Ringler Associates Makes Organizational Announcement And Other News Tidbits

Here are the best tidbits of recent news from the workers’ comp world:

 

Ringler Associates Incorporated Makes Organizational Announcement

Ringler Associates Incorporated, the nation’s largest structured settlement company, announces important organizational promotions for 2016 as well as additions and reelections to its Board of Directors. Brian Farrell: Effective immediately, shareholders at the Ringler Associates Annual Meeting on January 29, 2016 re-elected Brian M. Farrell, of Meriden, Connecticut to another term on the Board of Directors and the Board voted that Mr. Farrell shall become Vice Chairman of Ringler Associates, a newly created position in the company. Chairman W. Ross Duncan says the new position is part of the company’s continued strengthening of its succession planning and, “Brian has been in the structured settlement business since 2002, joining Ringler Associates in 2009 with expertise that has made him a natural leader for years to come.” Read more…

 

Tower MSA Partners’ Pre-MSA Triage Delivers Major Savings

Workers’ compensation payers using Tower MSA Partners’ Pre-MSA Triage have seen their Medicare Set-Aside allocations dramatically reduced. Tower’s Pre-MSA Triage identifies claims needing intervention before MSA. Payer saved over $1 mil on a single claim. Tower’s Pre-MSA Triage analyzes medical and pharmacy records, identifies unnecessary, inappropriate, cost-driving treatment and recommends interventions to improve patient and financial outcomes. The service ensures that MSAs include only accurate and appropriate medical and pharmaceutical allocations. “Triage projects the cost of a potential MSA and gives clients ways to reduce the costs before preparing the actual MSA,” said Tower CEO Rita Wilson. Read more…

 

 

Broadspire®”s Danielle Lisenbey to Receive Legends Award

Danielle Lisenbey, president and CEO of Broadspire, has been selected to receive the Donald T. DeCarlo Legends Award, which she will accept in April during the American Society of Workers Compensation Professional’s (AMCOMP) annual meeting in Las Vegas. AMCOMP presents the award each year to individuals who have shown commitment to the workers compensation arena by contributing time and effort and fostering efficiency of the system. It is a not-for-profit industry organization dedicated to professional excellence in the field of workers compensation. Read more…

 

 

Imagine A Better St. Louis: Express Scripts committed to corporate multiculturalism

Express Scripts is one of the most valuable companies in the country and also happens to call St. Louis home. It places a high value on having a diversified workforce, which is well-represented by women, minorities and young people. Senior Director of Diversity Susan Stith believes it only makes sense for the St. Louis-based company to hire the way they do because women usually make the healthcare decisions within a household. Stith told News 4 the workforce at Express Scripts is made up of 70 percent women, 37 percent of which are minorities. The average age of an employee at the company is 42. Read more…
 

Lean Living

Have you already stopped going to the fitness center, and given up on your diet? The wonderful thing about wellness is you can start your new plan whenever you choose, and you can go at your own pace. The Better Me Wellness team is always being asked what is the best workout program, and what diet do you recommend? The problem with answering this question is there is not one answer. Your neighbor’s bootcamp class may not be a good fit for you, and just because your co-worker is gluten-free, it doesn’t mean that you should jump on the bandwagon. Read more…

 

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

Hundreds of Ohio Employers Benefit from Workplace Safety

Keeping employees safe can certainly pay dividends for many employers.

 
Recently, more than 570 Ohio employers have received, or are in the process of receiving, nearly $15 million in safety grants from the Ohio Bureau of Workers Compensation.

 

Ohio BWC expects to finish awarding its Fiscal Year 2016 grants in the next few weeks to applications already in hand. This will be the quickest the money has been awarded since the amount of available dollars was tripled by Governor John Kasich three years ago.

