Menu Close

Tag: 2015 News

Newport Beach Paver Faces $5.6 Million Fraud Charges

A man was arraigned in Orange County Superior Court on charges of tax evasion and insurance fraud for failing to report over $5.6 million in payroll and failing to pay over $384,000 in taxes.

Darrin Shawn Wilson, 50, Newport Beach, is charged with 15 felony counts of misrepresenting facts to the State Compensation Insurance Fund (SCIF), five felony counts of misrepresenting facts to a workers’ compensation insurance company, 20 felony counts of failing to file a return with the intent to evade tax, 20 felony counts of willful failure to pay tax, and a sentencing enhancement for white collar crime and committing a theft exceeding $500,000 and a taking that exceeded $200,000. The defendant is out of custody on $500,000 bail and is scheduled for a pre-trial Feb. 9, 2016, at 8:30 a.m. in Department C-55, Central Justice Center, Santa Ana.

Wilson is the sole principal for American Blacktop Incorporated, dba Seal-It, an asphalt and paving company, and The Mavrick Company, a property management company.

Between Jan. 1, 2009, and July 31, 2012, Wilson is accused of obtaining a workers’ compensation policy of insurance for these companies and failing to report all of the payroll for his workers’ to SCIF in the amount of $4.3 million for the policy periods of 2009 to 2012. On Aug. 1, 2012, Wilson is accused of purchasing a workers’ compensation policy of insurance from the insurance company, AIG. He is accused of underreporting payroll for the AIG policy in an amount exceeding $1.3 million for the time period of Aug. 1, 2012, through Dec. 31, 2013.  From January 2009 through Dec. 31, 2013, Wilson is accused of failing to report to the EDD, accurate payroll in quarterly reports and failed to collect, account for, and pay over taxes required by law.

The insurance fraud came to light when a claim was submitted to SCIF from an injured worker who reported that he had fallen approximately 12 feet from a ladder while working for the Mavrick Company and suffered work-related injuries. Wilson is accused of disputing the claim, stating that the worker was employed by a painting company subcontractor at the time of the injury. SCIF in attempting to determine whether to accept or deny the claim learned that the painting company subcontractor was unlicensed and uninsured.

In construction, to be a subcontractor, one must hold a valid Contractor’s State License and must have a workers’ compensation insurance policy for its employees. Without a valid license and insurance, the subcontractors would be in fact employees of the employing company, thus in this case Mavrick Company. Wilson was required to disclose all payroll to the insurance companies in order to determine the premium for the policy, and he is accused of hiring numerous unlicensed and uninsured workers asserting they were subcontractors in an attempt to avoid paying premium.

Philip Sobol M.D. and Others Face Prison for Illegal Kickbacks

In a series of related cases the former chief financial officer of Pacific Hospital of Long Beach, two orthopedic surgeons and two others have been charged in long-running health care fraud schemes that allegedly referred thousands of patients for spinal surgeries and generated nearly $600 million in fraudulent billings over an eight-year period.

Two of the defendants have pleaded guilty and three others have agreed to plead guilty in the coming weeks. All five defendants have agreed to cooperate in the government’s ongoing investigation into kickbacks for patient referrals and fraudulent bills for spinal surgeries.

The schemes involved tens of millions of dollars in illegal kickbacks to dozens of doctors, chiropractors and others.As a result of the illegal payments, thousands of patients were referred to Pacific Hospital in Long Beach, where they underwent spinal surgeries that led to more than $580 million in bills being fraudulently submitted during the last eight years of the scheme alone. Many of the fraudulent claims were paid by the California worker’s compensation system and the federal government.

In a second, similar scheme that also involved spinal surgeries, doctors received illegal kickbacks for referrals to a Hawaiian Gardens hospital.

