Tag: 2020 News

The Centers for Medicare & Medicaid Services announced the proposed calendar year 2021 updates for the Medicare Physician Fee Schedule. The Official Medical Fee Schedule for the California worker’s compensation system correlates with Medicare fees. Hence the announced changes will have implications in the workers’ compensation industry.

The press release began by highlighting changes the Trump administration was making to expand permanently the telehealth benefits that Medicare beneficiaries have begun receiving during the COVID-19 pandemic, and then discussed changes it was making to the fee schedule — specifically to the paperwork requirements for evaluation and management (E/M) codes that doctors use to bill for office visits.

“The Trump administration has taken steps to eliminate burdensome billing and coding requirements for Evaluation and Management visits that make up 20% of the spending under the Physician Fee Schedule,” the release noted. “These billing and documentation requirements for E/M codes were established 20 years ago and have been subject to longstanding criticism from clinicians that they do not reflect current care practices and needs.”

“After extensive stakeholder collaboration with the American Medical Association and others, simplified coding and billing requirements for E/M visits will go into effect January 1, 2021, saving clinicians 2.3 million hours per year in burden reduction,” CMS said. “As a result of this change, clinicians will be able to make better use of their time and restore the doctor-patient relationship by spending less time on documenting visits and more time on treating their patients.”

The proposed rule lists (on p. 897) the estimated impacts of the rule’s payment changes for each specialty, which included losers as well as winners.

Three specialties fare the best: endocrinology, with a 17% increase; rheumatology, with a 16% increase; and hematology/oncology, with a 14% increase. At the bottom are nurse anesthetists and radiologists, both with an 11% decrease; chiropractors, with a 10% decrease; and interventional radiology, pathology, physical and occupational therapy, and cardiac surgery, all with a 9% decrease.

Surgical specialties in general took some of the biggest hits, with cuts in every category ranging from 5% to 9%.

The proposed rule also lists the fee schedule’s final conversion factor — the amount that Medicare’s relative value units (RVUs) are multiplied by to arrive at a reimbursement for a particular service or procedure under Medicare’s fee-for-service system. Due to budget neutrality changes required by law, the proposed 2021 conversion factor is $32.26, a decrease of $3.83 from the 2020 conversion factor of $36.09, CMS said.

And not everyone is happy with these changes. “Under the proposal, neurosurgeons face overall payment cuts of at least 7% at a time when the nation’s healthcare system is already stressed by the COVID-19 pandemic,” said a joint statement from the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS). “The reductions are primarily driven by new Medicare payment policies for office and outpatient visits that CMS will implement on January 1, 2021. Drastic cuts caused by changes to these visit codes … will undermine patient access to neurosurgical care.”

The California Department of Insurance announced a settlement agreement with AbbVie Inc. to resolve a lawsuit alleging violations of the California Insurance Frauds Prevention Act involving the marketing of blockbuster prescription drug HUMIRA.

AbbVie agreed to reform its HUMIRA marketing practices in California, including disclosing that registered nurses employed as “Ambassadors” to interact with patients about HUMIRA are actually paid by the company, not a medical provider, and reforming how HUMIRA is marketed to health care providers.

In addition, as provided for in the Act, AbbVie has also paid a combined $24 million to the State of California and the whistleblower who brought the case to the Department’s attention.

In October 2016, the Department began an investigation into AbbVie after recieving a whistleblower case filed by a registered nurse who was employed as an AbbVie Ambassador in Florida.

After its investigation, the Department intervened in that case and filed a Superseding Complaint alleging that whistleblower violated California’s Insurance Frauds Prevention Act. Among other things, the Department alleged that AbbVie violated the Act by unlawfully providing free and valuable professional goods and services to physicians to induce and reward AbbVie prescriptions.

The Department alleged that Nurse Ambassadors interfered with the flow of doctor-patient communications and did not directly answer questions pertaining to AbbVie marketing activities constituted kickbacks in violation of the Act, including, for example, the provision of meals and drinks to providers outside the context of speakers programs.

