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Fresno Sleep Clinic Owner Sentenced to 19 Months for $1M Fraud

Travis Gober, 45, of Hanford, was sentenced to 19 months in prison for committing health care fraud and aggravated identity theft by submitting more than $1 million in fraudulent claims for sleep studies to Medicare, U.S. Attorney Phillip A. Talbert announced.

According to court records, Gober owned the VIP Sleep Center, which operated sleep clinics in Fresno and Tulare Counties. Sleep clinics perform diagnostic sleep studies on patients to identify disorders like sleep apnea and narcolepsy.

From October 2019 through September 2021, Gober caused the VIP Sleep Center to submit thousands of claims totaling nearly $1 million to Medicare for sleep studies that were not actually performed on patients. The claims also falsely stated that the patients had been referred for the sleep studies by physicians with whom Gober had previously worked. This was done because Medicare will not pay for a sleep study unless the patient was referred by a physician.

Gober committed this fraud, at least in part, to try to payoff financial debts and address other financial difficulties that his brother, Jeremy Gober, had caused the VIP Sleep Center and him to incur without his knowledge or consent.

This case is the product of an investigation by the U.S. Department of Health and Human Services Office of Inspector General, the Federal Bureau of Investigation, and the California Department of Health Care Services. Assistant U.S. Attorney Joseph Barton is prosecuting the case.

Travis Gober’s brother, Jeremy Gober, was previously charged with, and has pleaded guilty to, health care fraud and aggravated identity theft related to other sleep clinics in the Central Valley. Jeremy Gober is scheduled to be sentenced on May 20, 2024.

In December 2022,  A federal grand jury returned an 11-count indictment today against Jeremy Gober, 42, of Hanford, charging him with health care fraud and aggravated identity theft.

According to court documents, Jeremy Gober owned and operated the Got Sleep center, which was a sleep clinic in Fresno and Orange County, California.

From August 2016 through July 2020, Jeremy Gober caused Got Sleep to bill Medicare and Medi-Cal for thousands of sleep studies, totaling over $8,000,000, that the company did not actually perform on patients. This included sleep studies where the patients had died before the dates on which the studies were purportedly performed.

Duo Sentenced to Prison in $21M DME Fraud

Anthony Duane Bell Sr. and his son, Anthony Duane Bell Jr., were sentenced in federal court to 65 months and 12 months and one day, respectively, for their roles in fraudulently receiving more than $21 million in Medicare payments and lying to cover it up.

The pair, along with others, conspired to commit Medicare fraud by billing for medically-unnecessary durable medical equipment such as knee, ankle, shoulder, wrist and back braces. Bell Sr. pleaded guilty to Medicare fraud while Bell Jr. pleaded guilty to making false statements to a federal officer.

U.S. District Court Judge William Q. Hayes also ordered Bell Sr. to pay $21,725,604.56 in restitution to Medicare and forfeit $806,375.12 and a luxury house in El Cajon. The forfeited property was purchased using money obtained from the fraud. In arriving at the sentence, Judge Hayes found that Bell Sr. intended to defraud Medicare of over $46 million dollars and received over $21 million dollars.

According to court records, the Bells created companies known as Universal Medical Solutions 1 and Universal Medical Solutions 2, which supplied durable medical equipment.

In order to find customers for their businesses, the Bells entered into sham agreements with “marketing” companies that, instead of marketing, provided packets of information about Medicare beneficiaries for $125 to $350 each. These packets of information included a Medicare beneficiary’s personal information, medical history, Medicare number, and an audio recording between a call center and the patient, in which the patient supposedly agreed to accept a brace.

The packet also included a signed prescription from a doctor, obtained via telemedicine, claiming that the brace was medically necessary for the patient – although in almost all cases the prescription was signed by a physician who had no previous doctor-patient relationship with the patient, was often in another state, and at most had conducted an audio call with the patient. In all cases the doctor had not conducted any kind of physical examination of the patient.

The Bells bought thousands of these patient packets, each time indirectly paying the telemedicine doctors through the “marketing” companies. The packets were referred to in the industry as “Doctor’s Orders” or “D.O.s.” The Bells purchased the “D.O.s” for a variety of braces, paying the most (up to $350) for a back brace prescription, the type of medical equipment for which Medicare offered the highest reimbursement.

