Menu Close
A licensed acupuncturist was sentenced to 30 months in prison for fraudulently billing Amtrak’s health care plan for $7.1 million in acupuncture, massages and facials that either were medically unnecessary or were never provided.

Guiqiong Xiao Gudmundsen, 53, a.k.a. "Kimi" Gudmundsen, of Anaheim Hills, was sentenced and also ordered her to pay $2,683,903 in restitution to Amtrak.

Back in October 2019, Gudmundsen pleaded guilty to one count of health care fraud and one count of money laundering.

Gudmundsen owned Healthy Life Acupuncture Center, which operated in Riverside and Los Angeles. From January 2008 until December 2015, Gudmundsen recruited Amtrak employees to visit Healthy Life and then, among other things, billed the Amtrak health care plan for acupuncture, which she knew wasn’t being provided.

She billed the health plan for medically unnecessary services such as massages and facials, as well as for work-related injuries she knew the Amtrak plan did not cover. Gudmundsen also provided medical services to non-Amtrak health care plan participants and then billed the plan for it under the name of an actual Amtrak plan participant.

Gudmundsen regularly waived co-payments, co-insurance, and deductibles for Amtrak health care plan participants, something the plan did not permit. She double billed to other insurance plans, and she provided services to returning patients falsely billed as “new patients” in order to take advantage of higher reimbursement rates.

During the course of the scheme, Gudmundsen billed Amtrak’s health care plan in amounts comparable to large research hospitals and medical institutions that dwarfed other acupuncturists, court papers state. In 2013, Gudmundsen was ranked 32nd in the United States among health care providers for the amount billed to the Amtrak health care plan - above Johns Hopkins Hospital in Baltimore, which was ranked 39th, according to court documents.

Finally, she knowingly and routinely funneled her ill-gotten gains through bank accounts opened in the names of a shell company and her relatives.

Gudmundsen’s "entire business model was based on fraud, infiltrating all the services that she provided (and those she did not provide)," prosecutors wrote in their sentencing memorandum.

This matter was investigated by Amtrak Office of Inspector General, IRS Criminal Investigation, and the U.S. Department of Labor’s Employee Benefits Security Administration ...
/ 2020 News, Daily News
A former Santa Clara city police officer has been charged with faking the severity of an injury so that he could receive thousands of dollars in fraudulent disability payments.

Kenneth Henderson, 53, will be arraigned on felony workers’ comp fraud charges in the Hall of Justice in San Jose.

Henderson’s arrest comes about a year after his wife - a former Santa Clara County Sheriff’s lieutenant - was arrested in Las Vegas for an almost identical felony. She was convicted last year.

According to prosecutors, both husband and wife competed as body builders.

Kenneth Henderson claimed that he was injured while picking up a stack of five traffic cones on October 18, 2015. As a result of the injury, he was eventually put on permanent disability and retired from the force in 2016. After retirement, he continued to receive treatment paid for by the City of Santa Clara. He continued to present himself as completely disabled.

Last July, the Santa Clara County District Attorney’s Office began investigating a referral by an insurance carrier who claimed that Henderson, despite his disability, was seen completing rigorous workouts at a 24 Hour Fitness center in Las Vegas.

The activities were captured on surveillance video when Henderson’s wife, Mandy Henderson, was being surveilled as part of a workers’ compensation insurance investigation by the Santa Clara County Sheriff’s Department.

Mandy Henderson was later convicted of felony workers’ compensation fraud.

A review of Kenneth Henderson’s insurance documents, medical records, and surveillance video revealed that he exaggerated his injury.

One doctor reported that his presentation during medical appointments was like that of a stroke victim ...
/ 2020 News, Daily News
Pharmacy giant Walgreens has agreed to pay $7.5 million to settle a consumer protection lawsuit, accusing the company of allowing a phony pharmacist to handle over 745,000 prescriptions. The lawsuit was filed and settled on Monday jointly by the Alameda County and Santa Clara County District Attorneys’ Offices in Alameda County Superior Court.

The settlement comes just over a year after the Mercury News revealed a California State Board of Pharmacy investigation alleging Walgreens stores in Fremont, Milpitas and San Jose allowed Kim Thien Le to perform pharmacist duties for more than a decade without ever having a pharmacist’s license.

During Le’s more than 15 years as both an intern pharmacist and a pharmacist, she handled more than 100,000 prescriptions for controlled substances such as oxycodone, fentanyl, morphine, and codeine, officials said.

"Walgreens failed to vet Ms. Le thoroughly when it promoted her to positions requiring a license and failed to make sure that its internal systems were strong enough to prevent an employee from evading them," a statement from the Alameda County District Attorney’s Office said.

After the state investigation began, Walgreens "undertook a re-verification of the licenses of all our pharmacists nationwide," Walgreens spokesman Jim Cohn said in an email.

He also noted that Le’s employment with the company ended in October 2017, but did not offer further comment on the settlement, which had been under negotiation between prosecutors and the company.

Under the settlement, Walgreens will also be required to create a verification program, post proof that all of its employees are licensed if their position requires one, conduct annual audits, and submit an annual compliance report to the Alameda County DA’s office, Lin said.

This settlement is not the first legal fallout since the revelations about the investigation came to light.

The California Attorney General's office in July charged Le with false impersonation, identity theft and obtaining money, labor or property by false pretenses. The case is still pending in Alameda County courts. Le has pleaded not guilty to all charges.

The Walgreens stores involved could have received a range of disciplines for their part in the case, from a reprimand up to suspension or revocation of their pharmacy licenses, officials said previously.

