Workers' Compensation Daily News for Sep 30, 2014
SB 863 Retroactively Limits Attorney Fees for Filing App Against Unrepresented Worker
Tue, 30 Sep 2014 11:13:39 - Pacific Time
Ellen Jones was employed as a lecturer by San Francisco State University (SFSU) from July 2005 to July 2006. During this period she injured her bilateral upper extremities and lower back. SFSU, retained legal counsel who, in turn, filed an application for adjudication of claim with the WCAB in May 2009. At the same time, SFSU noticed applicant’s deposition for July 2009. When this application was filed, applicant was unrepresented.
Applicant's attorney claimed an attorney fee as a result of the University having filed an application against an unrepresented worker. In September 2012, the WCJ issued his Findings, Award, and Order, which included the determinations that the employer "may not utilize section 4062.3, subdivision (g) to defeat liability for attorney fees pursuant to section 4064." The WCAB then granted the SFSU motion for reconsideration and removal, and amended this finding as follows before remanding for further proceedings: "The issue of whether [petitioner] may utilize section 4062.3(g) to defeat its liability for attorney fees pursuant to section 4064 is deferred with jurisdiction reserved at the trial level".
At the time the WCAB issued this remand/removal order with respect to the WCJ’s September 2012 Findings, Award and Order, the version of labor code section 4064, subdivision (c), in effect provided: "Subject to Section 4906, if an employer files an application for adjudication and the employee is unrepresented at the time the application is filed, the employer shall be liable for any attorney’s fees incurred by the employee in connection with the application for adjudication."
However, effective January 1, 2013, section 4064, subdivision (c) was amended pursuant to SB 863 to provide: "Subject to Section 4906, if an employer files a declaration of readiness to proceed and the employee is unrepresented at the time the declaration of readiness to proceed is filed, the employer shall be liable for any attorney’s fees incurred by the employee in connection with the declaration of readiness to proceed." Thus, the triggering event for the unrepresented applicant’s right to attorney fees changed from the employer’s filing of an application for adjudication of claim to the employer’s filing of a declaration of readiness to proceed. (Here, applicant filed this declaration of readiness to proceed.) In addition, when enacting these and other amendments to the Labor Code, the Legislature made the express finding that: "This act shall apply to all pending matters, regardless of date of injury, unless otherwise specified in this act, but shall not be a basis to rescind, alter, amend, or reopen any final award of workers’ compensation benefits." )
In July 2013, following the effective date of the amended version of section 4064, subdivision (c), the WCJ conducted further proceedings on remand from the WCAB’s December 13, 2012 decision. The WCJ thereafter issued Findings of Fact and an Opinion on Decision, dated October 16, 2013, in which it determined, based upon the amended statute, that applicant was not entitled to attorney fees. As such, the WCJ declared moot all other previously-decided issues relating to attorney fees.
This time, applicant sought reconsideration by the WCAB of the WCJ’s October 2013 findings and opinion on attorney fees. The WCAB, in an order dated January 14, 2014, granted her request for reconsideration and set aside the WCJ’s denial of fees under the newly revised statute, explaining: "We did not intend to state [in footnote one of the December 13, 2012 opinion and decision] that Finding of Fact number 6 [awarding applicant attorney fees under section 4064] was not a final decision subject to reconsideration, although we recognize that the footnote could be interpreted that way. In any event, a footnote in an Opinion on Decision does not change the effect of our affirmation [of] Finding of Fact number 6. Finding of Fact number 6 is a final decision." The WCAB thus concluded based on this reasoning that "the amendment of the Labor Code section 4064 does not affect applicant’s attorney’s fee request in this case," and remanded the matter to the WCJ for calculation of the amount of fees to which applicant was entitled.
The Court of Appeal reversed in the unpublished case of San Francisco State University v WCAB, Ellen Jones.
