The first of 14 defendants charged in three separate cases was arraigned on November 23, for their roles in a workers’ compensation re-training voucher fraud scheme that caused a loss to insurance carriers in excess of $22 million.

The 14 defendants are charged with a variety of counts including conspiracy, insurance fraud, capping, and receiving kickbacks.

An investigation started in January 2019 when the Riverside County DA’s Office, assisted by the California Department of Insurance and the California Bureau for Private Post-Secondary Education, started looking into suspected fraud at two for-profit vocational schools.

The fraud involved Supplemental Job Displacement Benefits (SJDB) provided by workers’ compensation insurance carriers, and was suspected at Ryon College in Riverside and Sutech School in Los Angeles.

The investigation revealed that two of the charged defendants, Oswaldo Forero, of Irvine; and Melbe Zepeda, of Bellflower, operated the two "sham" schools that were primarily funded by workers’ compensation vouchers.

These vouchers, with values ranging from $6,000 to $10,000, were intended for injured workers to be re-trained or to assist them in learning new skills to accommodate their disabilities enabling them to re-enter the workforce.

It is alleged that Forero and Zepeda employed numerous "cappers" to illegally recruit students to the two schools they operated.

These "cappers" were paid to sign up as many students as possible to attend the schools, even if the student didn’t have the requisite educational background - a high school diploma or equivalent.

The priority of the defendants was to make money using various tactics such as over-billing for laptops and tools, collecting lucrative vouchers for students that never or rarely attended the school, faking admission tests, and giving students cash for their vouchers ...

Drugmaker AstraZeneca says that late-stage trials show its COVID-19 vaccine is highly effective, buoying the prospects of a relatively cheap, easy-to-store product that may become the vaccine of choice for the developing world

The results are based on an interim analysis of trials in the U.K. and Brazil of a vaccine developed by Oxford University and manufactured by AstraZeneca. No hospitalizations or severe cases of COVID-19 were reported in those receiving the vaccine.

AstraZeneca is the third major drug company to report late-stage data for a potential COVID-19 vaccine as the world waits for scientific breakthroughs that will end a pandemic that has pummeled the world economy and led to 1.4 million deaths.

But unlike the others, the Oxford-AstraZeneca vaccine doesn’t have to be stored at freezer temperatures, making it potentially easier to distribute, especially in developing countries.

The Oxford-AstraZeneca vaccine was 90% effective in preventing COVID-19 in one of the dosing regimens tested; it was less effective in another. Earlier this month, rival drugmakers Pfizer and Moderna reported preliminary results from late-stage trials showing their vaccines were almost 95% effective.

While the AstraZeneca vaccine can be stored at 2 degrees to 8 degrees Celsius (36 degrees to 46 degrees Fahrenheit), the Pfizer and Moderna products must be stored at freezer temperatures. In Pfizer’s case, it must be kept at the ultra-cold temperature of around minus-70 degrees Celsius (minus-94 Fahrenheit).

The AstraZeneca vaccine is also cheaper. It has pledged it won’t make a profit on the vaccine during the pandemic, and has reached agreements with governments and international health organizations that put its cost at about $2.50 a dose. Pfizer’s vaccine costs about $20, while Moderna’s is $15 to $25, based on agreements the companies have struck to supply their vaccines to the U.S. government.

All three vaccines must be approved by regulators before they can be widely distributed.

Oxford researchers and AstraZeneca stressed they weren’t competing with other projects and said multiple vaccines would be needed to reach enough of the world’s population to end the pandemic.

AstraZeneca said it will immediately apply for early approval of the vaccine where possible, and it will seek an emergency use listing from the World Health Organization, so it can make the vaccine available in low-income countries.

The results reported Monday come from trials in the U.K. and Brazil that involved 23,000 people. Of those, 11,636 people received the vaccine - while the rest got a placebo.

Late-stage trials of the vaccine are also underway in the U.S., Japan, Russia, South Africa, Kenya and Latin America, with further trials planned for other European and Asian countries.

The AstraZeneca trials were paused earlier this year after a participant in the U.K. study reported a rare neurological illness. While the trials were quickly restarted in most countries after investigators determined the condition wasn’t related to the vaccine, the FDA delayed the U.S. study for more than a month before it was allowed to resume.

AstraZeneca has been ramping up manufacturing capacity, so it can supply hundreds of millions of doses of the vaccine starting in January, Chief Executive Pascal Soriot said earlier this month.
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The Department of Industrial Relations’ (DIR) Occupational Safety and Health Standards Board unanimously adopted emergency temporary standards to protect workers from hazards related to COVID-19. The emergency standards will be in effect immediately if approved by the Office of Administrative Law in the next 10 calendar days.