But Becerra’s office ultimately required Walgreens to pay a $335,000 civil penalty and $19,500 to cover the Department of Justice’s investigation costs, and to admit to the truth of the claims in the state board’s investigation, according to State Board of Pharmacy documents reviewed by this news organization.

Teresa Drenick, a spokeswoman for the Alameda County DA’s office, said of the $7.5 million settlement money from Walgreens, the two DA’s offices will split roughly $250,000 to cover investigative costs, while about $250,000 will go to the state’s Consumer Protection Trust.

The remaining $6,992,500 is evenly divided between the two DA’s offices to be used for consumer protection and enforcement in the future ...
/ 2020 News, Daily News
The Monterey County District Attorney announced that Hector Hernandez, a 38-year-old King City resident and owner of Hernandez Roofing, was sentenced to 5 years felony probation for insurance fraud and state tax evasion.

As a term of probation, Hernandez was ordered to pay $159,059.03 in restitution to his workers’ compensation insurance carrier, State Compensation Insurance Fund.

Between 2013 and 2016, Hernandez secured a workers’ compensation insurance policy for his business through the State Compensation Insurance Fund. In order to pay lower insurance premiums, he denied having any employees.

The District Attorney’s Office opened an investigation in February 2016, obtaining building permits showing that Hernandez handled about 96 roofing jobs in a 4 year period.

Interviews of workers and homeowners revealed that he used at least 3 employees for these jobs. Hernandez attempted to conceal the employees and wages by paying cash. Investigators calculated Hernandez defrauded the State Fund of $159,059.00 in premiums.

The District Attorney filed felony charges on January 23, 2018. The charges included intentionally misrepresenting his payroll to obtain a reduced premium - a violation of Insurance Code Section 11880(a).

Hernandez was also charged with payroll tax violations of the Unemployment Insurance Code. He pled guilty to 3 felonies on August 23, 2019.

The case was investigated by Monterey County Workers’ Compensation Fraud Unit Investigators Martin Sanchez and George Costa ...
/ 2020 News, Daily News
The California Department of Justice sued Johnson & Johnson in May 2016, after a years-long multistate investigation revealed the company had neglected to inform both patients and doctors of possible severe complications from its mesh products and misrepresented the frequency and severity of risks the products posed. The products are permanent surgical implants designed to treat stress urinary incontinence and pelvic organ prolapse in women.

After a nine-week trial, a San Diego Superior Court Judge issued the 128 page Statement of Decision requiring Johnson & Johnson to pay $343.99 million in penalties. Additional injunctive terms may be added after further briefing.

The suit filed by the California Department of Justice is one of several the company has faced worldwide regarding the mesh products. This judgment marks the first time a court of law has issued findings of fact and ruled that Johnson & Johnson did indeed engage in illegal false and deceptive business practices.

The lawsuit alleged that Johnson & Johnson misrepresented the safety of these products by concealing and misleading consumers about the possibility of serious and irreversible complications caused by mesh, including permanent pain with intercourse, loss of sexual function, chronic pain, permanent urinary or defecatory dysfunction, and potentially devastating impact on overall quality of life.

The ruling notes that "complications could be so severe that mesh removal would be necessary but, unlike other implants, removal is difficult and harmful and can take multiple surgeries; J&J also knew that some of the most severe complications of mesh can be irreversible."

The Judge also wrote the marketing for the products "repeatedly touted mesh's benefits while misrepresenting, downplaying, and concealing its potential for serious, long-term complications."

From 2008 to 2014, Johnson & Johnson sold more than 470,000 pelvic mesh products nationally, including more than 30,000 in California. Worldwide, more than 2 million women have had these mesh products implanted in their bodies.

The court affirmed that Johnson & Johnson and its subsidiaries Ethicon Inc. and Ethicon US LLC, violated California’s Unfair Competition Law and False Advertising Law.

Johnson & Johnson has faced over 35,000 personal injury lawsuits related to its pelvic mesh products. It has settled similar claims with the state of Washington for $9.9 million and with a coalition of 42 other states for $117 million ...
/ 2020 News, Daily News
The legendary physician founder of Johns Hopkins, Dr. William Osler, once famously said: "Just listen to your patient; he is telling you the diagnosis."

Many leaders of the nation’s biopharmaceutical industry claim they are listening to America’s patients, to their families and to their caregivers, who say they find medicines too expensive, and that they have lost trust in our industry.

A group of 215 leaders in the biotechnology and pharmaceutical industries, academia, and life science investors issued a "New Biotechnology and Pharmaceutical Industry Commitment to Patients and the Public." The coalition is focused on ensuring access to medicines with pricing that reflects innovation and value to patients

The signatories of this New Commitment are holding themselves accountable for ensuring patient access to their products and meeting the highest ethical standards and business practices.

They says they recognize a moral imperative to lead the biopharmaceutical industry towards more responsible business practices; and again, a moral obligation to ensure that medicines reach every person who can benefit from them.

Every signatory to this New Patient Commitment pledges to pricing medicines at launch to reflect innovation, a genuine commitment to achieve broad access for patients, and ensuring that price increases are sustainable and guided by the need for uninterrupted patient access.

They also commit to work with all public and private insurers to find ways to limit or eliminate co-pays and deductibles and to supporting robust market competition through the approval of safe and effective generic and biosimilar medicines after our legitimate patent and regulatory protections expire.

Pharmaceutical company actions that pay generic companies to "delay" entry of generic competition have no place in a system where true competition must be fierce and fair.

