Fraud as a Ticket Out
News stories and press releases from insurance departments nationwide regularly disclose the prosecution of prison guards for workers’ compensation fraud.
I often wondered why guards, obviously familiar with prison horrors, would risk incarceration.
The answer recently came during a conversation with a prosecutor regarding the conviction of Mark Navarrete, whose workers’ comp fraud case offers an extreme example of how work environments impact behavior.
Navarrete, a 12-year Santa Clara County Sheriff’s Office veteran, worked as a correctional deputy. The California county’s beleaguered jail system suffers horrendous problems.
Three of its guards, for example, currently face murder charges for beating a mentally ill inmate to death.
The day after I spoke with Santa Clara County Deputy District Attorney David Soares, video surfaced showing about 20 inmates pummeling each other inside the county’s main jail. The brawl erupted when one inmate brushed against another. The video shows what jail deputies face daily, the county sheriff said at a news conference.
Guards are responsible for policing inmates who grow increasingly volatile every day they are incarcerated. Fifty of them may share a single toilet, Soares said. It’s an awful work environment, leaving jailers desperate for an escape route and time away from the job.
Navarrete’s escape plan had several problems. A co-worker reported seeing a text with Navarrete bragging that a softball injury would become a work accident. A softball field security camera captured video of Navarrete injuring his arm while swinging for an inside pitch, and hospital documents revealed a timeline that refuted his workplace claim.
“I wanted to send a message that if individuals were encouraging the fraud they were going to go down too.” — David Soares, deputy district attorney, Santa Clara County
With widespread problems at the county jail, Soares dug deeper into Navarrete’s case to determine whether other deputies encouraged him in a conspiracy to defraud their employer.
“I saw this as a potentially endemic problem because of the issues within the jails and because we had recently had this homicidal death in the jail,” Soares said. “I wanted to send a message that if individuals were encouraging the fraud they were going to go down too.”
In the end, only Navarrete was prosecuted. He pled no contest, receiving a 120-day jail sentence, but was allowed to serve it at home with electronic monitoring. He must also pay nearly $23,000 in restitution.
Inhospitable work environments don’t encourage claimants to hurry and return to work. As Navarrete showed, they even encourage some workers to rationalize committing insurance fraud.
Navarrete’s work environment, awful as it is, doesn’t justify defrauding his employer. But it does offer an example, albeit an extreme one, of the workplace environment’s potential impact on workers’ comp costs. &
Managing the Madness of the Political Season
A story I often tell at PRIMA Institute is of a hot summer day in the heat of a political campaign season. Tasked with assisting security for the event, I helped with balloons, ice cream, crowds and the arrival of a “distinguished” politician.
Well, the heat melted the ice cream and the candidate was late, making for a tiresome, disappointing event. As the event closed, the candidate got into his big black SUV with tinted windows and proceeded to exit the public park.
In one pristine moment on that fine summer day, universes collided — school children arrived for a history lesson, the candidate’s posse turned on their vehicle engines and a flock of baby ducks, led by their parents, decided to cross the road.
As the SUV revved its engine in front of the school children — attempting a speedy exit — I did the only thing any sensible risk manager would do … I stood between the ducks and the SUV as a fellow employee shooed the ducks along.
He eventually revved his “engine” a little too loudly and too frequently — while the ducks still reside in the park generations later.
I found out later the politico’s “handler” called my boss and demanded I be fired.
Thankfully, my boss called me and asked me my side of the story and sided with the ducks. We often joke amongst ourselves when that individual’s name comes up that arrogance breeds contempt.
We also take solace that while the candidate won the race, he eventually revved his “engine” a little too loudly and too frequently — while the ducks still reside in the park generations later.
Let’s talk about those baby ducks and the common sense of any candidate for office and the reality of governance of “for the people, by the people” and a few basis rules of survival.
Rhetoric may sell headlines, but it doesn’t make for credibility in public service. The internet, as a vast trove of snippet storage, never lets anyone forget a misstep, a slip of a phrase or an unkept promise.
Risk professionals work with the community and law enforcement to provide opportunities for discussion and deal with the fallout of overzealous patrons in the search for democracy.
As public risk professionals manage the madness that descends upon their communities and the disruption it brings to daily governance, they’ll question their sanity, their patience and the limitations of providing the opportunity for free speech within a fixed budget.
The moral of the duck flock, you ask?
It’s about distinguishing between the pressures of singular political aspirations versus the patient reality of the community one serves. Sometimes, the smallest of our actions in that one split second of each of our judgments sets the standards of who we as a community should all aspire to be.
