Business Insurance reports that most employers invested in providing sanitizing stations, increasing deep cleaning of common areas and hanging signage to educate workers on COVID-19 prevention and hygiene, according to a study conducted by the National Safety Council released Friday.
National Safety Council Itasca, Illinois-based NSC researchers surveyed 334 safety and health decision-makers for organizations with at least 250 employees across the U.S. to determine what safety practices the companies were implementing, how much they were spending on COVID-19 prevention and what effect those safety practices were having on productivity, performance and the spread of the virus.
The researchers surveyed employers primarily in manufacturing, construction, retail and office operations, as well as other industries, between July 14, and Aug. 4, finding that companies spent on average slightly more than $5,000 per employee on safety practices, which ranged from making remote work possible to providing personal protective equipment and hand sanitizer.
Among the most common safety practices adopted by employers was offering hand sanitizers throughout the facilities (80%), requiring face masks/shields or other personal protective equipment (75%) and requiring operators to sanitize work surfaces, machines, stations and tools at the beginning and/or end of each shift (72%), the study revealed.
More than three-quarters of surveyed employers also increased the frequency of deep cleaning (71%), added COVID-19 educational signage (70%), created employee self-reporting symptom and positive screening protocols (69%) and implemented remote working for non-essential employees (69%).
Of the industries, retailers were the most likely to use temperature screening (70%) and spend the most per employee on COVID-19 prevention, followed by educational services and health care and social services.
At the time of the survey, employers in construction reported the highest number of confirmed COVID-19 cases among workers, followed by retail trade and educational services ...
National Safety Council Itasca, Illinois-based NSC researchers surveyed 334 safety and health decision-makers for organizations with at least 250 employees across the U.S. to determine what safety practices the companies were implementing, how much they were spending on COVID-19 prevention and what effect those safety practices were having on productivity, performance and the spread of the virus.
The researchers surveyed employers primarily in manufacturing, construction, retail and office operations, as well as other industries, between July 14, and Aug. 4, finding that companies spent on average slightly more than $5,000 per employee on safety practices, which ranged from making remote work possible to providing personal protective equipment and hand sanitizer.
Among the most common safety practices adopted by employers was offering hand sanitizers throughout the facilities (80%), requiring face masks/shields or other personal protective equipment (75%) and requiring operators to sanitize work surfaces, machines, stations and tools at the beginning and/or end of each shift (72%), the study revealed.
More than three-quarters of surveyed employers also increased the frequency of deep cleaning (71%), added COVID-19 educational signage (70%), created employee self-reporting symptom and positive screening protocols (69%) and implemented remote working for non-essential employees (69%).
Of the industries, retailers were the most likely to use temperature screening (70%) and spend the most per employee on COVID-19 prevention, followed by educational services and health care and social services.
At the time of the survey, employers in construction reported the highest number of confirmed COVID-19 cases among workers, followed by retail trade and educational services ...
Angela Stubblefield, 49, of Tacoma, Washington, was sentenced by U.S. District Judge Kimberly J. Mueller to two years and six months in prison and ordered to pay $219,871 in restitution for a disability benefits fraud and identity theft scheme.
According to court documents, between June 14, 2013, and May 1, 2017, Stubblefield and co-defendant Katherine Decker participated in a scheme to defraud the State of California by filing fraudulent claims for disability insurance benefits with the California Employment Development Department (EDD).
In furtherance of the scheme, Decker and Stubblefield used Decker’s position as an employee with the EDD to file fraudulent claims for disability benefits and to fraudulently extend existing disability claims, using the names and identities of real persons with and without their knowledge. In total, the conspiracy resulted in 15 fraudulent disability claims, resulting in a loss to the EDD of approximately $373,566.
Stubblefield was ordered to report to begin service of her sentence by Feb. 1, 2021. On Sept. 14, Stubblefield’s co-defendant Katherine Decker was sentenced by Judge Mueller to three years and seven months in prison for the disability benefits fraud and identity theft scheme.
"EDD employees rigorously work to protect the confidentiality of our claimant’s information and the integrity of the Disability Insurance program for Californians in need,” said EDD Director Sharon Hilliard. “We are grateful for the partnership of our federal and state partners in prosecuting any violator of that policy to the fullest extent of the law."
This case was the product of an investigation by EDD’s Investigation Division and the Federal Bureau of Investigation. Assistant U.S. Attorneys Shea J. Kenny and Amy S. Hitchcock prosecuted the case.
...
According to court documents, between June 14, 2013, and May 1, 2017, Stubblefield and co-defendant Katherine Decker participated in a scheme to defraud the State of California by filing fraudulent claims for disability insurance benefits with the California Employment Development Department (EDD).
In furtherance of the scheme, Decker and Stubblefield used Decker’s position as an employee with the EDD to file fraudulent claims for disability benefits and to fraudulently extend existing disability claims, using the names and identities of real persons with and without their knowledge. In total, the conspiracy resulted in 15 fraudulent disability claims, resulting in a loss to the EDD of approximately $373,566.
Stubblefield was ordered to report to begin service of her sentence by Feb. 1, 2021. On Sept. 14, Stubblefield’s co-defendant Katherine Decker was sentenced by Judge Mueller to three years and seven months in prison for the disability benefits fraud and identity theft scheme.
"EDD employees rigorously work to protect the confidentiality of our claimant’s information and the integrity of the Disability Insurance program for Californians in need,” said EDD Director Sharon Hilliard. “We are grateful for the partnership of our federal and state partners in prosecuting any violator of that policy to the fullest extent of the law."
This case was the product of an investigation by EDD’s Investigation Division and the Federal Bureau of Investigation. Assistant U.S. Attorneys Shea J. Kenny and Amy S. Hitchcock prosecuted the case.
...
The California workers’ compensation COVID-19 monthly claim count may have peaked in July, but the latest tally by the California Workers’ Compensation Institute shows that as of November 2, there have been 50,592 COVID-19 claims reported to the state Division of Workers’ Compensation so far this year - including 282 death claims.
That translates to 1 out of every 9 California job injury claims reported for accident year 2020.
The latest figures show that after climbing rapidly over the first 7 months of this year and hitting a record 14,453 claims in July, the number of COVID-19 workers’ compensation claims reported to the DWC began to dwindle. The updated count shows 6,710 claims with August injury dates, 3,779 claims with September injury dates, and 2,016 claims with October injury dates.
A significant number of claims from September and October could still be reported, but the initial claim counts from both these months were well below the early counts from June and July, so even accounting for the reporting lag associated with COVID-19 claims, those figures suggest a significant downtrend.
CWCI now projects that there could ultimately be 15,786 COVID-19 claims with July injury dates, 6,910 claims with August injury dates, 4,535 claims with September injury dates, and 5,242 claims with October injury dates, which puts the projected number of COVID-19 claims for the first 10 months of 2020 at 57,833.
Notably, denial rates for COVID-19 claims have stabilized within a narrow range, holding between 28.7 percent and 31.3 percent from April through August, while denial data on September and October claims is still too green for analysis as many of those claims remain under investigation.
The distribution by industry shows that COVID-19 claims remain heavily concentrated among a small number of industry sectors, with more than three quarters of the claims from the first 10 months of this year involving workers in health care (37.1 percent); public safety/government (15.0 percent); manufacturing (8.3 percent); retail (7.9 percent); transportation (5.1 percent), and food service (4.4 percent).
The data on claims reported through October is included in the latest update to CWCI’s COVID-19 and Non-COVID-19 Interactive Claim Application, an online tool that integrates data from CWCI, the DWC, and the Bureau of Labor and Statistics.
CWCI updates its COVID-19/Non-COVID 19 data app with new data every two weeks and plans to expand its features as more data on claim type and systemwide costs become available.
The application is available to the public ...
That translates to 1 out of every 9 California job injury claims reported for accident year 2020.
The latest figures show that after climbing rapidly over the first 7 months of this year and hitting a record 14,453 claims in July, the number of COVID-19 workers’ compensation claims reported to the DWC began to dwindle. The updated count shows 6,710 claims with August injury dates, 3,779 claims with September injury dates, and 2,016 claims with October injury dates.
A significant number of claims from September and October could still be reported, but the initial claim counts from both these months were well below the early counts from June and July, so even accounting for the reporting lag associated with COVID-19 claims, those figures suggest a significant downtrend.
CWCI now projects that there could ultimately be 15,786 COVID-19 claims with July injury dates, 6,910 claims with August injury dates, 4,535 claims with September injury dates, and 5,242 claims with October injury dates, which puts the projected number of COVID-19 claims for the first 10 months of 2020 at 57,833.
Notably, denial rates for COVID-19 claims have stabilized within a narrow range, holding between 28.7 percent and 31.3 percent from April through August, while denial data on September and October claims is still too green for analysis as many of those claims remain under investigation.
