Menu Close

Workers’ Compensation Daily News Archive

As Apple pushes deeper into health care with the Apple Watch, CNBC reports that the company is developing a plan to help people who are recovering from knee and hip replacement surgeries.

Apple announced a partnership with medical device company Zimmer Biomet, to combine a new app along with health-tracking data from the smartwatch to help determine why certain patients recover faster than others from the procedures. The companies are also working together on a clinical study.

Apple has its sights set square on the $3 trillion U.S. health-care sector and is continuously exploring medical applications for the watch, most recently adding an FDA-cleared EKG sensor. When it comes to orthopedics, more than than 1 million Americans get knee and hip replacements every year, and Zimmer Biomet is among the biggest manufacturers of reconstructive products.

Apple and Zimmer Biomet have created a mobile app called mymobility, which aims to help guide patients through their surgery to improve their experience, as well as their health outcomes. It includes educational resources, exercise videos and a way for patients to contact their surgeon and care team with questions and concerns.

The Apple Watch will track steps and heart rate data, allowing patients to share that information with their doctors to provide a clearer picture of how they're doing after surgery and to analyze potential setbacks. For example, if a patient is concerned about the level of pain, the care team could see that the patient walked five miles the previous day, so the problem may be overexertion rather than a serious complication.

Apple and Zimmer Biomet are hoping to enroll 10,000 people in the U.S. in the study. The app is initially available only to patients who enroll in the study, but it will eventually be rolled out to everyone, a spokesperson for Zimmer Biomet told CNBC. Participants who don't own an Apple Watch will receive one for the duration of the project. Fitbit has also looked at using its fitness trackers to monitor patients after surgery.

Zimmer Biomet CEO Bryan Hanson said in a statement that the partnership with Apple marks "one of the largest evidence-gathering clinical studies in orthopedic history."

Apple Chief Operating Officer Jeff Williams said in a separate statement that the new app lets patients and doctors connect in a way that was "not previously possible through traditional in-person visits."

The study is the second of its kind for Apple. In September 2017, the company kicked off its Heart Study in partnership with Stanford University, testing to see if it could detect in people a type of heart health irregularity called atrial fibrillation.

Williams told CNBC in November that Apple is open to working with some of the largest health-care companies in the space and said, "We have taken a thoughtful approach to this and embraced the medical community."

Apple is tackling among the biggest and fastest growing segments of medicine. Given the aging of the population, the number of people who receive knee and hip replacement surgeries is expected to rise in coming years.

Dan Williamson, Zimmer Biomet's group president for joint reconstruction, told CNBC a goal for the study is to "reduce anxiety for the patient and make sure the surgeon has the level of visibility they need."

The company worked with Cedars Sinai hospital in Los Angeles to figure out the optimal amount of activity for people recovering from hip and knee replacements. They reported a magic number of 1,000 steps, meaning those that reached the milestone in the days after the procedure were usually discharged sooner than those who fell short.

In another medical use for the Apple Watch, the company said recently it is donating 1,000 watches for a new study to track binge eating ...
Read More
/ / 2018 News, Daily News
It's no secret that the world is growing accustomed to the business of cannabis, but for $9.6 billion Canadian medical marijuana producer Canopy Growth, the future is approaching faster than many expect.

Canopy - which has gained traction on news of several-billion-dollar investments from Corona parent Constellation Brands - announced that it had shipped cannabis to the United States from Canada for medical research, a milestone in the U.S. government's acceptance of what it considers to be a Schedule 1 drug.

"Under [Drug Enforcement Administration] approval, we shipped, for the first time, legally - and I highlight 'legally' - cannabis from Canada to the U.S," Bruce Linton, the co-founder, Chairman and CEO of Canopy Growth, told CNBC's Jim Cramer.

"The DEA-approved partner, which we haven't announced yet, can actually begin to do medical research, clinical trials if necessary, [and] create the data set that enables people to know when, what, where, and maybe it can become federally regulated in the U.S. with some input that way," Linton said in an interview on "Mad Money."

Canopy's news comes less than one month after competing Canadian marijuana producer Tilray announced DEA approval to import cannabis to the United States for medical research at the University of California San Diego Center for Medicinal Cannabis Research.

California is one of eight states, excluding the District of Columbia, to fully legalize medical and recreational marijuana use. Thirty U.S. states currently have laws legalizing medical marijuana use in some form.

Today, the world has its eyes on Canada, where full legalization of adult marijuana use is set to take effect on Oct. 17. While the windfall will likely be massive for producers like Canopy, Linton is focused on the longer-term global opportunity.

Canada's legalization could be Canopy's key to seizing on that opportunity more than it already has, Linton added.

"Last week I was in the EU, the U.K. They know about Oct. 17 intimately and they're trying to figure out, 'Hm, if we're a government or businesses, how do we quit ignoring cannabis and govern it, regulate it, tax it and turn it into something that might be medicinal and for sure a much better formatted product for a party?'" he said.

"And so what's going to be the big bump isn't just Canada," he said. "If we do it right, Canopy leads. That gives us the position globally that then, all of a sudden, you add a zero or two to the number of people we're trying to serve."

