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Tag: 2020 News

EDD Remains Easy Fraud Target – Even From Prisoners

Hundreds of thousands of dollars have been fraudulently taken in two separate schemes that targeted California Employment Development Department unemployment insurance benefits that were intended for Californians hit hardest by the ongoing COVID-19 pandemic shutdown.

A federal grand jury in Fresno returned an indictment involving a prison-based scheme out of the Central California Women’s Facility (CCWF) in Chowchilla.

Inmate Sholanda Thomas, 36, and parolee Christina Smith, 37, were indicted for conspiracy to commit mail fraud and aggravated identity theft charges for the submission of several fraudulent EDD unemployment insurance claims in Thomas’ and other CCWF inmates’ names.

Recorded jail calls and emails show that Thomas and others engaged in “bundling,” that is, they obtained the names, dates of birth, and social security numbers for inmates at CCWF and relayed that information to Smith to submit the fraudulent claims. The claims were submitted shortly thereafter, and the benefits were loaded onto debit cards that were mailed to the addresses provided.

The underlying applications for the claims falsely stated that the inmates had worked within the prescribed period as hairstylists, barbers, and other occupations, and that they were available to work, which was not true because they were incarcerated. The claims would have been denied if accurate answers had been given. EDD and the United States have suffered a loss of over $200,000 as a result of the fraud.

Thomas and Smith used the proceeds for their own benefit, which included Smith keeping Thomas’ share in a shoebox pending Thomas’ release from prison, and Smith getting plastic surgery.

In the second scheme, Andrea M. Gervais, 43, of Roseville – a former Employment Development Department employee – allegedly participated in a mail fraud scheme involving approximately 100 fraudulent Pandemic Unemployment Assistance (PUA) claims in the names of persons other than Gervais.

According to the criminal complaint, at least 12 of the 100 claims were processed for payment, and over $200,000 in PUA benefits were paid out to Gervais’s Roseville address in the form of Bank of America debit cards. The total value of all fraudulent PUA claims from her residence was at least $2 million.

The investigation began when investigators discovered a PUA claim using the identity of a sitting United States Senator for approximately $21,000. This fraudulent claim was processed for payment, and Gervais received a PUA debit card in the United States Senator’s name. Investigators further discovered that Bank of America ATM cameras captured Gervais on multiple occasions withdrawing cash from at least seven of the PUA debit cards, and at least one captured transaction showed Gervais using the debit card issued to the United States Senator.

If convicted, Thomas and Smith face a maximum statutory penalty of 20 years in prison for conspiracy to commit mail fraud, and a mandatory and additional two-year prison sentence if convicted of aggravated identity theft. If convicted,

Gervais faces a maximum statutory penalty of 20 years in prison for mail fraud.

Sacramento Cleaning Company Owner Faces Premium Fraud

Jorge Gerardo Maldonado, 55, of Sacramento, was charged with three felony counts of insurance fraud after allegedly underreporting payroll and employees to illegally save on workers’ compensation insurance premiums, resulting in a $687,560 loss to three insurance carriers.

After one of the victim insurance companies suspected Maldonado of fraud, the California Department of Insurance launched an investigation into his Sacramento cleaning company Pro-Care Building Maintenance (Pro-Care). It found that Maldonado underreported payroll and committed premium fraud. Maldonado has owned Pro-Care since 2014.

On July 10, 2016, a Pro-Care employee was injured while on the job and a workers’ compensation insurance claim was filed with one of the company’s insurance carriers. During a review of the claim, it was found that Pro-Care underreported payroll and failed to report the end of policy payroll to the insurance company as the policy required.

The Department’s investigation further discovered that Maldonado failed to report payroll and employees of Pro-Care to three insurance carriers from 2017 through 2019. The alleged unreported payroll was over $5 million.

Maldonado self-surrendered to the Sacramento County Jail on Wednesday, December 23, 2020.

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

Injured Worker $575K Discrimination Jury Verdict Affirmed

In 2008, Charter Communications hired Anthony Lave as a “broadband tech.” Approximately two years after he was hired, Lave injured his back while working. He filed a workers’ compensation claim and, although he continued to work, Lave ultimately received a permanent disability rating of 30 percent.