The Bells could then, after shipping the brace to the patient, bill Medicare around $1,359.89 for each back brace, through their companies. The Bells also bought other braces, including wrist, knee, and shoulder braces, and billed Medicare at much higher prices than they paid for them.

When Bell Jr. was interviewed by the FBI, he lied about his knowledge of the scheme. The case is being prosecuted by Assistant U.S. Attorneys Valerie H. Chu and Christopher M. Alexander of the Southern District of California.

February 26, 2024 – News Podcast


Rene Thomas Folse, JD, Ph.D. is the host for this edition which reports on the following news stories: Supreme Court to Resolve Conflicting Decisions on ER Fees Class Actions. Court has Jurisdiction Over Employer’s Assets in Premium Fraud Case. Injured Worker’s $8.2M Verdict Against Alleged Employer Reversed. Fake Doctor Attempts to Open New Practice 2 Weeks After Prison Release. 7 Restaurant Industry Convictions for Insurance Fraud and Wage Theft. Bipartisan Coalition of 39 States in Support of Pending PBM Legislation. California Invests $18 Million in Grants to Prosecute Wage Theft. UCSF Launches Comprehensive Study of Long COVID.

Fraudulent Catheter Claims to Medicare Could Total $3 Billion

A report by National Criminal Justice Association; claimed that Medicare recipients from around the U.S. have said that a company called Pretty in Pink charged their health insurance companies thousands of dollars for urinary catheters that they never ordered or received. Flooded by complaints, the Pretty in Pink Boutique in Franklin, Tenn., a provider of accessories for cancer patients, <a href=”https://prettyinpinkboutique.com/how-to-report-insurance-fraud/” target=”_blank” >launched a webpage in September to explain</a> that its leaders were dumbfounded. The boutique said another company with the same name was submitting the claims.

The complaints are a piece of an alleged fraud scheme whose scale has little precedent in the history of Medicare, an estimated $2 billion, reports the Washington Post. The case involves fraudulent insurance claims submitted by seven companies to the taxpayer-funded health insurance program. Federal officials are investigating the allegedly fraudulent billing for catheters. the companies collectively went from billing just 14 patients for catheters to nearly 406,000.

The National Association of ACOs (NAACOS) initially reported these findings to the federal government. The association’s allegations came from a review of two billing codes for Medicare claims data from the Centers for Medicare & Medicaid Services (CMS) Virtual Research Data Center. They say urinary catheter payments to beneficiaries accounted for $153 million in 2021 before surging to $2.1 billion in 2023. Catheter spending by DMEs increased by 15.5% as false claims were filed around the country.

In nearly all 50 states, catheter payment growth has skyrocketed. Over half of U.S. states saw an increase in Medicare fee-for-service DME catheter payments of 500% or more from 2022 to 2023. Yet the majority of payments can be attributed back to just seven companies – three companies in New York and one each in Texas, Florida, Connecticut and Kentucky – NAACOS reported.

While the companies used real patients’ information to submit bills, NAACOS found no evidence that the patients wanted the catheters or even received them. “We’ve just never seen anything like this nationally,” said Clif Gaus of NAACOS, whose members spotted and reported the billings to federal officials last fall. Gaus’s team estimates that Medicare was wrongly billed $2 billion for the catheters in 2022 and 2023.

Urinary catheters were an appealing target for scammers because orders for the low-cost products – small tubes often made with latex or silicone – could escape scrutiny on billing for expensive equipment, surgeries and other high-cost claims.

After alerting federal authorities, NAACOS felt they needed to push the envelope when the problem persisted. Last week, major news publications broke the story, though states had begun warning beneficiaries of potential fraud months earlier, and local news outlets had started to uncover elements of the scandal.

Now, providers are worried about a broken insurance fraud reporting process and the impacts data breaches have on a national scale. And experts are concerned this could be just the tip of the iceberg.The Office of Inspector General (OIG) for the Department of Health and Human Services has not revealed whether there is an ongoing investigation, citing internal agency policy.

