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Telehealth Utilization Showed Slight Decrease in April

National telehealth utilization decreased 5.4 percent in April 2023, from 5.6 percent of medical claim lines in March to 5.3 percent in April, according to FAIR Health’s Monthly Telehealth Regional Tracker. The decrease followed an increase in March 2023.

In April, telehealth utilization also decreased in all four US census regions – the Midwest (4.7 percent), Northeast (6.3 percent), South (6.8 percent) and West (6.4 percent). The data represent the privately insured population, including Medicare Advantage and excluding Medicare Fee-for-Service and Medicaid.

Mental health conditions, the top-ranking telehealth diagnosis nationally and in every region, rose from 67.4 percent of telehealth claim lines nationally in March 2023 to 68.4 percent in April – the fourth straight month of national increases.

The percentage of telehealth claim lines for the second-place diagnosis, acute respiratory diseases and infections, decreased nationally in April, falling from 3.2 percent in March to 2.7 percent in April. This was the fourth consecutive national monthly decrease for this diagnosis.

Nationally, in April, developmental disorders switched positions with joint/soft tissue diseases and issues in the rankings; developmental disorders rose to third place while joint/soft tissue diseases and issues dropped to fourth place.

In April 2023, among the national top five diagnoses via asynchronous telehealth, mental health conditions switched positions with urinary tract infections in the rankings; claims for mental health conditions climbed to third place while those for urinary tract infections fell to fourth place.

In April, the percentage of asynchronous telehealth claim lines rose for hypertension nationally and in every region. Nationally, the percentage rose significantly from 9.7 percent in March to 12.5 percent in April. Hypertension rose from second to first place in the West and from fourth to second place in the South. It maintained its position nationally (second place) and in the other regions – second place in the Northeast and first in the Midwest.

In April, sleep disorders climbed in the rankings of asynchronous telehealth diagnoses from fifth to fourth place in the Northeast and from fourth to second place in the West. Diabetes mellitus rose in the rankings in three regions: from fifth to third place in the Midwest, from fourth to third place in the Northeast and from fifth to fourth place in the West.

In April 2023, utilization of audio-only telehealth services decreased in rural and urban areas nationally and in every region except the West, where it fell in rural areas but rose in urban areas.

For April 2023, the Telehealth Cost Corner spotlighted the cost of CPT®3 99213, established patient office or other outpatient visit, 20-29 minutes. Nationally, the median charge amount for this service when rendered via telehealth was $167.77, and the median allowed amount was $89.70

Cal/OSHA May Amend Citations Before, During and After ALJ Hearings

Martin Mariano, an employee of L & S Framing Inc., was working on a residential house under construction when he fell from the unprotected second floor stairwell onto the concrete ground floor below, sustaining serious injuries.

Ronald Aruejo, a senior safety engineer for the Cal/OSHA, issued plaintiff L & S Framing Inc., three general citations and one serious accident-related citation. Only the serious accident-related citation is at issue in this appeal.

The subsequent citation itself set forth the following: “[T]he employer did not provide the exposed sides of a stairway with temporary railings and toe board as prescribed in Section 1620. As a result, an employee was seriously injured when he fell from the exposed side of the stairway and landed approximately 11 feet below onto a concrete floor.” The citation cited section 1626, subdivision (a)(5), which is a section that does not exist. Plaintiff appealed the citation.

A hearing before an ALJ followed. The hearing occurred over four days, November 14 and 15, 2017, and September 5 and 6, 2018. On the first day of the hearing, the ALJ granted the Cal/OSHA’s request to amend the citation to refer to section 1626, subdivision (b)(5) which provides that “Unprotected sides and edges of stairway landings shall be provided with railings.” rather than nonexistent subdivision (a)(5), which according to Ronald Aruejo was a typographical error.

During the trial much of the testimony involved describing the correct characterization of the stairway within the meaning of various subsections of section 1626. At one pont the ALJ denied the Division’s mid-hearing request to amend the citation to allege a violation of section 1632, subdivision (b)(1) which requires that “Floor, roof and skylight openings shall be guarded by either temporary railings and toeboards or by covers.” And later denied the Division’s post-hearing motion to amend to allege violation of section 1626, subdivision (a)(2), which provides that ” Railings and toeboards meeting the requirements of Article 16 of these safety orders shall be installed around stairwells” and concluded the Division failed to prove the alleged violation of section 1626, subdivision (b)(5).

The Division filed a petition for reconsideration with the California Occupational Safety and Health Appeals Board which concluded the ALJ improperly denied the two requests to amend and upheld the citation based on violation of both section 1632, subdivision (b)(1) and 1626, subdivision (a)(2).

