Former Georgia insurance commissioner John Oxendine pleads guilty
U.S. Court News
John W. Oxendine of Johns Creek entered the guilty plea Friday in federal court in Atlanta. The 61-year-old had been indicted in May 2022 on charges of conspiracy to commit health care fraud and conspiracy to commit money laundering.
The crime is punishable by up to 10 years in prison, but Oxendine is likely to be sentenced to less. Federal sentencing guidelines discussed in the plea agreement suggest prosecutors will recommend Oxendine be imprisoned between 4 years, 3 months, and 5 years, 3 months, depending on what U.S. District Judge Steve Jones decides at a sentencing hearing set for July 12. Jones could also fine Oxendine and order him to serve supervised release.
Oxendine also agreed to pay nearly $700,000 in restitution to health insurers who lost money in the scheme, the plea document states. Prosecutors agreed to dismiss the money laundering charge as part of the plea.
“John Oxendine, as the former statewide insurance commissioner, knew the importance of honest dealings between doctors and insurance companies,” U.S. Attorney Ryan K. Buchanan said in a statement. “But for personal profit he willfully conspired with a physician to order hundreds of unnecessary lab tests, costing hundreds of thousands of dollars.”
Prosecutors say Oxendine conspired with Dr. Jeffrey Gallups to pressure other physicians who practiced with Gallups to order unnecessary medical tests from Next Health, a lab in Texas. Prosecutors said Oxendine pushed the plan in a September 2015 presentation to doctors who worked for Gallups’ practice.
The lab company, Oxendine and Gallups agreed the company would pay Gallups a kickback of 50% of the profit on the tests, Oxendine’s indictment said. Next Health paid $260,000 in kickbacks through Oxendine’s insurance consulting company, prosecutors said. Oxendine paid a $150,000 charitable contribution and $70,000 in attorney’s fees on Gallups,’ behalf, prosecutors said, keeping $40,000 for himself. Some patients were also charged, getting bills of up to $18,000 for the tests, prosecutors said.
Prosecutors said Oxendine told Gallups to lie and say the payments from Oxendine were loans when a compliance officer at Gallups’ company asked about them. Oxendine told Gallups to repeat the same lie when questioned by federal agents, prosecutors said. And they said Oxendine falsely said he didn’t work with the lab company or get money from Next Health when interviewed by The Atlanta Journal-Constitution.
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Workers’ Compensation Subrogation of Administrative Fees and Costs
When a worker covered by workers’ compensation makes a claim against a third party, the workers’ compensation insurance retains the right to subrogate against any recovery from that third party for all benefits paid to or on behalf of a claimant injured at work. When subrogating for more than basic medical and indemnity benefits, the Texas workers’ compensation subrogation statute provides that “the net amount recovered by a claimant in a third‑party action shall be used to reimburse the carrier for benefits, including medical benefits that have been paid for the compensable injury.” TX Labor Code § 417.002.
In fact, all 50 states provide for similar subrogation. However, none of them precisely outlines which payments or costs paid by a compensation carrier constitute “compensation” and can be recovered. The result is industry-wide confusion and an ongoing debate and argument with claimants’ attorneys over what can and can’t be included in a carrier’s lien for recovery purposes.
In addition to medical expenses, death benefits, funeral costs and/or indemnity benefits for lost wages and loss of earning capacity resulting from a compensable injury, workers’ compensation insurance carriers also expend considerable dollars for case management costs, medical bill audit fees, rehabilitation benefits, nurse case worker fees, and other similar fees. They also incur other expenses in conjunction with the handling and adjusting of workers’ compensation claims. Workers’ compensation carriers typically assert, of course, that, they are entitled to reimbursement for such expenditures when it recovers its workers’ compensation lien. Injured workers and their attorneys disagree.