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Court of Appeal Guts Massive Orange County Compound Medication Fraud Case

In 2014 an Orange County Grand Jury indicted 45-year-old Kareem Ahmed and 14 others, alleging he formulated topical creams and oversaw an extensive network of kickbacks that paid doctors and pharmacists more than $25 million to prescribe and distribute the products. Ahmed, president of Ontario company Landmark Medical Management, and the others faced a total of 44 counts on felony charges including conspiracy, trading rebates for patient referrals, insurance fraud and involuntary manslaughter, according to the original two grand jury indictments. The amounts individual doctors received between 2010 and 2013 allegedly ranged from $600,000 to more than $2.5 million. Among those Ahmed allegedly paid were Daniel Capen, M.D. (more than $2.5 million); Andrew Jarminski, M.D. (more than $1.9 million); pharmacist Michael Rudolph (more than $1 million); and Rahil Kahn, M.D. (more than $1 million), according to the indictment.

The grand jury was instructed that it had to unanimously find a defendant committed only a single act encompassed within the count to return a true bill on that count. After the grand jury found the indictments to be true, defendants demurred in the trial court, resulting in the People amending the indictments to add hundreds of new counts – a separate count for each victim – and adding an additional allegation in a single count of involuntary manslaughter.

The defendants moved to set aside the amended indictments on the ground the grand jury had not made separate findings as to each victim, but instead had been instructed to find only one act. Defendants posited that the amendments thus impermissibly changed the offenses charged by the grand jury in violation of Penal Code section 1009. As to the involuntary manslaughter count, the defendants contended the new allegation, embedded in the single charge of involuntary manslaughter, also impermissibly changed the offense charged by the grand jury. The court denied the motion.

The Court of Appeal reversed and remanded in the case of Kareem Ahmed v Superior Court.

The Court of Appeal ruled that “there is no logical basis upon which we can conclude that the grand jury made a finding as to each of the new counts in the amended indictment. The additional counts are new offenses, not shown to be found by the grand jury, and thus changed the offenses charged in violation of section 1009. Accordingly, the indictment was ‘not found, endorsed, and presented as prescribed in’ the Penal Code….. Based on our conclusion that adding multiple counts of insurance fraud changed the offense charged in violation of section 1009, we will grant the petition for writ of mandate setting aside most of the charges in the two indictments.”

The trial court was ordered to issue a new order granting the motion with respect to all counts in the Charbonnet indictment except counts 1, 298, and 323, and all counts in the Ahmed indictment except count 1. The court is further directed to, at the prosecutor’s election, order the case resubmitted to a grand jury pursuant to sections 997, 998, and 1009. Count 1 is a conspiracy charge not addressed in this writ petition. Counts 298 and 323 repeated counts 30 and 33 from the original indictment, which alleged violations with respect to a single victim during a timeframe entirely within the statute of limitations.

The defendants had argued that the indictments alleged conduct outside the statute of limitations. In particular, defendants argued the statute of limitations for violations of section 549 and Business and Professions Code section 650 is three years (§ 801), and the statute of limitations for a violation of section 550 is four years (§§ 801.5, 803, subd. (c)(6)). With the indictments being filed on June 17, 2014, defendants argued they cannot be tried for conduct prior to June 17, 2011 and June 17, 2010, respectively.

At this point it is not clear how much of this major case remains. After remand the district attorney will have an opportunity to attempt to resurrect part of its case. It is not known at this time how successful this will be.

CDC, DWC and Others Develop New Opioid Treatment Guidelines

As part of the urgent response to the epidemic of overdose deaths, the Centers for Disease Control and Prevention (CDC) issued new recommendations for prescribing opioid medications for chronic pain, excluding cancer, palliative, and end-of-life care. The CDC Guideline for Prescribing Opioids for Chronic Pain, United States, 2016 will help primary care providers ensure the safest and most effective treatment for their patients.