L & S Framing Inc.,filed a petition for a writ of mandate in the trial court and the trial court denied the petition. L & S Framing Inc., then filed an appeal with th California Court of Appeal which affirmed the trial court in the unpublished case of L & S Framing Inc., v Cal/SOSHA – C096386 (June 2023).

On appeal the employer asserts the trial court erred in permitting the Appeals Board to amend the citation, and asserts the Appeals Board ultimately found a violation based on two regulations that were not correctly pled.

In rejecting this assertion, the Court of Appeal noted that the Labor Code provides that the “rules of practice and procedure adopted by the appeals board shall be consistent with,” among other things, Government Code section 11507. which provides, in part: “At any time before the matter is submitted for decision, the agency may file, or permit the filing of, an amended or supplemental accusation . . . .” Thus, Government Code section 11507 contemplates amendments to accusations, and, pursuant to Labor Code section 6603, the rules of practice adopted by the Appeals Board shall be consistent with that provision.

Section 371.2, a rule of practice and procedure adopted by the appeals board, expressly addresses amendments of a citation or appeal. Among other things, it provides that a “request for an amendment that does not cause prejudice to any party may be made by a party or the Appeals Board at any time.”

“[A]mendments to pleadings in the administrative hearing context are liberally allowed.” (Calstrip Steel Corporation (Cal. OSHA, June 30, 2017, Nos. 12-R3D6-1998, 1999) 2017 CA OSHA App.Bd. Lexis 66 at p. *15.)

The employer also argued the issue of “did the location from which Mariano fell constitute a stairwell within the meaning of section 1626, subdivision (a)(2) and/or a floor opening within the meaning of section 1632, subdivision (b)(1).” Or is 1716.2, subdivision (f) the applicable regulation. That regulation requires fall protection “around all unprotected sides or edges” for work performed on floors that will later be enclosed by framed exterior walls, but only when the work is performed more than 15 feet above the floor level below. The fall here was less than 11 feet to the concrete floor below.

The Appeals Board concluded that, when plaintiff’s workers removed the railing, they “create[ed] a hole or empty space from which people or things could fall through.” The Appeals Board continued: “Mariano fell through the opening, which was unguarded and unprotected contrary to section 1632, subdivision (b)(1)’s mandate.”

Thus the Court of Appeal concluded the Appeals Board’s construction and interpretation of section 1632, subdivision (b)(1) comports with the plain meaning of the terms used in that provision. In the particular context of workplace health and safety here at issue, our high court has reviewed the statutory structure and – noting that the relevant provisions “speak in the broadest possible terms” – has concluded that “the terms of the legislation are to be given a liberal interpretation for the purpose of achieving a safe working environment.”

Public Entity Defendant Allowed Credit for Comp Benefits Paid Before Trial

Daquan Jones brought a tort action against the City of Firebaugh for personal injuries caused by a dangerous condition of public property. and Hiller Aircraft Corporation, among others.

On July 2, 2018, Jones and Cheatham were operating an 80-foot-long “sleeper berth: tractor trailer” when they arrived at the loading dock of Red Rooster, a tomato packing operation located near the intersection of M Street and 12th Street. After picking up tomatoes, Jones needed to move his vehicle to accommodate other drivers.

After leaving the tomato packing facility he was driving on M Street when the road unexpectedly terminated in front of the private property of Hiller Aircraft Corporation. Unable to turn around due in large part to concrete barricades on the road, Jones and his codriver John Cheatham entered Hiller’s property.

Hiller’s general manager Steven Palm refused to let Jones and Cheatham leave until they paid $50. Thereafter, Jones and Palm got into a physical altercation. While being restrained by Palm on the ground, Jones was run over by Cheatham, who was driving the trailer tractor off the property. Jones’s “whole left side” was then crushed by the trailer’s right rear tires while being restrained on the ground by Palm.

As of April 8, 2021, four days before trial commenced, workers’ compensation insurance payments in the amount of $1,253,884.43 were paid to Jones by his workers’ compensation insurer, QBE Americas, Inc. However, the workers’ compensation claim remained open, and the amount of the lien continued to grow as more payments are made for additional medical care..

Trial commenced April 12, 2021. On May 4, 2021, the jury returned a special verdict in favor of Jones. The court adjudged City and Hiller Aircraft Corporation jointly and severally liable for $5,743,907.51 in economic damages and City severally liable for $750,000 in noneconomic damages.

Postverdict, on July 9, 2021, City moved for reduction of judgment pursuant to Government Code section 985 identifying QBE Americas, Inc., a “private workers’ compensation insurer,” as the “sole collateral source.”

The trial court denied the motion for a reduction of the judgment, “as the City has not provided sufficient evidence of the amounts paid by the collateral source or what plaintiff owes under the lien.”