While AbbVie continues to deny the allegations, as a part of the settlement, AbbVie agreed to reforms, including:

— Ambassadors will disclose to patients that they are provided by AbbVie and do not work under the direction of the patient’s health care provider.
— The company will implement a policy modification prohibiting HUMIRA sales representatives from inviting HUMIRA prescribing health care providers to offsite business meals, except as part of the AbbVie speaker programs.
— AbbVie will provide patients with the U.S. FDA-approved HUMIRA medication guide and Ambassadors will direct patients to the medication guide and their health care provider regarding side effects and safety risk.
— The company will provide guidance and training that Ambassadors shall not have patient-specific discussions with providers who prescribe AbbVie.
— AbbVie employees will be prohibited from describing Ambassadors to health care providers as “extensions of their offices” and from providing to providers any contact information for Ambassadors who interact with HUMIRA patients.
— AbbVie employees and Ambassadors will not actively participate in conversations between patients and insurance companies.

The complete list of AbbVie’s business practice reforms can be found in the settlement.

Law enforcement authorities arrested four defendants charged in two federal grand jury indictments alleging a narcotics trafficking ring that sold illegal opioid prescriptions for cash through a series of sham medical clinics.

Those charged in the indictments include Dr. John Michael Korzelius, 68, a.k.a. “Dr. K,” of Camarillo, who worked at a Santa Ana pain management clinic where he allegedly wrote medically unnecessary prescriptions to “patients” who paid cash. Over the course of two years, Korzelius and other medical professionals working under his guidance, prescribed approximately 439,090 pills of 30mg oxycodone – the highest dose of short-acting oxycodone available, and the dose most popular for the drug-abusing population, according to court documents.

The charges in this matter are the result of an investigation by agents with the DEA and IRS Criminal Investigation into ChiroMed, which operated a group of chiropractic, medical and wellness clinics in Los Angeles, Orange and San Bernardino counties. Korzelius, along with other medical professionals, including physician’s assistants, allegedly met with fraudulent patients and provided them with unnecessary prescriptions for drugs, including oxycodone.

ChiroMed operated clinics across Southern California, including Santa Ana, Fontana, Westwood, Long Beach, Huntington Park, Wilmington, Redondo Beach, and Inglewood.

The two grand jury indictments charge 10 defendants with a variety of narcotics-related offenses, including conspiracy to distribute controlled substances, possession with intent to distribute oxycodone, distribution of fentanyl, and money laundering.

Along with Korzelius, the indictments charge:

— Justin Douglas Cozart, 42, of Woodland Hills, who operated and supervised the ChiroMed medical clinics;
— Damoon Joe Navarchi, 33, of Woodland Hills, who assisted Cozart in operating the clinics;
— Xavier Muduki Mabale, 42, of Anaheim, who is accused of recruiting sham patients to obtain fraudulent oxycodone prescriptions from the medical clinics;
— Mayra Barrios, 37, of Yorba Linda, who allegedly oversaw the day-to-day management of the medical clinics, including the issuance of fraudulent oxycodone prescriptions to sham patients;
— Harrison Maruje Mureithi, 42, of Norco, who allegedly coordinated the purchase, collection, packaging, and shipment of oxycodone to buyers on the East Coast;
— Duncan Muthoni Wanjohi, 23, of Anaheim, who allegedly assisted Mureithi in the buying and shipping of narcotics;
— Pierre Delva, Jr., 33, a.k.a. “ig Head,” of Medford, Massachusetts, who allegedly provided financing to Mureithi to purchase bulk quantities of oxycodone; and
— Louise W. Mureithi, 69, of Anaheim, Harrison Mureithi’s mother, who allegedly received packages of cash sent to her son for oxycodone;
— Majid Nojavan, 42, of Laguna Niguel, charged in a spinoff case from the primary investigation, who allegedly advertised oxycodone for sale on Craigslist, sold fentanyl to an undercover police officer, and escorted the undercover police office to an Inglewood medical clinic to obtain a fraudulent oxycodone prescription.

As a result of a two-year investigation into the fraudulent medical clinics, DEA agents seized 20,737 oxycodone pills, and $177,610 in cash. Law enforcement intercepted a mailed parcel contained a teddy bear stuffed with two bags of oxycodone pills.

If convicted of the charges, the defendants each would face a statutory maximum sentences of at least 20 years in federal prison.

The CWCI COVID-19 tracking tool (see story below) reports a stunning 14,470 California workers’ compensation claims filed so far this year. Some estimates show that the State will have twice that number in a few short months.

The Floyd Skeren Manukian Langevin, LLP – workers’ compensation and employment law firm – was asked about how the firm is responding to the pandemic and these claims from the employer’s point of view.