NAACOS wants the OIG to pay closer attention to fraud reports it receives from ACOs, and it wants to work with CMS to improve the reporting process, a spokesperson said. Despite the troubles ACOs faced in this ordeal, the association says this is why ACOs are so valuable, as fraud detection is more identifiable. NAACOS is also pushing for improved communication between Medicare administrative contractors. Beyond that, it seeks more provider participation and advocates for extending the alternative payment model incentive.

After public reports of a large-scale, year-long Medicare fraud scheme involving catheter billing, leaders from the Energy and Commerce, Ways and Means, and Oversight and Accountability committees, along with GOP Doctors Caucus Co-Chairs, announced on March 6 that they are seeking a briefing from Department of Health and Human Services (HHS) Inspector General (IG) Christi Grimm and Centers for Medicare and Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure.

At the time of their announcement, the estimated amount of the fraud in their headline was reported to be “$3 Billion.” This estimate was explained by saying “Public reporting estimates the cost of fraud from this scheme to be at least $2 billion.However, discussions between committee staff and stakeholders suggest the dollar figure may be closer to $3 billion.”

In a new letter, the lawmakers request briefings from the HHS IG and CMS by March 20, 2024, regarding what steps are being taken to address this reported fraud and prevent its reoccurrence.

DOI Announces Key Insurance-Related Board & Committee Appointments

The Insurance Commissioner announced several appointments to the California Department of Insurance related boards and committees.

These appointments include naming Ronald Coleman Baeza as the newest member of the California Life and Health Insurance Guarantee (CLHIGA) Board of Directors, Samantha Tradelius as the newest member of the Curriculum Board,reappointmed members Andrew Chick and Heather Pierce to the California Insurance Guarantee Association (CIGA) Board of Governors, reappointed member Debra Gore-Mann to the California Organized Investment Network (COIN) Advisory Board, reappointed members Linda Akutagawa, Imelda Alejandrino, Annalisa Barrett, and Cecil Plummer to the Insurance Diversity Task Force, and reappointed member Jeremy Smith to the California Workers’ Compensation Insurance Rating Bureau (WCIRB) Governing Committee.

CLHIGA consists of all insurance companies licensed to sell life and health insurance, and annuities in California, and it protects certain policyholders against a company’s financial failure. The Board of Directors is responsible for the overall oversight of CLHIGA, which includes approving contracts and reinsurance treaties, authorizing assessments, borrowing money, taking legal actions, and serving on committees that oversee audit and investment functions. The Board consists of up to thirteen member insurers who are selected by the board members and are subject to the approval of the Commissioner.AB 1104 (Chapter 236, Statutes of 2019) added two additional members to the board who represent the public generally and are appointed directly by the Commissioner.

The Curriculum Board oversees the development of pre-licensing and continuing education curriculum for agents and brokers to uphold professional standards that protect consumers. This includes a list of preapproved courses of study as well as courses of study for professional designations. This Board also develops standards for providers and instructors who offer courses and other training to licensed agents and brokers.

The CIGA Board of Governors oversees the guarantee association’s general operations and management in order to protect policyholders in the event of an insurance company insolvency. Established in 1969 by the Governor and California State Legislature, CIGA comprises all insurance companies admitted to sell homeowners, workers’ compensation, automobile, and other specified property and casualty lines of insurance in California.

The California Organized Investment Network (COIN) was established in 1996 within the Department of Insurance to guide insurers on making financially sound investments that yield environmental benefits throughout California and social benefits within the State’s underserved communities. Commissioner Lara has prioritized COIN investments which drive affordable housing, support small businesses, combat climate change, and encourage investors to utilize diverse investment managers more. The COIN Advisory Board provides guidance to the Commissioner and the COIN program to meet its mission and chief priorities.

The Insurance Diversity Task Force oversees the Department’s Insurance Diversity Initiative, which encourages insurers to advance diversity of insurance company corporate boards and increase procurement contracts with diverse businesses owned by women, veterans and disabled veterans, members of historically disadvantaged communities, and LGBTQ+ people. Additionally, the Task Force makes recommendations to the Commissioner regarding innovative ways to increase diversity within the insurance industry. Last year, Commissioner Lara introduced the first-ever Insurance Diversity Index, a groundbreaking benchmarking tool for a more inclusive insurance industry.