Federal prosecutors filed two cases related to the scheme, and earlier three other cases were unsealed by a federal judge. Those named in the cases are:

1) James L. Canedo, 63, of San Pedro, California, the former CFO of Pacific Hospital in Long Beach, who pleaded guilty on Sept. 4 to a criminal information charging him with participating in a conspiracy that engaged in mail fraud, honest services fraud, money laundering, paying or receiving kickbacks in connection with a federal health care program and violating the Travel Act, specifically, interstate travel in aid of a racketeering enterprise. The case against Canedo was unsealed a few days ago by U.S. District Judge Josephine L. Staton of the Central District of California, who is scheduled to sentence the defendant on June 17, 2016.
2) Philip Sobol, 61, of Studio City, California, an orthopedic surgeon who has agreed to plead guilty to conspiracy to commit mail fraud, honest services fraud and violations of the Travel Act; as well as a separate, substantive Travel Act violation. The information against Sobol and a related plea agreement were filed in U.S. District Court, where the Sobol is expected to be arraigned next month.
3) Alan Ivar, 55, of Las Vegas, a chiropractor who formerly resided in San Juan Capistrano, California, and owned several businesses based in Costa Mesa, California, was charged in a criminal information that alleges one count of conspiracy to commit mail fraud, honest services fraud, money laundering and violations of the Travel Act. In a plea agreement also filed at the same time, Ivar admitted that for well over a decade, he had an agreement with the owner of Pacific Hospital to refer patients in exchange for a monthly retainer. Ivar, who also agreed to plead guilty, is expected to be arraigned next month.
4) Paul Richard Randall, 56, of Orange, California, a health care marketer previously affiliated with Pacific Hospital and Tri-City Regional Medical Center in Hawaiian Gardens, pleaded guilty on April 16, 2012, before Judge Staton to conspiracy to commit mail fraud. Randall, who admitted recruiting chiropractors and doctors to refer patients to Tri-City in exchange for kickbacks, is scheduled to be sentenced on April 8, 2016.
5) Mitchell Cohen, 55, of Irvine, California, an orthopedic surgeon, was charged last week with filing a false tax return. Cohen admits in a plea agreement filed on Nov. 16 that he failed to report income received from kickback payments and is expected to be arraigned next month.

All five defendants have agreed to cooperate with the government’s ongoing investigation, dubbed “Operation Spinal Cap,” into the kickback schemes, which involved dozens of surgeons, orthopedic specialists, chiropractors, marketers and other medical professionals.

Under the terms of their plea agreements, Sobol faces a federal prison term of up to 10 years; Canedo, Ivar and Randall face up to five years in prison; and Cohen faces up to three years in prison on the tax charge. All of the defendants will be required to pay restitution to the victims of the scheme, which in Canedo’s case will be at least $20 million.

As part of the scheme, the conspirators typically paid a kickback of $15,000 for each lumbar fusion surgery and $10,000 for each cervical fusion surgery. Some of the patients lived hundreds of miles away from Pacific Hospital and closer to other qualified medical facilities. The patients were not informed that medical professionals had been offered kickbacks to induce them to refer the surgeries to Pacific Hospital. From 2005 through 2013, only part of the overall scheme, Pacific Hospital billed insurers more than $580 million for spinal surgeries on more than 4,400 patients. Insurers paid the hospital more than $226 million for the surgeries performed as a result of illegal kickbacks.

The conspirators in the Pacific Hospital scheme concealed the kickback payments by entering into bogus contracts to provide a “cover story” for the doctors, chiropractors and others who received illegal payments. For example, a number of doctors entered into agreements with a Pacific Specialty Physician Management (PSPM), a company owned by Drobot, under which the doctors received as much as $100,000 per month from PSPM in return for the right to purchase their medical practices – an option that was never exercised. PSPM paid some doctors inflated prices for the right to operate their practices and collect on their insurance claims. In still other cases, Pacific Hospital entered into contracts with doctors under which the doctors were to help the hospital collect on its surgery bills to insurance companies, but the hospital’s own collection staff, rather than the doctors, actually performed the collections work. Several doctors entered into lease agreements under which PSPM or Pacific Hospital paid rent for the use of office space, but rarely used the space. And other doctors had agreements to provide consulting services to Drobot’s companies, but did not actually provide the services. Still others, including marketers who introduced doctors to Pacific Hospital, had additional agreements with Drobot’s companies.

Sobol, Ivar and Cohen each received, respectively, $5.2 million, $1.24 million and $1.64 million in kickbacks.Together they referred more than 200 patients to Pacific Hospital.