The Court of Appeal reversed and remanded in the unpublished case of Jones v City of Firebaugh -F083759 (June 2023);

Government Code Section 985, subdivision (b), provides that a public entity may bring a posttrial motion to reduce a judgment against it by the amount a collateral source has paid, or is obligated to pay, for services or benefits provided to plaintiff prior to the commencement of trial. (Ibid.; Garcia v. County of Sacramento (2002) 103 Cal.App.4th 67, 72-73.)

A collateral source payment’ includes monetary payments paid or obligated to be paid for services or benefits that were provided’ on behalf of the plaintiff by “private medical programs, health maintenance organizations, state disability, unemployment insurance, private disability insurance, or other [similar] sources of compensation . . . .” (§ 985, subds. (a)(1)(B), (f)(2).)

The trial court concluded “it [wa]s not possible” “to make a reasoned calculation of the amount of any reduction” because (1) the workers’ compensation claim “has not been closed” and “is not likely to be closed in the foreseeable future because of plaintiff’s ongoing medical needs”; (2) “since the workers’ compensation claim remains open, the amount of the lien will continue to grow as more payments are made”; and (3) “the total amount of the lien has not yet been determined.” The court expressed concern “an order under section 985 would have the effect of terminating the lienholder’s right to seek compensation for future payments.”

However the Court of Appeal noted that the language of section 985 limits the inquiry to payments made “prior to the commencement of trial.”

The trial court’s order evinces the mistaken belief that a motion under section 985 reaches payments made for services or benefits provided after the commencement of trial. Since it applied the wrong legal standard, we find an abuse of discretion.”

The post judgment order was reversed. On remand, “the trial court shall reconsider the motion for reduction in judgment pursuant to section 985 in accordance with the proper legal standard.”

SCOTUS Defines Employer’s Obligation to Accommodate Religious Beliefs

Gerald Groff is an Evangelical Christian who believes for religious reasons that Sunday should be devoted to worship and rest.

In 2012, Groff took a mail delivery job with the United States Postal Service. Groff’s position generally did not involve Sunday work, but that changed after USPS agreed to begin facilitating Sunday deliveries for Amazon. To avoid the requirement to work Sundays on a rotating basis, Groff transferred to a rural USPS station that did not make Sunday deliveries.

After Amazon deliveries began at that station as well, Groff remained unwilling to work Sundays, and USPS redistributed Groff’s Sunday deliveries to other USPS staff. Groff received “progressive discipline” for failing to work on Sundays, and he eventually resigned.

Groff sued under Title VII of the Civil Rights Act of 1964, asserting that USPS could have accommodated his Sunday Sabbath practice without undue hardship on the conduct of USPS’s business. 42 U. S. C. §2000e(j).

The District Court granted summary judgment in favor USPS. The Third Circuit affirmed based on this Court’s decision in Trans World Airlines, Inc. v. Hardison, 432 U. S. 63, which it construed to mean “that requiring an employer ‘to bear more than a de minimis cost’ to provide a religious accommodation is an undue hardship.” 35 F. 4th 162, 174, n. 18 (quoting 432 U. S., at 84). The Third Circuit found the de minimis cost standard met here, concluding that exempting Groff from Sunday work had “imposed on his coworkers, disrupted the workplace and workflow, and diminished employee morale.”

The United States Supreme Court reversed in the case of Groff v DeJoy Postmaster General, – No. 22-174 (June 2023).

SCOTUS began it’s Opinion by noting “This case presents the Court’s first opportunity in nearly 50 years to explain the contours of Hardison. The background of that decision helps to explain the Court’s disposition of this case.”

Title VII of the Civil Rights Act of 1964 made it unlawful for covered employers “to fail or refuse to hire or to discharge any individual, or otherwise to discriminate against any individual with respect to his compensation, terms, conditions, or privileges [of] employment,because of such individual’s . . . religion.

As originally enacted, Title VII did not spell out what it meant by discrimination “because of . . . religion.” Subsequent regulations issued by the EEOC obligated employers “to make reasonable accommodations to the religious needs of employees” whenever doing so would not create “undue hardship on the conduct of the employer’s business.” 29 CFR §1605.1 (1968).

Hardison concerned an employment dispute that arose prior to the 1972 amendments to Title VII. In 1967, Trans World Airlines hired Larry Hardison to work in a department that operated “24 hours per day, 365 days per year” and played an “essential role” for TWA by providing parts needed to repair and maintain aircraft. Hardison later underwent a religious conversion and began missing work to observe the Sabbath. Attempts at accommodation failed, and TWA discharged Hardison for insubordination.

