What healthcare problems are consuming the largest share of healthcare dollars? Researchers decided to answer that question.
In total, the researchers analyzed 5.9 billion unique insurance claims, 150.4 million ambulance rides, dental procedures, and emergency room visits, 1.5 billion days spent within inpatient or nursing home care, and 5.9 million drug prescriptions. And they just published their results in the Journal of the American Medical Association.
Researchers say that when neck and low back pain are combined with other musculoskeletal disorders, including joint and limb troubles, Americans are spending more for treatment than on any other ailment or condition.
Just how much does that add up to? According to data from 2016, an almost inconceivable $380 billion was spent on spinal issues and joint pain.
In all (individuals, public insurance, private insurance), $3.1 trillion was spent on healthcare in the United States in 2016. That comes out to $9,655 for every U.S. citizen, and roughly 17.9% of the U.S. GDP. For reference on just how high prices have skyrocketed, in 1996, healthcare costs only represented 13.3% of the GDP.
"The vast costs associated with healthcare represent one of the most important and contentious issues facing Americans today," says Dr. Joseph Dieleman of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington’s School of Medicine and lead author of the study, in a release. "Our study provides comprehensive estimates over a 20-year period that highlight how healthcare and prescription drugs are paid for, what they are spent on, and how such payments have changed over time."
Of all 154 medical conditions included in this research, just lower back and neck pain alone accumulated the highest expenditures ($134.5 billion). After that, diabetes ($111.2 billion), ischemic heart disease ($89.3 billion), and falls ($87.4 billion) weren’t far behind in terms of costs.
Predictably, the majority of those costs were paid for by insurance providers, both public and private. Regarding lower back and neck pain; $76.9 billion was paid for by private insurance, and $45.2 billion was paid for by public insurance. Still, that left $12.3 billion that had to come out of someone’s pockets.
Meanwhile, private insurers paid $73.3 billion for other musculoskeletal disorders, public insurers covered $46.9 billion in costs, and $9.7 billion was paid for by individuals out of pocket.
For diabetes, $55.4 billion was paid by public insurance, $49.1 billion by private, and $6.7 billion was paid out of pocket.
How about ischemic heart disease? In all, $48.2 billion was paid for by public insurers, $37.9 billion worth of costs were covered by private insurers, and $3.2 billion was paid by individuals.
Finally, falls tallied a hefty tab as well; $40.7 billion was paid for by public insurance, $34.8 billion was paid for by private insurance, and $11.9 billion was settled out of pocket.
Most of that public insurance spending (58.6%) covered bill accumulated by patients over the age of 65. After adjusting for population and age fluctuations, public insurance spending increased much faster than private insurance. The study’s authors attribute this observation to Medicaid expansions ...
In total, the researchers analyzed 5.9 billion unique insurance claims, 150.4 million ambulance rides, dental procedures, and emergency room visits, 1.5 billion days spent within inpatient or nursing home care, and 5.9 million drug prescriptions. And they just published their results in the Journal of the American Medical Association.
Researchers say that when neck and low back pain are combined with other musculoskeletal disorders, including joint and limb troubles, Americans are spending more for treatment than on any other ailment or condition.
Just how much does that add up to? According to data from 2016, an almost inconceivable $380 billion was spent on spinal issues and joint pain.
In all (individuals, public insurance, private insurance), $3.1 trillion was spent on healthcare in the United States in 2016. That comes out to $9,655 for every U.S. citizen, and roughly 17.9% of the U.S. GDP. For reference on just how high prices have skyrocketed, in 1996, healthcare costs only represented 13.3% of the GDP.
"The vast costs associated with healthcare represent one of the most important and contentious issues facing Americans today," says Dr. Joseph Dieleman of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington’s School of Medicine and lead author of the study, in a release. "Our study provides comprehensive estimates over a 20-year period that highlight how healthcare and prescription drugs are paid for, what they are spent on, and how such payments have changed over time."
Of all 154 medical conditions included in this research, just lower back and neck pain alone accumulated the highest expenditures ($134.5 billion). After that, diabetes ($111.2 billion), ischemic heart disease ($89.3 billion), and falls ($87.4 billion) weren’t far behind in terms of costs.
Predictably, the majority of those costs were paid for by insurance providers, both public and private. Regarding lower back and neck pain; $76.9 billion was paid for by private insurance, and $45.2 billion was paid for by public insurance. Still, that left $12.3 billion that had to come out of someone’s pockets.
Meanwhile, private insurers paid $73.3 billion for other musculoskeletal disorders, public insurers covered $46.9 billion in costs, and $9.7 billion was paid for by individuals out of pocket.
For diabetes, $55.4 billion was paid by public insurance, $49.1 billion by private, and $6.7 billion was paid out of pocket.
How about ischemic heart disease? In all, $48.2 billion was paid for by public insurers, $37.9 billion worth of costs were covered by private insurers, and $3.2 billion was paid by individuals.
Finally, falls tallied a hefty tab as well; $40.7 billion was paid for by public insurance, $34.8 billion was paid for by private insurance, and $11.9 billion was settled out of pocket.
Most of that public insurance spending (58.6%) covered bill accumulated by patients over the age of 65. After adjusting for population and age fluctuations, public insurance spending increased much faster than private insurance. The study’s authors attribute this observation to Medicaid expansions ...
Opioid addiction and abuse is one of the factors driving legacy workers' compensation claims, and extending claim closure time. Recent California and national statistics show a decline in opioid prescribing patterns in claims, suggesting that perhaps the "opioid crisis" is no longer a crisis in claims.
An alternative hypothesis is that those addicted to opioids, remain addicted, and the "crisis" may still be present - just more hidden from view.
The supply chain seems to have shifted from pharmacies to cartels, or perhaps a mixture of the two, the combination of supply may result in a continuation of legacy claims driven mostly by addiction demands made on one supplier, or the other, or both.
In the past few years, Mexican drug cartels have been flooding the United States with methamphetamines and fentanyl, driving the supply so hard and dropping the price so low that it pushes up addiction rates and the market then demands more drugs.
Fentanyl, a synthetic opioid, is 100 times more potent than morphine.
The 2019 National Drug Threat Assessment from the DEA states that "Mexican cartels began to manufacture their own fentanyl and press the drug into pill form as the primary opioid substance, marketing the pills as ‘Mexican oxy’ to those seeking opiate-based pills on the street."
Meth and fentanyl are both made in labs, making it easier and cheaper for cartels to produce year-round, without the land area and large staff needed for crop maintenance that heroin and cocaine require.
In the past, fentanyl had mainly been mixed into heroin to boost the high, but now it’s often pressed into small blue tablets and stamped with "M30" to closely match the color and markings of prescription oxycodone pills.
Buyers may be unaware the pills contain fentanyl, of which a 2mg dose can be fatal.
"Fentanyl and other highly potent synthetic opioids - primarily sourced from China and Mexico - continue to be the most lethal category of illicit substances misused in the United States," the 2019 DEA report says.
The volume of fentanyl trafficked from Mexico is high, but the purity is typically low (less than 10 percent pure on average), according to the DEA.
"Conversely, fentanyl trafficked through the mail from China typically arrives in smaller quantities that are highly pure (frequently 90 percent or higher purity)," the DEA report states.
Clandestine fentanyl pill pressing operations are dotted all over the United States, according to the DEA.
"These operations are popular since traffickers can invest in as little as a kilogram of fentanyl powder and produce hundreds of thousands of counterfeit fentanyl-containing pills to generate large amounts of revenue," the report states.
The use of the dark web and cryptocurrency has made it more difficult for law enforcement to track transactions and communications ...
An alternative hypothesis is that those addicted to opioids, remain addicted, and the "crisis" may still be present - just more hidden from view.
The supply chain seems to have shifted from pharmacies to cartels, or perhaps a mixture of the two, the combination of supply may result in a continuation of legacy claims driven mostly by addiction demands made on one supplier, or the other, or both.
In the past few years, Mexican drug cartels have been flooding the United States with methamphetamines and fentanyl, driving the supply so hard and dropping the price so low that it pushes up addiction rates and the market then demands more drugs.
Fentanyl, a synthetic opioid, is 100 times more potent than morphine.
The 2019 National Drug Threat Assessment from the DEA states that "Mexican cartels began to manufacture their own fentanyl and press the drug into pill form as the primary opioid substance, marketing the pills as ‘Mexican oxy’ to those seeking opiate-based pills on the street."
Meth and fentanyl are both made in labs, making it easier and cheaper for cartels to produce year-round, without the land area and large staff needed for crop maintenance that heroin and cocaine require.
In the past, fentanyl had mainly been mixed into heroin to boost the high, but now it’s often pressed into small blue tablets and stamped with "M30" to closely match the color and markings of prescription oxycodone pills.
Buyers may be unaware the pills contain fentanyl, of which a 2mg dose can be fatal.
"Fentanyl and other highly potent synthetic opioids - primarily sourced from China and Mexico - continue to be the most lethal category of illicit substances misused in the United States," the 2019 DEA report says.
The volume of fentanyl trafficked from Mexico is high, but the purity is typically low (less than 10 percent pure on average), according to the DEA.
"Conversely, fentanyl trafficked through the mail from China typically arrives in smaller quantities that are highly pure (frequently 90 percent or higher purity)," the DEA report states.
Clandestine fentanyl pill pressing operations are dotted all over the United States, according to the DEA.
"These operations are popular since traffickers can invest in as little as a kilogram of fentanyl powder and produce hundreds of thousands of counterfeit fentanyl-containing pills to generate large amounts of revenue," the report states.
The use of the dark web and cryptocurrency has made it more difficult for law enforcement to track transactions and communications ...
Mitchell | Genex, a provider of cost containment technology, clinical services, and disability management, has announced an agreement to acquire Coventry Workers’ Comp Services from CVS Health. Coventry Workers’ Comp Services is a provider of care and cost management programs for workers' compensation and auto insurance carriers, third-party administrators, and self-insured employers. Coventry Workers’ Comp Services is currently a division of Aetna, a CVS Health company.
With this acquisition, Mitchell | Genex will expand its capabilities, and add Coventry’s leading PPO network to its continuum of care and cost containment offerings.
Peter Madeja, Genex Services President and CEO said "We are extremely proud and excited about adding another long-standing, reputable organization to the Mitchell | Genex team. This move will expand the breadth of our cutting-edge cost containment technology and clinical services with the deepest understanding of the workers’ compensation industry and will significantly build upon our network offerings. It reinforces our continuous commitment to help clients navigate through today’s challenges and build better outcomes to improve the lives of injured parties."
