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UR Process “Ripe” for Automation

A report in Property Casualty 360 makes the case that the utilization review process for workers’ compensation claims is ripe for automation. The practice of determining whether healthcare is medically necessary for an injured worker has remained relatively unchanged for decades.  Requests for authorization are submitted, a nurse compares the requested care against evidence-based medical guidelines, and a determination is issued.

The determination is a tool for the treating provider, the claims examiner, and the claimant. Applying the determination during the actual delivery of care is traditionally accomplished by a person, typically a claim examiner or adjuster, or by a medical bill reviewer or auditor, but rarely is it done through technology-enabled automation.

Automation can have many touchpoints in the utilization review workstream. One of the first is the request intake process. Unlike bill review, the Request for Authorization (RFA) form is not standardized across the United States. Some states have very specific requirements for submitting the RFA, whereas other states offer little or no guidance on form submittal, which leads to a very manual process for data entry into a utilization review system.

This is changing with new UR platforms that combine optical character recognition tools and automated intelligence or AI. The faster and more effectively that requests can be submitted for review, the sooner claimants can receive appropriate care.

The next step that is ideal for automation is the application of the appropriate evidence-based medical guideline. This includes identifying the correct criteria set, as well as the correct guideline itself. The hallmark of a good utilization review program is consistency. This includes consistency in meeting turnaround times, consistency in applying guidelines, and consistency in outcomes. Rules-based technology increases guideline accuracy. In situations where an exact match cannot be found, algorithms can serve up best matches.

Automation can also relieve delays when a treatment request is denied. Instead of waiting for the provider to submit an appeal, the noncertified case can be instantly routed to a peer reviewer for assessment. Using a peer reviewer can improve clients’ outcomes when the peer reviewer is in the same specialty, has state licensure in the state where the claimant resides and has a clear understanding of the process’ goals. Automating the referral process to peer review gets the case into the right hands quickly, allowing time for an effective peer-to-peer discussion.

The dissemination of the determination is critical to communication and essential for timely management of the referral. Automating distribution is a time saver for all levels of the case. However, the biggest jump in value is achieved by tightly integrating utilization review with medical bill review.

Today, the workers’ compensation industry relies on claims examiners or bill review auditors to make a visual comparison of the approved or denied treatment to actual care rendered. The flaws in this approach are obvious, and mistakes are unavoidable.

A more intelligent approach is through automation. To accomplish this, the bill review and utilization review platforms need to speak the same language. Utilization review is regularly completed as a narrative and bill review reads in code. The solution is to create the request and the outcome using a medical code set that the bill review system can understand, such as CPT®, a medical code set maintained by the American Medical Association.

SCIF Declares $105 Million Dividend

State Compensation Insurance Fund’s Board of Directors announced plans to distribute an approximate $105 million dividend to its qualifying policyholders with policies that took effect between Jan. 1 and Aug. 19, 2019.

This dividend equals approximately 15% of the estimated annual premium reported in State Fund’s mid-year 2019 financial statement.

State Fund’s Board will consider dividends again for the remainder of the 2019 policy year at its February meeting in 2020. While the board cannot guarantee future dividends, this mid-year declaration does not affect the possibility of a future payout for the remainder of the 2019 policy year.

Through July of this year, State Fund is reporting over $662.5 million in premium and over $78.6 million in realized capital gains.

Additionally, State Fund has implemented several initiatives over the past few years that have led to improved claims outcomes for injured workers and employers. These efforts, combined with the general improvement in the California workers’ compensation insurance environment, have led to a significant decrease in the cost of its claims. This early dividend declaration reflects these positive developments.

“Declaring a dividend at this time helps tens of thousands of California businesses better understand their workers’ compensation insurance costs for the year and plan accordingly,” said Vern Steiner, State Fund’s President and CEO. “Thanks to effective investment management and improved claims outcomes, we are in a strong, stable financial position and want to return money to our policyholders as quickly as possible.”

Since its creation in 1914, State Fund has paid out more than $5 billion in dividends to policyholders – significantly more than any oter California workers’ compensation carrier over that time.

State Fund policyholders will begin to receive dividend payments during the second half of next year.

Oxnard Field Worker Convicted in Fraud Case

The Ventura County District Attorney announced that Oxnard resident Ernestina Rodriguez, was placed on formal probation for a period of 36 months after having pled guilty to a felony violation of lnsurance Code section 1871.4(a)(l), making a false or fraudulent statement of a material fact for the purpose of obtaining workers’ compensation benefits.

She had previously made restitution in full to the victim, Zenith Insurance Company, in the amount of $9,333.50 and will serve 150 days in the Ventura County jail as a condition of probation.

