Category Archives: Insurance Fraud

Chiropractors in $2.3 Million PIP Insurance Fraud Scheme will Face RICO Charges

A federal judge ruled that the chiropractors who were allegedly behind a $2.3 million ploy to defraud an insurance company must face charges for violating the Racketeer Influenced and Corrupt Organizations Act (RICO) and Florida’s Deceptive and Unfair Trade Practices.

In July 2012, GEICO Insurance Company filed a lawsuit against two Orlando-based clinics—KJ Chiropractic Center LLC and Wellness Pain & Rehab Inc.—in addition to their two founders and a number of co-conspirators, known as “runners.” These runners helped perpetrate the suspected scam by exploiting willing third-party participants who faked accidents and injuries.

According to an article in Courthouse News Service, U.S. District Judge Charlene Edwards Honeywell said in her order that the fraudulent PIP claims resulted in more than $2.3 million in unwarranted insurance benefits and emerged from:

  • Staged accidents;
  • Real accidents in which claimants received treatment at clinics even though they were not truly injured; and
  • Real accidents in which claimants incurred some injuries, but received treatments that were pre-programmed, unnecessary, excessive and unlawful.

GEICO charged that the defendants advanced their unlawful plot by paying “anyone who referred accident victims to the clinics, offering cash directly to patients who agreed to accept unnecessary chiropractic treatment.” The insurance company also claimed the clinics provided treatment that was not in the best interest of patients because its sole intent was to maximize profits, the article said.

The U.S. District Court for Florida’s Middle District, Orlando Division, adopted Judge David Baker’s full recommendations made in October 2013 to deny the defendants’ motion to dismiss a second amended complaint on all but one count.

Judge Honeywell Edwards said she felt that GEICO adequately supported its argument with “factual allegations to state plausible claims for relief. As such, the court agrees with the Magistrate Judge that GEICO’s claims are sufficiently pled.”

The case is GEICO v. KJ Chiropractic Center LLC et. al., U.S. District Court for the Middle District of Florida, Case No. 6:12-CV-1138-ORL-36-DAB. Click on the link to read the complaint.

Comments Off

Filed under Case Law, Insurance Fraud

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.

Comments Off

Filed under Independent Medical Examinations (IME), Insurance Fraud

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.

Comments Off

Filed under 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).

Comments Off

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

Comments Off

Filed under 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.

Comments Off

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.

Comments Off

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

Fraudulent Rental Car Schemes an Emerging Trend in Auto-Related Crime

Auto insurance claims adjusters and special investigative units (SIU) have been put on notice about a proliferation of fraudulent auto schemes involving rental cars. This type of criminal activity will impact states with top hospitality industries, like Florida, where tourism was ranked number one and was responsible for welcoming 91.5 million visitors in 2012.

According to a recent Claims Journal article, Kraig Palmer, an investigator with the California Highway Patrol, warned that he has seen rental car schemes “rise faster than any other auto fraud trend” in the past 12 months.

Perpetrators are often found to be opportunistic drug addicts and knowledgeable street gangs, the article revealed. The crux of the fraud targets car rental companies and involves renting multiple cars. Then, the rented cars are used to commit crimes. They eventually are recovered, but often burned out or with significant collision damage.

It is a difficult crime to nail down because it can occur on many different levels—using multiple fraudulent or stolen identities. Also, incentive programs at the car rental companies make it easy to rent a car, often with online registration and no face-to-face interaction.

It’s not surprising, then, that insurers will see more claims involving fraudulently rented cars. The criminals and gangs have access to money, and will use that money to educate themselves on companies’ processes. All it takes is paying one disgruntled employee to gain knowledge of the claims process, Palmer added.

He recommends that insurance companies thoroughly examine auto property damage or auto bodily injury claims involving rental cars, searching for patterns such as: how long the vehicle was rented, how many vehicles were rented by the same individual, and if there were more vehicles rented by the same individual that experienced damage.

If there are red flags, Palmer suggests going to the regional security manager instead of the car rental agency. That manager will have access to the complete contract and credit amount. Due to privacy regulations, law enforcement will likely need to be involved, he concluded.

Comments Off

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

Jacksonville Woman Faces Insurance Fraud Charges in North Carolina

A Jacksonville, Florida, woman was arrested in connection with an auto insurance fraud scheme that occurred in North Carolina—her place of residence at the time.  Stacy Lasondo Jackson, 39, was charged with 10 counts each of insurance fraud and obtaining property by false pretense, according to a newscast on WRAL TV.

Investigators with North Carolina’s Department of Insurance found that Jackson was paid several thousand dollars from a variety of insurance companies after filing fraudulent insurance claims.  The claims were made for damage to her automobile and motorcycle between January and May of 2013.  Authorities believe the damage never happened or was reported more than once.

This past December, Jackson was arrested on similar charges in Florida, investigators said.  She has been extradited to North Carolina and placed in the Cumberland County jail under a $10,000 bond.

Comments Off

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

“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.”

Comments Off

Filed under Insurance Fraud