While prescription opioids can be part of effective pain management, they have serious risks. The new guideline aims to improve the safety of prescribing and curtail the harms associated with opioids, including opioid use disorder and overdose. The guideline also focuses on increasing the use of other effective treatments available for chronic pain, such as nonopioid medications or physical therapy.

In developing the guideline, CDC followed a rigorous scientific process using the best available scientific evidence, consulting with experts, and listening to comments from the public and partners. CDC is dedicated to working with partners to improve the evidence base, and will refine recommendations as better evidence is available.

Among the 12 recommendations in the guideline, three principles are key to improving patient care:

1) Nonopioid therapy is preferred for chronic pain outside of active cancer, palliative, and end-of-life care.
2) When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose.
3) Providers should always exercise caution when prescribing opioids and monitor all patients closely.

Health and Human Services Secretary Sylvia Burwell has made addressing opioid misuse, dependence, and overdose a priority. Other work on this important issue is underway within HHS. The evidence-based HHS-wide opioid initiative focuses on three priority areas: informing opioid prescribing practices, increasing the use of naloxone (a rescue medication that can prevent death from overdose), and expanding access to and the use of Medication-Assisted Treatment to treat opioid use disorder.

At the same time, the DWC is in the process of developing its own Opioid Treatment Guideline. The last public hearing on the DWC Guideline was in September, and the first fifteen day comment period ended last December. However, the DWC Guideline outlines a philosophical difference by stating “A key difference between occupational and non-occupational guidelines is that a main goal of the former is the restoration of function to ensure early return to work.”

It is clear that government at every level has recognized the opioid epidemic, and is responding with new Guideline initiatives. Time will tell if these efforts will be effective.

LA Rams Ignite Workers’ Compensation Firestorm With New Player Contract

NBC Sports reports that contracts being offered to new Los Angeles Rams players state that the laws of Missouri, not California, control the relationship. The NFL Players Association has in turn instructed all certified contract agents to reject that term as “inappropriate.”

Critics says other language in the contract makes the purpose of this strategy clear. The Rams hope to nudge any workers’ compensation claims away from California and into Missouri.

From the contract: “The parties hereto acknowledge that this Player Contract has been negotiated and executed in Missouri; that should any dispute, claim or cause of action (collectively ‘dispute’) arise concerning rights or liabilities arising from the relationship between the Player and the Club, the parties hereto agree that the law governing such dispute shall be the law of the State of Missouri. Furthermore, the exclusive jurisdiction for resolving Workers’ Compensation related claims shall be the Division of Workers’ Compensation of Missouri, and the Missouri Workers’ Compensation Act shall govern.”

The NFLPA strongly disagrees. “We believe that any reference to the state of Missouri is inappropriate since the Rams have relocated to California as evidenced by the fact that they have changed their name on their website to the Los Angeles Rams, are prepared to hold off-season workouts and training camp in California, and will practice and play their home games in California in 2016,” the union says in the memo to all agents.

The Rams, however, say that the use of such language is more geared toward player bonuses paid out in March as an effort to help players pay a lesser state income tax, according to the Los Angeles Daily News. Pro Football Talk offered another follow up on Sunday with the Rams offering further clarification that all deals will simply roll over into California when the team moves in April.

Forbes has yet to release its 2016 valuation of every NFL franchise, but the man in charge of putting them together told the Washington Post in January that upon moving back to Los Angeles, the Rams doubled their value. Michael Ozanian, Forbes’s executive editor, said then that the Rams are now worth about $3 billion following the move to Los Angeles and the construction of their palatial new stadium in Inglewood. Assuming that value, the Rams would then trail only the Dallas Cowboys and New England Patriots in Forbes’ rankings.

The team is planning to move out of Rams Park and St. Louis by the end of the month.

DWC Announces Appointments to Ethics Advisory Committee

The DWC Acting Administrative Director George Parisotto has appointed Jamie Spitzer, presiding workers’ compensation administrative law judge at the Anaheim DWC district office, and Neil Robinson, presiding administrative law judge of the Occupational Health and Safety Appeals Board (OSHAB), to serve as members of the Workers’ Compensation Ethics Advisory Committee.