 

“Ohio’s employers value the safety of their workers, and understand how investments in safety can reduce injuries and increase productivity,” said BWC Administrator/CEO Steve Buehrer. “We have seen our injury claims drop more than 10 percent, from 105,000 to 94,000 over the past five years, which tells us Ohio’s workplaces are getting safer.”

 

Since Fiscal Year 2011 both claims that involve medical care only, as well as those involving time off work have dropped. In FY 15, BWC approved 81,348 medical-only claims and 11,870 lost time claims compared to 89,505 medical only and 13,296 lost-time claims in FY11. This drop in claims has helped BWC reduce employer rates. Since 2011 private business rates have been reduced 21.4 percent overall, while public employers have seen a reduction of 26.5 percent.

 

Ohio Injury Rate Below National Average

 

Ohio’s safety record is echoed in recent figures released by the Bureau of Labor and Statistics, which continue to show Ohio’s injury rate is below the national average. Those statistics, from 2014, show Ohio’s injury rate is 2.9 injuries per 100 workers, compared to a national average of 3.4 injuries per 100 workers. Ohio’s rate is lower than all its neighboring states including Michigan (3.7), Indiana (4.0), Kentucky (3.8), West Virginia (4.1) and Pennsylvania (3.6).

 

“With a workforce approaching six million, even this small difference means tens of thousands fewer injuries than if we were at the national average,” noted Buehrer.

 

“Ohio’s safety grant program is a proven way for employers to reduce exposure to hazards and consequently prevent accidents and injuries in their workplaces,” says BWC’s Chief of Safety and Hygiene Abe Al-Tarawneh. “Our data show that employers who participated in this program in the past managed to reduce the frequency and cost of injuries in the area of the intervention by 66% and 81%, respectively.”

 

 

 

Author Kori Shafer-Stack, Editor, Amaxx Risk Solutions, Inc. is an expert in post-injury response procedures and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. www.reduceyourworkerscomp.com.  Contact: kstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

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Claim File Conferences Give Perspective On Moving Claims Forward

Claim offices frequently employ a technique known as individual file conferences where the adjuster and the supervisor set aside a specific time to discuss one or more large, serious and/or catastrophic claims. Frequently the workers’ compensation adjuster and supervisor will expand their claim file discussion to include the claims manager, other supervisors, other adjusters and the employer.

 

 

Employer Should Stay Involved On Claims

 

The employer should designate a representative, whether the workers’ compensation coordinator, or another person, to participate in the individual file conferences. This accomplishes two things. First, it allows the employer to be up to date on the status of their claims; particularly large, serious or catastrophic claims. Second, in the states where employer input is allowed, the employer can offer insights or recommendations on bringing the employee back to work.

 

The discussion coordinator, whether the adjuster or supervisor, designates or selects the particular workers’ compensation claim(s) to be reviewed. While the expected cost of a claim can be a reason for a claim to be selected for review, claim cost is not normally the basis for an individual file conference. The claim(s) chosen for discussion are selected based on the obstacles the adjuster has encountered in moving the claim forward. This can include issues of medical necessity, delayed return to work, narcotic addiction, hearing issues, etc. If more than one claim is included in the discussion, each file is discussed separately and independently of other claim(s).

 

The organizer of the individual file conference will set a date and time for the discussion. Prior to the electronic age, the group would sit around a conference room table to discuss the claim. Now days, the “group” may be in several separate locations and attend the conference by telephone, Skype, webinars or other electronic means.

 

 

Provides Additional Perspective On How To Handle Claim

 

The purpose of individual file conferences is to provide the claims handler with additional perspectives and thoughts on how to deal with an issue. Adjusters, like all other people, develop ways of doing things. Falling into a claim handling rut, where ever claim is handled similarly, can limit the adjuster’s field of vision on what to do on a particular claim.

 

The individual file conferences by providing other points of view improve the potential outcomes of the claim. The individual file conferences can be an extremely beneficial learning experience for the newer adjusters, but also provides “why didn’t I think of that” moments for even the seasoned old pros.