Whether the WCAB (or WCJ) made the proper decision in this regard hinges on whether there was "any final award" of workers’ compensation benefits, which includes the benefit of attorney fees, when the amended statute took effect on January 1, 2013. "Simply put, there was no 'final award' of attorney fees as of January 1, 2013, when the amendment took force. What we had in place was the WCAB’s December 13, 2012, order granting petitioners’ motion for reconsideration and removal, which expressly states that "the WCJ has not yet awarded attorney’s fees." Where the issue of applicant’s right to fees under section 4064 is "deferred" and the matter remanded to the WCJ - after the WCAB twice recognized in its opinion that the WCJ had "not yet awarded" such fees - we can conceive of no basis in law or reason for concluding that a "final award" of fees had already been, or was being, made. Read More...
Officials Say injured-On-Duty Program for Safety Workers Invites Abuse
Tue, 30 Sep 2014 11:13:32 - Pacific Time
The Los Angeles Times published the results of its investigation of the costs of the City of Los Angeles public safety worker injuries. It concluded that Los Angeles' police and firefighters take paid injury leave at significantly higher rates than public safety employees elsewhere in California. 1 in 5 Los Angeles police officers and firefighters took paid injury leave at least once last year, and that not only are the number of leaves going up, but they are getting longer. Taxpayers spent $328 million over the last five years on salary, medical care and related expenses for employees on injury leave. While on leave for a work-related injury, a police officer or firefighter earns 100% of his or her salary - but is exempt from federal or state taxes for a year. So it is actually more lucrative not to work than it is to work. Oh, and the state Legislature has repeatedly expanded the kinds of work-related "injuries" covered by the policy.
California legislators first mandated 100% pay for injured public safety employees during the Great Depression to ensure that those protecting the public wouldn't hesitate to chase a criminal or run into a burning building for fear of losing their livelihood. Over the years, lawmakers and local officials have expanded the range of ailments deemed to be job-related. They now include sore backs, heart disease, stress, cancer - even Lyme disease. Because police and firefighters are expected to stay in shape, an injury sustained playing racquetball at a firehouse would be covered. An LAPD officer recently was granted injury leave after he hurt himself bench pressing 400 pounds at the Police Olympics in Las Vegas. The increased leaves are putting a financial squeeze on emergency services in Los Angeles.
Total salaries paid to city public safety employees on leave increased more than 30% - to $42 million a year - from 2009 through 2013, the five-year period studied by The Times. The number who took leaves grew 8%, and they were out of work an average of nearly 9 weeks - a 23% increase compared with 2009. The increased frequency and cost of leaves has forced the Fire Department to spend millions of dollars a year in overtime and reduced the number of police officers on the street.
City leaders across California say the very design of the injured-on-duty program, IOD for short, invites abuse. Because injury pay is exempt from both federal and state income taxes, public safety employees typically take home significantly more money when they're not working. And time spent on leave counts toward pension benefits. "What's the incentive to come back to work?" asked Frank Neuhauser, executive director of the Center for the Study of Social Insurance at UC Berkeley and a leading workers' compensation researcher. The rate of claims in Los Angeles "is astronomical," he said. "It boggles the mind."
Nineteen percent of L.A. police and firefighters took at least one injury leave last year, a rate significantly higher than those of other large local governments, The Times found. For public safety employees of L.A. County and the city and county of San Francisco, the rate was 13%. In Long Beach, it was 12%. In San Diego, it was 10%. In all, L.A. police and firefighters on injury leave collected $197 million in salary from 2009 through 2013. Taxpayers spent an additional $131 million on their medical care, disability payments and related expenses, Personnel Department data show. A disproportionate amount of injury pay went to a small fraction of employees who took leaves again and again, sometimes reporting a new injury just as a previous leave was about to expire.
Fewer than 5% of injury claims by L.A. police and firefighters over the five years studied by The Times were attributed to acts of violence, smoke inhalation or contact with fire or extreme heat, Personnel Department data show. Most common are leaves for "cumulative trauma" - an umbrella term for medical problems that are not linked to a specific on-the-job injury. Those claims run the gamut of ailments that can afflict aging bodies regardless of profession: back strain, knee strain, high blood pressure, carpal tunnel syndrome. Cumulative trauma accounts for "the bulk of our big claims," typically filed by officers nearing retirement, said Karl Moody, a lawyer and former Los Angeles police officer who is head of workers' compensation investigations for the city attorney's office.
