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Tag: 2019 News

Tuolumne County Worker Sentenced

The Tuolumne County District Attorney’s Office announced the conviction of a Social Services Department employee for workers’ compensation insurance fraud.

Janice Richardson was employed as a personal care assistant provider for Tuolumne County and reported an on the job injury in April of 2014.

The alleged injuries arose from a motor vehicle collision Richardson was involved in during her scheduled work hours and in the performance of her duties.

Richardson filed a workers’ compensation injury claim and as a result, received medical treatment and workers’ compensation benefits.

During a subsequent investigation, it was alleged Richardson presented false statements and material misrepresentations during a deposition before the Workers’ Compensation Appeals Board. Richardson misrepresented facts as it related to her physical abilities and limitations associated with her injury.

On June 25, 2018, Richardson pleaded no contest to Insurance Fraud, in violation of Penal Code section 550(b)(2), in that she unlawfully and knowingly made a statement containing false and misleading information in support of her claim to obtain workers’ compensation insurance benefits.

Richardson was sentenced to three years probation, ordered to pay a fine of $1,000.00 to the workers’ compensation fraud account and ordered to pay restitution in the amount of $27,500.00 to the County of Tuolumne for reimbursement of workers’ compensation benefits and investigation costs.

This case was a joint investigation by Probe Information Services, the Tuolumne County District Attorney’s Office and the Amador County District Attorney’s Workers’ Compensation Fraud Unit.

The Fraud Unit investigates insurance fraud cases in Amador, Tuolumne, Stanislaus and Calaveras Counties through a grant provided by the California Department of Insurance.

WCRI Publishes Opioid Dispensing Study

A new study, Correlates of Opioid Dispensing, published by the Workers Compensation Research Institute (WCRI) identifies characteristics of injured workers and their employers that are associated with differences in opioid dispensing rates.

The study analyzed a range of possible correlates, including worker (age, gender), injury (type of injury), industry (industry group and employer’s payroll size), and location (county-level opioid dispensing rate, urban-rural classification, and health insurance coverage rate) characteristics. The following are some sample findings from the study:

Industry: For the same injuries, workers employed in mining and construction who received pain medications were more likely to receive opioids, as well as to receive opioids on a longer-term basis and at higher doses.
Location: Injured workers residing in counties with higher amounts of opioids dispensed per person and those residing in rural and very rural counties were more likely to receive opioid prescriptions.
Worker’s Age: Older workers were more likely to receive opioid prescriptions compared with younger workers.
Injury Type: A higher proportion of workers who sustained fractures, carpal tunnel, and neurologic spine pain received at least one opioid prescription for pain relief.

The data used for this analysis included 1.4 million pain medication prescriptions filled within 18 months postinjury for injuries that occurred between October 1, 2014, and September 30, 2015, in 27 states.

The states are Arkansas, California, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Jersey, New York, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Wisconsin.

The study was authored by WCRI’s Dr. Vennela Thumula and Te-Chun Liu. WCRI received funding from the Centers for Disease Control and Prevention/National Institute for Occupational Safety and Health to support this study. To learn more about this study or to purchase a copy, visit WCRI’s website at https://www.wcrinet.org/reports/correlates-of-opioid-dispensing.

Insurers Form Blockchain Network With IBM

CVS Health Corp’s Aetna and a host of other health insurers announced that they have partnered with IBM Corp to create a blockchain network aimed at cutting costs in the healthcare industry.

Big Blue is joined in this effort by Aetna (acquired last November by pharmacy and health plan provider CVS Health), health plan provider Anthem, Health Care Service Corporation (the largest customer-owned health insurance provider in the U.S.) and PNC Bank. These providers combined account for close to 100 million healthcare plans.

IBM said additional members will join the Health Utility Network in the coming months, including other health organizations, healthcare providers, startups, and technology companies.

