A report published by Politico claims that the pandemic has revealed new failings in the rickety technology that underpins public services in California, most recently leading Gov. Gavin Newsom to trumpet an erroneous decline in coronavirus infections.
The Silicon Valley state's woes reflect a larger problem in public-sector technology that has plagued governments for years - but are coming to the fore during the nation's coronavirus crisis.
Florida's unemployment claims website, built by Deloitte, has faltered so badly this year that Gov. Ron DeSantis called it a "jalopy." Other states, such as Wisconsin and New Jersey, are likewise struggling to keep pace with claims in part because they say their systems rely on decades-old programming language.
"Almost every month we are briefed on yet another incredible IT failure in state government," said California Assemblyman David Chiu, a San Francisco Democrat. "The challenge that state government has with technology has been going on for years, if not decades."
On top of California's backlog of nearly 1 million unemployment claims, the state has experienced longstanding issues at the Department of Motor Vehicles - whose offices only began accepting credit card payments last year.
California's IT problems stem in part from chronic underinvestment in new technology and mismanagement of the money it has put into upgrades. Paradoxically, California's state services also suffer from the wealth of technological know-how in their own backyard.
The pandemic has forced various state systems into overdrive. None has been tested like the Employment Development Department, which is buckling under a tenfold increase in people filing for unemployment and having to send checks to 4.4 million residents - more than 1 in 5 workers statewide.
71 state lawmakers said in a letter to Newsom last week. The letter pointed out a litany of failures at the EDD, including taking up to six weeks to return customer service phone calls; not providing translation of documents into languages other than English; and not allowing applicants to edit their applications once submitted or upload verification documents.
A more systemic problem, lawmakers said, is the state's overreliance on contractors who routinely come in tens of millions of dollars over budget and years behind schedule.
A billion-dollar project by Accenture to revamp the state's accounting, budgeting and procurement systems, called Fi$Cal, has been underway for the past 15 years; it was originally envisioned to take six years and cost $138 million. Last year, Newsom increased its budget by $150 million while at the same time narrowing its scope.
EDD's latest modernization plan has been underway since 2016 and isn't scheduled to finish until 2027. A previous attempt by EDD's longtime contractor, Deloitte, in 2010 ended up costing twice the original estimate and "never solved basic problems," the lawmakers said in their letter.
"Deloitte has received at least $259 million to do work on EDD’s IT system over the years, including at least two no-bid contracts during this pandemic," they wrote. "It’s clear that despite all of the money Deloitte has been paid, it has not successfully resolved EDD’s IT challenges or modernized its system."
Deloitte did not respond to a request for comment this week ...
The Silicon Valley state's woes reflect a larger problem in public-sector technology that has plagued governments for years - but are coming to the fore during the nation's coronavirus crisis.
Florida's unemployment claims website, built by Deloitte, has faltered so badly this year that Gov. Ron DeSantis called it a "jalopy." Other states, such as Wisconsin and New Jersey, are likewise struggling to keep pace with claims in part because they say their systems rely on decades-old programming language.
"Almost every month we are briefed on yet another incredible IT failure in state government," said California Assemblyman David Chiu, a San Francisco Democrat. "The challenge that state government has with technology has been going on for years, if not decades."
On top of California's backlog of nearly 1 million unemployment claims, the state has experienced longstanding issues at the Department of Motor Vehicles - whose offices only began accepting credit card payments last year.
California's IT problems stem in part from chronic underinvestment in new technology and mismanagement of the money it has put into upgrades. Paradoxically, California's state services also suffer from the wealth of technological know-how in their own backyard.
The pandemic has forced various state systems into overdrive. None has been tested like the Employment Development Department, which is buckling under a tenfold increase in people filing for unemployment and having to send checks to 4.4 million residents - more than 1 in 5 workers statewide.
71 state lawmakers said in a letter to Newsom last week. The letter pointed out a litany of failures at the EDD, including taking up to six weeks to return customer service phone calls; not providing translation of documents into languages other than English; and not allowing applicants to edit their applications once submitted or upload verification documents.
A more systemic problem, lawmakers said, is the state's overreliance on contractors who routinely come in tens of millions of dollars over budget and years behind schedule.
A billion-dollar project by Accenture to revamp the state's accounting, budgeting and procurement systems, called Fi$Cal, has been underway for the past 15 years; it was originally envisioned to take six years and cost $138 million. Last year, Newsom increased its budget by $150 million while at the same time narrowing its scope.
EDD's latest modernization plan has been underway since 2016 and isn't scheduled to finish until 2027. A previous attempt by EDD's longtime contractor, Deloitte, in 2010 ended up costing twice the original estimate and "never solved basic problems," the lawmakers said in their letter.
"Deloitte has received at least $259 million to do work on EDD’s IT system over the years, including at least two no-bid contracts during this pandemic," they wrote. "It’s clear that despite all of the money Deloitte has been paid, it has not successfully resolved EDD’s IT challenges or modernized its system."
Deloitte did not respond to a request for comment this week ...
46 year old Orlando Gillam, of Fresno, pleaded guilty to mail fraud in connection with false claims he submitted to public and private health insurers. He was indicted by a grand jury in April 2019.
According to court documents, Gillam is the founder and CEO of Dunamis Inc. Group Home, a nonprofit that provided services that included alcohol and drug treatment and counseling.
Between January 2016 and January 2018, Gillam falsely billed insurers hundreds of thousands of dollars for alcohol and drug treatment and counseling, mental health treatment, and group and individual psychotherapy purportedly rendered to multiple individuals.
Those individuals did not receive the services billed, and several of them were not Dunamis clients at all.
The conviction is yet another example of how California has become the "Rehab Riviera" of fraudulent treatment centers that seek to exploit California-specific regulations and sometimes-lax oversight in an attempt to cash in on the lucrative industry, despite the potential danger for those the industry is supposed to help.
In California, even someone convicted of fraud or drug dealing or medical malpractice can make money in rehab, often through the vertical integration of insurance payments for urine testing.
Orange County Register investigative journalists found this to be the case in their published expose of the industry some time ago.
This case is the product of an investigation by the Federal Bureau of Investigation, the Office of Personnel Management Office of Inspector General, and the U.S. Treasury Inspector General for Tax Administration. Assistant U.S. Attorney Vincente A. Tennerelli is prosecuting the case.
Gillam is scheduled to be sentenced on Nov. 20. He faces a maximum statutory penalty of 20 years in prison and a $$250,000 fine ...
According to court documents, Gillam is the founder and CEO of Dunamis Inc. Group Home, a nonprofit that provided services that included alcohol and drug treatment and counseling.
Between January 2016 and January 2018, Gillam falsely billed insurers hundreds of thousands of dollars for alcohol and drug treatment and counseling, mental health treatment, and group and individual psychotherapy purportedly rendered to multiple individuals.
Those individuals did not receive the services billed, and several of them were not Dunamis clients at all.
The conviction is yet another example of how California has become the "Rehab Riviera" of fraudulent treatment centers that seek to exploit California-specific regulations and sometimes-lax oversight in an attempt to cash in on the lucrative industry, despite the potential danger for those the industry is supposed to help.
In California, even someone convicted of fraud or drug dealing or medical malpractice can make money in rehab, often through the vertical integration of insurance payments for urine testing.
Orange County Register investigative journalists found this to be the case in their published expose of the industry some time ago.
This case is the product of an investigation by the Federal Bureau of Investigation, the Office of Personnel Management Office of Inspector General, and the U.S. Treasury Inspector General for Tax Administration. Assistant U.S. Attorney Vincente A. Tennerelli is prosecuting the case.
Gillam is scheduled to be sentenced on Nov. 20. He faces a maximum statutory penalty of 20 years in prison and a $$250,000 fine ...
Discovering the "date of injury" in a continuous trauma claim is both significant, and sometimes complicated.
It is significant since the carrier for the one year prior to the "date of injury" might not be the carrier on the last date of employment. So just using the last date of employment as the date of injury might not involve the correct carriers. Benefit rates increase on January 1 of each year. Thus the date of injury might effect the rate of benefits to be paid. And finally, the statute of limitations defense is based upon the date of injury, and the date the Application for Adjudication was filed.
A recent panel decision makes the determination of date of injury less complicated since it clarifies existing law on how to determine the date of injury in a continuous trauma claim.
Imelda Sosa submitted a claim form to her employer on June 3, 2011 for a specific injury "From shoulder to neck-sometimes whole arm." On July 7, 2011, Sosa's primary treating physician took applicant off work for a single day on June 13, 2011 and a single day on July 7, 2011.
After a period of medical treatment, Sosa filed an Application for Adjudication of Claim on November 7, 2012.
At trial, the parties stipulated that Sosa sustained an industrial injury during the period April 8, 1997 through December 10, 2012. However, the parties also submitted the issue of "date of injury" at trial.
The School District contended that applicant did not sustain compensable temporary disability in 2011 because applicant was paid industrial accident leave under the Education Code for a single day's absence and would not have been entitled to temporary disability under Labor Code section 4652.
The workers' compensation administrative law judge found that Sosa sustained a cumulative trauma injury through June 13, 2011. Reconsideration was denied in the panel decision of Sosa v Brawley Union High School District.
Labor Code section 3208.1 provides that a cumulative industrial injury occurs whenever the repetitive physically traumatic activities of an employee's occupation cause any disability or a need for medical treatment.
Pursuant to section 5500.5, liability for an injured worker's cumulative injury is limited to those employers who employed the employee during a period of one year immediately preceding the date of injury, as determined pursuant to Labor Code section 5412, or the last date on which the employee was employed in an occupation exposing her to the hazards of the cumulative injury, whichever occurs first. (Lab. Code, § 5500.S(a).)
