Author Archives: Michael A. Rosenberg, Esq.

U.S. Publishes Doctor-Level Data on $77 Billion in Medicare Billings

The Centers for Medicare and Medicaid Services recently released a treasure trove of 2012 Medicare payment data on 880,000 health care providers nationwide.

Intended to increase healthcare transparency, the data represents Medicare Part B claims totaling $77 billion in medical billings. Doctor visits, laboratory tests, and other treatments provided outside of a hospital setting are included in the database.

Payment history for 6,000 services and procedures is now available at the level of individual health care providers, including the identification of doctor names. Dollar amounts disclosed include Medicare reimbursements, as well as patient payments in the form of deductibles or co-insurance. Procedures on fewer than 10 Medicare recipients conducted by a single provider are excluded.

The U.S. Government Accountability Office (GAO) reports that 49 million elderly and disabled Americans received more than $555 billion in Medicare services during 2012. Fraud is an acknowledged element of the Medicare program, and the GAO estimates at least $44 billion in annual Medicare disbursements are made improperly.

Ophthalmologists and radiation oncologists are medical specialties that stand out as receiving high payment levels, relative to total national Medicare spending, according to the Wall Street Journal.

Dr. Salomon Melgen, a Florida ophthalmologist, received the highest level of 2012 Medicare reimbursement in the country, according to the Tribune Newspapers. Melgen’s billing practices and political connections have been the subject of a grand jury investigation.

Another Florida doctor, Ocala-based cardiologist Asad Qamar, took second place nationally with $22.9 million in 2012 Medicare payments, also as reported by the Tribune Newspapers.

A federal injunction, granted at the urging of the American Medical Association, has kept this data private since 1979. The Wall Street Journal published an investigative series on physician reimbursements in 2011, and in the following year its parent Dow Jones & Co. took legal action seeking database access. The injunction was ultimately overturned by a Florida judge.

Click on the link to access the CMS physician dataset.

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Filed under Independent Medical Examinations (IME), Insurance Fraud

Questionable PIP Claims Decline in Florida, Reports NICB

Tighter legislation, enhanced public awareness, and coordinated law enforcement efforts appear to be having a positive effect on PIP fraud in Florida, according to a recent report by the National Insurance Crime Bureau (NICB).

The new study published by the organization showed Florida’s personal injury protection (PIP) questionable claims (QCs) have dropped 7.6 percent from 2012 to 2013. More striking, however, was the extraordinary decline from 2010 through 2013, when Florida’s staged accident QCs decreased 61.82 percent during that time period.

Compare those statistics to 2009, when Florida not only topped the nation in PIP QCs reported to the NICB, but also had twice as many as the second-highest state, New York. From 2008 through 2010, the total number of QCs in Florida increased by 34 percent.

When NICB delved further into these results, it found that about 62 percent of total PIP costs and about 43 percent of PIP treatment costs came from soft tissue treatments. Massage treatments accounted for 22 percent of those treatments, and massage therapists had the largest increase in charges per patient at 51 percent from 2005 through 2010, after factoring in for medical inflation.

“We are encouraged by the decline in questionable claims that we’ve seen recently, but by no means are we declaring victory in Florida,” said NICB President and CEO Joe Wehrle.  “Florida remains a hotbed for fraudulent activity and we can’t afford to ease up for a moment in our fight against those who would abuse the system and burden Florida consumers.”

In September 2011, the Hillsborough County Commission was one of the first legislative bodies to enact a county ordinance to license PIP clinics and deter suspicious vehicle collisions in the county. Although an injunction against the law remains in effect, it hasn’t stopped other legislation. In February 2012, Miami-Dade County passed a similar ordinance requiring registration of PIP clinics, and the Florida legislature passed House Bill 119 in May 2012.

This two-part legislation institutes stronger penalties for medical providers who commit PIP fraud, including a five-year license suspension and a ten-year restriction from PIP reimbursement. It also imposes a 14-day post-accident window for accident victims to seek medical treatment and reduces specified PIP benefits and treatments. A lawsuit and injunction ensued, but eventually, the law was put into effect in late October 2013.

