The Medicare Fraud Strike Force in six cities charged 90 individuals — 27 doctors, nurses and other medical professionals — for their alleged participation in Medicare fraud schemes involving hundreds of millions. According to the story in Southern California Public Radio, eight of the people charged in Tuesday’s nationwide Medicare fraud crackdown operated in the Los Angeles area, and were responsible for $32 million in fraudulent billing. All told, the government’s Medicare Fraud Strike Force charged 90 health care workers, including doctors and suppliers, for allegedly bilking Medicare out of $260 million. he Medicare Fraud Strike Force charged people in six cities, including Los Angeles. The Strike Force is part of the Health Care Fraud Prevention and Enforcement Action Team, a joint initiative of the Justice Department and the Health and Human Services Department. Among the eight in the Los Angeles area, two are doctors, several run medical supply companies and the rest are marketers, whose job it is to bring Medicare beneficiaries to the doctors. The group is responsible for $32 million in fraudulent payments for equipment that was not necessary and for treatments that were never provided, according to the government.

Below are the individuals charged in California on Tuesday:

1) Robert A. Glazer, doctor at Glazer Medical Clinic in Los Angeles. Glazer allegedly billed for services that were never provided. He also allegedly received kickbacks for signing home health certificates that were not necessary and for prescribing equipment like power wheelchairs that were not needed. Between 2006 and 2014 Glazer was paid $735,000 by Medicare. Medical equipment companies were paid $2.6 million based on Glazer’s false prescriptions and Home Health Agencies received $16.4 million based on Glazer’s prescriptions. Glazer’s office did not return a call seeking comment.
2) Sylvia Ogbenyeanu Walter-Eze, Judith Bongcayoa Estrella and Wilmer David Guzman. Walter-Eze is owner of Ezcore 900, a durable medical equipment company in Valencia. Estrella and Guzman were marketers that brought Medicare patients to Ezcore. Walter-Eze is accused of filing false and fraudulent claims for power wheelchairs and accessories to Medicare. The company received nearly $2 million in payments from Medicare. The phone number for Ezcore 900 was disconnected, and the link to the company’s website is no longer functional.
3) Zoila O’Brien, patient recruiter/marketer for a medical equipment company. According to the court documents, she found Medicare beneficiaries and took them to a doctor for prescriptions they didn’t need and worked with the medical supplier to submit fraudulent claims. The indictment says she received $600 to $700 per beneficiary she found. In total, the court file alleges, the company she worked with was paid 356,000.
4) Eucharia Okeke, owner of Eastern Medical Supply in Inglewood. The indictment alleges she worked with a doctor who wrote fraudulent prescriptions for power wheelchairs. The lawsuit says she would pay marketers and doctors kickbacks for referring Medicare beneficiaries. Okeke’s company received $311,000 in payment. The phone number for Eastern Medical Supply was disconnected.
5) Jason Ling, medical doctor in Spring Valley, near San Diego. He wrote unnecessary prescriptions for Medicare recipients. He was working with Eucharia Okeke (above). His alleged activities resulted in payment of about $311,000 from Medicare. Ling did not return a call seeking comment.
6) Hakop Gambaryan, owner of Colonial Medical Supply in Van Nuys. According to the court documents Gambaryan was paid $1.7 million by Medicare for false and fraudulent claims. Gambaryan did not return calls seeking comment.

The Workers’ Compensation Appeals Board and the Division of Workers’ Compensation have created a new form and made modifications to two existing forms for use in the Electronic Adjudication Management System (EAMS). The new and modified forms will be posted on DWC’s website today. The changes were necessitated by SB 863. The forms are:

1) DWC-CA 10214 a-1 [Stipulations with Request for Award (Rev. 4/2014)]
2) DWC-CA 10208.3 [Declaration of Readiness to Proceed (Expedited Trial) (Rev. 4/2014)]
3)DWC-CA 10232.2 [Document Separator Sheet]

The DWC-CA 10214 a-1 [Stipulations with Request for Award DOI post 1-1-2013 (Rev. 4/2014)] is a new form to be used for injuries on or after January 1, 2013. Pursuant to SB 863, the 15 percent increase or decrease in permanent disability under Labor Code 4658(d) has been eliminated. This form is used by e-form filers and it is now available for use by OCR filers. The old form will be accepted for OCR filing for injuries on or after January 1, 2013 until October 1, 2014. At a later date, the revised form will be placed in use for JET filers.

The current form DWC-CA 10214(a) [Stipulations with Request for Award (Rev 11/2008)] remains in use for e-form and OCR filers for injuries before January 1, 2013. JET filers will continue to use this form for all dates of injury.

The DWC-CA 10208.3 [Declaration of Readiness to Proceed (Expedited Trial) (Rev. 4/2014)], which is used for expedited trials, was also modified. Medical treatment issues are limited to those not arising out of utilization review. Medical Provider Network (MPN) issues for medical treatment purposes have been added. Vocational rehabilitation appeal has been removed. This form is in use for e-form filers and it is now available for use by OCR filers. The older version of this form will be accepted for OCR filing until October 1, 2014. At a later date, the new form will be placed in use for JET filers.