Rodriguez was employed as a field worker in Oxnard and filed a workers’ compensation claim for injuries to her back, neck, and knees on February 14, 2015.

She was placed off work and began receiving medical treatment and temporary total disability benefits provided by Zenith Insurance.

During the time she received treatment, she denied to her treating physicians, a Qualified Medical Examiner, and at a deposition that she had ever filed any prior workers’ compensation claims involving the same body parts as she was claiming in February 2015.

In fact, the defendant had filed and settled two prior workers’ compensation claims for the same body parts in 2002 and 2010.

Her material misrepresentations affected the way her claim was apportioned and caused Zenith Insurance to pay her $9,333.50 in benefits that she was not entitled to receive.

Owners of Sushi Restaurants Guilty in Premium Fraud Case

In June 2018, the married owners of sushi and barbecue restaurants in Pleasant Hill, Manteca, and Tracy were charged with 30 felony counts, including conspiracy, related to alleged payroll tax evasion and fraud. They have have now taken a plea deal in a conspiracy case that alleged workers compensation fraud and tax evasion.

The Mercury News reported that Lafayette residents 63 year old Kyung Yeon, and 65 year old Richard Howard, were both sentenced at a hearing Wednesday afternoon, according to court records. Yeon, the lead defendant, pleaded no contest to single charges of tax evasion and workers compensation fraud, both felonies.

Yeon’s husband, Howard, pleaded no contest to a misdemeanor insurance evasion charge. The couple had originally been charged with 30 counts, including conspiracy.

Yeon will serve 90 days on house arrest and five years of probation, and pay a $20,000 fine, prosecutors said. Howard was given 100 hours of community service, two years of probation and a $1,000 fine. Both defendants must also pay around $80,000 in restitution.

Yeon and Howard own Matsu Sushi and Chop Chop Korean BBQ – both in Pleasant Hill – as well as Bluefin Sushi in Tracy and Matsu Sushi in Manteca. At the time of the alleged offenses, the restaurants had a total of 28 full- and part-time employees, according to court records.

In July 2016 a federal wage investigator with the U.S. Department of Labor alerted the Contra Costa County District Attorney’s office that Yeon and Howard owed around $270,000 in employee back wages over a three-year period, from December 2012 to December 2015, according to court records.

In response to the tip, a D.A. inspector filed a search warrant and obtained payroll tax records from the restaurant. Roughly a year later, prosecutors filed the fraud and tax evasion charges.

They were charged in June 2018, through a criminal complaint that alleged they evaded $1.1 million in payroll taxes by using “under the table” cash payment systems for employees at all four restaurants.

August 19, 2019 News Podcast


Rene Thomas Folse, JD, Ph.D. is the host for this edition which reports on the following news stories: Is Health Care Fraud Really This Easy???, Victorville Pharmacist to Serve 5 Years in Prison, Roofer Sentenced in $1M Premium Fraud Case, Generic Drugmakers Accused of Stonewalling Price Probe, Canada Forces $10B Reduction in Drug Prices, Employer Supports Surgeries in Foreign Hospitals with US Physicians, Few Patients Benefit from Meniscus Surgery, Scientists Report Emerging Role of Schwann Cells in Neuropathic Pain, Opioid and Cannabis Co-Use Increases Anxiety and Depression.

Patients Over Paperwork Initiative Targets $39B in Costs

The Centers for Medicare & Medicaid Services (CMS) launched the Patients Over Paperwork Initiative in 2017, which seeks feedback from industry stakeholders on ways to reduce administrative burdens in health care and improving the patient experience.

The Initiative was in accord with President Trump’s Executive Order that directs federal agencies to “cut the red tape” to reduce burdensome regulations.

This year, CMS received over 560 comments in response to its request for information.

The American Hospital Association (AHA) asserted that providers spend nearly $39 billion each year on administrative activities related to regulatory compliance.

Other stakeholders pointed to prior authorization as a problematic practice, with the American Academy of Ophthalmology calling it the “most burdensome requirement in Medicare.”

The American Association of Neurological Surgeons argues that patients are experiencing significant barriers to medically necessary care because of prior authorization requirements.

Numerous stakeholders called for prior authorization reform in Medicare Advantage plans, but America’s Health Insurance Plans (AHIP) has pushed back, saying that less than 15 percent of covered treatments and services require prior authorization.

However, stakeholders agreed that greater automation would reduce the burdens of prior authorization. Greater standardization of prior authorizations would increase the speed at which they are approved and reduce care delays.