The distribution by industry shows that COVID-19 claims remain heavily concentrated among a small number of industry sectors, with more than three quarters of the claims from the first 10 months of this year involving workers in health care (37.1 percent); public safety/government (15.0 percent); manufacturing (8.3 percent); retail (7.9 percent); transportation (5.1 percent), and food service (4.4 percent).
The data on claims reported through October is included in the latest update to CWCI’s COVID-19 and Non-COVID-19 Interactive Claim Application, an online tool that integrates data from CWCI, the DWC, and the Bureau of Labor and Statistics.
CWCI updates its COVID-19/Non-COVID 19 data app with new data every two weeks and plans to expand its features as more data on claim type and systemwide costs become available.
The application is available to the public ...
Pfizer and its collaborator BioNTech released early study results Monday indicating that their vaccine, BNT162b2, prevented more than 90% of infections with the virus that causes COVID-19. This conclusion was based on the first interim efficacy analysis conducted on November 8, 2020 by an external, independent Data Monitoring Committee (DMC) from the Phase 3 clinical study.
Details of the announcement include:
-- The vaccine candidate was found to be more than 90% effective in preventing COVID-19 in participants without evidence of prior SARS-CoV-2 infection in the first interim efficacy analysis.
-- The analysis evaluated 94 confirmed cases of COVID-19 in trial participants.
-- The study enrolled 43,538 participants, with 42% having diverse backgrounds, and no serious safety concerns have been observed; Safety and additional efficacy data continue to be collected.
-- Submission for Emergency Use Authorization to the U.S. Food and Drug Administration is planned for soon after the required safety milestone is achieved, which is currently expected to occur in the third week of November.
-- The clinical trial will continue through to final analysis at 164 confirmed cases in order to collect further data and characterize the vaccine candidate’s performance against other study endpoints.
Pfizer and BioNTech are continuing to accumulate safety data and currently estimate that a median of two months of safety data following the second (and final) dose of the vaccine candidate - the amount of safety data specified by the FDA in its guidance for potential Emergency Use Authorization - will be available by the third week of November.
Additionally, participants will continue to be monitored for long-term protection and safety for an additional two years after their second dose.
Dr. Albert Bourla, Pfizer Chairman and CEO said "We are reaching this critical milestone in our vaccine development program at a time when the world needs it most with infection rates setting new records, hospitals nearing over-capacity and economies struggling to reopen. With today’s news, we are a significant step closer to providing people around the world with a much-needed breakthrough."
Along with the efficacy data generated from the clinical trial, Pfizer and BioNTech are working to prepare the necessary safety and manufacturing data to submit to the FDA to demonstrate the safety and quality of the vaccine product produced.
Based on current projections it expects to produce globally up to 50 million vaccine doses in 2020 and up to 1.3 billion doses in 2021. Pfizer and BioNTech plan to submit data from the full Phase 3 trial for scientific peer-review publication ...
Details of the announcement include:
-- The vaccine candidate was found to be more than 90% effective in preventing COVID-19 in participants without evidence of prior SARS-CoV-2 infection in the first interim efficacy analysis.
-- The analysis evaluated 94 confirmed cases of COVID-19 in trial participants.
-- The study enrolled 43,538 participants, with 42% having diverse backgrounds, and no serious safety concerns have been observed; Safety and additional efficacy data continue to be collected.
-- Submission for Emergency Use Authorization to the U.S. Food and Drug Administration is planned for soon after the required safety milestone is achieved, which is currently expected to occur in the third week of November.
-- The clinical trial will continue through to final analysis at 164 confirmed cases in order to collect further data and characterize the vaccine candidate’s performance against other study endpoints.
Pfizer and BioNTech are continuing to accumulate safety data and currently estimate that a median of two months of safety data following the second (and final) dose of the vaccine candidate - the amount of safety data specified by the FDA in its guidance for potential Emergency Use Authorization - will be available by the third week of November.
Additionally, participants will continue to be monitored for long-term protection and safety for an additional two years after their second dose.
Dr. Albert Bourla, Pfizer Chairman and CEO said "We are reaching this critical milestone in our vaccine development program at a time when the world needs it most with infection rates setting new records, hospitals nearing over-capacity and economies struggling to reopen. With today’s news, we are a significant step closer to providing people around the world with a much-needed breakthrough."
Along with the efficacy data generated from the clinical trial, Pfizer and BioNTech are working to prepare the necessary safety and manufacturing data to submit to the FDA to demonstrate the safety and quality of the vaccine product produced.
Based on current projections it expects to produce globally up to 50 million vaccine doses in 2020 and up to 1.3 billion doses in 2021. Pfizer and BioNTech plan to submit data from the full Phase 3 trial for scientific peer-review publication ...
The Division of Workers’ Compensation has posted the 2019 DWC Audit Unit annual report on its website.
The Audit Unit annual report provides information on how claims administrators audited by the DWC performed and includes the Administrative Director’s ranking report for audits conducted in calendar year 2019. Out of the 40 companies ranked in this audit, congratulations to the following for ranking in the top 5 companies.
1. Sierra Pacific Industries/Anderson.
2. Northern California Special District Authority/Elk Grove.
3. Association of California Water Agencies/Joint Powers Ins. Authority/Roseville.
4. Applied Risk Services, Inc./Omaha, NE.
5. Acclamation Insurance Management Services/Fresno.
The Audit Unit annual report details the results of audits conducted in 2019 and provides the name and location of each insurer, self-insured employer, and third-party administrator audited during that time.
This report to the Legislature summarizes audits conducted in accordance with Labor Code sections 129 and 129.5 to assure that injured workers, and their dependents in the event of their death, are provided with all benefits due them in an expeditious manner. The audit findings, by law, must detail the number of files audited, the number and type of violations cited, and the amount of an undisputed compensation found due and unpaid to the injured worker.
The DWC Audit & Enforcement Unit completed 48 audits, of which 38 were routinely selected for PAR. In addition, another 10 audits were selected, of which 2 were target audits based on the failure of a prior audit, and 8 audits were based on credible referrals and/or complaints filed with the Audit Unit. The PAR audit subjects consisted of 16 insurance companies, 9 self-administered/self-insured employers, 22 third-party administrators (TPA), and 2 insurance companies/third-party administrators that combined claims-adjusting locations.
Performance of insurers, self-insured employers, and third party administrators subject to profile audit review and full compliance audit is rated in accordance with the performance standards set annually by the Administrative Director.
The DWC Administrative Director’s 2019 Audit Ranking Report lists, in ascending order by performance rating, the administrators audited in calendar year 2019 ...
The Audit Unit annual report provides information on how claims administrators audited by the DWC performed and includes the Administrative Director’s ranking report for audits conducted in calendar year 2019. Out of the 40 companies ranked in this audit, congratulations to the following for ranking in the top 5 companies.
1. Sierra Pacific Industries/Anderson.
2. Northern California Special District Authority/Elk Grove.
3. Association of California Water Agencies/Joint Powers Ins. Authority/Roseville.
4. Applied Risk Services, Inc./Omaha, NE.
5. Acclamation Insurance Management Services/Fresno.
The Audit Unit annual report details the results of audits conducted in 2019 and provides the name and location of each insurer, self-insured employer, and third-party administrator audited during that time.
This report to the Legislature summarizes audits conducted in accordance with Labor Code sections 129 and 129.5 to assure that injured workers, and their dependents in the event of their death, are provided with all benefits due them in an expeditious manner. The audit findings, by law, must detail the number of files audited, the number and type of violations cited, and the amount of an undisputed compensation found due and unpaid to the injured worker.
The DWC Audit & Enforcement Unit completed 48 audits, of which 38 were routinely selected for PAR. In addition, another 10 audits were selected, of which 2 were target audits based on the failure of a prior audit, and 8 audits were based on credible referrals and/or complaints filed with the Audit Unit. The PAR audit subjects consisted of 16 insurance companies, 9 self-administered/self-insured employers, 22 third-party administrators (TPA), and 2 insurance companies/third-party administrators that combined claims-adjusting locations.
Performance of insurers, self-insured employers, and third party administrators subject to profile audit review and full compliance audit is rated in accordance with the performance standards set annually by the Administrative Director.
The DWC Administrative Director’s 2019 Audit Ranking Report lists, in ascending order by performance rating, the administrators audited in calendar year 2019 ...
The Workers' Compensation Insurance Rating Bureau has just published its 2020 Geo Study - A Report on California Regional Differences. There are sharp differences in cost characteristics across regions of the state. This report highlights those differences.
Key findings include:
-- Even after controlling for regional differences in wages and industry mix, indemnity claim frequency is significantly higher in the Los Angeles (LA) Basin and significantly lower in the San Francisco Bay Area.