Two other Drobot companies, California Pharmacy Management (CPM) and its successor, Industrial Pharmacy Management (IPM), were also important players in the scheme. Both companies set up and managed what were essentially mini-pharmacies within doctors’ offices. CPM and IPM bought and dispensed medication that the doctors prescribed to their patients, and these businesses received a portion of the money reimbursed by insurance companies for the medications. Drobot, along with others at CPM and IPM, often agreed to increase the doctors’ shares of the insurance claims in return for those doctors’ referral of patients to Pacific Hospital. In many cases, for doctors who made such referrals, the conspirators “advanced” payments from CPM and IPM before the companies had collected any money for the medications or even prescribed them, and often simply “wrote off” payments as losses when collections fell short.

Randall, who also facilitated the Pacific Hospital scheme by introducing doctors to Drobot and coordinating kickback arrangements, pleaded guilty to participating in a separate, similar scheme involving Tri-City Regional Medical Center. According to his plea agreement, Randall acted as a “marketer” for Tri-City and conspired with hospital executives to pay kickbacks to doctors and chiropractors to refer workers’ compensation patients Tri-City for spinal surgeries. As in the Pacific Hospital scheme, the surgeries at Tri-City involved use of spinal surgery hardware that Randall distributed to Tri-City at inflated prices through his company Summit Medical Group, knowing that the cost would be passed on to insurers. Using proceeds from the sale of the hardware, Randall paid a 5 percent kickback to Tri-City and kickbacks of up to $20,000 per surgery to the doctors and chiropractors who referred the patients. In addition, Randall paid kickbacks to doctors in return for referrals of patients for toxicology tests though a separate company, Platinum Medical. The scheme resulted in several million dollars in losses to insurers.

WCAB Panel Defines Housekeeping as “Medical Care”

In 2002, Heather Reese sustained industrial injury while employed by All Saints Healthcare to her lumbar spine, psychological system, central nervous system (in the form of a sleep disorder) and cardiovascular system (in the form of deep vein thrombophlebitis). Stipulations with Request for Award for 100% permanent disability were approved including an award for future medical care.

In 2013, her PTP, Philip A. Sobol, M.D., requested authorization for home care assistance at four hours per day, five days per week for one year on an indefinite basis to aid in food preparation, cooking and cleaning, laundry, sweeping, mopping, vacuuming, household chores and grocery shopping due to the patient’s permanent disability. The State Fund adjuster sent a letter to Sobol denying the request for home care assistance (and other requests) but did not send the letter to Reese’s attorney.

On March 19, 2014 the parties proceeded to an expedited hearing on the need for home health care services. The WCJ found that despite the fact that UR was untimely Reese was not entitled to further medical treatment in the form of home health care services. In his Opinion, he noted that applicant had the burden to show that the requested treatment was reasonable and necessary. He found that the request for assistance for food preparation, cooking and cleaning, laundry, sweeping, mopping, vacuuming, household chores and grocery shopping was not considered medical treatment based on Bishop v. Workers’ Comp. Appeals Bd. (2011) 76 Cal.Comp.Cases 1192 (writ den.) (Bishop). With respect to the request for assistance with dressing and bathing, he found that Dr. Sobol had not provided a sufficient rationale.

The WCAB reversed in the panel decision of Reese v All Saints Healthcare. It rejected the view in Bishop and relied instead on Smyers v. Workers’ Comp. Appeals Bd (1984) 157 Cal.App.3d 36 [49 Cal. Comp. Cases 454] (Smyers). The Court of Appeal stated that “Our holding in the instant case extends coverage to recipients of housekeeping services when there is a demonstrated medical need. …. We hold that the proper approach by the Board is to treat the question of reimbursement under section 4600 for housekeeping services as a factual question to be resolved in each case by lay and expert evidence. The test then is whether household services in the particular case before the Board are medically necessary and reasonable.” Thus, under Smyers, applicant’s request for housekeeping services was not precluded.

