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Tag: 2019 News

San Diego Military Doctor Signs off on Fake Insurance Claims

A federal grand jury in San Diego returned a superseding indictment that charges U. S. Navy servicemembers Dr. Michael Villarroel, Paul Craig, and Christopher Toups with fraud, false claims and conspiracy to defraud the United States.

The charges arise from a scheme where the defendants filed fraudulent claims to obtain unearned benefits from the Traumatic Servicemembers Group Life Insurance Program (“TSGLI”).

The TSGLI program is an insurance program that compensates servicemembers who suffer serious and debilitating injuries while on active duty. The program is funded by fees paid directly by individual service members and the Department of Defense.

Dr. Michael Villarroel, a Commander in the U.S. Navy, was the medical doctor for the Explosive Ordinance Disposal Expeditionary Support Unit One (“EOD ESU One”) from March 2010 through May 2013. In that capacity, Dr. Villarroel knowingly signed off on false and fraudulent TSGLI applications on behalf of multiple servicemembers that were part of or connected to EOD ESU One.

Both Christopher Toups, a former Chief Petty Officer Construction Mechanic, and Paul Craig, a former Lt. Commander in the U.S. Navy, filed fraudulent TSLGI applications. To support their applications, each defendant submitted fabricated applications that included forged signatures and altered hospital records. According to the superseding indictment, Craig fraudulently collected $150,000 and Toups collected at least $100,000.

In addition to Christopher Toups, four other individuals were previously indicted in connection with this scheme. Three of those individuals – Richard Cote, Earnest Thompson, and Kelene Meyer – have pleaded guilty to conspiracy to commit wire fraud, and as part of their plea, admitted that the conspirators defrauded the TSGLI program of nearly $2 million.

According to the plea agreement, Meyer, a former nurse in the U.S. Navy, stated that Toups, Villarroel, and she received kickbacks for creating and filing the fraudulent TSGLI applications for other U.S. Navy servicemembers.

No WCAB Exclusive Jurisdiction Over AOE-COE in CIGA Case

School bus driver Colleen Knowles sought workers’ compensation from her employer, Mountain Empire Unified School District.

The District is a self-insured employer under the workers’ compensation scheme, and its workers’ compensation claims are administered through the San Diego County Schools Risk Management Joint Powers Authority. The JPA purchased excess workers’ compensation insurance to cover claims exceeding a set retention. The District is an additional insured under those policies.

When a dispute over compensation arose, Knowles and the District sought adjudication before the Workers’ Compensation Appeals Board. An administrative law judge ultimately approved their stipulation that Knowles suffered a “specific” injury on May 6, 2003.

The distinction between a “cumulative” and a “specific” injury matters for determining which of JPA’s excess insurance policies was triggered. As JPA’s excess insurer during the stipulated injury date, Kemper Insurance Company indemnified the JPA until it went insolvent. The JPA then approached California Insurance Guarantee Association, a statutorily created insolvency insurer of last resort, to make up what Kemper had failed to pay.

But CIGA is only obligated to pay “covered claims,” defined to exclude claims for which other insurance is available. On this basis CIGA denied coverage, asserting Knowles suffered a cumulative injury, which meant that JPA might recover from a different excess insurer (other than Kemper).

CIGA then sued the JPA and the District for declaratory relief, asserting that because Knowles suffered a cumulative injury, JPA’s claim was not a “covered claim.” In their cross-complaint, defendants sought reimbursement from CIGA of benefit payments made to Knowles after Kemper went insolvent.

The trial court granted both of Defendants motions for summary judgment on the complaint and cross-complaint. and entered judgment in their favor, requiring CIGA to reimburse $129,836.91 plus costs. CIGA appealed that decision.

Central to the court’s ruling, and to CIGA’s appeal, is a jurisdictional question: Does the superior court have jurisdiction to find that Knowles suffered a cumulative injury even if this conflicts with the stipulation before the WCAB, or is injury characterization an issue within the WCAB’s exclusive jurisdiction? The court granted defendants’ motions because it believed the WCAB had exclusive jurisdiction to decide the nature of Knowles’s injury. The Court of Appeal agreed that it did, in the published case of CIGA v the San Diego County Schools Risk Management Joint Powers Authority.