Years later, in 2014, Lave asked for time off, claiming he needed to take his wife to a medical appointment. Lave’s supervisor failed to respond for over a week. Frustrated with the lack of a response, Lave complained to a human resources employee but eventually abandoned his request for time off. This occurred again a few days later.

Lave claimed that his relationship with his supervisor worsened after Lave bypassed him and went to human resources regarding his leave requests. Lave testified that his supervisor would stare him down, and disciplined him for minor infractions, and continued to delay his responses to Lave’s leave requests.

Later, Lave’s preexisting back injury flared up in early 2015, leading him to take one day of sick leave. When he returned, the same supervisor issue a “milestone” to Lave for taking a sick day off. A “milestone” was the documentation Charter used to memorialize employee discipline. Lave complained to another human resources employee and then, days later, filed a formal complaint against his supervisor. The local human resources department would “handle the situation.”

Lave then reopened his workers’ compensation claim, and required time off by Charter’s own physician. He returned to work, but was suspended in less than a month because of a customer complaint. Lave filed another complaint with human resources, claiming his suspension was in retaliation for taking time off work. Lave never received a response to his complaint and was later terminated from employment.

Lave filed this lawsuit against Charter, alleging he was retaliated against based on his disability related to his back injury; for taking time off to accompany his wife to her medical appointment; for taking sick leave; for taking medical leave; and for filing complaints arising from his disability accommodation and leave requests.

A jury awarded him $575,000. And a post judgment awarded $400,800 in attorney fees, rather than the requested amount of $1,064,062.70. The judgment was affirmed in the unpublished case of Lave v Charter Communications.

The court of appeal found that the trial court correctly excluded evidence that Charter did not produce during discovery.

With regard to the remaining issues over the jury verdict, the court found that “Charter fails to undermine the jury’s ultimate finding in Lave’s favor and award of damages.

Cal/OSHA Targets Meatpacking and Food Processing Employers

Cal/OSHA has cited eight more employers for not protecting workers from COVID-19 during inspections at meat processing facilities across the state.

The inspections were opened upon learning of a COVID-19 fatality and several illnesses, and after receiving complaints. The employers cited failed to take required steps to prevent COVID-19 infection in the workplace such as safe physical distancing procedures or proper face covering usage for workers in production areas.

Enforcement of COVID-19 protections at meatpacking and food processing facilities has been a priority of Cal/OSHA given the high rates of positive cases and alarming number of deaths among food processing workers,” said Cal/OSHA Chief Doug Parker. “These citations represent a portion of our enforcement efforts in these industries. More citations will be issued when violations are identified and inspections are closed.”

On November 12, Cal/OSHA cited Smithfield Foods, Inc. in Vernon $58,100 in proposed penalties for multiple COVID-19 related violations, including two serious in nature, and its staffing firm CitiStaff Solutions was also cited $46,695 for two serious violations. Both employers failed to ensure that workers used face coverings properly in production areas and during breaks, and failed to provide effective training and instruction on how the virus is spread and how to disinfect areas properly. The investigators determined that Smithfield Foods, Inc. failed to adequately address at least 300 COVID-19 illnesses (including three that required hospitalization) amongst its employees and contracted workers hired by CitiStaff Solutions. Smithfield Foods, Inc. further failed to report serious COVID-19 illnesses to Cal/OSHA.

Central Valley Meat Co. was cited for not informing employees of possible exposure when coworkers were infected with COVID-19 and for failing to provide face coverings and ensure their proper use. Cal/OSHA opened a complaint-initiated inspection at the facility in Hanford on April 29 and identified violations in the employer’s training procedures and response to COVID-19 hazards. Citations were issued on December 11 with $50,000 in proposed penalties for two violations classified as serious.