The WCIRB Governing Committee sets policy, oversees WCIRB management, and reviews all issues involving pure premium rates, classifications, rating plans, rating systems, manual rules and policy, and endorsement forms. The WCIRB is a private organization licensed by the Department for the purpose of collecting, analyzing, and compiling rating data, with funding coming from assessments of its insurance company members. All workers’ compensation insurance companies in California are required by law to be members of the WCIRB.  

The next CLHIGA Board of Directors meeting will be held on May 7, 2024, the next Curriculum Board meeting is July 18, 2024, the next CIGA Board of Governors meeting is May 7 and May 8, 2024, the next COIN Advisory Board meeting is March 14, 2024, the next Insurance Diversity Task Force meeting is March 7, 2024, and the next WCIRB Governing Committee meeting is April 17, 2024.

More details are available at: www.insurance.ca.gov/boards. All positions are uncompensated.

New Workers’ Comp and UI Time of Hire Pamphlets for 2024

The California Chamber of Commerce has published a reminder “Mandatory Pamphlet Updates for California Employers.All California employers are required to distribute six pamphlets to employees, and two of them – Unemployment Insurance (UI) and Workers’ Compensation Rights and Benefits – have mandatory updates for 2024. To fulfill their legal obligations, employers must make sure they’re giving the most current pamphlet versions to their employees. And remember, if you have Spanish-speaking employees, you’re required to provide the pamphlet in both English and Spanish.

The first revised pamphlet ― the California Unemployment Insurance pamphlet – notifies employees of their right to unemployment insurance benefits when they are terminated, laid off or take a leave of absence. Employers must provide this information to any employee no later than the effective date of the termination. The UI pamphlet:

– – Describes California’s UI benefits program;
– – Contains information about what makes employees eligible or ineligible for unemployment benefits;
– – Provides information on how to apply for UI benefits; and
– – Fulfills your legal obligation to distribute UI information to all employees who become terminated, laid off or take a leave of absence (note: It is also a best practice to provide this pamphlet when an employee resigns).

The latest Unemployment Insurance pamphlet (DE 2320 and DE 2320S) has “Rev. 67 (1/24).”

Second is the Workers’ Compensation pamphlet, which informs of new employees of their rights and obligations regarding workers’ compensation. The Workers’ Compensation pamphlet describes:

– – The California’s workers’ compensation benefits program, including the types of benefits available;
– – How to predesignate a physician who will provide treatment for work-related injuries;
– – What to do if there is a dispute;
– – The penalties for making fraudulent claims; and
– – What to do if the employee becomes injured at work.

The current Workers’ Compensation pamphlet revision date is 2/1/24.

CalChamber offers a California Required Pamphlets Kit – in both English and Spanish – which contains 20 each of the six required pamphlets. These six pamphlets can also be ordered separately in packs of 20: Paid Family Leave (PFL), Rights of Victims of Domestic Violence, Sexual Assault and Stalking, Sexual Harassment, State Disability Insurance (SDI), Unemployment Insurance and Workers’ Compensation.

Keep in mind, PFL and SDI pamphlets had mandatory changes issued in June 2023 and July 2023, respectively, so make sure you are using the most updated version.

Anti-SLAPP Statute Partially Protects School District from FEHA Claim

Tina Royer was a tenured English professor with the the Los Rios Community College District. For the previous thirteen years, she had worked at the Folsom Lake College campus, and during most of the relevant time period, she was the chair of the English department. Josh Fernandez was an English professor at Folsom Lake College. As department chair, Royer was Fernandez’s supervisor.

Royer is Caucasian, Christian, married to a Christian minister, and active in her church, and her Christian background and conservative views are known to her colleagues at Folsom Lake College. Fernandez is Hispanic and is allegedly affiliated with Antifa.

In the fall of 2018, Fernandez was up for tenure, and Royer was one of three members of his tenure review committee. During the tenure review process, all three committee members expressed concerns about Fernandez’s conduct on campus. All three members of the tenure review committee initially determined Fernandez did not meet the guidelines for granting tenure.

