Column: Workers' Comp

Fraud as a Ticket Out

By: | April 28, 2016 • 2 min read
Roberto Ceniceros is senior editor at Risk & Insurance® and chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at [email protected] Read more of his columns and features.

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.

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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. &

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Column: Roger's Soapbox

Whiplashed by Claims

By: | March 1, 2016 • 3 min read
Roger Crombie is a United Kingdom-based columnist for Risk & Insurance®. He can be reached at [email protected]

Insurance fraud: disorganized crime that eventually costs all of us serious money.

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A few unlost dollars added to an insurance claim here; a gang of Russian hackers shooting for the real money there. Why earn when you can steal, one might feel.

It has become traditional in the UK to claim for whiplash injuries following a motor accident. Any sort of motor accident, even a minor one. Sometimes, not even following a motor accident. Ever more inventive claims are a hallmark of the British whiplash scene.

You were in bed, asleep, when a cyclist dinged your wing mirror? The rude awakening caused your neck injury. Your car was stationary when hit from behind at 2 mph? Turning round to see what happened threw your back out.

Thus it is that Britannia rules the waves of whiplash claims inundating insurance company offices.

A few unlost dollars added to an insurance claim here; a gang of Russian hackers shooting for the real money there. Why earn when you can steal, one might feel.

LV= is a British insurer, although what LV equals is unclear. It reports that the UK is the whiplash capital of the world. Such prestige.

One of every 38 insureds claims for whiplash damages annually. Such claims constitute almost eight in 10 of all British insurance claims, cost more than $3 billion a year, and raise the average annual premium by $130.

This is not to pooh-pooh all cervical acceleration-deceleration claims. (That’s the medical term for whiplash.) Awful things happen to people in motor accidents; many of the claims for whiplash and other spinal injuries are, of course, entirely valid.

Many are not. More than half of all British drivers involved in a collision receive a call or text from lawyers or repair shops, suggesting that they claim on their insurance. This despite a series of measures introduced in 2013 to correct “the compensation culture.” The changes included a ban on “referral fees” paid by claims firms for potential clients, and a cap on what doctors may charge for preparing whiplash injury reports.

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The list of parties guilty of perverting the course of claims justice, therefore, includes doctors and attorneys. What exactly does the term “professional” mean these days?

If I’ve sparked your interest in whiplash claims, have a care when searching Google for information on the subject, or you may put more than your back out. A Miss Whiplash leads the Corrective Party, a formally-registered British political grouping that protects the interests of prostitutes. She claims that “the tax man is a pimp and the government is a pimp as well.”

Both live on the earnings of others, so she may have a point.

Miss Whiplash herself was involved in a car accident in 2009 and suffered horribly. She did not claim for her namesake, but instead embraced Christianity. Would that more insurance claimants did the same — after all, remember the Ninth Commandment: Thou shalt not bear false witness.

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Sponsored Content by IPS

Compounding: Is it Coming of Age?

Prescription drug compounding is beginning to turn a corner in managing chronic pain.
By: | April 28, 2016 • 5 min read
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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

IPS_SponsoredContentThat 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

IPS_SponsoredContentAt 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.

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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.




Integrated Prescription Solutions (IPS) is a Pharmacy Benefit Management (PBM) and Ancillary Services partner to W/C and Auto (PIP) Insurance carriers, Self Insured Employers, and Third Party Administrators who specialize in Workers Compensation benefits management.
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