The appointments are effective immediately.

Judge Spitzer will fill the position designated for a presiding workers’ compensation administrative law judge, replacing Marina del Rey Presiding Judge Paige Levy, who was named chief judge for DWC in February.

Judge Robinson will fill the position of a member of the public outside the workers’ compensation community, previously held by Alameda Superior Court Judge Alice Vilardi.

The ethics advisory committee, established in 1995 by Title 8, California Code of Regulations, section 9722, reviews all ethics complaints from the public against workers’ compensation administrative law judges.

The committee reviews all complaints without learning the names of complainants or judges, and then makes recommendations to the administrative director and the DWC court administrator. The committee meets quarterly and members serve without compensation.

The regulation provides that the committee must include three members of the public representing organized labor; insurers and self-insured employers, an attorney who formerly practiced before the Workers’ Compensation Appeals Board and who usually represented insurers or employers, an attorney who formerly practiced before the Workers’ Compensation Appeals Board and who usually represented applicants, a presiding judge, a workers’ compensation administrative law judge (WCALJ) or retired WCALJ, and two members of the public outside the workers’ compensation community.

A judicial ethics complaint form and instructions can be found on the DWC website.

FDA Approves Exoskeleton for Paraplegics

The claim examiner’s task of reserving for future medical care is becoming more complex by the day. It is hard to even imagine what medical science will have to offer injured workers even a few years down the road. For example, Vanderbilt University just announced that the FDA has given clearance to market and sell the powered lower-limb exoskeleton created by a team of Vanderbilt engineers and commercialized by the Parker Hannifin Corporation for both clinical and personal use in the United States.

Indego®, which allows people paralyzed below the waist to stand up and walk, is the result of an intensive, 10-year effort. The initial development was funded by a grant from the National Institute of Child Health and Human Development. In 2012 Parker, a global leader in motion and control technologies, purchased an exclusive license to market the design and has worked closely with the Vanderbilt group to develop a commercial version of the medical device.

Until recently “wearable robots” like Indego were the stuff of science fiction. In the last 15 years, however, advances in robotics, microelectronics, battery and electric motor technologies have made it practical to develop them to aid people with stroke and spinal cord injuries. The device acts like an external skeleton. It straps in tightly around the torso. Rigid supports are strapped to the legs and extend from the hip to the knee and from the knee to the foot. The hip and knee joints are driven by computer-controlled electric motors powered by advanced batteries. Patients use the powered apparatus with walkers or forearm crutches to maintain their balance.

“You can think of our exoskeleton as a Segway with legs. If the person wearing it leans forward, he moves forward. If he leans back and holds that position for a few seconds, he sits down. When he is sitting down, if he leans forward and holds that position for a few seconds, then he stands up” one of the engineers said.

Indego is the second exoskeleton to receive FDA certification for U.S. use. The first was a device produced by Rewalk Robotics Ltd. However, Indego’s clearance came after completion of the largest exoskeleton clinical trail conducted in the United States. According to the Parker news release, “Over the course of more than 1,200 individual sessions, study participants were able to use Indego to safely walk on a variety of indoor and outdoor surfaces and settings with no serious adverse events.”

One of the design goals was to give users the maximum amount of personal freedom possible. One of his requirements, for example, was to allow the user to put the exoskeleton on and take it off while sitting in a wheelchair. As a result, the Indego is considerably lighter and less bulky than the other exoskeletons under development.

Beginning this summer,  the scientists will head a four-year U.S. Department of Defense-funded study of the tangible economic and rehabilitation benefits of exoskeletons for people with spinal cord injuries. This will be performed at three medical centers: James Haley Veteran’s Hospital in Tampa (the first VA center in the country to use Indego), the Mayo Clinic in Rochester, Minnesota and the Vanderbilt University Medical Center.

People who use wheelchairs regularly can develop serious problems with their urinary, respiratory, cardiovascular and digestive systems, as well as getting osteoporosis, pressure sores, blood clots and other afflictions associated with lack of mobility. The risk for developing these conditions can be reduced considerably by regularly standing, moving and exercising their lower limbs. The study, which will involve 24 participants, is designed to determine whether regular use of the Indego will also reduce these conditions.