The temporary standards apply to most workers in California not covered by Cal/OSHA’s Aerosol Transmissible Diseases standard. Under the new regulations, employers must have a written COVID-19 Prevention Plan that addresses the following:

-- System for communicating information to employees about COVID-19 prevention procedures, testing, symptoms and illnesses, including a system for employees to report exposures without fear of retaliation.
-- Identification and evaluation of hazards - screening employees for symptoms, identifying workplace conditions and practices that could result in potential exposure.
-- Investigating and responding to cases in the workplace - responding immediately to potential exposures by following steps to determine who may have been exposed, providing notice within one business day about potential exposures, and offering testing to workers who may have been exposed.
-- Correcting COVID-19 hazards - including correcting unsafe conditions and work practices as well as providing effective training and instruction.
-- Physical distancing - implementing procedures to ensure workers stay at least six feet apart from other people if possible.
-- Face coverings - providing face coverings and ensuring they are worn.
-- Adopting site-specific strategies such as changes to the workplace and work schedules and providing personal protective equipment to reduce exposure to the virus.
-- Positive COVID-19 case and illness recording requirements and making the COVID-19 Prevention Plan accessible to employees and employee representatives.
-- Removal of COVID-19 exposed workers and COVID-19 positive workers from the workplace with measures to protect pay and benefits.
-- Criteria for employees to return to work after recovering from COVID-19.
-- Requirements for testing and notifying public health departments of workplace outbreaks (three or more cases in a workplace in a 14-day period) and major outbreaks (20 or more cases within a 30-day period).
-- Specific requirements for infection prevention in employer-provided housing and transportation to and from work.

The Standards Board will file the rulemaking package today with the Office of Administrative Law, which has 10 calendar days to review and approve the temporary workplace safety standards enforced by Cal/OSHA.

Once approved and published, the full text of the adopted emergency standards will appear in the new Title 8 sections 3205 (COVID-19 Prevention), 3205.1 (Multiple COVID-19 Infections and COVID-19 Outbreaks), 3205.2 (Major COVID-19 Outbreaks) 3205.3 (COVID-19 Prevention in Employer-Provided Housing) and 3205.4 (COVID-19 Prevention in Employer-Provided Transportation to and from Work) of the California Code of Regulations. Pursuant to the state’s emergency rulemaking process, after an initial effective period the board will have two opportunities to readopt the temporary standards.

Cal/OSHA will expeditiously convene a stakeholder meeting that will include industry and labor representatives to review the requirements of the emergency regulation and solicit feedback and recommend updates.

The Occupational Safety and Health Standards Board, a seven-member body appointed by the Governor, is the standards-setting agency within the Cal/OSHA program. The Standards Board's objective is to adopt reasonable and enforceable standards at least as effective as federal standards. The Standards Board also has the responsibility to grant or deny applications for variances from adopted standards and respond to petitions for new or revised standards ...

Mark Redheffer, 48, of Fontana, was arraigned on felony counts of insurance fraud and attempted perjury after allegedly lying and concealing information in a workers’ compensation claim in order to receive over $63,000 in undeserved temporary disability benefits from his employer, Southern California Edison.

After receiving a referral from Redheffer’s employer, SCE, the Department of Insurance launched an investigation into Redheffer’s claim that he suffered injuries while working as a linesman apprentice in 2015.

The extensive investigation, which included surveillance of Redheffer to confirm the legitimacy of his claimed physical limitations and injury, exposed his workers’ compensation claim to be fraudulent.

The felony complaint alleges that Redheffer concealed material information relating to his medical history during an evaluation by a Qualified Medical Examiner, who determined that Redheffer suffered significant physical limitations and was no longer able to perform his job duties.

Additionally, Redheffer is charged with lying in a deposition in pursuit of the workers’ compensation claim.

Redheffer was charged with three felony counts of insurance fraud and attempted perjury. Prior to Redheffer’s arraignment on November 19, 2020, an arrest warrant had been issued in the amount of $50,000.

Redheffer is scheduled to return to court on January 29, 2021.

The case is being prosecuted by the San Bernardino County District Attorney’s Office ...

As employers continue to grapple with the fallout from the pandemic, the immediate threat of COVID-19 litigation looms large. To help stay one step ahead, the Jackson Lewis COVID-19 Employment LitWatch tracks complaints filed in federal and state courts nationwide that allege labor and employment law violations related to COVID-19.

The Jackson Lewis COVID-19 Employment LitWatch tracks civil complaints filed in federal and state courts across the country that both are related to the COVID-19 epidemic and raise labor and/or employment law issues. Cases that merely referenced COVID-19 are not included. The COVID-19 Employment LitWatch is meant to provide trends and should not be considered an exhaustive dataset.

Jackson Lewis has a dedicated team tracking and responding to the developing issues facing employers as a result of COVID-19, which includes members from:

-- Class Actions and Complex Litigation
-- Corporate Diversity Counseling
-- Disability, Leave and Health Management
-- Employee Benefits
-- General Employment Litigation
-- Labor and Preventative Practices
-- Wage and Hour
-- Workplace Safety and Health

The LitWatch data is based on a feed of thousands of civil complaints filed per day that is provided by Courthouse News Service (CNS).

A review of COVID-19-related labor and employment complaints filed between January - August 2020, determined that an overwhelming majority (approximately two-thirds) of complaints involve an allegation of wrongful termination. Typically, each of these complaints contains an underlying claim that led to the employee’s termination, such as, for example, an employee requesting an accommodation.