-- Regional differences in indemnity claim frequency have been fairly consistent over time and across industries. During all available years, the LA/Long Beach region has had the highest frequency, and the Peninsula/Silicon Valley region has had the lowest. The difference between these regions has grown over time. Since 2013, the largest improvement in relative indemnity claim frequency is in the Fresno/Madera region, and the greatest deterioration is in the Imperial/Riverside and the San Luis Obispo (SLO)/Santa Barbara regions.
-- Pharmaceutical costs throughout the state have dropped dramatically over the last several years, and the prevalence of opioid prescriptions for claims with pharmaceutical payments has also dropped dramatically. The largest decreases in pharmaceutical costs have occurred in Southern California regions, which had the highest pharmaceutical spending at the beginning of the study period. This has decreased the differences in pharmaceutical costs across regions over time.
-- The share of cumulative trauma claims as a percent of all claims is much higher in the LA Basin than in other parts of the state, and that gap has generally widened over time.
-- Medical-legal costs are significantly higher in the LA Basin and Santa Monica/San Fernando Valley regions than in the remainder of the state.
-- Paid allocated loss adjustment expenses (ALAE) are significantly higher in Southern California regions.
-- The share of open indemnity claims has decreased substantially in all regions since 2013. The largest decreases have been in the LA Basin regions that had the highest initial open indemnity claim shares. These changes have narrowed regional differences over time.
-- The share of indemnity claims with incurred costs greater than $250,000 at third report level is higher in regions that tend to have lower indemnity frequency.
-- The share of total claims that arise out of exposure to COVID-19 is higher in regions with lower relative indemnity frequency ...
Key findings include:
-- Even after controlling for regional differences in wages and industry mix, indemnity claim frequency is significantly higher in the Los Angeles (LA) Basin and significantly lower in the San Francisco Bay Area.
-- Regional differences in indemnity claim frequency have been fairly consistent over time and across industries. During all available years, the LA/Long Beach region has had the highest frequency, and the Peninsula/Silicon Valley region has had the lowest. The difference between these regions has grown over time. Since 2013, the largest improvement in relative indemnity claim frequency is in the Fresno/Madera region, and the greatest deterioration is in the Imperial/Riverside and the San Luis Obispo (SLO)/Santa Barbara regions.
-- Pharmaceutical costs throughout the state have dropped dramatically over the last several years, and the prevalence of opioid prescriptions for claims with pharmaceutical payments has also dropped dramatically. The largest decreases in pharmaceutical costs have occurred in Southern California regions, which had the highest pharmaceutical spending at the beginning of the study period. This has decreased the differences in pharmaceutical costs across regions over time.
-- The share of cumulative trauma claims as a percent of all claims is much higher in the LA Basin than in other parts of the state, and that gap has generally widened over time.
-- Medical-legal costs are significantly higher in the LA Basin and Santa Monica/San Fernando Valley regions than in the remainder of the state.
-- Paid allocated loss adjustment expenses (ALAE) are significantly higher in Southern California regions.
-- The share of open indemnity claims has decreased substantially in all regions since 2013. The largest decreases have been in the LA Basin regions that had the highest initial open indemnity claim shares. These changes have narrowed regional differences over time.
-- The share of indemnity claims with incurred costs greater than $250,000 at third report level is higher in regions that tend to have lower indemnity frequency.
-- The share of total claims that arise out of exposure to COVID-19 is higher in regions with lower relative indemnity frequency ...
An Inglewood woman and her mother-in-law, who both ran a South Los Angeles drug and alcohol abuse treatment program, each pleaded guilty to a health care fraud charge for fraudulently submitting more than $500,000 in claims for services that did not qualify for reimbursement or were never provided.
Mesbel Mohamoud, 47, and her mother-in-law, Erlinda Abella, 66, also of Inglewood, pleaded guilty to one count of health care fraud in separate hearings before United States District Judge Philip S. Gutierrez.
Mohamoud was the owner and executive director of The New You Center Inc. (TNYC), located in the Vermont Knolls neighborhood of South Los Angeles. Abella, who co-founded TNYC with Mohamoud in 2005, was the company’s program director. TNYC had contracts to provide medically necessary substance abuse treatment services through the Drug Medi-Cal program to adults and teenagers in Los Angeles County.
According to Mohamoud’s and Abella’s plea agreements, from January 2009 to December 2015, TNYC submitted false and fraudulent bills for counseling sessions that were not conducted at all, were not conducted at authorized locations, or did not comply with Drug Medi-Cal regulations regarding the length of sessions or the number of clients.
Mohamoud and Abella also allegedly caused TNYC to bill for clients who did not have a substance abuse problem, to falsify documents related to services supposedly provided to clients, and to forge client signatures on documents such as sign-in sheets.
For example, in September 2013, TNYC submitted a fraudulent claim for Medi-Cal reimbursement in the amount of $62.15 for a three-hour counseling session for a client on August 17, 2013 – the same day when the client was hospitalized and did not receive any counseling from TNYC.
In court documents, Mohamoud further admitted she knew that among the acts Abella directed TNYC counselors to engage in included enrolling clients in TNYC’s substance abuse treatment program even if the clients had used drugs or alcohol only occasionally or even just once.
Mohamoud and Abella admitted that TNYC submitted approximately $527,313 in false and fraudulent claims for group and individual substance abuse counseling services and was paid $260,101 on those claims.
Judge Gutierrez scheduled a January 25, 2021 sentencing hearing for Abella and a February 8, 2021 sentencing hearing for Mohamoud, at which time each of them will face a statutory maximum sentence of 10 years in prison.
The FBI, the California Department of Justice, Bureau of Medi-Cal Fraud and Elder Abuse, and the U.S. Department of Health and Human Services, Office of Inspector General investigated this matter. Assistant United States Attorney Cathy J. Ostiller of the Major Frauds Section is prosecuting this case ...
Mesbel Mohamoud, 47, and her mother-in-law, Erlinda Abella, 66, also of Inglewood, pleaded guilty to one count of health care fraud in separate hearings before United States District Judge Philip S. Gutierrez.
Mohamoud was the owner and executive director of The New You Center Inc. (TNYC), located in the Vermont Knolls neighborhood of South Los Angeles. Abella, who co-founded TNYC with Mohamoud in 2005, was the company’s program director. TNYC had contracts to provide medically necessary substance abuse treatment services through the Drug Medi-Cal program to adults and teenagers in Los Angeles County.
According to Mohamoud’s and Abella’s plea agreements, from January 2009 to December 2015, TNYC submitted false and fraudulent bills for counseling sessions that were not conducted at all, were not conducted at authorized locations, or did not comply with Drug Medi-Cal regulations regarding the length of sessions or the number of clients.
Mohamoud and Abella also allegedly caused TNYC to bill for clients who did not have a substance abuse problem, to falsify documents related to services supposedly provided to clients, and to forge client signatures on documents such as sign-in sheets.
For example, in September 2013, TNYC submitted a fraudulent claim for Medi-Cal reimbursement in the amount of $62.15 for a three-hour counseling session for a client on August 17, 2013 – the same day when the client was hospitalized and did not receive any counseling from TNYC.
In court documents, Mohamoud further admitted she knew that among the acts Abella directed TNYC counselors to engage in included enrolling clients in TNYC’s substance abuse treatment program even if the clients had used drugs or alcohol only occasionally or even just once.
Mohamoud and Abella admitted that TNYC submitted approximately $527,313 in false and fraudulent claims for group and individual substance abuse counseling services and was paid $260,101 on those claims.
Judge Gutierrez scheduled a January 25, 2021 sentencing hearing for Abella and a February 8, 2021 sentencing hearing for Mohamoud, at which time each of them will face a statutory maximum sentence of 10 years in prison.
The FBI, the California Department of Justice, Bureau of Medi-Cal Fraud and Elder Abuse, and the U.S. Department of Health and Human Services, Office of Inspector General investigated this matter. Assistant United States Attorney Cathy J. Ostiller of the Major Frauds Section is prosecuting this case ...
A Canoga Park-based company that sells home medical equipment has paid $565,873 to resolve allegations that it knowingly submitted false claims to federal health care programs for medically unnecessary medical supplies and supplies never delivered to patients.
Valley Home Medical Supply, Inc., which provides medical supplies and durable medical equipment, paid the settlement as part of an agreement that resolves a "whistleblower" lawsuit that alleged the company defrauded the Medicare and TRICARE programs from July 2006 until May 2013. With the payment of the settlement, United States District Judge Dale S. Fischer today dismissed the lawsuit.
Valley Home Medical Supply’s former president and chief executive officer, Kenneth Greenlinger, 75, of Oxnard, pleaded guilty in May 2017 to two counts of health care fraud and served an eight-month federal prison sentence. In the criminal case, Greenlinger was ordered to pay restitution of $1,072,618.
Kari Kitamura, a former employee of Valley Home Medical Supply, filed the civil lawsuit, United States ex rel. Kitamura v. Valley Home Medical Supply, CV12-11036 DSF(AGRx), in 2012 in United States District Court in Los Angeles. The United States elected to intervene in the lawsuit in 2017.