Indego has been available in Europe since November, when it received the CE Mark, the European Union’s equivalent of FDA approval. The initial price is $80,000. The next step is getting the device approved for health insurance reimbursement. This involves getting the Centers for Medicare and Medicaid Services (CMS) to approve a “rate code” for the exoskeleton: a numeric code that identifies the characteristics of patients who Medicare/Medicaid will reimburse for purchasing a given piece of medical equipment. Typically, the government will reimburse 80 percent of the cost of approved medical devices. In most cases private health insurance providers adopt the CMS code.

Aetna Subsidiary Says Organized Medical Fraud is Growing World Wide

An article in The Telegraph says that the multi-billion dollar problem of fraud across the medical world has been officially acknowledged. Even Dubai has admitted that patients in the emirate may be “over-diagnosed” and detained in hospital longer than necessary. The director of the Dubai Health Authority, is launching a scheme to regulate services provided by private hospitals across the UAE. He said: “Sometimes people are kept longer than necessary in a hospital or an intensive-care unit. These kinds of things are daily issues that insurance members face and they need to be protected.” Foreign nationals in Dubai, for whom insurance is mandatory, should welcome the development.

But medical fraud is far from uniquely a Middle Eastern practice. It is estimated to add 10 per cent to medical premiums across the globe. Countries with large expatriate communities head the list of offenders. People anxious about their health in a foreign country are easy targets. Insurers struggle against relatively borderline offenses, such as prescribing unwanted pain-killers, to over-diagnosis such as ordering unneeded MRI scans, to full-scale criminal activity by organized gangs.

InterGlobal, the insurer for expatriates, which won the 2012 industry award for unmasking criminal activity, can guarantee picking up a fraudulent claim every day, such is the extent of the problem. InterGlobal is now part of Aetna.The company played a key part in revealing a massive fraud in which a criminal ring is said to have submitted scores of bogus claims to numerous insurers over a 10-year period. The operation was fronted by a virtual hospital, non-existent consultants and a 24-hour switchboard. As Paul Weigall, InterGlobal’s sales and marketing director, put it, the hospital was “just a telephone in the desert”. He added: “A lot of insurers were caught out. We got on to the case and were only very lightly affected.”

The Middle East was a major zone of concern, he said. China is often quoted as another hot spot. “You’ll find a group of people who have built up a fabricated health care system, which will include hospitals, doctors and customers – making it very difficult for an insurer not to pay out on a claim that’s submitted. Then we find that nothing of that actually exists.

“We’ve been invoiced by a hospital that gives an address, answers a phone when we ring and then we find that hospital doesn’t exist. There are a number of people who are looking, on a very large basis, to defraud people. “However, there are also hospitals that overcharge. For example, you need 20 aspirin, they charge you for 200.”

Death by a Thousand Cuts – Another Employer Leaves California

For years, Andrew F. Puzder, the CEO of CKE Restaurants, the parent company of the Carl’s Jr. and Hardee’s fast-food chains, has been telling the world that while the U.S. government makes life needlessly miserable for businesses, and California, where it has been headquartered, is exponentially worse.

This week, CKE announced that it is moving its headquarters to Nashville, Tennessee. In June 2013, Puzder told the Wall Street Journal that his chain would not expand in California because the state “is not interested in having businesses grow,” noting among many other things that it takes 285 days to get a building permit after signing a lease. This means the chain has to pay rent for over nine months, plus the time needed to build, while not earning any revenues.

Puzder also wrote roughly 15 columns at Human Events in 2012, most of them bemoaning the sluggish U.S. economy and onerous U.S. government policies and regulations.

