Author Archives: Mark J. Rose, Esq.

Roig Lawyers Partner, Jeff Tutan, Speaks at 2014 Medical Claims Defense Network on Topic of Use of Mobile X-rays

On April 16, 2014, Roig Lawyers Partner, and Board Certified Trial Attorney, Jeff Tutan presented at the Medical Claims Defense Network Conference in Orlando, Florida.  Jeff Tutan, head of the firm’s trial practice group, discussed his recent success at jury trial in a case involving a medical provider’s claim for reimbursement for “mobile x-ray” services.  During the round table presentation, Attorney Tutan discussed how he, partner Jessica Martin, and senior associate attorney Jenna Hackman, successfully defended such a case involving these increasingly prevalent medical services.

For more information, contact attorney Jeff Tutan at jtutan@roiglawyers.com.

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Filed under Fla. Stat. 627.736 (2008), Fla. Stat. 627.736 (2012), Licensing

Jacksonville Chiropractor Arrested for Fraudulent Billing Scheme

Chiropractor Steven Rhodes faces a maximum of five years in prison after being arrested for a fraudulent billing scheme targeting multiple insurance companies.

Jeff Atwater, Florida’s Chief Financial Officer, announced the arrest earlier this week.

Ocean View Health, Inc., a Jacksonville Beach medical clinic owned by Rhodes, was used to generate fraudulent or inflated invoices. Allegations include charges for treatments never provided to clients, the submission of inflated numbers of treatments when medical treatment was provided, and the use of unlicensed staff in performing medical services.

“This kind of fraudulent activity places honest, hard-working Floridians at risk not only financially, but also physically,” said CFO Atwater. “I am proud of our investigative team for uncovering this scam and holding this fraudster accountable for his misdeeds.”

Insurance carriers affected by the scam include Kemper, State Farm, Nationwide, Esurance, Progressive, United Health, and Blue Cross Blue Shield.

Rhodes was booked into the Duval County Jail and released on bail.

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Filed under Insurance Fraud

Cash-Only Medical Clinics Target of Florida Senate Legislative Proposal

Drastic changes in how cash-only medical clinics operate in Florida may be on the way. State Sen. Eleanor Sobel, D-Hollywood has proposed legislation (SB746) that would subject cash-only clinics to the same regulations and licensing that traditional clinics undergo, consequently closing a loophole that enables some of these clinics to illegally dispense drugs such as steroids and human growth hormones. Cash-only clinics don’t accept Medicare or other insurance coverage.

According to an Insurance Journal story on March 26, the proposed bill aims to bring transparency to cash-only clinics and hold them accountable. The measure would require these clinics to be licensed and inspected by the state Agency for Health Care Administration (AHCA). Legislation would also make possible the application of pertinent criminal liability and penalties to all clinics that allow doctors with suspended or revoked licenses to practice.

The bill is especially directed at storefront clinics that open with the help of a crooked doctor, dispense drugs illegally, and then shut their doors before law enforcement can prosecute, the article reported. Under current law, a person opening a cash clinic can fill out an application and pay a $100 exemption fee which does not expire nor require renewal.

The AHCA says that it uses the same database as the public to verify the license of medical professionals and will extend the verification process to doctors heading cash-only clinics if the bill becomes law.

Sen. Sobel also noted that many suspected clinics thrive in South Florida and often operate as anti-aging facilities, such as Biogenesis of America. In 2013, Major League Baseball charged that clinic purportedly supplied performance-enhancing drugs to some of its players, but the lawsuit was dropped last month.

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Filed under Insurance Fraud

South Florida Man Accused of Car Insurance Fraud

A Weston man is accused of bilking insurance companies out of hundreds of thousands of dollars by filing claims based on details contained in accident reports from traffic accidents involving unsuspecting drivers and other consumers who never received claims payments, according to a press release issued by the Florida Department of Financial Services.

David M. Glincher has been charged with 25 counts of insurance fraud, 22 counts of grand theft, 19 counts of uttering forged instruments, and 1 count of aggravated white collar crime.

Total theft is estimated at almost $300,000, according to the announcement. The widespread scheme involved 270 victims.

Auto Loss Claim Consultants, LLC, a Florida business owned by Glincher, was used to obtain copies of crash reports. Glincher allegedly then sent fliers to victims, urging them to file “diminished-value” insurance claims. “Diminished-value” claims allow victims to recover the difference between a car’s value before the accident and after repairs have been made.

Even when people did not contact him to complete the claim forms, Glincher used information from the accident reports to file the claims and had the checks sent to him at his business, typically netting a few thousand dollars per claim.

An insurer reported Glincher after it received five suspicious claims, and an investigation revealed that Glincher had forged 19 signatures in order to file “diminished-value” claims for other people’s traffic accidents without them knowing it.

“Insurance fraud drives up costs for all Floridians, and we will not allow it to continue,” said Florida Chief Financial Officer Jeff Atwater.

Glincher is now free on $29,500 bond after being booked into the Broward County Jail. He faces up to 30 years in prison.

