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How Medicare Rates Overpay Physicians

Medicare reimbursement policies for outpatient services have encouraged physician integration with hospitals, according to a new study and commentary published in Health Services Research.

An article on MedPageToday claims that’s in part because Medicare reimbursement for physician services, on average, would have been $114,000 higher per physician per year for those who were integrated with a hospital, researchers found.

For primary care alone, reimbursement would have been $63,000 higher per physician per year for those who were integrated with a hospital. For medical specialties, the average reimbursement difference was $178,000, and for surgical specialties, it was $150,000.

The reimbursement difference per specialty ranged from $363,000 for urology to $15,000 for psychiatry, according to the study.

These numbers are astonishing,” healthcare technology consultant Dan O’Neill, MA, MS, tweeted. O’Neill is the former senior vice president and general manager of Change Healthcare and a former Robert Wood Johnson Foundation health policy fellow.

The incentives and waste here are just … incredible. As in, incredibly destructive,” O’Neill tweeted. “Just imagine how much worse this is for commercial payers, given the 200% to 400% markups (over Medicare) in hospital outpatient departments.”

Post and colleagues also found a modest association between a higher payment differential and the probability of integrating with a hospital. The effect was larger among primary care physicians and medical specialists, but not statistically significant among surgeons, they found.

Post also tweeted about the potential effects of vertical integration: “While integration is associated with higher prices, current evidence suggests a limited association with quality,” he wrote. “As a result, we’re not crazy about encouraging more of it.”

There are several reasons the study has garnered attention, Michael Chernew, PhD, professor of healthcare policy at Harvard Medical School and author of the study’s corresponding commentary, told MedPage Today.

“There’s an enormous amount of concern about healthcare prices in this country,” Chernew said. And much of the concern about high prices is because of consolidation.

Additionally, there is interest in Medicare spending, he said. One issue that has an impact on that is site-neutral payments.  “This study links them together in a way that is both interesting and policy-relevant,” Chernew said.

Merced Claimant Faces Fraud Charges for False History

Kia Lor, 54, of Merced, was arraigned on four counts of insurance fraud after an investigation by the Department of Insurance found that she allegedly lied about the extent of prior injuries in an attempt to receive nearly $7,000 in undeserved workers’ compensation payments.

On October 5, 2018, Lor, a former Nutrition Assistant at the Merced Community Action Agency, injured her lower back while lifting a cooler at a company picnic.

During the course of treatment, Lor denied any prior injuries to her lower back when completing paperwork and while talking with the workers’ compensation insurance carrier and the Qualified Medical Examiner.

However, during the course of the investigation, it was found that Lor had submitted multiple motor vehicle accident claims between 1999 and 2016 where she suffered injuries to her back.

Additionally, she filed a workers’ compensation claim in 2008 reporting a back injury.

Lor’s misrepresentations about the extent of her prior injuries could have resulted in her being paid $6,960 for permanent disability, but the investigation prevented the payment.

Lor was arraigned at the Merced County Superior Court. This case is being prosecuted by the Merced County District Attorney’s Office.

March 1, 2021 – News Podcast


Rene Thomas Folse, JD, Ph.D. is the host for this edition which reports on the following news stories: Supreme Court ends Practice of Rounding Time Clock Punches. Grocers Association Seeks “Hero Pay” Ordinance Injunction. Suit by COVID Infected Wife Against Husband’s Employer Fails. Sun-Maid Growers Faces Labor Law Class Action. 5 Year Sentence for Dr. Grusd Office Administrator Affirmed. California Father/Son Team Sentenced for $27M Healthcare Fraud. Farm Labor Contractor to Serve 6 Years for $2.5M Premium Fraud. SoCal Worker Arraigned for Fraudulent COVID Comp Claim. 2019 Ethics Advisory Committee Upholds Charges for 2 WCJs. NCCI Reports 2020 “Not a Bad Year” for Comp Claims.

Employer’s Vendor Has No Duty to Injured Worker

Robert Piontkowski, an employee of Chevron, was seriously injured on the job at the company’s El Segundo refinery when he was splashed with super-heated materials. Plaintiff subsequently received workers’ compensation benefits for the injuries he sustained.

