Tag: Workers Comp

(Reuters) — The U.S. government on Monday sued Rite Aid Corp., accusing the pharmacy chain of missing “red flags” as it illegally filled hundreds of thousands of prescriptions for controlled substances, including opioids.

In a complaint filed in Cleveland federal court, the Department of Justice said Rite Aid repeatedly filled prescriptions from May 2014 to June 2019 that were medically unnecessary, for off-label use, or not issued in the usual course of professional practice.

“The Justice Department is using every tool at our disposal to confront the opioid epidemic that is killing Americans and shattering communities across the country,” Attorney General Merrick Garland said in a statement.

Rite Aid pharmacists were accused of ignoring obvious signs of misuse, including in prescriptions for “trinities,” a combination of opioids, benzodiazepine, and muscle relaxants preferred by drug abusers for their increased euphoric effect.

The Justice Department also said Rite Aid intentionally deleted some pharmacists’ internal warnings about suspicious prescribers, such as “cash only pill mill???,” while admonishing them to “be mindful of everything that is put in writing.”

“These practices opened the floodgates for millions of opioid pills and other controlled substances to flow illegally out of Rite Aid’s stores,” Associate Attorney General Vanita Gupta said.

Rite Aid is one of the country’s largest pharmacy chains, with more than 2,330 stores in 17 U.S. states. It did not immediately respond to requests for comment.

The Justice Department accused Rite Aid of violating the federal False Claims Act by submitting false prescription claims to government health care programs such as Medicare and Medicaid.

 

 

 

Ninety-four percent of physicians report care delays associated with insurance prior authorization requirements and 80% report that such advance treatment approvals have led to early treatment abandonment, according to the results of a survey released Monday by the American Medical Association.

The survey of 1,001 doctors conducted in December 2022 also found that 31% of physicians report that prior authorization criteria – many of which are in place due to state regulations or parameters set by individual insurers — are “rarely or never evidence-based.”

Regarding effectiveness, 33% of physicians report that prior authorization has led to “a serious adverse event” for a patient in their care, and 9% report it’s led to “permanent bodily damage/disability or death.”

Eighty-six percent of those surveyed said prior authorization leads to higher overall utilization of health care resources and 64% said authorization requests have led to “ineffective” initial treatments.

On average, physicians handle 45 prior authorization requests a week and reportedly spend two business days each week managing such requests; 35% report they have had to hire additional staff to exclusively handle administrative duties related to such requests.

Two business owners pleaded guilty to multiple felony counts of insurance fraud and forgery as part of a $54 million workers compensation scheme, the California Department of Insurance reported.

Wesley Owens was owner and chief executive of Bison Workforce Solutions, a professional employer organization based outside of Atlanta. The department said its investigation found the company failed to pay about $29 million in premiums and bilked customers out of $25.5 million in fees they thought they were paying for comp coverage.

The investigation found Mr. Owens would obtain workers compensation insurance for his company, Bison, and then use the documents provided to it by the insurance company to generate fraudulent certificates of insurance, which they would issue to customers, the department said.

“The insurance carrier was told the policy was to cover a small, white-collar firm, not the… customers’ businesses, which included agricultural workers, roofers, limo drivers and a wide variety of other employees,” the department said.

The investigation also found Beau Wilson, who was aware of the fraud, recruited customers for Bison and received commissions for each client that used the fraudulent services. Bison was eventually unable to secure comp coverage from any insurer, at which point it contracted with another firm that already had a comp policy, which Mr. Owens used to generate fake certificates.

“In order to conceal the fact that its policy was being misused to insure (its) customers, Bison began payout out claims itself,” the department said. “When the expense of this was too much for the company to sustain, it eventually stopped paying out claims and left workers uncovered by workers compensation insurance and with no resources after being injured on the job.”

Both men will be sentenced to 10 years of probation and ordered to perform 60 days of community service, the department said. They will also be fined $350,000 each. In addition, both agreed to pay $14.15 million in restitution while on probation.

WorkCompCentral is a sister publication of Business Insurance. More stories here.

 

 

The New York Supreme Court Appellate Division has reversed a Workers’ Compensation Board decision in a case involving a New York City Transit Authority train conductor who sought comp benefits for post-traumatic stress disorder caused by witnessing a train passenger fatality.

The appeals court on Thursday remitted the case back to the comp board for further proceedings after finding the panel did not properly address issues raised by the claimant on administrative appeal.

The case involves a train conductor who filed for comp benefits after claiming he developed PTSD after witnessing a person fall between train cars and die in March 2021.

The transit authority, the self-insured employer, initially agreed to compensate the conductor with medical-only benefits, but later filed a notice of controversy arguing that there was no causal relationship between PTSD and employment and no compensable injury arising from the incident.

A comp judge had given the employer an opportunity to schedule an independent medical exam after finding evidence of PTSD, but the conductor objected, arguing the employer’s controversy notice was not timely filed, and asserting the employer’s initial acceptance of the claim should be binding.

On appeal, the Workers’ Compensation Board found that when a claim is never indexed, as was the case here, the provisions of comp law are inapplicable. It ruled the employer did not file an untimely notice of controversy.

In its ruling, however, the appeals court determined the board failed to address the issue of the employer initially accepting the comp claim, and that it offered no reasoning as to why it determined the employer’s notice of controversy was timely filed.

The court said it was precluded from undertaking any “meaningful appellate review” of the matter before the board re-examined the outstanding issues. 