Based in Downers Grove, IL, Coventry Workers’ Comp Services has been a full-service managed care organization for more than 35 years. The company brings approximately 2,000 professionals with deep industry expertise, along with a broad suite of services - network, clinical and specialty - powered by technology to enhance network development, clinical integration and operational efficiencies with a focus on total claims cost.
Following the closing of this acquisition, Coventry Workers’ Comp will continue to be led by Art Lynch, President and CEO, and operate under its brand.
"We are very excited to join Mitchell | Genex and further meet the needs of our ever-changing industry," said Lynch. "This is a forward-thinking partnership that combines one of the most robust PPO networks with an equally positioned firm in cost containment technology and clinical solutions. These capabilities, when combined with artificial intelligence and advanced analytics, will maximize our clients’ performance today and into the future."
Kramer Levin Naftalis & Frankel LLP and Axinn, Veltrop & Harkrider LLP are acting as legal advisors to Mitchell | Genex. Fried, Frank, Harris, Shriver & Jacobson LLP and Dechert LLP are acting as legal advisors to CVS Health. BofA Securities is acting as exclusive financial advisor to CVS Health.
The acquisition is subject to customary closing conditions, including applicable regulatory approvals. The financial terms of the transaction are not being disclosed ...
With this acquisition, Mitchell | Genex will expand its capabilities, and add Coventry’s leading PPO network to its continuum of care and cost containment offerings.
Peter Madeja, Genex Services President and CEO said "We are extremely proud and excited about adding another long-standing, reputable organization to the Mitchell | Genex team. This move will expand the breadth of our cutting-edge cost containment technology and clinical services with the deepest understanding of the workers’ compensation industry and will significantly build upon our network offerings. It reinforces our continuous commitment to help clients navigate through today’s challenges and build better outcomes to improve the lives of injured parties."
Based in Downers Grove, IL, Coventry Workers’ Comp Services has been a full-service managed care organization for more than 35 years. The company brings approximately 2,000 professionals with deep industry expertise, along with a broad suite of services - network, clinical and specialty - powered by technology to enhance network development, clinical integration and operational efficiencies with a focus on total claims cost.
Following the closing of this acquisition, Coventry Workers’ Comp will continue to be led by Art Lynch, President and CEO, and operate under its brand.
"We are very excited to join Mitchell | Genex and further meet the needs of our ever-changing industry," said Lynch. "This is a forward-thinking partnership that combines one of the most robust PPO networks with an equally positioned firm in cost containment technology and clinical solutions. These capabilities, when combined with artificial intelligence and advanced analytics, will maximize our clients’ performance today and into the future."
Kramer Levin Naftalis & Frankel LLP and Axinn, Veltrop & Harkrider LLP are acting as legal advisors to Mitchell | Genex. Fried, Frank, Harris, Shriver & Jacobson LLP and Dechert LLP are acting as legal advisors to CVS Health. BofA Securities is acting as exclusive financial advisor to CVS Health.
The acquisition is subject to customary closing conditions, including applicable regulatory approvals. The financial terms of the transaction are not being disclosed ...
A federal grand jury indicted Dr. Timothy Mulligan for the unlawful distribution of opioids, including fentanyl, outside the scope of professional practice and health care fraud.
According to the indictment, Mulligan, 67, of Santa Clara, Calif., is a licensed physician practicing in San Mateo County. A substantial part of Mulligan’s medical practice involved providing prescriptions for controlled substances - primarily opioids.
Mulligan issued an unusually high volume of prescriptions for potent opioids, including fentanyl. For example, according to a state government database, from about August 2014 through June 2018, Mulligan issued more than 9,000 prescriptions for opioids (totaling over 700,000 dosage units) to more than 250 patients.
Overall, Mulligan predominantly prescribed the strongest strength dosages when prescribing fentanyl, oxycodone, and hydrocodone. In certain instances, Mulligan issued opioid prescriptions in quantities that significantly exceeded generally accepted daily quantities for the drug.
The indictment states that because of the unusual pattern and volume of prescriptions issued by Mulligan and other warning signs, certain pharmacies declined to fill prescriptions issued by Mulligan or restricted the types of Mulligan’s prescriptions that they would fill.
As further alleged in the indictment, some individuals who obtained medically unnecessary prescriptions from Mulligan used private insurance or Medi-Cal to cover their office visits or pay for the drugs; others paid with cash. The insurance companies and Medi-Cal would not have paid for the office visits or paid out the pharmacy claims had they known the prescriptions were not medically necessary or were over-prescribed.
The indictment filed on February 27, 2020, charges Mulligan with three counts of distributing controlled substances outside the scope of professional practice, in violation of 21 U.S.C. §§ 84l(a)(l) & 841(b)(l)(C); and two counts of health care fraud, in violation of 18 U.S.C. § 1347.
If convicted, he faces a maximum sentence of 20 years in prison, a $1,000,000 fine, and a life term of supervised release for each count of distributing controlled substances; and 10 years in prison, a $250,000 fine, and a three-year term of supervised release for each count of health care fraud.
Anyone, including pharmacists and medical professionals, with information about prescriptions issued without a legitimate medical purpose is urged to contact the FBI Tip Line at (415) 553-7400 ...
According to the indictment, Mulligan, 67, of Santa Clara, Calif., is a licensed physician practicing in San Mateo County. A substantial part of Mulligan’s medical practice involved providing prescriptions for controlled substances - primarily opioids.
Mulligan issued an unusually high volume of prescriptions for potent opioids, including fentanyl. For example, according to a state government database, from about August 2014 through June 2018, Mulligan issued more than 9,000 prescriptions for opioids (totaling over 700,000 dosage units) to more than 250 patients.
Overall, Mulligan predominantly prescribed the strongest strength dosages when prescribing fentanyl, oxycodone, and hydrocodone. In certain instances, Mulligan issued opioid prescriptions in quantities that significantly exceeded generally accepted daily quantities for the drug.
The indictment states that because of the unusual pattern and volume of prescriptions issued by Mulligan and other warning signs, certain pharmacies declined to fill prescriptions issued by Mulligan or restricted the types of Mulligan’s prescriptions that they would fill.
As further alleged in the indictment, some individuals who obtained medically unnecessary prescriptions from Mulligan used private insurance or Medi-Cal to cover their office visits or pay for the drugs; others paid with cash. The insurance companies and Medi-Cal would not have paid for the office visits or paid out the pharmacy claims had they known the prescriptions were not medically necessary or were over-prescribed.
The indictment filed on February 27, 2020, charges Mulligan with three counts of distributing controlled substances outside the scope of professional practice, in violation of 21 U.S.C. §§ 84l(a)(l) & 841(b)(l)(C); and two counts of health care fraud, in violation of 18 U.S.C. § 1347.
If convicted, he faces a maximum sentence of 20 years in prison, a $1,000,000 fine, and a life term of supervised release for each count of distributing controlled substances; and 10 years in prison, a $250,000 fine, and a three-year term of supervised release for each count of health care fraud.
Anyone, including pharmacists and medical professionals, with information about prescriptions issued without a legitimate medical purpose is urged to contact the FBI Tip Line at (415) 553-7400 ...
The Contra Costa County District Attorney’s Office charged 52-years-old Maria Mendoza with numerous counts of insurance fraud. The charges allege four specific instances of workers’ compensation fraud against four different employers, and two additional instances of auto insurance fraud.
The investigation originated after reports of a staged slip and fall in October 2017 at an Olive Garden restaurant located in Pittsburg California. The suspect’s insurance claims history revealed a pattern of short stints of employment followed by claims against the employer.
The first workers’ compensation fraud charge relates to Mendoza’s employment at Pronto Cleaning Services in early 2014. The charge alleges that Mendoza’s employment terminated after only three months of work. She hired a workers’ compensation attorney to file multiple workers compensation claims, including an allegation that her three months of cleaning resulted in cumulative trauma to her hands, wrists, and knees. She and her attorney litigated the claim throughout 2016 and 2017.
The complaint further alleges that Mendoza obtained employment at Architectural Glass & Aluminum Company and worked in a factory setting in late 2014. Her employment terminated there after two months and again a workers’ compensation claim followed. The complaint alleges that she told medical professionals evaluating her that she made no prior claims and is not a party to any civil litigation.
The third workers’ compensation fraud charged relates to employment at Olive Garden. Olive Garden hired Mendoza for work in 2017, but after approximately five months several employees and a manager reported that Mendoza faked a slip and fall on her way to a scheduled disciplinary hearing. She again hired an attorney to file and litigate a workers’ compensation insurance claim for injuries to her knees and ankles from the fall.
The final workers’ compensation fraud charged relates to yet another slip and fall claim at Claim Jumper in 2018. After approximately one month at Claim Jumper Restaurant, Mendoza visited a doctor to report a new slip and fall at work. The complaint again alleges that she falsely told the doctor evaluating her that she never previously filed a workers’ compensation insurance claim.
She is also charged with filing an auto insurance claim alleging an accident in April of 2014. Mendoza claimed the same injuries that she pursued in her workers’ compensation claim against Pronto Cleaning, as well as filing a 2018 auto insurance claim for damage to the same vehicle that her attorney claimed was totaled in the 2014 accident.
...
The investigation originated after reports of a staged slip and fall in October 2017 at an Olive Garden restaurant located in Pittsburg California. The suspect’s insurance claims history revealed a pattern of short stints of employment followed by claims against the employer.
The first workers’ compensation fraud charge relates to Mendoza’s employment at Pronto Cleaning Services in early 2014. The charge alleges that Mendoza’s employment terminated after only three months of work. She hired a workers’ compensation attorney to file multiple workers compensation claims, including an allegation that her three months of cleaning resulted in cumulative trauma to her hands, wrists, and knees. She and her attorney litigated the claim throughout 2016 and 2017.
The complaint further alleges that Mendoza obtained employment at Architectural Glass & Aluminum Company and worked in a factory setting in late 2014. Her employment terminated there after two months and again a workers’ compensation claim followed. The complaint alleges that she told medical professionals evaluating her that she made no prior claims and is not a party to any civil litigation.
The third workers’ compensation fraud charged relates to employment at Olive Garden. Olive Garden hired Mendoza for work in 2017, but after approximately five months several employees and a manager reported that Mendoza faked a slip and fall on her way to a scheduled disciplinary hearing. She again hired an attorney to file and litigate a workers’ compensation insurance claim for injuries to her knees and ankles from the fall.
The final workers’ compensation fraud charged relates to yet another slip and fall claim at Claim Jumper in 2018. After approximately one month at Claim Jumper Restaurant, Mendoza visited a doctor to report a new slip and fall at work. The complaint again alleges that she falsely told the doctor evaluating her that she never previously filed a workers’ compensation insurance claim.