Although NICB does not receive all QC data in Florida, the data used to produce this report came from the same sources used in previous Florida QC reports. “Combining these legislative and regulatory efforts with a robust public awareness campaign and aggressive law enforcement response, the modest improvement in 2013 PIP QC data does suggest the initial stages of a positive downward trend,” NICB confirmed.

Click on the link to read the NICB Data Analytics ForeCAST Report regarding Florida Personal Injury Protection (PIP).

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

Straw Owner of Clinic Sentenced in $28 Million Medicare Fraud Scheme

Roberto Fernandez Gonzalez, a Florida man who federal prosecutors say served as the “straw owner” of a physical therapy clinic, was sentenced to 30 months in prison for participating in a Medicare fraud scheme, according to a Department of Justice release.

Fernandez was also ordered to forfeit $446,738 and pay the same amount in restitution. He pleaded guilty in June of 2013 to conspiracy to commit health care fraud.

Prosecutors say Fernandez and his co-conspirators used four physical therapy clinics, including Rehab Dynamics in Venice, FL, to submit a total of $28.3 million in fraudulent reimbursement claims to Medicare. Medicare paid roughly $14.4 million on those claims.

Fernandez’s co-conspirators obtained and controlled Rehab Dynamics, then engaged in a sham sale of the clinic to Fernandez. With no background in health care and no money to buy the business, Fernandez was strictly a front man.

The co-conspirators paid Fernandez $20,000 to operate as the straw owner from January 2008 through March 2008. During that period, Rehab Dynamics submitted $1.6 million in fraudulent Medicare claims, of which Medicare paid $446,738, the amount Fernandez was ordered to pay.

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,700 defendants who have collectively billed the Medicare program for more than $5.5 billion, according to a Department of Justice report.

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Filed under Insurance Fraud

Medical Costs Associated with Auto Accidents Rise Despite Reduced Injury Severity

Medical expenses tied to auto injury insurance claims have outpaced inflation, even though there has been a downturn in the seriousness of those reported injuries, according to a study recently released by the Insurance Research Council (IRC).

According to the report—Auto Injury Insurance Claims: Countrywide Patterns in Treatment, Cost and Compensation—the average claimed economic losses reached $14,207 per personal injury protection (PIP) claimant in 2012, growing at an annualized rate of 8 percent from 2007.  Economic losses include expenses for medical care, lost wages and other out-of-pocket expenditures. Among bodily injury (BI) claimants, the rate of average claimed losses grew 4 percent to $10,541 in 2012 from 2007.

However, the study found that over the same period, measures such as the “percentage of claimants who had no visible injuries at the accident scene” or who had “fewer than 10 days in which they were unable to perform their usual daily activities” provided evidence of a continuing decline in the severity of injuries.

The study also looked at a variety of factors in the upswing of medical care expenses, including the shift toward more costly treatments and diagnostic alternatives as well as dramatic increases in billed charges for visits to numerous types of medical providers. The use of pain clinics, attorney involvement, and claim abuse were found to exacerbate the increases in medical care expenses, the study found.

“Medical care costs continue to escalate, especially among first-party claimants,” Elizabeth Sprinkel, senior vice president of the IRC, announced. “Looking forward, the industry will need to continue its vigilance in contending with these expanding costs, particularly as it monitors the possible spillover effects from general healthcare reform.”

The 2014 edition of the study is the seventh of its kind conducted by the IRC.  The council collected data on more than 35,000 auto injury claims closed with payment under the five principal private passenger coverages. Twelve insurers, representing 52 percent of the private passenger auto insurance market in the United States, participated in the study. For more information, visit IRC’s website at http://www.insurance-research.org.

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Filed under Fla. Stat. 627.736 (2008)

Uninsured Florida Drivers May Be Factor in the State’s Rising Number of Hit-and-Runs

The Florida Highway Patrol (FHP) reports that there was an 8 percent increase in the number of hit-and-run crashes from 2012. Uninsured drivers may be a significant contributing factor in the 78,000 hit-and-run accidents occurring in 2013, a recent story in the Bradenton Herald postulates.