Partner Amanda Manukian pointed out the importance of her firm remaining fully operational during the pandemic shutdown. A few months ago, officials arrived at the office building in Pasadena where her branch office is located, and ordered the entire building to be closed within two hours.

Fortunately, she reported that as one of the tenants of the building, she easily complied with this time constraint, and her office was fully functional at home by the next day. Prior to the pandemic Floyd Skeren had installed advanced case management technology across all offices statewide. The technology, along with gigabit fiber internet connections between offices supported a seamless transition for the entire firm to stay-at-home work when required.

All of the firm’s staff and attorneys have been fully functional and productive, with essentially no disruption of work flow.

Bernadette O’brien, the firms employment law partner, has held webinars for the firms employment law clients every few weeks. She says that new COVID-19 regulations, both state and federal, are rapidly evolving day by day in response to pandemic. The webinar is updated regularly. and virtually provided for several hundred employers who attend this program for up-to-the-minute compliance guidance.

John Floyd, the firms founding partner, has organized a COVID-19 workers’ compensation defense team within his firm. All COVID-19 claims will be handled only by members of this team.

Mr. Floyd has several physicians doing forensic research for his team, identifying and obtaining the medical studies published every few days about the disease. The studies are reviewed, cataloged and circulated to his team.

This science is evolving, and will be used as a standard to review the medical evidence in these claims. The catalog of studies include many topics, such as the effectiveness of various protective gear, the incubation window between symptoms and infection to help identify the best time frame for the infection to have occurred, and other risk factors other than work for purposes of apportionment.

The COVID team has also done considerable legal research on the validity of Governor Newsom’s Executive Order N-62-20 which created a temporary presumption of industrial causation for some of the workers’ who file COVID-19 claims. The team is now filing briefs in COVID claims across the state, requesting a finding that N-62-20 is unlawful, and invalid as it exceeds the Governor’s authority under the California Emergency Services Act.

The brief then argues in the alternative, that if N-620-20 is found to be a valid exercise of emergency authority, then the costs of the presumption claims should be paid by the State of California, as it would constitute a “taking” for which the California Emergency Services Act requires compensation to be paid by the State to the employer for these claims.

Mr. Floyd concluded by saying that if anyone is interested in more details about how the COVID-19 defense team is responding to these claims, they may contact him by phone or email.

Even with proper PPE (personal protective equipment), frontline healthcare workers battling the coronavirus day in and day out are still at a three times higher risk of testing positive for COVID-19 in comparison to the general population. That’s the main conclusion drawn from a recent study conducted at King’s College London and Harvard University, and then published in Lancet Public Health..

Predictably, healthcare workers treating patients without adequate PPE are at a greater risk of coronavirus infection. Not as predictable, however, was the finding that BAME (Black, Asian, and minority ethnic) healthcare workers are at even greater risk of contracting the coronavirus while wearing proper PPE than their white counterparts.

According to researchers’ calculations, BAME frontline workers are at least five times more likely to test coronavirus positive than the non-Hispanic, white general population.

“The findings of our study have tremendous impact for healthcare workers and hospitals. The data is clear in revealing that there is still an elevated risk of SARS-CoV-2 infection despite availability of PPE,” explains senior study author Sebastien Ourselin, a professor at King’s College London, in a release. “In particular we note that that the BAME community experience elevated risk of infection and in some cases lack access to adequate PPE, or frequently reuse equipment.”

The research team analyzed a huge dataset of both American and British adults (2,035,395 individuals in general and 99,795 frontline healthcare workers). For every 100,000 healthcare workers, 2,747 tested positive for coronavirus. Meanwhile, for every 100,000 members of a general community, only 242 tests came back as COVID-19 positive.

Also, while just over 20% of healthcare workers reported feeling at least one coronavirus symptom (fatigue, loss of smell, loss of taste, etc), only 14.4% of the general population said the same.

This study indicates that PPE, while certainly important, is only a portion of the answer when it comes to protecting doctors and nurses. Besides just making sure healthcare workers have proper access to PPE, the authors say it may be time to start considering additional protection strategies.

Also, equally as important as providing PPE is making sure it is used correctly and properly cleaned before reuse. It’s probably a good idea for frontline workers to avoid reuse of PPE altogether, researchers say.

“The work is important in the context of the widely reported higher death rates amongst healthcare workers from BAME backgrounds. Hopefully a better understanding of the factors contributing to these disparities will inform efforts to better protect workers,” says joint first study author Dr. Mark Graham.