She is also charged with filing an auto insurance claim alleging an accident in April of 2014. Mendoza claimed the same injuries that she pursued in her workers’ compensation claim against Pronto Cleaning, as well as filing a 2018 auto insurance claim for damage to the same vehicle that her attorney claimed was totaled in the 2014 accident.
...
Andrews International assigned its employee Steven Paul Picazzo to work at Loyola Marymount University as a security officer between 2006 and 2013. In August 2013, LMU was erecting a new building on campus. C.W. Driver, Inc., was the project’s general contractor.
While on duty, Picazzo suffered a spinal cord injury when he tripped and struck his head against a railing at the construction site. He is now a quadriplegic. Andrews’s workers’ compensation carrier, Liberty Insurance Corporation, paid benefits to Picazzo.
Picazzo sued, among others, the general contractor Driver for negligence and for premises liability. LMU was not a named defendant. Liberty filed a complaint in intervention seeking reimbursement from any third party tortfeasor for benefits Liberty had paid. At trial, Liberty stipulated that it paid $2,849,209.62 in benefits to Picazzo.
The matter was tried by a jury, which found Driver, LMU, Picazzo, and Andrews negligent. However, the jury also found that Andrews’s negligence was not a substantial factor in causing harm to Picazzo, and therefore Andrews was not liable for damages. The jury awarded Picazzo total damages of $16,322,950.62
The jury allocated responsibility for the harm to Picazzo as follows: 40 percent to Driver, 15 percent to Picazzo, 45 percent to LMU, and zero percent to Andrews.
After trial, Driver moved to void Liberty’s lien on the theory LMU had a special employment relationship with Picazzo. Under this theory, if LMU specially employed Picazzo and the benefits Liberty paid were also paid on LMU’s behalf, then Liberty was not entitled to recover, as LMU was 45 percent at fault.
Liberty opposed the motion on the ground that whether LMU was Picazzo’s special employer was not submitted to the jury.
The trial court found against Liberty. Given what the trial court called Liberty’s "virtual admission" at trial that LMU was Picazzo’s special employer, the trial court found that Liberty’s lien should be reduced by the amount of LMU’s fault. Thus, the lien was wholly offset by LMU’s negligence, and Liberty recovered nothing on its lien from Driver.
Liberty appealed and the Court of Appeal reversed the judgment against Liberty on its complaint in intervention in the unpublished case of Picazzo v. C.W. Driver, Inc.
Whether a special employment relationship exists is generally a question of fact reserved for the trier of fact. (Kowalski, supra, 23 Cal.3d at p. 175; Wedeck v. Unocal Corp. (1997) 59 Cal.App.4th 848, 857.) Hence, the jury should have decided the issue.
Even if the trial court, rather than the jury, properly decided the special employer issue, the Court of Appeal still could not uphold the trial court’s ruling. That is, the trial court did not make its finding based on evidence that LMU specially employed Picazzo. Rather, the trial court based its finding of special employment on Liberty’s supposed "virtual admission" to that fact. However, there was no such admission ...
While on duty, Picazzo suffered a spinal cord injury when he tripped and struck his head against a railing at the construction site. He is now a quadriplegic. Andrews’s workers’ compensation carrier, Liberty Insurance Corporation, paid benefits to Picazzo.
Picazzo sued, among others, the general contractor Driver for negligence and for premises liability. LMU was not a named defendant. Liberty filed a complaint in intervention seeking reimbursement from any third party tortfeasor for benefits Liberty had paid. At trial, Liberty stipulated that it paid $2,849,209.62 in benefits to Picazzo.
The matter was tried by a jury, which found Driver, LMU, Picazzo, and Andrews negligent. However, the jury also found that Andrews’s negligence was not a substantial factor in causing harm to Picazzo, and therefore Andrews was not liable for damages. The jury awarded Picazzo total damages of $16,322,950.62
The jury allocated responsibility for the harm to Picazzo as follows: 40 percent to Driver, 15 percent to Picazzo, 45 percent to LMU, and zero percent to Andrews.
After trial, Driver moved to void Liberty’s lien on the theory LMU had a special employment relationship with Picazzo. Under this theory, if LMU specially employed Picazzo and the benefits Liberty paid were also paid on LMU’s behalf, then Liberty was not entitled to recover, as LMU was 45 percent at fault.
Liberty opposed the motion on the ground that whether LMU was Picazzo’s special employer was not submitted to the jury.
The trial court found against Liberty. Given what the trial court called Liberty’s "virtual admission" at trial that LMU was Picazzo’s special employer, the trial court found that Liberty’s lien should be reduced by the amount of LMU’s fault. Thus, the lien was wholly offset by LMU’s negligence, and Liberty recovered nothing on its lien from Driver.
Liberty appealed and the Court of Appeal reversed the judgment against Liberty on its complaint in intervention in the unpublished case of Picazzo v. C.W. Driver, Inc.
Whether a special employment relationship exists is generally a question of fact reserved for the trier of fact. (Kowalski, supra, 23 Cal.3d at p. 175; Wedeck v. Unocal Corp. (1997) 59 Cal.App.4th 848, 857.) Hence, the jury should have decided the issue.
Even if the trial court, rather than the jury, properly decided the special employer issue, the Court of Appeal still could not uphold the trial court’s ruling. That is, the trial court did not make its finding based on evidence that LMU specially employed Picazzo. Rather, the trial court based its finding of special employment on Liberty’s supposed "virtual admission" to that fact. However, there was no such admission ...
A federal grand jury returned a superseding indictment against Robert Rowen and Teresa Su, charging them with conspiracy to defraud the United States. In addition, each defendant also was charged with a separate count of tax evasion.
Robert Rowen, M.D., has been practicing medicine for more than three decades. He graduated Phi Beta Kappa from Johns Hopkins University before attending medical school at the University of California, San Francisco. Terri Su, M.D., has practiced integrative medicine for nearly 40 years. She is a Phi Beta Kappa and summa cum laude graduate of UCLA with a degree in biochemistry. She graduated UC Irvine Medical School in the top quarter of her class. The husband and wife team operate the Rowen Su Clinic in Santa Rosa, serving patients in Sonoma County and the Bay Area.
The medical doctors allegedly conspired to evade payment of Rowen’s federal income tax liabilities by concealing Rowen’s ability to pay his 1992 through 1997 and 2003 through 2008 federal income tax liabilities. Specifically, Rowen and Su allegedly placed his assets out of the reach of the United States Government, placed assets in the names of other persons or entities, deposited Rowen’s revenue into nominee bank accounts, used cash to conduct personal and professional business, converted his revenue into gold and silver coins, and provided false information to the IRS.
The indictment provides a description of various methods the couple allegedly used to conceal Rowen’s income. For example, the indictment describes how the couple instructed patients to make their checks for medical services payable to gold dealers who, in turn, purchased gold and silver coins.
In addition, the indictment alleges Rowen formed a company named Lotus Management LLC to receive revenue from a different company. Rowen then deposited the funds into a bank account opened in the name of Lotus Management LLC, and used the proceeds to purchase gold and silver coins.
Further, the couple allegedly used cash to pay the rent for the medical practice as well as to pay the balance on credit cards used to cover various business and personal expenses.
In sum, the indictment alleges that between January 3, 2007, and April 11, 2014, Rowen, both individually and through nominees, converted over $3,900,000 of his revenue to gold and silver coins. Count one of the superseding indictment charges Rowen and Su with conspiracy to defraud the United States, in violation of 18 U.S.C. § 371, and counts two and three of the superseding indictment charges the defendants each with one count of tax evasion, in violation of 26 U.S.C. § 7201.
The defendants face a maximum sentence of five years imprisonment, and a fine of $250,000, plus restitution. If convicted of tax evasion, the defendant faces a maximum sentence of three years in prison and a $250,000 fine.
The defendants currently are released on a $200,000 bond ...
Robert Rowen, M.D., has been practicing medicine for more than three decades. He graduated Phi Beta Kappa from Johns Hopkins University before attending medical school at the University of California, San Francisco. Terri Su, M.D., has practiced integrative medicine for nearly 40 years. She is a Phi Beta Kappa and summa cum laude graduate of UCLA with a degree in biochemistry. She graduated UC Irvine Medical School in the top quarter of her class. The husband and wife team operate the Rowen Su Clinic in Santa Rosa, serving patients in Sonoma County and the Bay Area.
The medical doctors allegedly conspired to evade payment of Rowen’s federal income tax liabilities by concealing Rowen’s ability to pay his 1992 through 1997 and 2003 through 2008 federal income tax liabilities. Specifically, Rowen and Su allegedly placed his assets out of the reach of the United States Government, placed assets in the names of other persons or entities, deposited Rowen’s revenue into nominee bank accounts, used cash to conduct personal and professional business, converted his revenue into gold and silver coins, and provided false information to the IRS.
The indictment provides a description of various methods the couple allegedly used to conceal Rowen’s income. For example, the indictment describes how the couple instructed patients to make their checks for medical services payable to gold dealers who, in turn, purchased gold and silver coins.
In addition, the indictment alleges Rowen formed a company named Lotus Management LLC to receive revenue from a different company. Rowen then deposited the funds into a bank account opened in the name of Lotus Management LLC, and used the proceeds to purchase gold and silver coins.
Further, the couple allegedly used cash to pay the rent for the medical practice as well as to pay the balance on credit cards used to cover various business and personal expenses.
In sum, the indictment alleges that between January 3, 2007, and April 11, 2014, Rowen, both individually and through nominees, converted over $3,900,000 of his revenue to gold and silver coins. Count one of the superseding indictment charges Rowen and Su with conspiracy to defraud the United States, in violation of 18 U.S.C. § 371, and counts two and three of the superseding indictment charges the defendants each with one count of tax evasion, in violation of 26 U.S.C. § 7201.
The defendants face a maximum sentence of five years imprisonment, and a fine of $250,000, plus restitution. If convicted of tax evasion, the defendant faces a maximum sentence of three years in prison and a $250,000 fine.
The defendants currently are released on a $200,000 bond ...
The Marin County District Attorney’s Office reported that a Novato man, already on probation for contracting without a license in a prior case, has been charged with committing the same crime again.
Victor Mauricio Mendez Rodas, 40, is also charged with failing to secure worker’s compensation insurance for crew members. He could face jail time and up to $15,000 in fines, the prosecution said.
Rodas is scheduled to appear in court on March 10.
The district attorney’s insurance fraud unit opened the case after learning that Rodas was allegedly performing work for an 83-year-old homeowner in San Rafael. The alleged crimes occurred from September to December.
"The homeowner reported that they became suspicious when Rodas demanded additional payments for unauthorized work and failed to get required permits for the work," the district attorney’s office said.