The database reflects a total of 1,107 civil complaints nationwide as of today. Not unexpectedly, 214 of these cases have been filed in California, of which 199 are in state and 15 are in federal courts.

The healthcare industry has generated 263 total complaints, followed by manufacturing with 89, and retail and consumer goods 76.
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Aggressive corrective actions aimed at reducing Medicare fee-for-service (FFS) improper payments have resulted in less healthcare fraud, waste, and abuse, as well as $15 billion in savings, according to the latest data from CMS.

The data released earlier today also revealed that the Medicare FFS improper payment rate declined to 6.27 percent in fiscal year (FY) 2020 from 7.25 percent in FY 2019. It was the fourth consecutive year that the Medicare FFS improper payment rate was below 10 percent, CMS reported.

Medicare FFS improper payments decreased the most in home healthcare. CMS reported $5.9 billion in savings attributed to fewer improper payments to home health agencies between FY 2016 and 2019.

The agency also saw a $1 billion reduction in estimated improper payments made to skilled nursing facilities in the last year.

Reductions in both the home health and skilled nursing facility improper payment rates can be attributed to CMS efforts to educate providers through the Targeted Probe and Educate program, as well as changes to the policy related to supporting information for physician certification and recertification for skilled nursing facility services, CMS stated.

Improper payments occur when reimbursements do not meet statutory, regulatory, administrative, or other legally application requirements, CMS explained. A common example is insufficient or missing documentation for a claim.

Without proper documentation or errors in the documentation, CMS cannot verify if its programs correctly reimbursed for the services rendered. As a result, CMS may over or underpay the provider for the claim.

Additionally, a smaller portion of improper payments should never have been made largely because of issues with medical necessity, coding, beneficiary eligibility, and other errors on the claim. These end up as losses to the government.

The agency has developed a five-pillar program integrity strategy for reducing improper payments. The five components of CMS’ strategy are stopping bad actors who have defrauded federal healthcare programs; preventing fraud; mitigating emerging programmatic risks related to value-based payment programs; reducing provider burden; and leveraging new technology (e.g., artificial intelligence and machine learning).

CMS implemented the strategy in 2019. Since then, there has been a $3.17 billion reduction in Medicare FFS improper payments, according to the new data.
...

Reinier Razon began working for Southern California Permanente Medical Group at its Kaiser Sunset location in January 2014, as a clinical laboratory scientist.

In 2016 Razon was involved in a dispute with Darren Wallace, the union steward assigned to the clinical laboratory scientists. According to Razon, Wallace assaulted him. Razon was treated two days later at the Kaiser emergency room for anxiety and diagnosed with "emotional stress reaction," which he believed was due to his encounter with Wallace.

Razon filed a workers’ compensation claim for stress and anxiety arising from his encounter with Wallace. That claim was pending when he filed his lawsuit against SCPMG in April 2017, for disability discrimination, failure to accommodate and failure to engage in the interactive process in violation of the California Fair Employment and Housing Act.

In March 2018 Razon settled his workers’ compensation claim for $45,000, as reflected in a standard, preprinted compromise and release form. He also signed a separate voluntary resignation letter. The document states it "releases Kaiser from any and all claims, known or unknown, which may exist at the time of execution of this Agreement." It specifically included "causes of action under Title VII of the Civil Rights Act of 1964 (race, color, religion, sex and national origin discrimination); the Americans with Disabilities Act; 29 USC section 62 (age discrimination). However, this list is expressly understood by the parities [sic] not to be all-inclusive."

The trial court granted SCPMG’s motion for summary judgment and entered judgment in favor of SCPMG, ruling Razon’s civil FEHA lawsuit was barred by his written release of all claims relating to his employment with SCPMG. The court of appeal affirmed the dismissal in the unpublished case of Razon v. Southern California Permanente.

Razon argues the release set forth in his voluntary resignation letter is enforceable only if the letter was attached to the preprinted compromise and release form used to resolve his workers’ compensation claims. No authority cited by Razon established attachment as a requirement. To the contrary, the Supreme Court in Claxton Court (34 Cal.4th at pp. 370, 378) expressly recognized release of the non-workers’ compensation claims could be effected through a separate document, independent of the workers’ compensation preprinted form. That is exactly what occurred here

Razon argues the absence of any express reference to his FEHA claims in the release creates a triable issue of fact whether the lawsuit, pending at the time the release was executed, was included within its scope. The Supreme Court in Claxton expressly rejected the need for the specificity that Razon suggests.

In his declaration in opposition to the summary judgment, Razon insisted he did not intend by signing the letter to release his FEHA claims. That undisclosed intent, however, is irrelevant to the interpretation of the release. (Otay Land Co., LLC v. U.E. Limited, L.P. (2017) 15 Cal.App.5th 806, 855) ...

On October 7, the Division of Workers’ Compensation’s Administrative Director issued an order adjusting the Hospital Outpatient Departments and Ambulatory Surgical Centers Fee Schedule portion of the Official Medical Fee Schedule to conform to changes in the Medicare system, effective for services rendered on or after October 1, 2020.