The company appears to have planned to move its headquarters to Nashville for years. This would explain why it has gone to the franchising model almost everywhere except Nashville. It can use its company-owned stores there to test new menu items and concepts before making them available to franchisees. CKE could have chosen any large metro area for this strategy, including the area surrounding its current California headquarters. But it did not. Nation’s Restaurant News specifically notes that “Among the refranchised units are restaurants in Hardee’s headquarters city of St. Louis and in Santa Barbara County, Calif., where Carl’s Jr.’s home office in Carpinteria is located.” Why did management clearly choose to go elsewhere? Among other things, Puzder told the Journal in 2013 that the Golden State’s labor laws are intolerable.

And Car’s Jr. joins a long list of California companies with an exit strategy. Some of them are big employers. In 2014, Toyota announced plans to move most of the 5,000 managers and employees from Toyota’s Torrance, Calif., headquarters to Plano Texas. Toyota has enjoyed a deep relationship with Texas through its $2.2-billion truck-assembly complex near San Antonio.

And remember many decades ago when General Motors had an assembly plant in Van Nuys. Southern California’s long history as an auto manufacturing center ended in 1992 when a flame-red Chevrolet Camaro rolled off the assembly line, the last of 6.3 million vehicles built there over 45 years. The Van Nuys factory, which also made Pontiac Firebirds, was the last auto plant in Southern California. Its demise -announced to the plant’s 2,600 workers – follows the closure in the early 1980s of a Ford Motor Co. plant in Pico Rivera and a GM plant in South Gate and the 1971 shutdown of a Chrysler Corp. plant in City of Commerce.

A recent published study of “California divestment events” – business decisions to shun the state paint a grim picture. These come in three types: companies that left the state entirely; companies that expanded in other states rather than in California; and a few companies that had planned to grow in the Golden State but changed their minds. The study found records of 1,510 divestment events occurring in California between 2008 and 2014, but that number is an incomplete accounting of the situation. “Experts in site selection generally agree that at least five events fail to become public knowledge for every one that does,” giving rise to the conclusion that the real total is probably more than 9,000 divestment events for this period.

We can say goodbye to number 9001, the Carl’s Jr. headquarters.

WCRI Says Physician Financial Incentives Cause “Case Shifting” to Comp

An article in Business Insurance claims that higher fee schedules generally result in cases being shifted from group health coverage to workers compensation. This conclusion was based on preliminary findings by the Workers Compensation Research Institute.

Depending on the injury, decisions about whether an injury is related to work may rely heavily on treating physician assessments, WCRI President and CEO Dr. John Ruser said Thursday during the Cambridge, Massachusetts-based group’s 2016 WCRI Annual Issues & Research Conference in Boston.

With fractures, contusions and lacerations, for example, it’s usually clear whether an injury occurred on the job, Dr. Ruser said of the study of injuries originating between 2008 and 2010. Causation is less obvious for soft tissue injuries such as knee and shoulder strains, giving doctors more discretion, he said. “It’s not about fraud,” Dr. Ruser said. “It’s about uncertainty, and financial incentives could influence that decision.”

According to WCRI’s preliminary findings on how fee schedules affect case-shifting, increasing workers comp reimbursement rates by 20% for physician services associated with office visits increases the odds that a soft tissue injury will be considered work-related by 6%. “It doesn’t sound like a lot, but it’s more than you think,” Dr. Ruser said, adding that the 6% increase in comp-related soft tissue injuries leads to a 1.5% increase in overall workers comp costs.

He said there was no evidence of case-shifting for patients with fractures, lacerations, contusions or traumatic injuries by trauma in all 50 states studied.

Though employers pay for both group health and workers comp, case-shifting leads to higher costs as workers comp typically pays higher prices for medical care, higher workers comp income benefits can cause cases to stay open longer, and income benefit payments often exceed nonoccupational disability insurance payments, which aren’t offered to everyone, Dr. Ruser said.

Patient incentives also can come into play, Dr. Ruser said, since there are no copays or deductibles in workers comp. “Everything else equal, the patient would be happy if a particular case was called work-related,” he said.

WCJ Ethics Advisory Committee Issues 2015 Annual Report

The Division of Workers’ Compensation has posted the 2015 ethics advisory committee’s annual report on its website. The ethics advisory committee is a state committee independent from the DWC that is charged with reviewing and monitoring complaints of misconduct filed against workers’ compensation administrative law judges.