Authorities obtained an arrest warrant for Rodas, who is not licensed with the state Contractor’s State Licensing Board, the prosecution said. The warrant was served Friday with assistance from the Marin County Probation Department Enforcement team.
Residents who hired Rodas or received solicitations from him can contact the Marin County District Attorney’s Office Insurance Fraud Unit at 415-473-6450.
Rodas was convicted of unlicensed contracting in April 2016 and March 2019, according to the criminal complaint filed by Deputy District Attorney Sean Kensinger on Feb. 19.
The 2016 case stemmed from a sting by the Marin district attorney’s office and the Contractors State License Board. Ten suspects were snared by undercover investigators offering work on a residential job in Novato.
The state had 285,630 licensed contractors as of Dec. 31, according to Kevin Durawa, a spokesman for the licensing board. He said investigations by the agency resulted in 3,957 legal actions against violators last year ...
Victor Mauricio Mendez Rodas, 40, is also charged with failing to secure worker’s compensation insurance for crew members. He could face jail time and up to $15,000 in fines, the prosecution said.
Rodas is scheduled to appear in court on March 10.
The district attorney’s insurance fraud unit opened the case after learning that Rodas was allegedly performing work for an 83-year-old homeowner in San Rafael. The alleged crimes occurred from September to December.
"The homeowner reported that they became suspicious when Rodas demanded additional payments for unauthorized work and failed to get required permits for the work," the district attorney’s office said.
Authorities obtained an arrest warrant for Rodas, who is not licensed with the state Contractor’s State Licensing Board, the prosecution said. The warrant was served Friday with assistance from the Marin County Probation Department Enforcement team.
Residents who hired Rodas or received solicitations from him can contact the Marin County District Attorney’s Office Insurance Fraud Unit at 415-473-6450.
Rodas was convicted of unlicensed contracting in April 2016 and March 2019, according to the criminal complaint filed by Deputy District Attorney Sean Kensinger on Feb. 19.
The 2016 case stemmed from a sting by the Marin district attorney’s office and the Contractors State License Board. Ten suspects were snared by undercover investigators offering work on a residential job in Novato.
The state had 285,630 licensed contractors as of Dec. 31, according to Kevin Durawa, a spokesman for the licensing board. He said investigations by the agency resulted in 3,957 legal actions against violators last year ...
Two owners and operators of a Los Angeles pharmacy were both sentenced to 144 months in prison for their roles in a health care fraud scheme where Medicare and CIGNA were billed more than $11.8 million in fraudulent claims for prescription drugs.
Aleksandr Suris, 51, of Sherman Oaks, California, was sentenced to 144 months in prison by U.S. District Judge S. James Otero of the Central District of California, who also ordered Suris to pay restitution of $11,826,444.65 to Medicare and $17,109.39 to CIGNA. The court ordered Suris to make an immediate partial restitution payment of $500,000.
Maxim Sverdlov, 45, also of Sherman Oaks, was sentenced to 144 months in prison by Judge Otero, who ordered him to pay $11,826,444.65 in restitution to Medicare. The court ordered Sverdlov to make an immediate partial restitution payment of $500,000.
On Aug. 20, 2019, after an 11-day trial, a jury found Suris guilty of two counts of conspiracy to commit health care fraud, six counts of health care fraud, and one count of conspiracy to commit money laundering. The jury found Sverdlov guilty of one count of conspiracy to commit health care fraud and one count of conspiracy to commit money laundering.
Suris and Sverdlov were the co-owners and co-operators of Royal Care Pharmacy (Royal Care) in Hollywood. According to the evidence presented at trial, from 2012 to 2015, Suris and Sverdlov fraudulently billed Medicare and CIGNA for prescription medications that Royal Care did not actually purchase or dispense to beneficiaries.
In order to hide the fraud, Suris and Sverdlov obtained fake drug invoices from co-conspirators to make it appear as if Royal Care had purchased the medicines for which it had billed Medicare and CIGNA, when it actually had not. Suris and Sverdlov also used these fake invoices to launder the proceeds of the fraud through a co-conspirator. In total, Suris and Sverdlov submitted more than $11.8 million in bogus claims to Medicare for prescription drugs that they never purchased or dispensed to patients.
This case was investigated by HHS-OIG, the FBI, IRS-CI and the California Department of Justice, and was brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Central District of California. Trial Attorney Robyn N. Pullio and Assistant Chief Daniel J. Griffin of the Fraud Section prosecuted the case.
The Fraud Section leads the Medicare Fraud Strike Force. Since its inception in March 2007, the Medicare Fraud Strike Force, which maintains 15 strike forces operating in 24 districts, has charged more than 4,200 defendants who have collectively billed the Medicare program for nearly $19 billion. In addition, the HHS Centers for Medicare & Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers ...
Aleksandr Suris, 51, of Sherman Oaks, California, was sentenced to 144 months in prison by U.S. District Judge S. James Otero of the Central District of California, who also ordered Suris to pay restitution of $11,826,444.65 to Medicare and $17,109.39 to CIGNA. The court ordered Suris to make an immediate partial restitution payment of $500,000.
Maxim Sverdlov, 45, also of Sherman Oaks, was sentenced to 144 months in prison by Judge Otero, who ordered him to pay $11,826,444.65 in restitution to Medicare. The court ordered Sverdlov to make an immediate partial restitution payment of $500,000.
On Aug. 20, 2019, after an 11-day trial, a jury found Suris guilty of two counts of conspiracy to commit health care fraud, six counts of health care fraud, and one count of conspiracy to commit money laundering. The jury found Sverdlov guilty of one count of conspiracy to commit health care fraud and one count of conspiracy to commit money laundering.
Suris and Sverdlov were the co-owners and co-operators of Royal Care Pharmacy (Royal Care) in Hollywood. According to the evidence presented at trial, from 2012 to 2015, Suris and Sverdlov fraudulently billed Medicare and CIGNA for prescription medications that Royal Care did not actually purchase or dispense to beneficiaries.
In order to hide the fraud, Suris and Sverdlov obtained fake drug invoices from co-conspirators to make it appear as if Royal Care had purchased the medicines for which it had billed Medicare and CIGNA, when it actually had not. Suris and Sverdlov also used these fake invoices to launder the proceeds of the fraud through a co-conspirator. In total, Suris and Sverdlov submitted more than $11.8 million in bogus claims to Medicare for prescription drugs that they never purchased or dispensed to patients.
This case was investigated by HHS-OIG, the FBI, IRS-CI and the California Department of Justice, and was brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Central District of California. Trial Attorney Robyn N. Pullio and Assistant Chief Daniel J. Griffin of the Fraud Section prosecuted the case.
The Fraud Section leads the Medicare Fraud Strike Force. Since its inception in March 2007, the Medicare Fraud Strike Force, which maintains 15 strike forces operating in 24 districts, has charged more than 4,200 defendants who have collectively billed the Medicare program for nearly $19 billion. In addition, the HHS Centers for Medicare & Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers ...
The Division of Workers’ Compensation has issued a notice of public hearing for proposed evidence-based updates to the Medical Treatment Utilization Schedule (MTUS), which can be found at California Code of Regulations, title 8, section 9792.23.
The public hearing is scheduled for Monday, March 30 at 10 a.m. in the auditorium of the Elihu Harris Building, 1515 Clay Street, Oakland. Members of the public may review and comment on the proposed updates no later than March 30.
The proposed evidence-based updates to the MTUS incorporate by reference the latest published guidelines from American College of Occupational and Environmental Medicine (ACOEM) for the following:
-- Occupational Interstitial Lung Disease Guideline (ACOEM November 8, 2019)
-- Knee Disorders Guideline (ACOEM December 3, 2019)
-- Workplace Mental Health Guideline: Depressive Disorders (ACOEM February 13, 2020).
The proposed evidence-based updates to the MTUS regulations are exempt from Labor Code sections 5307.3 and 5307.4 and the rulemaking provisions of the Administrative Procedure Act.
However, DWC is required under Labor Code section 5307.27 to have a 30-day public comment period, hold a public hearing, respond to all the comments received during the public comment period and publish the order adopting the updates online.
The DWC has also posted an amendment to the Hospital Outpatient Departments/Ambulatory Surgical Centers portion of the Official Medical Fee Schedule.
The amendment adopts Addenda A and B of CMS’ hospital outpatient prospective payment system rate for Calendar Year 2020 found in the [January 2020 Addendum A CORRECTION.02042020.xlsx] and [January 2020 Addendum B CORRECTION.02042020] files, and replaces the original files for services rendered on or after March 1, 2020.
The order can be found at the DWC website’s OMFS page ...
The public hearing is scheduled for Monday, March 30 at 10 a.m. in the auditorium of the Elihu Harris Building, 1515 Clay Street, Oakland. Members of the public may review and comment on the proposed updates no later than March 30.
The proposed evidence-based updates to the MTUS incorporate by reference the latest published guidelines from American College of Occupational and Environmental Medicine (ACOEM) for the following:
-- Occupational Interstitial Lung Disease Guideline (ACOEM November 8, 2019)
-- Knee Disorders Guideline (ACOEM December 3, 2019)
-- Workplace Mental Health Guideline: Depressive Disorders (ACOEM February 13, 2020).
The proposed evidence-based updates to the MTUS regulations are exempt from Labor Code sections 5307.3 and 5307.4 and the rulemaking provisions of the Administrative Procedure Act.
However, DWC is required under Labor Code section 5307.27 to have a 30-day public comment period, hold a public hearing, respond to all the comments received during the public comment period and publish the order adopting the updates online.
The DWC has also posted an amendment to the Hospital Outpatient Departments/Ambulatory Surgical Centers portion of the Official Medical Fee Schedule.
The amendment adopts Addenda A and B of CMS’ hospital outpatient prospective payment system rate for Calendar Year 2020 found in the [January 2020 Addendum A CORRECTION.02042020.xlsx] and [January 2020 Addendum B CORRECTION.02042020] files, and replaces the original files for services rendered on or after March 1, 2020.
The order can be found at the DWC website’s OMFS page ...
Floyd Skeren Manukian Langevin, LLP and Fisher & Phillips are are again co-sponsoring the 9th Annual Employment Law Seminar on August 21, 2020. This is an all-day conference, with break-out sessions, featuring Employment Law and Workers’ Compensation related-topics.
The conference is designed to provide the latest information, and helpful guidance, on Employment Law, human resources (HR), and Workers’ Compensation for employers, HR administrators, risk managers, and Workers’ Compensation claims adjusters.
HR and Minimum Continuing Legal Education (MCLE) credits will be available for attendees of the conference.
