Disbarred Florida Attorney Gets Prison Sentence in $28.3 Million Medicare Fraud

A disbarred Florida attorney who participated in a $28.3 million Medicare fraud scheme involving false claims for physical and occupational therapy services was recently sentenced in federal court in Tampa to 70 months in prison, the Justice Department announced.

Margarita Grishkoff, formerly of southwest Florida, initially pleaded guilty on January 24 to conspiracy to commit health care fraud. In addition to her prison term, U.S. District Judge Susan C. Bucklew of the Middle District of Florida sentenced the 60-year old to three years of supervised release and ordered her to pay $14,424,856 in restitution, jointly and severally with her co-conspirators.

Grishkoff, who is currently a resident of Charlotte, North Carolina, acknowledged in her guilty plea that approximately $28.3 million in fraudulent claims were submitted to Medicare by her and the scheme’s co-conspirators. Medicare paid approximately $14.4 million of those claims, which were made through physical therapy clinics throughout Florida from 2005 through 2009.

Court documents reveal that Grishkoff, who was disbarred in Florida in 1997, was vice president and director for Ulysses Acquisitions Inc., a Delaware holding company that purchased several comprehensive outpatient rehabilitation clinics and physical therapy providers to gain control of Medicare provider numbers. These clinics included: West Coast Rehab Inc. in Fort Myers; Rehab Dynamics Inc. in Venice; Polk Rehabilitation Inc. in Lake Wales; and Renew Therapy Center of Port St. Lucie LLC in Port St. Lucie.

The Justice Department also said that Grishkoff and her co-conspirators paid kickbacks to patient recruiters and clinic owners to get identifying information of Medicare beneficiaries and physicians. They subsequently took this information to create and submit false claims to Medicare through the clinics Ulysses Acquisitions owned. Claims for reimbursement were made on therapy services that were not legitimately prescribed or actually provided.

But it didn’t end there. Grishkoff and her co-conspirators used the clinics they controlled to submit false reimbursement claims on behalf of other clinics not owned by Ulysses, in exchange for a percentage of the Medicare reimbursement received.

These Miami-based therapy clinics included: Hallandale Rehabilitation Inc., Tropical Physical Therapy Corporation, American Wellness Centers Inc., and West Regional Center Inc. According to court documents, Grishkoff and her co-conspirators kept approximately 20 percent of the fraud proceeds and paid the remaining 80 percent to the co-conspirator clinic owners. Grishkoff further admitted that she arranged sham sales of her clinics to nominee or straw owners to disassociate herself and Ulysses Acquisitions from the fraudulent scheme. Those new owners were recent immigrants with no background or experience in the health care industry.

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Filed under Insurance Fraud

Jacksonville Couple Sentenced in “Family & Friends” PIP Insurance Fraud Ring

A married couple convicted of staging car crashes with family members—as we first reported on our FL-PIP Guide on June 23—was recently sentenced for their involvement in an extensive insurance fraud ring in Duval County.

According to a news release issued by the State Attorney’s Office for the Fourth Judicial Circuit, Jose Alberto Velez, 30, received 74 months in prison for three counts of knowingly participating in an intentional motor vehicle crash and five counts of false insurance claims. His wife, April Rosita Wynn, 23, was sentenced to 48 months in prison for two counts of knowingly participating in an intentional motor vehicle crash and four counts of false insurance claims.

A 2012 investigation by the State Attorney’s Office (SAO) and the Division of Insurance Fraud (DIF) found that Velez and Wynn, who are now married, had been recruiting family members and friends to participate in staged car crashes with them. They would then file Personal Injury Protection (PIP) claims through designated rehabilitation clinics, which provided bogus treatment for the participants’ fictional injuries.

Over the past year-and-a-half, almost 100 individuals have been arrested for their involvement in this insurance fraud scheme. Many have already been sentenced, including one of the ringleaders, David Rodriguez Lopez. He received 15 years in prison on charges of schemes to defraud over $50,000, false insurance claims over $100,000, and knowingly participating in an intentional motor vehicle crash.