Piontkowski claims he was injured because a pipe that would normally have drained those materials in a different manner was plugged.

Chevron had a services agreement with Veolia Environmental Services, Inc. to hydroblast such pipes at Chevron’s direction. Plaintiff also alleged that a few days prior to the accident, Chevron requested that Veolia unplug the drain line. At the time of the accident, Veolia had not yet reported to unplug the line.

Plaintiff filed this negligence action against Veolia alleging Veolia owed him a duty, as a third-party beneficiary of the services agreement, to timely respond to a request from Chevron to clean the drainpipe at issue and, further, that Veolia’s failure to clean the pipe caused the condition that led to his injury.

The trial court granted Veolia ES Industrial Services, Inc.’s motion for summary judgment, finding as a matter of law that plaintiff could not establish that Veolia owed him a legal duty of care. Plaintiff appealed. Finding no error, the court of appeal affirmed the judgment of the trial court in the unpublished case of Piontkowski v. Veolia ES Industrial Services, Inc.

In considering whether a party has a legal duty in a particular factual situation, a distinction is drawn between claims of liability based upon misfeasance and those based upon nonfeasance.

Misfeasance exists when the defendant is responsible for making the plaintiff’s position worse, i.e., defendant has created a risk. Liability for misfeasance is based on the general duty of ordinary care to prevent others from being injured by one’s conduct.

Conversely, nonfeasance is found when the defendant has failed to aid plaintiff through beneficial intervention. Liability for misfeasance is based on the general duty of ordinary care to prevent others from being injured by one’s conduct. Liability for nonfeasance is limited to situations in which there is a special relationship that creates a duty to act.

The basic idea is often referred to as the “no duty to aid rule,” which remains a fundamental and long-standing rule of tort law. As a rule, one has no duty to come to the aid of another. A person who has not created a peril is not liable in tort merely for failure to take affirmative action to assist or protect another unless there is some relationship between them which gives rise to a duty to act.

The services agreement was not intended to benefit Chevron’s employees nor was it focused on providing a safe work environment for them. Rather, it is plain from the agreement that Veolia’s services were intended to benefit Chevron by keeping its refineries and equipment operating smoothly.

Hawthorne Physician Settles Kickback Case for $215K

A Hawthorne-based physician has settled allegations that he violated the False Claims Act by receiving kickbacks and other improper payments in exchange for referring patients to Memorial Hospital of Gardena.

Dr. Ashok Kumar paid $215,228 on March 1 to settle the allegations brought against him in a whistleblower lawsuit that Memorial Hospital of Gardena provided compensation to Kumar, whom they hired as a medical director, that both exceeded the fair market value of his services and was an attempt to incentivize him to refer patients to their hospital.

The lawsuit alleged that Kumar violated the federal Anti-Kickback Statute as well as the Physician Self-Referral Law. The Anti-Kickback Statute imposes civil liability on those who willingly offer, solicit, receive or pay any sort of compensation in exchange for the referral of services provided by a federal health care program, including Medicare. The Physician Self-Referral Law, commonly known as the Stark Law, bans doctors from referring patients to receive designated health care services payable by Medicare or Medicaid from entities with which the doctor or an immediate family member has a financial relationship.

The settlement resolves allegations originally brought in a lawsuit by Dr. Joshua Luke, the former chief executive officer of Memorial Hospital of Gardena, against Kumar and other defendants under the whistleblower provisions of both the federal and California False Claims acts. Both statutes permit private parties to sue on behalf of the state and federal governments for false claims for government funds, and to receive a share of any recovery.

Dr. Luke will receive $42,529 from the federal government as his share of the recovery announced today. His allegations against the other defendants were resolved in 2018 when they agreed to pay the federal government an $8.1 million settlement. The allegations brought on behalf of the State of California have been resolved pursuant to a separate agreement.

This case was handled by Assistant United States Attorney Frank D. Kortum of the Civil Fraud Section, who worked closely with the U.S. Department of Health and Human Services – Office of Inspector General. Tips and complaints from all sources about potential fraud, waste, abuse and mismanagement can be reported to the Department of Health and Human Services, at 800-HHS-TIPS (800-447-8477).