Fernandez, however, had threatened to sue the District for attempting to curtail his activities on campus, and purportedly in response to his threat, Dean Snowden ultimately changed his mind about granting tenure. Royer claimed Dean Snowden and Folsom Lake College President Whitney Yamamura successfully pressured her to vote in favor of granting Fernandez tenure.

Although Royer voted in favor of granting tenure, her evaluation included some “less than satisfactory” marks, and Fernandez received a copy of the evaluation. Shortly thereafter, a colleague told Royer that Fernandez was telling other department members he “hated” her “because he received a ‘less than satisfactory’ evaluation” from her.

Around March 2019, Royer complained to the District about Fernandez’s conduct and the effect it was having on her physical and mental health, and she asked that his classroom be moved so it was not next to hers. The District declined to move Fernandez’s classroom, and offered to move her classroom instead, but she did not think she should have to move when she had done nothing wrong. She asked to work remotely in order to avoid interactions with Fernandez on campus. The District agreed

Controversies escalated, and ultimately Royer sued her employer for six separate violations of the Fair Employment and Housing Act (Gov. Code, § 12900 et seq.) (FEHA) and for invasion of privacy.

She claims a coworker subjected her to harassment because of her race and religion, and the District discriminated against her because of her race and religion, retaliated against her for complaining about harassment, failed to prevent harassment, and failed to reasonably accommodate her disability. She also claims that, after she filed a claim pursuant to the Government Claims Act (Gov. Code, § 810 et seq.), the District invaded her privacy by publishing the claim on its Web site without redacting her home address and confidential information about her disability.

The District responded to the lawsuit by filing a special motion to strike pursuant to Code of Civil Procedure section 425.16 (the anti-SLAPP statute). The District’s motion was directed at the entirety of the causes of action for harassment and invasion of privacy, and portions of the causes of action for discrimination, retaliation, and failure to prevent harassment.

The trial court granted the motion as to the discrimination cause of action and denied it as to the other causes of action. The District appealed, and the Court of Appeal reversed in part and affirmed in part, and remanded the case in the unpublished case of Royer v. Los Rios Community College District -C096484 (March 2024).

The District challenges the trial court’s finding that the invasion of privacy claim does not arise out of protected activity under the anti-SLAPP statutes.However when the board met to consider and act on Royer’s claim submitted pursuant to the Government Claims Act, that meeting was an official proceeding authorized by law within the meaning of the anti-SLAPP statute.

Royer argues she “is not suing [the District] for publishing her tort claim,” but instead is suing “because [it] published her tort claim in full without redacting her confidential information.” The trial court appears to have agreed, because it found, “the gravamen of [Royer’s] claim is not the publication of the Tort Claim itself, but the inclusion of her private medical and identifying information unnecessarily.” However the trial court thus should have proceeded to the second step and determined whether Royer met her burden of establishing a probability of prevailing.

The order denying the anti-SLAPP motion was reversed as to Royer’s first cause of action for harassment because she did not establish a probability of prevailing on that cause of action. The order denying the anti-SLAPP motion as to Royer’s seventh cause of action for invasion of privacy is also reversed because the trial court erred in finding it did not arise out of protected activity, and we remand this case to the trial court to determine whether Royer established a probability of prevailing on the invasion of privacy cause of action.

ASSP Publishes First Standard on Heat Stress in Construction

Since 1911, the American Society of Safety Professionals has helped occupational safety and health professionals protect people, property and the environment. The nonprofit society is based in Chicago’s suburbs. Its global membership of over 35,000 professionals develops safety and health management systems that prevent injuries, illnesses and fatalities.

ASSP has published the first national voluntary consensus standard addressing heat stress for workers in construction and demolition operations. Hundreds of thousands of workers frequently face outdoor hazards such as high heat and humidity.

This new industry consensus standard is an important development because there is no federal regulation focused on heat stress,” said ASSP President Jim Thornton, CSP, CIH, FASSP, FAIHA. “Employers need expert guidance on how to manage heat-related risks. They must have the tools and resources to identify and help prevent work hazards before an incident occurs.”

