Category Archives: Fraud

Damned If You Do, Damned If You Don’t

“You can always count on Americans to do the right thing – after they’ve tried everything else.”

Winston Churchill

“Our policy is to create a national health service in order to ensure that everybody in the country irrespective of means, age, sex or occupation shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available.

Winston Churchill

 

Veering away from the usual topics covered in this blog, I thought about some recent articles I saw about the attempt to repeal and replace, or to simply repeal the Affordable Care Act (ACA), which the current political regime wants to do.

The first article, in yesterday’s [failing] New York Times, warned that repealing the ACA would make it harder for people to retire early. Those who retire early, before reaching 65, can get retiree coverage from their former employers, but not many companies offer that coverage.

Those early retirees poor enough could turn to Medicaid, and everyone else would have to go to the individual market. Without the ACA, health care coverage would be more difficult to get, cost consumers more where available, and provide fewer benefits.

According to the article, if the ACA is repealed, retiring early would become less feasible for many Americans. This is called job-lock, or the need to maintain a job to get health insurance.

This is one of the concerns the ACA was supposed to address, in that it would reduce or eliminate job lock. Repealing the law could, according to the article, affect employment and retirement decisions.

The second article, from Joe Paduda, also from yesterday, reported that improving healthcare will hurt the economy, and Joe lays out the arguments for doing something or doing nothing to improve health care and what effect they would have on economic growth.

For example, Joe states that healthcare employs 15.5 million full time workers, or 1 out of every 9 job. In two years, this will surpass retail employment. As Joe rightly points out, those jobs are funded by employers and taxpayers. He suggests that some experts argue that healthcare is “crowding out” economic expansion in other sectors, thereby hurting growth overall.

But Joe also points out that by controlling health care costs, employment will be cut, and stock prices for pharmaceutical companies, margins for medical device firms, and bonuses at health plans will also be affected.

So, if cost control and increasing efficiency works, these lost jobs, reduced profits, and lower margins, Joe says, will hurt the economy. The economy will suffer if the health care sector is more efficient, and since healthcare is also a huge employment generator and an inefficient industry, fixing that inefficiency will reduce employment and growth.

Thus, the title of this article, “Damned if you do, damned if you don’t.”

But wait, there’s more.

Yesterday, a certain quote has been making the rounds through the media. It was uttered by Number 45. “Nobody knew health care could be so complicated.”

Yes, it is complicated and complex, but does it have to be so? If we consider the second Churchill quote above, and realize that the UK, France, Germany, Canada, and many other Western countries have some form of single payer, then one must conclude that it is only the US that has complicated and made too complex, the providing of health care to all of its citizens.

There are many reasons for this, which is beyond the scope of this article or blog, but there is one overriding reason for this complexity…GREED. Not the greed of wanting more of one thing, but the greed of profit, as one executive from an insurance company stated recently.

This brings me to the last of the articles I ran across yesterday. It was posted on LinkedIn by Dave Chase, founder of the Health Rosetta Institute. He cited a segment on the Fox News Channel’s Tucker Carlson program, in which Carlson interviewed a former hospital president who said that pricing was the main problem with the US healthcare system.

Mr. Chase does not solely rely on Carlson’s guest in his article, but cites other experts in the field as evidence that pricing failure is to blame.

If we are to except this as true, then it buttresses my point that the overriding problem is greed, for what else is the failure to control prices but a symptom of greed inherent in the American health care system, and something that does not exist elsewhere in the Western world.

Which brings me to Churchill’s first quote above. Since we Americans have tried the free market system of health care wanting, and have tried a reformed free market system, perhaps it is time to go all the way to a government-sponsored, Medicare for All, single payer system.

The bottom line is: we’re damned if we do, damned if we don’t. The question is, which is the lesser of two evils.

UPDATE: Here is Joe’s take on what will happen to the ACA in the next two years. I agree with his assessment.

Cut the C**P!

For my 300th article, I want to address the medical travel industry and its failure to rid itself of the crooks, liars, shysters, and phonies who prey upon the desperate.

Case in point, the article last Wednesday in the New York Times by Gail Kolata about one man’s experience getting stem cell therapy through medical travel.

This case is endemic of the industry’s impotence to police itself and get rid of those medical providers and hucksters who use slick promotional material to sell useless and often dangerous treatments or dubious procedures.

But what do you expect from an industry whose major organization is merely a conduit for funneling money into the pockets of the organization’s founders and their friends?

What do you expect from an industry that emphasizes attending conferences and not on standardizing the laws and processes for the provision of medical care across national borders.

When I started this blog over three years ago, I had high hopes that the industry would listen to what I had to say, and to at least consider offering medical travel to injured workers in the US. But as happened with the workers’ comp industry, no one has stepped up and offered to work with me.

I’m not mad at everyone in the industry. Many of you are very nice people and work very hard, but your focus is on such medical care as dentistry, cancer, cosmetic/plastic surgery, and other treatments not available in the US, or too expensive.

But helping those who are injured on the job, and many of whom are from many of the countries in this hemisphere who offer medical travel services, should be something some of you might want to do.

It was my hope that this industry would offer me a chance to change direction, but that has not happened, and now I am not sure if it ever will.  There does not seem to be any financial or employment opportunities here, just a lot of conferences and hyperbole.