The case is United States of America ex rel. Luke, State of California ex rel. Luke v. Gardena Hospital, L.P. DBA Memorial Hospital of Gardena, Avanti Hospitals, LLC, et al., CV 15-8732-MCS.

Prison Inmate and Accomplice Indicted for EDD COVID Fraud

A federal grand jury returned an indictment charging two defendants in a scheme that targeted California Employment Development Department unemployment insurance benefits that were intended for Californians hit hardest by the ongoing COVID-19 pandemic shutdown.

The three-count indictment charges Jason Vertz, 51, of Fresno, and Alana Powers, 45, an inmate at the Central California Women’s Facility in Chowchilla, with one count of conspiracy to commit mail fraud and two counts of aggravated identity theft.

The indictment was unsealed and Vertz was arraigned on Tuesday following his arrest.

According to court documents, Vertz and Powers submitted several fraudulent unemployment insurance claims in Powers’ and other Central California Women’s Facility inmates’ names to EDD.

Recorded jail calls and emails show that Powers and other inmates, provided names, dates of birth, and social security numbers for inmates at Central California Women’s Facility to Vertz to submit the fraudulent claims. Shortly thereafter, the benefits were loaded onto debit cards that were mailed to the addresses the defendants provided.

The underlying applications for the claims stated that the inmates had worked within the prescribed period as maids, cleaners, fabrication welders, and other occupations, and that they were available to work, which was not true because they were incarcerated.

The claims would have been denied if accurate answers had been given. EDD and the United States have suffered an actual loss of over $103,000 as a result of the fraud.

This case is the product of an investigation by the FBI, the California Department of Corrections and Rehabilitation Investigative Services Unit, and the California EDD.

If convicted of the conspiracy to commit mail fraud, Vertz and Powers each face a maximum statutory penalty of 20 years in prison and a fine of up to $250,000.

If convicted of the aggravated identity theft, they face a mandatory two-year sentence consecutive to any other sentence.

Cal/OSHA Cites More Employers for COVID Safety Violations

Cal/OSHA has cited multiple employers for not protecting workers from COVID-19 following inspections in various industries throughout the state.

Violations were identified in industries including construction, garment, correctional institutions and medical. Cal/OSHA opened the inspections after learning of COVID-19 fatalities and illnesses, and after receiving complaints. The full list of employers cited for COVID-19 violations is posted on Cal/OSHA’s website.

The employers cited for COVID-19 violations, and citations include but are not limited to:

Los Angeles Apparel, Inc. Garment Manufacturer Los Angeles – – $102,550
California Prison Industry Authority Correctional Institutions Vacaville – – $24,300
Integrated Pain Management Medical Group, Inc. Medical Practice San Leandro – – $9,450
Erickson Framing CA LLC Construction Fairfield – – $9,000
Erickson Framing CA LLC Construction Vacaville – – $9,000

The inspection at the Los Angeles Apparel factory occurred after reports of an outbreak, including six employees who died from COVID-19 complications. Cal/OSHA determined that Los Angeles Apparel intentionally did not report the COVID-19 fatalities. Cal/OSHA cited the employer for six serious, one willful-regulatory, three regulatory and seven general violations. One of the serious violations was failure to evaluate COVID-19 hazards, such as the lack of physical distancing or barriers to separate employees operating sewing machines. Another serious violation was the lack of employee training on preventing COVID-19 infection in the workplace.

An inspection was opened at the California Prison Industry Authority in Vacaville after the employer reported the serious illness of an employee hospitalized for COVID-19 complications, and another employee tested positive for the virus. Cal/OSHA cited the employer for three serious violations after finding deficiencies in its Aerosol Transmissible Diseases (ATD) and respiratory protection programs that exposed employees to COVID-19 infection.

Also cited for two COVID-19 related serious violations was Integrated Pain Management Medical Group, a San Leandro-based medical practice. Cal/OSHA opened an accident inspection following a report of an employee who was hospitalized for COVID-19 complications. The employer was cited after Cal/OSHA found that it failed to implement an effective employee COVID-19 screening procedure and that it had deficiencies in its respiratory protection program.

