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4 Comments
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John A. Don esq. Nov 3, 2016 a 7:58 am PDT
If you want to stop fraud - go after the cappers who solicit Latino workers for gatekeeper chiropractors and unscrupulous attorneys. The rogue attorneys are paying thousands of dollars a month for a quota of referrals that the "marketing agencies" must produce. It's gotten to the point where the same worker is being sold to more than one attorney causing bogus filings at the WCBA.
Diego Martinez Nov 3, 2016 a 7:58 am PDT
Jack one of the biggest cappers was indicted recently as you well know (Justicia Legal aka Carlos Arguello) and he continues to operate despite facing both criminal and civil actions. Moreover, the indicted chiros are walking away with a insignificant fine after making millions in fraudulent claims.
Charles Cleveland Nov 3, 2016 a 7:58 am PDT
I strongly agree with JackDon and dmanmex but many of these characters operate outside of the United States with call centers that are beyond our jurisdiction in Mexico. It's extremely difficult for an honest shop to compete against these cappers as they continue to run their advertising and sign-up operations..
Stuart Baron Nov 3, 2016 a 7:58 am PDT
Agree is Jackdon but would go further. Identify the lawyers the cappers are working for and report the attorneys to the Bar of investigation Nothing excites an attorney more than possible sanctions and even disbarment.
John A. Don esq. Nov 3, 2016 a 7:58 am PDT
Destie Overpeck is at the State Bar Office now - all referrals should go to her since she knows comp. & would probably be receptive to efforts that seek to clan up the system.
DEBORAH HALVERSON Nov 3, 2016 a 7:58 am PDT
Outstanding. Thank you Assemblyman, Tom Daly, for your valiant efforts. I am heartened to hear of the call for independent investigative audits of the California Workers' Compensation system.
An unbiased audit from a 'non-stakeholder' would reveal not only provider waste, fraud, and abuse, to be sure, but would finally uncover insurance and government fraud and abuse as well.
For example, the DWC insurance audit results are rarely even enforced at the level needed to curb payor violations. 90% of the penalties are 'forgiven.'
Truly, we must correct a 'privately funded WC commercial insurance premium rate system' which perilously reimburses at 'govt. level indigent reimbursement rates,' far from the actual, wholesale cost to provide the care. This was never the intent of legislature.
Think about it - taxpayers, in essence, must subsidize Medicare, Medi-Cal, CHIP, VA healthcare programs, and now California Workers' Compensation? WC Cost-shifting is simply not sustainable, especially for the catastrophic WC trauma/emergency cases.
The DWC/Insurances further conflate gross charges with 'costs' in an false argument to report 'out of control' medical costs. No one pays gross charges- they are an aberration of Medicare cost reporting and simply not relevant to actual medical costs and reimbursement. It paints a false narrative that 'providers' are somehow fraudulent in charging.
However, what is relevant are the real charges paid for Utilization Review (UR) and Bill Review (BR). They report their costs as medical costs, making it appear that healthcare provider costs are increasing at an alarming rate. In fact, UR and BR charges are increasing at an alarming rate.
Also audit the UR and BR internal practices, non-adherence to adjudication time deadlines, 'rental, silent PPO networks' and lack of medically adequate authorizations/payment recommendations.
My only hope is that like mandated 'lost leader' OMFS fee schedule pricing, this type of 'lost leader' charge pricing will be imposed on UR and BR as well.
They would cease to exist.
Here is yet another example, this time, of govt abuse at the CA DWC, which manipulates it's cost outlier calculation to ensure it's almost impossible to reach the cost outlier reimbursement. Even if a medical case qualifies for it, the actual additional payment is absurdly low - it never comes close to covering the actual wholesale cost of traumatic, emergent, catastrophic care. How dangerous is this?
Yes, let's audit ALL stakeholders equally, not just the providers.
Anonymous Nov 3, 2016 a 7:58 am PDT
Also have them investigate the CONFIDENTIAL MPN contacts that coerce doctors into signing a fee reduction if they want to be in the game. Another LC 139 violation that nobody wants to admit.
David Stein Nov 3, 2016 a 7:58 am PDT
Under the current system there is no way for a carrier to be investigated. If that was changed, work comp in CA would likely collapse since many of the big names would be indicted on various charges. Zenith would be hit hard and SCIF would lose at the least it's CEO. DOI and DWC ex and present would be exposed too. Maybe the governor is trying to avoid total collapse and needs time to fix the problems but minimize the fallout. Not likely though.
By the way, good job DOI on announcing the arrest of a small time IW fraud today again while carriers are infected with pain cream scams and hackers.