The Stanislaus County District Attorney’s Office announced the conviction of a retired Foster Farms employee for workers’ compensation insurance fraud.

Gurmail Singh was employed in the processing facility for the company and reported an on the job injury in November of 2014. Singh filed a workers’ compensation claim and as a result, received medical treatment and workers’ compensation benefits.

He retired from Foster Farms in June of 2015 and continued to receive benefits.

During a subsequent investigation, it was alleged Singh presented false statements and material misrepresentations during his deposition and at a medical appointment. Singh misrepresented facts as it related to his physical abilities and limitations associated with his injury and prior medical history.

On February 28, 2020, Singh pleaded no contest to Insurance Fraud, in violation of Insurance Code section 1871.4(a)(2), in that he unlawfully and knowingly made a false and fraudulent material statement in support of obtaining workers’ compensation insurance benefits.

He was convicted and sentenced to three years probation and ordered to pay restitution in the amount of $3,200 to Foster Farms for reimbursement of investigation costs.

This case was a joint investigation with Foster Farms’ Special Investigation Unit and the Amador County District Attorney’s Workers’ Compensation Fraud Unit.

The Fraud Unit investigates insurance fraud cases in Stanislaus County through a grant provided by the California Department of Insurance.

According to a new Coventry whitepaper, engaging a pharmacy nurse as soon as potential risks are identified is the most proactive approach to patient education and safety.

Pharmacy nurses are specially trained case managers who focus on at-risk claims due to emerging and complex pharmacy utilization, and communicate with prescribing physicians, injured workers, and claims handlers to positively impact drug utilization.

By using a wider lens to manage all aspects of the claim, these nurses:

— Ensure patient engagement, safety, and education.
— Confirm pharmacy utilization is medically appropriate and supports a timely recovery.
— Enable timely medical stability and return-to-work.
— Consult with case managers when complex pharmacy issues are identified on open claims.
— Provide consultation to claims handlers on pharmacy questions and issues.
— Review monthly pharmacy trend reports.
— Collaborate with clinical pharmacists on alternative medications.
— Utilize drug utilization assessment (DUA) to assist in provider discussions.

A pharmacy nurse can work quickly to identify concerning medications to reduce the likelihood of addiction. During early narcotic intervention, pharmacy nurses can call the prescriber to discuss alternative treatment plans to influence future prescribing habits and decrease narcotic utilization.

From first opioid utilization through discontinuation, a pharmacy nurse can support patients at each step of therapy, advocating for the safe and effective discontinuation of opioids for injured workers.

For employers dealing with existing claims, pharmacy nurses can also step in and make significant impacts on older claims with sizeable pharmacy utilization. The nurse reviews the pharmacy history and collaborates with the pharmacy benefit manager (PBM), provider, and injured worker to identify opportunities to reduce overall drug utilization while improving patient safety.

Anna Vishnevsky, 52, of Valley Village, the former owner of a Studio City medical clinic was sentenced to 37 months in federal prison for causing more than $11.5 million in bills to be submitted to health care benefit programs for unnecessary – and sometimes nonexistent – sleep studies, primarily for employees of United Parcel Service, Inc., and Costco Wholesale Corp.

She was also ordered her to pay $2,747,071 in restitution.

Vishnevsky, who owned Atlas Diagnostic Services, Inc., pleaded guilty in November 2018 to one count of health care fraud.

From March 2014 until June 2016, Vishnevsky participated in a scheme to defraud health care benefit plans. Vishnevsky and others working at her direction recruited patients to participate in sleep study testing at Atlas by offering them cash. She also offered them additional cash if they brought in other sleep study participants, including their co-workers and relatives.

Vishnevsky recruited patients, knowing that no doctor had prescribed sleep study testing for them and regardless of whether the testing was medically necessary or appropriate. Vishnevsky did not score or interpret the data from the testing or send it to anyone who could score or interpret it, which is necessary for diagnosis and treatment.

She submitted insurance claims for sleep study testing performed on the recruited patients, listing physicians that had never treated the patients. She also billed not only for the one night of sleep study testing that the patients had purportedly undergone – regardless of medical necessity – but also for an additional, consecutive night of sleep study testing that was never performed.

In total, Vishnevsky submitted more than $11.5 million in fraudulent insurance claims to health care benefit plans. She received approximately $3 million on those claims, of which $2,747,071 is still outstanding.

A co-defendant, Eddie Hernandez, 46, of Torrance, pleaded guilty in November 2018 to one count of health care fraud and is serving a 30-month federal prison sentence in this case. Hernandez was a UPS driver who helped Vishnevsky recruit people to participate in the fraudulent sleep studies.

What healthcare problems are consuming the largest share of healthcare dollars? Researchers decided to answer that question.