Cal/OSHA cited the Roseville-based framing contractor Erickson Framing CA, LLC following two COVID-19 complaint-based inspections at worksites in Vacaville and Fairfield. At the Vacaville site, the Cal/OSHA inspector found that the employer was not enforcing the use of face coverings or physical distancing between employees. In a subsequent inspection at the Fairfield worksite a month later, the Cal/OSHA inspector again found the same hazards: a lack of physical distancing and failure to require the use of face coverings. Cal/OSHA cited the employer for a serious violation in each instance for the employer’s failure to effectively establish, implement and maintain procedures to correct unhealthy conditions related to COVID-19 that affected its employees, including its failure to enforce face covering use and physical distancing for COVID-19 prevention.

DEA Says California Leads Nation on Illegal Fentanyl Seizures

DEA announced the release of the 2020 National Drug Threat Assessment, DEA’s annual publication outlining the threats posed to the United States by domestic and international drug trafficking and the abuse of illicit drugs.

Drugs trends in the United States continue to evolve. Although progress has been made in reducing the smuggling of fentanyl and fentanyl analogues from China following the DEA’s 2018 emergency scheduling action of fentanyl related substances and China’s enactment of fentanyl-class controls in May 2019, Mexican drug trafficking organizations have increased production causing more fentanyl to flow across our border. The opioid threat remains at epidemic levels, affecting large portions of the country. Meanwhile, the stimulant threat, including methamphetamine and cocaine, is worsening both in volume and reach, with traffickers selling increasing amounts outside of traditional markets.

According to the U.S. Centers for Disease Control and Prevention, more than 83,000 people lost their lives to drug-related overdoses in the twelve-month period ending in July of 2020, a significant increase from 2019, when more than 70,000 people died of overdoses.

Illicit fentanyl is one of the primary drugs fueling the epidemic of overdose deaths in the United States, while heroin and prescription opioids remain significant challenges to public health and law enforcement.

California highlights:

– – In 2019, California had more fentanyl seized than any other state.
– – In 2019, California, Ohio, and Texas reported the highest dollar amounts in bulk cash seizures for a combined total of $131,039,840 USC. In the first six months of 2020, California, New York, and Texas accounted for 39 percent of the bulk cash seized. Border restrictions between the United States and Mexico, brought on due to the pandemic, have increased the difficulty of transporting loads of bulk currency from the United States across the SWB into Mexico. As a result, large amounts of U.S. currency are being held along the U.S. side, awaiting transport to Mexico.
– – California had the second greatest amount of cocaine seized in 2019 due to the proximity of the Southwest Border (SWB) and high-traffic international airports and seaports.
– – DEA Field Divisions seized 6,951 kilograms of heroin in 2019, a 30 percent increase from 2018, with the largest amounts of heroin seized in Texas, California, Arizona, and New York. California, Texas and Arizona are all major entry points for heroin sourced from Mexico and also serve as transshipment points for the onward movement of heroin to domestic markets throughout the United States.
– – California leads the U.S. in methamphetamine conversion labs. Methamphetamine conversion laboratories are used to convert powder methamphetamine into crystal methamphetamine or to recrystallize methamphetamine in solution back into crystal methamphetamine.
– – In 2019, 26 percent of illicit fentanyl tablets contained a potential lethal dose of fentanyl which increased from 14 percent and 10 percent the two years prior.

Mexican cartels are increasingly responsible for producing and supplying fentanyl to the U.S. market. China remains a key source of supply for the precursor chemicals that Mexican cartels use to produce the large amounts of fentanyl they are smuggling into the United States.

NAIC Reports Top 6 Comp Carriers Have 36% Market Share

The National Association of Insurance Commissioners (NAIC) released data on life/fraternal and property/casualty insurers. The reports provide market share information and identify leading insurance writers in several key lines of business. The numbers in the reports will increase throughout the week and month as the report runs.

The 2020 market share data include countrywide direct written premiums for the top 25 groups and companies as reported on the state page of the annual financial statement for insurers that report to the NAIC.