Ms. Kitamura filed the lawsuit under the qui tam - or whistleblower - provisions of the False Claims Act, which permit private parties to sue on behalf of the United States and to receive a share of any recovery. As a result of the settlement, Ms. Kitamura will receive $124,492, which equals 22 percent of the settlement proceeds. Valley Home Medical Supply will also pay Ms. Kitamura $80,000 for attorney’s fees.
This case was handled by Assistant United States Attorney Lisa A. Palombo of the Civil Fraud Section, who worked closely with the Federal Bureau of Investigation and the U.S. Department of Health and Human Services - Office of Inspector General ...
Valley Home Medical Supply, Inc., which provides medical supplies and durable medical equipment, paid the settlement as part of an agreement that resolves a "whistleblower" lawsuit that alleged the company defrauded the Medicare and TRICARE programs from July 2006 until May 2013. With the payment of the settlement, United States District Judge Dale S. Fischer today dismissed the lawsuit.
Valley Home Medical Supply’s former president and chief executive officer, Kenneth Greenlinger, 75, of Oxnard, pleaded guilty in May 2017 to two counts of health care fraud and served an eight-month federal prison sentence. In the criminal case, Greenlinger was ordered to pay restitution of $1,072,618.
Kari Kitamura, a former employee of Valley Home Medical Supply, filed the civil lawsuit, United States ex rel. Kitamura v. Valley Home Medical Supply, CV12-11036 DSF(AGRx), in 2012 in United States District Court in Los Angeles. The United States elected to intervene in the lawsuit in 2017.
Ms. Kitamura filed the lawsuit under the qui tam - or whistleblower - provisions of the False Claims Act, which permit private parties to sue on behalf of the United States and to receive a share of any recovery. As a result of the settlement, Ms. Kitamura will receive $124,492, which equals 22 percent of the settlement proceeds. Valley Home Medical Supply will also pay Ms. Kitamura $80,000 for attorney’s fees.
This case was handled by Assistant United States Attorney Lisa A. Palombo of the Civil Fraud Section, who worked closely with the Federal Bureau of Investigation and the U.S. Department of Health and Human Services - Office of Inspector General ...
California voters Tuesday embraced a first of its kind ballot measure that allows app-based transportation and delivery drivers to remain classified as independent contractors, despite a state law known as AB5 that went into effect in January and says otherwise.
Companies Uber and Lyft, as well as DoorDash, Uber’s Postmates, and Instacart, all at the center of a $200 million plus push for an exemption to the law, can celebrate a victory that’s expected to save the gig economy firms from major costs of doing business in the state.
The ballot measure was among the last-ditch scenarios under which the companies would be allowed to keep their workers classified as independent contractors. A California appellate court affirmed a lower court’s ruling last month mandating that the workers be reclassified as employees based on AB5.
As written the new law applies to all app-based transportation (rideshare) and delivery companies. Drivers will remain classified as "independent contractors," not "employees," unless the company sets drivers’ hours, requires acceptance of specific ride or delivery requests, or restricts working for other companies.
The new law does not however apply to any other business or trade within what is generically known as the gig economy.
Proposition 22 does have some benefits for workers: The ballot measure entitles the gig-based transportation workers to some benefits typically not available to independent contractors.
Though the workers remain independent contractors in name, allowing the companies to avoid paying payroll taxes and providing full legal protections typically available to employees, workers will become eligible for limited employee-style benefits including a minimum wage for certain working hours equal to 120% of the state’s $13 per hour minimum (going up to $14 in 2021).
Workers will also be given health care stipends to spend toward private employer-provided healthcare insurance, in addition to $1 million in insurance coverage to cover on the job accidents and illness, as well as lost wages.
Prop 22 would be difficult to undo. A change to the law would require a seven-eighths majority in the California legislature.
Results of California’s initiative have been billed as likely to have a ripple effect beyond the gig economy, and across state lines. Rebecca Henderson, CEO, Global Businesses and Executive Board Member at talent solutions company Randstad, says she is working closely with companies, who are reassessing the health benefits or sick leave they provide to independent contractors, as they look to maintain workers in a rapidly changing environment ...
Companies Uber and Lyft, as well as DoorDash, Uber’s Postmates, and Instacart, all at the center of a $200 million plus push for an exemption to the law, can celebrate a victory that’s expected to save the gig economy firms from major costs of doing business in the state.
The ballot measure was among the last-ditch scenarios under which the companies would be allowed to keep their workers classified as independent contractors. A California appellate court affirmed a lower court’s ruling last month mandating that the workers be reclassified as employees based on AB5.
As written the new law applies to all app-based transportation (rideshare) and delivery companies. Drivers will remain classified as "independent contractors," not "employees," unless the company sets drivers’ hours, requires acceptance of specific ride or delivery requests, or restricts working for other companies.
The new law does not however apply to any other business or trade within what is generically known as the gig economy.
Proposition 22 does have some benefits for workers: The ballot measure entitles the gig-based transportation workers to some benefits typically not available to independent contractors.
Though the workers remain independent contractors in name, allowing the companies to avoid paying payroll taxes and providing full legal protections typically available to employees, workers will become eligible for limited employee-style benefits including a minimum wage for certain working hours equal to 120% of the state’s $13 per hour minimum (going up to $14 in 2021).
Workers will also be given health care stipends to spend toward private employer-provided healthcare insurance, in addition to $1 million in insurance coverage to cover on the job accidents and illness, as well as lost wages.
Prop 22 would be difficult to undo. A change to the law would require a seven-eighths majority in the California legislature.
Results of California’s initiative have been billed as likely to have a ripple effect beyond the gig economy, and across state lines. Rebecca Henderson, CEO, Global Businesses and Executive Board Member at talent solutions company Randstad, says she is working closely with companies, who are reassessing the health benefits or sick leave they provide to independent contractors, as they look to maintain workers in a rapidly changing environment ...
Zurich American Insurance Company of Illinois issued a workers’ compensation policy to the former parent of Accuire, LLC.
Accuire separated from its parent company and sought a short-term workers’ compensation policy from Zurich based on the experience modification rating it shared with its former parent. As payment under that agreement, Zurich charged Accuire an initial amount, which the parties agree constituted an estimate, subject to adjustment based on a payroll audit to be completed at the conclusion of the policy period.
Shortly after, the California Workers’ Compensation Insurance Rating Bureau increased Accuire’s experience modification rating and Zurich issued an endorsement reflecting this change to Accuire.
Zurich conducted its payroll audit and provided the results to Accuire. Based on the audit, Zurich demanded payment of an additional premium totaling $491,614. Accuire refused to pay because, notwithstanding any endorsements or rate changes, it claimed that Zurich had orally assured Accuire that its rates and costs would remain the same as they had been under the policy covering its former parent.
Zurich then sued Accuire for breach of contract and moved for summary judgment. Accuire failed to timely oppose the summary judgment motion under the district court’s local rules. A week after the local rule deadline passed, Accuire filed an ex parte application for leave to file a late opposition and attached its proposed response to the motion. The district court denied the application in a minute order and then granted Zurich’s motion for summary judgment.
Accuire appealed the summary judgment. The 9th Circuit Court of Appeals affirmed the summary judgment in the unpublished case of Zurich American Insurance Company of Illinois v Accuire LLC.
The district court’s order granting summary judgment analyzed and correctly rejected on the merits the defenses raised to enforcement of the contract.
Specifically, it held that under California law, Accuire’s parol evidence of prior assurances about rates and costs is inadmissible to contradict the terms of a fully integrated agreement like the one between Accuire and Zurich.
Moreover, it found similarly meritless Accuire’s claims that it cannot be bound because its representative failed to read the contract before agreeing to it, or that Zurich improperly modified rates by endorsement.
In sum, none of the purported disputes of material fact offered by Accuire on appeal precluded the district court from granting summary judgment ...
Accuire separated from its parent company and sought a short-term workers’ compensation policy from Zurich based on the experience modification rating it shared with its former parent. As payment under that agreement, Zurich charged Accuire an initial amount, which the parties agree constituted an estimate, subject to adjustment based on a payroll audit to be completed at the conclusion of the policy period.
Shortly after, the California Workers’ Compensation Insurance Rating Bureau increased Accuire’s experience modification rating and Zurich issued an endorsement reflecting this change to Accuire.
Zurich conducted its payroll audit and provided the results to Accuire. Based on the audit, Zurich demanded payment of an additional premium totaling $491,614. Accuire refused to pay because, notwithstanding any endorsements or rate changes, it claimed that Zurich had orally assured Accuire that its rates and costs would remain the same as they had been under the policy covering its former parent.