Hardison sued TWA and his union, and the Eighth Circuit sided with Hardison. The Eighth Circuit found that reasonable accommodations were available to TWA.

Applying this interpretation of Title VII and disagreeing with the Eighth Circuit’s evaluation of the factual record, the Court identified no way in which TWA, without violating seniority rights, could have feasibly accommodated Hardison’s request for an exemption from work on his Sabbath.

However, the parties in Hardison had not focused on determining when increased costs amount to “undue hardship” under Title VII separately from the seniority issue. But the Court’s opinion in Hardison contained this oft-quoted sentence: “To require TWA to bear more than a de minimis cost in order to give Hardison Saturdays off is an undue hardship.” Subsequently, “lower courts have latched on to ‘de minimis’ as the governing standard.”

Returning to the Groff case, SCOTUS concluded “that showing “more than a de minimis cost,” as that phrase is used in common parlance, does not suffice to establish “undue hardship” under Title VII. Hardison cannot be reduced to that one phrase. In describing an employer’s “undue hardship” defense, Hardison referred repeatedly to “substantial” burdens, and that formulation better explains the decision. The Court understands Hardison to mean that “undue hardship” is shown when a burden is substantial in the overall context of an employer’s business. This fact-specific inquiry comports with both Hardison and the meaning of “undue hardship” in ordinary speech.

Hence “Title VII requires an employer that denies a religious accommodation to show that the burden of granting an accommodation would result in substantial increased costs in relation to the conduct of its particular business.”

Central Coast Health Care Providers Agree to Pay $68M for False Claims

A county organized health system (COHS) that arranges services for Medi-Cal enrollees in Santa Barbara and San Luis Obispo counties and three Central Coast health care providers have agreed to pay a total of $68 million to resolve allegations that they violated the False Claims Act and the California False Claims Act by submitting false claims to Medi-Cal related to Medicaid Adult Expansion under the Patient Protection and Affordable Care Act (ACA).

The four entities that entered into settlement agreements with the United States and the State of California are the Santa Barbara San Luis Obispo Regional Health Authority, doing business as CenCal Health, a COHS that contracts to arrange for the provision of health care services under Medi-Cal, which is California’s Medicaid program; Cottage Health System, a not-for-profit hospital network operating in Santa Barbara County; Sansum Clinic, a non-profit outpatient clinic operating in Santa Barbara County; and Community Health Centers of the Central Coast (CHC), a non-profit community health center operating in Santa Barbara and San Luis Obispo counties.

Pursuant to the ACA, beginning in January 2014, Medi-Cal was expanded to cover the previously uninsured “Adult Expansion” population – adults between the ages of 19 and 64 without dependent children with annual incomes up to 133% of the federal poverty level. The federal government fully funded the expansion coverage for the first three years of the program. Under contracts with California’s Department of Health Care Services (DHCS), if CenCal did not spend at least 85% of the funds it received for the Adult Expansion population on “allowed medical expenses,” CenCal was required to pay back to the state the difference between 85% and what it actually spent. California, in turn, was required to return that amount to the federal government.

The four settlements resolve allegations that CenCal, Cottage, Sansum, and CHC knowingly submitted or caused the submission of false claims to Medi-Cal for “Enhanced Services” that were purportedly provided to Adult Expansion Medi-Cal members: by Cottage between January 1, 2014 and June 30, 2016; by Sansum and CHC between January 1, 2015 and June 30, 2016; and by certain other healthcare providers between January 1, 2014 and June 30, 2016.

The United States and California alleged that the payments were not “allowed medical expenses” permissible under the contract between DHCS and CenCal; were pre-determined amounts that did not reflect the fair market value of any Enhanced Services provided; and/or the Enhanced Services were duplicative of services already required to be rendered. The United States and California further alleged that the payments were unlawful gifts of public funds in violation of the California Constitution.

As a result of the settlements, CenCal will pay $49.5 million, Cottage will pay $9 million, Sansum will pay $4.5 million, and CHC will pay $3.15 million to the United States. In addition, California will receive payments totaling $1.85 million.

The civil settlements include the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by Julio Bordas, CenCal’s former medical director. Under the act, a private party can file an action on behalf of the United States and receive a portion of any recovery. Dr. Bordas will receive approximately $12.56 million as his share of the federal recovery.

The United States previously settled similar allegations against Dignity Health (which operates Arroyo Grande Community Hospital, French Hospital Medical Center in San Luis Obispo, and Marian Regional Medical Center in Santa Maria) and Twin Cities Community Hospital and Sierra Vista Regional Medical Center, two subsidiaries of Tenet Healthcare Corporation, relating to payments they received from CenCal under the Adult Expansion program.