Prove me wrong.


I am willing to work with any broker, carrier, or employer interested in saving money on expensive surgeries, and to provide the best care for their injured workers or their client’s employees.

Ask me any questions you may have on how to save money on expensive surgeries under workers’ comp.

I am also looking for a partner who shares my vision of global health care for injured workers.

I am also willing to work with any health care provider, medical tourism facilitator or facility to help you take advantage of a market segment treating workers injured on the job. Workers’ compensation is going through dramatic changes, and may one day be folded into general health care. Injured workers needing surgery for compensable injuries will need to seek alternatives that provide quality medical care at lower cost to their employers. Caribbean and Latin America region preferred.

Call me for more information, next steps, or connection strategies at (561) 738-0458 or (561) 603-1685, cell. Email me at: richard_krasner@hotmail.com.

Connect with me on LinkedIn, check out my website, FutureComp Consulting, and follow my blog at: richardkrasner.wordpress.com.

Transforming Workers’ Comp Blog is now viewed all over the world in over 250 countries and political entities. I have published nearly 300 articles, many of them re-published in newsletters and other blogs.

Share this article, or leave a comment below.

Fraud is Fraud…No Matter Who Does It

Saw this on Twitter, courtesy of Larry Klaahsen.

It is high time to stop all forms of fraud, waste, abuse, and to stop kidding ourselves that we are the only nation that can provide quality health care to all our citizens, workers or not.

It is high time that employers demand that their state’s work comp laws are opened up to the practice of medicine by other providers whose main motivations are not monetary, but humanitarian, and are strictly and thoroughly vetted.

But until that happens, this smiling faker and many others, including lawyers, physicians, judges and other stakeholders will continue to take advantage of the system, and the right-wing, libertarian billionaires will destroy workers’ comp and take us back to the 19th century.


I am willing to work with any broker, carrier, or employer interested in saving money on expensive surgeries, and to provide the best care for their injured workers or their client’s employees.

Ask me any questions you may have on how to save money on expensive surgeries under workers’ comp.

I am also looking for a partner who shares my vision of global health care for injured workers.

I am also willing to work with any health care provider, medical tourism facilitator or facility to help you take advantage of a market segment treating workers injured on the job. Workers’ compensation is going through dramatic changes, and may one day be folded into general health care. Injured workers needing surgery for compensable injuries will need to seek alternatives that provide quality medical care at lower cost to their employers. Caribbean and Latin America region preferred.

Call me for more information, next steps, or connection strategies at (561) 738-0458 or (561) 603-1685, cell. Email me at: richard_krasner@hotmail.com.

Will accept invitations to speak or attend conferences.

Connect with me on LinkedIn, check out my website, FutureComp Consulting, and follow my blog at: richardkrasner.wordpress.com.

Transforming Workers’ Comp Blog is now viewed all over the world in over 250 countries and political entities. I have published nearly 300 articles, many of them re-published in newsletters and other blogs.

Share this article, or leave a comment below.

The Miasma of Fraud

One last post before you celebrate Thanksgiving.

Business Insurance’s Stephanie Goldberg reported today, that five people have been charged  with workers’ comp insurance fraud in California, and that the insurance commissioner called it, “one of the largest workers’ compensation insurance fraud cases we have ever seen.”

In July, 2014, I wrote two articles about fraud in California, “The Stench of Fraud: Why Workers’ Comp Can No Longer Be a Closed System” and “The Stench of Fraud, Continued.”

Charged in the case was the former CFO of Pacific Hospital, James L. Canedo, two orthopedic surgeons, a chiropractor, and Paul Richard Randall, a health care marketer.

They were charged with illegally referring more than 4,000 patients for spinal surgeries, and generated more that $580 million in fraudulent bills during an eight-year period, according to the US Department of Justice, in a statement released yesterday.

Many of the claims were paid by the California work comp system, the rest by the federal government.

Canedo and Randall have pled guilty, and the other three have agreed to plead guilty, and under the terms of their plea agreements, each defendant could face prison terms and be required to pay restitution to their victims.

The US Attorney’s office for the Central District of California said in a statement that Canedo faces 10 years in prison and at least $20 million in restitution.

The scheme consisted of kickbacks of $15,000 for each lumbar fusion surgery, and $10,000 for each cervical fusion surgery, according to the US Attorney’s statement.

The ongoing investigation, dubbed “Operation Spinal Cap”, discovered that some of the patients lived hundreds of miles away from Pacific Hospital, and closer to other qualified facilities, the patients were not informed that medical professionals were offered kickbacks for referrals, and that insurers had paid the hospital more than $226 million for the surgeries.

Once again, we see that workers’ comp, especially in California, but also in other states, is like a fetid pool of rotting vegetation and other foul matter, so that what was once called a stench, is now a miasma that hangs over the surface of the system.

It does not have to be like that. It can be better. You can find an alternative to expensive surgeries and illegal payoffs, if only you would consider new ideas and new possibilities.

Or you can continue to breathe in the foul air. The choice is yours.

 

 

 

Let Our (Working) People Go

I want to pick up on a point that was made by David De Paolo yesterday in my post, STOP THE MADNESS!!!, and in David’s post today.