The date of injury for an industrial cumulative trauma injury is defined by Labor Code section 5412, as follows: "The date of injury in cases of occupational diseases or cumulative injuries is that date upon which the employee first suffered disability therefrom and either knew, or in the exercise of reasonable diligence should have known, that such disability was caused by his present or prior employment."
As used in Labor Code section 5412, "disability" means either compensable temporary disability or permanent disability. (Chavira v. Worker's Comp. Appeals Bd. (1991) 235 Cal.App.3d 463 [56 Cal.Comp.Cases 631]; State Compensation Insurance Fund v. Workers' Comp. Appeals Bd. (Rodarte) (2004) 119 Cal.App.4th 998 [69 Cal.Comp.Cases 579].)
Here, applicant had knowledge of an industrial injury and suffered disability as a result of the injury on June 13, 2011. Accordingly, the WCJ correctly determined applicant's date of injury ...
It is significant since the carrier for the one year prior to the "date of injury" might not be the carrier on the last date of employment. So just using the last date of employment as the date of injury might not involve the correct carriers. Benefit rates increase on January 1 of each year. Thus the date of injury might effect the rate of benefits to be paid. And finally, the statute of limitations defense is based upon the date of injury, and the date the Application for Adjudication was filed.
A recent panel decision makes the determination of date of injury less complicated since it clarifies existing law on how to determine the date of injury in a continuous trauma claim.
Imelda Sosa submitted a claim form to her employer on June 3, 2011 for a specific injury "From shoulder to neck-sometimes whole arm." On July 7, 2011, Sosa's primary treating physician took applicant off work for a single day on June 13, 2011 and a single day on July 7, 2011.
After a period of medical treatment, Sosa filed an Application for Adjudication of Claim on November 7, 2012.
At trial, the parties stipulated that Sosa sustained an industrial injury during the period April 8, 1997 through December 10, 2012. However, the parties also submitted the issue of "date of injury" at trial.
The School District contended that applicant did not sustain compensable temporary disability in 2011 because applicant was paid industrial accident leave under the Education Code for a single day's absence and would not have been entitled to temporary disability under Labor Code section 4652.
The workers' compensation administrative law judge found that Sosa sustained a cumulative trauma injury through June 13, 2011. Reconsideration was denied in the panel decision of Sosa v Brawley Union High School District.
Labor Code section 3208.1 provides that a cumulative industrial injury occurs whenever the repetitive physically traumatic activities of an employee's occupation cause any disability or a need for medical treatment.
Pursuant to section 5500.5, liability for an injured worker's cumulative injury is limited to those employers who employed the employee during a period of one year immediately preceding the date of injury, as determined pursuant to Labor Code section 5412, or the last date on which the employee was employed in an occupation exposing her to the hazards of the cumulative injury, whichever occurs first. (Lab. Code, § 5500.S(a).)
The date of injury for an industrial cumulative trauma injury is defined by Labor Code section 5412, as follows: "The date of injury in cases of occupational diseases or cumulative injuries is that date upon which the employee first suffered disability therefrom and either knew, or in the exercise of reasonable diligence should have known, that such disability was caused by his present or prior employment."
As used in Labor Code section 5412, "disability" means either compensable temporary disability or permanent disability. (Chavira v. Worker's Comp. Appeals Bd. (1991) 235 Cal.App.3d 463 [56 Cal.Comp.Cases 631]; State Compensation Insurance Fund v. Workers' Comp. Appeals Bd. (Rodarte) (2004) 119 Cal.App.4th 998 [69 Cal.Comp.Cases 579].)
Here, applicant had knowledge of an industrial injury and suffered disability as a result of the injury on June 13, 2011. Accordingly, the WCJ correctly determined applicant's date of injury ...
A Trinity County deputy sheriff phoned citizens James and Norma Gund - who do not work for the County - and asked them to go check on a neighbor who had called 911 for help likely related to inclement weather.
The Gunds unwittingly walked into a murder scene and were savagely attacked by the man who apparently had just murdered the neighbor and her boyfriend. The assailant fled.
The Gunds sued the County of Trinity and the deputy - Corporal Ron Whitman - for negligence and misrepresentation, alleging defendants created a special relationship with the Gunds and owed them a duty of care, which defendants breached by representing that the 911 call was likely weather-related and "probably no big deal" and by withholding information known to defendants suggesting a crime in progress - i.e., that the caller had whispered "help me," that the California Highway Patrol dispatcher refrained from calling back when the call was disconnected out of concern the caller was in danger, and that no one answered when the county dispatcher called.
Trinity County filed a motion for summary judgment on the ground that Grund's exclusive remedy was workers’ compensation. The trial court adopted the defense theory and entered summary judgment and the Gunds appealed. In 2018, the Court of Appeal affirmed the judgment in a published case.
The California Supreme Court ordered review on the court’s own motion, to decide the scope of workers’ compensation coverage available to the plaintiffs in this situation, as the availability of such coverage would constrain them in seeking other redress for their injuries.
This month the California Supreme Court published its review of the case, and agreed with both the trial court and the Court of Appeal in the case of Gund v County of Trinity.
"We entrust to police officers the enormous responsibility of ensuring public safety with integrity and appropriate restraint, a mission they sometimes pursue by requesting help from the very public they’re sworn to protect."
"When members of the public engage in 'active law enforcement service' at a peace officer’s request, California law treats those members of the public as employees eligible for workers’ compensation benefits. (Lab. Code, § 3366, subd. (a).)"
"While this allows such individuals to receive compensation for their injuries without regard to fault, it comes with a catch: Workers’ compensation then becomes an individual’s exclusive remedy for those injuries under state law." ...
The Gunds unwittingly walked into a murder scene and were savagely attacked by the man who apparently had just murdered the neighbor and her boyfriend. The assailant fled.
The Gunds sued the County of Trinity and the deputy - Corporal Ron Whitman - for negligence and misrepresentation, alleging defendants created a special relationship with the Gunds and owed them a duty of care, which defendants breached by representing that the 911 call was likely weather-related and "probably no big deal" and by withholding information known to defendants suggesting a crime in progress - i.e., that the caller had whispered "help me," that the California Highway Patrol dispatcher refrained from calling back when the call was disconnected out of concern the caller was in danger, and that no one answered when the county dispatcher called.
Trinity County filed a motion for summary judgment on the ground that Grund's exclusive remedy was workers’ compensation. The trial court adopted the defense theory and entered summary judgment and the Gunds appealed. In 2018, the Court of Appeal affirmed the judgment in a published case.
The California Supreme Court ordered review on the court’s own motion, to decide the scope of workers’ compensation coverage available to the plaintiffs in this situation, as the availability of such coverage would constrain them in seeking other redress for their injuries.
This month the California Supreme Court published its review of the case, and agreed with both the trial court and the Court of Appeal in the case of Gund v County of Trinity.
"We entrust to police officers the enormous responsibility of ensuring public safety with integrity and appropriate restraint, a mission they sometimes pursue by requesting help from the very public they’re sworn to protect."
"When members of the public engage in 'active law enforcement service' at a peace officer’s request, California law treats those members of the public as employees eligible for workers’ compensation benefits. (Lab. Code, § 3366, subd. (a).)"
"While this allows such individuals to receive compensation for their injuries without regard to fault, it comes with a catch: Workers’ compensation then becomes an individual’s exclusive remedy for those injuries under state law." ...
A San Gabriel Valley man was sentenced to 34 months in federal prison for fraudulently submitting more than $62 million in claims to the military’s TRICARE health care benefit program for bogus compounded medications prescriptions largely generated by the payment of large referral fees to marketers.
James Chen, 51, of Monterey Park, was sentenced by United States District Judge David O. Carter, who also ordered Chen to pay $28,283,844 in restitution. Chen pleaded guilty in June 2017 to one count of health care fraud.
Chen owned Clevis Management, Inc., a Commerce-based company that did business under the name Haeoyou Pharmacy (HY). HY hired marketers to obtain prescriptions for medications that were billed to TRICARE, a health care benefit program for military members and their families. HY also operated "Healtharchy.com," a "telemedicine" website through which individuals could seek prescriptions for medications without being examined by a physician.
Under Chen’s supervision, HY paid referral fees to outside businesses, including Mission Viejo-based Trestles RX LLC and Trestles Pain Management Specialists LLC, and to his own in-house marketers to obtain compounded medications prescriptions. The referral fees constituted more than 50 percent of the net reimbursements that HY received from TRICARE.
(As an interesting sidenote, it is worthy of note that in 2015, Mesa Pharmacy - a major lien claimant for compounded medications in California workers' compensation cases, filed a Superior Court action against Trestles Pain Specialists LLC, John Garbino, David Fish, and Raymond Riley alleging that Trestles Pain Specialists had contracted to provide marketing services of its compounded medications to doctors.)
Chen knew that none of the prescriptions arose from a bona-fide physician-patient relationship, as required by TRICARE rules. Chen also knew that a substantial number of the prescriptions were sent to HY from marketers, not physicians, though the claim forms falsely indicated otherwise. HY never attempted to collect copayments from patients, who were selected at random and denied ever seeking the compounded medications, which were of questionable medical value. All the medications were for generic pain, scarring, stretch marks, erectile dysfunction, or "metabolic general wellness" (vitamins), according to court documents.
During 2013, Chen submitted zero claims to TRICARE for reimbursement for filling compounded medication prescriptions. In Decembr 2014, his company submitted 31 such claims to TRICARE for $81,401. During the first five months of 2015, HY submitted 2,798 such claims to TRICARE seeking a total of $62,654,938.
The claims HY submitted to TRICARE for each compounded medication prescription were astronomical compared to previous claims that HY typically submitted for reimbursement. A claim to TRICARE for a single compounded medication prescription caused TRICARE to pay HY $194,707.
Chen and his co-schemers targeted TRICARE because few, if any, insurance carriers at the time would honor reimbursement claims for similar prescriptions.