California Supreme Court to Rule on Constitutionality of AB-5 Ballot Initiative

The California Supreme Court agreed to review the constitutionality of Uber and Lyft-backed ballot initiative that allows the companies to classify their drivers as independent contractors.

The controversy began In 2019 when the California Legislature enacted AB-5, which established a new test for distinguishing between employees and independent contractors for the purposes of the Labor Code and Unemployment Insurance Code.

In response, Davis White and Keith Yandell, supported by a group called Protect App-Based Drivers and Services proposed Proposition 22. Among the supporters of Protect Drivers and Proposition 22 were rideshare and delivery network companies such as Uber Technologies, Inc., Lyft, Inc., and DoorDash, Inc.

The voters approved Proposition 22 in November 2020, with 58.6 percent of voters in favor and 41.4 percent opposed. It added sections 7448 to 7467 to the Business and Professions Code.

Shortly afterwards, Hector Castellanos, Joseph Delgado, Saori Okawa, Michael Robinson, Service Employees International Union California State Council, and Service Employees International Union filed a petition for writ of mandate seeking a declaration that Proposition 22 is invalid because it violates the California Constitution.

The trial court granted the petition, ruling that the proposition (1) is invalid in its entirety because it intrudes on the Legislature’s exclusive authority to create workers’ compensation laws; (2) is invalid to the extent that it limits the Legislature’s authority to enact legislation that would not constitute an amendment to Proposition 22, and (3) is invalid in its entirety because it violates the single-subject rule for initiative statutes.

It issued a judgment ordering Katie Hagen, as director of the Department of Industrial Relations, not to enforce any of Proposition 22’s provisions.

Proposition 22’s proponents and the state appealed, arguing the trial court was mistaken on all three points.

The Court of Appeal agreed that Proposition 22 does not intrude on the Legislature’s workers’ compensation authority or violate the single-subject rule. But it concluded that the initiative’s definition of what constitutes an amendment violates separation of powers principles. Because the unconstitutional provisions can be severed from the rest of the initiative, it affirmed the judgment insofar as it declares those provisions invalid and to the extent the trial court retained jurisdiction to consider an award of attorney’s fees, and otherwise reversed in the published case of Castellanos v. State of California – A163655 (March 2023).

The Court of Appeal concluded that sections 7465(c)(3) and (4) are facially invalid on separation of powers grounds because they intrude on the judiciary’s authority to determine what constitutes an amendment to Proposition 22, and section 7465(c)(4) fails for the additional reason that it intrudes on the Legislature’s authority by artificially expanding Proposition 22’s article II, section 10(c) shadow.

However, the proper remedy for the separation of powers violation is to sever section 7465(c)(3) and (4) and allow the rest of Proposition 22 to remain in effect, as the voters indicated they wished. (§ 7467, subd. (a).) rather than strike Proposition 22 in its entirety.

And the Court of Appeal ruled that the “judgment is affirmed to the extent it declared sections 7465(c)(3) and (c)(4) invalid and to the extent the trial court retained jurisdiction to consider a motion for attorney fees under Code of Civil Proctedure section 1021.5. In all other respects, the judgment is reversed. The matter is remanded to the trial court with instructions to enter a new judgment not inconsistent with this opinion.”

On April 21. 2023 the plaintiffs filed a Petition for Review with the California Supreme Court. And on June 28, 2023 the Petition for Review was granted.

As part of the Order, the Supreme Court wrote “Pending review, the opinion of the Court of Appeal, which is currently published at 89 Cal.App.5th 131, may be cited, not only for its persuasive value, but also for the limited purpose of establishing the existence of a conflict in authority that would in turn allow trial courts to exercise discretion under Auto Equity Sales, Inc. v. Superior Court (1962) 57 Cal.2d 450, 456, to choose between sides of any such conflict.”

SoCal Chiropractor Among 78 Charged in $2.5B in Health Care Fraud

The Department of Justice, together with federal and state law enforcement partners, strategically coordinated a two-week nationwide law enforcement action that resulted in criminal charges against 78 defendants for their alleged participation in health care fraud and opioid abuse schemes that included over $2.5 billion in alleged fraud.

The defendants allegedly defrauded programs entrusted for the care of the elderly and disabled, and, in some cases, used the proceeds of the schemes to purchase luxury items, including exotic automobiles, jewelry, and yachts. In connection with the enforcement action, the Department seized or restrained millions of dollars in cash, automobiles, and real estate.

The identified defendants include a California chiropractor and acupuncturist. Neda Mehrabani, also known as “Neda Mehrabani Ladjevardi.” She is a chiropractor and acupuncturist licensed in the State of California and owned Health Clinic of Southern California, Inc.located at 5530 Corbin Avenue, Tarzana, California. Her website claims she became a Licensed Massage Therapist in 1994, a Doctor of Chiropractic in 1998 and a Licensed Acupuncturist & Herbalist in 2004.