They says they will not tolerate companies and other stakeholders who abuse this commitment to patients, or who abuse policies aimed at fairly rewarding innovation in pursuit of short-term financial gain. We will call out bad actors and bad practices.

Comments on the Commitment ranged from the cynical to the hopeful. Most reflected a "wait and see" attitude, and several questioned what such a commitment actually meant in practical terms ...
/ 2020 News, Daily News
Mitchell International released its Industry Trends Report for the fourth quarter of 2019.

The Casualty Edition, "The Power of Advanced Reporting Analytics" has been a hot topic for a few years now, and for good reason. More than half of analytics leaders reported a correlation between their organization’s analytics initiatives and seeing a "significant improvement" in their competitive standing. In the coming year, more than three quarters of that same group plan to expand or modernize their IT infrastructure to support analytics, according to a study from Forbes and Cisco.

In the insurance industry specifically, claims organizations are seeing varying results with their analytics programs. According to a McKinsey report, while more than half of CEOs at a variety of major P&C insurance carriers that they surveyed consider analytics a top priority, only one in six responded that analytics was making a large impact. The reasons for these struggles varied, including lack of alignment with strategic goals, poor integration and adoption or poor data quality.

When analytics is implemented correctly, it can have a significant positive impact on the claims process. As evidenced by the McKinsey study, getting analytics right can be challenging. The report outlined a few tips on how to use analytics effectively to make improvements in the claims process itself and to support a claims organization’s operations.

Within the claims process, claims organizations should be looking for different ways to highlight actionable insights for adjusters to react to and use throughout the process.

Use analytics to surface key findings in the claim to help give adjusters the full picture so they can improve decision making. For example, technology can help analyze if a claimant has been seeking treatment outside of the set treatment timeline, or if a bill was submitted for treatment that was unrelated to the injury. These types of analytics provide immediate information to adjusters so they can make more informed decisions, ultimately having a direct effect on the claim outcomes.

Implementing predictive analytics into the claims process could help claims organizations to accurately predict the severity of a claim or the types of symptoms typically associated with a type of injury. These types of predictions allow claims organizations to accurately triage claims to the right adjuster or group of adjusters to help make sure the claims are handled appropriately from the start.

Analyzing provider behavior and surfacing key insights for adjusters can help them to understand when a certain provider might be charging above the industry averages on a certain treatments, or treatments that may not be necessary for certain injuries. Questionable billing or treating practices can be further scrutinized by adjusters and nurses, or ultimately referred to the Special Investigations Unit. Implementing these types of provider analytics help claims organizations to be more confident that they are paying a fair amount on claims across the board, and that the injured workers are getting the right treatments ...
/ 2020 News, Daily News
Lawrence J. Gerrans was convicted by a federal jury of wire fraud and money laundering in connection with a scheme to defraud the medical device company he ran. The verdict issued following a two-week trial.

"The defendant siphoned millions of dollars from the medical device company he was entrusted to run, and then tried to cover up that crime," stated U.S. Attorney Anderson.

Evidence at trial showed that Gerrans, the president and chief executive officer of San Rafael-based medical device company Sanovas, employed a number of fraudulent methods to siphon funds out of Sanovas.

From January 12, 2015, through March 16, 2015, Gerrans systematically transferred more than $2.6 million from Sanovas to himself and two shell companies he controlled, Halo Management Group and Hartford Legend Capital Enterprises. That money was then used for an all-cash purchase of a luxury home in San Anselmo, at a purchase price of $2,570,000. At least $2.3 million of this money was laundered through Hartford Legend before being paid to the escrow account to purchase the house.

Evidence at trial also showed that Gerrans made false statements to a newly-created board of directors to seek their approval for a lucrative compensation plan and for reimbursement of retirement account funds that Gerrans had liquidated in 2013 and 2014. Evidence at trial showed that Gerrans had used the retirement account funds for personal expenditures, including a Maserati, a diamond ring, and rent on his personal residence, but he told the board of directors he had used the retirement account funds to benefit Sanovas. In another part of the scheme to defraud, evidence also showed that in 2017 Gerrans used a Sanovas corporate credit card for lavish personal expenditures, including a $44,000 vacation timeshare, $12,500 for high-end carpets for his home, and $32,000 to pay the property taxes on his personal residence.

Evidence at trial further showed that Gerrans provided false documents to the FBI during the criminal investigation, and that after he was first charged in the case he violated a court-ordered bond condition, attempted to tamper with a witness, and obstructed justice.

Judge Chen scheduled the defendant’s sentencing hearing for May 20, 2020.
/ 2020 News, Daily News
Jay Brome began his employment at the California Highway Patrol in 1996. During his nearly 20-year career he was openly gay. He claims that other officers subjected him to derogatory, homophobic comments; singled him out for pranks; repeatedly defaced his mailbox; and refused to provide him with backup assistance during enforcement stops in the field.

As a result, Brome feared for his life during enforcement stops, experienced headaches, muscle pain, stomach issues, anxiety and stress, and became suicidal by early 2015. In January 2015, he went on medical leave and filed a workers’ compensation claim based on work-related stress.

Brome’s workers’ compensation claim was resolved in his favor on October 27, 2015. He took industrial disability retirement on February 29, 2016, ending his employment with the Patrol.

On September 15, 2016, Brome filed an administrative complaint with the Department of Fair Employment and Housing. He filed a lawsuit the next day, asserting four claims under the Fair Employment and Housing Act for the conduct he alleged in his workers' compensation claim.

The CHP sought summary judgment, contending Brome’s claims were untimely because he did not file his administrative complaint within one year of the challenged actions, as required under former section 12960, subdivision (d).