This matter was investigated by the Defense Criminal Investigative Service; the FBI; Amtrak’s Office of Inspector General; IRS Criminal Investigation, the Office of Personnel Management’s Office of Inspector General; the U.S. Department of Health and Human Services - Office of Inspector General; the U.S. Department of Labor, Employee Benefits Security Administration; and the California Department of Insurance.
This case was prosecuted by Assistant United States Attorney Mark Aveis of the Major Frauds Section ...
James Chen, 51, of Monterey Park, was sentenced by United States District Judge David O. Carter, who also ordered Chen to pay $28,283,844 in restitution. Chen pleaded guilty in June 2017 to one count of health care fraud.
Chen owned Clevis Management, Inc., a Commerce-based company that did business under the name Haeoyou Pharmacy (HY). HY hired marketers to obtain prescriptions for medications that were billed to TRICARE, a health care benefit program for military members and their families. HY also operated "Healtharchy.com," a "telemedicine" website through which individuals could seek prescriptions for medications without being examined by a physician.
Under Chen’s supervision, HY paid referral fees to outside businesses, including Mission Viejo-based Trestles RX LLC and Trestles Pain Management Specialists LLC, and to his own in-house marketers to obtain compounded medications prescriptions. The referral fees constituted more than 50 percent of the net reimbursements that HY received from TRICARE.
(As an interesting sidenote, it is worthy of note that in 2015, Mesa Pharmacy - a major lien claimant for compounded medications in California workers' compensation cases, filed a Superior Court action against Trestles Pain Specialists LLC, John Garbino, David Fish, and Raymond Riley alleging that Trestles Pain Specialists had contracted to provide marketing services of its compounded medications to doctors.)
Chen knew that none of the prescriptions arose from a bona-fide physician-patient relationship, as required by TRICARE rules. Chen also knew that a substantial number of the prescriptions were sent to HY from marketers, not physicians, though the claim forms falsely indicated otherwise. HY never attempted to collect copayments from patients, who were selected at random and denied ever seeking the compounded medications, which were of questionable medical value. All the medications were for generic pain, scarring, stretch marks, erectile dysfunction, or "metabolic general wellness" (vitamins), according to court documents.
During 2013, Chen submitted zero claims to TRICARE for reimbursement for filling compounded medication prescriptions. In Decembr 2014, his company submitted 31 such claims to TRICARE for $81,401. During the first five months of 2015, HY submitted 2,798 such claims to TRICARE seeking a total of $62,654,938.
The claims HY submitted to TRICARE for each compounded medication prescription were astronomical compared to previous claims that HY typically submitted for reimbursement. A claim to TRICARE for a single compounded medication prescription caused TRICARE to pay HY $194,707.
Chen and his co-schemers targeted TRICARE because few, if any, insurance carriers at the time would honor reimbursement claims for similar prescriptions.
This matter was investigated by the Defense Criminal Investigative Service; the FBI; Amtrak’s Office of Inspector General; IRS Criminal Investigation, the Office of Personnel Management’s Office of Inspector General; the U.S. Department of Health and Human Services - Office of Inspector General; the U.S. Department of Labor, Employee Benefits Security Administration; and the California Department of Insurance.
This case was prosecuted by Assistant United States Attorney Mark Aveis of the Major Frauds Section ...
As part of the continuing efforts to improve the Coordination of Benefits & Recovery program the Centers for Medicare & Medicaid Services has transitioned a portion of the Non-Group Health Plan (NGHP) Medicare Secondary Payer (MSP) recovery workload from the Benefits Coordination & Recovery Center (BCRC) to its Commercial Repayment Center (CRC).
The Commercial Repayment Center has assumed responsibility for the recovery of conditional payments where CMS is pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation (WC) entity (referred to as as the identified debtor.
CMS will be hosting a Commercial Repayment Center (CRC) Non-Group Health Plan (NGHP) webinar to review the procedures and best practices for redeterminations. The event is scheduled for Thursday, September 24, 2020 at 1:00 PM ET.
The format will be opening remarks by CMS followed by a presentation from the CRC. This webinar will primarily focus upon how to effectively submit a redetermination request (sometimes called a first level appeal).
During the presentation, CMS will also be reviewing appeal requirements, what is and is not subject to appeal, and details about what documentation is needed to support the appeal request in various situations.
Those who want to attend should follow this link to login in - NGHP Appeals Webinar - and use this Conference Dial In Number: 888-829-8669, with this Conference Passcode: 6799170.
Please note that for this town hall, you will need to access the webinar link and dial-in using the information above to access the visual and audio portion of the presentation. Due to the number of participants, please dial in at least 15 minutes prior to the start of the presentation ...
The Commercial Repayment Center has assumed responsibility for the recovery of conditional payments where CMS is pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation (WC) entity (referred to as as the identified debtor.
CMS will be hosting a Commercial Repayment Center (CRC) Non-Group Health Plan (NGHP) webinar to review the procedures and best practices for redeterminations. The event is scheduled for Thursday, September 24, 2020 at 1:00 PM ET.
The format will be opening remarks by CMS followed by a presentation from the CRC. This webinar will primarily focus upon how to effectively submit a redetermination request (sometimes called a first level appeal).
During the presentation, CMS will also be reviewing appeal requirements, what is and is not subject to appeal, and details about what documentation is needed to support the appeal request in various situations.
Those who want to attend should follow this link to login in - NGHP Appeals Webinar - and use this Conference Dial In Number: 888-829-8669, with this Conference Passcode: 6799170.
Please note that for this town hall, you will need to access the webinar link and dial-in using the information above to access the visual and audio portion of the presentation. Due to the number of participants, please dial in at least 15 minutes prior to the start of the presentation ...
A southern California chiropractor was sentenced to 46 months in federal prison for conspiring to defraud a labor union’s health care benefit plan by offering kickbacks to patients for attending the clinic and by submitting approximately $4.8 million in sham billings.
Mahyar David Yadidi, 38, of West Los Angeles, was also ordered him to pay $1,976,832 in restitution. In November 2019, Yadidi pleaded guilty to one count of conspiracy to commit health care fraud.
Yadidi operated Philips San Pedro Chiropractic - formerly known as Synergy Healthcare and Wellness Center - in San Pedro. From July 2016 to October 2018, Yadidi operated a scheme to defraud the International Longshore and Warehouse Union - Pacific Maritime Association (ILWU-PMA) health care benefit plan. Yadidi worked with co-conspirators Ivan Semerdjiev, 41, of Irvine, a chiropractor who worked for Yadidi, and Julian Williams, 45, of San Pedro, a personal trainer who also worked for Yadidi.
ILWU-PMA health care plan members were induced by Yadidi to visit his clinic with offers of $50 in cash for each visit, according to a one-count criminal information filed in this case. Yadidi also paid plan members to allow him to bill the plan when members did not visit his clinic.
Yadidi offered monetary incentives to Williams, Semerdjiev, and other employees, as well as to patients, to recruit additional plan members to visit his clinic. Williams induced plan members to visit the clinic by falsely informing them that they could receive personal athletic training services from him that the plan would pay for.
Once plan members either visited Yadidi’s clinic or agreed to allow him to submit claims to the plan for non-existent visits, Yadidi billed and caused his employees to bill the plan for services that were not rendered, services that were not medically necessary, and chiropractic and physical therapy services that were performed by
Williams was neither licensed nor otherwise qualified to be performing those services.
At his instruction, Yadidi’s employees falsified records, including sign-in sheets that listed the dates plan members purportedly received services from Philips Chiropractic. Yadidi instructed Semerdjiev to falsify patient files to support the clinic’s fraudulent billing. Yadidi and his co-conspirators also created false entries in the name of plan members’ relatives, knowing that the union’s health care benefit plan allowed them an additional number of covered visits as well.
Yadidi continued to operate his scheme after he was terminated as an authorized provider by the ILWU-PMA plan in August 2017, six months after it conducted an audit of his clinic.
To continue the conspiracy, Yadidi changed the name of his clinic - which previously was called "Synergy" and falsely held out another person as the clinic’s primary owner and operator, when in fact, Yadidi continued to own, operate, and financially benefit from the clinic. Yadidi continued to submit claims to the plan in the sham owner’s name.
During the conspiracy’s duration, Yadidi’s clinic submitted $4,756,284 in fraudulent claims to the ILWU-PMA plan, for which the plan paid $1,976,832.
Williams and Semerdjiev each pleaded guilty to one count of conspiracy to commit health care fraud and were sentenced to six months and one year in federal prison, respectively ...
Mahyar David Yadidi, 38, of West Los Angeles, was also ordered him to pay $1,976,832 in restitution. In November 2019, Yadidi pleaded guilty to one count of conspiracy to commit health care fraud.
Yadidi operated Philips San Pedro Chiropractic - formerly known as Synergy Healthcare and Wellness Center - in San Pedro. From July 2016 to October 2018, Yadidi operated a scheme to defraud the International Longshore and Warehouse Union - Pacific Maritime Association (ILWU-PMA) health care benefit plan. Yadidi worked with co-conspirators Ivan Semerdjiev, 41, of Irvine, a chiropractor who worked for Yadidi, and Julian Williams, 45, of San Pedro, a personal trainer who also worked for Yadidi.
ILWU-PMA health care plan members were induced by Yadidi to visit his clinic with offers of $50 in cash for each visit, according to a one-count criminal information filed in this case. Yadidi also paid plan members to allow him to bill the plan when members did not visit his clinic.
Yadidi offered monetary incentives to Williams, Semerdjiev, and other employees, as well as to patients, to recruit additional plan members to visit his clinic. Williams induced plan members to visit the clinic by falsely informing them that they could receive personal athletic training services from him that the plan would pay for.
Once plan members either visited Yadidi’s clinic or agreed to allow him to submit claims to the plan for non-existent visits, Yadidi billed and caused his employees to bill the plan for services that were not rendered, services that were not medically necessary, and chiropractic and physical therapy services that were performed by
Williams was neither licensed nor otherwise qualified to be performing those services.