U.S. shares of Canopy, the first cannabis company to be listed on the New York Stock Exchange, gained 5.64 percent Friday trading as the rest of the stock market recovered from its multi-day losing streak ...
Read More
/ / 2018 News, Daily News
The Department of Justice announced that it is requiring CVS Health Corporation and Aetna Inc. to divest Aetna’s Medicare Part D prescription drug plan business for individuals in order to proceed with their $69 billion merger. The proposed divestiture to WellCare Health Plans, Inc. (WellCare), an experienced health insurer focused on government-sponsored health plans, including Medicare Part D individual prescription drug plans, would fully resolve the Department’s competition concerns.

"Today’s settlement resolves competition concerns posed by this transaction and preserves competition in the sale of Medicare Part D prescription drug plans for individuals," said Assistant Attorney General Makan Delrahim of the Justice Department’s Antitrust Division. "The divestitures required here allow for the creation of an integrated pharmacy and health benefits company that has the potential to generate benefits by improving the quality and lowering the costs of the healthcare services that American consumers can obtain."

The Department’s Antitrust Division, along with the offices of five state attorneys general, today filed a civil antitrust lawsuit in the U.S. District Court for the District of Columbia to enjoin the proposed transaction, along with a proposed settlement that, if approved by the court, would fully resolve the Department’s competitive concerns. The participating state attorneys general offices represent California, Florida, Hawaii, Mississippi, and Washington.

CVS, the nation’s largest retail pharmacy chain, and Aetna, the nation’s third-largest health-insurance company, are significant competitors in the sale of Medicare Part D prescription drug plans to individuals, together serving 6.8 million members nationwide.

According to the Department’s complaint, the combination of CVS, which markets its Medicare Part D individual prescription drug plans under the "SilverScript" brand, and Aetna would cause anticompetitive effects, including increased prices, inferior customer service, and decreased innovation in sixteen Medicare Part D regions covering twenty-two states. The complaint alleges that the loss of competition between CVS and Aetna would result in lower-quality services and increased costs for consumers, the federal government, and ultimately, taxpayers.

Under the terms of the proposed settlement, Aetna must divest its individual prescription drug plan business to WellCare and allow WellCare the opportunity to hire key employees who currently operate the business. Aetna must also assist WellCare in operating the business during the transition and in transferring the affected customers through a process regulated by the Centers for Medicare and Medicaid Services, an agency within the U.S. Department of Health and Human Services.

CVS, headquartered in Woonsocket, Rhode Island, operates the nation’s largest retail pharmacy chain, owns a large pharmacy benefit manager called Caremark, and is the nation’s second-largest provider of individual prescription drug plans, with approximately 4.8 million members. CVS earned revenues of approximately $185 billion in 2017.

Aetna, headquartered in Hartford, Connecticut, is the nation’s third-largest health-insurance company and fourth-largest individual prescription drug plan insurer, with over two million prescription drug plan members. Aetna earned revenues of approximately $60 billion in 2017.

As required by the Tunney Act, the proposed consent decree, along with the Department’s competitive impact statement, will be published in the Federal Register.

Any person may submit written comments concerning the proposed settlement within 60 days of its publication to Peter Mucchetti, Chief, Healthcare and Consumer Products Section, Antitrust Division, Department of Justice, 450 Fifth Street NW, Suite 4100, Washington, DC 20530. At the conclusion of the 60-day comment period, the court may enter the final judgment upon a finding that it serves the public interest ...
Read More
/ / 2018 News, Daily News
This year, NCCI tracked more than 800 state and federal workers compensation-related bills and monitored almost 200 workers compensation-related regulations. Legislation impacting workers compensation coverage for first responders continued to be a hot topic with more than 100 bills considered. Here are the key areas of legislative interest for the coming months.

The First Responder Bills addressed compensability for certain cancers and other diseases as well as compensability for post traumatic stress disorder.

California addressed this issue with AB 1749 which was signed into law this year. This new law was created as a result of the October 1, 2017, mass shooting in Las Vegas, Nevada. The new law provides that an employer, at its discretion or in accordance with specified policies, is not precluded from accepting liability for compensation for an injury sustained by a peace officer by reason of engaging in the apprehension or attempted apprehension of law violators or suspected law violators, or protection or preservation of life or property, or the preservation of the peace, outside the state of California.

Legalization of Marijuana. At least 25 states considered legislation to legalize marijuana for medical and/or recreational purposes this year; however, only a few states, including Louisiana, Oklahoma, and Vermont enacted laws. At this time, there are nine states, plus the District of Columbia, that have legalized the recreational use of marijuana, and three states, Idaho, Kansas, and Nebraska, that have not legalized marijuana in any form.

Opioids. In 2018, almost every state introduced legislation related to prescription drugs and about 20 states considered legislation addressing prescription drugs in workers compensation. Arizona and Hawaii passed legislation this session to address the use of opioids in workers compensation.

Gig Economy. In 2018, nine states considered legislation defining the term “marketplace contractor” to classify certain on-demand workers as independent contractors. Five of those states—Florida, Indiana, Iowa, Kentucky, and Tennessee—passed legislation in 2018.