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

Property-Casualty Insurers Face Cost Shifting Risk from The Affordable Care Act

The Insurance Research Council (IRC) has studied the possible impact of the Affordable Care Act (ACA) on the property-casualty industry. The IRC’s study concludes that there will be significant and long-lasting consequences to the property-casualty industry due to the change in healthcare markets and health insurance systems in the United States. Summarized below are some of the issues raised by the IRC’s research.

The first potential impact, which the IRC predicts will be major, is cost shifting from health insurance systems to property-casualty insurance systems. To offset anticipated reductions in revenues from health insurance providers due to cost containment efforts and initiatives by public and private health insurers, medical providers may seek to increase revenues from other payers, including property-casualty insurers. To do so, medical providers may seek higher reimbursements from other payers and increase the volume and mix of services provided to patients covered by other payers.

The widely varying levels of reimbursement leave some payers, including property-casualty insurers, particularly vulnerable to cost-shifting efforts by hospitals and other providers. While large health insurers are able to negotiate lower prices or significant discounts for medical services, the authority and ability of property-casualty insurers to negotiate reimbursement levels varies from state to state. This leaves the property-casualty insurer vulnerable to cost shifting from medical provider to insurer.

A second potential impact of the ACA is to prompt individuals with injuries to file a claim with a property-casualty insurer instead of a health insurer. The reason for the “claim shift” is that the ACA may have made it more expensive or difficult for the individual to file a health insurance claim. Many people are insured under health insurance plans that have high deductibles and coinsurance provisions that increase out-of-pocket costs for insured individuals. The claimant, therefore, may be motivated to file their claim with a property-casualty insurer, if possible, in order to avoid incurring costs due to high deductibles and cost-sharing requirements.

Additionally, health insurers may become more aggressive under the ACA in refusing to provide coverage for certain procedures. If insureds fear that their desired treatment will be denied by the health insurer, they may contend—legitimately or not—that their claim is covered by property-casualty insurance. Fraudulent or not, either way a claim shift will have occurred.

A third important potential impact of the ACA is a rise in fraudulent claims due to increased fraud-fighting emphasis. The IRC refers to a paper published by the National Insurance Crime Bureau (NICB) in which the NICB concludes: “because property-casualty insurance is not covered by the ACA, career criminals and unscrupulous medical providers will shift their attention to the property-casualty business to avoid increased scrutiny from health insurers.” The NICB did not estimate the magnitude of this potential effect, but did suggest some actions that property-casualty insurers could take to mitigate its potential impact (e.g., market-based fee schedules and bill review authority).

In conclusion, although not specifically targeted by the ACA, property-casualty insurers may nonetheless experience significant and long-lasting effects from the implementation of the ACA. The IRC recommends that property-casualty insurers begin considering and implementing tools to reduce the ACA’s potentially negative impact on the industry.

Click on the link to read the IRC study.

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Filed under Fla. Stat. 627.736 (2008)

“Operation On the Run” Results in Five Arrests Related to Miami PIP Insurance Scam

Five people were arrested for their involvement in a Personal Injury Protection (PIP) insurance scam as part of an undercover investigation that began in June 2013, Miami-Dade State Attorney Katherine Fernandez Rundle and City of Miami Police Chief Manuel Orosa jointly announced.  The five involved in the racket worked at Central Therapy Center, 2742 S.W. 8th Street in Miami, which has now been shut down.

The investigation, called Operation on the Run, started with a tip about people who staged car accidents and then perpetrated PIP fraud.  According to the State Attorney’s Office (SAO), an undercover Miami detective used a manufactured crash report to gain access to the fraudulent activity at the clinic and obtained information about how the clinic worked, how much money he could make, and how much additional money he could receive for recruiting new patients.

The detective received a cursory medical examination and superficial medical therapy on site, but also had to sign numerous blank medical forms, which led to insurance being charged for approximately 44 therapy treatment claims submitted for dates between July through September 2013.  Overall, Central Therapy Center billed the insurance company a total of $20,488.00 for injuries that never really happened.

Charged with organizing, planning or participating in a staged accident; false and fraudulent insurance claims; grand theft; organized scheme to defraud; and patient brokering were:  Rodolfo Rodriguez Gallo Blan, Vivian Caridad Garcia and Carlos A. Sanchez.

Yunaisky Machado Madruga and Belkys Hernandez were accused of false and fraudulent insurance claims; grand theft; and organized scheme to defraud.

“These types of clinics are the core elements of any ongoing PIP insurance fraud scam. They exist to steal, not heal,” State Attorney Katherine Fernandez Rundle said. “Those individuals who hope to snatch some cash from the pockets of Dade’s insured motorists should know that the Miami Police Department and my insurance fraud prosecutors are out to get you. Find a new line of business or prepare for jail.”

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Filed under Insurance Fraud

Motor Vehicle Crashes No Longer Leading Cause of Spinal Cord Injuries

Falls have taken the lead from motor vehicle accidents as the primary cause of serious traumatic spinal cord injuries in the United States, according to a recent study published online in the Journal of Neurotrama by the Johns Hopkins University School of Medicine.

