Tag: 2015 News

North Hollywood resident Gevorg “George” Kupelian was sentenced to 30 months in custody for his role in a $1 million fraud scheme and was ordered to repay $964,011 in restitution.

According to court documents, Gevorg Kupelian and others operated the El Centro Clinic, located at 485 Broadway Street, Suites C and D, in El Centro, California, as a Medicare-billing mill. Kupelian admitted that he set up the clinic and found a doctor to act as the official physician of record. But, as Kupelian acknowledged, the doctor served primarily as a “front” so that Kupelian could use his Medicare billing number to submit Medicare claims.

Kupelian has further admitted that he recruited and paid “cappers,” individuals whose sole task was to find senior citizens in El Centro and convince them to go to the Clinic. In exchange for providing their Medicare beneficiary numbers, the senior citizens received a free pair of shoes and/or a free buffet lunch. Once they arrived at the Clinic, the beneficiaries were subject to a pre-determined gauntlet of tests, which were not based on the patient’s medical needs and were provided without proper supervision by a physician. In some cases, the clinic billed Medicare despite the fact that the tests were not provided at all.

Kupelian also arranged for a so-called Physician Assistant (“PA”) to see patients (in lieu of the “front” doctor, who was often absent), write progress notes, and order tests. As detailed in today’s court proceedings, the so-called PA hired by Kupelian was, in fact, unlicensed to practice medicine in any capacity in California.

Many of the tests that the Clinic claimed to have administered to beneficiaries required either that a physician administer the test or that a physician be within the Clinic during testing. On over 800 occasions, the Clinic billed Medicare for these tests despite cell phone location records showing that the doctor was not in Imperial County at all during the times these tests were allegedly administered. The Clinic also submitted reimbursement from Medicare for allergy tests despite evidence showing that these tests were never performed in the Clinic by a doctor or anyone else.

The co-conspirators operated the El Centro Clinic in a manner designed to maximize Medicare reimbursements without regard to the medical needs of its patients. For example, they staffed the clinic, either by being personally present or arranging for others to be, in order to give the impression to the recruited Medicare beneficiaries and outside observers that the beneficiaries were being seen by qualified medical professionals. In fact, oftentimes the recruited beneficiaries would never see a doctor or other qualified medical professional during a particular visit to the El Centro Clinic. They also caused tests to be performed on recruited Medicare beneficiaries without regard to their medical necessity, including breathing tests, bladder tests, EKGs, and ultrasounds, for the primary purpose of generating billings to Medicare.

Kupelian also admitted creating “sample” lab sheets and billing forms with certain tests and diagnoses checked. He instructed the clinic’s employees to duplicate the checked boxes from the sample forms on patients’ actual forms, without regard to the patients’ actual medical conditions or what tests they actually needed or received. Moreover, Kupelian instructed the clinic’s employees that all patients were to undergo all of the tests offered by the clinic, without regard to the patients’ actual diagnoses or what tests they actually needed. After the unnecessary tests were conducted, Kupelian inserted false test results into patient files to make it appear that tests had been done and results were appropriately generated, when in fact they had not.

Using these tactics, the El Centro Clinic generated over $2.7 million in claims to Medicare, which resulted in payments of approximately $1.3 million to the doctor, 75% of which the doctor immediately transferred into Kupelian’s bank account. Out of his proceeds, Kupelian paid the other co-conspirators, including the cappers and the fake PA.

Kupelian was ordered to surrender on July 8, 2015.

Physical therapy may work as well as surgery for easing symptoms of lumbar spinal stenosis, a common cause of nerve damage and lower back pain among older people, according to a new study summarized by Reuters Health. Lumbar spinal stenosis, a compression of open spaces in the lower spinal column, can lead to pinched nerves, tingling, weakness and numbness in the back and the lower extremities. The condition becomes more common with age, and an estimated 2.4 million Americans may have it by 2021, according to the American Academy of Orthopedic Surgeons.

“Surgery is a riskier procedure, with about a 15 percent complication rate, and half of those are life-threatening,” said Dr. Anthony Delitto, chair of physical therapy at the School of Health and Rehabilitation Sciences at the University of Pittsburgh. “It isn’t a life-risking procedure to do physical therapy.” Delitto and colleagues set out to see if they could show that physical therapy, long known to be safer than surgery, could work as well as at easing symptoms. Between 2000 and 2005, they asked 481 patients who consented to surgery if they would be willing to join a study where they would be randomly chosen to proceed with the operation or receive physical therapy. Most declined, to avoid being assigned to the non surgical group, but 169 patients agreed to participate in the experiment. Ultimately, 87 patients had surgery and 82 were assigned physical therapy.

