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Premier Medical Agrees To Dismiss $70 Million In Work Comp Liens In So Cal
By Lonce LaMon - October 2, 2009

Premier Medical Management Systems, Inc., under intense criminal investigation by the Los Angeles County District Attorney's office, has agreed to dismiss 70 million dollars worth of their workers' compensation medical services liens from 23 workers' compensation insurance companies and self-insureds in Southern California.

Premier Medical has been under investigation and in litigation before the California Workers' Compensation Appeals Board since 2004.  According to the law firm of Heggeness, Sweet, Simington & Patrico, of San Diego, which is representing the insurers, Premier set up a network of 130 physician offices and clinics that stretched across the Los Angeles region.

Deputy District Attorney, Al MacKenzie, of the Los Angeles County District Attorney's Office's Fraud Interdiction Program, spoke to this writer yesterday by telephone.

"Not to be too coy, but this case still has not been finally resolved.  Once it's finally resolved, I'll be happy to discuss it at great length with you," he said.  But what he wasn't coy about, stating clearly and openly, was that the reason why this problem with Primier Medical was created was that neither the patients nor the doctors knew what was being billed for.

"Part of the kick I've been on with Judge O'Brien and Laura Clifford (Executive Director of the Employers' Fraud Task Force)," MacKenzie explained, "is about the fundamental idea of sending out EOBs (Explanation of Benefits letters) to the injured workers in the work comp system. "We've got people in the system who have legitimate (work comp) claims, and they want to be healed. And if we don't send them a copy of what's being billed for, then every vendor in the system, whether it's a hospital, medical doctor, chiropractor, physical therapist, pharmacy, medical equipment supply company, and you name it, basically has got a license to steal."

Premier's network advertised to and serviced mostly monolingual, Spanish-speaking persons, stated Joseph N. Patrico, one of the partners of Heggeness, etc.  Between the mostly Spanish speaking injured workers and the doctors treating them, neither knew what Premier was billing for.  Premier simply exagerrated treatments and numbers of visits and billed for them.

Patrico also said there was no way to know how many dubious and possibly fraudulent claims might have already been paid to Premier and its medical providers.

"You have got to figure a lot," he said. "There are 23 carriers, and probably an exponential amount of dollars involved. It was a very widespread group."

This statement from attorney Joseph Patrico brings up a salient point made yesterday by Deputy District Attorney Al MacKenzie. "By the time I get these cases, the barn has burned down, the money is long gone, and so I'm interested in preventing some of these losses. We get all kinds of restitution orders, but nobody has ever collected because, why?, the money's already been spent or it's been wired out of the country.  It's like the Bernie Madoff scandal.  We want to prevent these losses.  Because you're never going to recoup the money."

MacKenzie talked a good deal about how patients get their EOBs from the general health insurance carriers such as Blue Cross, Blue Shield, Humana, and give fraud referrals. "Humana got 600 insurance fraud referrals," because patients got their EOBs and said I never saw this doctor or I never got this treatment.

"I'm not trying to cram a law down somebody's (meaning the insurer's) throat," MacKenzie explained. "I'm just trying to create some prevention here.  If John Riggs (the workers' comp claims manager of Disney in Anaheim) and some of the other courageous people will try this (sending out the EOBs and/or medical-services-rendered invoices to the injured workers), and if it works as it does in Medicare and with the general health insurers, then everybody else in work comp will want to jump on the band wagon."

 
 

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