In June, Cal/OSHA became aware that several One World Beef Packer employees were hospitalized for complications related to COVID-19, including one employee who died. When Cal/OSHA inspected the Brawley facility, investigators noted that workers in the production lines and quality assurance area were not provided protective barriers and were working too close to each other. Furthermore, the employer failed to report the serious illnesses and fatality within the eight-hour time limit as required by law. Cal/OSHA cited One World Beef Packer $23,000 on December 11 for one serious violation and a regulatory violation for failing to report the serious illnesses.

After reports of outbreaks, Cal/OSHA opened inspections at meat processing plants in Vernon last June and July as part of a targeted enforcement effort. An onsite inspection at California Farms Meat Company confirmed the employer did not implement physical distancing procedures or install barriers in the production area, where workers separated chicken by hand and operated machines within close distance of each other. Cal/OSHA cited the employer $11,700 in proposed penalties on December 14 for the serious violation.

In July, Cal/OSHA opened inspections with CLW Foods and its staffing firms California Enterprises Employment and HR Staffing Solutions in Vernon. The employers were cited on December 14 for multiple violations, including some categorized as serious for failing to address COVID-19 hazards by training employees and ensuring proper physical distancing procedures on conveyor lines, in the production area and when employees took breaks. CLW Foods and California Enterprise Employment were also cited for failing to report serious COVID-19 illnesses to Cal/OSHA.

2021 Mileage Reimbursement Rate Declines to 56 Cents

The Internal Revenue Service just announced that the standard mileage rate for business miles will decrease to 56.0 cents per mile as of January 1, 2021, down 1.5 cents from the rate of 57.5 cents per mile for 2020.

As a result, the California Workers’ Compensation Institute reports that effective for travel on or after January 1, 2021, the rate that California workers’ compensation claims administrators pay injured workers for travel related to medical care or evaluation of their injuries will also decrease to 56.0 cents per mile.

The new workers’ compensation medical mileage rate will apply for 2021 travel dates, regardless of the date of injury on the claim, but for 2020 travel dates claims administrators should continue to pay 57.5 cents per mile.

California Labor Code §4600 (e)(2), working in conjunction with Government Code §19820 and Department of Personnel Administration (DPA) regulations, requires claims administrators to reimburse injured workers for such expenses at the rate adopted by the Director of the DPA for non-represented (excluded) state employees, which is tied to the IRS published mileage rate.

In its December 22 news release the IRS announced that as of January 1, 2021, the standard mileage rate will drop to 56.0 cents per business mile driven.

The IRS bases the standard mileage rate on an annual study of the fixed and variable costs of operating an automobile, which includes the cost of gasoline and depreciation.

There have been multiple mileage rate changes over the past decade, so the California Division of Workers’ Compensation has posted downloadable mileage-expense forms on the forms section of its website (DWC Forms (ca.gov) which show applicable rates based on travel date.

A new form with the 2021 rate will be posted shortly, but should not be used until reimbursements are made for 2021 travel.

Given the upcoming holidays, however, claims organizations should alert their staff and programmers as soon as possible that the medical mileage rate will decrease to 56.0 cents per mile for travel on or after January 1, 2021.

Virtual 28th Annual DWC Educational Conference Date Set

The California Division of Workers’ Compensation announced dates for its 28th annual educational conference. The conference will take place on a virtual platform from March 24-26, 2021.

Sessions will also be available to view on demand through April 9, 2021.

The largest workers’ compensation educational event in the state is usually held in March in both Northern and Southern California, although it will be online-only during the COVID-19 pandemic.

Speakers from the Division of Workers’ Compensation and the private sector will address the most current topics and issues confronting claims administrators, medical providers, attorneys, rehabilitation counselors and others involved in workers’ compensation.

The program will include valuable information for anyone with a professional interest in California workers’ compensation, a virtual exhibit hall featuring service providers, and sponsorship opportunities.

Continuing education credits will be offered for California adjusters and attorneys, HR professionals and rehabilitation providers, as well as DWC QME credits.

Additional information regarding the agenda, registration fees and instructions will be sent by email in late January 2021.

Questions or Concerns? Please contact the DWC at DWCEvents@dir.ca.gov.