Further, on June 12, 2014, the WCAB issued Neri Hernandez v. Geneva Staffing, Inc. dba Workforce Outsourcing, Inc. (2014) 79 Cal.Comp.Cases 682 (Appeals Board en banc) concerning home health care services. In Hernandez, the WCAB summarized the impact of section 4600(h): “Section 4600(h) makes clear that home health care services are included in the definition of ‘medical treatment,’ but it also limits an employer’s duty to provide that treatment by imposing two additional conditions which are part of an injured worker’s burden of proof. The first condition requires that home health care services be prescribed by a physician, and an employer may become liable for home health care services provided 14 days prior to receipt of a prescription. The second condition requires that an employer’s liability for home health care services is subject to either section 5307.1 or section 5307.8. (Id. at pp. 688-689.)

Highlights of National Healthcare Anti-Fraud Association Annual Conference

San Diego became the destination for information about anti-health-care fraud efforts, courtesy of the National Healthcare Anti-Fraud Association’s annual training conference. According to the recap published in Bloomberg BNA attendees were treated to an inside look at how law enforcement is fighting the scourge of health-care fraud.

First up on the docket was a presentation from Timothy Delaney, deputy assistant director of the Federal Bureau of Investigation’s criminal investigative division. According to Delaney, health-care fraud prison sentences have gotten increasingly longer, which has served as an effective deterrent. In addition, Delaney said the number of qui tam settlements and judgments has grown dramatically, from 43 in 1985, totaling around $2 billion, to 753 in 2014, totaling around $3 trillion.

Delaney said the major health-care fraud areas include mental health, durable medical equipment, labs and pharmaceuticals, and said there’s no lack of creativity behind some of the fraud schemes. For instance, Delaney said one doctor billed for wave therapy, which turned out to involve the doctor walking through a room full of patients and waving to them.

A presentation from the OIG that laid out the scope of existing pharmaceutical drug fraud. Shimon Richmond, the OIG’s special agent in charge of Miami, said that while the agency continues to have trouble with opiate drug fraud, non-controlled drug fraud is rising rapidly. Richmond said Medicare Part D spending has increased from $51 billion in 2006 to $121 billion in 2014, and out of the $121 billion, $113 billion was spent on non-controlled drugs.

Richmond was joined by the OIG’s Michael Cohen, who said the agency is concerned by the rise of high-dollar specialty drugs being approved by the FDA. Cohen said the high-priced drugs are too much of a temptation for fraudsters. For example, Cohen said the agency is keeping a close eye on the new Hepatitis C drugs that have recently hit the market, such as Solvadi and Harvoni.

Pfizer and Allergan Announce $160 Billion Merger

It what might be considered bad news for health insurers and consumers, pharmaceutical giants Pfizer Inc. and Allergan just announced a $160-billion merger that would create the world’s largest drugmaker with high-profile products such as Botox, Lipitor and Viagra, while increasing pressure on Washington policymakers to address corporate tax policy because the deal would shelter the new firm’s global earnings. Although New York-based Pfizer is the larger company, the deal is structured so that Allergan technically is the purchaser.

The Los Angeles Times reports that the move allows the new firm – which would take Pfizer’s name and be headed by its current chief executive, Ian Read – to be headquartered for tax purposes in Dublin, Ireland, where Allergan already is located, to take advantage of that nation’s lower corporate tax rate. The tactic, known as an inversion, would lead to an effective tax rate for the new company of about 17% to 18%, Pfizer and Allergan said Monday. Pfizer’s effective tax rate last year was about 27%. The new firm would have its global headquarters in New York, but its principal executive offices would be in Ireland, which has a 12.5% corporate tax rate. The U.S. has a 35% corporate tax rate, the highest of any developed economy.

Corporate mergers and acquisitions this year are on pace to break the record of $4.6 trillion set in 2007, according to Dealogic, which tracks the market. Healthcare, in particular, has seen a spree of takeovers as providers, insurers, pharmaceutical makers and drugstores reposition themselves for industry changes spawned by the federal Affordable Care Act.

But critics have raised concerns about the increased number of takeovers. In the case of healthcare, some have said that as the number of players in each sector shrinks, consumers will have fewer choices and prices will rise. The Pfizer-Allergan deal drew such criticism amid the ongoing debate about higher drug prices.