CMS has enacted several regulatory reforms as a result of information gathered through the Patients Over Paperwork Initiative, including reforming evaluation and management (E/M) coding, simplifying office visit documentation, and reducing the complexity of the Quality Payment Program.

Will prior authorization reform be the agency’s next target?

Conviction Illustrates Dark Web and Drugs

Sky Justin Gornik, age 39, of San Diego was sentenced to 70 months in prison for  participating in a conspiracy to deliver, distribute and dispense controlled substances through the internet. Gornik previously pled guilty to that charge and also admitted that he engaged in a conspiracy to launder drug proceeds using digital currencies.

As part of his guilty plea, Gornik admitted that he bought and sold controlled substances on the Dark Web.  Employing anonymous screen names, Gornik used multiple Dark Web marketplaces (including Alpha Bay, Trade Route, Abraxas, Evolution, Outlaw Market, and Dream Market) to buy and sell controlled substances.  

Specifically, Gornik admitted that he purchased and sold fentanyl and purchased the especially deadly opiate carfentanil using a variety of digital currencies. Gornik also purchased and sold multiple other controlled substances, including thousands of vials of ketamine, oxycodone pills, Dimethyltryptamine (DMT), Psilocybin and Psilocin, Amphetamine, Buprenorphine, Methamphetamine, and Naloxone.

Agents seized 1.7 grams of carfentanil inside Gornik’s residence on June 7, 2017. Carfentanil is a synthetic opioid approximately 10,000 more potent than morphine and 100 times more potent than fentanyl. The 1.722 grams of carfentanil seized in Gornik’s residence could equate to over 86,000 fatal dosages.  

Gornik also possessed sheets of fentanyl gelatin tablets (approximately 100 tabs per sheet), which agents seized during the search.  The public record reflects that Gornik obtained 600-1200 fentanyl gel tablets each week for approximately two years from a Dark Web vendor, identified as Steven Wallace George, who resides in Oklahoma.  George, who manufactured pure fentanyl obtained from China into gelatin tablets, was prosecuted by federal authorities in Oklahoma.

As part of his guilty plea, Gornik agreed to forfeit millions of dollars in digital or crypto currency including Bitcoins, Stratis, Ethereum, 2350 Monero, digital currency contained in Gornik’s Bittrex accounts, and digital currency contained in Gornik’s Poloniex accounts.  Gornik admitted that these digital or crypto currency represented drug trafficking proceeds of the offense and were involved in the offense of money laundering over the Dark Web.

This case is the result of the ongoing efforts by the Organized Crime Drug Enforcement Task Force (OCDETF), a partnership that brings together the combined expertise and unique abilities of federal, state and local law enforcement agencies. The principal mission of the OCDETF program is to identify, disrupt, dismantle and prosecute high-level members of drug trafficking, weapons trafficking and money laundering organizations and enterprises.

More Opiod Drugmakers Settle Claims

Reuters reports that Endo International Plc and Allergan Plc have agreed to pay $15 million to avoid going to trial in October in a landmark case by two Ohio counties accusing various drug manufacturers and distributors of fueling the U.S. opioid epidemic.

The tentative deals disclosed on Tuesday came ahead of the first trial to result from 2,000 lawsuits pending in federal court in Cleveland largely by local governments seeking to hold drug companies responsible for the deadly epidemic.

Endo announced said it had reached an agreement-in-principle to pay Cuyahoga and Summit counties $10 million to and provide them up to $1 million worth of two of its of its drug products free of charge.

Allergan has tentatively agreed to pay $5 million to resolve claims involving its branded opioids, though the deal does not resolve claims involving generic painkillers, said Frank Gallucci, a lawyer for Cuyahoga County.

The accords are the first to result from the counties’ cases, which were selected for the first bellwether, or test, trial in the litigation to allow parties to gauge the value of the remaining claims and inform potential settlement talks.

Other companies still set to face trial on Oct. 21 include drugmakers Purdue Pharma LP, Teva Pharmaceutical Industries Ltd and Johnson & Johnson and drug distributors McKesson Corp, Cardinal Health Inc and AmerisourceBergen Corp.

Endo, which in 2017 withdrew its painkiller Opana ER from the market, said the settlement includes no admission of wrongdoing.

More than 2,300 lawsuits by state and local governments are pending nationally, accusing drug manufacturers of deceptively marketing opioids in ways that downplayed their risks and drug distributors of failing to detect and halt suspicious orders.

Most of the lawsuits are before U.S. District Judge Dan Polster in Cleveland, who has pushed for a settlement and will preside over the bellwether trial.