Although this issue appears to be one of first impression in California, federal courts have rejected WCAB exclusivity in similar cases involving excess workers’ compensation insurance. (San Francisco BART Dist. v. General Reinsurance Corp. (N.D.Cal. 2015) 111 F.Supp.3d 1055, 1074 (BART I), affirmed (9th Cir. 2017) 726 F.App’x. 562 (BART II); San Diego Cty. Schs. Risk Mgmt. Joint Powers Auth. v. Liberty Ins. Corp., et al. (2018) 339 F.Supp.3d 1019, 1030 (Liberty).)

The Court of Appeal we agreed with these authorities and concluded, based on the purpose of excess insurance, that the superior court has jurisdiction to characterize Knowles’s injury in this action differently than was reflected in the WCAB stipulation.

Accordingly, it reversed the judgment and direct the trial court to enter a new order denying defendants’ motions for summary judgment.

Enough Fentanyl Seized to “Wipe Out” Entire State of Ohio

Investigators seized over 44 pounds of fentanyl in an Ohio drug bust, a quantity large enough to wipe out the state’s entire population “many times over,” officials revealed Wednesday.

The raid unfolded in Dayton last week. In addition to the fentanyl, investigators seized some 1,500 grams of suspected methamphetamine, 500 grams of suspected heroin, three firearms and $30,000, the Montgomery County Sheriff’s Office announced.

“Twenty kilograms of fentanyl is enough to kill the entire population of Ohio, many times over,” Vance Callender, the Homeland Security Investigations special agent in charge for Michigan and Ohio, said in a statement.

Officers arrested three suspects — Shamar Davis, 31, Anthony Franklin, 30, and Grady Jackson, 37. All faced charges including possession with intent to distribute 400 or more grams of fentanyl, the Montgomery County Sheriff’s Office said in a statement.

The quantity of fentanyl in this case amounts to chemical warfare and a weapon of mass destruction,” Ohio Attorney General Dave Yost said. “I applaud the work of our task force and our law enforcement partners – this is an enormous amount of deadly drugs that will no longer be on our streets.”

This multi-million dollar fentanyl seizure clearly shows the enormity of the opioid problem in this area,” Acting Special Agent in Charge Joseph M. Deters of the FBI’s Cincinnati Division added. “Law enforcement will continue to work aggressively to address the illegal drug supply, but there is also a continuing need to address demand as well.”

Ohio was one of four states in the U.S. — along with Pennsylvania, Massachusetts and New Hampshire — that saw an increase of more than 500 fentanyl-related incidents from 2014 to 2015, according to the latest data available from the U.S. Centers for Disease Control and Prevention.

Most recently, the state grappled with a surge of overdoses linked to fentanyl, resulting in six deaths over the span of 24 hours this past September. Prior to that, in July, nine people died from overdoses in a two-day period.

New CWCI Study Shows 94.1% UR/IMR Approval Rate

California workers’ compensation reforms enacted in 2003 and 2004 introduced a new process for approving medical services for injured workers, including the adoption of mandatory utilization review (UR) using evidence-based medicine guidelines.

Nearly a decade later, state lawmakers included reforms in SB 863 that added a new element to the medical service approval process, mandating the use of independent medical review (IMR) to resolve disputes over medical necessity.

The California Workers’ Compensation Institute’s latest study of California’s medical benefit delivery process expands on earlier analyses to determine the proportion of requested and/or delivered care that is approved versus denied after UR and IMR by service category.

Results show that 94.1 percent of services performed or requested from January 1, 2018 to October 31, 2018 were either approved (92.5 percent) or approved with modifications (1.6 percent), and 5.9 percent were denied, though outcomes varied by service category.

Evaluation and management services (e.g., office and emergency department visits, consultations) represented 29 .1 percent of the medical services in the 2018 data set and had an approval rate of 99.7 percent.

Surgery services were approved with or without modifications 94.9 percent of the time, while 89.4 percent of physical medicine services (physical therapy, chiropractic manipulation, and acupuncture) were approved with or without modifications.

The study also examines the impact of the UR provisions of 2016 legislation (SB 1160), which effective Janua1y 1, 2018, exempted certain services from prospective UR.

One goal of SB 1160 was to speed delivery of medical care, and while the study does find that the proportion of physical medicine services performed in the first 30 days increased from 2017 to 2018, there was no meaningful change in the delivery of other services. At the same time, the total volume of services performed in the first 60 days from injury did not increase and the denial rate for these services remained very low in both periods, ranging from 0.0 to 4.8 percent.

For the first time, the authors were able to estimate the proportion of UR denials and modifications that underwent IMR and found that an estimated 29 percent of UR modification and denial decisions were appealed and reviewed by an IMR physician.

