Tampa attorney Brad Culpepper has made a name for himself on the football field, in the courtroom and on reality television. But now an insurance company filed a civil lawsuit against him accusing him of workers’ compensation fraud.

For nine years, Culpepper went head to head against some of the biggest and strongest players in the National Football League. He parlayed fame on the field into success as a Florida personal injury attorney, living in a multi-million dollar bayfront mansion. Just last year, Culpepper was selected as a cast member for the CBS reality show “Survivor.”

But now a story in Tampa Bay News reports that nearly four years ago, Culpepper filed for workers’ compensation for injuries he suffered playing in the NFL. Doctors who examined him concluded that he was 89 percent disabled, and the insurance company, Fairmont Premier, gave him a $175,000 settlement. But what began as a claim similar to those made by other NFL players as well is now headed to court. In a lawsuit filed in Orange County, Calif., in July, attorneys for the insurance company say Culpepper lied to the doctors. He is “exquisitely fit and conditioned” and “is not disabled,” the suit says. Moreover, the attorneys say, he is feigning injury while taking part in highly publicized athletic competitions. “Defendant Culpepper’s conduct was fraudulent, deceptive and designed to inflate the value of his claim and to take advantage of and abuse the California workers’ compensation system,” the suit states.

Culpepper attorney Scott Schutzman called the insurance company attorneys’ version of events an “exaggeration.” No one disputes that Culpepper, 45, spent nearly a decade in professional football as a human battering ram. From 1992 to 2000, he was a defensive tackle for the Minnesota Vikings, the Bucs and the Chicago Bears. Before that he spent four years playing for the University of Florida, becoming an All­-American lineman and senior captain for the Gators.

After retiring from the NFL in 2001, he got a law degree, shed 75 pounds from his 280-pound frame and became a personal-injury lawyer in Tampa. In 2012, he became the lead plaintiff in a concussion lawsuit with 25 other players against the NFL. Culpepper also began practicing mixed martial arts, a sport that combines elements from a host of fighting styles. But attorneys for the insurance company say that when he was examined by several doctors in regard to his injury claim, he did not tell them about his new hobby. Had the insurer known, it would never have paid, the suit says.

Rather, the lawsuit alleges that Culpepper told physicians he had many injuries, from head and knee trauma to neurological and vision problems. He reported having “quite a bit of difficulty” with “usual work activities, usual hobbies and recreational activities, driving and sleeping” and could not sit for two hours at a time, according to the suit. “When asked if there are things he cannot do, defendant Culpepper testified that ‘everything is difficult,’ ” the lawsuit says.

In 2013, after the claim was settled, Culpepper was a contestant with his wife, Monica, on the reality TV show Survivor: Blood vs. Water, where veterans of the show compete with loved ones. He was eliminated after 14 days. It was “clean, old-school caveman stuff,” he told the Tampa Bay Times.

Schutzman, Culpepper’s attorney, took issue with the narrative in the insurance company’s lawsuit. “This man played in the NFL for 10 years. He has multiple doctors and medical records, including 14 or 15 MRIs, which show injuries to his knees, to his shoulders, to his head,” he said. “He’s had injury after injury after injury.” The fact that his client exercises and has appeared on a reality TV show is not sufficient to prove that he was never injured or does not continue to suffer, Schutzman said. He also disputed the lawsuit’s contention that Culpepper earned a black belt in mixed martial arts. “He doesn’t have a black belt; he has an honorary black belt,” he said.

However, the website for B.A. Warrior Training Center in Tampa lists Culpepper in its Black Belt Club, noting that “you all worked hard to attain your black belts in kickboxing.”

Although the WCIRB has recommended an increase in California compensation premiums, an improving workers compensation market – including better policy underwriting, increasing comp premiums and a national decline in claim frequency – is driving the National Council on Compensation Insurance Inc. to recommend more decreases in other state workers comp rates for next year.

Boca Raton, Florida-based NCCI, a nationwide workers comp ratings and research organization, is the comp rating agency for 35 states and the District of Columbia. It also provides actuarial data for ratemaking agencies in Indiana and North Carolina. According to an article in Business Insurance, NCCI has submitted workers comp advisory rate filings in 20 states so far this year. Of those filings, 15 have been for rate decreases and four have been for increases.The agency requested rates remain the same in 2015 for Colorado.