The point David has been talking about for two days now is the idea to allow employees to opt-out of the workers’ comp system in the same way that the states of Texas and Oklahoma allow employers to opt-out.

David discussed the plight of Glenn Johnson and his wife who were arrested and charged with workers’ comp fraud, but were not guilty of anything other than asserting their rights to sue for damages caused by an explosion when Glenn was operating a forklift.

The nightmare the Johnsons endured is what David wrote about in his post yesterday. Today, David goes on to advocate, and quite rightly, for the right of employees to opt-out of the workers’ comp system so that they can get just compensation.

For some time I have advocated the opt-out program as a way into the workers’ comp market for medical tourism destinations and facilitators, and now believe, as David does, that employees should also get the same right to leave the system, a system that has harmed and nearly threw both Johnsons into prison.

The way Glenn’s employer’s insurance company and their third party administrator handled Glenn’s case is a sign that things are out of control and need to be addressed before more Glenn Johnson’s are hurt by it.

Allowing an injured worker to not only received medical care outside of the provider network, and even outside the country, as Oregon and Washington state does, and to seek redress through other means besides the profiteering workers’ comp system makes sense, and should be adopted nationwide.

Opting out of a madhouse created by money-grubbing doctors, lawyers, crooked politicians, and judges and arbitrators who side with the defendants instead of the legitimately injured workers, is the best way to see that real justice is done.

And when an injured worker needs surgery, to force him or even his employer, to have the surgery performed at a hospital that charges thousands of dollars unnecessarily for a common operation is beyond stupidity, it is criminal.

Better that the employee and the employer be allowed to choose to go to a hospital that can provide the same or better quality of care, and at lower cost, at a medical tourism destination in Latin America or the Caribbean, especially if the employee is from there, or if doing so would give the injured worker a better chance to recover faster and in a more tranquil environment than at home.

In other words, let our working people go.

I am willing to work with any broker, carrier, or employer who is sick and tired of being bled by the Wall Street vulture capitalists and the entire medico-legal system known as workers’ comp, to save money, and to provide the best care for their injured workers or their client’s employees, while at the same time, helping to break the monopoly of the American health care cartel.

Call me for more information, next steps, or connection strategies. Ask me any questions you may have on how to save money on expensive surgeries under workers’ comp. Connect with and follow me on LinkedIn and my blog. Share this article, or leave a comment below.

What Price Profit?

WorkersComp

For my first post of 2015, I want to go back to a subject I wrote about last year, namely the fraud and abuse perpetrated against injured workers by their employers, by lawyers, by the medical profession and the insurance industry at large.

Wall Street hedge funds and private equity firms, in particular, who are taking an greater interest in the workers’ comp industry, and as has been written extensively about, are buying up various workers’ comp service providers, thus shrinking the industry and squeezing every last drop of profit from the claims process while cutting back on services, or even raising the price of those services.

I discussed the issue of fraud and the plight of an injured worker I called “Ms. X” in two articles; the first article, The Stench of Fraud: Why Workers’ Comp Can No Longer Be a Closed System, dealt with the use of phony or unapproved implants, the second article, The Stench of Fraud, Continued, described the ordeal Ms. X suffered after being injured at her place of employment.

Today’s article, also highlights the ordeal suffered by an injured worker, who I will call “Ms. A”. The following text below is the actual words written by Ms. A on her personal blog, with some minor editions by myself.

I will point out that Ms. A was an executive with a very large corporation, whereas Ms. X was an employee of a small firm, and was not an executive. This will give the readers some idea that the fraud and abuse is not confined to low income or clerical workers, but could be experienced by anyone, at any level of employment, so long as they are not the owners or managers of companies.

Here is Ms. A’s story:

January 9, 2015 marks 3 years since a witnessed slip and fall at _________ by ________________ in Big Bear, California and Traumatic Brain Injury. Still waiting for medical care and benefits. Thousands and thousands of dollars have been paid out in evaluations; very little in the way of ‘medical care’ requested by treating physicians.

Friends have suggested that since _________________________ and it’s Work Comp carrier, CNA Insurance,…refuse to provide medical care, and continue to refuse to reimburse nearly $30,000 in properly submitted medical expenses for mileage to their designated doctors and medically necessary treatment that they unlawfully denied, that GOFUNDME might help.

I lost professional credentials…. Hawaii Real Estate Sales License, California Real Estate Broker’s license, and California Notary license. Failures to provide medical care, disability benefits, and return to work opportunities! Thanks _______.

I was basically thrown out of a public CAREER NIGHT at ________________ Indio in December 2014, which was a public invitation to learn more about the company and working as a sales person. I was able to say hello to several co-workers while HR pondered on what to do with my attendance at their public event. The Project director advised that Human Resources said he could not talk to me, and… LOL, I was the only person from the “PUBLIC” who showed up for the event.

Social Security Disability has been denied twice, and Long Term Disability is at constant threat of being discontinued, despite the policy and fiduciary responsibilities.
Some say that upon diagnosis of anything to do with Brain Injury, Work Comp carriers fully and immediately breach fiduciary responsibilities and expedite 3D practices….”DELAY, DENY, DECEIVE” rather than to expedite immediate medical care to mitigate harm and risk.