At the start of the study, patients were at least 50 years old. They had to be able to walk at least a quarter mile without difficulty and have no underlying medical conditions such as dementia, severe vascular disease, cancer, or a prior heart attack. Most of them were sedentary or only mildly active, and they were typically obese. Patients in the surgery group were slightly younger, about 67 on average, compared with an average age of about 70 for patients receiving physical therapy.

The physical therapy regimen consisted of twice-weekly rehabilitation sessions for six weeks. Participants were allowed to opt out of this regimen in favor of surgery at any point during the study, and over an average two years of follow-up 47 of them, or 57 percent, did just that.

No matter what group they started in, participants achieved similar reduction of pain and other symptoms at two years. “The study demonstrates that both surgery and physical therapy are reasonable choices; the person who goes down either path ends up in the same place a year or two later,” said Dr. Jeffrey Katz, director of the Orthopedic and Arthritis Center for Outcomes Research at Brigham and Women’s Hospital in Boston. Katz, who wrote an editorial accompanying the study in Annals of Internal Medicine, noted that there’s still a role for surgery in treating lumbar spinal stenosis. But there’s no harm in trying physical therapy first, he said.

Because so many eligible patients opted not to participate in the study, and so many randomly selected for physical therapy abandoned it to get surgery, more research may still be needed in a larger group of patients to get a complete picture of the relative benefits of each option, said Dr. James Weinstein, chief executive of Dartmouth-Hitchcock health system, who wasn’t involved in the study. Still, “surgery should be the last option,” said Weinstein, lead author of a 2008 paper in the New England Journal of Medicine that found surgery more effective at curbing symptoms than non surgical alternatives.

Despite the small size of the current study and the number of patients who stopped physical therapy early, it still makes sense to try it before surgery, said Dr. Richard Deyo, a researcher in back pain at Oregon Health and Science University, in email to Reuters Health. “If they elect to have surgery at a later time, the results appear to be as good as for patients who choose earlier surgery,” said Deyo, who wasn’t involved in the study. “Some patients are inclined toward surgery because the high tech approach seems more definitive, attractive, and quicker. However, patients should realize they are likely to need physical therapy even after successful surgery, and recovery can be slow.”

Janak K. Mehtani M.D. is listed as a QME in psychiatry with an office on Fulton Avenue in Sacramento. He practices psychiatry under the business name Fair Oaks Psychiatric Associates. Recently the California Medical Board filed an Accusation against him complaining about his treatment of industrially injured patients and patients with chronic pain, anxiety, sleep disturbance and other problems.

The First Cause for Discipline alleges that his treatment was “grossly negligent.” The Second Cause alleges that he “he committed repeated negligent acts in his care and treatment” of the Patients described in the Accusation. In the Third Cause that he “prescribed controlled substances and dangerous drugs” to these patients without an appropriate medical examination or medical indication. In the Fourth Cause that he “failed to maintain adequate and accurate medical records in the care and treatment” of these patients. And in the Fifth Cause for Discipline “that he has engaged in conduct which breaches the rules or ethical code of the medical profession, or conduct which is unbecoming a member in good standing of the medical profession, and which demonstrates an unfitness to practice medicine.

These charges are allegations only, and should not be considered to be true or accurate until there has been a trial on the merits and Dr. Mehtani be afforded an opportunity to be heard and present evidence on his behalf.

However the Accusation does set forth what the California Medical Board considers to be the standard of care for industrially injured patients in a psychiatric setting. The standards set forth in this Accusation should be read and understood by claims administrators and other workers’ compensation professionals since this document sets forth standards that are seldom articulated in one document, with illustrative examples. This document should serve as a benchmark or checklist by which quality of treatment should be evaluated. Here are examples of the standards set forth in this Accusation by the California Medical Board.