Subsequently, on October 21, 2020, the Centers for Medicare and Medicaid Services (CMS) issued a corrected Addendum A and corrected Addendum B to supersede the previous documents.

The Administrative Director has issued an order dated November 5, 2020, to adopt CMS’ corrected Addendum A and Addendum B for Hospital Outpatient Departments/Ambulatory Surgical Centers services rendered on or after October 1, 2020. The order makes the following changes:

-- Incorporates by reference CMS’ HOPPS addendum A found in the October 2020 CORRECTION Addendum A (ZIP) – updated 10/21/2020 file, in place of the original file, for services rendered on or after October 1, 2020
-- Incorporates by reference CMS’ HOPPS addendum B found in the October 2020 CORRECTION Addendum B (ZIP) – updated 10/21/2020 file, in place of the original file, for services rendered on or after October 1, 2020
-- Corrects a clerical error in the reference to the Integrated Outpatient Code Editor provisions relating to Comprehensive APC (J1 and J2) Status Indicator.

The Administrative Director update order dated October 7, 2020 remains in effect for services rendered on or after October 1, 2020, except as modified by Administrative Director order dated November 5, 2020. The Orders and regulations can be found at the DWC OMFS web page ...

The Centers for Disease Control and Prevention (CDC) has awarded $1.5 million over three years to the University of Illinois at Chicago and Worcester Polytechnic Institute to fund projects aimed at reducing workers’ exposures to hazards through the development and use of collaborative robots, or co-robots.

CDC’s National Institute for Occupational Safety and Health (NIOSH) partnered with the National Science Foundation (NSF) to fund studies of co-robots in the workplace through NSF’s National Robotics Initiative. The Initiative supports research in the U.S. that will accelerate the development and use of co-robots, an emerging robotic technology that complements, not replaces, human workers. Co-robots work alongside people or other robots and can help improve worker safety.

"The future of work includes a workplace where robots work in tandem with, or are even worn by, human workers," said NIOSH Director John Howard, M.D. "This important research will help guide the development and use of co-robots that can help minimize health and safety risks to workers."

In healthcare, remote-controlled nursing robots have the potential to reduce workload and the risk of infection, especially in quarantine and intensive care environments. Researchers at Worcester Polytechnic Institute will develop a more intuitive interface to make it easier for nurses to operate robots from a distance. Researchers also will investigate best practices for integrating robots into current nursing education.

In manufacturing, lifting heavy objects can lead to costly and disabling work-related musculoskeletal disorders. Wearable robots, which provide mechanical assistance to the user’s joints, have the potential to reduce injuries from heavy lifting. Researchers at the University of Illinois at Chicago will develop and investigate the effectiveness of a personalized wearable robot worn on the lower body that senses the wearer’s physical effort and responds accordingly using soft-wearable electronics.

Through its Center for Occupational Robotics Research, NIOSH is proactively working across industrial sectors to guide the development and use of occupational robots that enhance workers’ safety, health, and well-being. The Center’s research looks at traditional industrial robots that work in robotic cells and cages away from human workers as well as at emerging robotic technologies such as co-robots; wearable robotics or powered exoskeletons; remotely controlled or autonomous vehicles and drones; and future robots that increasingly use advanced artificial intelligence.

NIOSH is the federal institute that conducts research and makes recommendations for preventing work-related injuries, illnesses and deaths. Additional information on NIOSH grant opportunities via the NIOSH Extramural Research and Training Programs can be found https://www.cdc.gov/niosh/oep/ here ...

A new survey finds 66 percent of Americans working remotely believe that taking sick days for anything less severe than COVID-19 would be looked down upon by their employer.

Moreover, three out of four respondents said that since getting coworkers sick is off the table, the bar for symptom severity warranting taking time off has been raised. The OnePoll survey reveals two in three Americans (67%) are much less inclined to take off from work when they are sick now. In fact, seven in 10 have even worked while feeling ill since they started working from home.

The poll, commissioned by ColdCalm, also examined the circumstances under which workers would actually take time off for sickness now that they perform their duties without ever leaving the house.

The survey of 2,000 Americans finds 63 percent feel a sore throat alone simply won’t cut it in 2020. Workers say they would need to actually lose their voice before they felt justified taking time off. Results also revealed that sometimes remote employees have been so desperate for an illness-related respite that half have taken undocumented time off and hoped that it went unnoticed.

Nearly half of respondents believe that COVID has made other illnesses look "minor" in comparison. Forty-five percent said the pandemic has made them more vigilant about avoiding illnesses, and 72 percent are more likely to take medication at the first signs of symptoms.

Even though the physical stress of commuting is eliminated for those working from home, their ability to handle their responsibilities can still be impacted by sickness. Among those Americans who worked from home while sick, 52 percent say their performance "decreased considerably" during their illness. Nearly six in 10 (57%) feel that working remotely through their illness actually enhanced their credibility with coworkers.