The first year, I could hardly speak, and leaving the house was only ‘as necessary’ to various doctor evaluations. My speech is still ‘dysfluent’ but improved. I experience cognitive fatigue more often than I care to admit. There are other impairments, but being a sales person and personal-development-activist who has walked on fire and bent rebar at the throat chakra, I muddle along to the best of my abilities.

If you remember 286 computers and dial-up, no clip-board, no copy and paste then you have an idea of what it can be like living with a brain injury.

I am a “High IQ TBI and Work Comp Survivor” Some new and old friends say I am still brilliant, just different, and much slower.

Typing is still a strong suit. Different lobes govern different functions. The brain is an amazing organ. Neuroscience is truly the New Frontier. Ask a Veteran today!

One doctor, in 2012, advised to “never tell anybody you have a brain injury, as it has a stigma”….He wanted me to spend out of pocket $500 for a day-planner to conceal the impairments. I didn’t start screaming loudly about it until year two, when I could better grasp the extremely dangerous situation I was in as an Injured Worker in America. It became very clear what a corrupt and vile system Work Comp in America, and elsewhere, is. Consider Japan’s Nuclear Meltdown workers.

If you say Work Comp is none of your business, I must assume you are not part of the Human Race.

When I slipped on ice and fell backwards on 1/9/12 and conked my head really hard at Big Bear, I laid in the snow for what seemed to be about 5 minutes. I was asked if I was ok, and I said, “No, I hit my head really really hard.” I was dazed and confused, but eventually got up, dusted the snow off, and reported to the sales meeting. My colleagues had a great laugh about my fall, and one even said, ‘Ewwwwwwww, she has Fukushima radiation all over her now from the hot-snow!’

I gave a ‘timeshare tour’ at 9 am, and I was very apologetic for my extreme confusion and disorientation and they were grateful for a short tour, and a fast gift.

Around 10 am, the administrative manager asked if I was going to a doctor, and I asked if I had to see any special doctor. He said, “See any doctor that accepts work comp” and provided me with an incomplete DWC-1 form, that had no insurance info on it. I drove down an icy mountain after the last tour of the day, about 20 miles, then another 40 miles of flat desert. How? Dunno! Just did.

Nobody thought I might need a ride to a doctor, or a hospital, or even a 911 ambulance ride? I haven’t worked since, and I have spent more than $30,000 out of pocket to discover and obtain help for brain injuries. Had I received immediate and appropriate care, I am told I might have returned to work that first year.

Recently, after denied TTD and PD benefits for months, and years of failures to authorize medical treatments, the attorney for _______suggested that if I reviewed the situation, it would be clear that the failure to obtain medical care is all my fault, and he further asked why I believe I am entitled to any benefits.

He sent a nasty little note with his legal opinion on my medical conditions, suggesting a Court Appointed ‘Conservator’ to make my decisions, since I struggle so with the Work Comp system. It sounded to me like he was suggested I agree to let the Court appoint an insurance company goon to finish the kill? Yikes. The contempt and disdain is mutual.

That doesn’t even mention the insurance guy who called and after listening to me whine about no medical care for nearly 3 years asked, “….so when ARE you going to die?”

The insurance company and attorneys had me driving everywhere; I don’t know how I did it either. One doctor wanted me to drive with a brain injury, sleep deprived, over 100 miles for an ‘exam’ and that’s where I drew the line. I knew that was insane, and would be a danger to me and to the driving public. Where do they find those Work Comp neurologists? Haven’t met a smart one yet.

You can see from her description of her ordeal, there is something going on with her claim and the claims of so many other injured workers.

She is coping with this traumatic event the best way possible, but the system that was designed to care for people like her has failed time and again, and for no other reason than to protect the profits of those who are inflicting harm on her, after initially suffering an injury not her fault.

A wise man once said, “for what hath it profit a man if he gains the whole world, and loses his soul,” To me, it would seem that the workers’ comp system, the legal system, the medical profession, and the insurance industry has lost its soul on the way to gaining the world and profit.

As for Wall Street, two hundred years of lying, cheating, stealing, conniving, and manipulating has proved that they have no soul, only dollar signs where their hearts and minds should be.

The Fiefdoms of Fools

Fiefdom: 2. Informal. anything, as an organization or real estate, owned or controlled by one dominant person or group.

Source: Dictionary.com

Last July, I wrote two pieces, The Stench of Fraud: Why Workers’ Comp Can No Longer Be a Closed System and The Stench of Fraud, Continued. These articles dealt with the issue of fraud in the workers’ compensation system. The first article was based upon David De Paolo’s article about physicians or hospitals in CA using phony or unapproved implants on patients.

The second article discussed the plight of a woman, also in CA, who I called “Ms. X”. Ms. X was injured in the course of her employment, and subsequent to her injury, was injured several times by the treating physician, the medical staff at facilities where she received treatment, her former plaintiff attorneys, the defense attorneys, the insurance company, and finally her employer, who fired her.