The aim is to create an inclusive blockchain network that can benefit multiple members of the healthcare ecosystem in a highly secure, shared environment. The goal is to allow the blockchain network to enable healthcare companies to build, share and deploy solutions that drive digital transformation in the industry.

The collaboration members intend to use blockchain to address a range of industry challenges, including promoting efficient claims and payment processing, to enable secure and frictionless healthcare information exchanges, and to maintain current and accurate provider directories.

However, IBM is far from the only tech firm trying to leverage the immutability and transparency of blockchain for the siloed and fragmented healthcare industry. Other prominent names in blockchain healthcare include Change Healthcare, Hashed Health, Guardtime, Gem and SimplyVital – to name a few.

In such a busy space it’s not surprising IBM is faced with some consortia competition. For example, in April of last year, Humana and United Health Group, two of the largest health insurers, teamed up on a blockchain pilot with data providers Quest Diagnostics, Multiplan and Optum.

Another healthcare blockchain called ProCredEx launched in November last year. It focuses on storing and sharing the credentials of medical and dental practitioners and is expected to save time and costs within the industry.

Outside of healthcare, PNC Bank has been public about its blockchain activities, joining a group of banks exploring Ripple’s xCurrent payment system for cross-border transactions.

So. Cal. Attorney Arrested For Trafficking Opioids

Members of a federal task force have arrested an attorney on narcotics distribution charges after detectives spent months following the woman and monitoring her drug sales on Craigslist. Prosecutors allege she illegally sold oxycodone pills after offering drugs for sale.

Jackie Ferrari, 36, a resident of Downey, who investigators believe recently started a new job at a Beverly Hills law firm, was arrested late Friday without incident by law enforcement officers affiliated with the High Intensity Drug Trafficking Area (HIDTA) Task Force, which operates under the direction of the Drug Enforcement Administration.

The criminal complaint filed on January 15 and unsealed this week specifically charges Ferrari with one count of distributing a controlled substance.

The affidavit in support of the complaint states that a law enforcement source with a long history of purchasing narcotics from Ferrari made a buy earlier this month in which Ferrari sold the informant 50 oxycodone pills for $1,200. Ferrari subsequently sent the informant and other likely customers a text message that she “recently obtained a new supply of oxycodone and [had] other drugs available for sale,” according to the affidavit.

The investigation into Ferrari began after a 22-year-old woman died in August of a fentanyl overdose, and text messages on the victim’s phone initially indicated she may have purchased the narcotics from Ferrari. While investigators currently do not believe that Ferrari sold the narcotics that led to the overdose death, they have continued to investigate her based on evidence that she is a large-scale trafficker in opiates via the website Craigslist.  

The affidavit also notes that records obtained from Craigslist pursuant to a subpoena demonstrate Ferrari’s long history of posting advertisements for the sale of narcotics using coded names such as “roxy dolls” (i.e., Roxicodone, a short-acting version of oxycodone), “Chinese **White** Rice” (i.e., “China white” or powdered heroin, which is often mixed with fentanyl) and “Black Rice” (i.e., black tar heroin).

Ferrari waived the option of a preliminary hearing and was released on $25,000 bond, said Thom Mrozek, a spokesman for the U.S. attorney’s office. If convicted of the charge in the criminal complaint, Ferrari would face a statutory maximum sentence of 20 years in federal prison.

OCDA Charges Max Matos M.D., and Jeff Catanzarite D.C.

Charges were filed against Max Humberto Matos M.D.,Jeffrey Scott Catanzarite D.C., Ronald Lee Martin and Veronica Martin by Orange County prosecutors . They were released on bail on January 8, and an arraignment is scheduled in Orange County Superior Court on February 18, at 8:30 am.

The Felony Complaint in case 18CF3512 alleges that Jeffrey Scott Catanzarite is a California licensed chiropractor, who incorporated the Center for Better Health, A Medical Group, Inc., as a Medical Professional Corporation. He operated a medical clinic in Costa Mesa, and Riverside California, that provided treatment to workers’ compensation claimants.