At his instruction, Yadidi’s employees falsified records, including sign-in sheets that listed the dates plan members purportedly received services from Philips Chiropractic. Yadidi instructed Semerdjiev to falsify patient files to support the clinic’s fraudulent billing. Yadidi and his co-conspirators also created false entries in the name of plan members’ relatives, knowing that the union’s health care benefit plan allowed them an additional number of covered visits as well.
Yadidi continued to operate his scheme after he was terminated as an authorized provider by the ILWU-PMA plan in August 2017, six months after it conducted an audit of his clinic.
To continue the conspiracy, Yadidi changed the name of his clinic - which previously was called "Synergy" and falsely held out another person as the clinic’s primary owner and operator, when in fact, Yadidi continued to own, operate, and financially benefit from the clinic. Yadidi continued to submit claims to the plan in the sham owner’s name.
During the conspiracy’s duration, Yadidi’s clinic submitted $4,756,284 in fraudulent claims to the ILWU-PMA plan, for which the plan paid $1,976,832.
Williams and Semerdjiev each pleaded guilty to one count of conspiracy to commit health care fraud and were sentenced to six months and one year in federal prison, respectively ...
The Division of Workers’ Compensation (DWC) has posted an order adopting regulations to update the evidence-based treatment guidelines of the Medical Treatment Utilization Schedule (MTUS).
The updates, effective for medical treatment services rendered on or after September 21, 2020, incorporate by reference the American College of Occupational and Environmental Medicine’s (ACOEM’s) most recent treatment guidelines to the Clinical Topics section of the MTUS.
The ACOEM guidelines that are incorporated by reference into the MTUS are:
-- Knee Disorders Guideline (ACOEM December 3, 2019)
-- Workplace Mental Health Guideline: Depressive Disorders (ACOEM January 13, 2020)
-- Occupational/Work-Related Asthma Guideline (ACOEM June 5, 2020)
-- Occupational Interstitial Lung Disease Guideline (ACOEM November 8, 2019)
The administrative order consists of the order and two addenda:
-- Addendum one shows the regulatory amendments directly related to the evidence-based updates to the MTUS.
-- Addendum two contains hyperlinks to the updated ACOEM guidelines adopted and incorporated into the MTUS by reference.
Health care providers treating, evaluating (QME), or reviewing (UR or IMR) in the California workers’ compensation system may access the MTUS (ACOEM) Guidelines and MTUS Drug List at no cost by registering for an account ...
The updates, effective for medical treatment services rendered on or after September 21, 2020, incorporate by reference the American College of Occupational and Environmental Medicine’s (ACOEM’s) most recent treatment guidelines to the Clinical Topics section of the MTUS.
The ACOEM guidelines that are incorporated by reference into the MTUS are:
-- Knee Disorders Guideline (ACOEM December 3, 2019)
-- Workplace Mental Health Guideline: Depressive Disorders (ACOEM January 13, 2020)
-- Occupational/Work-Related Asthma Guideline (ACOEM June 5, 2020)
-- Occupational Interstitial Lung Disease Guideline (ACOEM November 8, 2019)
The administrative order consists of the order and two addenda:
-- Addendum one shows the regulatory amendments directly related to the evidence-based updates to the MTUS.
-- Addendum two contains hyperlinks to the updated ACOEM guidelines adopted and incorporated into the MTUS by reference.
Health care providers treating, evaluating (QME), or reviewing (UR or IMR) in the California workers’ compensation system may access the MTUS (ACOEM) Guidelines and MTUS Drug List at no cost by registering for an account ...
On July 31, 2020, the California Department of Insurance revised Special Investigative Unit (SIU) Regulations were filed with the California Secretary of State. They will be effective October 1, 2020.
Next month, CDI Fraud Division will be conducting training presentations on these new regulations. The format and training dates will be announced in the near future.
The definition of contracted entity was revised by section 2698.30 to specify which entities that work with an insurance company are subject to the requirements within these regulations. This definition includes subcontractors and sub-subcontractors, This definition excludes affiliates and subsidiaries. It also excludes various contractors who provide expert opinions or contractors who perform a discrete/specific investigative task (provided the contractor does not participate in the claims handling function or make decisions on behalf of the insurer).
Section 2698.30 specifies the specific contract language required to be included in insurance company contracts with contractors, subcontractors, and sub-subcontractors that provide SIU or IAF services.
These changes were driven by CDI concerns that loose SIU oversight of decentralized, multi levels of contractors was leading to significant noncompliance and less effective SIU operations. Insurance companies have until April 1, 2021 to update their contracts to comply with this section.
The definition of timely release of documentation to the Fraud Division was clarified in section 2698.34 by insurance line (no later than 30 days, except Workers’ Compensation which is 60 days), the ways in which information can be provided to CDI was specified, and language to address password protected files was added.
Redundant language was removed and language was added in section 2698.35 to specify the insurer’s IAF procedures must include red flags that address each line of insurance or each insurance product transacted by the insurer.
Language was added to section 2698.35 that requires the SIU’s thorough analysis of the claim must take into consideration factors indicating insurance fraud, identifying which industry recognized databases are used by the SIU, the summary of the investigation is a stand-alone entry, and the SIU investigation summary must answer specific questions related to the alleged existence of insurance fraud.
Language was also added that requires if an SIU investigation is not opened due to the referral not being credible, the reason for that conclusion must be documented.
A number of these changes were driven by CDI’s concern that SIU effectiveness may suffer as the industry moves away from field investigators to a desk investigation structure. CDI is seriously concerned the industry may short change or understaff its SIU function as a cost cutting measure. These changes give CDI the ability to initiate an enforcement action should an insurance company decide to make this type of short sighted decision.
These and other important changes can be read in the full text of the new SIU Regulations ...
Next month, CDI Fraud Division will be conducting training presentations on these new regulations. The format and training dates will be announced in the near future.
The definition of contracted entity was revised by section 2698.30 to specify which entities that work with an insurance company are subject to the requirements within these regulations. This definition includes subcontractors and sub-subcontractors, This definition excludes affiliates and subsidiaries. It also excludes various contractors who provide expert opinions or contractors who perform a discrete/specific investigative task (provided the contractor does not participate in the claims handling function or make decisions on behalf of the insurer).
Section 2698.30 specifies the specific contract language required to be included in insurance company contracts with contractors, subcontractors, and sub-subcontractors that provide SIU or IAF services.
These changes were driven by CDI concerns that loose SIU oversight of decentralized, multi levels of contractors was leading to significant noncompliance and less effective SIU operations. Insurance companies have until April 1, 2021 to update their contracts to comply with this section.
The definition of timely release of documentation to the Fraud Division was clarified in section 2698.34 by insurance line (no later than 30 days, except Workers’ Compensation which is 60 days), the ways in which information can be provided to CDI was specified, and language to address password protected files was added.
Redundant language was removed and language was added in section 2698.35 to specify the insurer’s IAF procedures must include red flags that address each line of insurance or each insurance product transacted by the insurer.
Language was added to section 2698.35 that requires the SIU’s thorough analysis of the claim must take into consideration factors indicating insurance fraud, identifying which industry recognized databases are used by the SIU, the summary of the investigation is a stand-alone entry, and the SIU investigation summary must answer specific questions related to the alleged existence of insurance fraud.
Language was also added that requires if an SIU investigation is not opened due to the referral not being credible, the reason for that conclusion must be documented.
A number of these changes were driven by CDI’s concern that SIU effectiveness may suffer as the industry moves away from field investigators to a desk investigation structure. CDI is seriously concerned the industry may short change or understaff its SIU function as a cost cutting measure. These changes give CDI the ability to initiate an enforcement action should an insurance company decide to make this type of short sighted decision.
These and other important changes can be read in the full text of the new SIU Regulations ...
Liberty Mutual Insurance has been awarded an Innovation Award for its new Injured Worker Portal and Workers Compensation Guide. The award was presented by Business Insurance magazine. This is the fifth Business Insurance Innovation Award Liberty Mutual has received since 2015.
Technology has been improving and simplifying the claims process. The company's Injured Worker Portal and Workers Compensation Guide provide more information to injured workers through an easier-to-access platform and help injured workers access the care they need faster and more easily.
The guide and portal are part of Liberty Mutual's broader investments to improve the digital experience of commercial customers, which also include a recently launched customer portal.
"The Workers Compensation Guide and Portal solve two key issues facing workers compensation policyholders and TPA clients," said Senior Vice President of Workers Compensation Claims Wes Hyatt. "The first is fully engaging injured workers in the claims process, their recovery and eventual return to work. The second is the experience of the injured worker, a paramount concern of mid-size and large employers."
Liberty Mutual's award-winning Injured Worker Portal and Workers Compensation Guide are being rolled out to more of Liberty Mutual's workers compensation policyholders and customers of Helmsman Management Services, its wholly owned third-party administrator (TPA).
Other Innovation awards received by Liberty Mutual include:
-- Workers' Compensation Automation - Harnesses artificial intelligence and robotic process automation to better manage workers compensation claim costs and fully engage injured workers in their recovery.
-- Liberty Mutual SmartVideo - Delivers personalized online videos to workers comp claimants summarizing key information specific to each claim in order to produce better outcomes more quickly for injured workers.
-- LM Expedite - An application that speeds commercial auto claims by letting drivers take photos of damage and instantly request an estimate from their mobile phones.
-- Managing Vital Driving Performance - Helps reduce commercial auto accidents by quickly sorting through complex telematics data to recommend ways to improve commercial driver performance.
-- RiskTrac Workers Compensation Analytics Interactive Dashboard - A dashboard added to Liberty Mutual Insurance Co.'s risk management information system that provides workers compensation policyholders with a customized predictive model.