Prosecutors allege, in the Criminal Case Filed in Los Angeles Federal Court, that Mehrabani submitted false and fraudulent claims to Medicare for chiropractic services, utilizing CPT code 98942 (Chiropractic Manipulative Treatment, spinal 5 regions), purportedly provided to beneficiaries, when, in fact, the services had not been provided as represented and were not medically necessary. They allege that between June 2018 and in or around June 2022, she submitted approximately $3,332,365.00 in false and fraudulent claims for reimbursement for CPT code 98942 and received approximately $2,465,771.61 in payments on those claims.

Authorities in California, Florida, Georgia, Indiana, Kentucky, Louisiana, Michigan, New Jersey, New York, Ohio, Pennsylvania, South Carolina, Texas, Washington and Wisconsin are prosecuting the cases against the 78 defendants, including thee one filed against Neda Mehrabani.

Among the charges filed against the accused are allegations of telemedicine fraud, pharmaceutical fraud and accusations of opioid distribution. Charges were filed against 11 defendants in connection with the submission of over $2 billion in fraudulent claims resulting from telemedicine schemes.

In a case involving the alleged organizers of one of the largest health care fraud schemes ever prosecuted, an indictment in the Southern District of Florida alleges that the chief executive officer (CEO), former CEO, and Vice President of Business Development of purported software and services companies conspired to generate and sell templated doctors’ orders for orthotic braces and pain creams in exchange for kickbacks and bribes. The conspiracy allegedly resulted in the submission of $1.9 billion in false and fraudulent claims to Medicare and other government insurers for orthotic braces, prescription skin creams, and other items that were medically unnecessary and ineligible for Medicare reimbursement.

As part of the alleged conspiracy, individuals in a massive telemarketing operation, located in the United States and abroad, targeted the elderly and disabled with direct mail, television advertisements, and other forms of advertising to induce them to contact offshore boiler-rooms staffed by individuals who “up-sold” the elderly and disabled on unnecessary medical equipment and prescriptions. According to the indictment, the software platform that the defendants allegedly operated was actually a conduit for these telemarketers to coordinate the payment of illegal kickbacks and bribes to telemedicine companies to obtain doctors’ orders for Medicare beneficiaries. The defendants allegedly programmed the software platform to generate false and fraudulent orders for telemedicine practitioners to sign and obstruct Medicare investigations by concealing that the interactions with beneficiaries had occurred remotely using telemedicine. The program-generated orders falsified certifications that the telemedicine doctors had examined the beneficiaries in person, and falsified diagnostic testing that Medicare required for brace orders. After the original CEO sold the company in a corporate acquisition, the new corporate leadership allegedly chose to continue the pre-existing fraud scheme.

In another telemedicine fraud case, in the Eastern District of Washington, a licensed physician was charged for signing more than 2800 fraudulent orders for orthotic braces, including for patients whose limbs had already been amputated. As alleged, the physician took less than 40 seconds to review and sign each order.

The enforcement action also included charges against 10 defendants in connection with the submission of over $370 million in fraudulent claims submitted in connection with prescription drugs. In one case the owner and corporate officer of a pharmaceutical wholesale distribution company was charged for an alleged $150 million fraud scheme in which the company purchased illegally diverted prescription HIV medication, and then marketed and resold the medication by falsely representing that the company acquired it through legitimate channels. The defendant allegedly purchased the diverted medication at a substantial discount from individuals who obtained the drugs primarily through illegal “buyback” schemes in which they paid HIV patients cash for their expensive HIV medication and repackaged those pills for resale. To cover up their scheme, the defendant and others falsified labeling and product tracing documentation to make it appear legitimate. Pharmacies purchased the misbranded medications, dispensed them to patients, and billed them to health care benefit programs, all while the defendants reaped substantial illegal profits.

In a related case, on June 15, an individual in the Southern District of Florida was sentenced to 15 years in prison for his role in this nationwide scheme. According to court documents, the defendant illegally acquired large quantities of prescription drugs from patients for whom the drugs had been prescribed but not yet consumed. The defendant and others then repackaged the drugs and sold them to wholesale companies. In some instances, the medication that the defendant sold contained the wrong medication, broken pills, and even pebbles, leading to complaints by pharmacies. The defendant used his share of the proceeds to purchase luxury goods, including a $280,000 Lamborghini, a $220,000 Mercedes, and three boats.

The charges also targeted over $150 million in false billings submitted in connection with other types of health care fraud, including the illegal distribution of opioids and clinical laboratory testing fraud.