However, an examination of the top law firms identified in the UR data reveals that the IMR referral rates by applicant attorneys varied greatly. Some attorneys submitted nearly all of their clients’ treatment modifications and denials to IMR, while others sent none.

The last section of the study continues the Institute’s monitoring of IMR volumes and results. After a 7 percent increase in volume from 2017 to 2018, IMR volume for the first half of 2019 appears to be dropping back toward 2017 levels.

As in 2018, IMR reviewers have upheld UR decisions 88 percent of the time through the first half of 2019. In addition, a small number of physicians continue to drive a disproportionate share of the IMR volume, with the top 1 percent associated with 44 percent of the IMR decisions.

Ride-Share Companies Launch AB 5 Ballot Initiative

Some of the country’s largest ride-sharing companies proposed a California law on Tuesday that would let them continue to treat drivers as independent contractors while also guaranteeing them a minimum wage and money for health insurance.

The state Legislature enacted legislation this year, AB-5, requiring ride-sharing companies to treat drivers as employees, which would let them form a union and entitle them to benefits like a minimum wage and workers compensation.

But the law proposed Tuesday would exempt ride-sharing companies. The proposal must be approved by voters, not the state Legislature. If passed, it would supersede the Legislature’s action and any similar ordinances passed by local governments. It also prevents lawmakers from passing another law to block it.

The proposal will only get on the ballot in November 2020 if supporters can gather roughly 660,000 signatures from registered voters. Uber, Lyft and DoorDash have already pledged $90 million to support the effort, making it one of the most expensive ballot measures ever.

“We believe the nature of this work is truly unique,” said Brandon Castillo, spokesman for the Protect App-Based Drivers & Services Coalition. He said lawmakers are “forcing an employment model that just doesn’t work for the nature of this work.”

Castillo noted the coalition is willing to negotiate with lawmakers. If the Legislature passes a similar law by June 25, they would withdraw the ballot measure, he said.

That appears unlikely. Democratic Assemblywoman Lorena Gonzalez, who authored the bill requiring companies to treat drivers as employees, called the proposed ballot measure “disingenuous.” She argues it still would not give workers retirement benefits and overtime pay, and it would not let them organize a union.

“These billion-dollar corporations still refuse to offer their workers what every other employee in California is entitled to,” she said.

The new proposal would require drivers receive at least 120% of the state or local minimum wage, whichever is higher. It would let drivers keep all tips. It requires companies to pay drivers 30 cents a mile for expenses.

And drivers who work at least 15 hours a week would get money for health insurance. They could work for multiple companies and get multiple stipends. But companies could ask drivers to prove they have health insurance as a requirement for getting that money.

The proposal is already dividing drivers.

Researchers Say Lack of Evidence on Medicinal Cannabis

Evidence is weak for whether medicinal cannabis treatments can relieve mental illnesses such as anxiety, depression and psychosis, and doctors should prescribe them with great caution, researchers said on Monday.

Reuters Health published a review of scientific studies that analyzed the impact of medicinal cannabinoids on six mental health disorders, the researchers found “a lack of evidence for their effectiveness.”

Their findings have important implications for countries such as the United States, Australia, Britain and Canada, where medical cannabis is being made available for patients with certain illness, said Louisa Degenhardt, a drug and alcohol expert at Australia’s University of New South Wales in Sydney.

There is a notable absence of high-quality evidence to properly assess the effectiveness and safety of medicinal cannabinoids … and until evidence from randomized controlled trials is available, clinical guidelines cannot be drawn up around their use in mental health disorders,” she said as her results were published in The Lancet Psychiatry journal.

Despite a lack of clinical trial evidence, anecdotally some military veterans and others who suffer post-traumatic stress disorder (PTSD), depression and anxiety say they have found cannabis helpful in easing some of their symptoms. Other conditions cannabis is used for include nausea, epilepsy, and traumatic brain injury, but this study did not examine its impact on those.

Medicinal cannabinoids include medicinal cannabis and pharmaceutical cannabinoids, as well as their synthetic derivatives, THC, or delta-9-tetrahydrocannabinol – the main psychoactive ingredient of cannabis – and cannabidiol, or CBD.

“Cannabinoids are often advocated as a treatment for various mental health conditions,” Degenhardt said. “(But) clinicians and consumers need to be aware of the low quality and quantity of evidence … and the potential risk of adverse events.”