Purdue and Teva this year settled claims by Oklahoma’s attorney general for $270 million and $85 million, respectively, ahead of a trial before a state-court judge.

The state subsequently took Johnson & Johnson to trial. An Oklahoma judge will rule on Monday on whether the company should be held liable in a lawsuit by the state’s attorney general who argues the drugmaker should be forced to pay $17 billion for fueling the opioid epidemic.

More Opioid Drugmakers Settle Claims

Reuters reports that Endo International Plc and Allergan Plc have agreed to pay $15 million to avoid going to trial in October in a landmark case by two Ohio counties accusing various drug manufacturers and distributors of fueling the U.S. opioid epidemic.

The tentative deals disclosed on Tuesday came ahead of the first trial to result from 2,000 lawsuits pending in federal court in Cleveland largely by local governments seeking to hold drug companies responsible for the deadly epidemic.

Endo announced said it had reached an agreement-in-principle to pay Cuyahoga and Summit counties $10 million to and provide them up to $1 million worth of two of its of its drug products free of charge.

Allergan has tentatively agreed to pay $5 million to resolve claims involving its branded opioids, though the deal does not resolve claims involving generic painkillers, said Frank Gallucci, a lawyer for Cuyahoga County.

The accords are the first to result from the counties’ cases, which were selected for the first bellwether, or test, trial in the litigation to allow parties to gauge the value of the remaining claims and inform potential settlement talks.

Other companies still set to face trial on Oct. 21 include drugmakers Purdue Pharma LP, Teva Pharmaceutical Industries Ltd and Johnson & Johnson and drug distributors McKesson Corp, Cardinal Health Inc and AmerisourceBergen Corp.

Endo, which in 2017 withdrew its painkiller Opana ER from the market, said the settlement includes no admission of wrongdoing.

More than 2,300 lawsuits by state and local governments are pending nationally, accusing drug manufacturers of deceptively marketing opioids in ways that downplayed their risks and drug distributors of failing to detect and halt suspicious orders.

Most of the lawsuits are before U.S. District Judge Dan Polster in Cleveland, who has pushed for a settlement and will preside over the bellwether trial.

Purdue and Teva this year settled claims by Oklahoma’s attorney general for $270 million and $85 million, respectively, ahead of a trial before a state-court judge.

The state subsequently took Johnson & Johnson to trial. An Oklahoma judge will rule on Monday on whether the company should be held liable in a lawsuit by the state’s attorney general who argues the drugmaker should be forced to pay $17 billion for fueling the opioid epidemic.

More Opioid Drugmakers Settle Claims

Reuters reports that Endo International Plc and Allergan Plc have agreed to pay $15 million to avoid going to trial in October in a landmark case by two Ohio counties accusing various drug manufacturers and distributors of fueling the U.S. opioid epidemic.

The tentative deals disclosed on Tuesday came ahead of the first trial to result from 2,000 lawsuits pending in federal court in Cleveland largely by local governments seeking to hold drug companies responsible for the deadly epidemic.

Endo announced said it had reached an agreement-in-principle to pay Cuyahoga and Summit counties $10 million to and provide them up to $1 million worth of two of its of its drug products free of charge.

Allergan has tentatively agreed to pay $5 million to resolve claims involving its branded opioids, though the deal does not resolve claims involving generic painkillers, said Frank Gallucci, a lawyer for Cuyahoga County.

The accords are the first to result from the counties’ cases, which were selected for the first bellwether, or test, trial in the litigation to allow parties to gauge the value of the remaining claims and inform potential settlement talks.

Other companies still set to face trial on Oct. 21 include drugmakers Purdue Pharma LP, Teva Pharmaceutical Industries Ltd and Johnson & Johnson and drug distributors McKesson Corp, Cardinal Health Inc and AmerisourceBergen Corp.

Endo, which in 2017 withdrew its painkiller Opana ER from the market, said the settlement includes no admission of wrongdoing.

More than 2,300 lawsuits by state and local governments are pending nationally, accusing drug manufacturers of deceptively marketing opioids in ways that downplayed their risks and drug distributors of failing to detect and halt suspicious orders.

Most of the lawsuits are before U.S. District Judge Dan Polster in Cleveland, who has pushed for a settlement and will preside over the bellwether trial.

Purdue and Teva this year settled claims by Oklahoma’s attorney general for $270 million and $85 million, respectively, ahead of a trial before a state-court judge.

The state subsequently took Johnson & Johnson to trial. An Oklahoma judge will rule on Monday on whether the company should be held liable in a lawsuit by the state’s attorney general who argues the drugmaker should be forced to pay $17 billion for fueling the opioid epidemic.