Liberty Mutual offers workers compensation solutions through its Global Risk Solutions (GRS) division ...
Technology has been improving and simplifying the claims process. The company's Injured Worker Portal and Workers Compensation Guide provide more information to injured workers through an easier-to-access platform and help injured workers access the care they need faster and more easily.
The guide and portal are part of Liberty Mutual's broader investments to improve the digital experience of commercial customers, which also include a recently launched customer portal.
"The Workers Compensation Guide and Portal solve two key issues facing workers compensation policyholders and TPA clients," said Senior Vice President of Workers Compensation Claims Wes Hyatt. "The first is fully engaging injured workers in the claims process, their recovery and eventual return to work. The second is the experience of the injured worker, a paramount concern of mid-size and large employers."
Liberty Mutual's award-winning Injured Worker Portal and Workers Compensation Guide are being rolled out to more of Liberty Mutual's workers compensation policyholders and customers of Helmsman Management Services, its wholly owned third-party administrator (TPA).
Other Innovation awards received by Liberty Mutual include:
-- Workers' Compensation Automation - Harnesses artificial intelligence and robotic process automation to better manage workers compensation claim costs and fully engage injured workers in their recovery.
-- Liberty Mutual SmartVideo - Delivers personalized online videos to workers comp claimants summarizing key information specific to each claim in order to produce better outcomes more quickly for injured workers.
-- LM Expedite - An application that speeds commercial auto claims by letting drivers take photos of damage and instantly request an estimate from their mobile phones.
-- Managing Vital Driving Performance - Helps reduce commercial auto accidents by quickly sorting through complex telematics data to recommend ways to improve commercial driver performance.
-- RiskTrac Workers Compensation Analytics Interactive Dashboard - A dashboard added to Liberty Mutual Insurance Co.'s risk management information system that provides workers compensation policyholders with a customized predictive model.
Liberty Mutual offers workers compensation solutions through its Global Risk Solutions (GRS) division ...
If workers’ comp professionals weren’t already hopping on the tech-train, a report in Risk and Insurance claims they certainly are now as much of the workforce transitioned to telecommuting when COVID-19 collided with our realities back in March.
Digitization has been well on its way for decades, but the suddenly urgent need for remote work changed what it means to utilize technology.
A July 23 survey of 400 American workers’ compensation professionals, conducted by Lightico and Sapiens, highlighted the challenges and burdens of an amplified technology surge.
According to the report, technology is most easily and efficiently leveraged by companies with 500 to 1000 insureds. Forty-two percent of professionals within companies of that size said their organization is leveraging technology to its maximum ability. Forty-four percent of companies of the same size said that their processes have already been completely automated. Quick Improvements in New Environments
In the survey, 87% of respondents claim that they are currently leveraging data to improve underwriting and product development to drive revenues and profitability.
In addition to increased investment in technology, here’s what insurance companies are considering as they prepare for a new normal:
-- 76% of respondents are rethinking injury prevention training and education due to the new threat of COVID-19;
-- 86% of workers’ comp professionals are considering incorporating telemedicine into their overall medical cost containment strategy;
-- 89% are actively exploring better ways to communicate with employers and injured workers through multi-channel communication alternatives, such as texting;
-- 79% are looking at incorporating additional services or programs to insureds to offset premium impacts; and
-- 93% have seen a greater need for offering more flexible payment options to policyholders and injured workers (i.e. pre-paid debit card, ACH, virtual card, etc.).
A majority of respondents cited processes such as paperwork, compliance signatures, document collection, claims management and payments as the most burdensome during this transition to digitization.
Preparing for the new normal requires rethinking not just how technology can apply to these administrative processes, but every aspect of a program. Nearly all respondents, for example, are utilizing digitization to attract the next generation of claims handlers.
While the coronavirus has upended virtually every industry and aspect of life, it has also created a window for growth. For workers’ comp, it’s looking like that window will most likely be a computer screen ...
Digitization has been well on its way for decades, but the suddenly urgent need for remote work changed what it means to utilize technology.
A July 23 survey of 400 American workers’ compensation professionals, conducted by Lightico and Sapiens, highlighted the challenges and burdens of an amplified technology surge.
According to the report, technology is most easily and efficiently leveraged by companies with 500 to 1000 insureds. Forty-two percent of professionals within companies of that size said their organization is leveraging technology to its maximum ability. Forty-four percent of companies of the same size said that their processes have already been completely automated. Quick Improvements in New Environments
In the survey, 87% of respondents claim that they are currently leveraging data to improve underwriting and product development to drive revenues and profitability.
In addition to increased investment in technology, here’s what insurance companies are considering as they prepare for a new normal:
-- 76% of respondents are rethinking injury prevention training and education due to the new threat of COVID-19;
-- 86% of workers’ comp professionals are considering incorporating telemedicine into their overall medical cost containment strategy;
-- 89% are actively exploring better ways to communicate with employers and injured workers through multi-channel communication alternatives, such as texting;
-- 79% are looking at incorporating additional services or programs to insureds to offset premium impacts; and
-- 93% have seen a greater need for offering more flexible payment options to policyholders and injured workers (i.e. pre-paid debit card, ACH, virtual card, etc.).
A majority of respondents cited processes such as paperwork, compliance signatures, document collection, claims management and payments as the most burdensome during this transition to digitization.
Preparing for the new normal requires rethinking not just how technology can apply to these administrative processes, but every aspect of a program. Nearly all respondents, for example, are utilizing digitization to attract the next generation of claims handlers.
While the coronavirus has upended virtually every industry and aspect of life, it has also created a window for growth. For workers’ comp, it’s looking like that window will most likely be a computer screen ...
Fiore Industries provides qualified management, personnel, and equipment to operate and maintain effective, self-sufficient Airport Rescue and Fire Fighting and airport operational support services. These services are compliant with Federal Aviation Regulations Part 139, OSHA, NFPA, and IFSTA.
The company agreed to pay the United States $1,200,000 to resolve allegations that it caused false claims to be submitted to the government for payment.
Fiore is a subcontractor that provide fire protection services at NASA’s Ames field center in Mountain View, Calif. According to the settlement agreement made public today, the settlement resolves the government’s claims that in 2016 Fiore overcharged the government by seeking hundreds of thousands of dollars in additional payments from NASA based on inflated workers’ compensation rates. The government claimed that the rates Fiore submitted to justify the additional payments did not account for discounts Fiore knew it would receive but did not disclose to NASA.
"Federal contractors and subcontractors must deal squarely and honestly with the government at all times," said U.S. Attorney Anderson. "By signing this agreement, Fiore agrees to account for various deductions to which the government is entitled and also agrees to cooperate with any further investigation into other parties that may be responsible for overcharging. This agreement protects taxpayers by holding government contractors accountable for their claims practices."
The claims resolved by this settlement are allegations only, and there has been no determination of liability.
Assistant U.S. Attorney Sharanya Mohan handled the matter for the government, with assistance from Kurt Kosek. The settlement is the result of an investigation by the U.S. Attorney’s Office for the Northern District of California and the NASA Office of Inspector General, with significant assistance from other components of NASA ...
The company agreed to pay the United States $1,200,000 to resolve allegations that it caused false claims to be submitted to the government for payment.
Fiore is a subcontractor that provide fire protection services at NASA’s Ames field center in Mountain View, Calif. According to the settlement agreement made public today, the settlement resolves the government’s claims that in 2016 Fiore overcharged the government by seeking hundreds of thousands of dollars in additional payments from NASA based on inflated workers’ compensation rates. The government claimed that the rates Fiore submitted to justify the additional payments did not account for discounts Fiore knew it would receive but did not disclose to NASA.
"Federal contractors and subcontractors must deal squarely and honestly with the government at all times," said U.S. Attorney Anderson. "By signing this agreement, Fiore agrees to account for various deductions to which the government is entitled and also agrees to cooperate with any further investigation into other parties that may be responsible for overcharging. This agreement protects taxpayers by holding government contractors accountable for their claims practices."
The claims resolved by this settlement are allegations only, and there has been no determination of liability.
Assistant U.S. Attorney Sharanya Mohan handled the matter for the government, with assistance from Kurt Kosek. The settlement is the result of an investigation by the U.S. Attorney’s Office for the Northern District of California and the NASA Office of Inspector General, with significant assistance from other components of NASA ...
Ride-hailing will continue in California for the time being as Uber Technologies Inc. and Lyft Inc. won more time Thursday in their appeal of a ruling that ordered them to immediately classify their ride-hailing drivers as employees in compliance with state law.
The companies have five days to agree to expedited procedures outlined by a state appeals court judge Thursday, which includes consolidating both appeals and requiring the companies to submit sworn statements by Sept. 4 from their chief executives that the companies have developed plans to obey an Aug. 10 order to classify their drivers as employees instead of independent contractors.
"Should Lyft or Uber fail to comply with these procedures, the People may apply to this court to vacate this stay," wrote Stuart Pollak, presiding judge of the First District Court of Appeal in California. He set an Oct. 13 date for oral arguments in the case.
Uber and Lyft confirmed they will not be shutting down their ride-hailing services, as they had planned to do if they failed to secure an emergency stay.
"While we won’t have to suspend operations tonight, we do need to continue fighting for independence plus benefits for drivers," said Julie Wood, spokeswoman for Lyft.
Uber spokesman Davis White said, "We are glad that the Court of Appeals recognized the important questions raised in this case, and that access to these critical services won’t be cut off while we continue to advocate for drivers’ ability to work with the freedom they want."
In May, California’s attorney general and the city attorneys of San Francisco, Los Angeles and San Diego sued Uber and Lyft, accusing them of failing to obey California law by continuing to consider their drivers as independent contractors, and asked the court for an injunction to force the companies to classify them as employees. A San Francisco Superior Court judge ruled Aug. 10 that the ride-hailing giants must immediately comply but gave them a 10-day stay for their appeals. That expired Thursday.