First and foremost the Accusation reiterates the requirement that medical records clearly document medical findings, histories, complaints, and rationale for treatment decisions. Often this is not seen when reviewing subpoenaed records of treating physicians. For example, one of the patients complained of weight gain, yet the Accusation alleges that “there has been no documentation of Respondent’s discussion of her weight gain. There was no documentation of her diet, exercise, weight or anything that addresses the risk of weight gain associated with psychotropic medications.” Another concern was “Respondent failed to document the reason for prescribing Abilify, Ambien, and Cymbalta. Respondent failed to document and/or identify any concern about the risks of chronic use of a benzodiazepine Xanax and Ambien, which are not recommended for use greater than 60 days.” The Accusation goes on to say “Respondent’s charting is vague and suggests that the dose of Abilify was increased because the patient was having thoughts about cutting. Respondent failed to document what is being treated other than reducing anxiety and his concern about cutting. There is no description or identification of target symptoms, no identified measurable signs or symptoms to assess the progress or lack of progress in treatment. Respondent’s clinical descriptions are vague and difficult to interpret.” Later the Accusation states “Respondent also documented a global statement without providing any clinical justification or explanation. Respondent noted that “She remains disabled from gainful employment” without explaining and documenting exactly what was Patient GC’s disability, how the disability affects her life and what are the barriers for progress”.

The Accusation summarizes another case where the Respondent allegedly did not respond to letters sent by the State Compensation Insurance Fund, and “Respondent failed to document treatment goals and target symptoms so that the progress of treatment could be objectively evaluated. Respondent failed to document clinical reasons when there is a change in treatment,including change of medication as well as the dose.” These factors among others are according to the Board allegedly “gross negligence” and reason to bring disciplinary action against the QME.

The Accusation alleges concern about the lack of an interpreter. The Board alleges that a “medical assistant” was at times used as an interpreter, and during one follow up visit the “interpreter was not notified of the appointment so she was seen without one.” The Accusation alleges that “Respondent failed to provide an interpreter in order for Patient GC to freely share her feelings and be open to psychotherapeutic interventions.” This patient was seen for about 40 visits of “Medical Psychoanalysis.”

While these allegations may or may not be proven against this particular psychiatrist, they nonetheless set forth examples of what the California Medical Board considers to be appropriate care for industrially injured workers with psychiatric complaints, and what the Medical Board consider to be “gross negligence.” This Accusation should serve as a guideline for appropriate record keeping, and care. All too often this is not the case reflected in typical subpoenaed records that are reviewed.

Transportation Network Companies (TNCs) provide for pre-arranged transportation services for compensation through online-enabled applications or platforms (such as smart phone apps) that connect passengers with drivers who provide the services in their personal vehicles. The three most widely used TNCs are UberX (available in 53 countries and more than 140 U.S. cities), Lyft (available in at least 60 locations) and Sidecar (available in Boston; Charlotte, NC; Chicago; Long Beach, Los Angeles, Oakland, Marin and other San Francisco Bay Area cities; San Diego; Seattle; and Washington, DC).

Regulation of TNCs is in its infancy. The first step in regulating TNCs is to determine which state or local entity has authority over TNCs. Regulatory authority varies from state to state. California was the first state to regulate this new industry. Legislation is now pending in at least 35 other states. In California, TNCs are regulated on a statewide level by the California Public Utilities Commission (CPUC), while taxis are regulated by municipalities. The CPUC asserted jurisdiction over TNCs by classifying them as charter-party carriers, or transportation providers that provide pre-arranged services for a fee and are subject to regulation by the CPUC. Limousines and many shuttle services are examples of charter-party carriers. State law delegates authority for regulation of taxis to cities or counties since taxis are not classified as charter-party carriers since their services can be pre-arranged or on demand such as hailing a cab on the street.

The insurance issues associated with TNC activities arise because TNC drivers use personal cars for that commercial activity but do not have commercial auto insurance. The California Department of Insurance held an investigatory hearing March 21, 2014, relating to insurance issues for TNCs. As a result of the hearing, Insurance Commissioner Dave Jones recommended TNCs provide $1 million in primary liability insurance that begins the moment the driver switches on the app. The issue of Worker’s Compensation benefits and insurance has yet to be considered by regulatory bodies.

So now the issue of workers’ compensation coverage must be resolved in the courts. According to an article in Business Insurance, drivers for ride-sharing services Uber Technologies Inc. and Lyft Inc.,argue in two cases that they are employees and not independent contractors. This could put the tech upstarts on the hook for workers compensation costs if court challenges succeed. In separate lawsuits filed in U.S. District Court in San Francisco, plaintiffs seeking to represent Uber and Lyft drivers nationwide base their allegations on California’s labor law, since both Uber and Lyft reference the state’s law in their driver contracts, said Shannon Liss-Riordan, a plaintiff attorney in both cases and a partner at Lichten and Liss-Riordan P.C. in Boston. Judges in both cases have limited the potential classes to drivers in California, but Ms. Liss-Riordan said those decisions likely will be appealed.