However, because the crux of his case concerns circumstances that occurred before his medical leave began in January 2015, he asserted that exceptions to the one-year deadline were applicable. He argued that the filing of his workers’ compensation claim should stop the clock on his one-year filing deadline during the pendency of his compensation claim. The legal doctrine is known as "equitable tolling."

The trial court granted summary judgment in favor of the Patrol, holding that Brome’s claims were filed after the statute of limitations expired and a reasonable jury could not have concluded they were timely based on an exception to the deadline.

The Court of Appeal reversed in the published case of Brome v California Highway Patrol.

The equitable tolling doctrine operates to suspend or extend a statute of limitations as necessary to ensure fundamental practicality and fairness. In the case of McDonald v. Antelope Valley Community College Dist. (2008) 45 Cal.4th 88, the California Supreme Court held that the deadline for filing an administrative claim under the Act could be tolled while a plaintiff is voluntarily pursuing alternate remedies.

The time for filing a claim pursuant to the Act may be tolled where the plaintiff can establish three elements: timely notice, and lack of prejudice, to the defendant, and reasonable and good faith conduct on the part of the plaintiff.

It will be the jury’s job to reconcile the evidence at trial, and summary judgment was not justified ...
/ 2020 News, Daily News
Cal/OSHA is reminding employers in California to post their 2019 annual summary of work-related injuries and illnesses in a visible and easily accessible area at each worksite. The Form 300A summary must be posted each year through April 30.

Instructions and form templates are available for download from Cal/OSHA’s Record Keeping Overview.

The overview gives instructions on completing both the log (Form 300) and annual summary (Form 300A) of work-related injuries and illnesses.

The annual summary must be placed in a visible and easily accessible area at each worksite. Posting helps ensure workers are aware of work-related injuries and illnesses that occurred the previous year. Current and former employees and their representatives are entitled to a copy of the summary or the log upon request.

The 2019 definitions and requirements for recordable work-related fatalities, injuries and illnesses are outlined in the California Code of Regulations, Title 8, sections 14300 through 14300.48. Employers are required to complete and post the Form 300A even if no workplace injuries occurred.

Many employers in California must also comply with electronic submission of workplace injury and illness records requirements by March 2nd each year. Cal/OSHA has posted details on which employers are required to submit the electronic reports as well as other information online.

The California Division of Occupational Safety and Health, or Cal/OSHA, is the division within the Department of Industrial Relations (DIR) that helps protect California’s workers from health and safety hazards on the job in almost every workplace. Cal/OSHA’s Consultation Services Branch provides free and voluntary assistance to employers to improve their safety and health programs. Employers should call (800) 963-9424 for assistance from Cal/OSHA Consultation Services.

Employees with work-related questions or complaints may contact DIR’s Call Center in English or Spanish at 844-LABOR-DIR (844-522-6734) ...
/ 2020 News, Daily News
Bradley Dean Groscost, 59, of Westminster, and Felix Koltsov, 57, of Beverly Hills, self-surrendered last week to the Orange County Central Justice Center after being charged with multiple felony counts of insurance fraud, money laundering, and unlawful referrals for allegedly conspiring to bill insurers in excess of $20 million as part of a kickback referral scheme.

From 2014 to 2017, Groscost operated five workers’ compensation clinics in Southern California. Doing business as DSJ MGT, Inc. in Fountain Valley, Groscost controlled treatments, referrals, and medical and financial records at the clinics even though he was not licensed to practice medicine.

The Department of Insurance’s investigation, with the assistance of the National Insurance Crime Bureau, discovered that Groscost allegedly received approximately $2.1 million in kickbacks from Koltsov, owner of LFPS Inc. and Resource Pharmacy Inc., for patient referrals for urine drug screenings and compound cream prescriptions. Koltsov’s companies billed workers’ compensation insurance carriers over $20 million for these claims.

The investigation also revealed that Groscost allegedly failed to report employees to the Employment Development Department (EDD) and paid them as independent contractors. He failed to report over $5.1 million in wages to EDD and as a result, avoided paying over $510,000 in taxes. As of July 5, 2019, Groscost owed EDD over $1.6 million in taxes, penalties, and interest.

"These fraudulent workers’ compensation claims funnel resources away from injured workers and make it more difficult to provide the treatment to those workers who truly need it," said District Attorney Todd Spitzer. "The Orange County District Attorney’s Office is collaborating with the California Department of Insurance to crack down on workers’ compensation fraud and preserve resources for the truly injured."

"These co-conspirators allegedly ordered screenings and prescriptions for patients in order to enrich themselves, as part of a kickback referral scheme," said Insurance Commissioner Ricardo Lara. "By investigating health care fraud, my department is helping keep insurance costs down for all California consumers and businesses."

This case is being prosecuted by Deputy District Attorney Christine Oh of the Insurance Fraud Unit of the Orange County District Attorney’s Office. Koltsov surrendered to the court on January 22, 2020, and posted bail of $500,000. Groscost surrendered to the court on January 24, 2020, and remains in custody. His bail is set at $500,000 ...
/ 2020 News, Daily News
For the first time ever, researchers at the University of Sydney have successfully used human stem cells to produce "pain-killing" neurons. These neurons were then tested on a group of lab mice that were dealing with extreme pain. After just a single treatment, the mice’s pain symptoms were relieved with no side effects.

The research has just been published in the Journal Pain.

Moving forward, scientists will perform additional tests on pigs and other rodents. Then, if all goes well, testing on human patients dealing with chronic pain should begin within the next five years.

These pain-killing neurons could one day serve as a non-addictive, non-opioid pain management option for people all over the world.