The two companies are counting on California voters to approve Proposition 22, an initiative they and other gig companies have poured $110 million into to exempt gig workers from the law, Assembly Bill 5, which became effective Jan. 1.
With Prop. 22, the companies are proposing a "third way" that they say gives additional pay and benefits to drivers and preserves their flexibility to choose when they work. But the initiative falls short of classifying drivers as employees with all the benefits that entails, including being eligible for unemployment insurance ...
The companies have five days to agree to expedited procedures outlined by a state appeals court judge Thursday, which includes consolidating both appeals and requiring the companies to submit sworn statements by Sept. 4 from their chief executives that the companies have developed plans to obey an Aug. 10 order to classify their drivers as employees instead of independent contractors.
"Should Lyft or Uber fail to comply with these procedures, the People may apply to this court to vacate this stay," wrote Stuart Pollak, presiding judge of the First District Court of Appeal in California. He set an Oct. 13 date for oral arguments in the case.
Uber and Lyft confirmed they will not be shutting down their ride-hailing services, as they had planned to do if they failed to secure an emergency stay.
"While we won’t have to suspend operations tonight, we do need to continue fighting for independence plus benefits for drivers," said Julie Wood, spokeswoman for Lyft.
Uber spokesman Davis White said, "We are glad that the Court of Appeals recognized the important questions raised in this case, and that access to these critical services won’t be cut off while we continue to advocate for drivers’ ability to work with the freedom they want."
In May, California’s attorney general and the city attorneys of San Francisco, Los Angeles and San Diego sued Uber and Lyft, accusing them of failing to obey California law by continuing to consider their drivers as independent contractors, and asked the court for an injunction to force the companies to classify them as employees. A San Francisco Superior Court judge ruled Aug. 10 that the ride-hailing giants must immediately comply but gave them a 10-day stay for their appeals. That expired Thursday.
The two companies are counting on California voters to approve Proposition 22, an initiative they and other gig companies have poured $110 million into to exempt gig workers from the law, Assembly Bill 5, which became effective Jan. 1.
With Prop. 22, the companies are proposing a "third way" that they say gives additional pay and benefits to drivers and preserves their flexibility to choose when they work. But the initiative falls short of classifying drivers as employees with all the benefits that entails, including being eligible for unemployment insurance ...
Lawyer Scott Hughes, 44, of Newport Beach, California, has been accused of helping launder at least $20 million in an alleged cryptocurrency Ponzi scheme. He is a personal injury and criminal attorney, and reportedly represented applicants in workers' compensation matters in Orange and Los Angeles Counties.
The indictment unsealed Tuesday claims that Hughes and four other defendants promised guaranteed returns for phantom investments in cryptocurrencies through a company called the AirBit Club. Hughes is charged with conspiracy to commit money laundering and conspiracy to commit bank fraud.
Acting United States Attorney Audrey Strauss said: "As alleged, the defendants put a modern-day spin on an age-old investment scam, promising extraordinary rates of guaranteed return on phantom investments in cryptocurrencies. Thanks to HSI, the defendants are in custody and facing serious criminal charges."
Prosecutors say "those arrested today have not only been charged with running a multimillion-dollar cryptocurrency investment fraud and money laundering ring, but also for allegedly spending their victim’s money on luxury cars, jewelry, and homes. These alleged fraudsters pulled out all the stops to sell their scheme to their victims with enticing recruitment events, then shamelessly used proceeds of their scheme to recruit additional victims through even more aggressive and lavish marketing pitches.
According to the allegations in the Superseding Indictment the defendants participated in a coordinated scheme in which victim-investors were induced to invest in AirBit Club based on the promise of guaranteed profits in exchange for cash investments in club "memberships."
They marketed AirBit Club as a multilevel marketing club in the cryptocurrency industry, and falsely promised Victims that AirBit Club earned returns on cryptocurrency mining and trading and that victims would earn passive, guaranteed daily returns on any membership purchased.
Attorney Hughes, who is licensed to practice law in California, had previously represented two of the co-defendants in a Securities and Exchange Commission investigation related to another investment scheme known as Vizinova before aiding the two in perpetrating the AirBit Club Scheme by, among other things, helping to remove negative information about AirBit Club and Vizinova from the internet.
In many instances, as early as 2016, Victims who attempted to withdraw money from the AirBit Club Online Portal and complained to a Promoter were met with excuses, delays, and hidden fees amounting to more than 50% of the Victim’s requested withdrawal, if they were able to make any withdrawal at all ...
The indictment unsealed Tuesday claims that Hughes and four other defendants promised guaranteed returns for phantom investments in cryptocurrencies through a company called the AirBit Club. Hughes is charged with conspiracy to commit money laundering and conspiracy to commit bank fraud.
Acting United States Attorney Audrey Strauss said: "As alleged, the defendants put a modern-day spin on an age-old investment scam, promising extraordinary rates of guaranteed return on phantom investments in cryptocurrencies. Thanks to HSI, the defendants are in custody and facing serious criminal charges."
Prosecutors say "those arrested today have not only been charged with running a multimillion-dollar cryptocurrency investment fraud and money laundering ring, but also for allegedly spending their victim’s money on luxury cars, jewelry, and homes. These alleged fraudsters pulled out all the stops to sell their scheme to their victims with enticing recruitment events, then shamelessly used proceeds of their scheme to recruit additional victims through even more aggressive and lavish marketing pitches.
According to the allegations in the Superseding Indictment the defendants participated in a coordinated scheme in which victim-investors were induced to invest in AirBit Club based on the promise of guaranteed profits in exchange for cash investments in club "memberships."
They marketed AirBit Club as a multilevel marketing club in the cryptocurrency industry, and falsely promised Victims that AirBit Club earned returns on cryptocurrency mining and trading and that victims would earn passive, guaranteed daily returns on any membership purchased.
Attorney Hughes, who is licensed to practice law in California, had previously represented two of the co-defendants in a Securities and Exchange Commission investigation related to another investment scheme known as Vizinova before aiding the two in perpetrating the AirBit Club Scheme by, among other things, helping to remove negative information about AirBit Club and Vizinova from the internet.
In many instances, as early as 2016, Victims who attempted to withdraw money from the AirBit Club Online Portal and complained to a Promoter were met with excuses, delays, and hidden fees amounting to more than 50% of the Victim’s requested withdrawal, if they were able to make any withdrawal at all ...
The number of California workers’ compensation claims for COVID-19 continues to climb, as data from the Division of Workers’ Compensation (DWC) show that as of August 10, there were 9,515 claims reported for the month of July, bringing the total for the year to 31,612 claims, or 10.2% of all California job injury claims reported for accident year (AY) 2020.
Those claims include 140 death claims, up from 66 reported as of July 6.
Updated figures for May and June show sharp increases in COVID-19 claims for each of those months, as the number of COVID-19 claims with June injury dates more than doubled from 4,438 claims as of July 6 to 10,528 claims as of August 10, while COVID-19 claims with May injury dates rose from 3,889 cases to 4,606 claims (+18.4%), indicating a time lag in the filing, reporting, and recording of many COVID-19 claims.
Using claim development factors the California Workers’ Compensation Institute (CWCI) projects there could ultimately be 29,354 COVID-19 claims with July injury dates and 56,082 COVID-19 claims with January through July injury dates.
Health care workers continue to account for the largest share of California’s COVID-19 claims, filing 38.7% of the claims recorded for the first 7 months of this year, followed by public safety/government workers who accounted for 15.8%. Rounding out the top 5 industries based on COVID-19 claim volume were retail trade (7.9%), manufacturing (7.0%), and transportation (4.7%).
The updated data is included in the latest iteration of CWCI’s COVID-19 and Non-COVID-19 Interactive Claim Application, an online data tool that integrates data from CWCI, the Bureau of Labor and Statistics and the DWC to provide detailed information on California workers’ comp claims from comparable periods of 2019 and 2020.
The new version features data on 710,224 claims from the first 7 months of AY 2019 and AY 2020, including all 31,612 COVID-19 claims from AY 2020. The application allows users to explore and analyze:
CWCI will continue to update the application and expand its features and functions as more data on claim type and average and systemwide costs become available ...
Those claims include 140 death claims, up from 66 reported as of July 6.
Updated figures for May and June show sharp increases in COVID-19 claims for each of those months, as the number of COVID-19 claims with June injury dates more than doubled from 4,438 claims as of July 6 to 10,528 claims as of August 10, while COVID-19 claims with May injury dates rose from 3,889 cases to 4,606 claims (+18.4%), indicating a time lag in the filing, reporting, and recording of many COVID-19 claims.
Using claim development factors the California Workers’ Compensation Institute (CWCI) projects there could ultimately be 29,354 COVID-19 claims with July injury dates and 56,082 COVID-19 claims with January through July injury dates.
Health care workers continue to account for the largest share of California’s COVID-19 claims, filing 38.7% of the claims recorded for the first 7 months of this year, followed by public safety/government workers who accounted for 15.8%. Rounding out the top 5 industries based on COVID-19 claim volume were retail trade (7.9%), manufacturing (7.0%), and transportation (4.7%).
The updated data is included in the latest iteration of CWCI’s COVID-19 and Non-COVID-19 Interactive Claim Application, an online data tool that integrates data from CWCI, the Bureau of Labor and Statistics and the DWC to provide detailed information on California workers’ comp claims from comparable periods of 2019 and 2020.
The new version features data on 710,224 claims from the first 7 months of AY 2019 and AY 2020, including all 31,612 COVID-19 claims from AY 2020. The application allows users to explore and analyze:
CWCI will continue to update the application and expand its features and functions as more data on claim type and average and systemwide costs become available ...
The National Law Review spotlight is on a category of COVID-19 related workplace complaints that undoubtedly has caused many sleepless nights for employers around the country: deaths caused by COVID-19 infections allegedly connected to the workplace.