Gig Companies Launch “Prop 22” Type Initiatives in Key States

In November, gig companies including Uber, Lyft, DoorDash, and Instacart helped pass California’s Proposition 22, effectively writing their own labor law. Now the companies plan to bring similar legislation elsewhere.

Last month, the companies launched a group called the App-Based Work Alliance to support their agenda. Industry-supported bills in the works in New York state and Illinois would, like the California ballot measure, deny gig workers status as employees, and the workers’ compensation, paid family leave, sick pay, unemployment insurance, and minimum wage guarantees that come with it.

But the bills could give gig workers the right to form something resembling a union, allowing workers to bargain with multiple employers to create wage floors and standards. US workers in trucking, auto manufacturing, and grocery stores have participated in types of industry-wide bargaining, though the arrangement is more common in Europe.

The California Proposition 22, was written by gig companies, who then poured $205 million into supporting it, the most expensive campaign in the state’s history. Proposition 22 is near-irreversible – the law needs a “supermajority” of seven-eighths of the state’s legislature to be changed.

At the same time, gig companies invested in bringing the Proposition 22 fight elsewhere. Lyft stood up a political action committee called Illinoisans for Independent Work that spent at least $660,000 on ad buys and political contributions in local elections. In August, Uber released a white paper laying out its plans for “Independent Contractor+,” a new employment category it hopes to promote across the country.

Now New York, a less-than-traditional gig market in many ways, is set to be among the first states where a post-Proposition 22 battle might play out.

A constellation of gig companies and allies introduced the New York Coalition for Independent Work, which describes its mission as “protecting self-employed, app-based contractors’ independence and flexibility while also working to provide them with needed benefits.” But the state’s relatively labor-friendly climate means that gig companies will have to tread carefully – and that a pitched battle is likely ahead.

In statements, spokespeople for Uber, Instacart, and DoorDash said the companies would work with legislators to protect flexible work schedules for their gig workers, something they have said would be impossible if they were forced to treat the workers as employees.

DoorDash vice president of communications and policy Liz Jarvis-Shean said the company wants to work with state and federal lawmakers “to help create a new portable, proportional, and flexible framework that embraces today’s modern workforce.” Uber spokesperson Matthew Wing said the company supports state laws to require “all gig economy companies – including ours – to provide new benefits and protections to all independent workers.”

Back in California, drivers say plenty of organizing can happen without official bargaining rights or recognition from the gig companies. Moore, the Rideshare Drivers United organizer, says her organization is now focused on recouping unemployment insurance for drivers for the months before Proposition 22 went into effect, when, she says, drivers legally should have been treated as employees. “We’re not going away,” she says.

Duration of COVID Vaccine Immunity Remains Speculatory

Pharmaceutical companies are holding out hope that the mRNA technology used to develop breakthrough Covid-19 vaccines is flexible enough to provide for seasonal shots in case immunity gained from initial vaccination is short-lived.

The first Covid-19 vaccine approved for use in the U.S., Pfizer and BioNTech’s shot was purportedly 95% effective in preventing symptomatic coronavirus infections in a large study group. Positive study results have also been released for Moderna’s vaccine, which secured an emergency use authorization by the Food and Drug Administration on Dec. 18.

The jury is still out on how long the immunity induced by these rapidly developed mRNA vaccines will last.

Despite the encouraging clinical trial results, Pfizer is being cautious about speculating on the durability of immune response elicited by mRNA vaccines.

We don’t know how the virus will change, and we also don’t know how durable the protective effect of any vaccination will be,” the company said in a statement.

Pfizer said that if it turns out that the induced immunity lasts only a few months, mRNA vaccines are suitable for repeated administration as booster shots.

If a mutation in the Covid-19 virus affects Pfizer’s vaccine effectiveness, the company said, mRNA technology will enable “rapid development” of adjustments. The technology also allows for a fast production process without the need for complex mammalian cell systems used in traditional vaccine production, the company said.

Multiple other Covid-19 vaccine candidates using a variety of technologies are under development by other large pharmaceutical companies. Viral-vector vaccines, one from Johnson & Johnson, and another from a partnership between AstraZeneca and Oxford University, are in late-stage clinical trials.