Serious Criticism Aimed at Nominee for Head of FDA

Dr. Robert Califf, President Obama’s recent nominee to head the Food and Drug Administration, has been the target of serious criticism in recent weeks over his close ties to the pharmaceutical industry. He has received hundreds of thousands of dollars from Big Pharma.

The New York Times reports that Dr. Califf, a cardiologist, is a renowned clinical researcher who has deep respect for the system in which he works, and no one who knows him thinks he wants to weaken the regulatory agency he has been chosen to lead. But he has deeper ties to the pharmaceutical industry than any F.D.A. commissioner in recent memory, and some public health advocates question whether his background could tilt him in the direction of an industry he would be in charge of supervising.

While the previous commissioner, Dr. Margaret A. Hamburg, a former top health official in New York City, came from the field of public health, Dr. Califf ran a multimillion-dollar clinical research center at Duke University that received more than 60 percent of its funding from industry.

His financial disclosure form last year listed seven drug companies and a device maker that paid him for consulting and six others that partly supported his university salary, including Merck, Novartis and Eli Lilly. A conflict-of-interest section at the end of an article he wrote in the European Heart Journal last year declared financial support from more than 20 companies.

“In a sense, he’s the ultimate industry insider,” said Daniel Carpenter, a Harvard political science professor who has written extensively about the F.D.A.

But , Dr. Califf’s supporters note that a résumé studded with industry funding is not unusual in academic medicine. Doctors are paid consulting fees all the time, and universities routinely conduct clinical trials on behalf of companies. Those contracts help support university researchers’ salaries, a standard practice. Many emphasize that it does not imply an inherent conflict. His supporters contend that Dr. Califf’s vast experience in the clinical science world could be a major asset in his new post.

California Work-related Injury and Illness Rate Lowest in 13 Years

The Department of Industrial Relations (DIR) has posted California’s 2014 occupational injury and illness data with detailed information on employer-reported injuries involving days away from work. The data shows that the incidence of occupational injuries remains at its lowest level in 13 years.

“As a whole, the lower work-related injury and illness rates reflect California’s commitment to on-the-job health and safety,” said DIR Director Christine Baker. “However, employers in industry sectors that have a disproportionate share of work-related injuries must focus on prevention to further protect the health and safety of employees.”

The Survey of Occupational Injuries and Illnesses (SOII) data reflect a total of 460,000 reportable injury and illness cases in 2014, of which 265,000 cases involve lost work-time, job transfer, or restriction-from-duty cases (referred to as lost work-time cases), with over 140,000 of those cases involving days away from work. The incidence of nonfatal occupational injuries and illnesses in California remain at their lowest level in the past decade in all three categories.

For cases involving days away from work, Latino workers continue to experience the highest incidence of occupational injuries, comprising 59 percent of all reported days away from work cases. In construction, manufacturing, mining and natural resources, 3 out of 4 workers injured on the job and losing work days are Latino.

In private industry, new hires and young workers have higher rates of injury. One of every four workers whose injury or illness at work involved days away from work in private industry had been on the job less than a year. Teenagers from 16 to 19 years of age suffered the highest incidence of days away from work compared to all other age groups.

Sprains, strains and tears are the largest injury category involving days away from work. Among private sector workers, the greatest number of injuries or illnesses requiring days away from work were caused by overexertion and bodily reaction, by contact with an object or piece of equipment, and by falls, trips and slips.

Tables and charts reflecting nonfatal occupational injuries and illnesses data for 2014 (and prior years’ data) for California are posted online.

High School Security Officer Booked for Comp Fraud

Valentino H. Douglas, 45, of Rialto, was arrested and booked into the West Valley Detention Center on multiple counts of felony insurance fraud after receiving more than $112,000 in workers’ compensation benefits for an alleged work injury that actually occurred a month earlier while playing softball.

While employed as a security officer at Rialto High School, Douglas filed a workers’ compensation claim in July 2013, two months after an altercation with a student claiming that he injured his shoulder during the incident. An investigation by Department of Insurance detectives revealed Douglas sought treatment a month earlier for the same shoulder injury stating that it occurred while playing softball.