DWC-CA 10232.2 [Document Separator Sheet] (Rev. 4/2014) for OCR filing also updates the document types and titles used for OCR filers and the Unstructured E-form. At a later date it will be placed in use for JET filers.

The modifications to existing document types or document titles are posted in the DWC website. These changes to document types and titles are in use for OCR and e-form filers currently. The older version of this form will be accepted for OCR filing until October 1, 2014.

A new study in the Journal of Occupational and Environmental Medicine reveals a negative impact on medical costs, indemnity costs and lost time from work on workers’ compensation claims when physicians, rather than pharmacies, dispense narcotic-related drugs to injured workers within the first 90 days of injury. The study, titled “The Effect of Physician Dispensed Medication on Workers’ Compensation Claim Outcomes in the State of Illinois,” was authored by Jeffrey Austin White, director of Medical Management Practices & Strategy, and members of the Medical Center of Excellence team of Accident Fund Holdings, Inc., in partnership with researchers from the Johns Hopkins University School of Medicine.

The authors studied a sample of 6824 workers’ compensation indemnity claims that were opened and closed between January 1, 2007, and December 31, 2012, by Accident Fund Holdings in the State of Illinois.The number of prescriptions per claim and pharmaceutical, medical, and indemnity costs, as well as time out from work, were significantly higher in claims where a pharmaceutical was dispensed by the physician within 90 days of injury than in claims where physician dispensing did not occur. These differences persisted controlling for age, sex, attorney involvement, and injury complexity.The major findings of the study align with previous research from a February 2013 report on physician-dispensed repackaged drugs in the state of California by the California Workers’ Compensation Institute. “These studies leave little doubt that physician dispensing of medications, especially opioid medications, results in poor outcomes for injured workers,” said Dr. Dan Hunt, corporate medical director of Accident Fund Holdings. “Longer recoveries, more time away from work and increased medical costs are all unfortunate outcomes of this prescribing practice in workers’ compensation.”

In the last several years, there has been a surge in the cost and quantity of drugs dispensed from physician offices in workers’ compensation insurance. A 43% increase in drugs dispensed by physicians and a 63% percent increase in medication payments in the state of Illinois prompted researchers to perform an investigation on claims outcomes. The analysis demonstrated a 2.99 times higher number of prescriptions dispensed from the physician’s office in comparison to the pharmacy. When opioids were dispensed by the physician, the medical costs were 78% higher, the indemnity costs were 57% higher and the number of days off work were 85% higher than pharmacy dispensations after adjusting for differences in age, gender, attorney involvement and injury complexity.

“The ability of physicians to profit from dispensed narcotics in workers’ compensations puts a burden on the industry and jeopardizes the safety and well being of our injured workers,” said White. “State laws for managing and controlling physician dispensing in workers’ compensation are mostly non-existent and are, at the very least, in serious need of careful evaluation and reform.”

David Brian Lewis was employed by the California Department of Corrections at Centinela State Prison starting in 1998, where he worked most recently as a plumber. During the course of his employment, Lewis filed several claims for workers’ compensation benefits. In the instant proceeding, Lewis was prosecuted for insurance fraud concerning claims arising from an injury to his left arm in 2006 and an injury to his heels that he reported in 2009.

On October 24, 2006, Lewis filled out a workers’ compensation claim form reporting an injury that occurred at work on September 16, 2006, when he hit his left hand while using pliers and developed soreness in his forearm. Unbeknownst to his treating doctors, Lewis had a previous diagnosis of epicondylitis. Despite general questions about Lewis’s previous injuries and medical conditions during the patient intake process, Lewis did not disclose that he had been previously diagnosed with epicondylitis. While Lewis was off work because of the arm injury, coworkers noticed and reported certain activity by Lewis that they suspected to be inconsistent with Lewis’s claimed arm injury. In late 2006 or early 2007, a coworker saw Lewis driving his truck on a bumpy dirt road using his left hand. A coworker also noticed a photo of Lewis displayed at a gas station, in which Lewis was using his left hand to hold up a large fish that he caught in September 2007. Another coworker drove past Lewis’s house in March 2007 and observed Lewis getting his trailer ready to transport his all terrain vehicles on a camping trip.

On August 25, 2009, after having been back to work for approximately a year and a half following recovery from his arm injury, Lewis submitted an injury report and a workers’ compensation claim form stating that he had a cumulative trauma injury to his left and right heels. Unbeknownst to his treating doctors in the workers’ compensation system, Lewis had a previous history with plantar fasciitis and heel spurs. In June 1999, he reported to his family doctor that he was having pain in his left foot, and he was referred for further evaluation and was diagnosed bilateral plantar fasciitis. Lewis told his doctors 1999 that he had been having heel pain for the past 15 years. Lewis was asked when he first visited his PTP’s office in August 2009 whether he had any significant past medical history and specifically any previous foot injury. He did not disclose the prior problems with his heels. At trial, the People introduced evidence of certain activities that Lewis engaged in while being treated for heel pain that may have been inconsistent with his condition. Among other things, the jury heard evidence that during the period 2008 to 2012, Lewis was participating in a bowling league.