The circumstances under which California businesses may classify workers as independent contractors rather than employees under California wage laws have been greatly narrowed by a decision the California Supreme Court issued April 30, 2018.

The landmark decision in the case known as Dynamex presumes that all workers are employees, sets out a new three-part "ABC" test businesses must satisfy in order to classify workers as independent contractors, and, as one expects in California, places the burden on the business, not the worker, to prove that any particular worker is properly classified as an independent contractor. The decision has immediate ramifications for businesses throughout California.

Air Ambulances. There is pending federal legislation which is intended to preserve state authority to regulate network participation, reimbursement, and balance billing of air carriers providing air ambulance services. Currently the federal Airline Deregulation Act of 1978 has been held to preempt state regulation of air ambulance fees in some litigation. California’s Court of Appeal denied defendant’s petition for writ of review in the en banc deci ...
Read More
/ / 2018 News, Daily News
SB 880 which became law this summer, would authorize an employer, with the written consent of the employee, to deposit disability indemnity payments for the employee in a prepaid card account. This seemed like a new and novel idea. Unbeknownst to most of the industry, prepaid debit cards have been approved to pay workers' compensation benefits in California for nine years. It is certainly not a new concept here.

Last April, the California State Fund let InsurCard know that S.B. 880 had been introduced in the California Legislature to allow debit cards as a method of payment for Workers Compensation (WC) claims. The bill at the time would have established a 5-year pilot program at the State Fund. If the pilot was successful, the program would then be expanded beyond the State Fund to other companies.

Bob Mendte, InsurCard’s President, was surprised to hear this news and noted, "We have been using debit cards for WC claim payments in California for nine years. In 2008, InsurCard received detailed written approval from the Workers Compensation Director and has offered the debit card in California since that time."

InsurCard then contacted the current Workers Compensation Director, George Parisotto, and the Bill’s sponsor to make sure they were aware of InsurCard’s work and extensive experience in the State. Before they met in May, the Director’s staff had reviewed InsurCard’s credentials and the fact that its approvals had been confirmed by the State on several occasions beginning in 2008.

The Director affirmed that InsurCard’s prior approvals would continue to be honored and he recognized that no complaints have been received by the State in the nine years InsurCard has offered its debit card for WC. InsurCard will continue to offer the program in California, one of the 44 states where it does business.

After InsurCard met with the State, the California Legislature changed the bill to allow all payors to use debit cards when the Bill takes effect in January 2019.

InsurCard’s "Total Payment Solution" pays Workers Comp benefits to both claimants and healthcare providers with two network-branded cards: a personalized, reloadable plastic prepaid card for Workers Compensation indemnity payments to injured workers; and a virtual prepaid card for payments directly to healthcare providers. Both products have been praised by the industry for making electronic payments simpler, faster and secure.

InsurCard’s Instant-Issue Property card program lets adjusters deliver benefits to policyholders instantly and is used for property, auto, liability and catastrophe claims. The program is built on an existing, tested platform, ready to deliver in just a few weeks. For information, visit www.insurcard.com ...
Read More
/ / 2018 News, Daily News
Suspected drug dealer Trevon Lucas was indicted by a federal grand jury for distributing fentanyl that caused the death of a La Jolla resident, identified only as C.A.S. in court filings.

According to statements made by prosecutors at his detention hearing, C.A.S. was found dead in his mother’s home on the morning of June 30, 2018. Evidence obtained from C.A.S.’s cellular phone and a parking lot surveillance camera indicate he met Lucas to purchase prescription oxycodone pills around 11:20 p.m. the night before his mother found his body. Law enforcement officials recovered counterfeit oxycodone pills that contained fentanyl from C.A.S.’s residence, and the medical examiner has since identified fentanyl intoxication as the cause of death.

Lucas and three other residents of the Highland / San Bernardino area - Cenclair Fields, Donovan Carter, and Kevin Chandler - were also indicted for their roles in an ongoing conspiracy to distribute pharmaceutical pills containing hydrocodone. Law enforcement officials have gathered evidence indicating that Lucas and Carter posted advertisements on a well-known website to illegally sell prescription pills.

"Fentanyl is claiming record numbers of victims, most of whom don’t even know they’re swallowing a pill that’s laced with the deadly drug," said U.S. Attorney Adam Braverman. "Those who sell fentanyl resulting in death will be held accountable for their callous and reckless disregard for human life."

"We’re seeing a dangerous trend of drug dealers and cartels cutting various drugs with fentanyl, which is a recipe for death," said District Attorney Summer Stephan. "When you sell fentanyl to another human being, you are providing them with toxic poison that can kill them in a matter of seconds. Even a tiny amount of fentanyl can be deadly, which is why we’re working with our partners at the U.S. Attorney’s Office, and Drug Enforcement Administration to address this disturbing trend."

"Unless you buy your prescription pills from a legitimate pharmacy, it’s very likely you’ll get fake prescription pills laced with deadly fentanyl," said DEA Special Agent in Charge Karen Flowers. "Individuals seeking to make an easy buck are putting fentanyl into fake pills and passing them off as legitimate prescription medications. DEA and our law enforcement partners will continue to target and relentlessly pursue the individuals who are selling fake prescription pills laced with deadly fentanyl to citizens in our community."