"We are already moving towards testing in humans," says Associate Professor Greg Neely, a leader in pain research at the Charles Perkins Centre and the School of Life and Environmental Sciences, in a release.

"Nerve injury can lead to devastating neuropathic pain and for the majority of patients there are no effective therapies. This breakthrough means for some of these patients, we could make pain-killing transplants from their own cells, and the cells can then reverse the underlying cause of pain."

Researchers used human induced pluripotent stem cells (iPSC), derived from bone marrow, to create the neurons in a lab setting. Then, the neurons were placed inside the spinal cords of mice dealing with constant neuropathic pain.

"Remarkably, the stem-cell neurons promoted lasting pain relief without side effects," comments co-senior author Dr Leslie Caron. "It means transplant therapy could be an effective and long-lasting treatment for neuropathic pain. It is very exciting."

John Manion, the study’s lead author, adds: "Because we can pick where we put our pain-killing neurons, we can target only the parts of the body that are in pain. This means our approach can have fewer side effects." ...
/ 2020 News, Daily News
Luisa Rodriguez was employed by Kelly Services, and injured her low back, and claimed to have injured her neck, left leg, left hip, psyche, head, bilateral shoulders, and suffered a sleep disorder. Some of her treatment was provided on a lien basis.

Mr. Patrick Christoff executed a section 4903.S(d) declaration on behalf of lien claimants Comprehensive Outpatient Surgery Center (COSC) and Technical Surgery Support (TSS). In both declarations, Mr. Christoff declared under penalty of perjury that "the services or products described in the bill for services or products were actually provided to the injured employee"; and that "the billing statement . . . truly and accurately describes the services and products that were provided to the injured employee."

At trial the employer objected to the liens and claimed that Mr. Christoff did not have personal knowledge of the facts set forth in the declarations to sign them on behalf of lien claimants.

Christoff testified that he has worked for COSC since 2003 as an attorney, and he collects liens for COSC and TSS. His job duties included understanding billing procedures and codes, reviewing and negotiating bills, and reviewing surgical and medical reports, which includes over 10,000 operative reports. He reviewed these reports to have an understanding of what was billed for what service for each case. He also spoke to pain management doctors to get an understanding of the medical services that had been provided and billed to negotiate billing.

Christoff stated that he reviewed the operative reports to ensure that the description of the services in the operative reports matched the services that were billed in the invoice. Mr. Christoff testified that he relied on the information in the operative reports to determine the accuracy and specificity of the actual billing to ensure that they were the same and matched each other. Mr. Christoff explained that he received education on decompression procedures as well as training on bill review practices; he has reviewed over 10,000 bills. Mr. Christoff testified that he reviewed medical and surgical reports prior to signing his section 4903 .8( d) declarations on September 1, 2017.

On cross-examination, Mr. Christoff testified that he did not have any formal training or classroom instruction on CPT coding; did not attend any seminars in bill review; and did not recall being in the operating room for any of the procedures that were billed. Mr. Christoff testified that he based his declaration on the doctor's chart notes, and the doctor declared under penalty of perjury that the services were provided on that date.

The WCJ found that Christoff was competent to sign Labor Code section 4903.8(d) declarations on behalf of lien claimants Comprehensive Outpatient Surgery Center (COSC) and Technical Surgery Support (TSS). The decision was affirmed in the panel decision of Rodriguez v Kelly Services.

Here, Mr. Christoff s section 4903.S(d) declarations comply with section 4903.8(d) in that he declared under penalty of perjury the facts found in subsections (d)(l) and (d)(2). Therefore, the burden shifted to defendant to prove that Mr. Christoff's section 4903.S(d) declarations were invalid.

Defendant argues that lien claimants' 4903.S(d) declarations are invalid because Mr. Christoff is not competent to testify to the facts in his declarations; in particular, Mr. Christoff does not have "personal knowledge that the billing statement accurately describes the products/services provided to the injured employee and that those products/services were actually performed."

Although section 4903.8(d) does not define exactly what is meant by the phrase, "competent to testify," there guidance in Evidence Code section 702, which provides: "A witness' personal knowledge of a matter may be shown by any otherwise admissible evidence, including his own testimony."

Here, Mr. Christoff s knowledge of lien claimants' medical services was based, in part, on Dr. Williams' medical reports, which Dr. Williams declared and signed under penalty of perjury.

Based on the facts of this case, the WCAB concluded that Mr. Christoff is competent to testify to the facts stated in his section 4903. 8( d) declarations ...
/ 2020 News, Daily News
Arch Health Partners, Inc. has agreed to pay the United States $2,910,370 to resolve allegations that it violated the False Claims Act by submitting false claims to Medicare. Arch Health is a San Diego-based medical organization that contracts with physician groups to provide care through the Palomar Health system.

Palomar operates three hospitals in the San Diego area, Palomar Medical Center Escondido, Palomar Medical Center Downtown Escondido and Palomar Medical Center Poway, in addition to a physician network and other health care services on an outpatient basis.

The United States alleged that Arch Health violated the False Claims Act by submitting claims for federal reimbursement for medical evaluation and management services absent sufficient documentation regarding the nature and complexity of the services provided.

Those particular allegations were originally brought in a lawsuit filed by a former employee of Arch Health, Catherine Jones, under the qui tam, or whistleblower, provisions of the False Claims Act, which allow private citizens with knowledge of fraud against the government to bring suit on behalf of the government and to share in any recovery. Ms. Jones will receive $183,830 of the settlement proceeds.