This week’s update to the tracker includes two such cases - one relates to the alleged wrongful death of an employee from COVID-19, and the other concerns the death of an employee’s spouse.
In each case, the plaintiffs allege a lack of effective institutional response to the virus, as well as a failure to warn employees who may have come in contact with the COVID-19 virus in the workplace. The allegations in these cases demonstrate the importance of employers implementing a plan of action to mitigate the dangers to the workforce.
First, in Iniguez v. Aurora Packing Company, Inc., the plaintiff, administrator of a deceased woman’s estate, filed a wrongful death and survival action against the defendant, a meat-packing facility. The defendant employed the decedent’s husband as a butcher. The plaintiff alleges that in late April 2020, the decedent’s husband contracted COVID-19 while at work, and infected his wife, who died from the virus on May 2.
According to the plaintiff, the defendant knew employees had contracted COVID-19 at its facility, yet did nothing to mitigate the spread of the virus in the facility. The plaintiff alleges that the defendant was negligent by, among other things, failing to warn employees of a COVID-19 outbreak and failing to implement an infectious disease preparedness and response plan or infection prevention measures consistent with CDC and state department of health guidelines.
The plaintiff also asserts that the defendant actively created risk, including by "choosing not to": provide employees with PPE, implement engineering controls to prevent the virus from spreading, take reasonable measures to allow for social distancing, screen and monitor workers, implement and communicate leave policy, and provide handwashing breaks, hot water, and sanitizer.
In Montgomery v. Prevarian Senior Living, LP, the plaintiffs, the surviving family members of a deceased assisted living facility worker, allege wrongful death and gross negligence under Texas law. The plaintiffs allege that both the deceased and their daughter, one of the plaintiffs, worked for the assisted living and memory care facility, and both were exposed to COVID-19 when assigned by their employer to sit for hours at a time, unprotected, with a resident whom the employer knew (but did not tell its employees) had tested positive for the virus.
The plaintiffs allege that assisted living facilities have often been described as "epicenters" for COVID-19, and that the deceased in particular was at higher risk of experiencing severe COVID-19 complications, including death, due to being overweight and a minority. The plaintiffs allege that the employer owed the deceased a duty to provide a safe workplace.
As the pandemic continues, the unfortunate reality is that we expect to see more illness among employee populations, and more litigation alleging that an employer’s alleged unpreparedness and lack of transparency relative to COVID-19 resulted in the spread of the virus among an employee population, and caused sickness or even death.
As ever, mindful employers would do well to understand and follow the public health guidance coming out at the local, state, and federal levels ...
This week’s update to the tracker includes two such cases - one relates to the alleged wrongful death of an employee from COVID-19, and the other concerns the death of an employee’s spouse.
In each case, the plaintiffs allege a lack of effective institutional response to the virus, as well as a failure to warn employees who may have come in contact with the COVID-19 virus in the workplace. The allegations in these cases demonstrate the importance of employers implementing a plan of action to mitigate the dangers to the workforce.
First, in Iniguez v. Aurora Packing Company, Inc., the plaintiff, administrator of a deceased woman’s estate, filed a wrongful death and survival action against the defendant, a meat-packing facility. The defendant employed the decedent’s husband as a butcher. The plaintiff alleges that in late April 2020, the decedent’s husband contracted COVID-19 while at work, and infected his wife, who died from the virus on May 2.
According to the plaintiff, the defendant knew employees had contracted COVID-19 at its facility, yet did nothing to mitigate the spread of the virus in the facility. The plaintiff alleges that the defendant was negligent by, among other things, failing to warn employees of a COVID-19 outbreak and failing to implement an infectious disease preparedness and response plan or infection prevention measures consistent with CDC and state department of health guidelines.
The plaintiff also asserts that the defendant actively created risk, including by "choosing not to": provide employees with PPE, implement engineering controls to prevent the virus from spreading, take reasonable measures to allow for social distancing, screen and monitor workers, implement and communicate leave policy, and provide handwashing breaks, hot water, and sanitizer.
In Montgomery v. Prevarian Senior Living, LP, the plaintiffs, the surviving family members of a deceased assisted living facility worker, allege wrongful death and gross negligence under Texas law. The plaintiffs allege that both the deceased and their daughter, one of the plaintiffs, worked for the assisted living and memory care facility, and both were exposed to COVID-19 when assigned by their employer to sit for hours at a time, unprotected, with a resident whom the employer knew (but did not tell its employees) had tested positive for the virus.
The plaintiffs allege that assisted living facilities have often been described as "epicenters" for COVID-19, and that the deceased in particular was at higher risk of experiencing severe COVID-19 complications, including death, due to being overweight and a minority. The plaintiffs allege that the employer owed the deceased a duty to provide a safe workplace.
As the pandemic continues, the unfortunate reality is that we expect to see more illness among employee populations, and more litigation alleging that an employer’s alleged unpreparedness and lack of transparency relative to COVID-19 resulted in the spread of the virus among an employee population, and caused sickness or even death.
As ever, mindful employers would do well to understand and follow the public health guidance coming out at the local, state, and federal levels ...
California received a batch of mostly positive pandemic-related developments on Monday with data showing that the number of people dying of COVID-19 is beginning to decline and hospitalization rates continue to fall steadily.
Gov. Gavin Newsom also announced that San Diego County, the state's second largest, has made enough progress against the novel coronavirus that it could be removed from the watch list as early as this week.
In one of the key pandemic metrics, the seven-day daily rolling average of fatalities fell to fewer than 130 deaths per day on Sunday for the first time since last month, according to a Times analysis of state data. The number of hospital patients with COVID-19 has declined steadily for a month, the data show.
Community spread appears to be falling, too: The share of Californians who tested positive over a two-week period dipped to 6.5% Monday, an early indication that California is "stabilizing, and moving broadly in the right direction," Newsom said.
The promising data come two weeks after Newsom touted a falling infection rate, then backtracked after officials found errors in how the data had been reported. On Monday, for the first time since the data breakdown, the state updated its watchlist of areas with high case rates, offering a mixed picture around the state.
Although Santa Cruz was taken off the list, four small counties - Amador, Mendocino, Inyo and Calaveras - were added and must close businesses by Thursday.
The infection rate in San Diego has stayed beneath 100 cases per 100,000 residents for nearly a week. "It’s extraordinarily good news, speaking on behalf not just of the county but the state of California," Newsom said.
Los Angeles County continues to make progress toward getting off the watchlist, with the average daily number of infections, hospitalizations and deaths falling steadily, said Barbara Ferrer, the head of the Department of Public Health.
The county meets five of the six metrics used to measure progress against the pandemic, including testing more than 150 people per 100,000 residents per day, and maintaining a healthy margin of available intensive-care beds and ventilators.
The county continues to make progress on reducing community transmission to meet the most stubborn benchmark: a 14-day average of fewer than 100 coronavirus cases per 100,000 residents for three consecutive days.
Last week, the county reported 335 cases per 100,000 residents; on Sunday, the rate was 298 cases per 100,000.
Daily hospitalizations in Los Angeles County have fallen 37% over a month, from 2,219 cases per day in mid-July, to 1,388 cases in mid-August, Ferrer said. The average number of daily deaths has fallen from 43 to 30 over the same time period, she said.
The hospitalization rate data is "one of our best indicators that our efforts over the last few weeks are actually working," Ferrer said, in part because it was not affected by the data reporting errors.
...
Gov. Gavin Newsom also announced that San Diego County, the state's second largest, has made enough progress against the novel coronavirus that it could be removed from the watch list as early as this week.
In one of the key pandemic metrics, the seven-day daily rolling average of fatalities fell to fewer than 130 deaths per day on Sunday for the first time since last month, according to a Times analysis of state data. The number of hospital patients with COVID-19 has declined steadily for a month, the data show.
Community spread appears to be falling, too: The share of Californians who tested positive over a two-week period dipped to 6.5% Monday, an early indication that California is "stabilizing, and moving broadly in the right direction," Newsom said.
The promising data come two weeks after Newsom touted a falling infection rate, then backtracked after officials found errors in how the data had been reported. On Monday, for the first time since the data breakdown, the state updated its watchlist of areas with high case rates, offering a mixed picture around the state.
Although Santa Cruz was taken off the list, four small counties - Amador, Mendocino, Inyo and Calaveras - were added and must close businesses by Thursday.
The infection rate in San Diego has stayed beneath 100 cases per 100,000 residents for nearly a week. "It’s extraordinarily good news, speaking on behalf not just of the county but the state of California," Newsom said.
Los Angeles County continues to make progress toward getting off the watchlist, with the average daily number of infections, hospitalizations and deaths falling steadily, said Barbara Ferrer, the head of the Department of Public Health.
The county meets five of the six metrics used to measure progress against the pandemic, including testing more than 150 people per 100,000 residents per day, and maintaining a healthy margin of available intensive-care beds and ventilators.
The county continues to make progress on reducing community transmission to meet the most stubborn benchmark: a 14-day average of fewer than 100 coronavirus cases per 100,000 residents for three consecutive days.
Last week, the county reported 335 cases per 100,000 residents; on Sunday, the rate was 298 cases per 100,000.
Daily hospitalizations in Los Angeles County have fallen 37% over a month, from 2,219 cases per day in mid-July, to 1,388 cases in mid-August, Ferrer said. The average number of daily deaths has fallen from 43 to 30 over the same time period, she said.
The hospitalization rate data is "one of our best indicators that our efforts over the last few weeks are actually working," Ferrer said, in part because it was not affected by the data reporting errors.
...
Misleading health content has racked up an estimated 3.8 billion views on Facebook over the past year, peaking during the COVID-19 pandemic, advocacy group Avaaz said in a new report here on Wednesday.