Major states in which NCCI has requested decreases include Illinois, which recently approved a 5.5% decrease in workers comp rates for next year, and Oklahoma, which is considering a 7.8% decrease after the state began allowing employers to opt out of the workers comp system this year. Florida also is weighing a 2.5% decrease, the first potential workers comp rate cut for the state in four years. Mr. Burton said the trend is expected to continue as NCCI continues its rate filing season this fall, and said he’s ‘optimistic that the majority … of our filings will be approved as proposed.” “Underwriting results are good, premium is growing, and what has been one of the great stories over the years is (that) lost-time claims frequency has gone down,” Mr. Burton said of trends driving NCCI’s ratemaking this year. This is the first time in several years that NCCI advisory rates are expected to include more decreases than increases.

NCCI said at its annual conference in May that private workers comp insurers’ combined ratio declined to 101% in 2013 compared with 108% in 2012 and 115% in 2011. Meanwhile, private insurers’ workers comp premiums grew 5.4% year over year to $37 billion in 2013, driven largely by payroll growth and insurer pricing increases. Mr. Burton said those positive developments now are starting to make their way into workers comp rate filings.

Pam Ferrandino, executive vice president and casualty practice leader for Willis North America Inc. in New York, agreed that NCCI’s rate filings indicate favorable trends in the national workers comp landscape. She said that improved insurer profitability is allowing some to propose smaller renewal rate increases this year after years of pushing for policy pricing increases of up to 5%. “We’re beginning to see payroll growth, which also allows carriers to back off on some of the rate increases because it gives them a bigger base to spread some of the fundamental expenses across,” Ms. Ferrandino said.

Decreasing rate trends haven’t reached other major states that use proprietary rating agencies. In May, the New York Compensation Insurance Rating Board proposed a 6.8% increase in state workers comp advisory rates, effective Oct. 1. However, the New York Department of Financial Services rejected the proposal in July, keeping rates unchanged from last year. The San Francisco-based California Workers’ Compensation Insurance Rating Bureau has asked the California Department of Insurance to raise the state’s pure premium workers comp rate to $2.77 per $100 of payroll as of Jan. 1, 2015, compared with $2.68 at the start of this year. A WCIRB spokesman said increased workers comp claim frequency in Southern California played a role in its request for a rate hike, and the agency is researching the cause, he said.

Workers comp experts say they’re not surprised that California is outside the trend of falling state workers comp rates. They say reforms passed by the state in 2012 have helped hold down some cost pressures but haven’t completely alleviated them.

The Division of Workers’ Compensation has posted draft Qualified Medical Evaluator (QME) regulations to the online forum where members of the public may review and comment on the proposals.

The draft regulations set forth how parties in a represented case will be able to submit initial QME panel requests online and immediately receive a QME panel. The requesting party will then serve the panel request form, any required documentation, and the QME panel on all parties with a proof of service. The draft regulations also simplify the QME form 105 for unrepresented injured workers.

According to the proposed regulations, “Requests may be made twenty-four hours a day, seven days a week. Requests made on Saturday, Sunday or a holiday will be deemed to have been made the next business day. Requests made Monday through Friday after 5:00 p.m. and before 12:00 a.m. will be deemed to have been made the next business day and requests made between 12:00 a.m. and 8:00 a.m. will be deemed to have been made 8:00 a.m. of the same business day.

There is also a major change to rule § 31.1 “QME Panel Selection Disputes in Represented Cases.” Under the current rule, various disputes between the parties regarding the specialties of the physicians on the QME panel were to be resolved by the Medical Director, The several paragraphs pertaining to this administrative function are to be stricken from the new regulations. Instead, the proposed regulations simply provide that “Any disputes regarding the validity of the panel QME selection list or disputes regarding the appropriateness of the specialty designation may be resolved at the Workers’ Compensation Appeals Board.”

“The division has spent the last year working hard to stay current with the increased volume of panel requests and has remained in compliance. We are excited to further improve upon the process by creating an online system for represented parties,” said DWC Acting Administrative Director Destie Overpeck.

The forum can be found online on the DWC forums web page. Comments will be accepted on the forum until 5 p.m. on September 22.

Medical identity theft has become one of the fastest growing heathcare fraud problems in the nation. Some uninsured patients have been found to use false identification simply to secure free medical care. In a more serious situation, this case reported by the Monterey County District Attorney shows how identity theft can be used in an emergency room to obtain a free supply of illegal pain medication. The lesson here is to be more vigilant in workers’ compensation claim processing to make sure that medical services were actually delivered to the injured worker, especially when pain medication is involved.