Proactive measures like taking a homeopathic medicine, drinking lots of fluids to stay hydrated, and getting plenty of rest at the first sign of illness can mean the difference between having something that can be manageably worked through as opposed to one that knocks you off your feet for a few days ...

A little over two years after its $753 million acquisition of the prescription medicine delivery service Pillpack, Amazon has finally launched Amazon Pharmacy, its online and mobile prescription medication ordering and fulfillment service.

The launch of the new Pharmacy service within Amazon is a blow to other discount prescription services like the publicly traded GoodRx and companies like RxSaver and delivery services like ExactCare Pharmacy.

The competition from Amazon was likely one reason why GoodRx began offering telemedicine services as a point of differentiation and to move up the value chain. It will be interesting to see if Amazon will also move to providing virtual care for more than its employees.

Last year, the company rolled out Amazon Care for its workers in Seattle as part of a pilot service that provided both in-person and telemedicine services.

Using a secure pharmacy profile, Amazon customers can add their insurance information, manage prescriptions and choose payment options all through Amazon’s service. And in another small push towards wider healthcare services, and not just selling items, users are provided with "self-service help" tools on Amazon’s portal, and they also have the option to speak to pharmacists either via over the phone, for advice: "Friendly and knowledgeable pharmacists are available 24/7 to answer questions about medications."

After launching its own line of over-the-counter drugs in 2019, this is arguably Amazon’s broadest push into the healthcare business to-date, one that could open up very large, new revenue opportunities for the company, especially as the ongoing COVID-19 pandemic pushes consumers both toward more remote care, and using online channels for all their shopping needs.

While Amazon Pharmacy looks to be a US-only launch for now, it’s a global opportunity. Online pharmacy services are projected to hit revenues of $131 billion by 2025 worldwide. Prescription drugs, meanwhile, have been estimated to be a $904 billion industry this year, growing to nearly $1.3 trillion by 2025.

Amazon is also letting customers compare prices with their insurance co-pay, without insurance or with the savings available through the Prime prescription savings plan to choose the lowest option. Amazon is also staffing a pharmacy service accessible at all hours so that customers can answer questions about their medications.

In August, Amazon launched its fitness tracker, Halo. The personal health and wellness monitoring and advice service includes a $64.99 wrist tracker and an application suite for monitoring health.
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Pfizer has launched a pilot delivery program for its experimental COVID-19 vaccine in four U.S. states, as the U.S. drugmaker seeks to address distribution challenges facing its ultra-cold storage requirements.

Pfizer’s vaccine, which was shown to be more than 90% effective in preventing COVID-19 based on initial data, must be shipped and stored at -70 degrees Celsius (minus 94°F), significantly below the standard for vaccines of 2-8 degrees Celsius (36-46°F).

"We are hopeful that results from this vaccine delivery pilot will serve as the model for other U.S. states and international governments, as they prepare to implement effective COVID-19 vaccine programs," Pfizer said in a statement on Monday.

It picked Rhode Island, Texas, New Mexico, and Tennessee for the program after taking into account their differences in overall size, diversity of populations, immunization infrastructure, and need to reach individuals in varied urban and rural settings.

The four states will not receive vaccine doses earlier than other states by virtue of the pilot, nor will they receive any differential consideration, Pfizer said.

The company expects to have enough safety data on the vaccine from the ongoing large scale late-stage trials by the third week of November before proceeding to apply for emergency use authorization (EUA).

Pfizer and its partner BioNTech SE 22UAy.F have a $1.95 billion deal to supply 100 million doses of the vaccine to the U.S. government, which has an option to acquire up to an additional 500 million doses.

Earlier on Monday, rival Moderna Inc MRNA.O said its experimental vaccine was 94.5% effective in preventing COVID-19 based on interim data from a late-stage trial, boosting hopes that vaccines against the disease may be ready for use soon.

Both the Pfizer and Moderna vaccines use a new technology called synthetic messenger RNA to activate the immune system against the virus ...

This year, CMS has been quite active announcing several updates to its Medicare Secondary Payer Recovery Portal and holding a recent webinar on redetermination requests. CMS trends regarding post-settlement Total Payment Obligation to Claimant (TPOC) beneficiary recovery have been causing some challenges for workers’ compensation carriers from another angle. CMS will also be holding a webinar on the NGHP Beneficiary Recovery Process on December 9th.

In September, CMS and the Commercial Repayment Center (CRC) held a webinar session to address "redetermination" requests as part of the administrative appeals process regarding conditional payment disputes of non-group health plans (NGHP). CMS reviewed the five levels of the administrative appeals process before the CRC discussed the various appeals available to primary payers in the administrative appeals process.

The CRC outlined the specific arguments it will accept as part of a redetermination request as follows:

-- Termination of Ongoing Responsibility for Medicals (ORM) due to benefits exhaustion;
-- Termination of ORM due to settlement or other claim resolution;
-- Benefits denied/revoked by applicable plan;
-- Non-covered services;
-- Unrelated services; and
-- Duplicative primary payment.

