Tag: 2018 News

Chiropractor Michael E. Barri owned and operated the Santa Ana companies Tri-Star Medical Group and Jojaso Management Company. He pleaded guilty in 2016 to a conspiracy count and admitted that he received illegal kickbacks for referrals to Pacific Hospital of Long Beach from 2009 through October 2013.

He was sentenced in federal court on May 4. He was committed on Count One of the Information to the custody of the Bureau of Prisons to be imprisoned for a term of twelve months and one day. He was ordered to surrender himself to the institution designated by the Bureau of Prisons on or before 12 noon, on July 9, 2018.

Upon release from imprisonment, he will be placed on supervised release for a term of three years.

He pleaded guilty on March 11, 2016 to a conspiracy count and admitted that he received illegal kickbacks for referrals to Pacific Hospital of Long Beach. During a nine-month period that ended in 2013, Barri admitted receiving $158,555 in illegal kickbacks after referring a dozen patients to Pacific Hospital, where they had back surgeries. As a result of his referrals, Pacific Hospital billed insurance carriers approximately $3.9 million for spinal surgeries.

Barri has also been indicted by an Orange County Grand Jury in 2014 with charges of kickbacks and related offenses involving compounded medications, along with Kareem Ahmed the owner of Landmark Medical, and 13 other named providers. Much of that case was dismissed by the Court of Appeal in 2016. However some of the charges have been re-filed by the Orange County District Attorney, and it is not clear how much of the original indictment will proceed, and what defendants will be involved.

Despite his conviction, Barri filed case A150549 with the California First District Court of Appeal seeking to have the new lien fraud law, SB 1160 and AB 1244, declared to be unconstitutional, so that he and his companies could continue to collect workers’ compensation liens. Among other theories, Barri alleged “The Lien Stay Provision Violates Petitioners’ Right to Due Process Under the California and United States Constitutions.”

He did not get very far,, as the Court of Appeal rejected his request. The petition for a peremptory and/or alternative writs of mandate, prohibition, or other appropriate relief was denied as premature.

And there is some irony. As of today, Barri continues to hold a California license as a chiropractor with no record of any disciplinary action taken against him.

Within the next 60 days, Walmart and Sam’s Club will restrict initial acute opioid prescriptions to no more than a seven-day supply, with up to a 50 morphine milligram equivalent maximum per day.

This policy is in alignment with the Centers for Disease Control and Prevention’s (CDC) guidelines for opioid use.

Where state law for fills on new acute opioid prescriptions is less than seven days, Walmart and Sam’s Club will follow state law.

Additionally, as of Jan. 1, 2020, Walmart and Sam’s Club will require e-prescriptions for controlled substances. E-prescriptions are proven to be less prone to errors, they cannot be altered or copied and are electronically trackable.

Further, by the end of August 2018:

– In states that allow access, the company’s pharmacists will have access to and use the controlled substance tracking tool, NarxCare. NarxCare is a tool that helps pharmacists make dispensing decisions and provides pharmacists with the real-time interstate visibility that currently exists.
– Walmart and Sam’s Club are committed to having the opioid reversal medication naloxone behind the pharmacy counters of its stores and clubs and dispensing naloxone upon request, where allowed by state law. As an additional step, the company is reinforcing that its pharmacists provide naloxone recommendations for patients who might be at risk for overdose in alignment with CDC guidelines.
– The company will conduct additional training and education on opioid stewardship for its pharmacists, including a pain management curriculum.

These steps are in addition to actions the company has taken as part of the Walmart Opioid Stewardship Initiative in an effort to be part of the solution to our nation’s opioid epidemic. Among others, these actions include:

– Walmart and Sam’s Club pharmacy patients filling any new Class II opioid prescription receive a free DisposeRx packet and opioid safety information brochure when picking up their prescription. DisposeRx provides a virtually effortless way for patients to destroy leftover opioids without ever leaving home. Patients with chronic Class II opioid prescriptions are offered a free DisposeRx packet every six months. Existing pharmacy patients can request a free DisposeRx packet at any time.
–The company’s pharmacists counsel patients using the CDC’s guidelines on pain management, focusing on using the lowest effective dose for pain management for the shortest time possible.
– The company believes education on prescription drug abuse is a key part of the solution. Walmart U.S. helps sponsor youth-based curriculums on the risks associated with prescription drug abuse, including Prescription for Life with EverFi. These programs are educational tools that empower students with information and skills to address the opioid epidemic, should they face it in their community.

The Division of Workers’ Compensation (DWC) has posted proposed amendments to the Medical-Legal Fee Schedule to its online forum where members of the public may review and comment on the proposals. The draft regulations show additions to the regulatory language in red type, and include:

– Objective standards for the application of complexity factors in the fee schedule;
– Provisions that align the Medical-Legal Fee Schedule with the statutory scheme for reimbursement of medical-legal expenses;
– Elimination of provisions that refer to medical-legal evaluations no longer being performed; and
– Clarification of when billing under the Official Medical Fee Schedule can be accomplished in conjunction with billing under the Medical-Legal Fee Schedule.

There are no changes to the amount of fee schedule payments.

