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Tag: 2019 News

CMS “Physician Compare” Website Unreliable

A new study published in the JAMA Internal Medicine and reviewed by Reuters Health suggests that Physician Compare, a U.S. website created to help patients find high-quality doctors, is missing so much information on individual providers that it may not be helpful.

Quality reporting has been a work in progress for almost three decades since a landmark 1999 report from the Institute of Medicine, `To Err is Human,’ concluded that tens of thousands of patients deaths each year were the direct result of medical errors.

Physician Compare is the flagship effort by the U.S. Centers for Medicare and Medicaid Services. But while more than 1 million clinicians care for Medicare enrollees, only about 239,000, or 23 percent, had any quality information at all available on the Physician Compare website, researchers report in JAMA Internal Medicine.

And virtually none of the doctors had data tied to their individual job performance.

“To truly be able to inform patient decision-making, it is imperative that the data accessible to patients and their caregivers capture a large swath of clinicians,” said lead study author Jun Li of the University of Michigan in Ann Arbor.

In the current study, only about 21 percent of primary care providers reported some individual or group information related to outcomes from their practice. But almost all of this data was at the practice level, making it hard for patients to know who might be a better or worse choice among several physicians at one clinic.

And half of them provided details on no more than one or two quality outcomes.

Doctors who did share individual level outcomes tended to have very high quality scores, suggesting that physicians may only opt into the voluntary reporting system when they know the results will make them look good, the study authors note.

Clinicians also aren’t required to report data on outcomes for every patient, and they may choose only to submit information for cases that turned out well, researchers point out.

“Given its voluntary nature, it is not a surprise few doctors submit to this platform,” said Dr. Vineet Arora of the University of Chicago Medicine.

Convicted Vexatious Comp Litigant Arrested Again

64 year old Bruce Richard Senator,, was arrested in September 2006 after authorities read transcripts of emails and signed court affidavits where he complained that a wide conspiracy among judges and other government employees resulted in his workers compensation benefits being denied.

“I acquiesce to the use of force to punish the state of California for engaging in atrocities, violence and terrorism,: Senator wrote in one affidavit signed on July 4, 2006. … “The game is over. You lose.”

Deputy District Attorney Andre Manssourian argued that workers compensation judges William Whitely and Norman Delaterre – who handled Senator’s workers’ compensation case at one time or another – felt personally threatened by Senator and suffered “sustained fear.”

The Stanton California resident, who served as his own attorney during a two-week criminal jury trial in 2007, was convicted.

He fought that conviction, and the subsequent incarceration through the court system at least up until July 2017, when the federal 9th Circuit Court of Appeal denied his appeal of the denial of his Petition for Writ of Habeas Corpus.

In a 2013 Order to Show Cause RE: Vexatious Litigant, it was alleged that he had initiated approximately 26 civil actions in the Central District of California since 1999. “None of these actions has resulted in a judgment favorable to plaintiff. Moreover, many of them were dismissed as patently frivolous or for failure to state a claim.”

He has now again been accused of threatening five Orange County Superior Court judges. He pleaded not guilty to the charges last week in Orange County Superior court.

The nature of how the alleged threat was conveyed was not immediately known.

CHSWC Special Report on PQME Process

The Commission on Health and Safety and Workers’ Compensation (CHSWC) has released its 197 page twenty-fourth Annual Report for 2018. The Report presents information about the health and safety and workers’ compensation systems in California and makes recommendations to improve their operations.

The Annual Report summarizes the state of all the relevant areas of the workers’ compensation and health and safety systems. The Annual Report includes several Special Studies of targeted areas of interest. One of the Special Studies involved the PQME process. Key findings in the study of the PQME system included the following.

