Monthly Archives: April 2012

Major Gap In New PIP Law?

The Palm Beach Post reports that concern is growing over the effective dates involved in the new PIP law, House Bill 0119.  Some interpretations indicate that as of July 1, 2012, medical providers who would otherwise be treated as an appropriately reimbursable healthcare provider under PIP of No-Fault, would not be eligible for reimbursement under PIP until January 1, 2013, a separate effective date under Florida’s new PIP law, leaving a 6-month gap where certain providers would not be entitled to reimbursement.

According to the Palm Beach Post:

The state’s Agency for Health Care Administration “is making preparations to clarify confusion that may exist should the governor sign the bill into law,” AHCA spokeswoman Meagan Dougherty said. AHCA officials declined to offer details.

Florida Hospital Association General Counsel Bill Bell said his group has been involved in discussions about the issue, but he does not see a legal problem reimbursing qualified PIP providers.

The full article is available here.

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Filed under Fla. Stat. 627.736 (2012)

3 Clinics Closed and 13 People Arrested

After a year of investigation, the Miami Police Department announced a series of arrests and clinic closures as a result of Operation Crash Clinics. The investigation focused on the scheme of medical providers billing for medical services that were never provided along with their efforts to recruit “patients” who were never injured as a result of alleged motor vehicle accidents. The three clinics closed as result of the invetigation are:

Paradise Cosmetic Center, 8100 W. Flagler St.; Family Therapy, 14750 SW 26th St.; and Excellent Group Services, 10550 NW 77th Ct.

Undercover police officers posed as willing “patients” in a fake car crash in Little Havana organized by Eduardo Olivarez, 42, police said. Orosa said many of the participants — all of whom received a cut of the profits — came from the Little Havana, Coral Way and Flagami areas.

Apart from Olivarez, those arrested include: Andrés Blanco, 45; Marco Torres, 50; Meritania Amaro, 23; Omar Yeras, 64; Osvaldo García, 65; Alina Urgelles, 50; Luis Armando Pérez, 39; Sissi Ramos-Orosco, 26; Daysel Aguilar, 24; and Lorelys Diaz, 23.

To read the entire article click here

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Filed under Fla. Stat. 627.736 (2008), Insurance Fraud

Agency for Health Care Administration Mobile App

Yesterday the Agency for Health Care Administration (AHCA) released its mobile app allowing consumers the ability to obtain medical provider location & driving directions. AHCA says the following about the app:

“I am excited the Agency is able to make this mobile technology available,” said Secretary Liz Dudek. “The mobile facility locator will provide residents, consumers and tourists with easy access to facility information and driving directions for Florida health care facilities.”

Consumers can search for a facility by license type, county, city, proximity distance or a combination of those options.  After a facility has been selected, the mobile app will provide directions using the same directions feature on FloridaHealthFinder.gov or enter the facility address into the phone’s independent navigation application.

The app also allows the consumer to learn what type of beds and capacity the facility offers, along with the names of the facility administrator and owner. From the app, the user can link directly to the facility’s specific website, if available, to learn more. This additional resource can assist consumers in finding health care facilities that are nearby to them and fit their needs.

To download the app on Itunes click here

To download the app on Android click here

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Filed under Fla. Stat. 627.736 (2008), Licensing

Florida Supreme Court to Decide Fee Schedule Issue

Yesterday the 3rd District Court of Appeal rendered its decision Geico v. Virtual Imaging (a/a/o Maria Tirado). While the Court ruled it was bound by its prior decision denying the use of the Fee Schedule as found in Florida Statute 627.736, the Court also certified the fee schedule to the Florida Supreme Court. In certifying the question as a matter of great public importance the court found that

The Legislature’s amendment to the PIP statute sought to address the enormous costs and inefficiencies of the law prior to amendment. Litigation and fee-shifting to determine “reasonable” costs of standardized medical procedures should be passé by now. An MRI, for example, is now a common procedure. The medical cost accounting and national metrics supporting the Medicare Part B reimbursement figures for MRIs and other standard medical services are widely used and understood. An alternative charge based essentially on whatever the market will bear, on the other hand, invites litigation. A prevailing provider or insured may also recover attorney’s fees and costs, and resolution of these disputes also requires judicial resources at the expense of all State taxpayers. All of these circumstances are contrary to the original, no-fault objectives of the PIP statute.

Finally, a court that understands the legislature’s intent. The certified question reads as follows

WITH RESPECT TO PIP POLICIES ISSUED AFTER JANUARY 1, 2008, MAY THE INSURER COMPUTE PROVIDER REIMBURSEMENTS BASED ON THE FEE SCHEDULES IDENTIFIED IN SECTION 627.736(5)(a), FLORIDA STATUTES, EVEN IF THE POLICY DOES NOT CONTAIN A PROVISION SPECIFICALLY ELECTING THOSE SCHEDULES RATHER THAN “REASONABLE MEDICAL EXPENSES” COVERAGE BASED ON SECTION 627.736(1)(a)?