Lucas, Carter, Chandler, and Fields made their initial appearances in federal court Friday, October 5, before U.S. Magistrate Judge Barbara L. Major, followed by a detention hearing. Judge Major detained Lucas based on the seriousness of the charges against him, while setting bonds for Fields, Carter and Chandler. Their next hearing is scheduled for November 9, 2018 before U.S. District Judge Cathy Ann Bencivengo.

Lucas is the fifth person since January to be charged in the Southern District of California with Distribution of Fentanyl Resulting in Death. This case involved a collaborative effort between the United States Attorney’s Office and the San Diego County District Attorney’s Office ...
Read More
/ / 2018 News, Daily News
When it comes to non-drug therapies for back pain, U.S. insurance plans vary widely in what they will cover, claims a new study reported by Reuters Health..

Private and public insurers are missing important opportunities to promote alternatives to opioids, the investigators write in JAMA Network Open.

In fact, researchers found, insurers often provide little or no coverage for evidence-backed interventions for chronic pain such as acupuncture and psychological counseling.

"Insurers can be part of the problem or part of the solution," said study coauthor Dr. Caleb Alexander, an associate professor at the Center for Drug Safety and Effectiveness at the Johns Hopkins School of Public Health in Baltimore, Maryland. "We see a lot of variability in coverage of non-drug treatments for chronic pain. We have a long way to go."

Alexander and his colleagues examined the 2017 versions of 45 insurance plans - 15 Medicaid, 15 Medicare Advantage and 15 major commercial plans - to see what non-drug treatments for low back pain were covered. Nearly all the plans covered physical and occupational therapy.

But despite evidence in the literature to support use of acupuncture, 30 of the 45 plans explicitly did not cover it.

Of the 15 Medicaid plans, just three covered psychological interventions for chronic pain. The researchers could not determine the coverage policies regarding psychological interventions for the Medicare or commercial plans.

Therapeutic massage was almost never covered.

While certain types of non-drug therapies were covered by most policies, some insurers had steep co-pays. "You can provide all the coverage in the world, but if it’s not affordable for patients nobody is going to use it," Alexander said.

Even in the case of physical therapy, a well-established treatment for low back pain, the researchers found barriers to use. Some plans covered two visits, some six, some 12. Some allowed patients to refer themselves for physical therapy, while others required referral by a doctor.

Ultimately, it can be easier to prescribe a medication.

"All too often doctors reach for the quick solution, prescription drugs, especially opioids, to manage pain that would be more effectively and safely treated with non-pharmacological approaches," Alexander said. "This is a system that is designed with, and fosters, the idea that there is a pill for every ill. And we’re here 20 years after the start of the opioid epidemic, paying the price for that."

The new study is underscores a "very relevant problem, given the public health crisis we’re in now," said Dr. Alka Gupta, co-director of the Integrative Health and Wellbeing Program at NewYork-Presbyterian and an assistant professor of medicine at Weill Cornell Medicine in New York City.

"Low back pain is the second most common reasons for primary care visits," Gupta said. "Over the last several years we’ve seen more and more effective treatments coming out. Those were included in the updated guidelines released by the American College of Physicians in February. We’ve also seen that insurers have been slow to adapt their policy coverage to reflect that information." ...
Read More
/ / 2018 News, Daily News
Yolo County District Attorney Jeff Reisig and Colusa County District Attorney Matthew Beauchamp announced that 32-year-old, Daniel Ayala, of Colusa, was sentenced to 365 days of county jail, 5 years felony probation, and an $890 fine.

Ayala plead no contest to one count of felony workers’ compensation insurance fraud. As part of the plea agreement, Ayala’s remaining felony counts were dismissed in the interest of justice. The defendant’s county jail time is stayed pending successful completion of probation and a monthly restitution payment of $350 per month to fulfill his court-ordered restitution in the amount of $19,324.68.

While working for Greenwood Dairy in Orland, CA in January 2014, Daniel Ayala claimed he was injured while working.

Ayala received $15,876.63 in workers’ compensation benefits due to his reported injury. Based on Ayala’s medical complaints from his reported industrial accident in January 2014, Ayala was diagnosed with cervical strain and disc herniation according to his probation report.

Zenith Insurance contracted a private investigations company who recorded Ayala performing activity and tasks not consistent with his reported injury and his clinical symptoms. Ayala intentionally misrepresented his industrial injury in order to obtain workers’ compensation benefits that he would not otherwise be entitled to.

This case was investigated by the Fresno County District Attorney’s Office. The Fresno County Superior Court determined this case would be best prosecuted in the county of Colusa. The Colusa County District Attorney’s Office is a member of the Yolo County DA’s multi-jurisdictional Workers’ Compensation Insurance Fraud Program which covers the counties of Colusa, Sutter, and Yuba.