Degenhardt’s team sought to look at all available evidence for all types of medicinal cannabinoids. They included all study designs and investigated the impact on remission from and symptoms of depression, anxiety, attention-deficit hyperactivity disorder (ADHD), Tourette syndrome, PTSD and psychosis. They analyzed 83 published and unpublished studies covering around 3,000 people between 1980 and 2018.

They found that pharmaceutical THC – either with or without CBD – made psychosis worse, and did not significantly affect any other primary outcomes for the mental illnesses analyzed.

It also increased the number of people who reported side effects, and the number who decided to withdraw from a study due to side effects.

Tom Freeman, an addiction and mental health expert at Britain’s Bath University who was not involved with the study, said the findings highlighted an urgent need for high-quality trials of medical cannabis to strengthen the evidence – particularly given what he said was “significant demand” from patients.

Grand Jury to Review Opioid Drugmaker Litigation

Johnson & Johnson received grand jury subpoenas in August from the U.S. attorney’s office for the Eastern District of New York related to its opioid medication policies, the company said in a regulatory filing on Monday.

J&J said the subpoenas were related to anti-diversion policies and procedures and the distribution of its opioid medications developed by its Janssen pharmaceuticals unit.

The company said in the filing it believes the investigation relates to monitoring and reporting programs by manufacturers and distributors of opioids under the Controlled Substances Act.

“Like other companies that have manufactured opioid medications, Janssen has received subpoenas and investigative demands from various government entities, and this includes the August 2019 subpoena from the United States Attorneys Office for the Eastern District of New York,” the company said in a statement emailed to Reuters.

J&J said it understands the subpoenas are part of a “broader, industry-wide investigation” and said the company believes its anti-diversion policies and procedures complied with the law.

Johnson & Johnson last week lowered its previously reported third-quarter profit to account for a proposed $4 billion cash settlement related to the opioid crisis.

That followed a Reuters report citing sources that drug distributors McKesson Corp, AmerisourceBergen Corp and Cardinal Health had offered to pay $18billion in cash over 18 years, while J&J would pay $4 billion in cash.

The drug industry faces roughly 2,600 lawsuits brought bystate and local governments, hospitals and other entities seeking to hold drugmakers and distributors responsible for the toll of opioid abuse.

In August, an Oklahoma judge ordered J&J to pay $572.1 million to the state for its part in fueling an opioid epidemic, a sum that was substantially less than investors had expected.

Researchers Criticise Scientific Basis of Psychiatric Diagnosis

Labor Code 3208.3 supposedly set a standard for evaluating psychiatric injuries in California workers’ compensation claims.

The code requires that the worker be diagnosed using the terminology and criteria of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised, or the terminology and diagnostic criteria of other psychiatric diagnostic manuals generally approved and accepted nationally by practitioners in the field of psychiatric medicine. We are currently on the Fifth Edition.

But, no two people are exactly alike. Therefore, attempting to classify each unique individual’s mental health issues into neat categories just doesn’t work. That’s the claim coming out of a new study published in the scientific journal Psychiatry Research, that is sure to ruffle some psychologists’ feathers.

More people are being diagnosed with mental illnesses than ever before. Multiple factors can be attributed to this rise; many people blame the popularity of social media and increased screen time, but it is also worth considering that in today’s day and age more people may be willing to admit they are having mental health issues in the first place.

That’s why a new study conducted at the University of Liverpool has raised eyebrows by concluding that psychiatric diagnoses are “scientifically meaningless,” and worthless as tools to accurately identify and address mental distress at an individual level.

Researchers performed a detailed analysis on five of the most important chapters in the Diagnostic and Statistical Manual of Mental Heath Disorders (DSM). The DSM is considered the definitive guide for mental health professionals, and provides descriptions for all mental health problems and their symptoms. The five chapters analyzed were: bipolar disorder, schizophrenia, depressive disorders, anxiety disorders, and trauma-related disorders.

Researchers came to a number of troubling conclusions. First, the study’s authors assert that there is a significant amount of overlap in symptoms between disorder diagnoses, despite the fact that each diagnosis utilizes different decision rules. Additionally, these diagnoses completely ignore the role of trauma or other unique adverse events a person may encounter in their life.

Perhaps most concerning of all, researchers say that these diagnoses tell us little to nothing about the individual patient and what type of treatments they will need. The authors ultimately conclude that this diagnostic labeling approach is “a disingenuous categorical system.

“Although diagnostic labels create the illusion of an explanation they are scientifically meaningless and can create stigma and prejudice. I hope these findings will encourage mental health professionals to think beyond diagnoses and consider other explanations of mental distress, such as trauma and other adverse life experiences.” Lead researcher Dr. Kate Allsopp explains in a release.

