rather than undertake the administrative appeals process to dispute the conditional payment amount owed.
As alleged by the U.S. Attorney in the Complaint, on April 14, 2016, Defendants first notified the BCRC about Tijerina’s car accident on April 13, 2014. Additionally, on March 30, 2017, Defendants notified BCRC that Tijerina had settled his lawsuit with the responsible parties for $70,000.00. On April 10, 2017, BCRC sought to recover the Conditional Payments and sent Defendants an Initial Determination demanding reimbursement of $46,244.74 that the Medicare program paid for Tijerina’s medical expenses related to his lawsuit.
On April 19, 2017, Defendants filed a motion with the 278th Judicial District Court in Waller County, Texas, that challenged the Initial Determination by the Medicare program. The Defendants sent BCRC copies of their motion. On July 20, 2017, BCRC renewed its demand on behalf of Medicare for the full amount of $47,343.05, ignoring the State Court ruling.
On August 3, 2017, the Defendants without responding to BCRC’s Initial Determination or Demand Letter, sent BCRC a copy of an order issued by the 278th Judicial District Court in Waller County, Texas, that reduced the recovery of Medicare’s Conditional Payments by 90% to $4,700.00 and a check for $4,700.00. The District Court agreed with the Defendants assertion that the U.S. Supreme Court’s decision in Arkansas Dept. of Health v. Ahlborn applied, and that Medicare or the Centers for Medicare & Medicaid Services (CMS) is only entitled to the portion of the settlement that actually constitutes reimbursement for payments made. However, the District Court seemed to fail to realize the distinction between Medicaid and Medicare’s recovery rights, and that the underlying recovery in the Ahlborn decision pertained to Medicaid, and not Medicare (two distinct programs with distinct third-party recovery rights).
The lawsuit alleges that that to date, Medicare had not received additional payments to reimburse Medicare’s full conditional payment demand, and that the 278th Judicial District Court lacked subject matter jurisdiction to adjudicate a challenge to Medicare’s recovery of conditional payments. Further, the District Court’s order reducing or otherwise limiting Medicare’s recovery is void and unenforceable per the United States’ sovereign immunity. Lastly, the current amount alleged owed by Defendants to Medicare for its Conditional Payments is $53,445.93 ($42,643.05 principal, $10,802.88 interest).
Attorneys at Franco Signor claim that it is likely the U.S. Attorney will prevail in its lawsuit against Defendants and recover not only its full amount owed, plus interest. Historical case law has clearly established that responsible parties under the Medicare Secondary Payer Act (MSP) cannot avoid exhausting administrative remedies and go straight to Court to adjudicate conditional payment amounts. Further, the District Court’s application of Albhorn, a Medicaid decision to a Medicare claim for reimbursement, will likely be questioned upon further analysis by the Court in this lawsuit. What is surprising is that the U.S. Attorney’s office is seemingly refraining from seeking twice the amount claimed from the plaintiff attorney firm, although it could potentially amend its lawsuit.
The takeaway here is to always address conditional payments before settlement takes place. Disputing unrelated charges to the underlying case is easier before a determination in the form of a Demand is made by Medicare. Allowing plaintiff or their attorney to manage the matter creates exposure for the responsible party to potential claims ...