I let Ms. X speak in her own words so that the reader would understand the pain and suffering she was feeling was real, and not something that I made up to bolster my argument for transforming workers’ compensation. There are hundreds, if not thousands of Ms. X’s and Mr. X’s out there who are subjected to the dark side of the workers’ comp system in the US. And there are many others who file claims who never suffer abuse or fraud at the hands of the system.

But yet, there are still more vile and disgusting things happening to workers in this country, injured or not, legal or undocumented, native born or foreign, as David De Paolo discussed back in July in his article, How Dare They. David’s website, WorkCompCentral.com reported that over one hundred undocumented workers at a fruit packing plant in South Florida were arrested for workers’ compensation fraud, although only a few of them actually filed claims for workers’ compensation benefits. The company they worked for, Fruit Dynamics, hired the workers who were from Guatemala, Mexico, Honduras and El Salvador, knowing that they were undocumented.

The owners were never suspected in any complicity in the fraud, according to Maj. Geoffrey Branch of the Florida Division of Insurance Fraud. “At this time, we do not believe anybody affiliated with the ownership or management had any idea that any of these documents were fraudulent,” Branch said,“We believe that they thought they were on their face value valid, authentic documents.”  As David points out, the reason for the raid in the first place was because the original complaint was against the employer for intentionally hiring undocumented workers in a pattern of behavior and practice to underreport payroll and intimidate workers out of benefits for work injuries.

David also said that an attorney who had represented several of the workers over the years made the complaint to the Division because there was a pattern of practice that he noted.  The attorney said that the employer’s hiring and management practices were intentionally done to minimize workers’ compensation liabilities and abuse immigrant workers. The employer faced no retribution whatsoever from the law even though there is documented evidence that the company knew what it was doing and its insurance carrier went along with the plan in complicity, David added.

In today’s article, David revisits the case in Florida from July, and reports that the undocumented workers were given “diversion“, which would allow the charges to be dropped assuming compliance by the accused. However, the employer is under investigation, according to a report by WorkCompCentral.com. At the time of the arrests, the Chief Financial Officer of Florida said that the lead the investigators were following would “result in dozens of workers’ compensation arrests and many arrests for identity theft that have been potentially devastating for victims.”

Yet, as David pointed out in his article, that was not the case. The fact is that the few workers’ compensation cases that were in process by workers injured at the Fruit Dynamics plant in Naples, FL resulted in termination of the workers – the employer clearly was sending a message to its undocumented workers: don’t file a claim for injury. Clearly, David continues, the employer threatened, and executed, retaliatory action in order to keep its undocumented workforce complicit, and quiet.

Back in July, David stated that the arrests were “lightly veiled discrimination based on race. The masters aren’t prosecuted for their fraud and deceit, but the powerless workers are punished for their enslavement.”  On top of the fact that Fruit Dynamics engaged in immigration fraud, it is also under investigation for payroll fraud. David concluded that this is a case of racial discrimination bordering on enslavement.

Which brings us to the title of this article, The Fiefdoms of Fools. By that I mean that within the workers’ compensation system in the US, there are various fiefdoms that have been carved out and control the different spheres of influence each of them represent. As David discussed in his article about fraud in July, there are the fiefdoms of physicians and hospitals who commit fraud against the insurance companies and patients.

There are, as I discussed in my second article on the subject, fiefdoms of attorneys, both plaintiff and defense who abuse the system and the claimants, there are insurance companies who commit fraud against the employers, there are fiefdoms of medical facilities who commit fraud by falsifying medical records, there are fiefdoms of physicians who abuse and maim and injure the already injured for their own greed, and then there are the fiefdoms of employers, like Ms. X’s and Fruit Dynamics who terminate employees for filing a claim when they were legitimately injured, or in the case of Fruit Dynamics, unjustly terminated to cover up criminal activity of the company.

But we don’t have to look at what is going on in, or around the workers’ compensation system to see where there are other fiefdoms of employers who are abusing, intimidating, threatening, or retaliating against their employees. You only have to pick up a newspaper every now and then and read about a company like Wal-Mart eliminating health insurance for its employees, or the company that fired a worker who complained to his cable company Comcast, after Comcast contacted the employer.

It does not take much to learn that the American worker is being subjected to vile, disgusting, discriminating and obscene acts by their employer as a means to control and dominate them, in much the same way feudal serfs were controlled and dominated by their feudal masters hundreds of years ago. Each feudal lord had his own fiefdom that he ran as he saw fit. It is no different today with American employers and their employees. We have a former union president and his party to thank for that. The union movement has made many mistakes, but the Republican Party’s war on workers, in and out of unions is one reason why these fiefdoms exist.

Beyond the employee/employer dynamic, there are other kinds of fiefdoms that pertain to the subject of this blog. These fiefdoms are controlled by the various entities in workers’ compensation that have a stranglehold on the very way workers’ compensation claims are adjudicated, processed, treated and disposed of. The workers’ compensation third party administrator firms, claims management firms, pharmacy benefit management firms, bill review firms, and other service providers all have carved out their own little fiefdoms that they control and manipulate for their benefit and profit.

I began this article by defining the word “fiefdom”, but as the title implies, there can be more than one fiefdom, which is why it is plural in the title. As for the part about fools, what would you call people who insist on doing the same thing over and over again, expecting different results; what would you call employers, carriers, physicians, hospitals, medical facilities, lawyers, service providers and the rest who prey upon, abuse, harass, intimidate, retaliate, threaten and terminate employees for no other reason than filing a claim for benefits they rightly deserve after being injured on the job; and what would you call people who knowingly commit fraud for profit? I’d call them fools.