Zurich then sued Accuire for breach of contract and moved for summary judgment. Accuire failed to timely oppose the summary judgment motion under the district court’s local rules. A week after the local rule deadline passed, Accuire filed an ex parte application for leave to file a late opposition and attached its proposed response to the motion. The district court denied the application in a minute order and then granted Zurich’s motion for summary judgment.
Accuire appealed the summary judgment. The 9th Circuit Court of Appeals affirmed the summary judgment in the unpublished case of Zurich American Insurance Company of Illinois v Accuire LLC.
The district court’s order granting summary judgment analyzed and correctly rejected on the merits the defenses raised to enforcement of the contract.
Specifically, it held that under California law, Accuire’s parol evidence of prior assurances about rates and costs is inadmissible to contradict the terms of a fully integrated agreement like the one between Accuire and Zurich.
Moreover, it found similarly meritless Accuire’s claims that it cannot be bound because its representative failed to read the contract before agreeing to it, or that Zurich improperly modified rates by endorsement.
In sum, none of the purported disputes of material fact offered by Accuire on appeal precluded the district court from granting summary judgment ...
Memorial Health Services, a Fountain Valley-based non-profit health care organization, has agreed to pay more than $31.5 million to resolve allegations that it overbilled Medicaid for prescription medication purchased and reimbursed under a federal drug pricing program.
The settlement agreement is the result of a voluntary disclosure made in October 2019 by Memorial Health, which under the name MemorialCare Health System operates Long Beach Memorial Medical Center, Miller Children's and Women's Hospital, and Orange Coast Memorial Medical Center.
After an internal audit, Memorial Health determined that its hospitals and pharmacies overbilled the United States and California, which jointly fund Medicaid - known in California as Medi-Cal - a program that helps lower-income people with their medical costs.
According to the settlement agreement, from December 2016 to October 2019, Memorial Health improperly charged higher "usual and customary" costs, rather than lower "actual acquisition costs," as required under the 340B Drug Pricing Program. This federal program requires drug manufacturers to provide outpatient medication to eligible health care organizations at significantly reduced prices.
The overbilling allegedly resulted from Memorial Health billing for its usual costs following a federal court’s temporary stay of the implementation of the California law requiring 340B providers to bill Medi-Cal at actual acquisition cost rates. But once a court lifted the temporary ban, Memorial Health failed to implement actual acquisition cost pricing.
Memorial Health ultimately overbilled the United States and California $21,021,786 and the $31.5 million settlement represents 1.5 times the alleged overbilling, the agreement states. Memorial Health has agreed to pay the United States $12,613,071.60 and California $18,919,607.40 to resolve the allegations, bringing the total settlement amount to $31,532,679.
After making its voluntary disclosure, Memorial Health cooperated with the federal and state authorities’ investigation ...
The settlement agreement is the result of a voluntary disclosure made in October 2019 by Memorial Health, which under the name MemorialCare Health System operates Long Beach Memorial Medical Center, Miller Children's and Women's Hospital, and Orange Coast Memorial Medical Center.
After an internal audit, Memorial Health determined that its hospitals and pharmacies overbilled the United States and California, which jointly fund Medicaid - known in California as Medi-Cal - a program that helps lower-income people with their medical costs.
According to the settlement agreement, from December 2016 to October 2019, Memorial Health improperly charged higher "usual and customary" costs, rather than lower "actual acquisition costs," as required under the 340B Drug Pricing Program. This federal program requires drug manufacturers to provide outpatient medication to eligible health care organizations at significantly reduced prices.
The overbilling allegedly resulted from Memorial Health billing for its usual costs following a federal court’s temporary stay of the implementation of the California law requiring 340B providers to bill Medi-Cal at actual acquisition cost rates. But once a court lifted the temporary ban, Memorial Health failed to implement actual acquisition cost pricing.
Memorial Health ultimately overbilled the United States and California $21,021,786 and the $31.5 million settlement represents 1.5 times the alleged overbilling, the agreement states. Memorial Health has agreed to pay the United States $12,613,071.60 and California $18,919,607.40 to resolve the allegations, bringing the total settlement amount to $31,532,679.
After making its voluntary disclosure, Memorial Health cooperated with the federal and state authorities’ investigation ...
The Division of Workers’ Compensation announces that the 2021 minimum and maximum temporary total disability rates will increase on January 1, 2021. The minimum TTD rate will increase from $194.91 to $203.44 and the maximum TTD rate will increase from $1,299.43 to $1,356.31 per week.
Labor Code Section 4453(a) (10) requires the maximum and minimum weekly earnings upon which TTD is based be increased by an amount equal to percentage increase in the State Average Weekly Wage (SAWW) as compared to the prior year. The SAWW is defined as the average weekly wage paid to employees covered by unemployment insurance as reported by the U.S. Department of Labor for California for the 12 months ending March 31 in the year preceding the injury. In the 12 months ending March 31, 2020, the SAWW increased from $1,325 to $1,383—an increase of 4.3774 percent.
The calculation of the 2021 SAWW increase is as follows:
2021 SAWW - 2020 SAWW/2020 SAWW
$1,383-$1,325 = 58/1325 = 4.3774%
The calculation of 2021 minimum TTD rate for 2021 is as follows:
Minimum earnings for 2020 x SAWW increase x 2/3 = minimum TTD rate for 2021
292.36 x 1.043774 = $305.16 minimum TTD earnings x 2/3 =$203.44 minimum rate for 2021
The calculation of maximum TTD rate for 2021 is as follows:
Maximum earnings for 2020 x SAWW increase x 2/3 = maximum TTD rate for 2021
1949.15 x 1.043774 = $2,034.47 maximum TTD earnings x 2/3 = $1356.31 maximum rate
Under Labor Code Section 4659(c), workers with a date of injury on or after January 1, 2003 who receiving life pension (LP) or permanent total disability (PTD) benefits are also entitled to have their weekly LP or PTD rate adjusted based on the SAWW.
SAWW figures may be verified using the U.S. Department of Labor’s Unemployment Insurance Database ...
Labor Code Section 4453(a) (10) requires the maximum and minimum weekly earnings upon which TTD is based be increased by an amount equal to percentage increase in the State Average Weekly Wage (SAWW) as compared to the prior year. The SAWW is defined as the average weekly wage paid to employees covered by unemployment insurance as reported by the U.S. Department of Labor for California for the 12 months ending March 31 in the year preceding the injury. In the 12 months ending March 31, 2020, the SAWW increased from $1,325 to $1,383—an increase of 4.3774 percent.
The calculation of the 2021 SAWW increase is as follows:
2021 SAWW - 2020 SAWW/2020 SAWW
$1,383-$1,325 = 58/1325 = 4.3774%
The calculation of 2021 minimum TTD rate for 2021 is as follows:
Minimum earnings for 2020 x SAWW increase x 2/3 = minimum TTD rate for 2021
292.36 x 1.043774 = $305.16 minimum TTD earnings x 2/3 =$203.44 minimum rate for 2021
The calculation of maximum TTD rate for 2021 is as follows:
Maximum earnings for 2020 x SAWW increase x 2/3 = maximum TTD rate for 2021
1949.15 x 1.043774 = $2,034.47 maximum TTD earnings x 2/3 = $1356.31 maximum rate
Under Labor Code Section 4659(c), workers with a date of injury on or after January 1, 2003 who receiving life pension (LP) or permanent total disability (PTD) benefits are also entitled to have their weekly LP or PTD rate adjusted based on the SAWW.
SAWW figures may be verified using the U.S. Department of Labor’s Unemployment Insurance Database ...
A new study from the Workers Compensation Research Institute (WCRI) quantifies the 30-day and 90-day reoperation and readmission rates for workers’ compensation patients undergoing lumbar spine surgeries, and compares these rates with those for non-workers’ compensation patients reported by other studies.
The study, Reoperation & Readmission Rates for Workers’ Compensation Patients Undergoing Lumbar Surgery, also discusses the major types of reoperations and the main reasons for readmissions, examines medical payments per claim, and describes interstate variation in the prevalence of reoperation and readmission.
The following is a sample of the study’s major findings:
-- Seven and eight percent of workers’ compensation patients undergoing lumbar spine surgery had a reoperation and/or readmission within 30 and 90 days after their operation, respectively. These percentages are higher than reported in the literature for non-workers’ compensation patients.
-- Seventeen percent of patients were readmitted within 30 days of a fusion, largely for nonoperative reasons. This readmission rate was two to seven times higher than the rate for non-workers’ compensation patients reported in other studies. This was the primary driver of the higher 30-day all-cause readmission rate for discectomy/decompression and fusion groups combined in workers’ compensation patients compared with other patients.
-- There was considerable variation in the prevalence of reoperation and readmission across the study states. The percentages of lumbar spine surgery cases with reoperations and/or readmissions within two years ranged from about 1 in 10 workers’ compensation patients in North Carolina and Minnesota to more than 1 in 5 in California.