To read the entire opinion click here.

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Filed under Fla. Stat. 627.736 (2008), The Statutory "Fee Schedules"

Yasmani Marquez of K&A Rehab Sentenced to 5 Years For Kidnapping

Tuesday, 24-year-old Yasmani Marquez of Westchester, Florida was sentenced to 5 years in prison as a result of an earlier conviction for kidnapping a cohort in a dispute over a $20,000 claim in an insurance scam.  According to the Miami Herald, “[t]he victim, acting in self-defense, shot and wounded Marquez after he had been held hostage for hours in May 2011.”

Reports state that Marquez ran K&A Rehab Center in Westchester, a clinic involved in fraudulent insurance claims as a result of staged accidents.

Miami-Dade prosecutor Ana Manrara had this to say, “Although he was not charged with insurance fraud, he is the primary example of how those committing insurance fraud, formerly a paperwork crimes, leads people to do violent crime.”

The Miami Herald reports, Yasmani Marquez was, “in cahoots with four others who were later arrested for allegedly submitting $77,000 in bogus claims to four different clinics in Miami and Hialeah.”

The full article from the Miami-Herald is available here.

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Filed under Fla. Stat. 627.736 (2008), Insurance Fraud

Fox Business asks: “Is a car accident a lottery ticket?”

According to the Insurance Information Institute (III), about 10 percent of all property and casualty industry losses are due to fraud.  Fox News recently addressed the III’s analysis of fraud, categorizing it as either “hard” fraud, like staged losses or accidents, or “soft” fraud involving exaggeration of otherwise potentially legitimate claims.

Where is “hard fraud” most likely?  In states with No Fault insurance, like Florida.   From the article:

That guarantee of care tempts organized fraud rings to game the system in states with no-fault insurance laws, such as Florida and New York.

The kingpins of these rings tend to “prey on folks within certain minority groups,” who may not know the language and laws very well, Scafidi says. People from within these groups are paid to stage or cause accidents. For example, they may say a wreck occurred when it never did. Or, they may use their cars to force an innocent driver to hit a vehicle that is occupied by a driver and passengers on the fraudsters’ payroll. After the accident, these “victims” claim they are injured and demand compensation.

Other fraud rings simply bribe victims of genuine accidents to exaggerate their injuries.

According to the III, each Floridian pays about $58 a year due to fraudulent claims.

And in the end, injured drivers wind up cheated as well. Florida’s no-fault law is supposed to cover lost wages and burial expenses, but the pain clinics and referral services instead make sure medical costs use up the entire amount.

“This is money that would have gone directly to the insured but by function of the medical provider exhausting those benefits, the consumer receives nothing,” a report by the Office of the Insurance Consumer Advocate states.

The full story is available here.

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Filed under Insurance Fraud

Interview With Dan Anderson, Head of Florida Division of Insurance Fraud

Appointed this February, Dan Anderson began his career as a Florida law enforcement officer.  As a 25-year veteran of the Drug Enforcement Agency, Anderson now heads the Florida Department of Financial Services, Division of Insurance Fraud.  In an interview with the Coalition Against Insurance Fraud, Anderson explains the effect of stricter clinic licensing requirements in Hillsborough County and the Miami-Dade County PIP ordinance we mentioned in a previous post.  Anderson also had this to say about the expected effects of the yet to be signed amended PIP law:

I think one of the potential game changers is the prohibition on billings. One of the bigger problems over the last few years was the explosion of clinics owned by massage therapists, many of whom we have proven to be straw owners and obtaining false exemptions from the AHCA license requirements. If the massage therapists can no longer bill, it could dramatically affect a large percentage of the PIP fraud that exists. This is not to say that all massage therapists are bad or committing fraud, but it is clear from our investigations and information collected by the Insurance Consumer Advocate at CFO Atwater’s direction that many have played a substantial role.

The other game changer is the limit of PIP benefits to $2,500 unless declared an emergency medical condition. It cuts down on the profit margin of the accident clinics, which have been paying large sums to recruit patients. This takes a big bite out of their ability to pay for patients, as their pool from which that money is drawn from dwindles.

We are also looking forward to the formation of the PIP Fraud Strike Force. This Strike Force, along with DIF, will look for ways to reduce fraud in the system. This group of dedicated professionals will be an additional tool in our fight against PIP fraud and will be able to accept donations for additional on-the-ground resources for law enforcement and state attorneys in the ongoing fight against PIP fraud.

The full interview is available here.

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Filed under Fla. Stat. 627.736 (2008), Insurance Fraud, The Statutory "Fee Schedules"