Los Angeles officials can't say for sure why the city has so many workers filing injury claims or how many may be illegitimate. That's a big problem. City officials offer a number of theories for the rise in claims and costs: an aging workforce; delays in approval of medical treatment; and the cuts in police overtime, which eliminated a key financial incentive for injured officers to return to work quickly. But among the most frequently cited explanations is a kind of cultural shift in the workforce - as employees see their colleagues take more and longer leaves, they do the same. "I would say, without any ill-intent, it just becomes a practice," said David Luther, interim general manager of the city's Personnel Department. "It becomes somewhat automatic." Mayor Eric Garcetti has promised a back-to-basics agenda, and here's a pretty basic one for him to work on. He and the City Council must investigate why Los Angeles has such high rates of injury claims by police officers and firefighters and then commit to reforms that reduce fraud and abuse of a system designed to protect workers in high-risk professions. Read More...
So. Cal. Neurosurgeons and Hospital Allegedly Involved in Implant Kickback Scheme
Mon, 29 Sep 2014 13:19:23 - Pacific Time
The United States has filed civil complaints in a federal district court in Los Angeles, under the False Claims Act against Michigan neurosurgeon Dr. Aria Sabit, spinal implant company Reliance Medical Systems, a Utah company, two Reliance distributorships - Apex Medical Technologies and Kronos Spinal Technologies, both , Florida companies - and the companies’ owners, Brett Berry, John Hoffman and Adam Pike. Reliance Medical Systems allegedly sold spinal implants in Southern California through distributorships that it controlled, including Apex Medical Technologies and Kronos Spinal Technologies. Drs. Aria Sabit and Sean Xie were physician-investors in Apex, and Drs. Gowriharan Thaiyananthan who practices neurosurgery in Orange California and Ali Mesiwala who practices in Pomona California were allegedly physician-investors in Krons. The complaints allege that Apex Medical and Kronos Spinal paid physicians, including Sabit, to induce them to use Reliance spinal implants in the surgeries they performed. The litigation also involves Ventura County neurosurgeon Moustapha Abou-Samra, M.D. and Community Memorial Health System hospital in Oxnard.
The complaints allege that Berry and Pike founded Reliance in 2006, and subsequently created more than 12 physician-owned distributorships that sold Reliance devices. Each of Reliance’s distributorships sold spinal implants ordered by their physician-owners for use in procedures the physician-owners performed on their own patients. The complaints allege that Reliance used one of its distributorships, Apex Medical, to funnel improper payments to Sabit for using Reliance spinal implants in his surgeries. According to the complaints, Sabit began using Reliance implants on his patients only after he acquired an ownership interest in Apex and started receiving payments from the sale of Reliance’s spinal implants. Apex allegedly paid Sabit $438,570 between May 2010 and July 2012, during which time Sabit used Reliance implants in approximately 90 percent of his spinal fusion surgeries. The government also alleges that these payments caused Sabit to perform medically unnecessary or excessive surgeries on certain patients who did not need the spinal implants.
The government further alleges that Reliance operated a second distributor, Kronos, in southern California, which made improper payments to two other physicians, Drs. Ali Mesiwala and Gowriharan Thaiyananthan. Allegedly, Reliance’s owners were recorded telling a potential Kronos investor that Reliance was formed as part of a plan to "get around" the federal Anti-Kickback Statute, which prohibits such improper payments, and that Reliance pays its physician-investors enough in the first month or two to "put their kids through college."
The allegations that Sabit performed medically unnecessary or excessive surgeries were raised in a separate lawsuit filed by Dr. Cary Savitch and Dr. Gary Proffett under the qui tam, or whistleblower, provisions of the False Claims Act. The act allows private citizens with knowledge of fraud to bring civil actions on behalf of the government and to share in any recovery. The act also permits the government to intervene in the whistleblowers’ lawsuit. In this case, the government has both intervened in the whistleblowers’ medical necessity claims and filed a separate lawsuit containing kickback claims against both Sabit and the Reliance defendants.