The Center for Program Integrity of the Centers for Medicare & Medicaid Services (CPI/CMS) separately announced that it took adverse administrative actions in the last six months against 90 medical providers for their alleged involvement in health care fraud.

Jury Finds DME Company Owner Guilty of $24M in Fraudulent Claims

A South Bay woman was found guilty of nearly two dozen felonies for billing Medicare more than $24 million by submitting fraudulent claims for medically unnecessary durable medical equipment – mostly power wheelchairs (PWC) – and PWC repairs, many of which were never performed.

Tamara Yvonne Motley, 54, a.k.a. “Tamara Ogembe,” of Redondo Beach, was found guilty by a federal jury of 20 counts of health care fraud, two counts of aggravated identity theft, and one count of conspiracy to commit money laundering.

Following the reading of the guilty verdicts, United States District Judge Stanley Blumenfeld Jr. remanded Motley into custody.

According to evidence presented at her five­-day trial, from July 2006 to August 2014, Motley was the de facto owner of the Hawthorne-based Action Medical Equipment and Supplies. From January 2013 to November 2016, Motley was the de facto owner of the Ventura-based Kaja Medical Equipment & Supply. Both companies were enrolled with Medicare in the names of Motley’s out-of-state relatives.

Motley orchestrated a scheme in which she paid marketers for patient referrals and then directed them to take patients to corrupt physicians, who prescribed medically unnecessary durable medical equipment, such as PWCs, that Motley’s companies used to submit fraudulent bills to Medicare.

In January 2011, when Medicare changed the reimbursement rules for PWCs to make the upfront payments less lucrative to suppliers, Action switched to billing Medicare for PWC repairs, and continued that scheme at Kaja once Action was shut down.

These repairs were not medically necessary because the patients did not need the PWCs to begin with, were not needed to make the PWCs serviceable in any event, and often simply were not performed. These repairs were expensive – often billed for $3000-$4000 – and accounted for nearly half of Action’s billings and almost all of Kaja’s.

Over an eight-year period, Action billed Medicare more than $18.2 million for DME – most for PWCs, but also for PWC accessories, knee braces and back braces – and the repair or replacement of PWCs. Medicare paid Action nearly $10.3 million.

Between July 2013 and November 2016, Kaja billed Medicare $6.3 million, primarily for PWC repairs. Medicare paid Kaja approximately $2.8 million for those claims.

Judge Blumenfeld scheduled an October 3 sentencing hearing, at which time Motley will face up to 10 years in federal prison for each health care fraud count, up to 20 years in federal prison for the money laundering conspiracy count, and a mandatory sentence of two years in federal prison consecutive to the other sentences for the aggravated identity theft counts.

Two other defendants have been convicted in this case:

– – Cynthia Karina Marquez, 47, of Paramount, who worked as an office manager at both Action and Kaja, pleaded guilty in December 2019 to two counts of making false statements affecting a health care program. She received a time-served sentence, was placed on supervised release for three years, and was ordered to pay $9,886,646 in restitution.
– – Juan Roberto Murillo, 46, of Montebello, who worked at both medical supply companies as a repair technician, pleaded guilty in November 2019 to one count of conspiracy to commit money laundering. He was sentenced to three years’ probation and was ordered to pay $2,504,119 in restitution.

The United States Department of Health and Human Services, Office of Inspector General; the FBI; and the California Department of Justice investigated this matter. Assistant United States Attorneys Kristen A. Williams and David H. Chao of the Major Frauds Section are prosecuting this case.

WCIRB Releases Report on Insured 2022 Losses and Expenses

Pursuant to Section 11759.1 of the California Insurance Code, the Workers’ Compensation Insurance Rating Bureau has prepared its 2022 California Workers’ Compensation Losses and Expenses report containing estimated California workers’ compensation costs for 2022 based on insured employer experience.

The report also reflects payments made by the California Insurance Guarantee Association (CIGA) in the statewide loss payments for calendar years 2010 through 2022.

Highlights from the report are as follows:

– – Calendar year 2022 earned premium totaled $15.3 billion (as compared to the $13.6 billion of premium earned in 2021).

– – Total insurer paid losses (i.e., excluding payments made by CIGA) in 2022 were $8.3 billion, or 54% of calendar year earned premium. Combining insurer paid losses with a $0.8 billion increase in total insurer loss reserves resulted in total insurer incurred losses, excluding payments made by CIGA, of $9.1 billion, or 60% of the premium earned in 2022

– – In 2022, $4.4 billion, or 53% of total loss payments, were for medical benefits.

– – In 2022, $4.0 billion, or 47% of total loss payments, were for indemnity benefits (including vocational rehabilitation benefits).

