NM Claims Retirement Center Abused Patients
Ethics
The State of New Mexico claims Dr. Ali Ghaffari and his pharmacist wife owned and operated the substandard and abusive Buena Vista Retirement Center in Clovis, and bilked the state through Medicaid fraud. The state also sued Dr. Ali Ghaffari Sr., and claims the Ghaffaris "caused egregious and ongoing resident harm, abuse, and neglect, and the grossly deficient living conditions at Buena Vista."
In its federal claim, the state says the Ghaffaris collected $4.9 million from Medicaid. It claims the family "knowingly caused and/or conspired to cause Buena Vista to submit bills to Medicaid for providing qualified nursing home services, despite knowing that in fact Buena Vista was not doing so. At all material times, defendants knowingly assisted one another and cooperated in submitting the false claims and accepting the payments received therefrom ... . defendants Ali Ghaffari and Linda Ghaffari personally benefited from the payments received from the Medicaid program."
The state demands penalties and treble damages for false claims, and other relief.
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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.