According to the article, about one in four Florida drivers have no auto insurance, and Florida has the fifth-highest auto insurance rates in the United States—figures that lay the groundwork for a spate of drivers with no insurance fleeing the scene.

The 78,000 hit-and-runs last year—which involved bodily harm or property damage—caused more than 17,000 injuries and 154 deaths, the FHP says.

A spokesperson for the Insurance Information Institute, Lynne McChristian, says the link between having no auto insurance and the increase in hit-and-runs can be expected.

“They bolt when they have an accident because they are already breaking the law by not having insurance, and then they have caused an accident on top of it,” McChristian said in the article.

Other factors contributing to the wave of hit-and-runs are driving under the influence of alcohol or drugs, driving with a suspended operator’s license, driving while on probation, or driving scared due to any of the other factors, according to FHP Lt. Greg Bueno.

However, FHP is fighting the growing number of hit-and-runs statewide, Bueno said, with a new awareness campaign: “Hit & Run, Bad 2 Worse.”  The campaign intends to educate drivers about the consequences of leaving the scene of an accident.

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Filed under Fla. Stat. 627.736 (2008)

Sinkhole at National Corvette Museum Swallows Eight Showcase Cars

The National Corvette Museum in Bowling Green, Kentucky, reported that a sinkhole in the Skydome wing of its building was the cause of motion detectors being set off and alerting security early Wednesday morning.  Eight prized Corvettes were swallowed by the 40-ft. wide, 25-ft. deep crater, as shown in the photo below from the museum.

Corvettes

According to an article in the New York Times, no one was injured or present at the time of the incident.  Although the museum is still evaluating the damages, estimates are in the millions of dollars.  A spokesperson for the museum, however, said that insurance would cover the cars.

Property Casualty 360° notes that assessing damage will be multifaceted when determining the insurance company’s payouts, such as:

  • Whether a geotechnical engineer should make an evaluation of the area to determine the likelihood of one sinkhole triggering other similar events
  • What the potential loss of equipment, used in extracting the vehicles, would be
  • The type of coverage and whether proper assessments had been made on the actual value of the vehicles
  • What the deductibles are – as high as 10% for these types of vehicles, or in the case of a commercial policy (which the museum would likely carry) ranging from zero up to tens of thousands of dollars
  • Payouts for cars on loan (there were two in this case), and if possible subrogation would be involved
  • Whether the sinkhole damage would be covered and if the entire loss would be considered a single event—applying the deductible once as opposed to paying the deductible on each vehicle

The museum was closed to the public on Wednesday, but an article on CNN.com said that geologists and engineers from Western Kentucky University used remote-controlled drones to determine that the Skydome suffered no structural damage.  With the exception of the Skydome area, the museum was slated to resume its regular operating hours on Thursday.

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Filed under Uncategorized

Hollywood Couple Arrested for Filing a Fraudulent Stolen Vehicle Insurance Claim

Miguel and Francheska Quintero were recently arrested when it was found they allegedly arranged to have their vehicle removed from their home while they were away, in order to report it missing and subsequently make an insurance claim on the supposed stolen vehicle.

CFO Jeff Atwater announced the arrest of the Hollywood couple after an investigation by the Department of Financial Services’ Division on Insurance Fraud uncovered the plot.

On the day of the alleged theft, reports show that Miguel Quintero told Hollywood police that his 2011 Chevrolet Tahoe was locked and parked outside his home before it was stolen. The following day, Francheska Quintero filed a stolen vehicle report with GEICO insurance.

However, Quintero’s neighbor made a statement disclosing that he called Quintero on the phone to alert him about ‘two men’ who were attempting to start the Tahoe on the day of the theft.  According to the neighbor, Quintero told him that he was aware of the activity and tried to dissuade him from calling police by saying, “you don’t know anything about this.” The neighbor confirmed that he saw the two men successfully jumpstart the vehicle and drive it away.

Prior to Quintero filing the police report, a Doral police officer noted an abandoned vehicle parked off the road, and later research revealed that the vehicle was owned by Quintero.

At the time of the theft last July, the couple supposedly owed $35,173 on the vehicle loan and was three months behind on car payments.