– – In total, about $72 million in vocational rehabilitation-related benefits were paid in calendar year 2022. This was 1.8% of all indemnity payments in 2022, of which 92% was for education related benefits. (For comparison purposes, in 2021, vocational rehabilitation benefits paid was $67 million, or 1.8% of all indemnity payments, of which 90% was for education-related benefits.)

– – Insurer incurred loss adjustment expenses (allocated and unallocated) in 2022 were $2.7 billion, or 17% of earned premium. This includes the full cost to insurers of administering, adjudicating and settling claims. Incurred loss adjustment expenses include $850 million in defense attorney expenses incurred in 2022. (For comparison purposes, in 2021, incurred loss adjustment expenses were 16% of earned premium, including $806 million in defense attorney expenses.)

– – Although generally part of incurred indemnity losses rather than expenses, the amount paid in 2022 to applicant attorneys was derived from the WCIRB’s Annual Expense Call. In 2022, applicant attorneys were paid $395 million. (In 2021, applicant attorneys were paid $389 million)

– –  In total, incurred losses and expenses in calendar year 2022 were $15.0 billion, or 98% of earned premium. Based on insurer statutory Annual Statement information, the WCIRB estimates policyholder dividends incurred in 2022 to be 0.6% of 2022 earned premium, resulting in an underwriting profit of $0.2 billion.

Cal/OSHA Cites The Two Employers of Seven Mass Shooting Victims

66 year old Chunli Zhao, a Chinese citizen, allegedly shot and killed four workers and wounded a fifth employee last January 23rd at California Terra Garden. He then went to nearby Concord Farms, where he had worked previously, and allegedly fatally shot three former co-workers.

Zhao told KNTV-TV in a courthouse interview that he committed the shootings, then drove to the police station to turn himself in. But no one was there, so he waited about two hours in the parking lot for officers to finally approach and arrest him. He said he was bullied and worked long hours on the farms and his complaints were ignored, the station reported. He also told the reporter who interviewed him that he has a green card, but had no problem buying a gun in 2021.  He also said he thinks he is mentally disturbed, according to the report of the interview.

In a jail interview with NBC News Zhao claimed a forklift he was operating was hit by a coworker on a bulldozer and that he was asked to pay $100 to cover the cost of the damage. Zhao went on to say he vented his frustration over the bill 30 minutes before the shooting.

He then went back to confront his boss again, shooting both his supervisor and the coworker he blamed for the accident.

According to CBS News, the San Mateo County District Attorney confirmed a report that the Half Moon Bay mass shooting suspect claimed the incident stemmed from his anger over a $100 equipment bill.

The victims who died have been identified as Zhishen Liu, 73, Aixiang Zhang, 74, Qizhong Cheng, 66, Jingzhi Lu, 64, Marciano Martinez Jimenez, 50, Yetao Bing, 43, and Jose Romero Perez, 38. An eighth victim, Pedro Romero Perez, was critically injured but survived the shooting.

A spokesperson for California Terra Garden confirmed Zhao lived on the property with his wife, but said the farm had no knowledge of any bullying complaints.

Zhao has a history of threatening coworkers, according to court documents obtained by the ABC7 News I-Team. In 2013, Chunli Zhao had a restraining order filed against him by a former roommate and coworker. They both worked at a restaurant when Zhao reportedly lost his job, the documents say.

According to these documents, the roommate says Zhao threatened that if he didn’t get his job back, he would kill him. Zhao, at one point, even held a pillow over his face, reportedly trying to suffocate him.

The documents also note he said, “he wants to come back to work. If this can’t be done, this will be a bigger problem which will not be good, pleasant for anyone.”

He pleaded not guilty to seven counts of murder and one count of attempted murder at his arraignment on February 16. Prosecutors say this was the deadliest attack in San Mateo County’s history.

In the aftermath of this tragedy, Cal/OSHA has now cited the two employers in Half Moon Bay following an investigation into the workplace violence that killed the seven agricultural workers on January 23, 2023.

Cal/OSHA cited California Terra Garden, Inc. for 22 violations, including five classified as serious and one classified as serious accident-related for failing to have a plan or procedures to immediately notify employees of an active shooter threat and instruct them to seek shelter. Total proposed penalties are $113,800.

Concord Farms Inc. was cited for 19 violations, three of them serious, including failure to address previous incidents of workplace violence and develop procedures to correct and prevent this hazard. Total proposed penalties are $51,770.

Both employers were cited for failing to establish a workplace safety plan that evaluated the threat of workplace violence and train workers in a language they can understand. Both employers were also cited for failure to secure labor camp permits for onsite worker housing.

Other state agencies continue to investigate at the worksites, which may result in additional enforcement actions.