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Tag: 2021 News

Convicted Claimant Pleads Guilty to 2nd $1.6M EDD Fraud

A former California Employment Development Department employee has agreed to plead guilty to a federal criminal charge for causing nearly 200 fraudulent COVID-related unemployment relief claims to be filed in other people’s names, resulting in more than $1.6 million in ill-gotten gains.

Gabriela Llerenas, a.k.a. “Maria G. Sandoval,” 49, of Perris, signed a plea agreement in which she has agreed to plead guilty to a single-count information charging her with mail fraud.

Court records show that Llerenas previously worked at EDD as a disability insurance program representative. She resigned in March 2002 after admitting to fraudulently authorizing and paying disability benefits administered by EDD. She was sentenced to 37 months in federal prison in connection with that scheme.

The new scheme that Llerenas has admitted running took advantage of the expanded eligibility for unemployment insurance benefits made possible by the Coronavirus Aid, Relief, and Economic Security (CARES) Act passed by Congress and signed into law in March 2020.

From April to October 2020, Llerenas filed and caused the filing with EDD that falsely asserted the named claimants were self-employed independent contractors – often identifying them as cake decorators or event attendants – who were negatively affected by the COVID-19 pandemic. Llerenas obtained some of the names, Social Security numbers and other identifying information she used to submit the fraudulent claims through her prior work as a tax preparer.

In her plea agreement, Llerenas also admitted to falsely stating on some of the applications that the claimants were residents of California entitled to unemployment insurance benefits administered by EDD when in fact they lived elsewhere. She also admitted that, on some applications, she inflated the amounts of income she reported for the claimant to maximize the benefit amount. She also admitted to sometimes filing a dozen or more fraudulent EDD claims in a day.

As a result of the fraudulent unemployment benefits applications that Llerenas filed and caused to be filed, EDD authorized Bank of America to mail debit cards in the names of the claimants to addresses she provided, including her residence, her husband’s business location, her mother’s apartment and the addresses of friends and other family members.

Llerenas admitted that she charged the named claimants a fee for filling the applications, which was often paid out of the fraudulently obtained benefits. In at least one case, she told the named claimant that she was still employed at EDD and could control the distribution of the unemployment insurance benefits, and then demanded an additional payment for “releasing” the benefits.

In total, 197 debit cards were fraudulently issued because of this scheme, resulting in losses to EDD and the United States Treasury that Llerenas has admitted were at least $1,633,487.

Llerenas is scheduled to make her initial appearance on September 22. The criminal offense to which Llerenas has agreed to plead guilty carries a statutory maximum sentence of 20 years in federal prison.

WCIRB Multiple Enterprises Rule Changes Effective 9/1/21

Most businesses in California are Single Enterprises, which means that all the normal and usual operations for the business are assigned to a single classification.

However, some businesses have two or more operations that cannot be easily described by a single classification. For these employers, the Multiple Enterprises rule provides direction in determining whether one or more classifications can be assigned.

Effective September 1, 2021, the Multiple Enterprises rule was amended to clarify the rule and definitions applicable to operations that constitute Multiple Enterprises to promote consistent and accurate data reporting as well as to make the rule simpler and easier to administer.

Under the revised Multiple Enterprises rule, the key to determining whether operations can be separately classified is physical separation of the operations. If the distinct operations of the business are physically separated, each operation can be separately classified; if they are not physically separated, the operations must be assigned to the highest-rated classification applicable to any of these operations conducted in a common workspace.

Visit the Multiple Enterprises page on wcirb.com to view the full text of the new rule.

Watch WCIRB Classification Education and Development Director Brian Gray explain the Multiple Enterprises rule changes in this six-minute video.

2 Inch Leg Shortening is “Amputation” for 240 Week TD Cap

Sampson Parker worked as a bus driver for AC Transit in December 2016 when he injured his his left leg, left ankle, left foot, and right wrist.Following his injury, he underwent multiple surgeries.

The last surgery occurred on October 15, 2019, when he underwent the placement of a revision intramedullary tibial nail placed in a locking fashion along with an open reduction, internal fixation (ORIF) utilizing two plates and screws for fixation along with the implantation of bone morphogenic protein and that the surgery caused a shortening of his left lower leg.

On February 8, 2021, his primary treating physician, Scott Petersen, M.D., issued a report stating that he was maximally medically improved. Dr. Peterson’s physical examination revealed that his left leg was six centimeters shorter than the right. Dr. Petersen described the last surgical procedure as a “limb shortening surgery.”