There is a great line-up of presenters including Kevin Kish, Director of the Department of Fair Employment and Housing, as keynote speaker. Featured Topics Include:
-- The latest developments at the Department of Fair Employment and Housing impacting employers; 2020 vision for the workplace;
-- Key risks to avoid in the crossover between Employment Law and Workers’ Compensation;
-- An update on strategies for defending post-termination Workers’ Compensation cases;
-- Guidance on implementing a compliant workplace catastrophe plan (e.g. for pandemic flu, major fire, and earthquake);
-- Information every employer needs to know about the "California Consumer Privacy Act";
-- Ten best practices for avoiding costly HR mistakes in managing family and medical leave, pregnancy disability leave, and paid sick leave, along with a Case Law update;
-- Key strategies for investigating and defending Workers’ Compensation psychiatric claims involving harassment claims;
-- A review of the top ten essential workplace polices for 2020; and
-- Key tips on avoiding the big Employment Law verdict.
This years event will take place on August 21, at the Disneyland Hotel, 1150 West Magic Way, Anaheim, CA 90802. Registration is at 8:00 am, and the conference is from 8:30 am to 5:00 pm
Last year’s event sold out, so make your reservation as soon as possible! Registration can be made online.
You may direct any questions to "events@floydskerenlaw.com." ...
The conference is designed to provide the latest information, and helpful guidance, on Employment Law, human resources (HR), and Workers’ Compensation for employers, HR administrators, risk managers, and Workers’ Compensation claims adjusters.
HR and Minimum Continuing Legal Education (MCLE) credits will be available for attendees of the conference.
There is a great line-up of presenters including Kevin Kish, Director of the Department of Fair Employment and Housing, as keynote speaker. Featured Topics Include:
-- The latest developments at the Department of Fair Employment and Housing impacting employers; 2020 vision for the workplace;
-- Key risks to avoid in the crossover between Employment Law and Workers’ Compensation;
-- An update on strategies for defending post-termination Workers’ Compensation cases;
-- Guidance on implementing a compliant workplace catastrophe plan (e.g. for pandemic flu, major fire, and earthquake);
-- Information every employer needs to know about the "California Consumer Privacy Act";
-- Ten best practices for avoiding costly HR mistakes in managing family and medical leave, pregnancy disability leave, and paid sick leave, along with a Case Law update;
-- Key strategies for investigating and defending Workers’ Compensation psychiatric claims involving harassment claims;
-- A review of the top ten essential workplace polices for 2020; and
-- Key tips on avoiding the big Employment Law verdict.
This years event will take place on August 21, at the Disneyland Hotel, 1150 West Magic Way, Anaheim, CA 90802. Registration is at 8:00 am, and the conference is from 8:30 am to 5:00 pm
Last year’s event sold out, so make your reservation as soon as possible! Registration can be made online.
You may direct any questions to "events@floydskerenlaw.com." ...
California Attorney General Xavier Becerra, as part of a coalition of 18 attorneys general, filed a lawsuit challenging the U.S. Department of Labor’s (DOL) new rule limiting joint employer liability under the Fair Labor Standards Act (FLSA).
Under the Trump Administration’s new rule, Bacerra claims it would become substantially more difficult to establish when organizations are inappropriately shielding themselves from joint employment liability under the FLSA. In the lawsuit, the coalition argues that the rule is contrary to the FLSA’s statutory purpose and violates the Administrative Procedure Act.
In filing the lawsuit, the states argue that the rule’s definition of joint employer does not adequately reflect today’s workplaces, where growing numbers of businesses are outsourcing functions to third-party management companies, independent contractors, staffing agencies, or labor providers.
Entities found to be joint employers can be held accountable for workplace violations against an employee, even if the person is formally employed by another entity.
However, the new rule would make it much harder to establish joint employer liability. For example, under the new rule, employers can attempt to avoid liability by simply asserting that, although they had the ability to exercise control, they did not in fact exercise it.
The coalition further argues that the rule is an unreasonable interpretation of statute, that DOL does not articulate a satisfactory reasoned explanation for the rule, and that DOL lacks critical information and dismisses data and analysis assessing the impact of the rule on workers and joint employers.
While DOL’s rule will create harmful and unnecessary confusion, Bacerra said that workers in California will continue to be protected by the state’s broad definition of an employer.
In filing the lawsuit, Attorney General Becerra joins the attorneys general of New York, Pennsylvania, Colorado, District of Columbia, Delaware, Illinois, Maryland, Massachusetts, Michigan, Minnesota, New Mexico, New Jersey, Oregon, Rhode Island, Vermont, Virginia, and Washington ...
Under the Trump Administration’s new rule, Bacerra claims it would become substantially more difficult to establish when organizations are inappropriately shielding themselves from joint employment liability under the FLSA. In the lawsuit, the coalition argues that the rule is contrary to the FLSA’s statutory purpose and violates the Administrative Procedure Act.
In filing the lawsuit, the states argue that the rule’s definition of joint employer does not adequately reflect today’s workplaces, where growing numbers of businesses are outsourcing functions to third-party management companies, independent contractors, staffing agencies, or labor providers.
Entities found to be joint employers can be held accountable for workplace violations against an employee, even if the person is formally employed by another entity.
However, the new rule would make it much harder to establish joint employer liability. For example, under the new rule, employers can attempt to avoid liability by simply asserting that, although they had the ability to exercise control, they did not in fact exercise it.
The coalition further argues that the rule is an unreasonable interpretation of statute, that DOL does not articulate a satisfactory reasoned explanation for the rule, and that DOL lacks critical information and dismisses data and analysis assessing the impact of the rule on workers and joint employers.
While DOL’s rule will create harmful and unnecessary confusion, Bacerra said that workers in California will continue to be protected by the state’s broad definition of an employer.
In filing the lawsuit, Attorney General Becerra joins the attorneys general of New York, Pennsylvania, Colorado, District of Columbia, Delaware, Illinois, Maryland, Massachusetts, Michigan, Minnesota, New Mexico, New Jersey, Oregon, Rhode Island, Vermont, Virginia, and Washington ...
MSP Recovery LLC, a law firm out of Miami, Florida has been initiating class action litigation country-wide as assignees on behalf of Medicare Advantage Plans (MAPs) alleging that various primary payers have failed to reimburse MAP conditional payments allegedly giving rise to a Private Cause of Action under the Medicare Secondary Payer Act (MSP), specifically located at 42 USC §1395y(b)(3)(A). The litigation success of this organization should serve as a wakeup call for secondary payers, including the workers' compensation industry. Here is the statutory back story to a new success story (for them) in a recently published appellate decision.
In 1980, to "curb the rising costs of Medicare," Congress enacted the Medicare Secondary Payer Act, 42 U.S.C. § 1395y, which flipped the payment order, such that private insurers became the primary payers and Medicare became the secondary payer. A primary payer can include an entity responsible for providing workers' compensation medical care.
When a primary-payer plan doesn’t or can’t pay "promptly" - say, for instance, when it is contesting liability - Medicare can make a conditional payment on behalf of a beneficiary, for which it can later seek reimbursement from the primary plan. If Medicare pays and then seeks reimbursement, only to be refused, the United States can sue the primary plan (or a medical provider) to recover its payment.
Section 1395y(b)(2)(B)(iii) contains a statute of limitations that requires the government to sue within three years of the date that Medicare receives notice of a primary payer’s responsibility to pay. The Act also contains a "private cause of action," codified at § 1395y(b)(3)(A), which is available to Medicare beneficiaries and other private entities, who "are often in a better position than the government to know about the existence of responsible primary plans" that haven’t reimbursed Medicare or paid a beneficiary’s healthcare provider.
The private cause of action rewards successful plaintiffs with double damages after giving Medicare its share of the recovery, the plaintiff can keep whatever is left over. Unlike the government cause of action, the private cause of action contains no statute of limitations.
In 1997, in yet another effort to make Medicare more efficient, Congress enacted Medicare Part C, or the "Medicare Advantage" program. The legislation created Medicare Advantage Organizations. MAOs - like Medicare itself - were categorized as secondary payers. MAOs can sue to recover from primary plans that should pay, but don’t. MAOs, must utilize the Act’s private cause of action, rather than the government cause of action.
The case of MSPA Claims v. Kingsway Amigo began with an automobile accident in 2012. One of the people injured was a Medicare beneficiary who received her benefits from a Medicare Advantage Organization - Florida Healthcare Plus - that later assigned its claims to MSPA Claims (aka MSP Recovery LLC).
The other party involved in the accident was insured by Kingsway Amigo Insurance. The Medicare beneficiary obtained treatment for her accident-related injuries and Florida Healthcare made $21,965 in payments. The beneficiary settled a personal-injury claim with Kingsway and received a $6,667 settlement payment.
In 2015 MSPA sued Kingsway under the Act’s private cause of action. MSPA argued that Kingsway was the primary payer and Florida Healthcare was the secondary payer, giving MSPA - as Florida Healthcare’s assignee - the right to recover.
Kingsway filed a motion for judgment on the pleadings, arguing that MSPA’s claim was stale because it didn’t comply with the Act’s claims-filing provision limiting recovery claims to 3 years from the time item or service was furnished. The complaint alleged that services were provided between April 29 and July 26, 2012, Kingsway contended that a request for reimbursement had to have been made before July 26, 2015, which it wasn’t.
The district court granted Kingsway’s motion and MSPA appealed. The Court of Appeals for the 11th Circuit disagreed and reversed in the published case of MSPA Claims v. Kingsway Amigo .
The central issue in the appeal was whether MSPA’s failure to comply with the Medicare Secondary Payer Act’s claims-filing provision, § 1395y(b)is fatal to its suit against Kingsway, as the district court concluded.
In rendering its decision, the 11th Circuit Court noted that the plain reading of the MSP claims filing provision did not preclude MSPA Claims from filing suit. Essentially, the Court found that the dependent "notwithstanding" clause and the permissive term "may" in the actual text of the MSP claims filing provision means that MAOs are not required to bring suit as a prerequisite in the 3 year period.
Essentially, the permissive language within the law does not erect a separate bar that private plaintiffs must overcome to sue under the MSP private cause of action ...
In 1980, to "curb the rising costs of Medicare," Congress enacted the Medicare Secondary Payer Act, 42 U.S.C. § 1395y, which flipped the payment order, such that private insurers became the primary payers and Medicare became the secondary payer. A primary payer can include an entity responsible for providing workers' compensation medical care.
When a primary-payer plan doesn’t or can’t pay "promptly" - say, for instance, when it is contesting liability - Medicare can make a conditional payment on behalf of a beneficiary, for which it can later seek reimbursement from the primary plan. If Medicare pays and then seeks reimbursement, only to be refused, the United States can sue the primary plan (or a medical provider) to recover its payment.