Letting Problems Fester

 

Yesterday, my father was admitted to a local hospital reluctantly by his primary care physician, and on the wishes of my younger brother, who is also a physician. His doctor wanted to put him in a hospice; my brother had the good sense to convince the primary to admit him to the hospital.

My father has been ignoring a very a serious problem with his legs that has left them inflamed, infected and with open wounds and leaking. And despite pleadings and arguments with him from me, my brother, his doctor, and a home health agency we are using to take care of my mother, he has resisted going to the hospital, or even taking responsibility for the state of his health.

For a few years now, he has been treated for this condition by a dermatologist, who has wrapped his legs with bandages and put Calamine lotion on it. They have prescribed compression stockings for him to wear, but he has only worn them whenever he asked an aide to put them on for him.

But because of the leakage and bleeding, the aides and the agency have told him that they cannot do anything for him until his legs are treated.

I have told him that a dermatologist is not the right doctor to treat this problem, but he has insisted on going back there time and again because of the attention they paid to him in the past, especially one young woman who no longer works there who he was infatuated with.

I might add that this doctor was one of doctors in a database the New York Times published online of physicians who received a majority of the payouts from Medicare in 2012.

Hopefully, now that he is in the hospital, he will get the proper treatment and his legs will improve.

The reason I am telling you this is that the workers’ compensation system has so many “health problems” that are being ignored or treated with ineffective and useless treatments.

Sort of like what is wrong with my father…plenty of open wounds and sores, and other underlying issues that is being treated by the wrong kind of doctor.

These problems, as I have discussed in the past, such as the fraud and abuse of injured workers, the opioid abuse problem, general health care plans charged less for the same surgeries under workers’ comp, and so many other issues, have either been ignored, or are being mistreated because some in the workers’ comp industry are infatuated with the service they are receiving from their service providers and cannot understand that these companies are not interested in solving these problems, only prolonging them because they profit from it.

Also, they are pursuing “treatments” that are ineffective and only make the problems worse, as in the case of my father and his dermatologist.

But unlike my father who finally allowed his doctor to admit him to the hospital, the workers’ comp industry is refusing to seek proper treatment.

“Aged statutes and old case law” is one excuse they offer. Another is because doctors and lawyers are milking and gaming the system and they won’t or can’t do anything about this. And finally, they refuse to seek treatment because they are under the delusion that everything they have tried so far, or will try in the future to address these problems will work, if they only keep doing so.

But we have already seen that some states are allowing employers to opt-out of the system. In one state, a judge has ruled that that state’s system unconstitutional. Joe Paduda has been writing on his blog about private equity firms buying up Third Party Administrator companies and workers’ comp service providers in an effort to consolidate the workers’ comp claims process from right after the first report of injury to the management of the claim, to the management of the pharmacy benefits, and all other services.

As this vertical integration proceeds, it is likely that costs will go up, profits will flow to the top, meaning to the private equity firms and their investor clients, and services provided may not be adequate to treat the injured worker because of the demand for greater efficiency in the process and for ever more profits to be squeezed out of the system.

So, do we see if the “patient” still refuses to get the help it desperately needs, or does it go on pretending that there is nothing wrong, and dies a slow death.

I am glad my father finally agreed to get help. I am still waiting for the workers’ comp industry to do the same. It needs to go to the “hospital” not a hospice.

 

 

Corruption Not Limited To US Health Care

Tip of the hat to Joe Paduda today for highlighting topics on Health Wonk Review, one of which dealt with the fact that corruption is a global problem in health care.

The HWR blog today, entitled “Health Wonk Review: Polar Vortex Edition, July 2014”, pointed to another blog called Health Care Renewal, that discussed how corruption in health care is not limited to the US, and cited problems in India, which happens to be one of the largest medical tourism destinations in the world.

The article in Health Care Renewal, entitled, “Health Care Corruption, “No Dirty Little Secret,” but “An Open Sore” – Lessons from India for the US”, quotes from various sources the scope of corruption found in India and the parallels to corruption in the US.

Some of the issues found in both India and the US are as follows:

  • Neoliberalism and privatization
  • Kickbacks to physicians for referrals
  • Kickbacks from pharmaceutical firms
  • Huge fees charged to medical students

Those of you have read my recent posts, “The Stench of Fraud: Why Workers’ Comp Can No Longer Be a Closed System” and “The Stench of Fraud, Continued” won’t be surprised that corruption exists elsewhere. But the fact that it does exist elsewhere should not blind us to the reality that we can do something about it here at home, especially when it concerns injured workers, and represents a complete and utter disregard for the Hippocratic oath that states, “First, do no harm”.

It would seem that this admonishment from Hippocrates falls on deaf ears when there is money to be made from inflicting pain and suffering, as well as heaping abuse on innocent, injured workers.

The Stench of Fraud, Continued

In The Stench of Fraud: Why Workers’ Comp Can No Longer Be a Closed System, I briefly mentioned the plight of one individual, who I called “Ms. X”.