The Property/Casualty Market Share report contains cumulative market share data for the following lines of business: personal auto, commercial auto, workers’ compensation, medical professional liability, homeowners and other liability (excluding auto liability) insurance.

The top six carriers have more than a third of the market share (35.95%). Here are the top six.

1) Travelers Grp – Written Premium of $3,737,454,477 – – Market Share 8.91%.
2) Hartford Fire & Cas Grp – Written Premium of $2,992,053,652 – – Market Share 7.13%.
3) Zurich Ins Grp – Written Premium of $2,495,405,266 – – Market Share 5.95%.
4) Chubb Ltd Grp – Written Premium of $2,294,088,995 – – Market Share 5.47%.
5) Amtrust Financial Serv Grp – Written Premium of $1,895,538,139 – – Market Share 4.52%.
6) Berkshire Hathaway Grp – Written Premium of $1,673,865,206 – – Market Share 3.99%.

Other highlights from the report include:

– – With 69.47% of property/casualty insurance companies reporting to date, direct premiums written for all lines of business are $520,900,408,551.
– – The top 10 property/casualty companies reporting to date have a cumulative market share of 50.04%.
– – The two largest lines of business, private passenger auto and homeowners, have direct written premiums of $162,476,549,796 and $76,733,238,097, respectively, as of March 1.

The reports reflect data filed by insurers as of March 1 and will be refreshed daily through March 5 and then each Monday throughout March. The full 2020 Market Share Reports for Life/Fraternal Groups and Companies and the full 2020 Market Share Reports for Property/Casualty Groups and Companies will be available this summer and will contain more in-depth information.

Employer Groups Lose Bid to Stop Cal/OSHA COVID Regs

Following the implementation of the California Division of Occupational Safety and Health’s (Cal/OSHA) COVID-19 Emergency Temporary Standards (ETS) on November 30, 2020, several employers and trade associations filed a lawsuit in San Francisco Superior Court for declaratory and injunctive relief against Cal/OSHA.

The lawsuit, National Retail Federation, et al. v. California Department of Industrial Relations, et al. (Case No. CGC20588367), was the first filed seeking to prevent the agency from enforcing the ETS.

Shortly thereafter, the Western Growers Association filed a related case in Los Angeles Superior Court. However, in an effort to avoid “duplicative and inconsistent rulings,” the Western Growers Association lawsuit was transferred to San Francisco and the cases are being heard together.

The lawsuits alleged that the ETS were improper for several reasons, including that Cal/OSHA “exceeded the scope of its authority to promote occupational safety and health by attempting to regulate wages and paid leave” and “arbitrarily and capriciously deprive[d] Plaintiffs of property without just compensation or due process, particularly with respect to the COVID-19 testing and mandatory periods of paid exclusion from work.”

On January 28, 2021, Superior Court Judge Ethan P. Schulman heard oral argument on the motions for a preliminary injunction in both cases. Both sides articulated a number of arguments.

Jason S. Mills of Morgan, Lewis & Bockius LLP argued on behalf of the NFR, and claimed that two new requirements – mandatory testing and paid leave for exposed employees – exceed the agency’s authority. Freeing employers from those two requirements won’t lead to increased Covid-19 cases in workplaces, he argued.

David A. Schwarz of Sheppard, Mullin, Richter & Hampton LLP represented the Western Growers Association asked the court to also block provisions regulating employee-provided housing and transportation. The regulations, which dictate things like the distance between beds and the number of people allowed on a bus, border on logistical absurdity when applied to the agricultural industry, Schwarz said. And he asserted that the labor shortage in that industry will be exacerbated by these rules.

Last Thursday, Judge Schulman denied the request for a preliminary injunction. His ruling said that the standards board “properly found that the COVID-19 pandemic constitutes an emergency” and that prior guidance was “not sufficient to address” the risk of occupational spread.

Judge Schulman also dismissed the argument that Cal/OSHA lacked the authority to enforce the ETS, and held that if he granted the injunction, “numerous workers in California would suffer severe and irreparable harm.”