Lewis was charged with insurance fraud based on his 2006 claim and his 2009 claim. After a month-long trial, a jury convicted Lewis of eight counts of insurance fraud in connection with workers’ compensation benefits that he received during two different time periods. Lewis appealed, and the court of appeal reversed in the unpublished opinion of People v Lewis.

Lewis challenged the judgment, arguing (among other things) that the trial court prejudicially erred in not giving a unanimity instruction to the jury; Defense counsel requested that the trial court instruct the jury on the requirement that the jury reach a unanimous decision as to which acts Lewis committed in violation of each count. The trial court declined to give the instruction, stating that the instruction was not needed “when there is a continuous course of conduct.” Lewis contends that the trial court prejudicially erred in declining to deliver a unanimity instruction. The Court of Appeal agreed and reversed.

The requirement that the jury be instructed on unanimity in certain cases is based on the principle that “[i]n a criminal case, a jury verdict must be unanimous.” Cases have long held that when the evidence suggests more than one discrete crime, either the prosecution must elect among the crimes or the court must require the jury to agree on the same criminal act. This requirement of unanimity as to the criminal act is intended to eliminate the danger that the defendant will be convicted even though there is no single offense which all the jurors agree the defendant committed.

The judgment is reversed and this matter is remanded for further proceedings.

Leopoldo Benavides worked as a roofer. On February 7, 2005 he lost his footing and fell a distance of about 12 feet. The fall fractured his right ankle and injured his back. Benavides and his employer’s workers’ compensation insurance carrier agreed to a July 23, 2008, a stipulated award reflecting that Benavides’s injury had left him 51 percent permanently disabled. The stipulation was based upon the evaluations of the AME, orthopedic surgeon Roger S. Sohn, M.D.

After the stipulated award, Dr. Sohn examined Benavides again on December 28, 2010, and issued a new report increasing Benavides’s whole person impairment rating for the spine. This time, Dr. Sohn opined that Benavides had impairment secondary to the fractured femur and “increasing impairment” of the spine. In a subsequent deposition, Dr. Sohn explained that he changed his opinion based on the May 9, 2008 EMG finding, which he stated “automatically boost[ed]” Benavides’s DRE to a category V under the American Medical Association guidelines. Under further questioning, Dr. Sohn acknowledged that the EMG finding confirmed the decline in Benavides’s condition had occurred before the stipulated award was entered on July 23, 2008.

On February 8, 2010, Benavides filed a petition to reopen, alleging his condition had worsened and that his disability exceeded the rating provided by the July 23, 2008 stipulated award.  The WCJ initially denied the petition, concluding that Benavides had not sustained a new and further disability following that award. The WCJ vacated his initial finding and decision, after Benavides filed a petition for reconsideration. In his new findings and decision, the WCJ explained that Dr. Sohn now rated Benavides as more disabled than the July 23, 2008 stipulated award reflected, and Benavides should therefore be rated as 72 percent permanently disabled.

On reconsideration, a two-to-one majority of the appeals board disagreed. The majority found that Benavides had not sustained a “new and further disability” as required under Labor Code section 5410, because the decline in Benavides’s condition occurred before entry of the award. The majority also concluded that “good cause” to reopen the case under section 5803 was not established, because there was nothing “in the record to suggest that [Benavides] was unable to send the EMG study to Dr. Sohn before the award was issued.” In that regard, the majority noted that Benavides had not shown why the new evidence could not have been discovered and produced at a hearing held prior to the July 23, 2008 award.

In the unpublished decision of Benavides v WCAB, the Court of Appeal reversed and concluded there was good cause to reopen the case and annulled the decision of the appeals board and remand with directions to reinstate the WCJ’s award of a 72 percent disability rating.

Labor Code section 5803 accords the appeals board continuing jurisdiction to rescind or revise its awards, “upon good cause shown.” Such cause may consist of newly discovered evidence previously unavailable, a change in the law, or “any factor or circumstance unknown at the time the original award or order was made which renders the previous findings and award ‘inequitable.’ ” (LeBoeuf v. Workers’ Comp. Appeals Bd. (1983) 34 Cal.3d 234, 242) More specifically, an award based upon a stipulation may be reopened or rescinded if the “stipulation has been ‘entered into through inadvertence, excusable neglect, fraud, mistake of fact or law, . . . or where special circumstances exist rendering it unjust to enforce the stipulation.’ ” (Huston v. Workers’ Comp. Appeals Bd. (1979) 95 Cal.App.3d 856, 865-866)

Dr. Sohn issued a pre-award report rating Benavidas’s impairment without first requesting and reviewing an EMG, and the WCJ approved the parties’ stipulation, unaware of the fact that an existing EMG demonstrated Benavidas’s spinal condition was significantly worse than reflected in Dr. Sohn’s report. Whether the stipulation was the result of inadvertence, excusable neglect, or mistake of fact, the error justifies reopening the resulting award. “Indeed, when Benavides brought his petition to reopen, the evidence clearly established that the stipulated award was inequitable.”