In total, the researchers analyzed 5.9 billion unique insurance claims, 150.4 million ambulance rides, dental procedures, and emergency room visits, 1.5 billion days spent within inpatient or nursing home care, and 5.9 million drug prescriptions. And they just published their results in the Journal of the American Medical Association.

Researchers say that when neck and low back pain are combined with other musculoskeletal disorders, including joint and limb troubles, Americans are spending more for treatment than on any other ailment or condition.

Just how much does that add up to? According to data from 2016, an almost inconceivable $380 billion was spent on spinal issues and joint pain.

In all (individuals, public insurance, private insurance), $3.1 trillion was spent on healthcare in the United States in 2016. That comes out to $9,655 for every U.S. citizen, and roughly 17.9% of the U.S. GDP. For reference on just how high prices have skyrocketed, in 1996, healthcare costs only represented 13.3% of the GDP.

“The vast costs associated with healthcare represent one of the most important and contentious issues facing Americans today,” says Dr. Joseph Dieleman of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington’s School of Medicine and lead author of the study, in a release. “Our study provides comprehensive estimates over a 20-year period that highlight how healthcare and prescription drugs are paid for, what they are spent on, and how such payments have changed over time.”

Of all 154 medical conditions included in this research, just lower back and neck pain alone accumulated the highest expenditures ($134.5 billion). After that, diabetes ($111.2 billion), ischemic heart disease ($89.3 billion), and falls ($87.4 billion) weren’t far behind in terms of costs.

Predictably, the majority of those costs were paid for by insurance providers, both public and private.  Regarding lower back and neck pain; $76.9 billion was paid for by private insurance, and $45.2 billion was paid for by public insurance. Still, that left $12.3 billion that had to come out of someone’s pockets.

Meanwhile, private insurers paid $73.3 billion for other musculoskeletal disorders, public insurers covered $46.9 billion in costs, and $9.7 billion was paid for by individuals out of pocket.

For diabetes, $55.4 billion was paid by public insurance, $49.1 billion by private, and $6.7 billion was paid out of pocket.

How about ischemic heart disease? In all, $48.2 billion was paid for by public insurers, $37.9 billion worth of costs were covered by private insurers, and $3.2 billion was paid by individuals.

Finally, falls tallied a hefty tab as well; $40.7 billion was paid for by public insurance, $34.8 billion was paid for by private insurance, and $11.9 billion was settled out of pocket.

Most of that public insurance spending (58.6%) covered bill accumulated by patients over the age of 65. After adjusting for population and age fluctuations, public insurance spending increased much faster than private insurance. The study’s authors attribute this observation to Medicaid expansions.

Mitchell | Genex, a provider of cost containment technology, clinical services, and disability management, has announced an agreement to acquire Coventry Workers’ Comp Services from CVS Health. Coventry Workers’ Comp Services is a provider of care and cost management programs for workers’ compensation and auto insurance carriers, third-party administrators, and self-insured employers. Coventry Workers’ Comp Services is currently a division of Aetna, a CVS Health company.

With this acquisition, Mitchell | Genex will expand its capabilities, and add Coventry’s leading PPO network to its continuum of care and cost containment offerings.

Peter Madeja, Genex Services President and CEO said  “We are extremely proud and excited about adding another long-standing, reputable organization to the Mitchell | Genex team. This move will expand the breadth of our cutting-edge cost containment technology and clinical services with the deepest understanding of the workers’ compensation industry and will significantly build upon our network offerings. It reinforces our continuous commitment to help clients navigate through today’s challenges and build better outcomes to improve the lives of injured parties.”

Based in Downers Grove, IL, Coventry Workers’ Comp Services has been a full-service managed care organization for more than 35 years. The company brings approximately 2,000 professionals with deep industry expertise, along with a broad suite of services – network, clinical and specialty – powered by technology to enhance network development, clinical integration and operational efficiencies with a focus on total claims cost.

Following the closing of this acquisition, Coventry Workers’ Comp will continue to be led by Art Lynch, President and CEO, and operate under its brand.

“We are very excited to join Mitchell | Genex and further meet the needs of our ever-changing industry,” said Lynch. “This is a forward-thinking partnership that combines one of the most robust PPO networks with an equally positioned firm in cost containment technology and clinical solutions. These capabilities, when combined with artificial intelligence and advanced analytics, will maximize our clients’ performance today and into the future.”

Kramer Levin Naftalis & Frankel LLP and Axinn, Veltrop & Harkrider LLP are acting as legal advisors to Mitchell | Genex. Fried, Frank, Harris, Shriver & Jacobson LLP and Dechert LLP are acting as legal advisors to CVS Health. BofA Securities is acting as exclusive financial advisor to CVS Health.

The acquisition is subject to customary closing conditions, including applicable regulatory approvals. The financial terms of the transaction are not being disclosed.