The United States also alleged, based on certain self-disclosures by Arch Health, that it paid compensation to referring physicians and physician groups that was above fair market value in violation of the Anti-Kickback Act, the Stark Statute, and, by extension, the False Claims Act.

The investigation was conducted by the United States Attorney’s Office for the Southern District of California, the U.S. Department of Health and Human Services’ Office of Inspector General, and the Federal Bureau of Investigation. U.S. Attorney Brewer commended the excellent work by AUSA Glen Dorgan of the office’s Civil Division, whose diligence was a major factor in resolving this matter.

This case is captioned United States ex rel. Jones v. Arch Health Partners, Inc., et al., Case No. 3:17-cv-0090-MMA-BLM, and the matter was handled by Assistant U.S. Attorney Glen F. Dorgan of the Affirmative Civil Enforcement Unit of the U.S. Attorney’s Office ...
/ 2020 News, Daily News
A Nigerian American pathologist portrayed by Will Smith in the 2015 film, "Concussion," Bennet Omalu M.D. is partly responsible for the most important sports story of the 21st century. He triggered thousands of claims against the NFL that have settled for around $1 billion, and hundreds of workers' compensation claims filed, and now for the most part settled, in California.

Since 2005, when Omalu first reported finding widespread brain damage in a former NFL player, concerns about CTE have inspired a global revolution in concussion safety and fueled an ongoing existential crisis for America’s most popular sport. Omalu’s discovery - initially ignored and then attacked by NFL-allied doctors - inspired an avalanche of scientific research that forced the league to acknowledge a link between football and brain disease.

Nearly 15 years later, Omalu has withdrawn from the CTE research community and remade himself as an evangelist, traveling the world selling his frightening version of what scientists know about CTE and contact sports. In paid speaking engagements, expert witness testimony and in several books he has authored, Omalu portrays CTE as an epidemic and himself as a crusader, fighting against not just the NFL but also the medical science community, which he claims is too corrupted to acknowledge clear-cut evidence that contact sports destroy lives.

And since his discovery, Omalu told Sports Illustrated, researchers have uncovered evidence that shows adolescents who participate in football, hockey, wrestling and mixed martial arts are more likely to drop out of school, become addicted to drugs, struggle with mental illness, commit violent crimes and kill themselves.

But a new report from the Washington Post - "From scientist to Salesman How Bennet Omalu, Doctor of 'Concussion' Fame, Built a Career on Distorted Science" tells the other side of his story.

After more than a decade of intensive research by scientists from around the globe, the state of scientific knowledge of CTE remains one of uncertainty. Among CTE experts, many important aspects of the disease - from what symptoms it causes, to how prevalent or rare it is - remain the subject of research and debate.

But across the brain science community, there is wide consensus on one thing: Omalu, the man considered by many the public face of CTE research, routinely exaggerates his accomplishments and dramatically overstates the known risks of CTE and contact sports, fueling misconceptions about the disease, according to interviews with more than 50 experts in neurodegenerative disease and brain injuries, and a review of more than 100 papers from peer-reviewed medical journals.

Omalu did not discover CTE, nor did he name the disease. The alarming statistics he recites about contact sports are distorted, according to the author of the studies that produced those figures. And while Omalu cultivates a reputation as the global authority on CTE, it’s unclear whether he is diagnosing it correctly, according to several experts on the disease.

Omalu’s definition for CTE, as described in his published papers, is incredibly broad and all-encompassing, describing characteristics that can be found in normal, healthy brains, as well as in other diseases, according to experts including Ann McKee, lead neuropathologist for Boston University’s CTE Center. "His criteria don’t make sense to me," McKee said. "I don’t know what he’s doing."

McKee’s assessment was supported by three neuropathologists who worked with her to develop guidelines for diagnosing CTE used by researchers around the world.

McKee and other experts confirmed, in interviews, something that long has been an open secret in the CTE research community: Omalu’s paper on Mike Webster - the former Pittsburgh Steelers great who was the first NFL player discovered to have CTE - does not depict or describe the disease as the medical science community defines it. McKee and other experts believe Webster had CTE, based on his history of head trauma and his mental disorders. But the paper Omalu published shows images that are not CTE and could have come from the brain of a healthy 50-year-old man, they said.

"This is the problem," McKee said. "People lump me with him, and they lump my work with him, and my work is nothing like this." "My God, if people were actually following these [Omalu’s] criteria, the prevalence of this disease would be enormous, and there’s absolutely no evidence to support that."

Omalu declined several requests for an interview and refused to answer any questions for this story. In an email, he dismissed questions raised by experts as coming from "a minority of doctors who are seeking very cheap and bogus popularity . . . who work directly or indirectly with these sports organizations." "Your paper engaging in such bogus controversies will bolster some people’s allegations of ‘Fake News,’ " Omalu wrote.

This is typically how Omalu responds to criticism: by claiming it comes from scientists corrupted by relationships with sports leagues. But his depiction of the science of CTE and his prominence in the CTE research community have yielded his own financial benefits.

Billing himself as the man who discovered CTE, Omalu has built a lucrative business as an expert witness for hire in lawsuits - including in the growing CTE-related litigation field - charging a minimum of $10,000 per case, according to his testimony. He also maintains a busy schedule of paid speaking engagements, charging $27,500 per appearance, records show, as he delivers his sermon against contact sports ...
/ 2020 News, Daily News
A cosmetic surgeon who oversaw a long-running health care fraud scheme that conned insurance companies into paying tens of millions of dollars for unnecessary cosmetic procedures has been extradited from Israel to serve a 20-year federal prison sentence issued while he was a fugitive.