On May 18, 2021, the matter proceeded to trial on the issues of whether he qualified for the amputation exception to the 104 week cap on temporary total disability indemnity and if so, whether his entitlement to receive temporary disability indemnity would run continuously or whether it would stop after 104 weeks had been paid and resume on the date of the last surgery.

A Findings and Award issued concluding that the surgical removal of bone from Parker’s left lower extremity combined with a shortening of the limb constituted an amputation pursuant to Labor Code section 4565(c)(3)(C), and that he was entitled to receive temporary disability indemnity for the period beginning on December 17, 2018 and continuing through February 7, 2021.

Reconsideration of this finding was denied in the panel case of Parker v AC Transit (ADJ10741808).

The Labor Code provides that for an employee who suffers from the certain injuries or conditions (in this case an amputation), aggregate disability payments for a single injury occurring on or after April 19, 2004, causing temporary disability shall not extend for more than 240 compensable weeks within a period of five years from the date of the injury. Otherwise the limit is 104 weeks.

In Cruz v. Mercedes-Benz of San Francisco, (2007) 72 Cal. Comp. Cases 1281, 1283 (Appeals Board en banc), the Appeals Board defined “amputation” as “the severance or removal of a limb, part of a limb, or other body appendage.

It is undisputed that as a result of a “limb shortening surgery,” Parker lost approximately two inches from his left lower extremity, a protruding external body part. The amputation exception does not require the severance of an entire body part

HHS Announces Plan to Directly Negotiate Drug Prices

A new federal plan has been announced – that is aimed at lowering prescription drug prices – endorses giving the government sweeping power to directly negotiate the cost of medicines, calling it one of the key steps Congress could take to make drugs “more affordable and equitable” for all Americans.

The plan, which was developed by the Department of Health and Human Services and released on Thursday, mirrors a range of legislative options that both House and Senate lawmakers have floated in recent years.

Those include capping out-of-pocket costs in Medicare Part D, limiting how quickly pharmaceutical companies can hike prices on existing drugs and banning so-called pay-for-delay agreements aimed at blocking generic competition to brand-name drugs.

Under the HHS plan, the government would directly negotiate prices for drugs in Medicare parts B and D, with those prices also being available to private insurance plans and any employers who want to participate.

House Democrats passed a similar provision as part of a major drug pricing bill in 2019. But it never made it into law, and some in the party’s centrist wing have since vowed to oppose drug price negotiation.

The HHS plan also lays out a series of administration actions that the department could take to fulfill what it identified as three “guiding principles,” making drugs more affordable, improving competition within the industry and encouraging innovation.

Those options included testing value-based payment models and boosting cost-sharing support to certain low-income Medicare beneficiaries. It also suggests that improved data collection from insurers and pharmacy benefit managers could give the government better insight into drug pricing, as well as rebates and out-of-pocket spending on prescription medications.

HHS developed the report in response to an executive order that President Joe Biden issued earlier this year aimed at improving competition across a range of industries, including the drug sector. Executive Order 14036, “Promoting Competition in the American Economy” identifies a lack of competition as a key driver for problems across economic sectors.

The report states that “Americans spend more than $1,500 per person on prescription drugs and pay prices that are far higher than any comparable nation. Prices for brand name drugs are rising faster than inflation.”

NFL Players Plead Guilty to Nationwide Healthcare Fraud Scheme

Three former National Football League players have pleaded guilty for their roles in a nationwide scheme to defraud a health care benefit program for retired NFL players. A total of 15 defendants have pleaded guilty in connection with this scheme.

Clinton Portis, 40, of Fort Mill, South Carolina, and Tamarick Vanover, 47, of Tallahassee, Florida, pleaded guilty on Friday, Sept. 3. Robert McCune, 40, of Riverdale, Georgia, pleaded guilty on Aug. 24. The former players admitted to participating in a scheme to defraud the Gene Upshaw NFL Player Health Reimbursement Account Plan. The Plan was established pursuant to the NFL’s 2006 collective bargaining agreement and provided for tax-free reimbursement of out-of-pocket medical care expenses that were not covered by insurance, and that were incurred by former players, their spouses, and their dependents – up to a maximum of $350,000 per player.