The number of providers registered as QMEs continues to decline (17% since 2007), but less rapidly than it did prior to 2007.
The number of requests for QME panels has increased rapidly, 87 percent since 2007.
— The decline in QMEs and increase in panel requests means that the number of requests per QME has doubled (+101%).
— Coupled with a continuing increase in the average paid amount for QME reports, the average QME earns 240 percent more from panel reports now than in 2007.
— All the increase in panel requests is from represented track cases, up 400 percent despite the elimination of panels for most medical treatment issues (replaced by the IMR process). This increase was equally driven by requests from both applicants and defendants.
— Panel requests for unrepresented cases declined 55 percent, driven entirely by a decline in requests by injured workers. The number of requests by claims administrators in unrepresented cases changed little.
— The DWC began collecting the reasons for panel requests on represented cases in 2015. Those data show that the primary reasons for panels are: compensability (42.5%), permanent disability (21.4%), and Permanent & Stationary (P&S) status (11.4%).

In response to the earlier study, SB 863 placed limits on the number of locations (10) at which QMEs can be registered. This has had the effect of distributing QME panels more evenly and widely among registered providers.

Very-high-volume QMEs (with 11-100+ registered locations) have been eliminated.
— However, a high proportion of panel assignments (55%-60%) are still assigned to the busiest 10 percent of QMEs, nearly all of whom have exactly 10 offices and are in orthopedic specialties.
— Unlike the very-high-volume QMEs studied earlier, the top 10 percent and 5 percent of QMEs by the number of panels in the current system produce reports that show less bias. Even the top 5 percent of QMEs by volume give ratings that are only slightly more conservatively than average.

Another Settlement in State Opioid Litigation

Some of the first of several trials against opioid drugmakers and distributors were set for trial this year to determine how juries would react to the charges. Others remain under the supervision of the federal court system.

It was assumed that the defendants would not budge on settlement. That assumption has proven to be wrong as now drug distributor McKesson Corp has agreed to pay $37 million to resolve a lawsuit by the state of West Virginia seeking to hold it responsible for contributing to the opioid epidemic, the state’s attorney general said on Thursday. The West Virginia accord may set an industry-favoring benchmark for other claims.

The McKesson settlement comes more than a month after Purdue agreed to pay $270 million to resolve the Oklahoma attorney general’s lawsuit alleging the drug maker of fueling the opioid crisis in the state. Oklahoma is pushing ahead with a May trial against Johnson & Johnson and Teva Pharmaceutical Industries Ltd., which are accused of fueling a wave of overdoses tied to opioid painkillers.

The settlement was the largest that a distributor has struck with a state in the litigation. West Virginia in 2017 settled similar cases against rival distributors Cardinal Health Inc and AmerisourceBergen Corp for $20 million and $16 million, respectively.

McKesson did not admit wrongdoing as part of the settlement. “McKesson is committed to working with others to end this national crisis … and is pleased that the settlement provides funding toward initiatives intended to address the opioid epidemic,” the company said in a statement.

Opioids, including prescription painkillers, heroin and fentanyl, were involved in a record 47,600 overdose deaths in 2017, according to the U.S. Centers for Disease Control and Prevention.

The epidemic has prompted lawsuits by state and local governments accusing drug manufacturers like Purdue Pharma of deceptively marketing opioids and distributors like McKesson of failing to detect the diversion of the drugs for illicit purposes.

McKesson in January 2017 agreed to pay $150 million to resolve a federal investigation by the U.S. Drug Enforcement Administration into whether it failed to report suspicious orders of addictive painkillers.

Hesperia Pharmacist Pleads Guilty in Opioid Case

A High Desert pharmacist has pleaded guilty to a charge of illegally distributing the opioid oxycodone, admitting that she filled hundreds of counterfeit prescriptions.

Pauline Tilton, 49, of Hesperia, a licensed pharmacist and the owner of Oasis Pharmacy in Victorville, pleaded guilty Monday to one count of distribution of oxycodone and one count of money laundering related to more than a quarter millions dollars of revenue generated by the illegal sales. In conjunction with Tilton’s guilty pleas, Oasis Pharmacy also pleaded guilty Monday to the same two felony offenses.