With respect to involved Ventura County defendants, the private complaint alleges that in the spring of 2009, defendant Moustapha Abou-Samra, M.D. a Board Certified neurosurgeon and president of Ventura County Neurosurgical Associates with full privileges at Community Memorial Health System (CMH), recruited Aria Omar Sabit, M.D., a non-board certified neurosurgeon, to relocate from New Jersey to Ventura County, California to be employed by Abou-Samra's corporation. Sabit was allegedly allowed to perform highly specialized neurosurgical operative procedures including spinal surgeries with open reduction and internal fixation, spinal fusions, laminectomies and pedicle screw implantation at CMH despite demonstrations that his surgeries were allegedly plagued with high infection rates, high return-to-surgery rates, violations of operating room protocols, failures in instrumentation, surgical mishaps, inappropriate case selection and high complication rates. Sabit had allegedly performed over 375 procedures from June 2009 to December 2010 while under provisional privileges at CMH. Some 27 patients who were injured by Sabit's procedures brought individual lawsuits in the Superior Court of the State of California for the County of Ventura against Sabit and some of the other defendants for medical malpractice. Not all of these plaintiffs are Medicare beneficiaries. Sabit was using Apex manufactured instrumentation in many of the surgeries at CMH and that Sabit had a financial interest in Apex. Sean Xie, M.D., a neurosurgeon in Los Angeles to whom Sabit referred some of his patients with complications from Sabit's surgeries, also had an interest in Apex.
This investigation was a coordinated effort among the Commercial Litigation Branch of the department’s Civil Division and the U.S. Department of Health and Human Services-Office of the Inspector General. The lawsuits were filed in the Central District of California (Los Angeles), and are captioned United States ex rel. Carey Savitch, M.D., and Gary Proffett, M.D. v. Aria Sabit, M.D., Moustapha Abou-Samra, M.D., and Community Memorial Health System, Case No. 13-3363, and United States v. Reliance Medical Systems, Apex Medical Technologies, Kronos Spinal Technologies, Bret Berry, John Hoffman, Adam Pike, and Aria Sabit, M.D. Case No 14-6979 Read More...
Ruling Says Sacramento Bee Misclassified Carriers
Mon, 29 Sep 2014 13:19:17 - Pacific Time
A Sacramento Superior Court judge ruled that the Sacramento Bee misclassified its newspaper carriers as independent contractors when they were, in fact, employees. Judge Gerrit Wood found the newspaper had the right to control the manner and means of how the carriers performed their duties, making them employees under the law.
According to the story in Bizjournal, the Sacramento Bee plans to contest the ruling. Publisher and president Cheryl Dell called it a "bewildering" and "a failure of justice. The Bee is extremely disappointed in the decision and strongly believes that the individual newspaper carriers were properly classified as independent contractors," Dell said in a statement. "Our classification of carriers as independent contractors is in full compliance with regulations issued directly to the newspaper industry by the state of California."
Whether workers are employees or independent contractors is a hot issue in California and nationwide because it affects the cost of doing business and protections for workers. Employers do not pay unemployment, state disability and or workers’ compensation taxes for independent contractors, which means significantly lower payroll taxes and, potentially, a competitive edge when bidding for work.
Misclassification means payback time that can run in the millions. When litigation is protracted - as it is in this five-year-old class action - attorneys' fees and court costs get cranked up, too.
The fight in this case was narrowed over time to whether carriers who worked for the Sacramento Bee any time between 2005 and 2009 should be reimbursed for mileage expanses because they were incorrectly classified as independent contractors. The decision follows a nine-week trial in Sacramento Superior Court earlier this year. With more than 5,100 people in the class, the mileage tab could be more than $21 million Callahan said.
How much The McClatchy Co., parent company to The Sacramento Bee, has paid lawyers to defend the case is unknown. But plaintiffs’ attorneys costs so far are more than $12 million - and McClatchy often had four or more lawyers in court, Callahan said.
