Tag Archives: Fraud

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.

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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.

 

 

 

Independent Medical Review Upheld as Constitutional

As I mentioned this morning to a good friend, I normally shy away from writing about California work comp issues, but the following article by Stephanie Goldberg, is indicative of how the legal system has been corrupted to the extent that benefits are denied to injured workers when it is proved they are necessary to deal with their injuries, especially those that leave the worker unable to be gainfully employed.

In other words, the courts have helped the employers screw the workers once again, and this is not coming from ProPublica/NPR.

Here is the article from Business Insurance:

http://www.businessinsurance.com/article/20151029/NEWS08/151029727/constitutionality-of-workers-comp-medical-review-process-upheld-by?tags=|68|309|70|74|92|329|304

We can and should do better, and not just for blue collar workers, but for white collar workers as well. which is what Ms. Stevens is. And I know two other white collar women in CA who have also gotten the shaft from the system. I wrote about them in three separate articles, “The Stench of Fraud: Why Workers’ Comp Can No Longer Be a Closed System“, “The Stench of Fraud, Continued“, and “What Price Profit?“.

From what I have heard about the IMR process, not all of the reviewers are equipped or knowledgeable to review cases, and they only look at medical records (which by one account had been changed), so the process is unfair, no matter what the court said.

Workers’ comp is being undermined from within and without. It is only a matter of time until it it is completely gutted and done away with. That is the fault of stupid and greedy people, but it is also our fault for choosing leaders who allow this to happen because instead of looking out for the people, they look out for the interests of the wealthy and powerful.

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.

STOP THE MADNESS!!!

As this is my official 150th post, I thought that the following post from David De Paolo needs to be seen by everyone who cares about the direction the US is headed, the way the global economy is headed, and what is happening to the working class in the US, especially injured workers such as Glenn Johnson, Cecilia Watt, Linda Ayres, and many others.

We have been lulled to sleep by a slick talking former Hollywood actor (a third rate one, and second rate president), his media and political consultants, a kinder, gentler grandfather figure with two dummy ex-governor sons, their media and political consultants, talk radio pundits who abuse and insult those they do not like, and a conservative movement funded by the late Richard Mellon Scaife, the Koch Brothers, Art Pope, Rupert Murdoch, and many others, to take this country back more than one hundred years when workers had no rights and bosses were like gods.

David’s excellent post should make us all pause to consider what we are doing to our fellow Americans and be angry, for unless you are a millionaire or billionaire, you too can experience the same or similar circumstances these people have gone through, and worse.

To paraphrase Marx (that’s Karl, not Groucho), “Worker’s of the World, Unite! You have nothing to lose but your lives!”

https://www.linkedin.com/pulse/option-necrosis-david-depaolo?trk=hb_ntf_MEGAPHONE_ARTICLE_POST

If you are as angry and disturbed over this blatant disregard for the dignity of working people, and are tired of the “system” being run for the benefit of the insurers and those who benefit financially, then contact me for more information on how we can offer injured workers better medical care that actually saves money, and does not allow profiteers to abuse people.

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.