This case was the first to be charged as the result of an investigation into corrupt pharmacies dubbed “Operation Faux Pharmacy.” As part of that operation, in 2017 the U.S. Attorney’s Office for the Central District of California filed search warrants with the U.S. District Court for the Central District of California on several pharmacies that are part of the prescription opioids investigation. Search warrants were issued against United Pharmacy Inc. in Los Angeles, CA; Home Care Pharmacy in Simi Valley, CA; Oasis Pharmacy in Victorville, CA; Blythe Drug in Blythe, CA; Dial Drug Pharmacy in Laguna Hills, CA; Procare Pharmacy in Murrieta, CA; Sunny Hills Pharmacy in Fullerton, CA; and Tower Pharmacy in Mission Viejo, CA.

The DEA identified the fraudulent pharmacies as those with “exceptionally high numbers of oxycodone prescriptions, excessive or frequent opioid purchases, multiple customers with identical addresses, or customers traveling extreme distances to specific pharmacies despite access to more convenient options,” the agency said in a statement.

According to court documents, over the course of just one year that ended in July 2017, Tilton filled at least 345 fraudulent prescriptions for oxycodone. The prescriptions were written under the name and DEA registration number of a retired doctor. Tilton admitted knowing the prescriptions were fraudulent, outside the usual scope of professional practice, and without a legitimate medical purpose.

As a result of the 345 prescriptions, Tilton and Oasis Pharmacy illegally diverted approximately 62,100 tablets of oxycodone. Many of the fraudulent oxycodone prescriptions also included prescriptions for alprazolam and promethazine with codeine. Those three drugs – oxycodone, alprazolam, and promethazine with codeine – comprise the “Holy Trinity,” a frequently abused and life-threatening cocktail of controlled substances.

In return for filling the fake prescriptions, Tilton and Oasis Pharmacy received hundreds of thousands of dollars in cash payments. Between January 2016 and June 2017, Tilton deposited $268,621 of illicit cash proceeds from her illegal drug distribution into three banks accounts over which Tilton held sole signature authority.

Tilton and Oasis Pharmacy pleaded guilty before United States District Judge Otis D. Wright II, who scheduled sentencing hearings on August 12 for both defendants.

When she is sentenced, Tilton will face a statutory maximum penalty of 30 years in federal prison. Oasis Pharmacy could be ordered a fine of up to $1.25 million.

CMS Announces New Payer Recovery Portal

Gordon and Rees reported that effective April 1, the Medicare Secondary Payer Recovery Portal (MSPRP) is equipped to accept electronic payments for Medicare conditional payment reimbursements.

Answers to common inquiries were subsequently released by CMS on April 12, 2019 called “Electronic Payments on the Medicare Secondary Payer Recovery Portal (MSPRP) and Commercial Repayment Center Portal (CRCP) Frequently Asked Questions and Answers.” Such functionality was originally referenced in the Strengthening Medicare and Repaying Taxpayers (SMART) Act of 2012.

In the alert, CMS specifically indicated that to make an electronic payment through the MSPRP, one does not need a new or updated user access. The option is available to any user on any matter to which the user already has access.

Payments are not required to be made through the MSPRP. Payers may continue to remit a paper check to satisfy Medicare conditional payment demands. However, any refund issued by the Medicare recovery contractor will still be made via paper check and will not be made electronically, to date.

In order to make an electronic payment through the MSPRP, the matter to which you wish to apply payment must be in “demand” status. There is no option to remit payment electronically unless the amount has been demanded.

Therefore, if payment is desired to be made on a Conditional Payment Notice instead of a Demand for Reimbursement, a written check still must be mailed to the CRC/BCRC for application to the claim.

Furthermore, CMS clarifies that when paying online, this does not mean that the full demand amount must be paid. If a Redetermination Request has been submitted on a portion of the conditional payments being asserted, a user can still submit a partial electronic payment.