I called her that because her case is still winding through the medico-legal system in her state, and I do not want to prejudice her case, or add to her woes by embarrassing her, even though she herself is bringing light to her situation by using all resources available to her,

But I felt that once I mentioned her in my previous post, it was alright to expound on the subject of fraud, and discuss her case without identifying her personally.

According to her own words to me [bracketed below] and in her correspondence to others, this is how her nightmare began:

I am an injured worker who was maimed by the medical providers in the insurance carrier’s network of medical providers. Mine is a long story that began December 12, 2011 when I was hurt at work.

[A herniated lumbar disk from working in a sitting position in excess of 65 hours one week and during that week, picking up boxes of banking and files from time to time. I began to feel discomfort in my lower back, went home, took it easy over the weekend, went back to work on Monday, worked for approx. an hour or hour and a half, got up, went to the copy machine, made my copies, bent over to pick them up and then that is when the disk herniated.]

On the day that I was hurt at work, the human resources manager told me that she was going to call the insurance carrier to find out what to do or where to send me. When she returned, she wanted me to sign a “release letter”. I had just gotten that job on November 16, 2011. I got the message that someone there didn’t want me to file a WC claim by virtue of the effort to induce me to sign a release letter. I needed that job and hoped that my back would feel better. I didn’t sign a release letter but I did write a letter indicating that I was hurt at the copier but that I didn’t want to go to their Doctors. I asked if I could go home. At some point, the HR manager gave me a couple of Advil and water for the pain. I had gone home from there – Monday, 12/12/2011. By Thursday, 12/15/2011, my back did not improve, so I placed a call into the HR Mgr. and said that I need to see their Doctors… the HR Mgr. responded by saying something to the effect “Why, you don’t have any money to go to your own Doctor?” (Not verbatim). I was taken aback by this. She knew I was hurt at work. She continued by saying, “We have a release letter signed by you!”. I responded by saying something to the effect that I never signed a release letter. We argued… and so on.

She goes on to say in her correspondence that:

…former employer who fired me less than 3 months after I filed a WC injury. On the very day that I filed a WC claim, my employer placed an ad on Craigslist to replace me. I didn’t learn until sometime in May 2012 that my former employer lied to the insurance carrier about the circumstances of my injury and what I had said. For the record, I was hurt at work and due to the working conditions and surroundings, including my desk and number of hours that I had to work, 65-66 hours the previous week. Our office had very little storage, therefore, myself and the other Escrow Officer, had to pack up boxes of files for closings and banking. We lifted these boxes weekly and sometimes daily due to the lack of space.

Because of what has happened to me, I have been upfront with Doctors outside of the workers comp system. At one of the Doctors, a pain management Doctor that I went to see in early 2014 – March or so, one of the female investigators that I had seen near my apartment on prior occasions (or was her twin) showed up and was placed inside a room before I was, I arrived first, was placed inside the room next to her. During that visit to the Doctor after being placed in the room next to the investigator, the receptionist from the front desk asked me several times if I did recreational drugs and had I ever done recreational drugs. Clearly, a continued effort to create a negative review of me and/or my history. Another Doctor who I visited to get a referral to an orthopedic Doctor insisted that what I describe does not happen. She said that there are no instances in the US of a person being forced under anesthesia. Further, she said that I was delusional and that I should see a psychiatrist, and that the pain that I have is psychologically driven and not real pain.

She was given three epidurals, and this is what happened to her after the first epidural, which went without incident:

I was forced under anesthesia for simple lumbar epidurals. At the 2nd epidural procedure, after objecting to anesthesia, I was told I had no choice, that it was the policy of the surgery center (_____ ___ Outpatient Surgery Center) that all patients must undergo anesthesia. I awakened from that with severe neck pain and slight left arm pain. My Doctor had injected my neck, left side of my spine, left leg with some sort of chemical that tingled and popped like Alka Seltzer. In fact, the tingling went from my lower left lumbar down my left leg all the way up my back and felt like a popping sensation in my head. I was there to receive a lumbar steroid epidural injection and “trigger point shots” in the left side lumbar area.

The next epidural procedure, I made it clear I that I did not want to be placed under anesthesia not only on the phone (a day prior to the procedure) but also before the procedure in pre-op and I re-stated the same in the operating room for everyone to hear. I restated that I was to get a local pain blocker (just as I had during the first lumbar epidural). Instead, my Doctor abruptly shoved the needle into my back without any pain blocker whatsoever. I could feel the needle going through the textures of my back (not precisely or with care into the spinal area where the disk is). My head flew up as I screamed “Wait!” or “Stop!”. He would not relent! As my head hit the operating room table (where a towel and prop to lay my head was), he moved the needle inside me to the nerve in my back next to my spine and held it against the nerve! The pain was so excruciating that I bit into the towel that was for my head to rest on and screamed with the towel in my mouth. Pure agony! He would not stop! I had no choice once again but to give into anesthesia. When I awakened, I thought to myself, Oh my God, they didn’t! I had injuries now throughout my back, neck, shoulders and arm. I could feel the nerves firing all over my back and next to both sides of my spine from the injections of some sort of chemical (the Alka Seltzer feeling again) that over the coming months, burned and corroded the ligaments in my spine, tendons and muscles in my back. It felt as though I was being burned from the inside out. PAIN from burning, PAIN from damage and maiming! I can now and then could feel that some of the tissue/muscles were pushed away from my spine creating the feeling of divots or holes on both sides of my spine. I could feel what seemed to be a muscle pushed away and hanging down on to the right mid side of my person. The ligaments that are in my neck and run up into my skull feel damaged, sore. My spine felt “chiseled” in specific areas most prominently in the top of my back and neck and the bottom near the lumbar sacrum area. I now have instability in my spinal column. I can feel the vertebrae in my spinal column moving not in sync with the other vertebrae…