Between 2008 and 2016, he operated the Center for Better Health under the name Southland Spine and Rehabilitation Medical Center, Inc..

To comply with the laws of Medical Professional Corporations, Catanzarite listed himself at all times as a 49-percent owner of Center for Better Health/Southland Spine, while also holding the positions of President and Secretary.

In 2012, Catanzarite promoted Max Humberto Matos, M.D., a treating physician for Center for Better Health/Southland Spine to be its Vice President, Medical Director and gave him a 51 percent ownership interest on paper. But prosecutors allege that despite Matos’s listed ownership interest, Catanzarite was the sole actual owner of Center for Better Health/Southland Spine, controlling its finances, and being responsible for making all substantive decisions.

Catanzarite employed Ronald Lee Martin and Veronica Martin through their company Priority One Health Resources, to run Center for Better Health/Southland Spine’s marketing department.

The Center for Better Health/ Southland Spine allegedly contracted to pay Grupo Medlegal LA and subsequently Medlegal Network, Inc. $1000 for each patient provided to Center for Better Health/Southland Spine for which it could bill workers’ compensation insurers. It typically paid Grupo Medlegal LA and Medlegal Network, Inc. $4,000 per week for 4 patient referrals.

The defendants also contracted to pay Providence Scheduling, for each patient provided to Center for Better Health/Southland Spine for which it could bill insurers. They typically paid Providence Scheduling Inc. $10,000 to $15,000 every 45 days for patient referrals.

Prosecutors claim that between January 3, 2011, and October 13, 2015, Catanzarite paid Grupo Medlegal LA $92,014.66 and Medlegal Network, Inc. $1,324,219.68 for unlawful patient referrals.

Prosecutors allege a number of crimes as a result of the defendants failure to disclose this information to a list of worker’s compensation insurance carriers and third party administrators who paid benefits on these claims.

Eight Indicted in $123M Compound Med Fraud

A Riverside County judge has unsealed indictments against eight people accused of operating an international conspiracy to defraud the California workers’ compensation system of more than $123 million.

In March 2017, the Riverside and San Bernardino County District Attorney’s Offices began an investigation into Blue Oak Medical Group. The evidence was presented to a Riverside County criminal grand jury which, after hearing six weeks of testimony, handed down indictments on Jan. 17, 2019.

The indictments, which were unsealed by Superior Court Judge O.G. Magno on Tuesday, name Kenneth Amodeo, 60, of Agoura Hills; Rosa Bernal, 46, of Covina; Shannon Devane, 41, of Downey; Janek Hunt, a 44-year-old Estonian national; Edgar Lozano, 52, of Porter Ranch; Matthew Rifat, 49, of El Cajon; Hector Sandoval, 54, of Sherman Oaks; and Munir Uwaydah, a 52-year-old Lebanese national.

Amodeo is a pharmacist, Rifat is an attorney, and Uwaydah is a physician whose license currently is not active. Uwaydah has been under indictment in Los Angeles County in a related case since 2015.

The next court date for Amodeo, Bernal, and Lozano is Feb. 6, 2019, for arraignment and the next court date for Devane, Hunt, and Rifat, is Feb. 26, 2019, for a trial readiness conference. Defendants Sandoval and Uwaydah are not in custody and arrest warrants have been issued.

The eight defendants in this case are charged with a variety of counts including conspiracy, fraud, and money laundering and sentence-enhancing white-collar crime allegations.

Amodeo, Bernal and Lozano were each being held in lieu of $4.7 million bail at the Smith Correctional Facility in Banning; Devane and Rifat were each being held in lieu of $4.7 million at the Robert Presley Jail in Riverside; and Hunt was being held in lieu of $4.7 million at the Byrd Detention Center in Murrieta. Arrest warrants are pending against Sandoval and Uwaydah, neither of whom were in custody.