According to court documents, Portis caused the submission of false and fraudulent claims to the Plan on his behalf over a two-month period, obtaining $99,264 in benefits for expensive medical equipment that was not actually provided. Vanover recruited three other former NFL players into the fraudulent scheme and assisted them in causing false and fraudulent claims to be submitted to the Plan, obtaining $159,510 for expensive medical equipment that was not actually provided. McCune orchestrated the nationwide fraud, which resulted in approximately $2.9 million in false and fraudulent claims being submitted to the Plan and the Plan paying out approximately $2.5 million on those claims between June 2017 and April 2018.

Portis and Vanover pleaded guilty two days after a trial against them resulted in a hung jury and a mistrial on certain counts against Vanover. McCune, the third defendant in that trial, pleaded guilty to all charges against him on the second day of trial. A retrial on the charges against Portis and Vanover had been scheduled.

Portis and Vanover were originally indicted, along with McCune and seven other defendants, in the Eastern District of Kentucky in December 2019 for their roles in the fraud. Since the initial charges were announced, five additional retired NFL players were charged in the scheme. All 12 of the other defendants charged have pleaded guilty to conspiracy to commit health care fraud: Joseph Horn, Correll Buckhalter, Carlos Rogers, James Butler, Etric Pruitt, Ceandris Brown, John Eubanks, Antwan Odom, Darrell Reid, Anthony Montgomery, Fredrick Bennett, and Donald “Reche” Caldwell, who passed away in June 2020.

Portis and Vanover pleaded guilty to conspiracy to commit health care fraud and agreed to pay full restitution to the Plan. Portis is scheduled to be sentenced on Jan. 6, 2022, and Vanover is scheduled to be sentenced on Jan. 22, 2022. They each face a maximum penalty of 10 years in prison.

McCune pleaded guilty to conspiracy to commit wire fraud and health care fraud, 13 counts of health care fraud, 11 counts of wire fraud, and three counts of aggravated identity theft. McCune is scheduled to be sentenced on Nov. 19. He faces a maximum penalty of 20 years in prison for conspiracy to commit wire fraud and health care fraud, 10 years for each count of health care fraud, 20 years for each count of wire fraud, and two years for each count of aggravated identity theft.

A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

This case was investigated by the FBI and included efforts by various FBI Field Offices and Resident Agencies, including Los Angeles, San Diego, Sacramento, and Newport Beach, California.

WHO Says COVID-19 is “Here to Stay”

WHO officials said on Tuesday that Covid-19 is likely “here to stay with us” as the virus continues to mutate in unvaccinated countries across the world and previous hopes of eradicating it diminish.

According to the report by CNBC,“I think this virus is here to stay with us and it will evolve like influenza pandemic viruses, it will evolve to become one of the other viruses that affects us,” Dr. Mike Ryan, executive director of the World Health Organization’s Health Emergencies Program, said at a press briefing in Geneva Switzerland.

Officials at the global health agency have previously said vaccines do not guarantee the world would eradicate Covid-19 like it has other viruses. Several leading health experts, including White House chief medical advisor Dr. Anthony Fauci and Stephane Bancel, CEO of Covid vaccine maker Moderna, have warned that the world will have to live with Covid forever, much like influenza.

“People have said we’re going to eliminate or eradicate the virus,” Ryan said. “No we’re not, very, very unlikely.”

If the world had taken early steps to stop the spread of the virus, the situation today could have been very different, WHO officials said.

“We had a chance in the beginning of this pandemic,” Maria Van Kerkhove, the WHO’s technical lead on Covid-19, said Tuesday. “This pandemic did not need to be this bad.”

In January, Nature asked more than 100 immunologists, infectious-disease researchers and virologists working on the coronavirus whether it could be eradicated. Almost 90% of respondents think that the coronavirus will become endemic – meaning that it will continue to circulate in pockets of the global population for years to come.

“Eradicating this virus right now from the world is a lot like trying to plan the construction of a stepping-stone pathway to the Moon. It’s unrealistic,” says Michael Osterholm, an epidemiologist at the University of Minnesota in Minneapolis.

But failure to eradicate the virus does not mean that death, illness or social isolation will continue on the scales seen so far. The future will depend heavily on the type of immunity people acquire through infection or vaccination and how the virus evolves.

Influenza and the four human coronaviruses that cause common colds are also endemic: but a combination of annual vaccines and acquired immunity means that societies tolerate the seasonal deaths and illnesses they bring without requiring lockdowns, masks and social distancing.