"We got the decision," said John Poulos, the Sacramento attorney who represents the newspaper. "In our view, it’s problematic and lowers the state of California regulations that govern newspaper carriers relative to employment or independent contractor status. Our evidence at trial showed the Bee complied." If the tentative decision holds, plaintiffs’ attorneys will have to provide records that document the mileage expenses, Poulos said. Then the newspaper can file an appeal. An appeal cannot be filed until the decision is finalized. If there is not an appeal, the case moves to the damages phase.
Filed in 2009, the cases goes back to 2005 because there is a four-year statute of limitations. The issue doesn’t apply after 2009 because the newspaper gradually shifted to a third-party distribution channel. Distribution was mixed during the time period of the lawsuit. Read More...
Final Hospital Outpatient Departments and ASC Fee Schedule Now Effective
Fri, 26 Sep 2014 09:00:45 - Pacific Time
The Acting Administrative Director of the Division of Workers’ Compensation (DWC) has amended Title 8, Code of Regulations Section 9789.32 of the hospital outpatient departments and ambulatory surgical centers (HOPD/ASC) fee schedule regulations . The amendment was filed with the Secretary of State on September 23, 2014.
The amendment corrects the payment methodology formula set forth in Section 9789.32(1)(c)(B)(ii) for service s rendered on or after September 1, 2014.
As set forth in Labor Code section 5307.1(c)(1), the maximum facility fee for services performed in a hospital outpatient department, shall not exceed 120 percent of the fee paid by Medicare for the same services performed in a hospital outpatient department. Senate Bill 863 also required that for services rendered in ambulatory surgical centers on or after January 1, 2013, the maximum facility fee shall not exceed 80 percent of the fee paid by Medicare for the same services performed in a hospital outpatient department.
Effective Jan. 1, 2013, the Acting Administrative Director amended the HOPD/ASC fee schedule (Title 8, California Code of Regulations, sections 9789.30 et seq.), to implement Senate Bill 863 as it relates to the OMFS HOPD/ASC fee schedule.
In March of 2014, the Division initiated a rulemaking action to amend the HOPD/ASC fee schedule as follows: 1. Transition payment policies from the pre-2014 OMFS physician fee schedule to the OMFS RBRVS-based physician fee schedule; 2. Eliminate the alternative payment methodology for hospital outpatient and ASC services rendered on or after September 1, 2014; and in accordance with changes to Medicare’s fee-related structure and payment rules for the hospital outpatient departments prospective payment system (OPPS), adjust the Workers’ Compensation Multiplier (which included the additional percentage added to the Medicare Multiplier for outliers).
On May 22, 2014, after considering public comments received during a public hearing and one written comment period, the Acting Administrative Director submitted the amended regulations to the Office of Administrative Law for file and print only. The amended regulations were filed with the Secretary of State on June 3, 2014. The regulations are effective for services rendered on or after September 1, 2014.
The objective of the current rulemaking action is to amend the OMFS HOPD/ASC fee schedule to correct the payment methodology for "Other Services" that are paid according to the RBRVS Practice Expense relative value units. The RBRVS conversion factor should be applied in the payment methodology instead of the HOPD/ASC Workers’ Compensation Multiplier that was adopted by the HOPD/ASC fee schedule regulations. Correcting the payment methodology to include the application of the RBRVS conversion factor is beneficial because payment would otherwise be incorrectly calculated.
This amendment is necessary to correct the formula to include the application of the RBRVS Conversion Factor instead of the HOPD/ASC Workers’ Compensation Multiplier, otherwise erroneous payment calculations will occur for this group of services. The current formula incorrectly uses the HOPD/ASC multiplier when the services are paid according to the RBRVS-based physician services fee schedule payment factors. Without application of the RBRVS conversion factor, the Practice Expense relative values could not be converted into a dollar amount. (The RBRVS conversion factor takes into account the multiplier.) Read More...
L.A. Probation Officer Faces Fraud Charges
Fri, 26 Sep 2014 09:00:37 - Pacific Time
A Los Angeles County Probation officer was arrested Tuesday for allegedly filing false workers' compensation documents, according to L.A. County Probation Chief Jerry Powers.