Finally, CMS reported that the electronic payments utilize Pay.gov to secure the transaction, where payments can be made utilizing a savings/check account, debit card, or PayPal linked to a bank account. Credit cards, however, are not being accepted for payment at present. Also, the limit for each payment method is posted, as well.

Once payment has been made. a confirmation of payment will be posted to the MSPRP on the Payment Status page. Additionally, an Electronic Payment History status will list the status of all electronic payments, as well as the amount and payment date.

In summary, the new electronic payment system appears to streamline the payment process significantly, with much quicker application times and updates to the portal.

Broker Prosecuted for 73 Bogus Policies

Angel Estrada, 22, a formerly licensed insurance producer and owner of Angel Estrada Agency, allegedly swindled a national insurer out of more than $140,000 in commissions by writing bogus commercial insurance policies to earn large commissions.

According to the Department of Insurance investigators, between 2016 and 2017, Estrada submitted 74 applications for commercial insurance policies and was paid large commissions.

Estrada then used a portion of his commission money to fund initial premium payments on new bogus policy applications to secure additional commissions.

Investigators allege Estrada continued this practice until the insurer audited his business and revealed the alleged scam. Internal auditing and underwriting by the national carrier revealed only one of the 74 policies Estrada submitted had an actual premium payment.

Based on the evidence, Department investigators secured an arrest warrant and Estrada surrendered in Los Angeles Superior Court, and was released on his own recognizance. Estrada was charged with grand theft, California Penal Code 487

The case is being prosecuted by the Los Angeles County District Attorney’s Office.

Another Drugmaker Accused of Kickbacks

The U.S. Justice Department has joined a pair of whistleblower lawsuits alleging a drugmaker now owned by Mallinckrodt Plc improperly promoted an expensive multiple sclerosis treatment and paid kickbacks to doctors who prescribed the drug.

Reuters reports that the lawsuits, filed in federal court in Philadelphia, claimed Questcor Pharmaceuticals, which Mallinckrodt acquired in 2014, defrauded government healthcare programs by illegally marketing H.P. Acthar Gel. Last year, Acthar represented 35 percent of Mallinckrodt’s $3.2 billion in net sales.

Mallinckrodt in a statement said it disagrees with the allegations and has been in “advanced settlement talks with the government over the past several months.”

The lawsuits were filed in 2012 and 2013 by former Questcor employees Charles Strunck and Scott Clark under the False Claims Act, which allows whistleblowers to sue companies on the government’s behalf to recover taxpayer money paid out based on fraudulent claims.

The lawsuits are filed under seal so the government can investigate their claims. The Justice Department following an investigation may intervene in the cases, which is typically a major boost for them.

In his complaint, Strunck alleged Questcor in an effort to boost sales paid doctors illegal kickbacks in the form of bribes, speaker fees and consulting deals in exchange for promoting and prescribing Acthar.

His lawsuit also alleged that Questcor’s sales staff used deceptive and misleading marketing tactics to promote Acthar for uses and treatment regimens not approved by the U.S. Food and Drug Administration.

The Justice Department in court filings in both lawsuits made public on March 11 said it was intervening in the cases and planned to file its own complaint within 90 days. The lawsuits were then unsealed.

Mallinckrodt in January 2017 agreed to pay $100 million to resolve claims that Questcor violated antitrust laws by sharply increasing the price of Acthar while ensuring that no rival medicine appeared on the market.

WCRI Study Shows Stable Comp Costs

The average total cost of a workers’ compensation claim in California remained stable since the enactment of comprehensive reforms six years ago, but results mask recent changes in key cost components, according to a recent study by the Workers Compensation Research Institute (WCRI).

Medical payments per claim increased annually for the first time since reforms were enacted in 2013, while indemnity benefits remained stable in the latest 12- and 24-month valuations after annual growth since 2013. Benefit delivery expenses per claim decreased in the most recent 24-month valuation after a period of stability.