The Yolo County multi-jurisdictional Workers’ Compensation Insurance Fraud unit works to prevent and investigate claimant fraud, medical provider fraud, premium fraud, and uninsured employers. The most common type of workers’ compensation insurance fraud is claimant fraud, which Daniel Ayala was convicted of. Claimant fraud occurs when an employee lies or omits a material fact in order to obtain benefits that they would not have otherwise been entitled to. Examples would be to lie about how an injury occurred, the extent of their injury, or not to report outside employment and income ...
Read More
/ / 2018 News, Daily News
Coventry recently announced the release of the fourth part of its 2017 Drug Trends Series, which is based on all calendar year transactions billed through its PBM Program, First Script, as well as transactions from medical bill review to reflect the total pharmacy experience for their client base.

This fourth installment of the series is dedicated to topicals, specialty medications, and regulatory development. Although topicals and specialty drugs represent only 6% of total aggregate prescriptions, they account for 17.9% of total aggregate cost, thus warranting increased attention.

Although topicals and specialty drugs represent only 6% of total aggregate prescriptions, they account for 17.9% of total aggregate cost, thus warranting increased attention. Topicals represent 4.8% of total prescriptions and 12.8% of total drug cost and are being prescribed as an alternative to some oral medications; however, the lack of clinical efficacy and exorbitant pricing eliminates them as a favorable first-line therapy option. While they are declining in the managed environment due to utilization controls they continue to increase in the unmanaged space.

Specialty medications, which are typically used to treat patients with complex, chronic conditions, have become widely discussed in workers’ comp due to their significant costs. Although they represent approximately 1% of drug utilization, they account for nearly 5% of prescription drug costs. Key trends from this fourth part included:

Managed Topical Medications
- Cost per claim has decreased modestly over the last 2 years, 0.3% (2016) and 1.9% (2017).
- Utilization has fallen by at least 6% per year over the last 2 years.
- Cost per script has increased for the last 3 years, from a high of 20.9% (2015) to a low of 4.9% (2017).

Unmanaged Topical Medications
- Cost per claim has increased over the last 2 years, 9.1% (2016) and 29.4% (2017).
- Increasing utilization has occurred for the last 2 years (1.5% in 2016 and 9.8% in 2017).
- Cost per script has increased at least 7% each year spiking at 17.9% in 2017.

Managed Specialty Medications
- 7-8% increases in cost per claim per year.
- Specialty usage, although less than 1% of all scripts, has increased by at least 9% per year.
- Cost per script has experienced a 3-year downward trend (1.7% in 2017), influenced by declining use of hepatitis C medications

Unmanaged Specialty Medications
- Significant fluctuations in cost per claim trending up 22.1% in 2016 and down 22.5% in 2017.
- Specialty usage accounted for less than 2.5% of all scripts and has decreased between 2-6% per year.
- Cost per script, influenced by varying usage of medications used to treat anemia, rose 24.6% in 2016 and fell 17.8% in 2017 ...
Read More
/ / 2018 News, Daily News
The FDA put out its in-house assessment of Trevena’s new pain med, now up for review, and at first blush it’s not looking good for the biotech today.

In an assessment of the drug’s efficacy and safety, insiders tagged Trevena’s treatment for a mixed set of data that highlighted how morphine often produced better pain relief for the target patient population. The biotech’s opioid, furthermore, has "high abuse potential," according to the FDA, raising a red flag for analysts who have watched lawmakers and the FDA organize a nationwide campaign against opioid abuse.

Investors added up the warnings, and beat a hasty retreat. Trevena’s shares $TRVN lost more than half their value in a short time, with most betting against the biotech at their upcoming outside panel review this week.

Trevena was cited by the FDA on the trial design, chided for creating an endpoint on the comparative respiratory safety burden of their drug and morphine - which has well documented problems on that score - uncertain over its clinical meaningfulness.

The FDA called out the drug for causing adverse events, including "hepatic adverse events and QT prolongation."

Efficacy was also a mixed bag, with morphine significantly outperforming their drug at key doses.

In FDA’s analysis for Study 3002, two of the three doses of oliceridine (0.35 mg and 0.5 mg) demonstrated a statistically greater reduction in pain intensity than placebo, but the 0.1 mg dose did not. In Study 3002, morphine demonstrated a greater reduction in pain intensity relief than two of the doses of oliceridine (0.1 mg and 0.35 mg) that was statistically significant. The reduction in pain intensity by morphine was not greater than that of the highest oliceridine dose (0.5 mg). Currently, Trevena is only seeking approval of the 0.1 mg and 0.35 mg doses.

There have been questions circulating about this drug, their data and the company as a whole since early 2017, when analysts first started questioning the Phase III results and the way it stacked up - or didn’t - against morphine. The company was forced to undergo a painful restructuring and the CEO, Maxine Gowen, officially stepped down at the beginning of this month.

It’s not unusual for in-house reviews to take the most skeptical view of a drug, but Trevena appears to have fallen well short of the kind of grade needed to win over outside experts on Thursday. We’ll see what the experts say, leaving the FDA to come to a final decision. But Trevena is fighting an uphill battle ...
Read More
/ / 2018 News, Daily News
A Riverside County jury has convicted a doctor from Menifee in a four-year scheme to defraud workers’ compensation insurance companies by billing them $90,000 for unneeded medical-legal reports, and lied when he claimed he was certified to prepare them, the Riverside County District Attorney’s office said.