Dr. David M. Morrow, 75, a former Rancho Mirage resident, arrived late Thursday night at Los Angeles International Airport. During a court hearing, United States District Judge Josephine L. Staton ordered that Morrow immediately begin serving his prison sentence.

In September 2017, Judge Staton sentenced Morrow in absentia to 240 months in federal prison for running a scheme that duped health insurance companies into paying tens of millions of dollars for cosmetic procedures with false claims that procedures being performed were medically necessary. When the sentence was issued, Morrow had been on the run for four months after pleading guilty to conspiracy to commit mail fraud and filing a false tax return.

Morrow fled the United States along with his wife, Linda Morrow, 67, who was deported by Israel last July. Linda Morrow is facing a 31-count grand jury indictment that charges her with participating in the $50 million scheme run through The Morrow Institute (TMI) in Rancho Mirage. In a separate case, she faces contempt of court charges for fleeing the United States while free on bond in the health care fraud case. Her trial date in the contempt of court case is June 16.

Linda Morrow was the executive director of TMI, while David Morrow, a dermatologist-turned-cosmetic-surgeon, was the owner. The Morrows oversaw a scheme in which TMI submitted millions of dollars in claims for procedures that were certified as "medically necessary" - but in fact were cosmetic procedures such as "tummy tucks," "nose jobs" and breast augmentations.

Authorities believe the Morrows fled in May 2017. Prior to becoming fugitives, they failed to report to court officials, among other things, the sale of their $9.45 million home in Beverly Hills.

Court records show that, prior to the Morrows fleeing to Israel, they transferred more than $4 million dollars to Israeli bank accounts using the names of third parties. Recently filed court documents detail how both Morrows used fraudulent Mexican passports - with their photos, but other persons’ names - to enter Israel, and after they entered Israel they applied for Israeli citizenship using those fraudulent identities.

When the Morrows were arrested in Israel last year, they were no longer using the fraudulent Mexican identities, but were living under different fake identities and were using fraudulent Guatemalan passports. When Israeli law enforcement arrested Linda Morrow, she falsely claimed that her name was "Hannah." Court documents also show that FBI agents have determined that the Morrows used an Israeli attorney and others in Israel in an attempt to launder more than $2 million ...
/ 2020 News, Daily News
A joint effort by the Orange County District Attorney’s Office and the California Department of Insurance has shut down an alleged $3.2 million health care fraud ring which preyed on vulnerable substance abuse patients in order to bilk an insurance company out of millions.

Steven Lomonaco, 61, of Laguna Beach, Mahyar "Christian" Mohases, 37, of Santa Ana, Robert Williams, 41, of Murrieta, Nicholas Reeves, 42, of Aliso Viejo, and James Frageau, 29, of Temecula have been charged with multiple felony counts including insurance fraud and money laundering in connection with the scheme.

Mohases, Williams, Reeves, and Frageau have each been charged with two counts of committing medical insurance fraud, one count of fraudulent written claim to an insurance company, two counts of money laundering in excess of $150,000, four counts of money laundering, and one enhancement for aggravated white collar crime over $200,000. They each face a maximum sentence of 14 years if convicted on all charges.

Lomonaco has been charged with two counts of committing medical insurance fraud, one count of fraudulent written claim to an insurance company, one count of medical insurance fraud, and one enhancement for aggravated white collar crime over $200,000. He faces a maximum sentence of 8 years 4 months if convicted on all charges.

Mohases, Frageau, Williams and Reeves are accused of finding patients across the country who were seeking help for substance use recovery and flying them to California to enter treatment at Casa Bella International Inc., which was owned and operated by Lomonaco. In order to obtain payment from the insurance company for these patients, Mohases, Frageau, Williams and Reeves directed employees to fill out policies for the patients using false information.

They are accused of lying on the insurance applications, stating that patients lived in California, when in actuality the addresses were for employees or businesses related to the co-conspirators. Lomonaco paid the other co-conspirators upwards of $10,000 per patient who stayed enrolled in treatment for more than 30 days.

In order to pay the insurance premiums, the defendants are accused of developing a massive money laundering scheme in which they filtered money through non-profit, StopB4UStart, by providing "donations" from Mohases, Frageau, Williams and Reeves under their corporation, Nationwide Recovery. These "donations" would be cashed out, and the owner of StopB4UStart would receive cashier’s checks in specified amounts based on the information he received from one of the other co-conspirators. More than 800 checks in total were used to pay the insurance premiums on the fraudulent policies.

Mohases was arrested on January 13, 2020 and arraigned on January 14, 2020, he has pleaded not guilty. He is out on $250,000 bail and is scheduled for a pre-trial on February 5, 2020 in Department C-57.

Reeves was arrested on January 14, 2020 and arraigned on January 15, 2020, he has pleaded not guilty. He is out on $100,000 bail and is scheduled for a pre-trial on January 22, 2020 in Department C-55. A preliminary hearing for this suspect is scheduled for February 13, 2020 in Department C-55.

Frageau appeared in Court on warrant on January 15, 2020, he was arraigned on January 15, 2020. He is out on $250,000 bail and is scheduled for a continued arraignment on February 7, 2020.

Williams turned himself into Huntington Beach Police Department on January 15, 2020. No arraignment date has been scheduled for him yet.

Lomonaco was arrested on January 16, 2020. He is scheduled to be arraigned January 17, 2020 ...
/ 2020 News, Daily News
Egisto Salerno, a medical doctor practicing in San Diego, pleaded guilty to illegal opioid distribution, admitting that he signed bogus prescriptions for multiple deceased or incarcerated patients.