The proposals clarify the use of the complexity factors relating to causation, medical research, record review and apportionment. The factors that indicate the presence of extraordinary circumstances in a medical-legal evaluation are more clearly defined. The language required in a report to define extraordinary circumstances is explained.

For example, medical legal physicians often quote, and bill for “medical research” they claim to have performed as part of the evaluation. They charge by the hour.  But, sometimes they bill for boilerplate “research” and language used over and over in subsequent reports.

This will be limited in the new regulations should they be adopted.  The proposed language does not allow for billing for medical research, “using sources that have not been cited in any prior medical report authored by the physician in the preceding 12 months in support of a claim citing or relying upon this complexity factor.”

Realistic limits on certain areas of billing are implemented.

The forum can be found on the DWC forums webpage under “current forums.” Comments will be accepted on the forum until 5 p.m. on Friday, May 18, 2018.

Michael Williams, 34, of Daly City, was arrested on 21 felony counts of insurance fraud and grand theft after allegedly working for multiple employers while collecting over $85,000 in workers’ compensation benefits from two different insurers.

In November 2014, Williams was working as an electrician when he sustained a work-related injury. He filed a workers’ compensation claim with the State Compensation Insurance Fund and began collecting temporary disability benefits.

An investigation by the California Department of Insurance revealed that in March 2015 Williams began working for a different employer, yet continued allegedly collecting payments from SCIF.

In May 2015, Williams sustained another work-related injury and filed another workers’ compensation claim this time with Travelers Insurance.

Between March 2015 and November 2016, Williams allegedly worked for and was paid by three different employers. At one point, Williams was collecting payments from SCIF and Travelers for two different work-related injuries.

To continue collecting benefits, William allegedly misrepresented his level of abilities, earnings and employment status to SCIF and medical providers including providing false statements to his Qualified Medical Examiner to collect permanent disability benefits after the temporary benefits were exhausted.

Williams was also charged with grand theft for allegedly using his former employer’s credit card for personal expenses including an engagement ring.

“Individuals who file fraudulent workers’ compensation claims take advantage of a system designed to help honest workers injured on the job,” said Insurance Commissioner Dave Jones.

“Unscrupulous people cheating the system cost Californians millions of dollars every year in higher premiums through increased rates and higher costs of goods and services. My department will remain diligent in investigating insurance fraud to protect California consumers and businesses.”

In November 2010, Brad Culpepper filed a claim for workers’ compensation benefits for injuries he allegedly suffered playing professional football. In 2000, Culpepper played six games in California while a member of the Chicago Bears, making him eligible for California benefits.

Fairmont Premier Insurance Company settled with Culpepper for $175,000 by way of an Order Approving  Compromise and Release.

Shortly after the settlement Culpepper became a contestant on the reality television show Survivor, a show which can be physically demanding on its contestants.Fairmont alleges in its subsequent civil action against him, that during the pendency of Culpepper’s workers’ compensation claim, he engaged in activities such as running and kickboxing that were inconsistent with his claimed disability. Fairmont also alleges Culpepper misled the medical examiners hired as part of the claim process to evaluate his condition.

On December 21, 2015 Fairmont filed the instant qui tam action in California state court under California’s Insurance Fraud Prevention Act (IFPA) § 1871.7(e)(1). Culpepper removed the case to federal court on the basis of diversity,and moved to dismiss under Fed. R. Civ. P. 12(b)(1).

Culpepper argued that California Labor Code § 5901 divests the court of jurisdiction to hear this case. CLC § 5901 divests courts of jurisdiction to consider causes of action “arising out of any final order, decision or award” of the WCAB until after the WCAB has had an opportunity to reconsider its prior ruling. The district court granted Culpepper’s motion and dismissed the suit because it concluded that the instant qui tam suit “arises out of” the OACR, which is a “final order” per § 5901, and because Fairmont had not asked the WCAB to reconsider the OACR prior to filing this suit.

The United States Court of Appeals for the 9th Circuit reversed in the unpublished case of People of the State of California ex rel. TIG Insurance Co. v Culpepper.

IFPA § 1871.7(b) authorizes a relator to bring a qui tam claim on behalf of the State of California when the relator discovers violations of, inter alia, CPC § 550.3 CPC § 550 in turn prohibits “knowingly present[ing] or caus[ing] to be presented any false or fraudulent claim” for insurance.

Fairmont alleges Culpepper violated CPC § 550 when he “presented” a fraudulent claim for insurance. Its claim therefore arises from Culpepper’s allegedly fraudulent presentation of his claim for insurance benefits, not from the settlement of that claim or from the WCAB’s approval of that settlement. Even if no settlement had ever been reached, a suit under CPC § 550 may still be available so long as the relator has discovered the presentation of a fraudulent claim. This suit therefore does not arise from the OACR, and the trial court has subject matter jurisdiction to hear it. The Court said it will not construe the term “arising out of” beyond its plain meaning as Culpepper suggests.

The WCAB also does not have exclusive jurisdiction over this appeal because this is an action on behalf of the State of California, not an action for benefits against an employer. People ex rel. Alzayat v. Hebb, 18 Cal. App. 5th 801, 830 (Cal. Ct. App. 2017).