Pain Doctor Pays $200,000K to Resolve Opiate Overprescribing

San Diego area pain clinic doctor Brenton Wynn, M.D., has paid $200,000 to resolve allegations that he illegally prescribed opioids and other dangerous drugs to his patients. Wynn has an office at 502 Euclid Ave., Suite 200, in National City.  He was a graduate of Howard University College of Medicine in 1998.

The Controlled Substances Act provides that doctors may write prescriptions for opioids only for a legitimate medical purpose while acting in the usual course of their professional practice. The United States alleged that Dr. Wynn wrote opioid prescriptions to patients without a legitimate medical purpose and/or outside the usual course of his professional practice for more than five years.  Dr. Wynn wrote prescriptions for fentanyl, oxycodone, hydromorphone, methadone, oxymorphone, and morphine.

The United States further alleged that Dr. Wynn prescribed at the same time a dangerous combination of opioids and benzodiazepines such as Xanax and Valium.  Of even more concern, Dr. Wynn allegedly prescribed to some patients a combination of at least one opioid, one benzodiazepine and one muscle relaxant such as Soma.  Drug abusers colloquially refer to the opioid, benzodiazepine, and muscle relaxant combination as the “Trinity” or “Holy Trinity” because of its rapid euphoric effects.  These drug combinations are known to significantly increase the risk of addiction, abuse, and overdose.

Based on its investigation, the United States alleged that Dr. Wynn prescribed large quantities of opioids to his patients that reached high daily MME levels, often even exceeding 120 MME.  The United States further alleged that Dr. Wynn sometimes continued to prescribe dangerous opioids even when his patients’ urine drug test results showed that they were not taking the drugs Dr. Wynn prescribed.

The DEA has a pending administrative action against Dr. Wynn (Docket No. 20-10) to revoke his ability to prescribe opioids and other controlled substances.

“While the vast amount of medical professionals prescribe opioids legitimately and are meeting their patients’ standard of care, DEA will vigorously pursue information from the public about the doctors who are not,” said DEA Special Agent in Charge John W. Callery. “DEA will always protect the public from doctors who put their patients in harm’s way.”

Assistant U.S. Attorney Dylan M. Aste of the U.S. Attorney’s Office for the Southern District of California handled this matter along with DEA investigators.

Mu COVID Variant Spreads to 49 States

The Mu coronavirus variant has been recorded in 49 US states, with Florida and California reporting the highest numbers of Mu infections. California has recorded 384 Mu variant cases, with 167 cases contained in Los Angeles County area. Until recently, Alaska had the highest number of Mu cases, with 146 people testing positive for the variant. With its relatively small population, of 730,000 people, Mu made up four per cent of the state’s sample size.

Nebraska is the only state in the United States to have not detected a case of the Mu variant of COVID-19, which may render vaccines less effective.

Since being first identified in Colombia in January, the Mu variant has spread to 41 countries, including the United States. Mu is not an “immediate threat“, said Dr Anthony Fauci, in a news conference. But scientists will be “keeping a very close eye on it”.

“This variant has a constellation of mutations that suggests that it would evade certain antibodies, not only monoclonal antibodies, but vaccine- and convalescent serum-induced antibodies,” he said.

At least one case of the Mu variant has been detected in the District of Columbia and every state in the U.S. aside from Nebraska, according to Outbreak.info, a website that provides open source data on COVID-19 variants.

LA County Public Health issued a statement explaining more work is needed to tell what we are dealing with: “More studies are needed to determine whether Mu variant is more contagious, more deadly or more resistant to vaccine and treatments than other Covid-19 strains,” it said.

Maine, Connecticut and Florida round out the list of states with the highest prevalence of Mu cases. Florida’s had the second-highest number of samples, at 384 of the 60,475 samples that were sequenced being of the Mu variant.

The World Health Organization labeled Mu a variant of interest on August 30 because its characteristics could make it more transmissible or resistant to vaccines. However, the Centers for Disease Control and Prevention (CDC) has yet to make the same classification.

WCIRB Publishes Annual Medical Trends Report

The Workers’ Compensation Insurance Rating Bureau of California has released the 2020 California Workers’ Compensation Aggregate Medical Payment Trends report comparing medical payment information from 2018 to 2020.