There is a lot more detail to her case that is beyond the scope of this blog to address, but I am sure my readers have gotten a clear idea of what she has gone through. As a former Claims Examiner and Claims Administrator for a wrap-up insurance program, I have never seen, nor heard of such abuse inflicted upon an injured worker.

This poor woman, who was just doing her job, was taken advantage of by a broken, corrupt and dysfunctional workers’ compensation system that makes the injured worker seem like the guilty party, when it is the providers and legal system who are guilty of injuring and maiming the worker.

To illustrate just how they are characterizing this woman, here is another part of her correspondence regarding an attempt to make her out to have a psychological problem:

The insurance carrier and/or it’s attorneys are working hard to impair my credibility. Several attempts to have me include a psych claim ,since I finally realized that I was being maimed, have been made. Even the AME has placed a notation in his last report that is false – saying that I have ongoing psychological “???”. For the record, I haven’t any history of psych issues. This is a lie that is meant to bode well in favor of the defense. I have never before had a psychological condition. I did mark on a form that I was depressed but that was due to the pain! Not anything else.

In my insurance career, I came across another poor soul who suffered from depression due to the pain he suffered as a result of his injury. At the time, I was the No-Fault Claims Supervisor of the NY office of an automobile insurance company that insured Black Car limousines (Owner and Owner and Another). A Coptic Christian gentleman from Egypt cried in my office before he was seen by our medical consultant. Recognizing that my job was to limit the amount of money we paid to this individual, I did speak to our consultant just prior to the examination. It was the least I could do for this person. So reading what Ms. X has written does not surprize me in the least.

A letter Ms. X forwarded to me from a defense attorney even stated that her epidurals were harming her and not helping. This letter was part of a plan to get her to settle for a few thousand dollars. The lawyer’s text is as follows:

Additionally, the applicant appears to not be benefitting from the treatment, in fact, the treatment by both the employer’s physician and your physician [addressing claimant’s former attorney] appears to be harming rather than helping the applicant.

She also stated in her correspondence that she discovered that:

…some of my medical forms, surgery reports, paperwork had been falsified, changed over and above my signature and due to the anesthesia form (copy handed to me) was marked differently than the first page that I signed and more.

Finally, to make matters worse, she received a letter from a law firm representing her workers’ comp primary physician, demanding her to cease and desist from making false and libelous statements on the internet about their client. From what I understand, this is the physician who the defense attorney said above was harming her. It is no wonder that by mistreating Ms. X this workers’ comp doctor prompted her to take the actions she did to warn people about his conduct.

As I mentioned in the last post on this subject, Ms, X would have been homeless if it was not for her sister. She was subsequently fired from her job as a Manager of her department by her employer after filing the workers’ comp claim.

The events and actions discussed by Ms. X and disclosed here by me, further elaborates just how much the stench of fraud and abuse in the system has become unbearable. These words that I have quoted are but a small part of the whole story Ms. X has told people about, but it is clear that there is something rotten in the state of CA, if not in the state of Denmark, paraphrasing Shakespeare. And we all know that when something is rotten, the stench is overpowering.

Yet, the medico-legal system is arrayed against Ms. X, and the end result, I am afraid will be that she loses, and her work comp settlement will be liened against by the primary physician’s attorney, or the case will be decided in the insurer/employer’s favor, and Ms. X will be unable to go back to work, and will be forever marked as someone who brings attention to herself and not in a positive light. And furthermore, she may be marked as having a psychological issue, when in reality, she is only trying to get the proper treatment for her herniated disk. This psychological defense strategy smacks of something the Soviets used to do to political dissidents.

One gets the feeling that even though the Soviet Union is no more, we are more like the Soviet Union and other authoritarian states, in that the individual is powerless against the power and prestige of physicians, hospitals, lawyers, the courts, and other medical providers, and the system itself.

If ever there was a more clearer case of why we need to transform workers’ comp from the broken, corrupt and dysfunctional system I have been describing these past two years, this case is it.

How different Ms. X’s life would have been if she had gone to an honest and reputable treating physician, received the proper medical treatment, and if necessary, gotten back surgery to repair her herniated disk, even if she received the surgery from her employer or insurance carrier in another country, as a medical tourism option.

And how different her life would be if she did not have to be threatened with a lawsuit from a shyster law firm that is representing a shyster physician, as well as being misrepresented by bad attorneys, so that I had to ask someone I knew if he could help her. There is a saying, “a fish rots from the head down”, and in this case, the stench of the fish called ‘Workers’ Comp fraud’ is taking down the entire system.