 

At each individual file conference, the adjuster keeps a list of the suggestions and recommendations made to move the workers’ compensation claim forward. The list of suggestions and recommendations can be incorporated into the adjuster’s diary of issues and activities that need to be addressed or completed on each file.

 

For individual file conferences to be productive and not a waste of time for the participants besides the adjuster, the adjuster on the claim file should be prepared to discuss each individual claim. This includes having an outline of the issues to be discussed that are preventing the claim from moving forward at the normal pace.

 

 

File Conferences Are About Moving The Claim Forward

 

Employer participation in individual file conferences is not an opportunity for the employer to learn about the history of a claim from day one. As an employer if you are going to participate in the individual file conferences, you need to have kept abreast of the claim throughout the history of the claim. The individual file conference is about moving the claim forward to the conclusion. It is not about educating the employer.

 

While the employer should not waste the other participants time getting up to date on the file, the employer should also insist the discussion remain focused on the particular claim issues at hand and not allow the discussion to drift off on to unrelated issues or other claims.

 

Individual file conferences should be scheduled as needed as only a truly bad claim would entail having an on-going schedule of dates to discuss it. This does not mean that individual file conferences cannot be set on a schedule (example: second Tuesday of the month, 2 p.m.).   If a preset schedule is used, the claims to be discussed each date should be changed, and the individual file conference cancelled if there is not a claim that needs the extra attention that the individual file conference provides.

 

 

Different Perspectives Can Be Invaluable to Resolving a Claim

 

Individual file conferences can result in the claim taking a turn the workers’ compensation adjuster did not foresee prior to the file conference. The perspectives provided by other participants can be invaluable to resolving the claim. However, if the same participants are in all the file conferences, the value of the input will decline over time as the adjusters learn what the other participants will suggest. For this reason, in large claim offices the participants beyond the adjuster, the supervisor and the employer should be changed constantly. In the small claim offices, the adjuster can invite a nurse case manager, defense counsel, work comp judges, plaintiff attorneys (not related to the claim) and others to participate in the discussion.

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

Injured Workers Leads to Fines Against Ohio Business

Three workers suffered amputation injuries within four months at a Columbiana, Ohio envelope printing facility because their employer failed to protect them from moving machine parts on 26 of the 27 company production lines, a federal inspection found.

 
Following a U.S. Department of Labor Occupational Safety and Health Administration inspection, the agency cited Envelope 1 on Dec. 15 for three willful and four serious violations. Proposed penalties total $88,200.

 

“When repeated amputation injuries occur at a business, safety is not a priority,” said Howard Eberts, OSHA’s area director in Cleveland. “After OSHA initiated its first inspection involving an amputation in June 2015, Envelope 1 failed to take immediate steps to protect workers. If they had, it may have prevented other injuries.”

 

OSHA’s investigation found the following:

 

  • On June 19, 2015, a machine operator had a finger amputated when it caught in a pinch point of printing section rollers as he wiped a roller. The 52-year-old employee had been employed at the plant for six months.
  • On Sept. 16, 2015, a 29-year-old employee suffered partial amputation of his left finger as he cleared material from a scoring section of an envelope line. The operator’s hands were exposed to operating parts because the machine lacked adequate safety guards.
  • On Sept. 28, 2015, a 73-year-old worker had part of this thumb amputated as he adjusted rollers during the setup of an envelope printing section.

 

Envelope 1 was given 15 business days from receipt of its citations and penalties to comply, request an informal conference with OSHA’s area director in Columbus, or contest the findings before the independent Occupational Safety and Health Review Commission.

 

 

 

Author Kori Shafer-Stack, Editor, Amaxx Risk Solutions, Inc. is an expert in post-injury response procedures and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. www.reduceyourworkerscomp.com.  Contact: kstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

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Understanding Federal Workers’ Compensation Claims

Federal workers’ compensation claims are a growing area of business for many third party administration companies.  With this growth comes an opportunity for team members to learn a new line of work and enhance the services they provide.