“Workers’ compensation fraud is a costly crime that we all pay for,” said Insurance Commissioner Dave Jones. “Insurers pass along the cost of their losses to businesses through higher insurance premiums and those costs are passed onto to consumers through higher prices for goods and services. Ultimately, there is a ripple effect on our economy.”

Videotape evidence also showed Douglas exercising with a boot camp group with no apparent physical limitations. When questioned about his statements to physicians and his exercise activity, Douglas continued to misrepresent the facts of his alleged injury. The case is being prosecuted by the San Bernardino District Attorney’s office.

Privette Doctrine Precludes Tort Claim for Cell Tower Radiation Injury

Glaus Pyle Schomer Burns and Dehaven, Inc. is in the telecommunications business. Part of Glaus Pyle’s operations includes doing work for major cell companies by providing site audits on cell phone transmission equipment. Glaus Pyle subcontracted with ITC Service Group, which provided workers to conduct the site audits. Under this contract, employees of ITC Service Group traveled to the locations of the cell phone transmission sites being audited to conduct the site inspections. ITC Service Group assigned Chris Anderson to the job of inspecting the sites.

In June 2009, Anderson was injured when conducting a field inspection of cell phone transmission equipment. Anderson’s injury stemmed from exposure to radio frequency radiation emitted from the cell tower. Anderson filed a workers’ compensation claim against ITC Service Group, and he settled that claim. In June 2011, Anderson sued Glaus Pyle, alleging negligence and gross negligence in connection with his injuries. The theory of his case was that Glaus Pyle negligently maintained the site and was grossly negligent in failing to protect him from excess radiation.

Glaus Pyle filed a motion for summary judgment, contending it did not owe Anderson a duty of care because employees of an independent contractor cannot sue the third party that hired the contractor to do the work. The trial court agreed with Glaus Pyle, granting summary judgment. The Court of Appeal affirmed in the unpublished case of Anderson v Glaus Pyle Schomer Burns and Dehaven, Inc.

In affirming the dismissal, the Court of Appeal relied on the “Privette” doctrine. “Generally, when employees of independent contractors are injured in the workplace, they cannot sue the party that hired the contractor to do the work. . . . [¶] By hiring an independent contractor, the hirer implicitly delegates to the contractor any tort law duty it owes to the contractor’s employees to ensure the safety of the specific workplace that is the subject of the contract.” (SeaBright Ins. Co. v. US Airways, Inc. (2011) 52 Cal.4th 590, 594; see Privette v. Superior Court (1993) 5 Cal.4th 689, 696; Toland v. Sunland Housing Group, Inc. (1998) 18 Cal.4th 253, 257 [the hiring person “has no obligation to specify the precautions an independent hired contractor should take for the safety of the contractor’s employees” and “[a]bsent an obligation, there can be no liability in tort”].)

FDA Approves Nasal Spray for Opioid Overdose

The U.S. Food and Drug Administration approved the first-ever nasal spray emergency treatment for opioid overdose on Wednesday. The reformulated drug, sold as Narcan, comes as a nasal spray and should help first responders, police and others deliver the antidote in emergency situations. Known generically as naloxone, it reverses the effects of opioids – drugs that include legal painkillers such as oxycodone and illegal narcotics such as heroin.

Data from the Centers for Disease Control and Prevention indicates opioid overdose led to about 23,500 deaths in the United States in 2013, a four-fold jump from 1999. A majority of these deaths occur in non-medical settings, stressing the need for user-friendly treatments that can be administered without the help of a medical practitioner, Adapt Chief Executive Seamus Mulligan told Reuters.

The treatment, Narcan, which Adapt plans to launch by January, is expected to have wide coverage under health insurance with affordable co-pays, Mulligan added. Ireland-based Adapt bought the development and commercialization rights to Narcan from London-based Lightlake Therapeutics Inc in December 2014. The company says the nasal spray is cheaper and easier to use than injections.

Group purchasers, such as law enforcement, fire fighters, departments of health, local school districts, colleges and universities, and community-based organizations will be able to purchase the spray at a discounted price of $37.50 per 4 mg device. Some first responders already convert naloxone injections into a nasal spray using nozzles and other equipment..