As part of this session, the CRC emphasized adherence to established appeal timelines and other related requirements is critical. On this point, the CRC advised redeterminations must be received within 120 days from the date a Medicare demand letter is received by the named debtor, which CRC noted is presumed to be five days after the date of demand.

CMS’s trend of having the BCRC pursue the claimant post-settlement is currently causing some challenges and frustration particularly in workers’ compensation settlements.

Specifically, the BCRC is increasingly opening conditional payment recovery cases upon receipt of TPOC information and issuing final demands with the claimant named the debtor. This occurs even in situations where the parties have previously worked with the CRC to resolve conditional payment cases related to ORM.

When this happens, the carrier cannot interact with the BCRC on the claim without having a separate Proof of Representation (POR) executed by the claimant. This, in turn, complicates the workers’ compensation carrier’s ability to ensure that Medicare’s recovery is resolved if they cannot secure a POR from the claimant post-settlement.

To prevent this, workers’ compensation carriers wishing to ensure conditional payment exposure is fully resolved may need to consider securing a POR from the claimant as part of the settlement process to avoid having to chase the claimant post-settlement for this required authorization.

CMS has recently announced that it is holding a Non-Group Health Plan (NGHP) Beneficiary Recovery Process Webinar on December 9, 2020, at 1:00 p.m. ET. CMS indicates that its primary intended audience is "attorneys who represent beneficiaries and other beneficiary representatives." ...

Ashot Mamikonyan and Lorraine Watson, the final two of nine defendants charged in an extensive fraud scheme involving All Care One Community Health Center in Huntington Park have been arraigned.

All Care One Community Health Center was located at 7300 Santa Fe Avenue in Huntington Park, California. Its NPI number is 1467752626.

In July, charges were filed against the defendants, all of whom worked for, owned, or were officers at All Care One. The group is alleged to have committed fraud amounting to over $2.5 million from California’s Family Planning, Access, Care, and Treatment (FPACT) program from 2014 to 2016.

From 2014 to 2016, All Care One was paid more than $5 million for FPACT claims. It is estimated that more than half of the $5 million was the result of fraudulent claims.

The alleged scheme involved sending staff to low income areas in Los Angeles to solicit people to provide their patient identifying information and a urine sample in exchange for a kickback. The personal information and urine were brought back to All Care One where medical assistants were instructed to falsify charts for these individuals, and then doctors, nurse practitioners, and midwives signed off on the charts as though they provided medical services related to family planning or sexually transmitted diseases.

All Care One marketers also allegedly offered kickbacks to lure individuals into the clinic for treatment, and many of these patients were treated by an unlicensed doctor.

In addition to Mamikonyan and Watson, felony charges have also been filed against seven other individuals involved in the scheme: Gevork George Ter-Mkrtchyan, Syuzan Harutyunyan, Karim A. Soliman, Guadalupe Morena Moreno, Jessica Villa, Maria D. Vasquez, and Anna Marie Soto. This group includes All Care One’s former owner, officers and employees.

Additionally, Mamikonyan was charged with the unlicensed practice of medicine, Harutyunyan was charged with aiding and abetting the unlicensed practice of medicine, and Moreno was charged with paying and receiving kickbacks ...

Indivior Solutions was sentenced to pay $289 million in criminal penalties in connection with a previous guilty plea related to the marketing of the opioid-addiction-treatment drug Suboxone. The sentence was pursuant to a plea agreement.

In total, the payments made by Indivior Solutions and its parent companies, Indivior Inc. and Indivior plc, along with payments made under a 2019 resolution with Indivior’s former parent, Reckitt Benckiser Group plc, and criminal penalties paid pursuant to plea agreements with two former Indivior executives will exceed $2 billion.

That amount represents the second-largest monetary resolution obtained by the Department of Justice in a case involving an opioid drug.

Suboxone, which contains the powerful opioid buprenorphine, is a drug product approved for use by recovering opioid addicts to avoid or reduce withdrawal symptoms while they undergo treatment for opioid-use disorder.

In connection with its guilty plea, Indivior Solutions admitted to making false statements to the Massachusetts Medicaid program (MassHealth) related to the relative safety of Suboxone Film, a version of Suboxone, around children.

Indivior Solutions pleaded guilty on July 24, 2020, to a one-count felony criminal information charging false statements relating to health care matters.

Last June, Indivior’s former CEO, Shaun Thaxter, pleaded guilty to a one-count misdemeanor information related to Indivior’s false and misleading representations to MassHealth. He was sentenced to a six-month term of incarceration and $600,000 in criminal fines and forfeiture.

Last August. Indivior’s former medical director, Tim Baxter, pleaded guilty to a one-count misdemeanor information related to Indivior’s false and misleading representations to MassHealth. His sentencing is scheduled for Dec. 17.

Indivior Solutions that in October 2012 it sought to convince MassHealth to expand Medicaid coverage of Suboxone Film in Massachusetts and sent MassHealth a misleading chart and false data indicating that Suboxone Film had the lowest rate of accidental pediatric exposure (i.e., children taking medication by accident) of all buprenorphine drugs in Massachusetts, when in fact it did not.