87 year old Benjamin Gould Cox, was convicted on Oct. 4, 2018, of seven counts of insurance fraud and seven counts of perjury for lying to the California Medical Board in relation to his performance during his disciplinary probation. Dr. Cox is scheduled to be sentenced on Nov. 13, 2018, in Dept. 64 at the Hall of Justice in Riverside. He could face up to 18 years in state prison when he’s sentenced.

Prosecutors said that the defendant, who has been practicing medicine since the early 1960s and has been previously disciplined for professional violations. The Medical Board placed Cox on probation in 2013, restricting his practice, because of documented instances in which he had failed to appropriately diagnose and establish treatment plans for a number of patients. Cox completed his probation in 2016.

The California Department of Industrial Relations brought to the attention of the Riverside County District Attorney’s Insurance Fraud Team that Dr. Cox was billing for fraudulent medical-legal reports. Medical-legal reports are used by the Workers’ Compensation Appeals Board. They are created when an injured worker and the insurer have a dispute that needs resolution. Most medical-legal reports are prepared by a Qualified Medical Evaluator (QME).

The Department of Industrial Relations certifies who may be a QME and provides them to the parties in dispute. The insurance companies are required to pay for the reports generated by a QME. Even though Dr. Cox was not a QME and there were no disputes that required a medical-legal report, he nonetheless billed multiple insurance companies including Berkshire Hathaway,Hartford, Liberty Mutual, State Compensation Insurance Fund, Zenith Insurance, Zurich Insurance, and Employers Insurance for more than $90,000 in medical-legal reports.

In addition to violating numerous rules and regulations regarding the creation and content of medical-legal reports, Dr. Cox perjured himself in California Medical Board disciplinary probation reports regarding his status as a QME. As part of his disciplinary probation, the Medical Board required Dr. Cox to provide quarterly statements to ensure that he was complying with his terms of probation.

For years after his QME certificate expired Dr. Cox wrote that he was a "Qualified Medical Evaluator" on his quarterly reports.

The Superior Court issued an Order on February 1, 2018 prohibiting him from practicing medicine during the pendency of his criminal case.

Cox remains free on $30,000 bail ...
Read More
/ / 2018 News, Daily News
Howard William Neel was a mobile driver for Elite Security. His car was hit while he was pumping gas on December 12, 2009. He made numerous false statements regarding his injuries and what caused them to several doctors. Based on the false representations, defendant submitted and received workers’ compensation benefits for his injuries.

Neel was found guilty by jury of six counts of insurance fraud. (Ins. Code, § 1871.4, subd. (a)(1).) The trial court suspended imposition of sentence and placed him on a three-year term of formal probation.

Among the terms and conditions, Neel was required to maintain his residence as approved by the probation officer and not to change his residence without prior written approval of the probation officer; defendant was also prohibited from leaving California without written permission from the probation officer. The trial court also ordered defendant to cooperate with any psychological or psychiatric testing or counseling suggested by the probation officer, and to authorize the release of any records from a psychologist, psychiatrist, counselor, or physician.

Defendant contends on appeal that general condition No. 4’s requirement to "maintain [his] residence as approved by the probation officer and not change [his] residence without written approval of the probation officer" is unconstitutionally overbroad and impermissibly restricts his right to travel.

The Court of Appeal agreed in the unpublished case of People v Neel, and the matter is remanded to the trial court with directions to either strike general condition No. 4 or to revise it in a manner consistent with this opinion. In all other respects, the judgment is affirmed.

He relies in large part on People v. Bauer (1989) 211 Cal.App.3d 937, where the First Appellate District, Division Two, found unconstitutional a probation condition that required the defendant to obtain the probation officer’s approval of his residence. (Id. at pp. 943-945.) The condition was evidently intended to prevent the defendant from residing with his overprotective parents. (Id. at p. 944.) The court explained: "The condition is all the more disturbing because it impinges on constitutional entitlements -- the right to travel and freedom of association. Rather than being narrowly tailored to interfere as little as possible with these important rights, the restriction is extremely broad. The condition gives the probation officer the discretionary power . . . to banish [the defendant]."

The Supreme Court noted in People v. Olguin (2008) 45 Cal.4th 375, 384 (Olguin) that even if a condition of probation has no relationship to the crime of which a defendant was convicted and involves conduct that is not itself criminal, the condition is valid as long as the condition is reasonably related to preventing future criminality.

The probation condition at issue in Olguin was different in key respects from that presented here. First and foremost, the condition in Olguin required the probationer to notify and inform the probation officer, not to obtain prior permission and approval. Second, the dispute in Olguin centered on pets, not residences. Here, in sharp contrast, condition No. 4 confers open-ended authority to the probation officer to prevent defendant from changing his residence ...
Read More
/ / 2018 News, Daily News
MSP Recovery LLC, a law firm out of Miami, Florida has been initiating class action litigation country-wide as assignees on behalf of Medicare Advantage Plans (MAPs) alleging that various primary payers have failed to reimburse MAP conditional payments allegedly giving rise to a Private Cause of Action under the Medicare Secondary Payer Act (MSP), specifically located at 42 USC §1395y(b)(3)(A).