According to the study’s authors, the traditional diagnostic system being used today wrongly assumes that any and all mental distress is caused by a disorder, and relies far too heavily on subjective ideas about what is considered “normal.”

Data Analytics Busts La Jolla Physician

Dr. Roger A. Kasendorf, an osteopathic physician practicing in La Jolla, agreed to pay $125,000 to resolve allegations that he illegally prescribed opioids to his patients. The highly addictive and frequently abused opioids he prescribed included fentanyl, hydromorphone, oxymorphone, and oxycodone.

In response to the Justice Department’s focus on combatting the opioid epidemic, the Drug Enforcement Administration (DEA) and the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG) investigated Dr. Kasendorf’s prescribing practices.

This investigation arose from data analytics tools which allow the Department of Justice to perform a variety of functions, including identifying statistical outliers, such as which doctors prescribe the highest opioid dosages and which doctors prescribe combinations of opioids and other drugs known to increase the risk of addiction, abuse, and overdose.

Based on the investigation, the United States contends that Dr. Kasendorf wrote prescriptions for opioids, including fentanyl, that were not issued for a legitimate medical purpose and while not acting in the usual course of his professional practice in violation the Controlled Substances Act and the False Claims Act.

The Centers for Disease Control and Prevention (CDC), the American Academy of Pain Medicine, the American Pain Society, state agencies and medical boards, and other medical literature provide guidance on appropriate practices when prescribing opioids.

One common tool is for health care providers to determine the Morphine Milligram Equivalent (MME, also commonly referred to as Morphine Equivalent Dose or MED) of prescribed opioids. MME is a uniform scale used to determine daily opioid dosage by using an equivalency factor to calculate a dose of morphine that is equivalent to the prescribed opioid.

The CDC recommends primary care clinicians who prescribe opioids for chronic pain outside of active cancer treatment, palliative care, or end-of-life care should avoid increasing opioid daily dosage over 90 MME or carefully justify a decision to titrate daily dosage to over 90 MME.

Prescribers should also seek to avoid prescribing opioid pain medication in combination with benzodiazepines (e.g., Xanax, Valium, Klonopin) when possible, and should consider whether the benefits outweigh the risks of combining opioids with other depressants (i.e., muscle relaxants and sleep medications).

Researchers Take Second Look at Chirpractic Care

A new research review reported by Reuters Health suggests that people with chronic back and neck pain who receive chiropractic care may be less likely to use opioid painkillers.

Researchers examined data from six previously-published smaller studies with a total of more than 62,000 participants with spinal pain. Across all of the studies, 11% to 51% of the patients used chiropractic care.

People who saw a chiropractor were 64% less likely to use opioids than people who didn’t, researchers report in the journal Pain Medicine.

“Patients with spinal pain who visit a chiropractor may receive treatments such as spinal manipulation, massage, acupuncture, exercises and education as appropriate,’ said lead author Kelsey Corcoran of Yale School of Medicine in New Haven, Connecticut.

These therapies may lead to decreased pain, improved range of motion and increased function,” Corcoran said by email. “If a patient’s pain is well controlled by the treatment they received from a chiropractor, they may subsequently need less pain medications or even none at all.”

Chiropractors don’t prescribe opioids. However, all of the studies in the analysis examined whether receipt of chiropractic care was associated with whether patients also received opioid prescriptions from other clinicians.

It’s not clear from this analysis whether people already using opioids to manage pain might be able to cut back or eliminate opioid use after getting chiropractic care.

“In general, I think that patients wishing to avoid Rx (especially opioid) would do well to seek care from providers who can provide potentially helpful alternatives to opioid treatments – this could include chiropractors, physical therapists, massage therapists, pain psychologists, yoga instructors, and mindfulness-based stress reduction classes, etc.,” said Dan Cherkin, an emeritus senior scientific investigator at Kaiser Permanente Health Research Institute in Seattle, Washington, who wasn’t involved in the study.

The challenge is that some of these options aren’t always available or covered by insurance, Cherkin added.

Still, organizations such as the Veterans Health Administration and the American College of Physicians currently recommend that patients try conservative treatments commonly delivered by doctors of chiropractic instead of opioids, said Christine Goertz, a researcher at Duke University in Durham, North Carolina, who wasn’t involved in the study.

“The current study indicates that patients who follow these recommendations are, in fact, less likely to receive an opioid prescription,” Goertz said by email.

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