 

 

Quick Background on Federal Work Comp

 

The federal workers’ compensation system was established in the early 1900s to deal with work-related injuries sustained by federal employees.  This program is administered under the Federal Employees Workers’ Compensation Act, and covers all federal government disability insurance in the United States.

 

Like state-based workers’ compensation programs, this law covers a variety of indemnity and medical benefits.  Federal workers with compensable injuries in the workplace are also entitled to various vocational rehabilitation benefits.

 

 

 

How the Federal Workers’ Compensation Operates

 

The federal workers’ compensation program is the responsibility of the Office of Workers’ Compensation Programs (OWCP) within the United States Department of Labor.  This office administers the benefits federal workers are entitled to if they claim to or have in fact sustained a compensable workplace injury.  Other groups of federal workers’ compensation programs include the following:

 

  • Energy Employees Occupational Illness Compensation Program;
  • Federal Employees’ Compensation Program;
  • Longshore and Harbor Workers’ Compensation Program; and
  • Black Lung Benefits Program.

 

 

Understanding Federal Workers’ Compensation Benefits

 

Injured workers under the above programs are entitled to various benefits that are often found in state workers’ compensation programs.  The difference lies in the determination and payment lengths of these benefits.

 

  • Continuation of Pay or “COP” is defined under 20 C.F.R. §10.200 and serves as an injured workers wage loss benefits. For most federal work injuries, the injured party is entitled to 100% of their regular pay for a period no longer than 45 calendar days as long as the person is disabled.  This percentage is then reduced and the employee continues to receive either total or partial disability benefits until they are reassigned or fully return to work.  Unlike their state counterparts, COP is considered “compensation” and therefore taxable under the Internal Revenue Code.  It is also subject to retirement and other deductions.

 

  • Medical Benefits. Under the federal workers’ compensation scheme, an injured work is entitled to choose the primary doctor of their choice without objection. The ability to change doctors is limited for subsequent changes.  The workers’ compensation plan pays for all reasonable and necessary medical treatment provided it is causally related to the work injury.

 

  • Vocational Rehabilitation. Injured workers under the federal framework are also expected to make efforts to either return to their pre-injury work, or accept a comparable assignment within their work restrictions.  Issues regarding return to work can include assignments to a different work shift or other differentiating characteristics.

 

There are also various other factors to consider when dealing with federal workers’ compensation benefits.  These factors include the pay grade of an employee, length of service within the federal government and the nature of their work.

 

 

Other Factors to Consider

 

Dealing with federal workers’ compensation matters presents additional issues for parties involved in these cases.  This includes strict limitations on the ability of employees to have their benefits discounted or terminated.  The use of other traditional methods of cost containment such as utilization review and independent medical examinations is also limited based on statute and practice.  If one is not familiar with these practices, it is important to consult an expert or attorney.

 

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

Workplace-NL Notes New Certification Training Registry

A new, online Certification Training Registry is now available for all workers, employers and WorkplaceNL-approved training providers and trainers in Newfoundland and Labrador (Canada). Workers’ records for required safety training will be electronic instead of paper-based certificates.

 

Workers, employers and OH&S officers can access up-to-date certification training records through a smartphone or any web-enabled device. This allows them to better monitor expiry dates on required training, and ensure workplace compliance with OH&S legislation. A mobile app will be available early 2016.

 

“Workers and employers can receive alerts when training is about to expire, and then check the online marketplace to find a course from a WorkplaceNL-approved trainer near them,” said Leslie Galway, CEO. “This is a more robust system to help track and ensure that anyone working in some very high-risk areas receive the training needed to help save their lives, or their co-workers lives.”

 

The estimated 170,000 paper-based training certificates that are already issued are still valid until their stated expiry. Renewal or new training records going forward will be electronic and easily accessed in the new, online system.