The study analyzes workers with low back pain who underwent either lumbar discectomy/decompression or lumbar fusion surgery in 18 states for injuries that arose between October 1, 2015, and September 30, 2016, and follows the postoperative experience for each case through March 31, 2018.
The 18 study states, which represent 61 percent of all workers’ compensation benefits paid nationwide, are Arkansas, California, Florida, Georgia, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Michigan, Minnesota, New Jersey, North Carolina, Pennsylvania, Tennessee, Texas, Virginia, and Wisconsin.
"Post-surgery readmissions and reoperations are the primary quality indicators being used by commercial, governmental, and a limited number of workers’ compensation payors in their value-based purchasing programs," said John Ruser, President and CEO of WCRI. "The study can help policymakers and other stakeholders shed light on the areas where quality improvement is most needed. It can also prove to be useful to patients as they consider treatment options."
For more information about this study or to download a copy, visit www.wcrinet.org ...
The study, Reoperation & Readmission Rates for Workers’ Compensation Patients Undergoing Lumbar Surgery, also discusses the major types of reoperations and the main reasons for readmissions, examines medical payments per claim, and describes interstate variation in the prevalence of reoperation and readmission.
The following is a sample of the study’s major findings:
-- Seven and eight percent of workers’ compensation patients undergoing lumbar spine surgery had a reoperation and/or readmission within 30 and 90 days after their operation, respectively. These percentages are higher than reported in the literature for non-workers’ compensation patients.
-- Seventeen percent of patients were readmitted within 30 days of a fusion, largely for nonoperative reasons. This readmission rate was two to seven times higher than the rate for non-workers’ compensation patients reported in other studies. This was the primary driver of the higher 30-day all-cause readmission rate for discectomy/decompression and fusion groups combined in workers’ compensation patients compared with other patients.
-- There was considerable variation in the prevalence of reoperation and readmission across the study states. The percentages of lumbar spine surgery cases with reoperations and/or readmissions within two years ranged from about 1 in 10 workers’ compensation patients in North Carolina and Minnesota to more than 1 in 5 in California.
The study analyzes workers with low back pain who underwent either lumbar discectomy/decompression or lumbar fusion surgery in 18 states for injuries that arose between October 1, 2015, and September 30, 2016, and follows the postoperative experience for each case through March 31, 2018.
The 18 study states, which represent 61 percent of all workers’ compensation benefits paid nationwide, are Arkansas, California, Florida, Georgia, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Michigan, Minnesota, New Jersey, North Carolina, Pennsylvania, Tennessee, Texas, Virginia, and Wisconsin.
"Post-surgery readmissions and reoperations are the primary quality indicators being used by commercial, governmental, and a limited number of workers’ compensation payors in their value-based purchasing programs," said John Ruser, President and CEO of WCRI. "The study can help policymakers and other stakeholders shed light on the areas where quality improvement is most needed. It can also prove to be useful to patients as they consider treatment options."
For more information about this study or to download a copy, visit www.wcrinet.org ...
Almirante Perez, 43, of Highland, was arraigned on multiple felony counts of insurance fraud and tax evasion after allegedly underreporting employees and wages in an attempt to reduce his businesses’ insurance premiums and payroll taxes by over $2.5 million.
Perez was the owner of Capital Janitorial Services, Cal Best Service Group Inc., Southern Pacific Janitorial Group and United Pacific Contractors Inc., from March 2013 to November 2018.
An investigation by the Department of Insurance revealed Perez failed to report employees and wages to his workers’ compensation insurance carrier and to the Employment Development Department (EDD). The investigation discovered $1,982,597 in underreported premium fraud and $609,430 in payroll taxes owed to the EDD.
It is further alleged, as to some of the counts, that the offenses alleged are related felonies, a material element of which is fraud and embezzlement, which involved a pattern of related felony conduct, and the pattern of related felony conduct involved the taking of, and resulted in the loss by Republic Underwriters Insurance Company, NorGuard Insurance Company, dba Atlas General Insurance Company, and Ohio Security Insurance Company of more than five hundred thousand dollars ($500,000).
These allegations subject Almirante Perez to the additional punishment provided for in Penal Code sections 186.11(a)(2), which is the aggravated white collar crime enhancement. White collar crime generally refers to non-violent crime, often involving professionals, for financial gain. White collar crime may involve small amounts of money or millions of dollars. The penalties for white collar crimes in California depend, in part, on the extent of the alleged crime.
The Insurance Commissioner said that "Legitimate businesses and California consumers pay the price when business owners cheat the system by illegally underreporting employees and wages."
Perez was arraigned on October 22, 2020, at San Bernardino County Superior Court and pleaded not guilty to all charges. The San Bernardino County District Attorney’s Office is prosecuting this case ...
Perez was the owner of Capital Janitorial Services, Cal Best Service Group Inc., Southern Pacific Janitorial Group and United Pacific Contractors Inc., from March 2013 to November 2018.
An investigation by the Department of Insurance revealed Perez failed to report employees and wages to his workers’ compensation insurance carrier and to the Employment Development Department (EDD). The investigation discovered $1,982,597 in underreported premium fraud and $609,430 in payroll taxes owed to the EDD.
It is further alleged, as to some of the counts, that the offenses alleged are related felonies, a material element of which is fraud and embezzlement, which involved a pattern of related felony conduct, and the pattern of related felony conduct involved the taking of, and resulted in the loss by Republic Underwriters Insurance Company, NorGuard Insurance Company, dba Atlas General Insurance Company, and Ohio Security Insurance Company of more than five hundred thousand dollars ($500,000).
These allegations subject Almirante Perez to the additional punishment provided for in Penal Code sections 186.11(a)(2), which is the aggravated white collar crime enhancement. White collar crime generally refers to non-violent crime, often involving professionals, for financial gain. White collar crime may involve small amounts of money or millions of dollars. The penalties for white collar crimes in California depend, in part, on the extent of the alleged crime.
The Insurance Commissioner said that "Legitimate businesses and California consumers pay the price when business owners cheat the system by illegally underreporting employees and wages."
Perez was arraigned on October 22, 2020, at San Bernardino County Superior Court and pleaded not guilty to all charges. The San Bernardino County District Attorney’s Office is prosecuting this case ...
The Division of Workers’ Compensation has issued a notice of public hearing for the amendment of the Medical-Legal Fee Schedule, which can be found at California Code of Regulations, title 8, sections 9793-9795.
The public hearing will be held via Zoom on Monday, December 14, 2020 at 10 a.m. Options for participation are at the bottom of this notice.
The proposed amendments to the medical-legal fee schedule include, but are not limited to, the following:
-- A 25% increase in the multiplier used for setting fees for evaluations.
-- Standardization of the fee that can be charged for a missed appointment.
-- Flat fees for comprehensive, follow-up, and supplemental medical-legal evaluations.
-- A single rate for review of medical records based upon the amount of pages reviewed.
-- A meet and confer requirement for records sent to the physician.
-- Elimination of complexity factors from the Medical-Legal Fee Schedule.
-- An increased modifier for reports dealing with psychiatric issues.
-- An increase in the hourly fee for medical-legal testimony.
The implementation of a predominantly fixed fee for all procedure billing codes is anticipated to reduce frictional costs. Moving to a flat-fee-based schedule and removing complexity factors is contemplated to reduce the incidence of disputes over billing.
The fee schedule was formulated after multiple stakeholder meetings where carriers, employers, physicians, and medical management companies were able to provide input. In addition, the proposed regulations were revised after review of the results of a 15-day comment period from a prior forum posting of the proposed regulations. The notice and text of regulations can be found at the proposed regulations page.
The proposed amendment to revise the Medical-Legal Fee Schedule is exempt from the rulemaking provisions of the Administrative Procedure Act. However, DWC is required under Labor Code sections 5307.3 and 5307.4 to have a 30-day public comment period, hold a public hearing, respond to all the comments received during the public comment period and publish the order adopting the new regulations online.
Members of the public may attend the public meeting as follows:
-- Computer: Join from PC, Mac, Linux, iOS or Android: https://dir-ca-gov.zoom.us/j/92474087436
-- Or Telephone Dial options: +1 253 215 8782 +1 301 715 8592 +1 312 626 6799 +1 346 248 7799 +1 669 900 6833 +1 929 205 6099 USA 1 (866) 434-5269 (US Toll Free) - Conference code: 956474
-- Find local AT&T Numbers: https://www.teleconference.att.com/servlet/glbAccess?process=1&accessNumber=2532158782&accessCode=956474
Members of the public may review and comment on the proposed regulations no later than December 15, 2020 ...
The public hearing will be held via Zoom on Monday, December 14, 2020 at 10 a.m. Options for participation are at the bottom of this notice.
The proposed amendments to the medical-legal fee schedule include, but are not limited to, the following:
-- A 25% increase in the multiplier used for setting fees for evaluations.
-- Standardization of the fee that can be charged for a missed appointment.