Indivior Solutions further admitted that sending the false and misleading information occurred in the context of marketing and promotional efforts directed at MassHealth, which were overseen by top executives.

MassHealth announced it would provide access to Suboxone Film for patients with children under the age of six shortly after Indivior provided the false and misleading information to agency officials.
...

30 year old Alexander Cody Smith, of Canoga Park was arraigned on three felony counts of workers’ compensation insurance fraud after allegedly misrepresenting past injuries to receive over $38,000 in undeserved medical treatments and temporary disability benefits from his employer’s insurance company.

Smith, while working for Engen Enterprises Inc., claimed he injured his back on March 16, 2018, as he was lifting a box.

Over the course of his medical treatment, Smith complained of back pain to his treating physician and later added complaints of neck pain to the claim. According to his claim and his doctor’s medical report, Smith denied any previous injuries or complaints about his back, specifically to his thoracic or lumbar spine.

An investigation by the California Department of Insurance revealed a history of medical complaints related to both Smith’s neck and back, which reportedly began in October 2015, according to subpoenaed records from his former health care provider and rehabilitation specialists.

The records show Smith received medical treatment from February 25, 2017, through March 13, 2018, and according to the records, it was at this time Smith reported feeling depressed due to his pain. This was just three days prior to the date he claimed he got injured at work while lifting the box.

The Department’s investigation revealed Smith misrepresented the history of his prior back injuries. Smith’s actions were likely made in an attempt to continue treatment for his ongoing condition, which was not work-related. Smith provided false information regarding his prior existing issues, which resulted in excessive and unnecessary medical evaluations, treatments, and temporary disability benefits at a cost of $38,746 to his employer’s insurance company.

Smith was arrested on October 28, 2020 and arraigned on October 30, 2020. The Los Angeles County District Attorney’s Office is prosecuting this case ...

Many recent studies show stunning public mistrust in vaccines. And mistrust could push levels that potential COVID-19 vaccines are taken in the United States below the rates needed to protect communities against the disease.

One new prepublication study of 8,000 people in the U.S. and Britain found that fewer people would "definitely" take a COVID-19 vaccine than the 55% of the population scientists estimate is needed to provide so-called "herd immunity".

The study comes as one of the major vaccine efforts showed promising results. Pfizer said on Monday its experimental COVID-19 vaccine is more than 90% effective based on interim data from late stage trials. The data were seen as a crucial step in the battle to contain a pandemic that has killed more than a million people.

-- People without a college degree, those in low-income groups and non-whites are more likely to reject a COVID-19 vaccine, the study found.

-- Women were more likely than men to refuse a COVID-19 vaccine, but more respondents in both countries said they would accept a vaccine if it meant protecting family, friends, or at-risk groups.

In the United States alone, another study by the Pew Research Center found, the share of adult Americans who say they would "definitely" or "probably" get a Covid-19 vaccine fell from 72 percent in May to 51 percent in September.

An October Harris poll showed that 78% of Americans think that the speedy approval process of a coronavirus vaccine is driven by politics - not by proof that shots work. About 83% said they would worry about a safe a coronavirus vaccine is if it was approved quickly.

And recent Axios-Ipsos polls confirms that vaccine resistance is growing. The percentage of people who say they are likely to get the first generation COVID-19 vaccine as soon as it is available fell from about 47% in August, to 39% at the end of September.

Heidi Larson, a professor at the London School of Hygiene & Tropical Medicine, who co-led the newest study said "This threatens to undermine the levels of COVID-19 vaccine acceptance." She is also director of the international Vaccine Confidence Project ...

Medical provider networks for workers compensation have become increasingly popular over the last two decades. In conjunction with increased market penetration, some MPNs have broadened their services: As a way to improve outcomes, they do not just provide medical care, they manage the medical services on a claim, including interacting with the patient.

A new report published by NCCI looked at the impact of MPNs on workers compensation claim costs for 10 common WC injuries.

Comparing claims managed in-network to claims managed out-of-network across states and for 10 common injuries:

-- Average paid medical costs are higher in-network for the more costly back and shoulder injuries and lower for several less costly injuries.
-- In-network cases have more and higher-level office visits,as well as more physical therapy modalities,than comparable out-of-network cases.
-- Except for the more costly back injuries, in-network claims (as compared with out-of-network):
-- -- Are less likely to be admitted to a hospital.
-- -- Cost less for hospital outpatient services.
-- -- Cost more for physician services.
-- For all 10 injuries and for both permanent partial and temporary total claims, the average total incurred cost per claim for in-network claims is lower than, or about the same as, that for out-of-network claims.
-- In-network claims are more likely to have permanent injury awards than out-of-network claims; selection bias may play a role here
-- WC medical costs for physician services are higher than comparable Group Health costs. The main driver of this difference is higher utilization of services to treat WC cases.
-- For all but a few injuries with comparatively small numbers of cases, greater MPN penetration in a state is associated with greater MPN utilization of physician services in the state.

Differences at a state level may be considered in a follow-up study performed later ...