Julian Demitre Rosario, age 22, was sentenced by the Honorable Wendy Duffy for insurance fraud and unlawful use of personal identifying information. The defendant was placed on five years of felony probation, ordered to serve 210 days in custody, be subject to search and seizure and pay victim restitution. The court retained jurisdiction over victim restitution for Premier Insurance, Blue Shield, CHOMP and the two individuals whose identity the defendant used to obtain medical treatment. The estimation of the total restitution is approximately $50,000. The defendant was immediately remanded into custody after sentencing.

During the month of July, 2014 on four different dates, the defendant went to CHOMP’s emergency room complaining of abdominal pain. Each time the defendant was seeking to obtain narcotics. He informed personnel of his true name one time, a variation of his name another time and two other individuals’ names the other two times. On the last date while the defendant was receiving treatment from a doctor, another emergency room doctor recognized the defendant and that he was using a false identity and insurance. CHOMP personnel contacted Monterey Police who responded, interviewed the defendant and then arrested him. The defendant had been contacted by police regarding similar allegations on a previous occasion. During the two contacts, he gave inconsistent versions of who he was, his age, and why he was at the hospital.

The case was investigated by Monterey Police Officer Amy Carrizosa and District Attorney Investigator Mark Trueblood. This case was handled by the Healthcare Fraud Unit of the Monterey County District Attorney’s Office. This unit aggressively investigates and prosecutes prescription drug fraud and insurance fraud in Monterey County. The unit also investigates and prosecutes cases involving use of another’s identity to secure healthcare benefits; healthcare related embezzlement; unlawful healthcare solicitations/referrals; fraudulent or inflated pharmacy billings; prescription fraud and abuse; out-patient surgery center fraud; and fraudulent disability claims.

Surgeries for industrial claims that require implants are very costly. Surprisingly, few patients are even aware of who manufactured the implant, why the one they received was chosen, or what would have been the best choice. Neither is this analysis routinely performed by claims or UR. One would think that choice of product might make a difference in treatment outcome. But surprisingly, a new study reviewed by Medical News Daily says that several new and widely used hip and knee implants appear to have no clinically relevant improved benefits compared with older, more established implants. A review of the evidence was published on thebmj.com.

Furthermore, the safety of several new technologies “could be compromised,” warn the researchers, who call for improved stakeholder oversight to prevent patients from being further exposed to new devices “without proper evidence of improved clinical benefits and safety.” Since the failures of some metal on metal hip implants were brought to light, the introduction of new joint implants has been the focus of major scientific and policy discussions.

An International research team, led by Art Sedrakyan, Associate Professor at Weill Cornell Medical College in New York, argues that the momentum for change generated by these recent high profile failures is important and there is an urgent need to evaluate the evidence for introducing new implants. Working with the US Food and Drug Administration (FDA), they reviewed the evidence for five recently introduced and widely used implantable devices for total joint replacement surgery.

Data from clinical trials and observational studies involving 15,384 implants in 13,164 patients and data from national joint registries were used to compare safety and effectiveness over existing, well-proven and comparable devices for the same condition. After study design and quality were taken into account, none of the five device innovations was found to improve functional or patient-reported outcomes. Comparative data with well-established alternative devices (over 1.2 million implants in registries) did not show improved device survival.

The researchers also found higher rates of repeat surgery (revisions) associated with three of the new devices, used in both hip and knee replacement surgery. “We did not find convincing high-quality evidence supporting the use of five substantial, well-known and already implemented device innovations in orthopaedics,” they say. “Furthermore, none of these five technologies were found to be safer or to have better survival compared to the established implants.” This indicates that new technologies “are being introduced to the commercial market without sufficient high-quality evidence for improved benefit over existing, well-proven and safe but equally suitable alternative implant solutions,” they argue.

They call for improved stakeholder oversight “to prevent patients from being further exposed to these or future innovations introduced without proper evidence of improved clinical efficacy and safety.” These data “shine a light on the limited regulatory oversight that exists in Europe, the US, and other countries regarding incremental device innovations,” write researchers at Brigham and Women’s Hospital and Harvard Medical School, Boston, in an accompanying editorial.

They support the study authors’ recommendation for controlled introduction of new versions of medical devices “so that they are not used widely until there is more clarity about their comparative effectiveness and safety.” They also call for better communication of the benefits and risks of new technology to patents “to inform their health care decision-making.” They conclude: “Reforms that provide for more robust post-market oversight of incremental innovations in medical device technologies will be key in helping to promote more rational use of these products.”

It would seem wise that Utilization Review professionals not only consider the question of medical necessity for a proposed surgery, but the science behind the implantable devices to be used before they are bought, paid for, and installed in a surgical process;