Marilyn Rivers’ views are her own and don’t represent the City of Saratoga Springs.
Compounding: Is it Coming of Age?
The WC managed care market has generally viewed the treatment method of Rx compounding through the lens of its negative impact to cost for treating chronic pain without examining fully the opportunity to utilize “best practice” prescription compounds to help combat the opioid epidemic this nation faces. IPS stands on the front lines of this opioid battle every day making a difference for its clients.
After a shaky start cost-wise, prescription drug compounding is turning the corner in managing chronic pain without the risk of opioid addiction. A push from forward-thinking states and workers’ compensation PBMs who have the networks and resources to manage it is helping, too.
Prescription drug compounding has been around for more than a decade, but after a rocky start (primarily in terms of cost), compounding is finally coming into its own as an effective chronic pain management strategy – and a worthy alternative for costly and dangerous opioids – in workers’ compensation.
According to Greg Todd, CEO and founder of Integrated Prescription Solutions Inc. (IPS), a Costa Mesa, Calif.-based pharmacy benefit manager (PBM) for the workers’ compensation and disability market, one reason compounding is beginning to hit its stride is because some states have enacted laws to manage it more effectively. Another is PBMs like IPS have stepped up and are now managing compound drugs in a much more proactive manner from an oversight perspective.
By definition, compounding is a practice through which a licensed pharmacist or physician (or, in the case of an outsourcing facility, a person under the supervision of a licensed pharmacist) combines, mixes, or alters ingredients of a drug to create a medication tailored to the needs of an individual patient.
During that decade, Todd explains, opioids have filled the chronic pain management needs gap, bringing with them an enormous amount of problems as the ensuing addiction epidemic sweeping the nation resulted in the proliferation and over-consumption of opioids – at a staggering cost to both the bottom line and society at large.
As an alternative, compounded topical cream formulations also offer strong chronic pain management but have limited side effects and require much reduced dosage amounts to achieve effective tissue level penetration. In fact, they have a very low systemic absorption rate.
Bottom line, compounding provides prescribers with an excellent alternative treatment modality for chronic pain patients, both early and late stage, Todd says.
Time for Compounding Consideration
That scenario sets up the perfect argument for compounding, because for one thing, doctors are seeking a new solution, with all the pressure and scrutiny they’re receiving when trying to solve people’s chronic pain problems using opioids.
Todd explains the best news about neuropathic pain treatment using compounded topical analgesic creams is the results are outstanding, both in terms of patient satisfaction in VAS pain reduction but also in reduction potentially dangerous side effects of opioids.
The main issue with some of the early topical creams created via compounding was their high costs. In the early years, compounding, which does not require FDA approval, had little oversight or controls in place. But in the past few years, the workers compensation industry began to take notice of the solid science. At the same time, medical providers also were seeing the same science and began writing more prescriptions for compounding – which also offers them a revenue stream.
This is where oversight and rigor on the part of a PBM can make a difference, Todd says.
“You don’t let that compounded drug get dispensed when you’re going to pay for it without having a chance to approve it,” Todd says.
Education is Critical
At the same time, there is the growing, and genuine, need to start educating the doctors, helping them understand how they can really deliver quality pain management to a patient without gouging the system. A good compounding specialty pharmacy network offering tight, strict rules is fundamental, Todd says. And that means one that really reaches out to work with the doctors that are writing the prescriptions. The idea is to ensure that the active ingredients being chosen aren’t the most expensive sub-components because that unnecessarily will drive the cost of overall compound “through the ceiling.”
IPS has been able to mitigate costs in the last couple years just by having good common sense approach and a lot of physician outreach. Working with DermaTran Health Solutions and its national network of compounding pharmacies, IPS has been successfully impacting the cost while not reducing the effectiveness of a compounded prescription.
In Colorado, which has cracked down on compounding profiteering, Legislative change demanded no compound could be more than $350.00 period. What is notable, in an 18-month window for one client in Colorado, IPS had 38 compound prescriptions come through the door and each had between 4 and 7 active ingredients. Through its physician education efforts, IPS brought all 38 prescriptions down 3 active ingredients or less. IPS also helped patients achieve therapeutic success (and with medical community acceptance). In that case, the cost of compound prescriptions was down to an average of $350, versus the industry average of $788. Nationwide IPS has reduced the average cost of a compound prescription to $478.00.
Todd says. “We’ve still got a way to go, but we’ve made amazing progress in just the past couple of years on the cost and effective use of compound prescriptions.”
For more information on how you can better manage your costs for compound prescriptions, please call IPS at 866-846-9279.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with IPS. The editorial staff of Risk & Insurance had no role in its preparation.