Cynthia Wesley, a detention officer assigned to Central Juvenile Hall, was arrested at 10:30 p.m. Tuesday night on one count of filing a fraudulent insurance claim and one count of falsifying worker's compensation documents, Powers told KPCC, adding that Wesley was booked into Temple City Sheriff's station Tuesday night and was released on Wednesday on $60,000 bail.
KPCC reported last week on abuse of workers' compensation and disability policies among county probation officers.
Powers said Probation Department officials made the arrest in conjunction with the Los Angeles County Sheriff's Department.
Wesley's disability claim was labeled as suspicious by county probation investigators in May, according to Powers. A closer look by both probation and California Department of Insurance investigators revealed Wesley allegedly "manufactured" some of the claim forms she submitted to a supplemental disability insurance company to get benefits the department says she wasn't entitled to. Read More...
FBI Says 4.5 Million Community Health Systems Records Stolen by China Hackers
Thu, 25 Sep 2014 05:45:55 - Pacific Time
Your medical information is worth 10 times more than your credit card number on the black market.
Last month, the FBI warned healthcare providers to guard against cyber attacks after one of the largest U.S. hospital operators, Community Health Systems Inc,, with facilities nationwide and in California, said Chinese hackers had broken into its computer network and stolen the personal information of 4.5 million patients. Security experts say cyber criminals are increasingly targeting the $3 trillion U.S. healthcare industry, which has many companies still reliant on aging computer systems that do not use the latest security features. "As attackers discover new methods to make money, the healthcare industry is becoming a much riper target because of the ability to sell large batches of personal data for profit," said Dave Kennedy, an expert on healthcare security and CEO of TrustedSEC LLC. "Hospitals have low security, so it's relatively easy for these hackers to get a large amount of personal data for medical fraud."
Interviews with nearly a dozen healthcare executives, cybersecurity investigators and fraud experts provide a detailed account of the underground market for stolen patient data. The data for sale includes names, birth dates, policy numbers, diagnosis codes and billing information. Fraudsters use this data to create fake IDs to buy medical equipment or drugs that can be resold, or they combine a patient number with a false provider number and file made-up claims with insurers, according to experts who have investigated cyber attacks on healthcare organizations.
Medical identity theft is often not immediately identified by a patient or their provider, giving criminals years to milk such credentials. That makes medical data more valuable than credit cards, which tend to be quickly canceled by banks once fraud is detected. Stolen health credentials can go for $10 each, about 10 or 20 times the value of a U.S. credit card number, according to Don Jackson, director of threat intelligence at PhishLabs, a cyber crime protection company. He obtained the data by monitoring underground exchanges where hackers sell the information.
The percentage of healthcare organizations that have reported a criminal cyber attack has risen to 40 percent in 2013 from 20 percent in 2009, according to an annual survey by the Ponemon Institute think tank on data protection policy. Founder Larry Ponemon, who is privy to details of attacks on healthcare firms that have not been made public, said he has seen an increase this year in both the number of cyber attacks and number of records stolen in those breaches. Fueling that increase is a shift to electronic medical records by a majority of U.S. healthcare providers.
Marc Probst, chief information officer of Intermountain Healthcare in Salt Lake City, said his hospital system fends off thousands of attempts to penetrate its network each week. So far it is not aware of a successful attack. "The only reason to buy that data is so they can fraudulently bill," Probst said.
Healthcare providers and insurers must publicly disclose data breaches affecting more than 500 people, but there are no laws requiring criminal prosecution. As a result, the total cost of cyber attacks on the healthcare system is difficult to pin down. Insurance industry experts say they are one of many expenses ultimately passed onto Americans as part of rising health insurance premiums. Consumers sometimes discover their credentials have been stolen only after fraudsters use their personal medical ID to impersonate them and obtain health services. When the unpaid bills are sent on to debt collectors, they track down the fraud victims and seek payment.