-- Flat fees for comprehensive, follow-up, and supplemental medical-legal evaluations.
-- A single rate for review of medical records based upon the amount of pages reviewed.
-- A meet and confer requirement for records sent to the physician.
-- Elimination of complexity factors from the Medical-Legal Fee Schedule.
-- An increased modifier for reports dealing with psychiatric issues.
-- An increase in the hourly fee for medical-legal testimony.
The implementation of a predominantly fixed fee for all procedure billing codes is anticipated to reduce frictional costs. Moving to a flat-fee-based schedule and removing complexity factors is contemplated to reduce the incidence of disputes over billing.
The fee schedule was formulated after multiple stakeholder meetings where carriers, employers, physicians, and medical management companies were able to provide input. In addition, the proposed regulations were revised after review of the results of a 15-day comment period from a prior forum posting of the proposed regulations. The notice and text of regulations can be found at the proposed regulations page.
The proposed amendment to revise the Medical-Legal Fee Schedule is exempt from the rulemaking provisions of the Administrative Procedure Act. However, DWC is required under Labor Code sections 5307.3 and 5307.4 to have a 30-day public comment period, hold a public hearing, respond to all the comments received during the public comment period and publish the order adopting the new regulations online.
Members of the public may attend the public meeting as follows:
-- Computer: Join from PC, Mac, Linux, iOS or Android: https://dir-ca-gov.zoom.us/j/92474087436
-- Or Telephone Dial options: +1 253 215 8782 +1 301 715 8592 +1 312 626 6799 +1 346 248 7799 +1 669 900 6833 +1 929 205 6099 USA 1 (866) 434-5269 (US Toll Free) - Conference code: 956474
-- Find local AT&T Numbers: https://www.teleconference.att.com/servlet/glbAccess?process=1&accessNumber=2532158782&accessCode=956474
Members of the public may review and comment on the proposed regulations no later than December 15, 2020 ...
Nimesh Shah, owner of Blue Star Learning, a technical training school in San Diego, was sentenced to 45 months in custody as a result of a multi-year scheme that defrauded the Department of Veterans Affairs out of almost $30 million in education benefits.
Shah was ordered to forfeit about $3 million and pay the VA more than $29 million in restitution. Shah’s wife Nidhi Shah, who was the vice president and director of education at the school, was sentenced to two years of probation as a result of lying to investigators in the course of the investigation into the school.
Shah took extraordinary efforts to deceive regulators from the Department of Veterans Affairs to ensure the school continued to receive VA funds.
Shah provided the VA with false documents, invented fake students and created fake student files. He provided spreadsheets with false employment information and fraudulent contact information for purported graduates of the school and their made up employers.
Eligible schools must be accredited yearly and as part of the process must show that graduates are successfully finding work in their field. To comply, Shah created fictional graduates and hired people overseas to pose as satisfied alumni with fake emails and phone numbers.
He purchased cellular telephones so that he and his employees could field VA regulator calls to purported employers of school graduates, and hired individuals overseas to pretend to be satisfied Blue Star Learning students in response to VA regulator emails.
In reality, the vast majority of actual graduates of the program were working in jobs not related to the training, prosecutors said.
As laid out in court records, Shah’s scheme appears to be one of the largest Post-9/11 G.I. Bill fraud cases that has been prosecuted around the country.
As a result of Shah’s fraud, the VA issued over $11 million in tuition payments to Blue Star Learning, and over $18 million in housing allowances and stipends. In total, as a result of Shah’s fraud, the VA lost $29,350,999 ...
Shah was ordered to forfeit about $3 million and pay the VA more than $29 million in restitution. Shah’s wife Nidhi Shah, who was the vice president and director of education at the school, was sentenced to two years of probation as a result of lying to investigators in the course of the investigation into the school.
Shah took extraordinary efforts to deceive regulators from the Department of Veterans Affairs to ensure the school continued to receive VA funds.
Shah provided the VA with false documents, invented fake students and created fake student files. He provided spreadsheets with false employment information and fraudulent contact information for purported graduates of the school and their made up employers.
Eligible schools must be accredited yearly and as part of the process must show that graduates are successfully finding work in their field. To comply, Shah created fictional graduates and hired people overseas to pose as satisfied alumni with fake emails and phone numbers.
He purchased cellular telephones so that he and his employees could field VA regulator calls to purported employers of school graduates, and hired individuals overseas to pretend to be satisfied Blue Star Learning students in response to VA regulator emails.
In reality, the vast majority of actual graduates of the program were working in jobs not related to the training, prosecutors said.
As laid out in court records, Shah’s scheme appears to be one of the largest Post-9/11 G.I. Bill fraud cases that has been prosecuted around the country.
As a result of Shah’s fraud, the VA issued over $11 million in tuition payments to Blue Star Learning, and over $18 million in housing allowances and stipends. In total, as a result of Shah’s fraud, the VA lost $29,350,999 ...
The Los Angeles County District Attorney’s Office announced that a chiropractor and a claims adjuster have been charged with conspiring to process false insurance claims for payment amounting to more than $1.6 million.
65 year old Agop Sarafian, the claims adjuster of La Crescenta, and 65 year old Shahe Kevork Topjian, the chiropractor of Granada Hills, each face one felony count of insurance fraud in case BA491001. Their arraignment will be scheduled at Department 30 of the Foltz Criminal Justice Center.
HIs office was located at 22030 Clarendon Street, Suite 111, in Woodland Hills. His NPI number is 1477817898 and was assigned on June 2012. The practitioner's primary taxonomy code is 111N00000X with California license number 21857.
Head Deputy Marc Beaart of the Healthcare Fraud Division said that the alleged insurance fraud occurred between June 8, 2007 and November 25, 2019. In November 2019, State Compensation Insurance Fund where Sarafian worked began an internal investigation before the California Department of Insurance and the Los Angeles County District Attorney’s Office became involved.
The pair is accused of defrauding State Fund by setting up fake workers’ compensation lien settlements to receive undeserved insurance payouts.
If convicted as charged, the defendants each face a maximum sentence of five years in county jail.
The case remains under investigation by the California Department of Insurance, Fraud Division ...
65 year old Agop Sarafian, the claims adjuster of La Crescenta, and 65 year old Shahe Kevork Topjian, the chiropractor of Granada Hills, each face one felony count of insurance fraud in case BA491001. Their arraignment will be scheduled at Department 30 of the Foltz Criminal Justice Center.
HIs office was located at 22030 Clarendon Street, Suite 111, in Woodland Hills. His NPI number is 1477817898 and was assigned on June 2012. The practitioner's primary taxonomy code is 111N00000X with California license number 21857.
Head Deputy Marc Beaart of the Healthcare Fraud Division said that the alleged insurance fraud occurred between June 8, 2007 and November 25, 2019. In November 2019, State Compensation Insurance Fund where Sarafian worked began an internal investigation before the California Department of Insurance and the Los Angeles County District Attorney’s Office became involved.
The pair is accused of defrauding State Fund by setting up fake workers’ compensation lien settlements to receive undeserved insurance payouts.
If convicted as charged, the defendants each face a maximum sentence of five years in county jail.
The case remains under investigation by the California Department of Insurance, Fraud Division ...
On September 22, 2020, the U.S. Department of Labor announced a proposed rule addressing how to determine whether a worker is an employee under the Fair Labor Standards Act (FLSA) or an independent contractor.
In this rulemaking, the Department proposes to:
-- Adopt an "economic reality" test to determine a worker’s status as an FLSA employee or an independent contractor. The test considers whether a worker is in business for themselves (independent contractor) or is economically dependent on a putative employer for work (employee);
-- Identify and explain two "core factors," specifically: the nature and degree of the worker’s control over the work; and the worker’s opportunity for profit or loss based on initiative and/or investment. These factors help determine if a worker is economically dependent on someone else’s business or is in business for themselves;
-- Identify three other factors that may serve as additional guideposts in the analysis including: the amount of skill required for the work; the degree of permanence of the working relationship between the worker and the potential employer; and whether the work is part of an integrated unit of production; an Advise that the actual practice is more relevant than what may be contractually or theoretically possible in determining whether a worker is an employee or an independent contractor.
This proposed rule has triggered a heated battle over the requirements for being an independent contractor.
Weighing in on the battle is the California Attorney General as well as what he says is " a coalition of 24 attorneys general - as well as local authorities in Chicago, New York City, Philadelphia, and Pittsburgh" who oppose the proposed rule. The coalition joined in writing a comment letter that opposed the DOL position on the rule.
They say that the "proposal upends the test currently used under the federal Fair Labor Standards Act (FLSA) that determines whether workers are entitled to critical employee protections such as paid sick leave, overtime, and unemployment insurance."
In the comment letter, the coalition urges the Trump Administration to withdraw what they call "the unlawful proposal." ...