 

The system stores the electronic training records for workers in all eight of the certification training standards authorized by WorkplaceNL: confined space entry, fall protection, OH&S Committee/WHSR/Ds, power line hazards, first aid, traffic control person, mine rescue and diving. First-aid records will be available in early 2016.

 

Certified training standards ensure safe and healthy workplaces. Since introducing Fall Protection training in 2012, the injury rate for fall from heights has dropped by 21 per cent. A positive change, but more work is needed as there are still 15 Newfoundlanders and Labradorians injured at work every day.

 

Workers and employers can access the CTR from WorkplaceNL’s website, www.workplacenl.ca.

 

 

 

Author Kori Shafer-Stack, Editor, Amaxx Risk Solutions, Inc. is an expert in post-injury response procedures and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. www.reduceyourworkerscomp.com.  Contact: kstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

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Cost Mitigation Techniques for Chiropractic Work Comp Claims

Chiropractic care remains a popular medical treatment modality for workers’ compensation claims involving the spine, joints and other injuries.  It is important to members of the claims management team to be proactive on these claims in order to avoid paying for excessive care and to make whole the injured worker.

 

While most chiropractors are thoughtful medical providers, there is an opportunity for abuse.  This article explores areas of concern and evaluation.

 

  • Evidence of a reasonable treatment plan: Every medical provider must set forth a reasonable treatment plan.  This includes care an employee receives at a chiropractor.  It should be demanded that a chiropractor provide a plan that is reasonable from the onset of care.

 

  • Documentation of the details of the treatment: This includes a detailed description of the medical care and treatment provided.  Evaluate carefully those records that tend to have repetitive treatments.

 

  • The degree and duration of the relief resulting from the treatment: Scrutinize records that show a trend of improvement that is then followed by an exacerbation of symptomology requiring ongoing care.  Be cautious of unexplained events that happen and question the veracity of such claims.

 

  • Whether the frequency of treatment was warranted: All medical care and treatment needs to be justified.  This includes the recommendations for future medical care and treatment.  This issue can be challenged via an independent medical examination.

 

  • The relationship of the treatment to the goal of returning the employee to suitable employment: This is another area that is ripe for review via an independent medical examination.  A careful review of the first several weeks should give claim management team members and idea if the chiropractor in question has the best interests of the injured worker in mind.

 

  • Potential aggravation of underlying conditions by additional chiropractic treatment: Evidence of this element is common when people overuse chiropractic care.  If the injured worker is not receiving lasting relief after several weeks, it may be time to try a different form of care.

 

  • The cost of treatment in light of relief provided: Chiropractic care can become expensive over time.  Carefully review and scrutinize all billing statements.  Pay particular attention to applicable medical fee schedules for services rendered by a chiropractor.

 

If discovery rules permit, obtaining the employee’s deposition testimony at some point can be helpful when defending a claim involving ongoing chiropractic care.  Areas to explore at a deposition or through other means of discovery should include the following:

 

  • The employee’s testimony about the relief obtained;

 

  • Whether scheduling is on a regular basis as opposed to an as-needed basis;

 

  • The period of relief from pain received with ongoing treatment;

 

  • The use of alternative medical providers in the event of continuing pain; and

 

  • The employee’s overall activities and the extent of the employee’s ability to continue to work;

 

  • A recommendation of long-term chiropractic care into the future which suggests a maintenance program rather than treatment of the injury; and

 

  • Hints of a psychological dependency for chiropractic care.

 

Conclusions

 

Members of the claim management team need to play an active role when defending claims involving chiropractic care.  Claims that are not properly managed can get out of control fast.  On the other hand, a proactive approach can result in employees making a fast return to work and the discontinuance of medical care and treatment.

 

Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: mstack@reduceyourworkerscomp.com.

 

 

©2016 Amaxx LLC. All rights reserved under International Copyright Law.