The government's efforts to combat Medicare fraud have focused on traditional types of scams that involve provider billing and over billing. Fraud involving the Medicare program for seniors and the disabled totaled more than $6 billion in the last two years, according to a database maintained by Medical Identity Fraud Alliance. "Healthcare providers and hospitals are just some of the easiest networks to break into," said Jeff Horne, vice president at cybersecurity firm Accuvant, which is majority-owned by private equity firm Blackstone Group. "When I've looked at hospitals, and when I've talked to other people inside of a breach, they are using very old legacy systems - Windows systems that are 10 plus years old that have not seen a patch." Read More...
Owner of Emmanuel Medical Supply in Long Beach Convicted in Federal Fraud Case
Thu, 25 Sep 2014 05:45:49 - Pacific Time
The former owner of a Long Beach, California, medical supply company was sentenced to serve 30 months in prison and ordered to pay $1,490,532 in restitution for his role in a scheme to provide unnecessary power wheelchairs to Medicare patients, resulting in $2.6 million in fraudulent claims to Medicare.
According to court documents, Akinola Afolabi, 55, of Long Beach, California, was the owner and president of Emmanuel Medical Supply, a durable medical equipment supply company in Long Beach. From June 2006 through September 2009, Afolabi provided medically unnecessary power wheelchairs and other medical equipment to Medicare beneficiaries, and submitted fraudulent claims to Medicare for this equipment. Afolabi admitted that he paid "marketers" to obtain Medicare beneficiary information that he used on the false claims. Afolabi admitted that prescriptions for the equipment and related medical documents were fraudulent, and that some of the beneficiaries did not even receive the wheelchairs or other medical supplies that were billed.
From June 2006 through September 2009, Afolabi submitted approximately $2,668,384 in fraudulent claims to Medicare for power wheelchairs and related services, and Medicare paid approximately $1,490,532 on those claims.
The case was investigated by the FBI and was brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Central District of California. This case is being prosecuted by Trial Attorney Fred Medick of the Criminal Division’s Fraud Section. Read More...
Living in a Disadvantaged Neighborhood Worsens Pain Outcomes After Trauma
Wed, 24 Sep 2014 10:15:22 - Pacific Time
Individuals living in disadvantaged neighborhoods have worse musculoskeletal pain outcomes over time after stressful events such as motor vehicle collision than individuals from higher socioeconomic status neighborhoods, even after accounting for individual characteristics such as age, sex, income, education, and employment status. Since apportionment under SB 899 is based upon "causation", medical evaluators may wish to consider this study when determining the actual cause behind an the AMA Guides pain add-on rating.
According to the summary by the University of North Carolina School of Medicine, individuals living in disadvantaged neighborhoods have worse musculoskeletal pain outcomes over time after stressful events such as motor vehicle collision than individuals from higher socioeconomic status neighborhoods, even after accounting for individual characteristics such as age, sex, income, education, and employment status.
These were the findings of a multi-site research study led by Samuel McLean, MD, MPH, associate professor of anesthesiology and emergency medicine at the University of North Carolina School of Medicine. The results of the study were published online by the journal Pain. "We all like to believe that we are immune to the circumstances of our environment," said Dr. McLean. "These results suggest that when it comes to chronic musculoskeletal pain development after traumatic/stressful events, the poet John Donne was right " ‘No man is an island.' "
The investigators enrolled 948 European-American individuals who presented to emergency care centers in four U.S. states for evaluation after car accidents. Patients were enrolled at the time of their presentation for emergency care, and then received follow-up evaluation at 6 weeks, 6 months, and 12 months. Approximately 90 percent of participants completed follow up at each time point.
Information regarding each study participant’s neighborhood environment was determined by geocoding their home address to a "census tract." A census tract is the smallest territorial unit for which population data are available in the U.S. Census tract data was then used to determine neighborhood socioeconomic status using the Socioeconomic Position Index. This index generates a total score by averaging scores of the following measures: percent unemployed, percent below the U.S. poverty line, percent with high school education or less, percent of expensive homes (owner-occupied homes worth $300,000 or more) in the neighborhood, and median household income.