In this rulemaking, the Department proposes to:
-- Adopt an "economic reality" test to determine a worker’s status as an FLSA employee or an independent contractor. The test considers whether a worker is in business for themselves (independent contractor) or is economically dependent on a putative employer for work (employee);
-- Identify and explain two "core factors," specifically: the nature and degree of the worker’s control over the work; and the worker’s opportunity for profit or loss based on initiative and/or investment. These factors help determine if a worker is economically dependent on someone else’s business or is in business for themselves;
-- Identify three other factors that may serve as additional guideposts in the analysis including: the amount of skill required for the work; the degree of permanence of the working relationship between the worker and the potential employer; and whether the work is part of an integrated unit of production; an Advise that the actual practice is more relevant than what may be contractually or theoretically possible in determining whether a worker is an employee or an independent contractor.
This proposed rule has triggered a heated battle over the requirements for being an independent contractor.
Weighing in on the battle is the California Attorney General as well as what he says is " a coalition of 24 attorneys general - as well as local authorities in Chicago, New York City, Philadelphia, and Pittsburgh" who oppose the proposed rule. The coalition joined in writing a comment letter that opposed the DOL position on the rule.
They say that the "proposal upends the test currently used under the federal Fair Labor Standards Act (FLSA) that determines whether workers are entitled to critical employee protections such as paid sick leave, overtime, and unemployment insurance."
In the comment letter, the coalition urges the Trump Administration to withdraw what they call "the unlawful proposal." ...
The Workers' Compensation Appeals Board issued two En Banc decisions reinstating a few of the Rules of Practice and Procedure that had been suspended earlier this year as a result of limitations caused by the COVID-19 pandemic.
The first case was Workers’ Compensation Appeals Board State of California In Re: Covid-19 State Of Emergency En Banc - No. 5 - Case No. Misc. No. 264.
The relevant section of the Opinion provided that "The Appeals Board hereby rescinds its suspension of WCAB Rules 10755, 10756 and 10888 effective as of the date of this decision. Suspension of the other Rules as outlined in the March 18, 2020 In Re: COVID-19 State of Emergency En Banc (Misc. No. 260) remains in effect until further notice."
These three rules pertain to sanctions available to the WCJ for failure to appear and scheduled hearings. The rules that are now renstated can be reviewed using the links below.
-- § 10755. Failure to Appear at Mandatory Settlement Conference in Case in Chief.
-- § 10756. Failure to Appear at Trial in Case in Chief.
-- § 10888. Dismissal of Lien Claims.
The second case was Workers’ Compensation Appeals Board State of California In Re: Covid-19 State Of Emergency En Banc - No. 6 - Case No. Misc. No. 265.
The relevant section of the Opinion provided that "The Appeals Board hereby rescinds its suspension of WCAB Rules 10620 and 10670(b)(3) as of December 1, 2020. These Rules will become effective again with respect to all workers’ compensation matters on December 1, 2020. Therefore, WCAB Rules 10620 and 10670(b)(3) apply to all trials on or after December 1, 2020."
These two rules pertain to requirements for filing and service is proposed exhibits for trial. The rules that will be reinstated on December 1 can be reviewed using the links below.
-- § 10620. Filing Proposed Exhibits.
-- § 10670. Documentary Evidence.
Other than these five rules, all other Emergency Orders of prior En Banc decisions remain in effect ...
The first case was Workers’ Compensation Appeals Board State of California In Re: Covid-19 State Of Emergency En Banc - No. 5 - Case No. Misc. No. 264.
The relevant section of the Opinion provided that "The Appeals Board hereby rescinds its suspension of WCAB Rules 10755, 10756 and 10888 effective as of the date of this decision. Suspension of the other Rules as outlined in the March 18, 2020 In Re: COVID-19 State of Emergency En Banc (Misc. No. 260) remains in effect until further notice."
These three rules pertain to sanctions available to the WCJ for failure to appear and scheduled hearings. The rules that are now renstated can be reviewed using the links below.
-- § 10755. Failure to Appear at Mandatory Settlement Conference in Case in Chief.
-- § 10756. Failure to Appear at Trial in Case in Chief.
-- § 10888. Dismissal of Lien Claims.
The second case was Workers’ Compensation Appeals Board State of California In Re: Covid-19 State Of Emergency En Banc - No. 6 - Case No. Misc. No. 265.
The relevant section of the Opinion provided that "The Appeals Board hereby rescinds its suspension of WCAB Rules 10620 and 10670(b)(3) as of December 1, 2020. These Rules will become effective again with respect to all workers’ compensation matters on December 1, 2020. Therefore, WCAB Rules 10620 and 10670(b)(3) apply to all trials on or after December 1, 2020."
These two rules pertain to requirements for filing and service is proposed exhibits for trial. The rules that will be reinstated on December 1 can be reviewed using the links below.
-- § 10620. Filing Proposed Exhibits.
-- § 10670. Documentary Evidence.
Other than these five rules, all other Emergency Orders of prior En Banc decisions remain in effect ...
The Centers for Medicare & Medicaid Services added 11 codes to the list of telehealth services payable under the Medicare Physician Fee Schedule (MPFS). Coverage which are retroactive to March 1, 2020, and is effective for the duration of the public health emergency (PHE) for COVID-19.
Alex Azar has once again renewed the public health emergency (PHE) for the coronavirus pandemic (COVID-19). Set to expire Oct. 23, the PHE is now set to expire Jan. 21, 2021 - one year after declaring a PHE for COVID-19 in the United States.
As a result, the Division of Workers’ Compensation (DWC) has posted an order dated October 20, 2020 adjusting the Physician and Non-Physician Practitioner Services section of the Official Medical Fee Schedule (OMFS) to conform to additional Medicare fee schedule changes pursuant to Labor Code section 5307.1.
DWC has adopted the updated telehealth list which includes 11 new codes which are effective for services rendered on or after October 14, 2020.
The order adopting the updated Physician and Non-Physician Practitioner fee schedule can be found on the DWC fee schedule web page.
The following are the new telehealth codes added by this order:
-- 93797 Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session)
-- 93798 with continuous ECG monitoring (per session)
-- 93750 Interrogation of ventricular assist device (VAD), in person, with physician or other qualified health care professional analysis of device parameters (eg, drivelines, alarms, power surges), review of device function (eg, flow and volume status, septum status, recovery), with programming, if performed, and report
-- 95970 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain, cranial nerve, spinal cord, peripheral nerve, or sacral nerve, neurostimulator pulse generator/transmitter, without programming
-- 95971 with simple spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional
-- 95972 with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional
-- 95983 with brain neurostimulator pulse generator/transmitter programming, first 15 minutes face-to-face time with physician or other qualified health care professional
-- 95984 with brain neurostimulator pulse generator/transmitter programming, each additional 15 minutes face-to-face time with physician or other qualified health care professional (List separately in addition to code for primary procedure)
-- G0422 Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session
-- G0423 with or without continuous ECG monitoring; without exercise, per session
-- G0424 Pulmonary rehabilitation, including exercise (includes monitoring), one hour, per session, up to two sessions per day ...
Alex Azar has once again renewed the public health emergency (PHE) for the coronavirus pandemic (COVID-19). Set to expire Oct. 23, the PHE is now set to expire Jan. 21, 2021 - one year after declaring a PHE for COVID-19 in the United States.
As a result, the Division of Workers’ Compensation (DWC) has posted an order dated October 20, 2020 adjusting the Physician and Non-Physician Practitioner Services section of the Official Medical Fee Schedule (OMFS) to conform to additional Medicare fee schedule changes pursuant to Labor Code section 5307.1.
DWC has adopted the updated telehealth list which includes 11 new codes which are effective for services rendered on or after October 14, 2020.
The order adopting the updated Physician and Non-Physician Practitioner fee schedule can be found on the DWC fee schedule web page.
The following are the new telehealth codes added by this order:
-- 93797 Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session)
-- 93798 with continuous ECG monitoring (per session)
-- 93750 Interrogation of ventricular assist device (VAD), in person, with physician or other qualified health care professional analysis of device parameters (eg, drivelines, alarms, power surges), review of device function (eg, flow and volume status, septum status, recovery), with programming, if performed, and report
-- 95970 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain, cranial nerve, spinal cord, peripheral nerve, or sacral nerve, neurostimulator pulse generator/transmitter, without programming
-- 95971 with simple spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional
-- 95972 with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional
-- 95983 with brain neurostimulator pulse generator/transmitter programming, first 15 minutes face-to-face time with physician or other qualified health care professional
-- 95984 with brain neurostimulator pulse generator/transmitter programming, each additional 15 minutes face-to-face time with physician or other qualified health care professional (List separately in addition to code for primary procedure)
-- G0422 Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session
-- G0423 with or without continuous ECG monitoring; without exercise, per session
-- G0424 Pulmonary rehabilitation, including exercise (includes monitoring), one hour, per session, up to two sessions per day ...