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

 

OSHA Steams Ahead with Final Transportation Ruling

The Occupational Safety and Health Administration recently issued a final rule establishing procedures and time frames for handling employee retaliation complaints under the National Transit Systems Security Act and the Federal Railroad Safety Act. The final rule became effective Nov. 9, 2015.

 
NTSSA establishes protections against retaliation for public transportation agency employees who engage in whistleblowing activities related to public transportation safety or security.

 

FRSA provides protections against retaliation for railroad carrier employees who report a work-related injury or engage in other whistleblowing activities related to railroad safety or security. These protections extend to employees of contractors and subcontractors who do work for public transportation agencies and railroad carriers.

 

Both provisions were enacted by the 9/11 Commission Act of 2007. FRSA was amended in 2008 to prohibit railroad carriers from denying, delaying or interfering with employees’ medical or first aid treatment. The FRSA amendments also require that injured employees be promptly transported to the nearest hospital upon request.

 

“Railroad workers have the right to report injuries and to follow their doctor’s treatment plans for injuries sustained in the course of their employment without fearing that they will be retaliated against,” said Assistant Secretary of Labor for Occupational Safety and Health Dr. David Michaels. “Railroad and public transit agency workers must never be silenced by the threat of losing their job when their safety or the safety of the public is at stake.”

 

In 2010, OSHA published an interim final rule and requested public comments. The final rule responds to the comments, incorporates recent case law under the statutes and updates the rules to improve both employees’ and employers’ access to information about the case during OSHA’s investigation and their ability to participate in OSHA’s investigation.

 

OSHA enforces the whistleblower provisions of 22 statutes protecting employees who report violations of various securities, commercial motor vehicle, airline, nuclear power, pipeline, environmental, rail, maritime, health care, workplace safety and health, and consumer product safety laws and regulations. For more information, please visit www.whistleblowers.gov

 

 

 

Author Kori Shafer-Stack, Editor, Amaxx Risk Solutions, Inc. is an expert in post-injury response procedures and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. www.reduceyourworkerscomp.com.  Contact: kstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

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Southern California Medical Fraud Ring Busted

Eight medical professionals and associates are charged in federal grand jury indictments with buying and selling patients in a bribery scheme involving $25 million in improper claims for medical services and devices which were then billed to California Workers Compensation insurance companies, according to the United States Attorney’s Office (Southern District of California).

 
FBI agents along with investigators from the California Department of Insurance and the San Diego County District Attorney’s Office served five search warrants and three seizure warrants recently at locations in San Diego, Chula Vista, National City, Murietta and Los Angeles.

 

Authorities arrested five people, including a radiologist, a chiropractor, a medical equipment provider, a medical clinic administrator and a so-called medical marketer. An attorney and a medical service provider were summoned to appear in federal court. One indicted defendant, Gonzalo Paredes, remained a fugitive and a warrant has been issued for his arrest.

 

These defendants, plus six corporations, are charged in three federal grand jury indictments unsealed today with conspiracy and honest services mail fraud. The indictments allege that these players either paid or received tens of thousands of dollars to buy or sell hundreds of patients, without the patients’ knowledge – therefore depriving those patients of their right to their doctors’ honest services.

 

This is how the schemes worked:

 

Patients who said they were injured on the job filed a workers comp claim with the state of California and sought treatment for their injury. In this round of indictments, the workers sought help from a chiropractor.

 

Chiropractors Were Gateway to Fraud

 

The chiropractors were the gateway to a wide-array of health care fraud. In these cases alone they prescribed medical equipment, referred the patients for MRIs and X-Rays, and ordered specialized treatments such as Shockwave therapy.

 

As alleged in one of the indictments, Los Angeles radiologist Ronald Grusd paid bribes to a San Diego chiropractor in exchange for patient referrals. The bribes were funneled to the chiropractor via Grusd’s corporation, Willows Consulting, a shell company. The checks were labeled “professional services,” but this was a sham.