Other cases are currently pending.

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Filed under Insurance Fraud

Texting Laws Appear to Reduce Traffic Fatalities

States with primary enforcement laws against texting while driving appear to be having an impact on reducing traffic deaths, a new study released by the University of Alabama at Birmingham (UAB) – School of Public Health has found.

Primary enforcement means that there doesn’t have to be another reason for a police officer to stop a vehicle.

A recent Claims Journal article summarized some of the UAB findings, one of the most notable being a three percent decrease in fatalities among all age groups associated with states supporting primary texting bans. This translates to an average of 19 deaths prevented per year in states with such bans.

However, researchers revealed that states with secondary enforcement of texting bans (an officer must have another reason to stop a vehicle) didn’t see any real decrease in fatalities. Researchers also found bans on texting are most effective with young drivers, while bans on handheld cell phones are most effective with older adult drivers.

According to 2011 data from the Centers for Disease Control and Prevention, 31 percent of U.S. drivers, aged 18-64 years, said that they had read or sent text or email messages while driving at least once in the 30 days prior. That year saw 3,331 fatalities and 387,000 injuries involving distracted drivers.

Using roadway fatality data captured in the Fatality Analysis Reporting System between 2000 and 2010, Alva O. Ferdinand, Dr.P.H., J.D., led the longitudinal panel study. She wanted to examine what impact texting laws have had on roadway crash-related fatalities and how variations in states’ laws affect those results to ultimately determine which laws are most beneficial in improving roadway safety.

Researchers’ results indicated that states with primary texting bans:

  • Were “significantly associated” with reduced traffic fatalities in all age groups
  • In all age groups, a 3 percent reduction in traffic deaths equates to 19 deaths prevented each year
  • Reduced fatalities 11 percent among 15- to 21-year olds when targeted to young drivers.

States with secondary enforced restrictions also saw no significant reduction in traffic fatalities. In addition, states that prohibit use of cell phones without hands-free technology saw significant reductions in fatalities among the 21- to 64-year old age group.

Ferdinand hopes the findings help policymakers implement laws that are most effective in reducing traffic deaths. Her results are published in the August issue of the American Journal of Public Health.

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Filed under Fla. Stat. 627.736 (2008)

Allstate to Recover Almost $1 Million in PIP Case against Dr. Sara Vizcay

In a case brought by Allstate in the Florida Middle District, the court ruled on August 1st that the Defendant’s Motion for Declaration of Mistrial was denied, the Plaintiff’s Motion for Declaratory Judgment was granted in part, and the final judgment was ordered.

Dr. Sara C. Vizcay and the seven medical clinics listed below were the Defendants in the case.

  • Best Care Medical Center, Inc.
  • Caleb Health Care, Inc.
  • Florida Rehabilitation Practice, Inc.
  • Global Diagnostic Center, Inc.
  • Personal Medical Center, Inc.
  • P.V.C. Medical Center, Inc.
  • Regional Enterprises for Health Corporation

Fraudulent billing practices and failure to comply with the licensing requirements of the Florida Health Care Clinic Act (HCCA) formed the basis of Plaintiff allegations. In a jury trial earlier this year, the jury found that each Defendant misrepresented material facts.

The court noted that the “jury unanimously found Plaintiffs proved, by a preponderance of evidence, that Dr. Vizcay failed to substantially comply with her statutory medical director duties to systematically review bills … and to ensure those bills were not fraudulent or unlawful.”

The total amount to be recovered by Allstate is $942,883.41, and Plaintiff is not obligated to pay any unpaid amounts.

The case is Allstate v. Sara C. Vizcay, M.D. et al., U.S. District Court for the Middle District of Florida, Case No. 8:11-CV-804-EAK-EAJ. Click on the link to read the August 1, 2014 Order of Judgment.

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Filed under Case Law, Insurance Fraud

Eleventh Circuit Dismisses PIP Case Involving EMC and Massage Therapy

A class action suit filed by plaintiff Accumed Chiropractic against Progressive Select Insurance was dismissed on July 31, 2014 by Circuit Court Judge Antonio Arzola. Judge Arzola concluded that the action was inappropriate for class action treatment.