Francheska and Miguel Quintero were arrested and transported to the Broward County Jail.

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Filed under Insurance Fraud

Woman Busted for Insurance Fraud After Collecting Claim Money on a Stolen Car that She Pawned

A Greenacres woman was arrested for insurance fraud involving her car that she reported stolen in 2012.

Palm Beach County court records show that Lindela Edmonds faces charges of insurance fraud and making a false report of a non-existent crime.  She was arrested on January 15.

According to West Palm Beach police, the 44-year old Edmonds pawned her 2007 Toyota Camry at the pawn shop, Queen of Pawns, on February 17, 2012 and received $5,500 for the transaction. The next day, she went to the police and reported her car stolen from a parking lot in the 3100 block of N. Jog Road.

After filing the police report, she filed a loss of vehicle claim with GEICO and collected $12,326 from the insurance company.  But that isn’t the end of the story.

The Queen of Pawns wanted to sell the car because Edmonds had not returned for it a year later.  It was then that police discovered the vehicle was listed as stolen. The pawn transaction receipt is dated the day before Edmonds reported her car stolen, along with a copy of her driver’s license and thumb print.

In addition, the notarized insurance claim is signed by Edmonds. Ironically, her signature appears beneath a warning: “anybody who knowingly defrauds an insurer by using false information is guilty of a felony in the third degree,” the Sun-Sentinel reported.

Edmonds was booked at the Palm Beach County Jail on January 16 and released on $3,000 bond.

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Filed under Insurance Fraud

Miami Clinic Owner Pleads Guilty in $20 Million Health Care Fraud

Isabel Medina, the owner and operator of Merfi Corp., pleaded guilty to conspiracy to commit health care fraud before U.S. District Judge Ursula Ungaro of the Southern District of Florida. The 49-year old Miami resident was tied to several fraud schemes that totaled more than $20 million.

Merfi was a medical clinic that employed physicians, physician assistants and other medical professionals who were authorized to write prescriptions for home health care services. According to court documents, Medina and her co-conspirators channeled those prescriptions and other pertinent medical documentation to area home health agencies, including Flores Home Health Care, and patient recruiters in return for kickbacks and bribes.

As previously reported in our blog on December 4, it was discovered that Flores Home Health actually operated for the sole purpose of billing the Medicare program for expensive physical therapy and home health care services that were not medically necessary or were not provided, similar to what was found with the other home health care agencies’ operations.

Medina has acknowledged her involvement in the fraudulent schemes. She could receive a maximum penalty of 10 years in prison. Sentencing has been scheduled for March 14, 2014.

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Filed under Insurance Fraud

Florida Ranks #6 in Worst Drivers Nationally

Drivers in the sunshine state are the most careless in the country, according to survey results compiled by CarInsuranceComparison.com from multiple sources, including the National Highway Traffic Safety Administration, the National Motorists Association, and Mothers Against Drunk Driving.

Florida ranked as one of the Top 10 states in the country for bad driving, with an overall rank of #6, a slight improvement from its #4 ranking in prior years.

Each state was evaluated on the basis of five data points, with high scores reflecting poor performance in the lineup of all 50 states plus the District of Columbia. Individual category rankings for Florida are as follows:

  • Careless Driving = 51
  • Tickets = 48
  • Failure to Obey (Traffic Signals + Seat Belts) = 38
  • Fatalities Rate per 100 Million Vehicle Miles Traveled = 33
  • Drunk Driving = 18

States that ranked the worst for bad drivers, according to the survey, are Louisiana (#1), South Carolina (#2), Mississippi (#3), Texas (#4), and Alabama (#5).

Careless driving can be caused by distractions like cell phones and texting. Florida’s low ranking in tickets written, at 48 out of 51, indicates that drivers may feel less at risk of punishment for their poor driving behavior.

The worse the drivers rank in a given state, the higher the auto insurance premiums. Florida ranks among the top 10 most expensive states for car insurance, at #10, according to a 2012 article in the Palm Beach Post. The average Florida driver pays $1,784 in auto insurance premiums a year, or 3.36 percent of household income, based on national statistics.

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Filed under Insurance Fraud