 

In order to further hide the illegal kickbacks, checks were issued to intermediaries – defendants Alexander Martinez and his father, Ruben – through their front companies, “Line of Sight” and “Desert Blue Moon.” The Martinezes took their “cut” and then, in turn, paid off the chiropractor.

 

Grusd’s practice, California Imaging Network Medical Group, has clinics in San Diego, Los Angeles, Beverly Hills, Fresno, Rialto, Santa Ana, Studio City, Bakersfield, Calexico, East Los Angeles, Lancaster, Victorville and Visalia.

 

In another indictment, a second San Diego chiropractor, Dr. George Reese, with offices on El Cajon Boulevard, referred patients to a Los Angeles area medical service provider (controlled by attorney Lee Mathis and Fernando Valdes, president of Foremost Shockwave Solutions ) in return for bribes. The bribes were set by the conspirators at $100 per patient and paid through an intermediary. After taking a cut amounting to $25 per patient, the intermediary would pay the remaining $75 per patient to Reese.

 

Although disguised as “office rent” payments, the illegal bribes were paid in cash during clandestine exchanges in restaurants and parking lots. For example, $6,000 in cash was delivered to Reese in the parking lot of the Jolly Roger in Oceanside, hidden in a gift bag. Other times, it was passed in envelopes or stashed inside newspapers.

 

According to the indictment, Reese and his codefendants generated and submitted bills to insurers totaling in the tens of millions of dollars. Most of these treatments involved the providing of “Shockwave therapy,” which uses low energy sound waves to initiate tissue repair. Proceeds from the insurance claims generated through this scheme were paid to Mathis and Valdes.

 
In the final indictment, a San Diego chiropractor referred patients to a licensed provider of durable medical equipment, Julian Garcia. In return Garcia paid the chiropractor $50 for each patient – in cash, to disguise the kickbacks. Garcia then improperly billed Workers Comp insurers millions for hot and cold packs for patients who had been secured by bribes.

 

Anyone with information about healthcare fraud may call the FBI at 1-800-CALL-FBI, or 1-800-225-5324 or the California Department of Insurance’s toll-free fraud hotline, 800-927-4357.

 

 

 

Author Kori Shafer-Stack, Editor, Amaxx Risk Solutions, Inc. is an expert in post-injury response procedures and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. www.reduceyourworkerscomp.com.  Contact: kstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

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Massachusetts Man Indicted on Comp Fraud Charges

A Wilmington, Massachusetts man has been indicted on larceny and workers compensation fraud charges in connection with collecting more than $26,000 in disability benefits while he allegedly continued to work, Attorney General Maura Healey announced recently.

 
Jerry Keith Bull, age 49, of Wilmington, was indicted recently by a Middlesex Grand Jury on charges of Larceny over $250 by False Pretenses and Workers Compensation Fraud. He will be arraigned in Middlesex Superior Court at a later date.

 

The AG’s Office began investigating this matter after it was referred by the Insurance Fraud Bureau (IFB) in November 2014.

 

Investigation revealed that Bull suffered an injury working in a restaurant in June 2009, and began receiving temporary total disability benefits after he made a workers comp claim for medical expenses and recovery of loss wages.

 

In April 2010, Bull began working in a restaurant in Burlington, MA while continuing to collect benefits. During this time period, Bull allegedly intentionally made false statements regarding his wages and failed to disclose his return to work in order to continue to collect workers comp benefits.

 

Authorities allege that Bull fraudulently collected approximately more than $26,000 in disability benefits between April 2010 and June 2011.

 

 

 

Author Kori Shafer-Stack, Editor, Amaxx Risk Solutions, Inc. is an expert in post-injury response procedures and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. www.reduceyourworkerscomp.com.  Contact: kstack@reduceyourworkerscomp.com.

 

©2014 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.

 

WORK COMP CALCULATOR:   http://www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR:   http://www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

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