In a decision just issued out of the Third Circuit Court of Appeals, Ocean Harbor Cas. Ins. v. Claims, 2018 Fla. App. LEXIS 13569 (September 26, 2018), the Court found that the trial court erred in certifying the class of Florida MAPs. Because MSP Recovery asserts that Ocean Harbor was responsible as a primary plan not due to pre-existing settlements, but simply due to the entry of no-fault insurance contracts under Florida’s no-fault statutes, this would involve a series of mini-trials which would need to be assessed on a case by case basis, and accordingly class certification was not appropriate.

Franco Signor LLC notes that there are a few interesting discussions in this 3rd Circuit decision which primary plans should take away, particularly if the primary plan is currently subject to litigation by MSP Recovery involving no-fault claims:

- MSP Recovery (or Medicare Advantage Plans) recovery rights are not automatic without "demonstrated responsibility." The MSP does not eliminate the terms and conditions of an underlying state No-Fault law or supersede an existing state insurance policy. Here, MSP Recovery has attempted to show "demonstrated responsibility" under the MSP by "the other means" language of the MSP (since there is no settlement, judgment or award). Demonstrated responsibility by other means must be demonstrated under the state’s no-fault laws and the actual no-fault policy and must be proven on a case-by-case basis.

- What is also interesting about this decision is the discussion of whether Ocean Harbor failed to exhaust administrative remedies. MSP Recovery claims that it made an "organization determination" that Ocean Harbor owed the conditional payments and it could have challenged these payments pursuant to 42 CFR § 422.566. The court noted that there is nothing in the regulations that provides a federal administrative remedy for a primary plan like Ocean Harbor to challenge such an "organization determination." The regulation cited by MSP Recovery only applies to claims by an enrollee (MAP beneficiary) against the MAP. While the SMART Act did finally afford primary plans with formal appeal rights, this appeals process only applies to conditional payments made under traditional Medicare Parts A and B. Accordingly, there is no method for primary plans to administratively contest an allegation by MSP Recovery/MAPs that it was responsible to make a particular payment.

This decision reinforces the current conundrum facing primary plans in MAP private cause of action double damages litigation. Medicare Advantage Plans desire the benefits of acting like traditional Medicare in seeking the ability to sue and recover double damages for unreimbursed conditional payments.

But, MAPs cannot have the benefits of acting like Medicare without carrying the burdens and providing due process to primary plans. MAPs need to afford primary plans with a formal appeal process if they want to act like Medicare.

And even more importantly, primary plans need a reliable source to determine whether their claimants are enrolled in a MAP. Currently, Medicare only returns traditional Medicare enrollment to primary plans ...
Read More
/ / 2018 News, Daily News
Scientists at the Krembil Research Institute have developed a novel therapeutic treatment that has the potential to stop knee and spine osteoarthritis in its tracks.

A team led by Principal Investigator Dr. Mohit Kapoor, Arthritis Research Director at UHN, published the results in Annals of the Rheumatic Diseases in a paper titled "microRNA-181a-5p antisense oligonucleotides attenuate osteoarthritis in facet and knee joints."

"This is important because there are currently no drugs or treatments available to patients that can stop osteoarthritis," says Dr. Kapoor, a Krembil Senior Scientist.

Osteoarthritis is the most common form of arthritis. It affects about five million Canadians and is characterized by a breakdown of the protective cartilage found in the body's spine, hand, knee and hip joints.

"Current treatments for osteoarthritis address the symptoms, such as pain, but are unable to stop the progression of the disease," says Dr. Kapoor. "The blocker we've tested is disease modifying. It has the ability to prevent further joint destruction in both knee and spine."

Utilizing a variety of experimental models, including animal models and human tissue samples, the Krembil team zeroed in on a biomarker, or molecule, called microRNA-181a-5p, which is believed to also cause the inflammation, cartilage destruction and collagen depletion.

Using a blocker consisting of Locked Nucleic Acid-Antisense Oligonucleotides (LNA-ASO), the team was able to stop destruction and protect the cartilage.

"The blocker is based on antisense technology. When you inject this blocker into the joints, it blocks the destructive activity caused by microRNA-181-5p and stops cartilage degeneration," said Dr. Akihiro Nakamura, first author of the paper and a post-doctoral research fellow in the Kapoor Lab.

In addition to testing with animal models, the research team applied this approach using cells and tissues from Toronto Western Hospital patients who have knee and/or spine osteoarthritis.

"The technology in osteoarthritis is in its infancy, but the research has now taken a big step forward. If we are able to develop a safe and effective injection for patients, this discovery could be a game changer," said Dr. Raja Rampersaud, an orthopedic spine surgeon and clinician scientist at Toronto Western who collaborated with the Kapoor team.

Next steps for the research team include commencement of safety studies, determining proper dosage and developing a method for injecting the blocker directly into the knee and spine joints.