A new study from the California Workers’ Compensation Institute shows the steep drop in the number of inpatient hospitalizations involving California injured workers over the past decade was largely due to the ongoing decline in spinal fusions and a more recent decline in lower extremity joint surgeries.

The study reviews discharge data compiled by the state Office of Statewide Health Planning and Development (OSHPD) on 35.9 million inpatient hospital stays from 2010 through 2019 paid by workers’ compensation, Medicare, Medi-Cal and private insurance, in order to identify workers’ compensation inpatient trends and to compare the volume and types of California inpatient hospitalizations covered by workers’ compensation to those covered by the three other systems.

Workers’ comp is by far the smallest of the medical delivery systems reviewed, accounting for just 0.4 percent of all inpatient stays in 2019, which is not surprising given that it has only accounted for between 1.4 percent and 1.6 percent of California healthcare costs over the past decade.

However, over the same 10-year span the study found that the number of workers’ comp inpatient hospitalizations declined 36.2 percent, more than twice the 15.9 percent decline noted for private coverage, and in sharp contrast to the 4.0 percent increase in Medicare and the 14.5 percent increase in Medi-Cal hospitalizations.

The study found that a key factor leading to the reduction of workers’ comp inpatient stays was the sharp decline in the number of injured workers receiving spinal fusions, which fell 53.1 percent between 2010 and 2019, a decline that was spurred by multiple factors including the adoption of utilization review and independent medical review programs requiring that treatment meet evidence-based medicine standards, the elimination of duplicate payments for implantable devices used in spinal surgeries, and fraud convictions that led to the sale of hospitals that had a high volume of workers’ comp back surgeries.

At the same time the overall number of work injury claims declined and there were technological and procedural advances that allowed more services to be provided in outpatient settings, prompting the growth of ambulatory surgery centers and an expansion of services at those facilities.

The study notes that spinal fusions were not the only type of workers’ compensation inpatient hospitalizations that saw a significant decline, as the number of workers’ comp discharges associated with lower extremity joint replacements has gradually declined in each of the past five years, falling from 2,727 workers’ comp discharges in 2014 to 2,140 in 2019, a net decrease of 21.5 percent.

In addition to tracking inpatient trends for California workers’ compensation, Medicare, Medi-Cal and private plans over the 10-year study period, the study also provides detailed data showing the breakdown of workers’ comp inpatient stays among the top 5 Major Diagnostic Categories (MDCs); the proportion of surgical vs. "medical" (non-surgical) hospitalizations in each of the 4 payer groups; the top 5 workers’ comp surgical and medical inpatient discharges by diagnostic-related group (MS-DRG) in 2019; the breakdown of the top 10 workers’ comp MS-DRGs across payer groups in 2019; the volume and prevalence of spinal fusion surgeries by payer group from 2010 through 2019; and the top 10 hospitals for workers’ comp inpatient care as well as the 10 hospitals with the highest ratio of workers’ compensation inpatients to total inpatients.

CWCI members and subscribers can access the report in the Research section and others can purchase it for $14 from the online Store. CWCI members may also log in to the Research section to access an updated version of CWCI’s Inpatient Hospitalization Claim Interactive Tool ...

The Travelers Companies, Inc. announced the launch of Global Companion Plus+. This new product builds upon the company’s broad property and casualty offerings for U.S. firms with foreign exposures.

Features of Global Companion Plus+ include:

-- Primary Foreign Voluntary Workers Compensation: Protects employees who are working outside of their home countries.
-- Financial Interest: Provides a separate $1 million limit for U.S.-based companies as an extra layer of protection when an eligible foreign subsidiary suffers a covered loss.
-- Global Panel Counsel Service: Helps businesses in need of legal assistance abroad find in-country representation experienced in local regulations and languages.
-- Emergency Evacuation Coverage: Offsets the cost of employees who must evacuate while abroad. This now includes coverage for natural disasters, political unrest and endemic disease.

"Even if a business does not have a physical foreign footprint, having international customers, worldwide vendors or employees who occasionally travel to different countries could create exposures that may not be covered by a typical domestic business insurance policy," said Tony Giannone, Vice President of the Multinational Accounts Practice at Travelers. "We have updated our Global Companion Plus+ product to include a more robust offering that fills coverage gaps for our customers who could experience claims or lawsuits outside of the U.S."

Travelers provides global coverage in conjunction with its strategic alliances in the International Network of Insurance (INI), which includes major international insurance companies from more than 150 countries. As the INI’s exclusive U.S. insurer, Travelers is able to offer customers access to experts around the world who have a deep understanding of local laws, regulations, customs and services, including specialized local claim professionals coordinated through Travelers’ Global Claim team.

INI Partners are independent insurers as well as experienced leaders within their respective markets. Each network partner is approved by the INI Board of Directors and follows the same contractual membership obligations and service guideless worldwide. Partners carefully picked based on defined criteria such as: financial strength, servicing capabilities and experience and claims handling expertise.

To learn more about Global Companion Plus+, visit Travelers.com/GlobalSolutions ...