After adjusting for individual-level factors including participant sex, age, highest level of educational attainment, family income, and employment status, living in a more disadvantaged area was found to increase pain burden in the months after the car accident. Results remained significant after adjustment for receiving opioids at the time of emergency care, litigation status, obesity (body mass index), at-risk drinking habits prior to the accident, and mental health status prior to the accident.
There are many ways that living in a poor neighborhood might increase pain across time after a car accident. One potential factor is that living in a disadvantaged neighborhood increases stress and has been shown to affect the function of an individual’s stress (i.e., "fight or flight") system. To test this hypothesis, the investigators collected blood samples from participants, and evaluated whether those participants with a common genetic variant which makes one more vulnerable to stress were more affected by the adverse effect on pain of living in a disadvantaged environment. The investigators found that this was the case: those without the genetic variant were relatively unaffected, whereas those with the gene had large and clinically significant differences in pain outcomes depending on their neighborhood environment.
"This finding suggests that the increased stress of living in a disadvantaged neighborhood affects biological systems in the body in ways that increase pain and worsen pain outcomes," said Dr. McLean. "These results also add further evidence that stress systems are involved in the development of chronic pain. This is really important, because we have to understand the biology in order to be able to develop better preventive interventions."
First author of the study is Jacob Ulirsch, BS, a former collaborator in Dr. McLean's lab. UNC co-authors include Mark A. Weaver, PhD, research assistant professor in the UNC Gillings School of Global Public Health; and Andrey V. Bortsov, research assistant professor in the UNC Department of Anesthesiology. This research was supported by a grant R01 AR056328 from the National Institutes of Health. Read More...
Survey Shows Californians Turn on Obamacare
Wed, 24 Sep 2014 10:15:16 - Pacific Time
The Affordable Care Act continues to divide Californians, who remain skeptical four years after its passage despite the state’s relatively smooth launch in which more than 1.2 million people enrolled in health insurance coverage.
A new survey released late Tuesday found some 42 percent of state residents generally view the law favorably, while 46 percent harbor unfavorable opinions. Support is down somewhat since May, before a wave of targeted TV ads began in a handful of competitive congressional districts.
Democrats view the law positively while an overwhelming majority of Republicans (80 percent) see it unfavorably. Of the 1 in 5 Californians who say that they were aided by the law, 31 percent say that it allowed them or a family member to obtain or retain health care. Meanwhile, of the 1 in 5 who said they have been harmed by the law, more than half reported it led to higher costs while about 20 percent say it made it more difficult to get coverage.
The survey, by the Public Policy Institute of California, also determined likely voter sentiment on other major issues: Read More...
Past Week News Archive
City of Santa Monica Reports 12% Increase in Comp Costs: Tue, 23 Sep 2014 12:14:18 - Pacific Time: Read More...
New MPN Regulations Take Effect: Tue, 23 Sep 2014 12:14:11 - Pacific Time: Read More...
WCAB Rules UR Process Applies to MPN Physicians: Mon, 22 Sep 2014 10:19:09 - Pacific Time: Read More...
New Fibromyalgia Study Points to Mental Mechanisms: Mon, 22 Sep 2014 10:19:02 - Pacific Time: Read More...
LA County Probation Department Reduces Claims by One Third: Fri, 19 Sep 2014 08:38:53 - Pacific Time: Read More...
Alpha Ambulance Inc. Manager Guilty in $5.5 Million Fraud Conspiracy: Fri, 19 Sep 2014 08:38:44 - Pacific Time: Read More...
Defense Attorney Prevails in Disgruntled Applicant's Civil Case: Thu, 18 Sep 2014 13:16:39 - Pacific Time: Read More...
DWC Adjusts DME Fee Schedule: Thu, 18 Sep 2014 13:16:32 - Pacific Time: Read More...
NFL Legend, Brad Culpepper, Sued in Orange County for Comp Fraud: Wed, 17 Sep 2014 10:16:54 - Pacific Time: Read More...
DWC Proposes Revisions to Copy Service Fee Schedule: Wed, 17 Sep 2014 10:16:47 - Pacific Time: Read More...