Funding for this study was provided by the Krembil Foundation, The Toronto General & Western Hospital Foundation and The Canadian Institutes of Health Research (CIHR) ...
Read More
/ / 2018 News, Daily News
On Wednesday, the United States Senate accomplished a rare feat - passing a bipartisan bill with a vote of 98-1. The bill now heads to President Donald Trump’s desk, following the vote in the Senate and a prior vote in the House of Representatives of 393-8. This legislation adds multiple resources to the opioid epidemic as well as restrictions intended to aid in the fight against the spread of the epidemic. The bill is a combination of dozens of smaller proposals sponsored by hundreds of lawmakers. Here are some of the 41 key components of the Opioid Package (H.R. 6):

Law Enforcement
  • Reauthorization of Key Law Enforcement Programs (Section 8205-8212) - Reauthorizes law enforcement programs through the Office of National Drug Control Policy, such as programs such as the High Intensity Drug Trafficking Area programs, drug courts, COPS Anti-Meth Program, and COPS anti-heroin task force program;
  • First Responder Training (Section 7002) - Expands first responder training, authorized through the Comprehensive Addiction and Recovery Act, to include training on safety around fentanyl and other synthetic and dangerous substances;
  • Public Health Laboratories Detecting Fentanyl and Other Synthetic Opioids (Section 7011) - Improves coordination between public health laboratories and laboratories operated by law enforcement to improve detection of fentanyl and other synthetic opioids;
  • Synthetics Trafficking and Overdose Prevention (Section 8006, 8007) - Improves Federal agencies ability to detect synthetic opioids and other substances from entering the United States through the mail;
  • Opioid Addiction Recovery Fraud Prevention (Sections 8021-8023) - Subjects those who engage in unfair or deceptive acts with respect to substance use disorder treatment services or substance use disorder treatment products to civil penalties for first time violations by the FTC; includes a savings clause for existing FTC and FDA authorities.
  • Reauthorization of the comprehensive opioid abuse grant program (Section 8092) - Reauthorize the comprehensive opioid abuse grant program at the Department of Justice;
Ending Illegal Patient Brokering
  • Criminal penalties (Section 8122) - This provision makes it illegal to pay or receive kickbacks in return for referring a patient to recovery homes or clinical treatment facilities;
Healthcare Integration
  • Treatment, Education, and Community Help To Combat Addiction (Section 7101) - Expands medical education and training resources for healthcare providers to better address addiction, pain, and the opioid crisis;
  • Preventing Overdoses While in Emergency Rooms (Section 7081) - Improves emergency departments ability to effectively screen, treat, and connect substance use disorder patients with care;
  • Alternatives to Opioids in the Emergency Department (Section 7091) - Explores alternative pain management protocols in order to limit the use of opioid medications in emergency departments;
  • Inclusion of opioid addiction history in patient records (Section 7051) - Requires HHS to develop best practices for prominently displaying substance use disorder treatment information in electronic health records, when requested by the patient;
Treatment Capacity Expansion
  • IMD CARE Act (Section 5052) - Expands Medicaid coverage up to 30 days for individuals between 21 and 65 years old receiving care in a treatment facility for all substance use disorders, lifting the 16 bed restriction;
  • Expansion of Telehealth Services (Section 1009, 2001, 3232) - Expands access to substance use disorder treatment and other services through the use of telehealth;
  • Comprehensive Opioid Recovery Centers (Section 7121) - Establishes model comprehensive treatment and recovery centers to ensure individuals have access to quality treatment and recovery services;
  • Supporting family-focused residential treatment (Section 8081, 8083) - Enhanced family-focused residential treatment; $20 million in funding for HHS to award to states to develop, enhance, or evaluate family-focused treatment programs to increase the number of evidence-based programs;
Medication Assisted Treatment
  • More Flexibility for Prescribing Medication Assisted Treatment (Section 3201, 3202) - Increases the number of waivered health care providers that can prescribe or dispense treatment for substance use disorders, such as certified nurses and accredited physicians;
  • Grants to enhance access to substance use disorder treatment (Section 3203) - authorizes grants to support the development of curriculum that will help health care practitioners obtain a waiver to prescribe MAT;
  • Delivery of a Controlled Substance by a Pharmacy to be Administered by Injection or Implantation (Section 3204) - Allows pharmacies to deliver implantable or injectable medications to treat substance use disorders directly to health care providers;
  • Expanding Access to Medication in In-Patient Facilities (Section 5052) - Expanded Medicaid coverage up to 30 days for inpatient facilities applies to providers who provide a minimum of two types of medicines to treat opioid use disorder;
Prescription Medication Safety and Disposal
  • Empowering Pharmacists in the Fight Against Opioid Abuse (Section 3212) - Develops and disseminates training resources to help pharmacists better detect fraudulent attempts to fill prescription medications;
  • Safe Disposal of Unused Medication (Section 3222) - Allows hospice workers to dispose of unused medications on site or in patients homes;
  • Access to Increased Drug Disposal (Section 3251-3260) - Awards grants to states to enhances access of prescription drug disposal programs;
  • Safety-enhancing Packaging and Disposal Features (Section 3032) - Requires certain opioids to be packaged into 3 or 7 day supplies and requires safe prescription drug disposal options to be given to patients upon receiving medications;


"We have an urgent, bipartisan consensus, a virtually unanimous agreement, to deal with the most urgent public health epidemic facing our country today in virtually every community," said Senator Lamar Alexander, chairman of the Senate health committee and lead sponsor of the bill.

...
Read More
/ / 2018 News, Daily News
Loading...