Based on information found in publically filed documents, the defendants used the sham clinics to take advantage of thousands of patients by prescribing nearly all of them the same high priced cocktail of unnecessary medications, regardless of the patients’ condition. Many of the medications were produced by pharmacies under the control of the defendants and the patients often received little, if any, of the medicine they were prescribed.

The defendants funneled the fraudulently obtained proceeds from the scam through a network of shell companies, ultimately sending the money to co-conspirators throughout Southern California, Europe, and the Middle East.

The investigation in this case involved multiple agencies including the Riverside County District Attorney’s Office, the San Bernardino County District Attorney’s Office, the Orange County District Attorney’s Office, and the California Pharmacy Board.

The cases, RIF1990022 and RIF1990023, are being prosecuted by Riverside County Deputy District Attorneys Matthew Murray, Erika Mulhere, and Kristen Allison of the DA’s Insurance Fraud Team, and San Bernardino County Deputy District Attorney Michael Chiriatti.

Cal Med Board Investigating 450 Physicians

The Medical Board of California has launched investigations into doctors who prescribed opioids to patients who, perhaps months or years later, fatally overdosed, according to a report by Kaiser Health News.

The effort, dubbed “the Death Certificate Project,” has sparked a conflict with physicians in California and beyond, in part because the doctors being investigated did not necessarily write the prescriptions leading to a death. The project is one of a kind nationally, although a much more limited program is operated by North Carolina’s board.

So far, the board has launched investigations into the practices of about 450 physicians and referred the names of 72 nurse practitioners, physician assistants and osteopathic physicians to their respective licensing boards. To date, the regulators have formally accused at least 23 doctors of negligent prescribing, and more accusations are expected.

Using terms such as “witch hunt” and “inquisition,” many doctors said the project is leading them or their peers to refuse patients’ requests for painkiller prescriptions – no matter how well documented the need – out of fear their practices will come under disciplinary review.

The project, first reported by MedPage Today, has struck a nerve among medical associations. Dr. Barbara McAneny, the American Medical Association president and an Albuquerque, N.M., oncologist whose cancer patients sometimes need treatment for acute pain, called the project “terrifying.” She said “it will only discourage doctors from taking care of patients with pain.”

The influential California Health Care Foundation also has pushed back against the project, saying it could harm patients.

Unusually aggressive for the board, the program is a reaction to the by now well-known phenomenon of physicians overprescribing opioids. Nationally, a host of policy changes and educational efforts have driven down the rate of opioid prescriptions in recent years.

The goal of California’s program, quietly launched four years ago, is not necessarily to link a doctor’s specific prescription to a specific patient’s death – although many of the cases do – but to find doctors whose patterns of prescribing are so dangerous they may lead to patients’ ultimately fatal addictions.

Kimberly Kirchmeyer, executive director of the Medical Board of California, defended the project. She said the effort has found patterns of “gross negligence,” incompetence and excessive prescribing.

“I understand their frustrations,” she said of the complaining doctors, “but we do have to continue our role with consumer protection.” She noted that part of the point of the project is to educate doctors and, through probation requirements, change the behavior of those who prescribe excessively. “That’s education that could potentially save patients in the future,” said Kirchmeyer, whose agency licenses some 141,000 doctors.

Some consumer groups consider the board’s bold effort to find overprescribing doctors not aggressive enough.

“It’s long overdue,” said Carmen Balber, executive director of the nonprofit Consumer Watchdog. The board should investigate opioid-related deaths that occurred more recently, she said: “They need to get their act together and speed things up.”

McAneny, of the AMA, noted that prescribing practices now deemed unacceptable came out of public policies years ago that “compelled doctors to treat pain more aggressively for the comfort of our patients.” Also, payers have measured quality of care by whether their patients answered surveys about whether their pain was well-controlled.

Similarly, Dr. David Aizuss, a Los Angeles ophthalmologist who is president of the California Medical Association, said state and federal guidelines that took effect in 2014 and 2016 impose much more stringent prescribing precautions than “what was going on six or seven years ago.”