Section 1395y(b)(2)(B)(iii) contains a statute of limitations that requires the government to sue within three years of the date that Medicare receives notice of a primary payer’s responsibility to pay. The Act also contains a "private cause of action," codified at § 1395y(b)(3)(A), which is available to Medicare beneficiaries and other private entities, who "are often in a better position than the government to know about the existence of responsible primary plans" that haven’t reimbursed Medicare or paid a beneficiary’s healthcare provider.
The private cause of action rewards successful plaintiffs with double damages after giving Medicare its share of the recovery, the plaintiff can keep whatever is left over. Unlike the government cause of action, the private cause of action contains no statute of limitations.
In 1997, in yet another effort to make Medicare more efficient, Congress enacted Medicare Part C, or the "Medicare Advantage" program. The legislation created Medicare Advantage Organizations. MAOs - like Medicare itself - were categorized as secondary payers. MAOs can sue to recover from primary plans that should pay, but don’t. MAOs, must utilize the Act’s private cause of action, rather than the government cause of action.
The case of MSPA Claims v. Kingsway Amigo began with an automobile accident in 2012. One of the people injured was a Medicare beneficiary who received her benefits from a Medicare Advantage Organization - Florida Healthcare Plus - that later assigned its claims to MSPA Claims (aka MSP Recovery LLC).
The other party involved in the accident was insured by Kingsway Amigo Insurance. The Medicare beneficiary obtained treatment for her accident-related injuries and Florida Healthcare made $21,965 in payments. The beneficiary settled a personal-injury claim with Kingsway and received a $6,667 settlement payment.
In 2015 MSPA sued Kingsway under the Act’s private cause of action. MSPA argued that Kingsway was the primary payer and Florida Healthcare was the secondary payer, giving MSPA - as Florida Healthcare’s assignee - the right to recover.
Kingsway filed a motion for judgment on the pleadings, arguing that MSPA’s claim was stale because it didn’t comply with the Act’s claims-filing provision limiting recovery claims to 3 years from the time item or service was furnished. The complaint alleged that services were provided between April 29 and July 26, 2012, Kingsway contended that a request for reimbursement had to have been made before July 26, 2015, which it wasn’t.
The district court granted Kingsway’s motion and MSPA appealed. The Court of Appeals for the 11th Circuit disagreed and reversed in the published case of MSPA Claims v. Kingsway Amigo .
The central issue in the appeal was whether MSPA’s failure to comply with the Medicare Secondary Payer Act’s claims-filing provision, § 1395y(b)is fatal to its suit against Kingsway, as the district court concluded.
In rendering its decision, the 11th Circuit Court noted that the plain reading of the MSP claims filing provision did not preclude MSPA Claims from filing suit. Essentially, the Court found that the dependent "notwithstanding" clause and the permissive term "may" in the actual text of the MSP claims filing provision means that MAOs are not required to bring suit as a prerequisite in the 3 year period.
Essentially, the permissive language within the law does not erect a separate bar that private plaintiffs must overcome to sue under the MSP private cause of action ...
The California Attorney General announced a global settlement framework between state attorneys general, local subdivisions, and Mallinckrodt, its subsidiaries, and certain other affiliates. Mallinckrodt is currently the largest generic opioid manufacturer in the United States.
The company said that it had an agreement with a key committee of lawyers representing thousands of local governments suing various drug industry players over opioids - and that the deal has the support of the attorneys general of 47 states and territories.
In the agreement, Malinckrodt agrees to pay $1.6 billion in cash to a trust that will cover the costs of opioid addiction treatment and related efforts, with the potential for increased payment to the trust. The company also agrees that its future generic opioid business will be subject to stringent injunctive terms that, among other things, will prohibit marketing of its opioid products and ensure systems are in place to prevent the drugs from falling into the wrong hands.
Documents gathered as the company prepared for trial showed that a Mallinckrodt sales manager told a distributor in 2009 of the pills: "Just like Doritos; keep eating, we'll make more." A company spokesman later called the statement "outrageously callous."
The company argued in court filings that unlike makers of brand-name drugs, it did not promote opioids to doctors or understate the addiction risks. But plaintiffs in the cases said Mallinckrodt continued to ship suspicious orders without making sure the drugs weren't going to be diverted to the black market.
Under its agreement, Mallinckrodt is filing for bankruptcy. The plan calls for it to make payments for eight years after the company emerges from the protections. That route is similar to one OxyContin maker Purdue Pharma is taking to settle opioid claims against it.
"Reaching this agreement in principle for a global opioid resolution and the associated debt refinancing activities announced today are important steps toward resolving the uncertainties in our business," Mark Trudeau, president and CEO of the company, said in a statement.
Joe Rice, a lawyer on the executive committee of plaintiffs suing in federal court over opioids, said in an interview Tuesday that some details of the Mallinckrodt agreement still remain to be ironed out.
Mallinckrodt's announcement comes weeks before a trial on the toll of opioids is scheduled to start in Central Islip, New York. The looming trial has been a factor in a ramped-up push for other drugmakers and distributors to settle, as well.
There have been increasingly public tensions between attorneys general and the private lawyers for local governments over the biggest of the proposed settlements, which would involve at least the three biggest U.S. drug distribution companies.
States have also been divided on whether to accept the deal, under which the distributors would pay a total of $18 billion over 18 years ...
The company said that it had an agreement with a key committee of lawyers representing thousands of local governments suing various drug industry players over opioids - and that the deal has the support of the attorneys general of 47 states and territories.
In the agreement, Malinckrodt agrees to pay $1.6 billion in cash to a trust that will cover the costs of opioid addiction treatment and related efforts, with the potential for increased payment to the trust. The company also agrees that its future generic opioid business will be subject to stringent injunctive terms that, among other things, will prohibit marketing of its opioid products and ensure systems are in place to prevent the drugs from falling into the wrong hands.
Documents gathered as the company prepared for trial showed that a Mallinckrodt sales manager told a distributor in 2009 of the pills: "Just like Doritos; keep eating, we'll make more." A company spokesman later called the statement "outrageously callous."
The company argued in court filings that unlike makers of brand-name drugs, it did not promote opioids to doctors or understate the addiction risks. But plaintiffs in the cases said Mallinckrodt continued to ship suspicious orders without making sure the drugs weren't going to be diverted to the black market.
Under its agreement, Mallinckrodt is filing for bankruptcy. The plan calls for it to make payments for eight years after the company emerges from the protections. That route is similar to one OxyContin maker Purdue Pharma is taking to settle opioid claims against it.
"Reaching this agreement in principle for a global opioid resolution and the associated debt refinancing activities announced today are important steps toward resolving the uncertainties in our business," Mark Trudeau, president and CEO of the company, said in a statement.
Joe Rice, a lawyer on the executive committee of plaintiffs suing in federal court over opioids, said in an interview Tuesday that some details of the Mallinckrodt agreement still remain to be ironed out.
Mallinckrodt's announcement comes weeks before a trial on the toll of opioids is scheduled to start in Central Islip, New York. The looming trial has been a factor in a ramped-up push for other drugmakers and distributors to settle, as well.
There have been increasingly public tensions between attorneys general and the private lawyers for local governments over the biggest of the proposed settlements, which would involve at least the three biggest U.S. drug distribution companies.
States have also been divided on whether to accept the deal, under which the distributors would pay a total of $18 billion over 18 years ...
A urologist was sentenced to 71 months in federal prison for submitting fraudulent billings totaling more than $700,000 to Medicare for medically unnecessary and nonexistent treatments, sometimes billing for purported patient visits miles apart and occurring at the exact same time.
Mark Wilfred Tamarin, 65, of Manhattan Beach, was sentenced by United States District Judge Dale S. Fischer, who also ordered him to pay nearly $345,000 in restitution.
After a seven-day trial in July 2019, a jury found Tamarin guilty of six counts of wire fraud and one count of attempted health care fraud. He has been in federal custody since the trial’s conclusion.
According to the evidence presented at trial, from 1987 until 2014, Tamarin was a partner Advanced Urology Medical Offices (AUMO), which had offices in Torrance and West Los Angeles.
From January 2009 until January 2013, at AUMO, where the majority of the patients were covered by Medicare, Tamarin billed Medicare for services he did not and could not have performed and also ordered medically unnecessary tests.
Tamarin covered Kindred Hospital, a sub-acute medical center in Ladera Heights, for AUMO. Kindred is a facility designed for patients with serious medical problems and in need of long-term care, but for whom a traditional hospital setting is unnecessary.
There, he billed for numerous patient visits that never happened and for services he never provided. The evidence presented at trial showed that on multiple occasions between 2009 and 2013, Tamarin purportedly was in two places miles apart at the same time he was treating patients in both locations.
At his office at AUMO, Tamarin ordered medically unnecessary tests for his patients. In particular, he ordered two to three times the number of post-void residual (PVR) tests and renal ultrasounds for urology patients in comparison to his three medical partners. Tamarin ordered so many PVRs that the office’s medical assistants suggested that the office purchase a second PVR machine. Tamarin ordered these tests before speaking with or seeing a patient despite the fact that the tests themselves only were appropriate in limited medical circumstances.
In total, Tamarin caused more than $700,000 in fraudulent claims to be billed to Medicare, of which Medicare paid approximately $219,934 in fraudulent Kindred claims and $124,802 in medically unnecessary PVR and renal ultrasound claims ...
Mark Wilfred Tamarin, 65, of Manhattan Beach, was sentenced by United States District Judge Dale S. Fischer, who also ordered him to pay nearly $345,000 in restitution.
After a seven-day trial in July 2019, a jury found Tamarin guilty of six counts of wire fraud and one count of attempted health care fraud. He has been in federal custody since the trial’s conclusion.
According to the evidence presented at trial, from 1987 until 2014, Tamarin was a partner Advanced Urology Medical Offices (AUMO), which had offices in Torrance and West Los Angeles.
From January 2009 until January 2013, at AUMO, where the majority of the patients were covered by Medicare, Tamarin billed Medicare for services he did not and could not have performed and also ordered medically unnecessary tests.
Tamarin covered Kindred Hospital, a sub-acute medical center in Ladera Heights, for AUMO. Kindred is a facility designed for patients with serious medical problems and in need of long-term care, but for whom a traditional hospital setting is unnecessary.
There, he billed for numerous patient visits that never happened and for services he never provided. The evidence presented at trial showed that on multiple occasions between 2009 and 2013, Tamarin purportedly was in two places miles apart at the same time he was treating patients in both locations.