Dr. Marc Hellerstein, a biochemistry lab head at the University of California, Berkeley, said researchers will be focused next year on determining which vaccine produces the longest-lived immune response against Covid-19. Of particular importance is the immune response of T cells including CD8+ cells, immune system agents that kill off virus-infected cells in the body, Hellerstein explained.    

Surgeon Facing $29M Fraud Released After Positive COVID Test

Randy Rosen M.D., an Orange County surgeon and jail inmate accused in a $29 million insurance fraud scheme who is facing decades behind bars, was temporarily set free ahead of the weekend after testing positive for coronavirus to the criticism of local officials.

Rosen, who was involved in a civil federal lawsuit involving a health care fraud scheme at a Long Beach hospital that was settled in 2017, was was indicted in this new case along with co-defendant Liza Vismanos

Vismanos owns the Wellness Wave surgical center in Beverly Hills and the Lotus Labs medical laboratory in Los Alamitos. Rosen/Vismanos entered into a fraud scheme specifically targeting patients from addiction recovery rehabs to bill their private medical insurance carriers primarily for two types of procedures; a non-FDA approved Naltrexone implant and Cortisone injections.

Rosen and Visamanos were first arrested back on June 30 on a combined 144 counts including money laundering, submitting fraudulent insurance claims and withholding material facts on insurance claims.

CBS Los Angeles reports that District Attorney Todd Spitzer called the release of 57-year-old Rosen – who is being monitored by an electronic bracelet – unfair.

Rosen’s attorney argued before a judge that Rosen “is at substantial risk of poor outcome (of the coronavirus) because of his multiple co-morbidities for his current COVID-19 infection which requires medical follow-up.”

Rosen faces a maximum sentence of 84 years in state prison if convicted as charged, while Visamanos faces 36 years.

After Rosen’s positive COVID-19 test, he has been released, and now Spitzer is calling him a flight risk and questioned whether he would leave the country.

“If I knew I had an out for 30 days and money available and the means to get the heck of out this country, quite frankly I think I’d probably take the opportunity,” Spitzer said. “Whether we see him back again is the big question.”

Feds Approve “Surprise Medical Bill” Ban

Congress is poised to include a ban on “surprise” medical bills as part of its massive year-end spending package that lawmakers are expected to vote on Monday.

In a joint statement Sunday night, House Speaker Nancy Pelosi and Senate Minority Leader Chuck Schumer confirmed that “bipartisan, bicameral legislation that will end surprise billing for emergency and scheduled care” will be part of $1.4 trillion spending bill, which also includes an additional $900 billion in coronavirus relief money.

The long sought-after legislation will protect insured patients from receiving expensive medical bills when they inadvertently receive out-of-network care. Americans of all stripes support the effort: A survey published Friday by the Kaiser Family Foundation found that 80% of adults support abolishing the practice.

Although lawmakers in both parties had been pushing for a plan to fix the issue for years — with the support President Trump, who had made it a key campaign priority — the effort drew fierce opposition from powerful lobbying groups representing the health care industry, who questioned how much the insurer would have to pay the doctor once the patient was removed from the equation.

A previously announced deal called for health insurers and providers to negotiate most billing disputes or bring their complaints to a mediator. The final legislation moves even further in favor of doctors and hospitals by preventing the arbiter from using the lower payment rates paid by Medicaid and Medicare programs, according to Politico, which obtained a copy of the bill summary.

Lawmakers also diluted a measure that would have required health insurers to disclose information to employers about their drug costs and rebates through their contracts with middlemen known as pharmacy benefit managers. The legislation now calls for insurers to submit more general information on medical costs and prescription drug spending, according to Politico.

Rep. Richard Neal, chairman of the House Ways and Means Committee, called the proposal a “win for patients and their families that will improve America’s health care system.”

An earlier clash between Neal, who had previously blocked proposals to stop surprise medical billing, and three other committees – House Energy and Commerce, House Education and Labor and Senate Health, Education, Labor and Pensions – threatened to derail the reform efforts. After securing changes that were friendlier to doctors and hospitals, however, Neal agreed to support the proposal.

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