ANSI/ASSP A10.50-2024, Heat Stress Management in Construction and Demolition Operations, offers guidance on protecting workers; explains how to acclimate workers to high heat conditions; and provides requirements for training employees and supervisors. The standard contains checklists and flowcharts designed to help companies develop clear and effective heat stress management programs that bridge the regulatory gap.

“There are tens of thousands of heat-related illnesses each year linked to construction and demolition sites, and workers have died from exposures to excessive heat,” said John Johnson, CSP, chair of the ANSI/ASSP A10 standards committee. “This new standard outlines industry best practices and proven solutions to protect workers who commonly do strenuous jobs in challenging conditions.”

The A10.50 standard identifies engineering and administrative controls a company can implement to ensure that workers get proper rest, water breaks and shade while still meeting business needs. Recommendations such as medical monitoring and using a buddy system can reduce risks and help prevent heat-related illnesses in many work environments.

While the scope of the standard focuses on construction and demolitions, the guidance can be adapted to protect workers performing other outdoor jobs such as tree trimming, farming, road maintenance and pipeline painting.

The impacts of heat stress can range from mild symptoms such as heat rash and heat cramps to severe conditions including heat exhaustion and heat stroke, which can be fatal. According to the U.S. Bureau of Labor Statistics, more than 400 work-related deaths have been caused by environmental heat exposure since 2011. The standard includes a detailed emergency response plan if a worker has a severe reaction to excessive heat.

The A10.50 subcommittee that wrote the standard consisted of 30 safety and health experts from businesses, trade unions, consulting firms, universities and government agencies. The inclusive process took three years.

Voluntary consensus standards provide the latest expert guidance and fill gaps where federal standards don’t exist. Companies rely on them to drive improvement, injury prevention and sustainability. With government regulations being slow to change and often out of date, federal compliance is not sufficient to protect workers.

ASSP leads the development of voluntary consensus standards for the workplace. In its last fiscal year, ASSP created, reaffirmed or revised 15 standards, technical reports and guidance documents, engaging 1,400 safety experts who represented 500 organizations. The Society also distributed more than 14,000 copies of standards.

The organization encourages companies to join ASSP in spreading awareness of heat-related hazards on National Heat Awareness Day on May 31 and during Extreme Heat Awareness Month in July.

Doctor Sentenced to 3 Years for Illegally Issuing Telehealth Prescriptions

A former Antelope Valley physician was sentenced to 37 months in federal prison for illegally dispensing prescriptions for often-abused controlled substances – including opioid-based medications – during telemedicine sessions with “patients” from across the United States.

Raphael Tomas Malikian, 39, who resides in Llano and Palmdale, was sentenced also ordered to pay a fine of $20,000.

Malikian pleaded guilty in October 2023 to one count of aiding and abetting the acquisition of a controlled substance by fraud and one count of distribution of oxycodone.

The Medical Board of California suspended Malikian’s medical license in November 2021. His license expired in November 2022.

From at least December 2019 to August 2021, Malikian was a licensed physician in California and, in this role, was authorized by the Drug Enforcement Administration (DEA) to prescribe medication. Malikian also owned and operated Happy Family Medicine, a medical clinic that was advertised as being in a co-working space in the Hollywood, but primarily offered telehealth services via telephone or text message communications.

Malikian issued prescriptions for controlled substances to customers without first obtaining the person’s full medical history, conducting a physical examination, requiring medical testing, or utilizing diagnostic tools. Malikian did not verify his customers’ identities before prescribing controlled substances, and he allowed customers to obtain prescriptions in the names of others.

He also worked with two co-conspirators, who provided Malikian with false names, addresses, dates of birth, and Malikian issued controlled substance prescriptions accordingly, which the co-conspirators then filled and re-sold on the black market.

Many of Malikian’s fraudulent controlled substance prescriptions contained notes on the prescriptions or accompanying documentation that falsely urged pharmacies not to verify such prescriptions because medications were urgently needed and the failure to dispense could be life threatening because of the COVID-19 pandemic.

Malikian issued hundreds of false prescriptions for liquid promethazine with codeine during this period – including to people he knew were fictitious patients and which totaled more than 82 liters – and directed them to be sent to various pharmacies across the nation for co-conspirators to obtain.