A nationally representative sample of 43,137 adults treated in hospital emergency rooms for spinal cord injury in the U.S. between 2007 and 2009 was studied by Johns Hopkins researchers. What they discovered is that the incidence of falls per million in patients 65 and older increased from 79.4 per million to 87.7 per million at the same time that the number of falls in 18- to 64-year olds actually dropped from 52.3 per million in 2007 to 49.9 per million.

Motor vehicle crashes were found to be the leading cause of 35.5 percent of traumatic spinal cord injury, in second place behind falls at 41.5 percent. Also, the average age of adults with traumatic spinal cord injuries rose from 41 years to 51 years.

Researchers believe a triple combination of the general aging of the population, more active lifestyles of many Americans over 65, and airbags and seatbelt laws may be contributing factors as to why falls have surpassed car crashes as the leading cause of traumatic spinal cord injuries.

The National Spinal Cord Injury Statistical Center figured the lifetime costs of care for someone with a serious spinal cord injury can range from $1 million to $5 million, depending on age of the person at the time of injury and the severity of the injury. Advances in patient care have led to longer life expectancies, but also bigger medical bills.

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Filed under Fla. Stat. 627.736 (2008)

Two Arrested for Related PIP Insurance Fraud

Leonardo F. Marquez Garcia of Miami and Dayleann Marie Vallejo-Ruiz of Orlando were recently arrested on charges of PIP insurance fraud.

More arrests are expected in the ongoing investigation by the Florida Department of Financial Services’ Division of Insurance Fraud, CFO Jeff Atwater announced.

Investigators found that Garcia would allegedly perform ‘initial examinations’ on victims of vehicle crashes, and then refer his patients to the Injury Rehabilitation Center, a clinic owned and operated by Vallejo-Ruiz.

Vallejo-Ruiz, a licensed massage therapist, would then have patients sign blank treatment forms which were later submitted to the insurance company to pay for treatment that was never provided. Allstate Insurance Company was billed for the alleged medical treatments supposedly provided between February 3 and March 16, 2012, on two crash victims.

Garcia also submitted his requests for payment for his initial examinations on behalf of Global Rehabilitation Center, Inc., in Miami Lakes. However, it was discovered that Garcia—an Area of Critical Needs Doctor—was not licensed to practice medicine at that facility because it was not an Area of Critical Needs clinic. Garcia was subsequently charged with the unlicensed practice of medicine for operating outside the scope of his license.

The Orange County State Attorney’s Office is prosecuting the case.  Each defendant stands to face up to 15-20 years in prison if convicted.

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Filed under Insurance Fraud

AHCA Revokes License of M&D Mobile Diagnostic

In 2008, M&D Mobile Diagnostic applied for and was issued a Certificate of Exemption to operate a health care clinic in Lake Worth, FL. In 2013, the state Agency for Health Care Administration filed an Administrative Complaint seeking to revoke that certificate and, on January 16, 2014, issued a final order revoking M&D Mobile’s exemption certificate.

In accordance with Florida law, a health care clinic must be licensed if it provides health care services to individuals and then bills third party payers for those services. An exception to the licensing rule exists where health care services are provided by a “licensed health care practitioner,” as defined by statute, and the business is wholly owned by that practitioner. Under those circumstances, the term “clinic” does not apply, and the entity may claim to be exempt from licensure and receive a “Certificate of Exemption” from the state health care administration.

The applicant, Michael Josaphat, based his claim for exemption from licensure on being a licensed health care practitioner, as defined by statute. However, Josaphat’s license is for a Certified Radiologic Technologist license. The Health Care Agency determined that such a license is not one fitting the statutory definition of “licensed health care practitioner,” and therefore does not entitle Josaphat to a Certificate of Exemption. The Agency ordered, therefore, that the certificate be revoked and M&D subject to sanctions.

The case is State of Florida, Agency for Health Care Administration, v. M&D Mobile Diagnostic Imaging, Inc., Case No. 13-544PH, AHCA File No. 2013010999.

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Filed under Case Law

PIP Insurance Premiums Dropping for Florida Insureds

PIP premiums declined an average of 13.2% following adoption of House Bill 119, according to a preliminary analysis conducted by the Florida Office of Insurance Regulation (“FLOIR”). Savings were measured from the first required rate filing due in October, 2012.

FLOIR measured changes to the overall auto premium as well as the PIP premium for the Top 20 Florida auto insurers, representing a total of more than 75% of the total Florida market.

The research results are in line with insurer expectations, based on projected rates calculated using a Pinnacle study. The decrease in PIP premiums varies significantly by carrier, with some rates dropping by single digits while others fell by 20% to 30%.

The State of Florida passed HB 119, known as Personal Injury Protection (PIP) for Auto Insurance Fraud, in 2012 in an effort to stem PIP fraud. PIP premium savings were projected to be in the range of 14% to 24.6%, and were intended to be passed along to Florida drivers.

PIP represents only a portion of the expense reflected in total auto premiums, so the overall reduction in total premiums is less than the PIP cost reductions.

Click on the link to read the full FLOIR press release about Personal Injury Protection (PIP) Premiums Going Down.

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Filed under Insurance Fraud