The report found that content from 10 "superspreader" sites sharing health misinformation had almost four times as many Facebook views in April 2020 as equivalent content from the sites of 10 leading health institutions, such as the World Health Organization and the Centers for Disease Control and Prevention.
The social media giant, which has been under pressure to curb misinformation on its platform, has made amplifying credible health information a key element of its response. It also started removing misinformation about the novel coronavirus outbreak that it said could cause imminent harm.
"Facebook’s algorithm is a major threat to public health. Mark Zuckerberg promised to provide reliable information during the pandemic, but his algorithm is sabotaging those efforts by driving many of Facebook’s 2.7 billion users to health misinformation-spreading networks," said Fadi Quran, campaign director at Avaaz.
"We share Avaaz’s goal of limiting misinformation, but their findings don’t reflect the steps we’ve taken to keep it from spreading on our services" said a Facebook company spokeswoman.
"Thanks to our global network of fact-checkers, from April to June, we applied warning labels to 98 million pieces of COVID-19 misinformation and removed 7 million pieces of content that could lead to imminent harm. We’ve directed over 2 billion people to resources from health authorities and when someone tries to share a link about COVID-19, we show them a pop-up to connect them with credible health information," she said.
Avaaz’s report also said that warning labels from fact-checkers were applied inconsistently even when misinformation had been found to be false.
The report tracked how content from a sample of misinformation-sharing websites was shared on Facebook by interpreting available Facebook data between May 2019 and May 2020 ...
The report found that content from 10 "superspreader" sites sharing health misinformation had almost four times as many Facebook views in April 2020 as equivalent content from the sites of 10 leading health institutions, such as the World Health Organization and the Centers for Disease Control and Prevention.
The social media giant, which has been under pressure to curb misinformation on its platform, has made amplifying credible health information a key element of its response. It also started removing misinformation about the novel coronavirus outbreak that it said could cause imminent harm.
"Facebook’s algorithm is a major threat to public health. Mark Zuckerberg promised to provide reliable information during the pandemic, but his algorithm is sabotaging those efforts by driving many of Facebook’s 2.7 billion users to health misinformation-spreading networks," said Fadi Quran, campaign director at Avaaz.
"We share Avaaz’s goal of limiting misinformation, but their findings don’t reflect the steps we’ve taken to keep it from spreading on our services" said a Facebook company spokeswoman.
"Thanks to our global network of fact-checkers, from April to June, we applied warning labels to 98 million pieces of COVID-19 misinformation and removed 7 million pieces of content that could lead to imminent harm. We’ve directed over 2 billion people to resources from health authorities and when someone tries to share a link about COVID-19, we show them a pop-up to connect them with credible health information," she said.
Avaaz’s report also said that warning labels from fact-checkers were applied inconsistently even when misinformation had been found to be false.
The report tracked how content from a sample of misinformation-sharing websites was shared on Facebook by interpreting available Facebook data between May 2019 and May 2020 ...
Last Friday, President Donald Trump signed an expansion of the federal Public Safety Officers' Benefits Program to include disability or death from COVID-19 among the criteria for payments.
The Public Safety Officers' Benefits Program (PSOB) provides a death benefit to the eligible survivors of Federal, state or local public safety officers whose death was the direct and proximate result of a personal (traumatic) injury sustained in the line of duty (certain fatal, line of duty heart attacks and strokes are also covered).
The act also provides a disability benefit to eligible public safety officers who have been permanently and totally disabled as the direct result of a catastrophic personal injury sustained in the line of duty. The injury must permanently prevent the officer from performing any gainful work.
The amount of the PSOB benefit is $359,316.00 for eligible deaths and disabilities occurring on or after October 1, 2018. The amount of the PSOB educational assistance benefit for one month of full-time attendance on or after October 1, 2018 is $1,224.00.
The Safeguarding America's First Responders Act of 2020 is similar to the HEROES Act, which secured benefits for the families of those who gave their lives during the Sept. 11 terrorist attacks.
The new Act extends the Public Safety Officers Benefits Program by creating a presumption that if a first responder is diagnosed with the coronavirus within 45 days of their last day on the job, the Department of Justice will treat it as a line of duty incident and provide the payments.
The Act provides that "..unless competent medical evidence establishes that the death of a public safety officer (as defined in section 1204 of title I of the Omnibus Crime Control and Safe Streets Act of 1968 (34 U.S.C. 10284)) was directly and proximately caused by something other than COVID-19, COVID-19 (or complications therefrom) suffered by the public safety officer shall be presumed to constitute a personal injury within the meaning of section 1201(a) of title I of the Omnibus Crime Control and Safe Streets Act of 1968 (34 U.S.C. 10281(a)), sustained in the line of duty by the officer.."
Before, the illness had to be officially linked to a job-related source. That burden of proof required painstaking contact tracing efforts.
U.S. Sen. Chuck Grassley, an Iowa Republican who introduced the measure in the U.S. Senate, said the law was needed to keep the survivors of first responders who die from COVID-19 from having to prove their loved one contracted it on the job ...
The Public Safety Officers' Benefits Program (PSOB) provides a death benefit to the eligible survivors of Federal, state or local public safety officers whose death was the direct and proximate result of a personal (traumatic) injury sustained in the line of duty (certain fatal, line of duty heart attacks and strokes are also covered).
The act also provides a disability benefit to eligible public safety officers who have been permanently and totally disabled as the direct result of a catastrophic personal injury sustained in the line of duty. The injury must permanently prevent the officer from performing any gainful work.
The amount of the PSOB benefit is $359,316.00 for eligible deaths and disabilities occurring on or after October 1, 2018. The amount of the PSOB educational assistance benefit for one month of full-time attendance on or after October 1, 2018 is $1,224.00.
The Safeguarding America's First Responders Act of 2020 is similar to the HEROES Act, which secured benefits for the families of those who gave their lives during the Sept. 11 terrorist attacks.
The new Act extends the Public Safety Officers Benefits Program by creating a presumption that if a first responder is diagnosed with the coronavirus within 45 days of their last day on the job, the Department of Justice will treat it as a line of duty incident and provide the payments.
The Act provides that "..unless competent medical evidence establishes that the death of a public safety officer (as defined in section 1204 of title I of the Omnibus Crime Control and Safe Streets Act of 1968 (34 U.S.C. 10284)) was directly and proximately caused by something other than COVID-19, COVID-19 (or complications therefrom) suffered by the public safety officer shall be presumed to constitute a personal injury within the meaning of section 1201(a) of title I of the Omnibus Crime Control and Safe Streets Act of 1968 (34 U.S.C. 10281(a)), sustained in the line of duty by the officer.."
Before, the illness had to be officially linked to a job-related source. That burden of proof required painstaking contact tracing efforts.
U.S. Sen. Chuck Grassley, an Iowa Republican who introduced the measure in the U.S. Senate, said the law was needed to keep the survivors of first responders who die from COVID-19 from having to prove their loved one contracted it on the job ...
The U.S. Attorney’s Office has reached a $3.5 million settlement with specialty pharmacy Advanced Care Scripts, Inc, to resolve allegations that ACS conspired with pharmaceutical manufacturer Teva Neuroscience, Inc. to enable Teva to pay kickbacks to Medicare patients taking Copaxone, a Teva drug approved for treatment of multiple sclerosis.
When a Medicare beneficiary obtains a prescription drug covered by Medicare Part B or Part D, the beneficiary may be required to make a partial payment, which may take the form of a co-payment, co-insurance, or deductible. These co-pay obligations may be substantial for expensive medications.
Congress included co-pay requirements in these programs to encourage market forces to serve as a check on health care costs, including the prices that pharmaceutical manufacturers can demand for their drugs.
The Anti-Kickback Statute prohibits pharmaceutical companies from offering or paying, directly or indirectly, any remuneration - which includes money or any other thing of value - to induce Medicare patients to purchase the companies’ drugs.
Advanced Care Scripts served as a contracted vendor for Teva and provided, among other things, benefits investigation services to certain patients who had been prescribed Copaxone. As part of the settlement, the company acknowledged certain facts.
Advanced Care Scripts knowingly enabled a large pharmaceutical manufacturer to pay kickbacks to Medicare patients taking its expensive drug. Prosecutors say that such conduct undermined the Medicare program’s co-pay structure, which Congress created as a safeguard against inflated drug prices.
"Advanced Care Scripts (ACS) willingly served as a pawn in a kickback scheme, putting profit over patient needs, by helping Teva to time its foundation payments to boost sales of Teva's own drug, which ACS then dispensed," said Joseph R. Bonavolonta, Special Agent in Charge of the FBI Boston Division ...
When a Medicare beneficiary obtains a prescription drug covered by Medicare Part B or Part D, the beneficiary may be required to make a partial payment, which may take the form of a co-payment, co-insurance, or deductible. These co-pay obligations may be substantial for expensive medications.
Congress included co-pay requirements in these programs to encourage market forces to serve as a check on health care costs, including the prices that pharmaceutical manufacturers can demand for their drugs.
The Anti-Kickback Statute prohibits pharmaceutical companies from offering or paying, directly or indirectly, any remuneration - which includes money or any other thing of value - to induce Medicare patients to purchase the companies’ drugs.
Advanced Care Scripts served as a contracted vendor for Teva and provided, among other things, benefits investigation services to certain patients who had been prescribed Copaxone. As part of the settlement, the company acknowledged certain facts.
Advanced Care Scripts knowingly enabled a large pharmaceutical manufacturer to pay kickbacks to Medicare patients taking its expensive drug. Prosecutors say that such conduct undermined the Medicare program’s co-pay structure, which Congress created as a safeguard against inflated drug prices.
"Advanced Care Scripts (ACS) willingly served as a pawn in a kickback scheme, putting profit over patient needs, by helping Teva to time its foundation payments to boost sales of Teva's own drug, which ACS then dispensed," said Joseph R. Bonavolonta, Special Agent in Charge of the FBI Boston Division ...
