Tag: 2013 News

The National Insurance Crime Bureau (NICB) just released an analysis of workers’ compensation questionable claims (QC) referrals submitted from Jan. 1, 2011, through June 30, 2013. The report finds that while the total number of WC claims has been decreasing, the percentage that is deemed “questionable” has been rising.

QCs are claims that NICB member insurance companies refer to NICB for closer review and investigation based on one or more indicators of possible fraud. A single claim may contain up to seven referral reasons.

California ranked first generating a total of 2,270 WC QCs. It was followed by Illinois with 689. New York was third with 688.

In 2011, 3,349,925 WC claims were found in the Insurance Services Office (ISO) ClaimSearch® database. That number decreased to 3,244,679 in 2012, and is on track to decrease again in 2013 based on the 1,498,725 claims received in the first half of 2013.

In 2011, 3,474 WC QCs were referred to NICB. That number increased to 4,460 in 2012 – a 28 percent rise. WC QCs accounted for 3.5 percent of the 100,201 QCs submitted in 2011, and increased to 3.8 percent of the 116,171 QCs in 2012.  Through the first half of 2013, 2,325 WC CQs have been referred to NICB (3.7 percent of 62,352 total QCs), compared with 1,681 through the first half of 2011 and 2,174 through the first half of 2013.

The distribution of WC QCs follows a standard Monday – Friday workweek with the QCs almost evenly divided during the week with steep drop-offs in the numbers for Saturday and Sunday.

There are several referral reasons from which NICB member companies can select to further describe a QC. The top three referral reasons were the same in each year. First was “claimant fraud” with 6,107. Second was “prior injury/not related to work” with 2,319, and third was “malingering” with 1,380.

An injury not related to work is typically a person who suffers an injury during a recreational or day off activity but fails to report it until at work, thus claiming the injury happened on the job. A malingerer is someone who has suffered a legitimate injury but continues to feign symptoms, thus collecting benefits long after he or she has fully recovered.

The full report is available online..

The U.S. Food and Drug Administration has issued final rules governing the development of mobile medical apps, saying it will focus its oversight on those products that have the potential to harm consumers if they do not function properly.

The rules, announced on Monday, come more than two years after the FDA released draft guidance in which it proposed regulating any mobile app deemed to be a medical device.

The FDA said it will only regulate products that transform smartphones into devices the agency currently regulates, such as electrocardiography (ECG) machines that can determine whether a patient is having a heart attack.

The agency will also regulate apps that would be used as an accessory to a regulated device, such as one that displays images used by physicians to diagnose patients.

The agency said it will not regulate the sale or general consumer use of smartphones or tablets or mobile app distributors such as the iTunes store or Google Play store. Nor will it regulate personal wellness apps such as pedometers or heart-rate monitors.

Dr. Jeffrey Shuren, director of the FDA’s medical device division, said on a conference call with reporters that whether the agency regulates a product will depend on its function and its risk. If a heart device used in a hospital is currently regulated, chances are a mobile app will be too.

“It’s not about the platform. It’s about the functionality,” Shuren said. “An ECG is an ECG.”

Such products will need to be cleared by the FDA before being allowed on the market. The agency has cleared about 100 mobile medical apps over the past decade, of which 40 were cleared in the last two years. Shuren said the average review time was 67 days.

The agency said it is not going to enforce its powers on mobile apps it considers relatively safe such as those that help patients organize and track their health information, or promote strategies for maintaining a healthy weight or adhering to medication dosing schedules.

According to a report published in March by research2guidance, a research firm, the market for mobile health apps will reach $26 billion by 2017. Currently, there are about 97,000 mobile health applications in major app stores, the report said.

A Spring Valley woman pleaded guilty to taking part in a multi-year scheme to falsify medical certifications while working as an advocate for immigrants seeking help in obtaining U.S. citizenship or government benefits.

Nawal Talia, 57, admitted during a hearing in federal court in San Diego that she recruited patients for National City psychologist Roberto Velasquez, who was sentenced earlier this year to 21 months in prison and ordered to repay more than $1.5 million to the Social Security Administration in the largest single restitution order in the agency’s history.

As part of her job, Talia for several years submitted documents to federal agencies on behalf of her clients, certifying that they were mentally disabled. Rather than obtain benefits legitimately, she and Velasquez worked together to falsify medical certifications and fabricate patient histories, according to prosecutors.

Talia admitted that she helped Velasquez falsify disability-exception certification forms used by the Department of Homeland Security during the naturalization process and medical letters used by the Social Security Administration to award Supplemental Security Income and disability payments. She conceded that she lied on both types of documents about the length of time her clients had been under the care of Velasquez. In one case, she certified that a patient had been treated by Velasquez for a year, when the person actually had met Velasquez only once, court papers show.

In another instance, she filed a Social Security appeal falsely certifying that a man had been treated by Velasquez for 11 months. Talia simply made up that number so he appeared to be eligible for disability benefits, when Talia knew he was not, according to court documents. Investigators established that Talia repeatedly lied about durations of treatment in order to create a “track record” that would satisfy reviewers at the Social Security Administration and immigration agencies.