This report analyzes medical payment and utilization trends by provider type, service locations and different service types. The report also includes an analysis on utilization and cost of opioid prescriptions and physical medicine services over time and by region.

General Trends in the Medical Payments and Transactions in CY2020

– – Overall medical payments declined significantly, largely driven by a sharp drop in the number of claims during the COVID-19 pandemic.
– – Average medical payment per claim and the number of transactions per claim started to increase despite the continuous declines in prior years, potentially due to a decrease in the number of smaller medical-only claims in 2020.
– – Utilization of telehealth services increased sharply, in particular, during the pandemic

Fastest Growing Physician Services Procedures and Therapeutic Group

– – Physical Medicine and Rehabilitation procedures continued to grow and are the fastest growing physician services.
– – Use of Analgesics Anti-Inflammatory increased more significantly than that of any other therapeutic groups.

Opioid and Physical Medicine Utilization and Costs

– – The share of claims that involve opioid prescriptions continued to decrease. Suburban and rural areas have seen higher shares of claims involving opioid prescriptions, while urban areas generally have lower shares.
– – On the contrary, the share of claims that involve physical medicine services increased steadily. Urban areas had a higher share of claims involving physical medicine services, while more suburban and rural areas had lower shares.

The report is available in the Research section of the WCIRB website.

19 Guilty Pleas in SoCal Substance Abuse Facility $18.5M Fraud Case

The former president and chief executive officer of a Long Beach substance abuse treatment provider was sentenced to 84 months in federal prison for participating in a scheme in which more than $18.5 million in fraudulent claims were submitted to California’s Drug Medi-Cal program for alcohol and drug treatment services for high school and middle school students.

Richard Mark Ciampa, 67, of Commerce, was sentenced and also ordered to pay $17,640,325 in restitution. Ciampa pleaded guilty on January 6 to one count of health care fraud.

Prosecutors have obtained a total of 19 guilty pleas in this case and related cases, including former ARS Program Manager Lori Renee Miller, 60, of Lakewood, multiple former ARS managers and counselors, and Dr. Leland Whitson, 81, of Redondo Beach, the former Medical/Clinical Director of ARS who previously pleaded guilty to making a false statement affecting a health care program.

Gregory Hearns, 65, of Long Beach, the billing supervisor for ARS who compiled the monthly billing and arranged for its submission to Medi-Cal, LaLonnie Egans, 63, of Long Beach, a former manager, and Tina Lynn St. Julian, 57, of Inglewood, a former counselor, are expected to go on trial on January 6. They are charged with multiple counts of health care fraud.

Ciampa founded the non-profit Atlantic Recovery Services (ARS), later called Atlantic Health Services, in 1996 and served as its president and CEO until its closure in April 2013 following a suspension in payments. ARS provided substance use disorder treatment services to students at local high schools and middle schools through Medi-Cal and its Drug Medi-Cal program.

From March 2009 to April 2013, Ciampa participated in a scheme to defraud Medi-Cal in which ARS billed the Drug Medi-Cal program for services to students who did not medically need alcohol or drug treatment. ARS also billed Drug Medi-Cal for group and individual counseling sessions that were not provided or did not meet the requirements for reimbursement as to size, length or setting. ARS employees falsified documents to support the false claims.

In March 2009, Drug Medi-Cal ordered ARS to repay an overpayment assessed to the organization, which caused a significant amount of financial pressure on Ciampa. Ciampa, in turn, passed along this financial pressure to his employees and threatened the employees that they would lose their jobs with ARS or have their hours reduced to part-time if they did not generate significant billings.

Ciampa was aware or willfully blind to the fact that, in response to his threats, ARS employees were generating false and fraudulent claims for submission to Drug Medi-Cal. He also encouraged ARS employees to engage in fraud, telling them they should “find a way” to enroll more students in ARS’ program despite Drug Medi-Cal’s medical necessity requirement.

The scheme was executed in several ways, including ARS counselors and managers maintaining student caseloads by enrolling students in the ARS substance abuse counseling program even if they had used drugs or alcohol only occasionally or even just once.

For example, in December 2011, ARS fraudulently submitted a claim for Medi-Cal reimbursement for an individual counseling session for a student on November 23, 2011 – a school holiday and the day before Thanksgiving – when the student was absent and the counselor listed on the claim did not provide any counseling.

In total, $18,530,927 in fraudulent claims were submitted because of the scheme, resulting in an actual loss to Medi-Cal of $17,640,325.

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