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Tag: 2016 News

Apportioning Disability to Loneliness? Is There a Scientific Basis?

California allows apportionment of disability based upon causation. The potential for apportionment using this landmark change in the law has yet to be fully implemented in claim administration. Now a new study just published in the Proceedings of the National Academy of Sciences may lead the way to a new apportionment concept.

Two decades of research indicate causal associations between social relationships and mortality, but important questions remain as to how social relationships affect health, when effects emerge, and how long they last. Drawing on data from four nationally representative longitudinal samples of the US population, researchers from the University of North Carolina, Chapel Hill, and others implemented an innovative life course design to assess the prospective association of both structural and functional dimensions of social relationships (social integration, social support, and social strain) with objectively measured biomarkers of physical health (C-reactive protein, systolic and diastolic blood pressure, waist circumference, and body mass index) within each life stage, including adolescence and young, middle, and late adulthood, and compare such associations across life stages.

The researchers found that a higher degree of social integration was associated with lower risk of physiological dysregulation in a dose – response manner in both early and later life. Conversely, lack of social connections was associated with vastly elevated risk in specific life stages.

For example, social isolation increased the risk of inflammation by the same magnitude as physical inactivity in adolescence, and the effect of social isolation on hypertension exceeded that of clinical risk factors such as diabetes in old age.

Analyses of multiple dimensions of social relationships within multiple samples across the life course produced consistent and robust associations with health. Physiological impacts of structural and functional dimensions of social relationships emerge uniquely in adolescence and midlife and persist into old age.

Thus, according to the researchers “Our study strengthened support for causal linkages between social relationships and physical functioning.”

Fighting Fraud is 2016 Department of Insurance Top Priority

The culmination of the Department of Insurance’s efforts in 2015 resulted in more than $69 million recovered for Californians from consumer complaints and market conduct exams. More than $56 million in grants were awarded to district attorney’s to fight insurance fraud, there was nearly $25 million recovered through lawsuits in which the Department joined whistleblowers to combat health insurance fraud, and more than $200 million obtained by the Department to settle a long standing dispute over a failed insurance company.

The Department also approved first of their kind insurance products for the sharing economy and built new web-based consumer tools to benefit Californians. To help Californians reduce the risk of damage to their homes from an earthquake, $3 million was also obtained in general funding for the California Earthquake Brace + Bolt program.

Fighting fraud continues to be a priority for the Department. Insurance fraud is a multi-billion dollar drain on California’s economy. For fiscal year 2015/2016 the Department awarded $34.95 million in grants to district attorneys to combat workers compensation fraud and more than $21.95 million in grant funding to fight auto and organized auto fraud. As of November 30, Department of Insurance detectives arrested 745 individuals for alleged insurance fraud this year.

In an effort to curb California’s underground economy the department led a statewide multi-agency outreach effort visiting more than 75 businesses to educate business owners about their obligations to comply with insurance, licensing, workplace safety, labor laws and tax codes. This effort resulted in more than 15 citations, multiple stop work orders and nearly $300,000 in fines.

Happy New Year! – Introducing Cross-Industry Medical Fraud

Cross – industry fraud – where healthcare fraud, property/casualty and workers’ compensation fraud intersect – is the next step in identifying potentially bad providers. LexisNexis completed a study that revealed an overlap between providers who commit fraud on the healthcare side and those who do it on the property/casualty side. In addition, there was a greater probability that those providers would be involved in identity theft, tax evasion as well as other criminal activity.

“There was about a 22 percent overlap of seeing the same doctors generally practicing on both the healthcare side and the auto side,” says Todd Fannin, director of claims for LexisNexis Risk Solutions. “Within that data set, about four percent of those had been identified as being potentially bad providers by either property/casualty or healthcare insurers.”

Additional studies seeking to determine the prevalence of cross-industry fraud across the insurance, credit, financial and wider private industry markets have demonstrated how a collaborative approach between industry members can shine a light on previously hidden fraud patterns. In a recent LexisNexis Risk Solutions survey of fraud mitigation professionals, 84 percent of respondents from insurance, health care, government, financial services, communications and retail indicated that they are seeing at least some cross-industry evidence in fraud cases they investigate, and more than three quarters indicated that the impact of fraud that was linked to other industries had a moderate to extremely high financial impact on their organization.