The suit was brought on behalf of plaintiff itself and two putative classes. The first class was to be anyone who was denied payment by Progressive under PIP or MedPay insurance coverage where Progressive’s denial was based on an assertion that an Emergency Medical Condition for the insured was not established.

The second class was to be defined as anyone whose PIP or MedPay claim was denied because the health care service was for massage therapy or acupuncture. Plaintiff sought both declaratory relief and damages for breach of contract.

Plaintiff stipulated at the hearing that it did not have standing to sue for MedPay benefits. As for the PIP claims, Judge Arzola found that the “necessary and individualized questions associated with the underlying PIP claims of the class will predominate in this Action.” As a matter of law, therefore, plaintiff’s case could not proceed as a class action, and the complaint was dismissed without prejudice.

The case is Accumed Chiropractic & Wellness Center, Inc. v. Progressive Select Insurance Company, Case No. 13-CA-029396 (Fla. 11th Cir. Ct., July 31, 2014). Click on the link to view the court order.

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Filed under Case Law

FL PIP Guide Readers: Vote Now for the 100 Best Legal Blawgs

Readers of the FL PIP Guide are invited to show their support for the blog by voting in the ABA Journal’s annual competition for the 100 Best Legal Blawgs.

Please nominate Roig Lawyers’ FL PIP Guide blog by clicking here to provide a brief explanation on why you like the blog!

In addition to your name and affiliation, you will be asked to provide the URL to the FL PIP Guide (www.flpipguide.com).

You also have the chance to identify a specific blog post that you consider to be representative of the quality of coverage provided by the FL PIP Guide.

Click on the link below to get started.
http://www.abajournal.com/blawgs/blawg100_submit/

Friend-of-the-blawg briefs are due no later than 5 p.m. ET on Friday, August 8, 2014.

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Filed under Uncategorized

Defendant’s Motion to Dismiss Granted with Prejudice in PIP Benefits Case Involving Challenge to “Emergency Medical Condition” (EMC) Provision

In a second ruling within one week involving Florida’s amended PIP law, the U.S. District Court for the Southern District of Florida dismissed a case challenging reimbursement under the amended statute’s “emergency medical condition” or “EMC” provision. See our earlier post titled Court Grants Defendant’s Motion to Dismiss in Robbins v. Garrison P & C.

Sendy Enivert sued her auto insurance company, Progressive Select, alleging breach of contract for failing to pay her PIP benefits to a limit of $10,000. Enivert’s claim involved the newly added provision to Florida’s PIP law which limits PIP benefits depending on whether a claimant has suffered an emergency medical condition.

Plaintiff Enivert interpreted this language to mean that an insured is limited to $2,500 only if a medical provider determines that there is no emergency medical condition. She argued that because, in her case, no medical provider ever made such a determination, she was entitled to the full $10,000. In other words, because no medical provider determined that she did not have an emergency medical condition, she was entitled to full benefits.

Defendant Progressive read the statute to mean the opposite, i.e., that a medical provider must affirmatively determine that an emergency medical condition does exist in order for the insured to be eligible for reimbursement of the full amount.

The court agreed with Progressive, concluding that the PIP statute clearly indicates that a determination that a claimant has suffered an emergency medical condition is required in order to receive benefits in excess of the $2,500 limit. Since a medical provider did not determine that Enivert had an emergency medical condition, she was not entitled to the full $10,000 in benefits.

The court also looked to the legislative intent behind the PIP statute. It concluded that the clear legislative intent was to decrease PIP fraud by placing more stringent requirements in order to receive the maximum amount of benefits.

Based on the above, the court granted Progressive’s motion to dismiss Enivert’s case.

The case is Sendy Enivert v. Progressive Select Insurance Co., Civil Action No. 14-CV-80279-Ryskamp/Hopkins (S.D. Fla. July 23, 2014). Click on the link to read the court ruling.

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Filed under Case Law, Fla. Stat. 627.736 (2012)