According to his plea agreement, Salerno illegally distributed 78,544 hydrocodone pills. Hydrocodone is an opioid pain medication commonly known as Norco or Vicodin. Salerno admitted that his prescriptions for the 10 mg tablets were outside the usual course of his medical practice and were without a legitimate medical purpose.

Salerno also admitted that an undercover federal agent who visited Salerno’s clinic on six occasions received six hydrocodone prescriptions containing Salerno’s signature.

In a separate instance, on a date when the undercover agent did not visit the clinic and the doctor did not see him, Salerno acknowleged that a prescription was written in the name used by the undercover agent and that Salerno completed and signed a progress note in the "patient" chart for the purported visit that did not occur.

Salerno used his medical practice on El Cajon Boulevard in San Diego to carry out this criminal activity between November 2014 and February 2018, the plea agreement said.

During this period, Salerno also acknowledged that he pre-signed prescriptions and often allowed his non-physician employees to complete those prescriptions; and that, with regard to one of the multiple dead "patients," his signature appeared on at least five prescriptions made out in the "patient’s" name that were issued and filled more than a year after the "patient" died.

Salerno is the seventh defendant to enter a guilty plea in connection with the pending case that flowed from the investigation of this "pill mill." Each of the defendants is awaiting sentencing.

The plea agreements of the six other defendants show that paid patient "recruiters" were bringing "patients," many of whom were homeless, to Salerno’s office to secure hydrocodone prescriptions; that, after the prescriptions were written, the "patients" were brought to pharmacies to fill the prescriptions; "patients" turned over their hydrocodone tablets to the recruiters in exchange for payment and, in some instances, recruiters picked up the tablets from the pharmacies themselves; and, in turn, those hydrocodone pills were being sold by the lead recruiter in San Diego and that such pills were also smuggled into Mexico and sold to a pharmacy there.

Salerno will be sentenced on May 11, 2020 ...
/ 2020 News, Daily News
Nolte Sheet Metal, Inc., owned in part by Ernie Nolte, fabricates air conditioning ducts.

In 2014, Cal/OSHA inspected the Company’s shop and issued citations for various violations of California Code of Regulations, title 8.

The Company filed an appeal with the Occupational Safety and Health Appeals Board (Appeals Board). In a January 29, 2016 decision, the administrative law judge (ALJ) appointed by the Appeals Board concluded the evidence supported the violations underlying the challenged citations. The ALJ also found the violations underlying four of these citations were properly classified as "serious."

The Company filed a petition for reconsideration, which was granted. In an October 7, 2016 decision after reconsideration, the Appeals Board upheld the ALJ’s determinations.

The Company then filed a petition for a writ of administrative mandamus. In a September 8, 2017 order, the Fresno County Superior Court denied writ relief.

On appeal from the superior court’s order, the Company advances several arguments. First, the court should have exercised its independent judgment when it reviewed the Appeals Board’s decision. Second, the Company did not freely and voluntarily consent to Cal/OSHA’s inspection. Third, Cal/OSHA lost the original inspection file, which deprived the Company of due process of law. Finally, the violations underlying four of the citations were misclassified as "serious."

The Court of Appeal affirmed the Order and rejected these arguments in the partially published decision of Nolte Sheet Metal Inc. v Occupational Safety and Health Appeals Board.

In Tex-Cal Land Management, Inc. v. Agricultural Labor Relations Bd. (1979) 24 Cal.3d 335, 346, which involved the Agricultural Labor Relations Act, our Supreme Court held "the Legislature may accord finality to the findings of a statewide agency that are supported by substantial evidence on the record considered as a whole and are made under safeguards equivalent to those provided by the [Agricultural Labor Relations Act] for unfair labor practice proceedings, whether or not the California Constitution provides for that agency’s exercising ‘judicial power.’ "

These safeguards include “the separation of prosecutorial from adjudicatory functions [citations], notice, written pleadings, evidentiary hearings [citations], and a requirement that orders be accompanied by findings based on the preponderance of the reported evidence [citations].” (Tex-Cal, supra, at p. 345.)

In view of Tex-Cal, the Court of Appeal concluded that the superior court properly applied the substantial evidence standard of review ...
/ 2020 News, Daily News
TRISTAR, the largest privately owned, independent third party claims administrator in the United States, has agreed to acquire Aspen Risk Management Group.

Aspen delivers workplace safety stand-alone, or as part of loss control, or ergonomics. Whether conducting loss control surveys, delivering safety training, or performing remote ergonomic assessments, the Group works to identify risk and opportunities using a combination of technology and human insight. Its solutions can significantly reduce both the frequency and severity of losses.

This acquisition is a significant step forward in establishing a strategic TRISTAR presence in the loss control and workplace safety market. In addition to its risk control services, Aspen provides remote ergonomics, online service platforms, and specialty services for both commercial and government clients.

Commenting on the acquisition, Steve Thompson CEO of Aspen stated: "For the past 15 years our team has worked hard to become exceptional at risk control and workplace safety. Joining TRISTAR gives us the chance to carry our primary purpose of saving lives, preventing injuries & illnesses, and protecting our clients from harm all across America!”

Tom Veale, President of TRISTAR stated: "Aspen’s reputation and extensive experience in both the insurance and self-insurance space are a natural addition to the TRISTAR family. They are differentiators in the industry and we look forward to introducing them to our clients and partner network."

All Aspen employees will continue operating out of the existing locations under the name Aspen Risk Management Group, a TRISTAR Company.

Terms of the transaction were not disclosed ...
/ 2020 News, Daily News