Traditional data analytics tools are limited in that they have focused primarily on data sets that are too narrow. There is therefore a need for fraud mitigation professionals to expand their field of vision. Such an initiative helps organizations detect and intercept fraud before it happens, to safeguard from losses due to fraud. This is significant because traditional “pay-and-chase” models that prioritize recovery over prevention have been exposed as overly costly and less effective than advanced “prevention-based” models that attempt to stop the fraud before it occurs.

The National Health Care Anti-Fraud Association (NHCAA) sponsors the Special Investigation Resource and Intelligence System (SIRIS), where members share information regarding fraud cases they have encountered for the purpose of helping to mitigate fraud elsewhere. The Association was founded in 1985 by several private health insurers and federal and state government officials. It is focused exclusively on the fight against health care fraud. As a private-public partnership – members comprise more than 100 private health insurers and those public-sector law enforcement and regulatory agencies having jurisdiction over health care fraud committed against both private payers and public programs. One mission is serving as a national resource for health care anti-fraud information and professional assistance to government, industry and media.

Is Cell Phone Use Tomorrow’s CT Claim?

When the Centers for Disease Control and Prevention published new guidelines 18 months ago regarding the radiation risk from cellphones, it used unusually bold language on the topic for the American health agency: “We recommend caution in cellphone use.” The agency’s website previously had said that any risks “likely are comparable to other lifestyle choices we make every day.”

But, according to the story in the New York Times, within weeks the C.D.C. reversed course. It no longer recommended caution, and deleted a passage specifically addressing potential risks for children.

Mainstream scientific consensus holds that there is little to no evidence that cellphone signals raise the risk of brain cancer or other health problems. Nevertheless, more than 500 pages of internal records obtained by The New York Times, along with interviews with former agency officials, reveal a debate and some disagreement among scientists and health agencies about what guidance to give as the use of mobile devices skyrockets.

Bernadette Burden, a C.D.C. spokeswoman, said in a statement that the original changes made in June 2014 stemmed from “a C.D.C.-wide effort to make health information for the public easier to understand” but led to confusion that the agency was making a new policy statement. “To correct that misperception and to confirm that C.D.C. had not changed its policy or recommendations, C.D.C. posted a clarification statement,” she said, adding that the cellphone industry did not weigh in before changes were made.

Christopher J. Portier, former director of the National Center for Environmental Health, the C.D.C. division that made the changes, disagreed with the decision to pull back the revised version. “I would not have removed it,” he said in an interview. “I would have been in support of a recommendation that parents look carefully at whether their children need cellphones or not.”

Mr. Portier also served on the International Agency for Research of Cancer, a branch of the World Health Organization that in May 2011 called low-frequency radiation from cellphones and other devices a possible carcinogen. Mr. Portier’s view is not shared by many other experts. While sporadic claims about cellphones and cancer go back several decades, most American organizations echo the Federal Communications Commission, which says radio-frequency energy is not “effectively linked” with “any known health problems.”

John D. Boice Jr., president of the National Council on Radiation Protection and Measurements, said his own research had found “no evidence for associations with brain tumors or any other cancers.”

The European Environment Agency, like some others in Europe, strikes a more cautious tone than American agencies. “Scientific opinion is split on the issue – many different studies have reached different conclusions based on the same evidence,” the European agency says. It advocates “a precautionary approach to policy making in this area.”

The study cited most often is Interphone, a multination review published by the I.A.R.C. in 2010. CTIA, in a statement, noted that Interphone found “over all, no increase in risk.” But Interphone did find “some indications of an increased risk of glioma,” a type of brain tumor, among the heaviest 10 percent of cellphone users, though “the researchers concluded that biases and errors limit the strength of these conclusions and prevent a causal interpretation.”

California workers’ compensation is a liberal system. It will only take time for a few test cases to reach claim departments.