 

The Occupational Safety and Health Administration has cited a Florida roofing contractor after a 15-year-old worker fell 20 feet from the top of a two-story home and suffered severe head and spinal injuries.

OSHA said Friday it cited Lake Mary, Florida-based JGN Services LLC for three serious violations and proposed penalties of $8,702 for the February 2022 incident. The agency said the contractor failed to install a guardrail, safety net or personal fall arrest system for employees doing roof work, allowed the improper use of ladders, and failed to train workers on recognizing fall hazards.

OSHA assessed a $55,841 civil penalty against JGN under the Child Labor Enhanced Penalty Program, saying the company violated child labor laws that ban employers from allowing minors under the age of 18 to perform certain roofing activities.

JGN was further required to pay $106,600 in back wages and liquidated damages after investigators determined it misclassified some workers as independent contractors and failed to pay proper overtime rates.

Texas is the latest state to consider creating legal protections for warehouse workers.

H.B. 4394, introduced Thursday, would create a list of guidelines for employers who staff and operate in warehouses or distribution centers, setting parameters on such issues as quotas, employee work speed data, employee safety notification requirements, and unlawful retaliation.

The changes would go into effect on Sept. 1 if the bill passes.

Lawmakers in Minnesota recently introduced similar legislation aiming to make warehouse work safer and such laws went into effect in Illinois and New York this year. A related issue, the U.S. Occupational Safety and Health Administration is also cracking down on workplace safety issues at Amazon Inc. warehouses. 

 

The Texas legislature is considering a bill that would create a rebuttable presumption that a deceased worker was intoxicated at the time of a deadly incident if an autopsy determines the presence of drugs or alcohol.

H.B. 4556, introduced Thursday, would presume that drug or alcohol positivity would mean the worker was “intoxicated and did not have the normal use of mental or physical faculties,” and thus surviving family members would not be eligible for death benefits. Under current law, workers compensation claims filed by workers who were proven to be intoxicated at the time of their accident are not compensable.

The proposed amendment addressing autopsy testing states that the presumption may be rebutted “only by credible and objective evidence that the person was not intoxicated.”

Lawmakers also introduced S.B. 2121, which would limit civil liability of property owners of certain projects when a worker is injured and works for an employer that opted to not carry workers comp insurance, as permitted in Texas.

 

The Minnesota Supreme Court ruled a deputy sheriff receiving workers compensation benefits after being diagnosed with post-traumatic stress disorder was not entitled to continue receiving benefits after his diagnosis changed.

The state high court on Wednesday agreed with the Workers’ Compensation Court of Appeals, which reversed a compensation judge’s decision allowing the deputy to continue receiving benefits after the diagnosis change.

The deputy, employed by Mower County from November 2007 to March 2020, argued he should have been entitled to continued comp benefits because he remains disabled from a mental illness.

A doctor had reevaluated the deputy, determining he no longer met the criteria for PTSD.

The deputy argued that even though he no longer had diagnosed PTSD, he still experienced disablement and should be entitled to benefits.  

The compensation judge found the deputy to be temporarily totally disabled and awarded him benefits from April 1, 2020, to the present. The Workers’ Compensation Court of Appeals reversed the order, determining the deputy’s occupational disease was resolved, making him ineligible for continued benefits.

The state Supreme Court said an employer’s liability for comp benefits ends when a worker is no longer disabled by a work-related injury, and that in this case the deputy was no longer disabled for the purposes of comp after a doctor said he no longer suffered from PTSD.

The court ruled that while it is sensitive to the “well-being of Minnesota workers experiencing mental illness,” it is up to the legislature to change the law concerning who may be entitled to comp benefits and under what circumstances.

In Minnesota, the court noted, the only mental impairment to qualify for workers comp is PTSD, and other disabling mental impairments are specifically excluded from comp coverage.

 

 

Accused of lapses in inspection processes, the Occupational Safety and Health Administration “may have conducted incomplete inspections and workers may have been exposed to hazardous working conditions for an extended period of time,” according to an independent audit commissioned by the U.S. Department of Labor’s Office of the Inspector General.

The auditor, hired in response to a complaint made to the DOL, reviewed 100 complaint and referral cases that were opened and closed in 2019 and 2020 and concluded that “OSHA did not consistently ensure complaints and referrals were adequately addressed nor regularly enforce hazard abatement timelines,” according to the report.  

The audit “found OSHA did not consistently involve the complainant and/or witnesses in the investigation or inspection process” and that “OSHA has no policy requiring Compliance Safety and Health Officers to interview or otherwise involve the complainant after the complaint is filed, yet that person may have key insights to ensure alleged hazards are being addressed.”

Of the 76 complaint cases reviewed, OSHA interviewed the complainant in only half of them, and in all sampled cases where OSHA interviewed the complainant and/or witnesses, each person was only interviewed once, according to the report.

The auditor also “found OSHA’s files did not contain clear reasoning as to why it did not conduct an inspection for 11 out of 30 sampled cases where a complaint or referral met its criteria for conducting an inspection” and that it “did not regularly ensure safety and health violations from complaints and referrals were corrected in a timely manner.”

The auditor reported that OSHA lacks adequate processes and a methodology to determine when complainants and witnesses should be interviewed and the appropriate amount of their involvement.

OSHA “generally disagreed” with the auditor’s recommendations on how to improve its investigations but “agreed that it can improve its documentation, customer service, and training,” according to the report.

In its response, OSHA questioned whether the sample of 100 cases was adequate in generalizing lapses in the agency’s response to complaints.