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A little known group called the “California Fraud Assessment Commission” is the driving force in defining what medical groups and what conduct will be the subject of criminal prosecution.  This is a state commission charged with funding local prosecutor’s offices for the purpose of investigating and prosecuting medical fraud.  The old adage, “follow the money” applies to the fraud assessment commission.  What it funds, gets investigated. 

Who sits on this commission?  Primarily members of the insurance industry and two union representatives.  The current lineup (as of 8/21/2015), taken from the commission’s website, is as follows:

Lilia Garcia - Ms. Garcia was born and raised in East Los Angeles, was appointed to the Fraud Assessment Commission in June of 2007 representing labor. Ms. Garcia is the executive director of the Maintenance Cooperation Trust Fund (MCTF). The MCTF is a statewide janitorial watchdog organization that investigates janitorial contractors for employment law violations.

Douglas Williams - Mr. Williams is the Business Manager for Iron Worker's 433 and is a newly appointed Fraud Assessment Commission member who is representing labor. In 1994,

Donald Marshall - Mr. Marshall was appointed to the Fraud Assessment Commission in January 2010 representing workers' compensation insurers. Since 2003, he has served as vice president of the national anti-fraud program for Zenith National Insurance Company.

Zenith has been one of the most aggressive insurers involved in the prosecution of medical providers, especially chiropractors.  Mr. Marshall is the commission chairperson.

John Riggs - Mr. Riggs was appointed to the Fraud Assessment Commission in January 2010 representing self-insured employers. Since 2003, he has served as manager of workers' compensation for Disney Worldwide Services.

Riggs was also involved with Zenith Insurance as a branch claims manager.

Joel Sherman - Mr. Sherman is the Director of Safety, Workers' Compensation and Regulatory Compliance for Grimmway Farms, a large vegetable grower/packer/shipper based in Kern County, California. 

Mr. Sherman is Vice-Chairperson of the commission.

There is a new appointee, Karla Rhea, Ph.D..  Her background is not published on the website but she has served as the Administrative Officer for two distinct joint powers authorities.  Her responsibility is to ensure coverage for public schools and community colleges in the areas of property, liability, workers' compensation, construction and employee benefits.  Basically, her background is in risk management.

Vernon Steiner - President and CEO, State Compensation Insurance Fund (SCIF)

From the above backgrounds, Workers Compensation will clearly be a major funding focus.  The unions will look to fund medical providers who run up large bills but provide substandard treatment.   On this issue they will find support from the other members.  As SCIF and Zenith have significant internal fraud units, they will combine funding from this commission with donations of Zenith SIU investigators and resources, to local prosecutors.

The donated resources include access to expert witnesses, computer professionals as actual investigators who can work side by side with law enforcement.

At the January 2015 meeting there was a presentation made to the commission. The presentation was by the Department of Industrial Relations and Kern County.  The Department of Industrial Relations regulates workers compensation and the speaker was attorney James Fisher, Counsel
Division of Workers’ Compensation as well as Deputy District Attorney Kate Zimmerman
of Kern County.  James Fisher has been involved in many prosecutions over the years.  He was a participant in our 2007 MUA trial where 5 chiropractors were arrested and one (my client) actually brought to trial.  Our jury hung 10-2 for acquittal and a few weeks later charges against all chiropractors were dismissed.  We later sued the insurance company that was behind the filing of the charges. 

The name “James Fisher” should be tracked by any attorney who represents medical professionals.  Where “James Fisher” goes, the money tends to go and prosecutions follow.  The conduct of the Department of Industrial Relations is significantly affected by Fisher and the attorneys in that office and in this writer’s experience they are strongly pro-industry.

For example, this link on the web is to an April 2, 2015 fraud conference where James Fisher was a speaker.    The new chair of the commission, Donald Marshall, also lectured at that seminar.

More on this subject later.  But be aware that the investigators are well funded and highly organized.  They crunch large amounts of insurance data and have sophisticated and standardized investigative tools.  You may feel safe, but if you have a large practice in target areas, they are watching you.