At his office at AUMO, Tamarin ordered medically unnecessary tests for his patients. In particular, he ordered two to three times the number of post-void residual (PVR) tests and renal ultrasounds for urology patients in comparison to his three medical partners. Tamarin ordered so many PVRs that the office’s medical assistants suggested that the office purchase a second PVR machine. Tamarin ordered these tests before speaking with or seeing a patient despite the fact that the tests themselves only were appropriate in limited medical circumstances.
In total, Tamarin caused more than $700,000 in fraudulent claims to be billed to Medicare, of which Medicare paid approximately $219,934 in fraudulent Kindred claims and $124,802 in medically unnecessary PVR and renal ultrasound claims ...
A county judge in San Diego has ruled that Instacart misclassified the overwhelming majority of its California workforce.
While it will not have any immediate effect, the injunction represents a critical first step in enforcing the new state law known as "AB5."
The statute, which took effect earlier this year, attempts to ensure that so-called "gig economy" and other workers are considered employees, rather than unilaterally being declared independent contractors. Under state law, employees are eligible for consideration benefits, including workers’ compensation, unemployment, unionization rights and more. Companies save millions annually by avoiding such financial costs.
"We disagree with the judge’s decision to grant a preliminary injunction against Instacart in San Diego," the company said Monday night in a statement provided by Instacart spokeswoman Natalia Montalvo.
"We’re in compliance with the law and will continue to defend ourselves in this litigation. We are appealing this decision in an effort to protect shoppers, customers and retail partners. The court has temporarily stayed the enforcement of the injunction, and we will be taking steps to keep that stay in place during the appeals process so that Instacart’s service will not be disrupted in San Diego."
The labor law case, People of California v. Maplebear - Instacart’s official corporate name - was initially brought by the San Diego city attorney in September.
Instacart "avoids paying its ‘shoppers’ a lawful wage," San Diego City Attorney Mara W. Elliott said late Monday.
The "landmark ruling makes clear that Instacart employees have been misclassified as independent contractors, resulting in their being denied worker protections to which they are entitled by state law," Elliott said in a statement to NBC News. "We invite Instacart to work with us to craft a meaningful and fair solution."
Even though the judge’s order was issued Feb. 18, it was not formally served on the parties until Monday. The order will not take effect until Friday, the same day as a hearing related to arbitration, another central issue in this case.
"The ruling on the motion for preliminary injunction is not an adjudication of the ultimate rights in controversy," San Diego Superior Court Judge Timothy Taylor wrote. "It simply represents the court's discretionary decision whether defendant should be restrained from exercising a claimed right pending trial."
The judge’s ruling practically invited Instacart to appeal.
"Frankly, the sooner the Court of Appeal can hold forth on these issues, the sooner the parties will have a clear and definite signal of what is expected of them," Taylor wrote.
Similar companies including Uber have resisted the law and have a multi-pronged approach, including arguing that its drivers are not "core" to its business and should be treated as contractors. Uber has also lead the charge for a new ballot measure that supporters say would "protect flexibility," while critics say would gut the heart of AB5 and the state Supreme Court ruling that underpins it ...
While it will not have any immediate effect, the injunction represents a critical first step in enforcing the new state law known as "AB5."
The statute, which took effect earlier this year, attempts to ensure that so-called "gig economy" and other workers are considered employees, rather than unilaterally being declared independent contractors. Under state law, employees are eligible for consideration benefits, including workers’ compensation, unemployment, unionization rights and more. Companies save millions annually by avoiding such financial costs.
"We disagree with the judge’s decision to grant a preliminary injunction against Instacart in San Diego," the company said Monday night in a statement provided by Instacart spokeswoman Natalia Montalvo.
"We’re in compliance with the law and will continue to defend ourselves in this litigation. We are appealing this decision in an effort to protect shoppers, customers and retail partners. The court has temporarily stayed the enforcement of the injunction, and we will be taking steps to keep that stay in place during the appeals process so that Instacart’s service will not be disrupted in San Diego."
The labor law case, People of California v. Maplebear - Instacart’s official corporate name - was initially brought by the San Diego city attorney in September.
Instacart "avoids paying its ‘shoppers’ a lawful wage," San Diego City Attorney Mara W. Elliott said late Monday.
The "landmark ruling makes clear that Instacart employees have been misclassified as independent contractors, resulting in their being denied worker protections to which they are entitled by state law," Elliott said in a statement to NBC News. "We invite Instacart to work with us to craft a meaningful and fair solution."
Even though the judge’s order was issued Feb. 18, it was not formally served on the parties until Monday. The order will not take effect until Friday, the same day as a hearing related to arbitration, another central issue in this case.
"The ruling on the motion for preliminary injunction is not an adjudication of the ultimate rights in controversy," San Diego Superior Court Judge Timothy Taylor wrote. "It simply represents the court's discretionary decision whether defendant should be restrained from exercising a claimed right pending trial."
The judge’s ruling practically invited Instacart to appeal.
"Frankly, the sooner the Court of Appeal can hold forth on these issues, the sooner the parties will have a clear and definite signal of what is expected of them," Taylor wrote.
Similar companies including Uber have resisted the law and have a multi-pronged approach, including arguing that its drivers are not "core" to its business and should be treated as contractors. Uber has also lead the charge for a new ballot measure that supporters say would "protect flexibility," while critics say would gut the heart of AB5 and the state Supreme Court ruling that underpins it ...
The Institute for Clinical and Economic Review (ICER), a small but influential Boston-based research group, has signed a deal with private technology company Aetion to help it use patient health data in its reports on whether individual drugs are priced properly.
Large national regulators, including the U.S. Food and Drug Administration and United Kingdom’s National Institute for Health and Care Excellence (NICE), are considering increasing the use of data gathered outside of clinical trials on the effectiveness of treatments, often referred to as real-world data.
The FDA is running a pilot project using Aetion’s technology to analyze insurance claims to try to replicate clinical trial results, as part of a requirement to comply with healthcare legislation called the 21st Century Cures Act. It is seeking to determine under what circumstances such data could replace clinical trials, which have long been the foundation of medicine regulation.
Former FDA Commissioner Scott Gottlieb is a board member at Aetion.
The agreement with Aetion, which licenses the required claims data, will allow ICER to better inform its cost-effectiveness reports beyond clinical trial data and other information provided by patients, pharmaceutical companies and research papers.
ICER will pilot the use of real world analysis in follow-up reports on how patients are being prescribed and how they react to treatments that have reached the market through one of the FDA’s accelerated approval pathways.
ICER President Steve Pearson said it can use data collected by Aetion to analyze the standard of care for a disease, or to see if larger numbers of patients in medical practice react similarly to drugs as those in tightly controlled clinical trials.
For instance, he said, patients may be taking different dosages than given in trials, which could impact the cost effectiveness of a drug.
ICER is not a government agency and has no authority to set prices. But many large health insurers take their reports into account when they negotiate prices with drug manufacturers and determine patient access. Drugmakers also take into account ICER estimates when they set prices for new medicines.
New York-based Aetion has funding from venture capitalists including from units of Amgen and McKesson, as well as from drugmakers Sanofi and Ucb and health insurer Horizon Health Services ...
Large national regulators, including the U.S. Food and Drug Administration and United Kingdom’s National Institute for Health and Care Excellence (NICE), are considering increasing the use of data gathered outside of clinical trials on the effectiveness of treatments, often referred to as real-world data.
The FDA is running a pilot project using Aetion’s technology to analyze insurance claims to try to replicate clinical trial results, as part of a requirement to comply with healthcare legislation called the 21st Century Cures Act. It is seeking to determine under what circumstances such data could replace clinical trials, which have long been the foundation of medicine regulation.
Former FDA Commissioner Scott Gottlieb is a board member at Aetion.
The agreement with Aetion, which licenses the required claims data, will allow ICER to better inform its cost-effectiveness reports beyond clinical trial data and other information provided by patients, pharmaceutical companies and research papers.
ICER will pilot the use of real world analysis in follow-up reports on how patients are being prescribed and how they react to treatments that have reached the market through one of the FDA’s accelerated approval pathways.
ICER President Steve Pearson said it can use data collected by Aetion to analyze the standard of care for a disease, or to see if larger numbers of patients in medical practice react similarly to drugs as those in tightly controlled clinical trials.
For instance, he said, patients may be taking different dosages than given in trials, which could impact the cost effectiveness of a drug.
ICER is not a government agency and has no authority to set prices. But many large health insurers take their reports into account when they negotiate prices with drug manufacturers and determine patient access. Drugmakers also take into account ICER estimates when they set prices for new medicines.
New York-based Aetion has funding from venture capitalists including from units of Amgen and McKesson, as well as from drugmakers Sanofi and Ucb and health insurer Horizon Health Services ...
Some of the industry’s largest pharmaceutical companies, including Pfizer and Eli Lilly have developed a blockchain-based system to track prescription drugs across the supply chain to better halt the flow of counterfeit medicines.
Some two dozen companies in the industry including drugmakers, distributors, retailers and delivery firms created the blockchain-based MediLedger Network, which it has been testing in the verification of drug returns. They said they intend to further expand the system this year.
Blockchain, which first emerged as the technology underlying virtual currency bitcoin, is a shared database maintained by a network of computers.
The MediLedger group submitted a report to the U.S. Food and Drug Administration laying out the benefits of blockchain for this specific issue, Susanne Somerville, chief executive officer at technology company Chronicled, told Reuters.
The company claims that Blockchain has the capacity to break apart the silos dividing pharmaceutical suppliers and customers, while also building bridges for secure record keeping of each transaction that protects every party and ensuring fidelity across supply chains.
"Even though the drug supply in the United States is safe, there are small percentages - of potential counterfeit drugs. Certainly, there’s a lot of evidence of diverted drugs," Somerville told Reuters in an interview.
She said counterfeit drugs are a big problem in third world countries, where it is estimated that half of their drugs are counterfeit. "This is a plan intended that this never happens in this country."
Among the 24 participating companies are Amgen, FedEx, GlaxoSmithKline, Novartis, AmerisourceBergen, Sanofi, Walgreens Boots Alliance and Walmart.
The World Health Organization estimates that counterfeit medicines worth $79.26 billion are traded annually.
"The current point-to-point systems infrastructure lacks the ability to keep data in sync across the healthcare supply chain, which ultimately increases the risk of counterfeit, diverted or otherwise illegitimate products," David Vershure, head of channel and contract management for Roche’s Genentech unit, said in a statement.
The core function of the MediLedger Network is to validate the authenticity of drug identifiers throughout the supply chain, the MediLedger report said. This can all be done without any proprietary data being shared openly on the blockchain or ever leaving a company’s control.