From April to July of 2020, Malikian prescribed to a buyer 702 pills of 10 milligrams oxycodone and 240 milliliters of promethazine with codeine. The customer, in fact, was an undercover law enforcement officer. Malikian issued each prescription to this buyer without conducting proper medical evaluations or verifying the buyer’s identity and was performed outside the scope of professional practice and without a legitimate medical purpose.

In addition, from May to July of 2020, Malikian prescribed to a customer – who also was an undercover law enforcement officer – 234 pills of the painkiller Norco, which contained a total of 2,340 milligrams of the opioid hydrocodone, and 180 pills of alprazolam, an anxiety medication sold under the brand name Xanax. Once again, Malikian issued each prescription to this buyer without conducting proper medical evaluations or verifying the buyer’s identity and was performed outside the scope of professional practice and without a legitimate medical purpose.

The DEA investigated this matter. The California Department of Justice, Bureau of Medi-Cal Fraud and Elder Abuse provided substantial assistance.. Assistant United States Attorney Brittney M. Harris of the International Narcotics, Money Laundering, and Racketeering Section prosecuted this case.

CWCI Releases Study on CT Litigated Claims

A new California Workers’ Compensation Institute (CWCI) study shows that almost half of all litigated claims in the LA Basin are cumulative trauma (CT) claims that involve physical or mental injuries that arise over time from repetitive stress, motion, or exposures, rather than from a specific event or accident.

The CWCI study, based on a sample of 1.4 million California work injury claims with 2010 to 2022 carrier notice dates, examines the growth of CT claims as a share of litigated claims in the California workers’ compensation system and explores the claim characteristics most associated with CT claims.  

The study found that statewide, CT claims increased from 29.4% to 37.5% of all litigated claims over the 13-year study period.  Regional results showed that over that same period, CT claims’ share of all litigated claims was fairly stable in Northern California and the Central Valley, but increased in 2022, while in Southern California CT claims’ share of the litigated claims increased steadily throughout the period.

The sharpest increase was in the Inland Empire/Orange County, where CT claims jumped from 30.2% of the litigated claims in 2010 to 40.6% in 2022, slightly more than the increase in Los Angeles County, where CT claims went from 38.6% to 48.7% of the litigated claims, and San Diego where CT claims increased from 25.0% of the litigated claims to 33.4%.  

A regression analysis, which controls for the influence of other variables, showed that the differences between the regions were only partially explained by differences in other underlying claim characteristics.  

Other key findings include:

– – Other than regional factors, differences in tenure had the strongest impact on differential CT rates. Employees with less than a year of tenure at the time of injury had a much lower CT rate (26.0%) than more tenured workers, as CT rates increased incrementally as tenure increased, climbing as high as 49.0% among workers with more than 10 years on the job.
– – A review of the CT rates across nine major industry sectors showed that CT claims were most prevalent in the manufacturing sector, where they accounted for nearly half (48.8%) of the litigated claims, which was almost twice the proportion noted in the construction sector. The food service sector had the second highest CT rate, with 46.9% of the claims in this sector involving CT injuries, while the agriculture sector had the lowest CT rate (24.2%). Regression results showed that while the type of industry influences CT rates, for most sectors other factors such as region and job tenure play a comparable role.
– – Workers under the age of 30 had a somewhat lower CT rate (28.3%) than workers who are over 30, whose CT rates ranged from 35.1% to 38.8%, though more than a third of all CT claims in the study involved injured workers who were under 40. Regression analysis showed that age is not a strong predictor of CT rates compared to other factors.
– – CT rates were considerably higher for workers at the lower end of the wage scale, with CT rates of 40.0% for workers making less than $300 per week and 42.1% for those earning $300 to $599 per week. In contrast, workers making more than $900 per week all had similar CT rates, with CT claims representing between 30.0% and 31.7% of their litigated claims. As with age, regression analysis showed that the employee’s average weekly wage is not a strong predictor of CT rates compared to other factors.

CWCI’s analysis of CT claims has been published in a Research Note, Cumulative Trauma and Litigated Claims in the California Workers’ Compensation System.  The report is available to the public here, and is available to CWCI members and research subscribers who log in to the Research section of the website.