If Uber and Lyft drivers are deemed employees, the companies would need to evaluate providing workers comp coverage, said officials at the National Council on Compensation Insurance Inc. Court transcripts are sealed, but, according to wire service reports, in a January hearing in the Lyft case, U.S. District Judge Vince Chhabria said rulings in other California cases typically have found that “people who do the kinds of things that Lyft drivers do here are employees.”  U.S. District Judge Edward Chen reportedly said “I don’t find that a very persuasive argument,”in a separate January hearing in the Uber case, in which the company argues it is a software platform, not an employer. Final rulings have not yet been made in either suit, both of which have been pending since 2013

The insurance industry is watching the cases closely. For example, NCCI identified ride-sharing services as one of the top emerging comp issues for 2015. The National Association of Insurance Commissioners (NAIC) adopted a white paper addressing the insurance coverage gaps associated with ridesharing services offered by Transportation Network Companies. The white paper was issued to assist state insurance regulators and state legislators throughout the United States who are considering how best to address insurance coverage gaps associated with TNCs and ridesharing. The paper recommends a range of potential state based regulatory solutions. Issues including insurance coverage gaps, coverage amounts and types of coverage are discussed, as well as the need for consumer outreach and education regarding these new transportation services.

Citing lower medical loss development, as well as indemnity and medical severities that continue to emerge below expectations, the insurer and public members of the WCIRB Governing Committee voted this week to authorize the WCIRB to submit a mid-year pure premium rate filing to the California Department of Insurance (CDI). The filing will propose a July 1, 2015 advisory pure premium rate of $2.46 per $100 of payroll which is 5.0% lower than the corresponding industry average filed pure premium rate of $2.59 as of January 1, 2015 and 10.2% less than the approved average January 1, 2015 advisory pure premium rate of $2.74.

The Governing Committee’s decision was based on the WCIRB Actuarial Committee’s analysis of insurer loss and loss adjustment experience as of December 31, 2014, which was reviewed at public meetings of the Actuarial Committee held on March 18, 2015 and March 30, 2015. While loss adjustment expenses continue to emerge at levels higher than expected, those higher costs are more than offset by better than projected loss experience. The primary drivers of the indicated reduction in advisory pure premium rates are:

1) Significant improvement in medical loss development since the WCIRB’s amended January 1, 2015 Pure Premium Rate Filing, which decreases the estimates of ultimate historical accident year loss ratios and the resultant future year medical cost projections.
2) Continued decline in the average cost of indemnity and medical on indemnity claims—particularly in the 2014 accident year. For the second consecutive year following the implementation of SB 863, medical severities declined by more than 4%.
3) Significant improvement in accident year 2014 experience, in large part driven by lower than expected severity growth.

The WCIRB anticipates submitting its filing to the CDI by April 6, 2015. The filing and all related documents will be available in the Publication and Filings section of the WCIRB website and the WCIRB will issue a Wire Story once the filing has been submitted. Documents related to the Governing Committee meeting, including the agenda and materials displayed or distributed at the meeting, are available on the Governing Committee page of the WCIRB website.

California joins other states that are announcing rate reductions this month. North Carolina Governor Pat McCrory announced that an average decrease in workers’ compensation insurance premium rates paid by North Carolina businesses will take effect in April 2015. The North Carolina Department of Insurance estimates that 95 percent of the state’s employers will see an average decrease of 3.4 percent in their 2015 premium rate. The remaining 5 percent, which constitutes businesses that purchase coverage through an “assigned risk pool,” will see an average decrease of 4.5 percent. These significant decreases are a welcome change from 2014 premium rates which were 4.2 percent higher than what most employers paid in 2013.

Workers compensation advisory rates will decrease 5.99% for Pennsylvania employers this month, according to Pennsylvania Gov. Tom Wolf. This is the fourth year in a row that Pennsylvania workers comp advisory rates have decreased, according to the governor’s statement.

Private employers in Ohio will see a 10.8% workers compensation rate decrease as of July 1, the Ohio Bureau of Workers’ Compensation said. The 10.8% rate cut, approved by the Ohio Bureau of Workers’ Compensation’s board of directors is expected to yield a $153 million decrease in projected annual premium, the bureau said in a statement.