The crackdown on doctors has created fear, said Dr. Robert Wailes, a pain medicine specialist in Encinitas and chair of the California Medical Association’s Board of Trustees. “What we’re finding is that more and more primary care doctors are afraid to prescribe and more of those patients are showing up on our doorsteps,” he said.

Officially, the CMA stops short of saying the medical board should stop the project, perhaps to avoid any perception that the association condones overprescribing. But it has asked the board to hire an independent reviewer to assess the criteria the board is using to decide which physicians to investigate, and whether physicians in certain specialties or regions of the state are being targeted more than others.

Walgreens Settles Fraud Claim for $269M

Walgreens Boots Alliance Inc. has entered into an agreement with federal prosecutors in Manhattan to settle Medicaid and Medicare fraud allegations in two separate actions brought against the national pharmacy chain, according to court records unsealed by U.S. District Judge Paul Crotty of the Southern District of New York.

The first settlement, approved on January 16, 2019 requires Walgreens to pay $209.2 million to resolve allegations that it improperly billed Medicare, Medicaid, and other federal healthcare programs for hundreds of thousands of insulin pens it knowingly dispensed to program beneficiaries who did not need them.

The second settlement, approved on January 15, 2019, requires Walgreens to pay $60 million to resolve allegations that it overbilled Medicaid by failing to disclose to and charge Medicaid the lower drug prices that Walgreens offered the public through a discount program.

The settlement requires Walgreens to pay approximately $168 million to the United States, and Walgreens has agreed separately to pay approximately $41.2 million to state governments.

In both settlements, prosecutors say Walgreens admitted and accepted responsibility for conduct the Government alleged in its complaints under the False Claims Act.

According to federal prosecutors, the insulin fraud occurred through two specific Walgreens policies. First, the company’s electronic management system prevented pharmacists from dispensing partial boxes of insulin pens, even when a patient didn’t require that much insulin.

Second, when the amount distributed exceeded what was prescribed for a total number of daily doses, Walgreens falsely stated in reimbursement forms that what was handed out did not go over that limit.  As part of the other fraudulent scheme, Walgreens used its Prescription Savings Program to overcharge federal health care programs, according to prosecutors.

While it was providing customers a discount on drugs ordered through the program, Walgreens was failing to tell Medicaid what the prices were when it billed for reimbursement. This led to Medicaid paying more than it should have for the discounted medications.

In a statement provided by a Walgreens spokesman, the company said it was pleased to have the issues resolved. The company claimed to have fully cooperated with the government, and to have admitted to no wrongdoing.

Employment Terminated for Violation of DIR Gift Policy

Tess Viceral, Cristina Cornell, and Imelda Canovas were long-term employees of the Department of Industrial Relations (DIR). Viceral worked as a supervisor under manager Cora Lee at times relevant to this appeal.

Viceral supervised Cornell and Canovas who were employed as Workers’ Compensation Consultants (WCCs). WCCs have the authority to settle workers’ compensation claims up to $75,000 and select third-party vendors to handle the claims.

DIR has policies against gifts received by a DIR employee from vendors with whom the DIR employee regularly does business if the gift is intended to reward the DIR employee for doing business with the gift giver.

This policy was not strictly enforced until Lee became manager in November 2012. Since the policy was not strictly enforced, vendors would sometimes take DIR employees to lunch, give gift cards, and bring edible treats to DIR offices.

Lee met with Viceral in late 2012 to remind Viceral of the gift policy and instructed Viceral to relay the message to the WCCs under her supervision, but Viceral failed to do so. Viceral and the WCCs continued to attend lunches and accept promotional gifts, and vendors continued to bring food to DIR offices.