The MediLedger project was created in response to the FDA’s call early last year for pilot projects testing an electronic inter-operable system as outlined in the Drug Supply Chain Security Act (DSCSA) ...
Some two dozen companies in the industry including drugmakers, distributors, retailers and delivery firms created the blockchain-based MediLedger Network, which it has been testing in the verification of drug returns. They said they intend to further expand the system this year.
Blockchain, which first emerged as the technology underlying virtual currency bitcoin, is a shared database maintained by a network of computers.
The MediLedger group submitted a report to the U.S. Food and Drug Administration laying out the benefits of blockchain for this specific issue, Susanne Somerville, chief executive officer at technology company Chronicled, told Reuters.
The company claims that Blockchain has the capacity to break apart the silos dividing pharmaceutical suppliers and customers, while also building bridges for secure record keeping of each transaction that protects every party and ensuring fidelity across supply chains.
"Even though the drug supply in the United States is safe, there are small percentages - of potential counterfeit drugs. Certainly, there’s a lot of evidence of diverted drugs," Somerville told Reuters in an interview.
She said counterfeit drugs are a big problem in third world countries, where it is estimated that half of their drugs are counterfeit. "This is a plan intended that this never happens in this country."
Among the 24 participating companies are Amgen, FedEx, GlaxoSmithKline, Novartis, AmerisourceBergen, Sanofi, Walgreens Boots Alliance and Walmart.
The World Health Organization estimates that counterfeit medicines worth $79.26 billion are traded annually.
"The current point-to-point systems infrastructure lacks the ability to keep data in sync across the healthcare supply chain, which ultimately increases the risk of counterfeit, diverted or otherwise illegitimate products," David Vershure, head of channel and contract management for Roche’s Genentech unit, said in a statement.
The core function of the MediLedger Network is to validate the authenticity of drug identifiers throughout the supply chain, the MediLedger report said. This can all be done without any proprietary data being shared openly on the blockchain or ever leaving a company’s control.
The MediLedger project was created in response to the FDA’s call early last year for pilot projects testing an electronic inter-operable system as outlined in the Drug Supply Chain Security Act (DSCSA) ...
Medicare Secondary Payer (MSP) is the term generally used when the Medicare program does not have primary payment responsibility (that is, when another entity has the responsibility for paying for medical care before Medicare). These entities with primary payment responsibility include GHPs and NGHP entities, such as liability insurers (including self-insured entities), no-fault insurers, and workers’ compensation arrangements.
Section 111 of the Medicare/Medicaid SCHIP Extension Act (MMSEA) of 2007, at its most basic level, requires insurers and self-insureds to both identify Medicare beneficiaries with whom they pay benefits or settlements associated with workers’ comp, no fault or liability claims and - once identified - report data to Medicare as directed by the Secretary of Health & Human Services.
The reporting act originally mandated that failure to comply with the reporting requirements "shall be subject to a civil money penalty of $1,000 for each day of noncompliance" for each individual for which the information should have been submitted.
Enter the SMART Act. On January 10, 2013, President Obama signed into law the Medicare IVIG Access and Strengthening Medicare and Repaying Taxpayers Act of 2012. The SMART Act, among other things, softened the language relative provide CMS with discretion not only to the imposition of the penalty but also into the amount of the penalty.
Now, civil money penalties "may be (rather than shall be) subject to a civil money penalty of up to $1,000 for each day of noncompliance with respect to each claimant." The SMART Act also required the Secretary to quickly solicit proposals determining "specified practices for which such sanctions will and will not be imposed" via the regulatory process.
About a year after the SMART Act was signed into law, CMS kicked off the rulemaking process with an advance notice of proposed rulemaking (ANPRM). Now, nearly a decade later, CMS has proposed the penalty rules for non-reporting or improper reporting.
This proposed rule will ensure that the appropriate insurers are compliant with their reporting requirements and primary payment responsibilities for healthcare services covered by their healthcare coverage programs. A 60-day public comment period seeks feedback on the proposals.
Here are some highlights of the proposed rule.
-- Under the proposed new rule, should a GHP fail to perform the required Section 111 reporting within one year of the coverage effective date, it would be subject to a CMP of $1,000 for each day of noncompliance for each individual whose coverage information should have been reported. A maximum penalty of $365,000 per individual per year would apply.
-- Should it fail to perform the required Section 111 reporting at all within one year of the date a settlement or other payment obligation was established, an NGHP would be subject to a CMP of up to $1,000 for each day of noncompliance for each individual whose information should have been reported. A maximum penalty of $365,000 per individual per year applies.
-- Entities that have performed Section 111 reporting as required, but subsequently provide information that contradicts reported information in response to MSP recovery efforts, would be subject to a CMP based on the number of days that the entity failed to appropriately report updates to beneficiary records. For GHP entities, penalties would be $1,000 per day of noncompliance per individual. For NGHP entities, the penalty would be up to $1000 per day of noncompliance, for a maximum penalty of $365,000 (365 days) per individual.
-- CMS has proposed an error tolerance that would not exceed a 20% threshold. In the public comment period it is seeking feedback on the threshold value for entities that have submitted their Section 111 reporting and Medicare identifies data errors. Reported information that exceeds any of the established error tolerance(s) threshold(s), and exceeds those tolerances for any four out of eight consecutive reporting periods, would be subject to a CMP with the fourth occurrence above the tolerance submission.
The proposed rule can be found online ...
Section 111 of the Medicare/Medicaid SCHIP Extension Act (MMSEA) of 2007, at its most basic level, requires insurers and self-insureds to both identify Medicare beneficiaries with whom they pay benefits or settlements associated with workers’ comp, no fault or liability claims and - once identified - report data to Medicare as directed by the Secretary of Health & Human Services.
The reporting act originally mandated that failure to comply with the reporting requirements "shall be subject to a civil money penalty of $1,000 for each day of noncompliance" for each individual for which the information should have been submitted.
Enter the SMART Act. On January 10, 2013, President Obama signed into law the Medicare IVIG Access and Strengthening Medicare and Repaying Taxpayers Act of 2012. The SMART Act, among other things, softened the language relative provide CMS with discretion not only to the imposition of the penalty but also into the amount of the penalty.
Now, civil money penalties "may be (rather than shall be) subject to a civil money penalty of up to $1,000 for each day of noncompliance with respect to each claimant." The SMART Act also required the Secretary to quickly solicit proposals determining "specified practices for which such sanctions will and will not be imposed" via the regulatory process.
About a year after the SMART Act was signed into law, CMS kicked off the rulemaking process with an advance notice of proposed rulemaking (ANPRM). Now, nearly a decade later, CMS has proposed the penalty rules for non-reporting or improper reporting.
This proposed rule will ensure that the appropriate insurers are compliant with their reporting requirements and primary payment responsibilities for healthcare services covered by their healthcare coverage programs. A 60-day public comment period seeks feedback on the proposals.
Here are some highlights of the proposed rule.
-- Under the proposed new rule, should a GHP fail to perform the required Section 111 reporting within one year of the coverage effective date, it would be subject to a CMP of $1,000 for each day of noncompliance for each individual whose coverage information should have been reported. A maximum penalty of $365,000 per individual per year would apply.
-- Should it fail to perform the required Section 111 reporting at all within one year of the date a settlement or other payment obligation was established, an NGHP would be subject to a CMP of up to $1,000 for each day of noncompliance for each individual whose information should have been reported. A maximum penalty of $365,000 per individual per year applies.
-- Entities that have performed Section 111 reporting as required, but subsequently provide information that contradicts reported information in response to MSP recovery efforts, would be subject to a CMP based on the number of days that the entity failed to appropriately report updates to beneficiary records. For GHP entities, penalties would be $1,000 per day of noncompliance per individual. For NGHP entities, the penalty would be up to $1000 per day of noncompliance, for a maximum penalty of $365,000 (365 days) per individual.
-- CMS has proposed an error tolerance that would not exceed a 20% threshold. In the public comment period it is seeking feedback on the threshold value for entities that have submitted their Section 111 reporting and Medicare identifies data errors. Reported information that exceeds any of the established error tolerance(s) threshold(s), and exceeds those tolerances for any four out of eight consecutive reporting periods, would be subject to a CMP with the fourth occurrence above the tolerance submission.
The proposed rule can be found online ...
Improving employment conditions and equity markets have driven the workers’ compensation insurance industry’s performance in recent years. IBISWorld reported that the industry saw 2.1% annual growth from 2013 to 2018. Meanwhile, the National Association of Insurance Commissioners (NAIC) reported that the industry amassed $58 billion in direct written premiums in 2018. The cumulative market share of the 10 largest insurance groups stood at 45.2%.
Here are the top 10 workers’ comp insurance providers, according to NAIC, ranked by countrywide premium and market share:
1. Travelers Direct Written Premiums: $4.3 billion Market Share: 7.4%
2. Hartford Direct Written Premiums: $3.4 billion Market Share: 5.9%
3. Berkshire Hathaway Direct Written Premiums: $2.8 billion Market Share: 4.7%
4. Zurich Insurance Direct Written Premiums: $2.7 billion Market Share: 4.7%
5. AmTrust Financial Services Direct Written Premiums: $2.6 billion Market Share: 4.5%
6. Chubb Ltd Direct Written Premiums: $2.5 billion Market Share: 4.3%
7. Liberty Mutual Direct Written Premiums: $2.5 billion Market Share: 4.3%
8. New York State Insurance Fund Direct Written Premiums: $2.3 billion Market Share: 3.9%
9. AIG Direct Written Premiums: $1.7 billion Market Share: 2.9%
10. Blue Cross Blue Shield of Michigan Direct Written Premiums: $1.6 billion Market Share: 2.7% ...
Here are the top 10 workers’ comp insurance providers, according to NAIC, ranked by countrywide premium and market share:
1. Travelers Direct Written Premiums: $4.3 billion Market Share: 7.4%
2. Hartford Direct Written Premiums: $3.4 billion Market Share: 5.9%
3. Berkshire Hathaway Direct Written Premiums: $2.8 billion Market Share: 4.7%
4. Zurich Insurance Direct Written Premiums: $2.7 billion Market Share: 4.7%
5. AmTrust Financial Services Direct Written Premiums: $2.6 billion Market Share: 4.5%
6. Chubb Ltd Direct Written Premiums: $2.5 billion Market Share: 4.3%
7. Liberty Mutual Direct Written Premiums: $2.5 billion Market Share: 4.3%
8. New York State Insurance Fund Direct Written Premiums: $2.3 billion Market Share: 3.9%
9. AIG Direct Written Premiums: $1.7 billion Market Share: 2.9%
10. Blue Cross Blue Shield of Michigan Direct Written Premiums: $1.6 billion Market Share: 2.7% ...