The scheme came to light during an undercover operation conducted jointly by the Department of Homeland Security, Immigration and Customs Enforcement, and the Office of Inspector General, Social Security Administration..

Scans of people’s knees are less likely to reveal a problem when the referring doctor has a financial stake in the imaging center or the equipment used, suggesting some tests may be unnecessary, according to a new study published in the journal Radiology and summarized by Reuters Health.

Researchers concluded that When doctors have a financial interest in the imaging facility, their patients are 33 percent more likely to get a test result that shows nothing wrong, compared to patients of doctors with no financial interest. “It does raise the questions: Are these studies being performed unnecessarily? Are these machines being over utilized because of an unconscious bias?” Dr. Matthew Lungren, the study’s lead author who did the research while at Duke Medicine in Durham, North Carolina, said.

In medical circles, it is known as “self referral” when doctors send patients to get images or scans taken at centers they partially own.

Lungren and his colleagues reviewed 700 MRIs of knees taken between January and April 2009 at a single imaging facility and ordered by two groups of doctors practicing in the same geographic area. One set of doctors had a financial stake in the imaging facility and the other did not. The patients in each group were similar to each other in age and the doctors in each practice also had similar training.

Of the 350 MRIs ordered by the group with a financial interest in the imaging equipment, 117 of the tests were negative for a problem with the knee. That compared to 88 negative results among the 350 MRIs ordered by the group without a financial interest in the MRI machines.

“There are a lot of possible explanations for this but the bottom line is that there is a significantly higher number of negative studies coming out of the one specific group,” Lungren said. He cautioned the new study cannot show that owning a stake in an imaging center or its equipment caused doctors to order unnecessary tests.

For example, Lungren and his colleagues write that the doctors in the group that owns part of the imaging center and its equipment may have a culture of ordering more tests, compared to the group without a stake in the imaging centers or equipment.

But Dr. David Levin, professor and chairman emeritus of the Department of Radiology at Thomas Jefferson University in Philadelphia, said he is not surprised by the results. “This whole issue of self-referral and imaging has a long history,” he said. “Every study that’s ever been done shows self-referring physicians are going to do more imaging than physicians who refer patients to hospitals or imaging centers.”

An MRI of the knee can cost between $700 and $1,000.

Allstate Insurance Company received a judgment this month of more than $7 million, following a Racketeering Influenced in Corrupt Organizations (RICO) investigation nearly 10 years in the making.

The RICO complaint was filed in 2008 in the Las Vegas Federal District Court against chiropractor Obteen Nassiri, D.C., and his businesses: Advanced Accident Chiropractic Care, ONN Management, Digital Imaging Services and Digital X-Ray. Since the suit was filed, the Chiropractic Physicians’ Board of Nevada revoked Obteen Nassiri’s license.

Allstate’s lawsuit alleged Nassiri began defrauding Allstate in 2003 by exaggerating clinical findings, submitting improbable diagnoses, charging for treatment he did not provide, providing unnecessary and excessive treatment, grossly misrepresenting billing, making inappropriate referrals, and exhibiting a general pattern of illegal and fraudulent conduct. The jury in the case also found Nassiri’s spouse, Jennifer Nassiri, liable for negligent misrepresentation in the overall fraudulent scheme to harm Allstate. The verdict sided with Allstate in June and the final judgment and award was made this month. The total judgment against the defendants included an award to Allstate for $3.59 million in compensatory damages, $2.51 million in punitive damages and $1 million in pre-judgment interest. The company is also pursuing more than a million dollars in attorney’s fees and costs.

Over the last decade, Allstate has filed a series of civil fraud related cases against alleged perpetrators in various states across the nation.

Allstate recently filed a $5.6 million lawsuit in August in New Jersey. It alleges that Shams M. Qureshi MD, age 63, made payments to individuals who acted as middlemen by brokering auto accident patients from New Jersey and New York clinics to Qureshi’s surgery center.

In early 2013 Allstate filed against three New York-area medical providers who allegedly engaged in a fraudulent medical billing scheme seeking $1.7 million Property Casualty 360 reports that since 2003, the insurer has filed a total of 46 fraud lawsuits in the state of New York State seeking more than $233 million in damages.

Last year A Los Angeles Superior Court Judge has ordered Daniel H. Dahan, D.C., and his business, Progressive Diagnostic Imaging, to pay Allstate Insurance Company $7 million in a qui tam (“Whistleblower”) lawsuit arising out of a scheme to defraud insurance companies. Dahan is president of Practice Perfect Management and Consulting Services, of Long Beach, California, which specializes in helping chiropractors set up clinics that combine chiropractic, medical, and physical therapy services. Allstate’s lawsuit alleged that Dahan purchased report-writing software that purported to analyze x-rays and form medical opinions and diagnoses, including opinions concerning permanent impairment ratings, and thereafter formed Progressive Diagnostic Imaging to solicit x-rays from chiropractors, with the assurance that “board certified radiologists” would analyze the films.

As far back as 2004 a Dallas jury found that Texas’ largest chiropractic chain, Accident and Injury Pain Center Inc., conspired in a statewide scheme designed to defraud Allstate. The jury ordered them to pay $2.8 million in actual damages and $3 million in punitive damages.