Lee again reminded Viceral of the gift policy and sent her a confirming memorandum in early March 2013. A week or so later, Viceral finally held a meeting with the WCCs, reminding them of the gift policy and instructing them not to accept gifts from vendors. However, this did not seem to stop Viceral and the WCCs from attending lunches, and Canovas from handing out vendor gift cards.

An investigation was launched by DIR’s human resources division. Ultimately, Canovas, Cornell, and Viceral received notices of adverse action terminating their employment for improperly accepting gifts, falsifying their statements of economic interest, falsifying timesheets, and being dishonest in their investigatory interviews. Other WCCs involved either were not disciplined or had their terminations revoked after admitting dishonesty and settling for suspensions.

Canovas, Cornell, and Viceral appealed their terminations to the State Personnel Board. The ALJ found that Appellants were dishonest and that retaliation was not the primary basis for the termination, and he upheld the termination as proper. The Superior Court denied a petition for a writ of mandate. The Court of Appeal affirmed the termination in the unpublished case of Canovas v. State Personnel Bd.

The Court of Appeal concluded that the administrative hearing was fundamentally fair after noting that the appellants raised “a plethora of complaints, most of which are barely coherent.”

Political Battle Over ABC Employment Test Heats Up

When can companies in California classify their workers as independent contractors instead of employees?

According to a report by KQED, that’s the question that’s been hot on the minds of California lawmakers, labor unions and tech companies since April, when the California Supreme Court ruled that businesses must satisfy three guidelines to classify workers as contractors.

In Dynamex Operations West, Inc. v. Superior Court, the state Supreme Court ruled that a worker can be considered a contractor only if: A. The worker is free from the control and direction of the hirer in connection with the performance of the work. B. The worker performs work that is outside the usual course of the hiring entity’s business. C. The worker is customarily engaged in an independently established trade, occupation, or business. This is now known as the ABC Test.

Allan Zaremberg, head of the California Chamber of Commerce, said the ruling puts the Legislature in a unique position. A state law could override the court decision and return California to the pre-Dynamex test for employee status.

The court’s decision is especially concerning to tech companies like Uber, Lyft and Instacart, whose businesses rely heavily on a revolving army of contractors. They’re among a group of tech firms partnering with the state Chamber of Commerce to lobby for legislation that would loosen restrictions on who could be included as a contractor.

Without a new law, these companies would have to abide by the court’s guidelines.

Uber, which has long been the largest and most influential on-demand gig company in the country, has always insisted that its drivers are not employees. The San Francisco-based company argues that it’s not a taxi company, but rather a tech firm that creates a platform or marketplace to connect riders to independent drivers. In other words, it says, its employees are the people who build its technology, not the one who drive people around.

It’s the second requirement of the Dynamex ruling that poses the biggest dilemma for big gig-focussed companies like Uber. Because the San Francisco-based firm is in the business of giving rides, and its drivers are the ones who provide them, the company would be hard-pressed, under the court’s guidelines, to classify those workers as anything but employees.

Some companies feel like that test is going to alter their business model, and in some cases that’s true,” said Steve Smith, a spokesman for the California Labor Federation, which would like to see more workers classified as employees. If that presents a hardship for some tech companies, that’s just too bad, Smith added.

Assemblywoman Lorena Gonzalez, D-San Diego, authored AB 5, a bill that would require companies to follow the court’s guidelines. It might not make sense for all workers to be classified as employees, she said, but gig workers still need some protections.

Another bill, AB 71, would roll back the court’s recent decision.

Uber and other gig companies have taken various steps in recent years to ensure that they can continue categorizing their workers as contractors. In some cases, like New York, they have set up drivers’ organizations, which have less power than union organizations. Many workers don’t see this as a sufficient solution.

This fight also places Gov. Gavin Newsom, who received campaign support from both labor and the tech industry, in a particularly tricky position. He contends the issue should have been resolved before it went to court, and has urged both sides to find common ground.

He recently said his administration is even considering the creation of a committee to address the issue. “Because we could have been making determinations before that case ended up at the court,” he said.