“The changes in 2016 and 2017 claims in medical, indemnity, expenses, and many of their key components may indicate the beginning of a new pattern after the previous trends from reforms ended,” said Ramona Tanabe, executive vice president and counsel of WCRI.

Senate Bill 863 took effect in 2013 and was designed to increase permanent disability benefits for injured workers while also creating cost savings and improving the efficiency of the workers’ compensation process, where possible.

The study, CompScope Benchmarks for California, 19th Edition, compared California with workers’ compensation systems in 17 other states. For the study, WCRI analyzed workers’ compensation claims with experience through March 2018.

The study also found that California had higher litigation expenses – the frequency of and payments per claim for both medical-legal services and defense attorneys in California were higher than most study states.

And that total costs per all paid claims in California were higher than most study states for 2015 claims with an average of 36 months of experience, mainly driven by a higher percentage of claims with more than seven days of lost time.

Chamber of Commerce Publishes 2019 Job Killer List

The California Chamber of Commerce has released its annual Job Killer list, which includes 28 bills that would harm California’s economic growth and job creation should they become law. “These bills represent some of the worst policy proposals affecting California employers and our economy currently being considered by Legislature,” said CalChamber President Allan Zaremberg. Of the 28 bills on this list, those of most concern to employers include:

AB 51 (Gonzalez; D-San Diego) Ban on Arbitration Agreements – Significantly expands employment litigation and increases costs for employers and employees by banning arbitration agreements made as a condition of employment, which is likely preempted under the Federal Arbitration Act and will only delay the resolution of claims.
AB 628 (Bonta; D-Oakland) Uncapped New Leave of Absence for Employees and Their Family Members – Significantly expands the definition of sexual harassment under the Labor Code, which is different than the definition in the Government Code, leading to inconsistent implementation of anti-harassment policies, confusion, and litigation. Also, provides an unprecedented, uncapped leave of absence for victims of sexual harassment and their “family members” which is broadly defined.
AB 673 (Carrillo; D-Los Angeles) Unfair Expansion of Penalties Against an Employer for Alleged Wage Violation – Unfairly exposes an employer to being penalized twice for the same violation, by allowing both an employee and the Labor Commissioner to recover the same civil penalties through civil litigation.
AB 882 (McCarty; D-Sacramento) Limitation on Ability to Maintain a Safe Workplace. Significantly undermines an employer’s ability to maintain a safe, drug-free workplace, by prohibiting an employer from discharging an employee who has tested positive for a drug that is being used for medical purposes.
AB 1468 (McCarty; D-Sacramento/Gallagher; R-Yuba City) Targeted Tax on Opioids – Unfairly imposes an excise tax on opioid distributors in California, which will increase their costs and force them to adopt measures that include reducing workforce and increasing drug prices for ill patients who need these medications the most, in order to fund drug prevention and rehabilitation programs that will benefit all of California.
SB 37 (Skinner; D-Berkeley) Staggering Corporate Tax Hike – For certain companies, SB 37 would raise California’s corporate tax rate – already one of the highest in the nation – up to a staggering 22.26%, which amounts to an increase of about 150% and which will undoubtedly discourage companies from locating or further investing in the state.
SB 135 (Jackson; D-Santa Barbara) Substantial Expansion of California Family Rights Act – Significantly harms small employers in California with as few as 5 employees by requiring these employers to provide 12 weeks of a protected leave of absence each year, in addition to existing leaves of absences already required, as well as potentially requiring larger employers to provide 10 months of protected leave, with the exposure to costly litigation for any alleged violation.
SB 567 (Caballero; D-Salinas) Expands Costly Presumption of Injury – Significantly increases workers’ compensation costs for public and private hospitals by presuming certain diseases and injuries are caused by the workplace and establishes an extremely concerning precedent for expanding presumptions into the private sector.

CalChamber will periodically release job killer watch updates as legislation changes. Reporters are encouraged to track the current status of the job killer bills