The EAC is composed of nine members, each appointed by the administrative director of the DWC for a term of four years. The composition of the EAC reflects the constituencies within the California workers’ compensation community. The EAC meets four times a year at the DWC headquarters. Although EAC meetings are open to the public, the Committee meets in executive session when it engages in the review and discussion of actual complaints, and that portion of the proceedings is closed to the public.The ethics advisory committee is required to make a public report each year summarizing activities in the previous calendar year. Anyone may file a complaint with the EAC. Complaints may be submitted anonymously, but all complaints must be presented in writing.

The 2015 annual report may be viewed or downloaded at the DWC website. In this report, the EAC considered a total of 38 of the 44 new complaints it received in calendar year 2015, in addition to 6 complaints pending from 2014. The complaints set forth a wide variety of grievances. A large proportion of the complaints alleged legal error not involving judicial misconduct or expressed dissatisfaction with a judge’s decision. The majority of complaints were filed by unrepresented employees.

The EAC recommended that “further action be taken” in three lien cases. (cases 9, 10 and 26 in the report) All three complained about a lack of courtesy, dignity, and rudeness on the part of the WCJ, and threatening and intimidating behavior. Cases 9, and 10 were the same case reported by two people. The dispute involved allegations that the WCJ called a doctor’s office and ordered that the doctor appear at a hearing that day. The doctor responded that he was observing a three day religious holiday and could not appear before that was over. The WCJ allegedly responded “I don’t believe you.” The second complaint was filed by a witness at that hearing. “The complainant alleged that the judge appeared smug, negative, and downright abusive to all the parties.” In both cases the EAC “recommended to the CJ that further action be taken and recommended that this matter be referred to personnel.”

In case 26, he complainant, a lien claimant, alleged that the judge displayed rude, abusive, undignified, ill-mannered, intemperate, disrespectful, and discourteous conduct by yelling at the complainant and imposing sanctions for not producing the lien claimant representative at the hearing, even though no subpoena had been served. The complainant filed a Petition for Reconsideration. The Petition was granted for further review. The complainant also attached three panel decisions in different cases that found that the judge engaged in abuse of discretion. Following its review of the investigation, the committee recommended further action and referred this matter to personnel.

Kim Kardashian Target of Subrogation Lawsuit

Kim Kardashian was sued Tuesday by the workers’ compensation carrier for a company that employed a man who says he was injured in a 2014 Beverly Hills collision involving a car driven by the reality star. Applied Risk Services Inc. filed the lawsuit in Los Angeles Superior Court, seeking unspecified damages. Applied Risk Services is the TPA for California Insurance Company, the workers’ compensation carrier for John Paul Co. Inc. of Van Nuys, which employed Rafael Antonio Linares of Moreno Valley at the time of the collision.

Linares sued Kardashian in a separate complaint filed March 1, which says the crash occurred on Sunset Boulevard near Benedict Canyon Drive on March 11, 2014. Linares has had to seek medical care and his car was damaged and is now worth less than before the collision, according to his court papers. Kardashian reportedly collided with Linares’ silver sedan while turning left in her black Mercedes G Wagon. Though some reports claim that the mother-of-two had her turn signal on at the time, Linares maintains that Kardashian was driving recklessly.

Linares and Kardashian were both able to drive their vehicles to the nearby Beverly Hills Hotel, Gossip Cop reported, where “they exchanged information and even hugged.” There were no tickets issued at the time of the incident.

In reporting the Kim Kardashian lawsuit Tuesday, TMZ shared a photo of the damage to Kim’s G-Wagon after the incident and notes that sources close to Kim called the damage to her vehicle “minimal.” The TMZ photo shows a small scuff on the bumper of the star’s SUV.

The Applied Risk Services suit seeks recovery from the 35-year-old Kardashian of all workers’ compensation benefits paid to Linares as a result of his injuries from the accident.