Insurance companies globally lose more than US$80 billion to fraud every year. A growing number of fraudulent insurance claims, increasing need to have transparent and trustworthy systems, and a focus on reducing the total cost of ownership will most likely drive the growth of the market. A new study from ReportLinker projects global blockchain will have a compound annual growth rate of 84.9% between 2018 and 2023 ($64.5M to $1.393.8M) in the insurance market. The identity management and fraud detection segment are expected to hold the largest market size during that period.
The insurance sector of the Asia-Pacific (APAC) area is increasing its adoption of blockchain technology now and is expected to grow the fastest.
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Since Hurricane Season is underway, here’s a Daily Business Review article published by Roig Lawyers Partner Patricia Preciado that still holds true today.
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Aerial image of Florida Keys after Hurricane Irma
Filed under AOB, Assignment of Benefits, Claims Handling, Florida, Hurricane Andrew, Hurricane Irma, Hurricane Matthew, Insurance, Insurance Claims, Insurance Defense, Insurance Fraud, Lawsuits, Property Insurance
Jorge Lorenzo, Yahima Pardo and Roberto De Jesus Alonso, all of Miami, were sentenced to prison and ordered to pay more than $40 million as a result of their involvement in what is considered the Medicare fraud scheme that caused the greatest loss to the government in 2015.
In addition to the nearly $40.4 million in restitution, the government seized over $2 million in cash and personal assets including Rolex and Cartier watches and artwork by prominent Cuban artists.
The case, before U.S. District Judge William Dimitrouleas, centered around Lorenzo’s ownership or control of 8 home health agencies in Miami-Dade County that received in excess of $40 million from Medicare as a result of fraudulent claims by way shell owners at each agency funneling claim payments to other fictitious companies staffed by co-conspirators. Once indication of a Medicare fraud investigation arose, Lorenzo would close the home health agency, keeping them open for only 8 months on average.
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A routine traffic stop uncovered the scheme of a former employee of a health insurance company who stole the identities of customers.
Quinzella J. Romer, 39, was sentenced to 32 months in prison and ordered to pay $16,264 in restitution. Romer pleaded guilty to one count of possession of 15 or more unauthorized access devices (Social Security numbers) issued to other people and one count of aggravated identity theft.
The federal prosecutor said Romer’s scam started unraveling after a traffic stop in Coral Springs in 2014. Police noticed Romer had an outstanding warrant for petit theft, and during a pat down, officers found a Florida driver’s license in another person’s name and a cellphone.
After getting a search warrant, officers found 20 screenshots on the phone containing 50 names with Social Security numbers and dates of birth. Romer had taken the shots between 2007 and 2013 during her work as a short-term disability benefit manager at a health insurance company.
An investigation revealed that 12 of the numbers in Romer’s phone were victims of tax-related identity theft in 2013. Tax returns filed on behalf of those names sought refunds of $38,196, with the Internal Revenue Service actually paying out $16,264.
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The U.S. government confiscated $11 million worth of properties involved in a healthcare fraud scheme centered in Mississippi that also involved residents of Florida, Alabama and Utah, according to a report in the Clarion-Ledger of Jackson, MS.
The Internal Revenue Service described the criminal activity as a compounding pharmacy scheme. The pharmacies engaged in “price rolling,” in which a pharmacy submits a bill to an insurance company to test the amount the provider will reimburse for a specific prescription. The claim is canceled, then another claim is sent for a compounded formula to see if that is reimbursed at a higher rate. Compounding is the process of creating a prescription unique for the patient’s particular needs, such as providing the same medicine in a pill and a liquid.
The IRS also said the scheme involved split billing, where a prescription is split into smaller portions. The split prescription can include separate dispensing fees as well as automatic refills that might not have been intended by the doctor.
Search warrants were served in January during the compounding pharmacy investigation. No arrests were made, but the properties were recently confiscated by the feds because evidence showed they were purchased with dirty money. Such civil forfeiture is based on the idea that the property, not the owner, has violated the law.
Following the 12 warrants, the government interviewed hundreds of people and confiscated 24 vehicles, five planes, two boats and money from 80 bank accounts totaling $15 million, according to a Mississippi Bureau of Narcotics spokeswoman.
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A federal appeals court has revived a lawsuit against HCA Holdings charging that HCA and three of its Florida hospitals violated Florida’s Deceptive and Unfair Practices Act.
The U.S. Court of Appeals for the Eleventh Circuit’s April 26 ruling overturned a February 2015 federal court decision in the Middle District of Florida that dismissed the class action. That suit accused three HCA hospitals—Memorial Hospital Jacksonville, North Florida Regional Medical Center of Gainesville and JFK Medical Center in Atlantis—of charging unreasonably high fees for emergency radiological services covered by Florida’s Personal Injury Protection (PIP) insurance.
The four Florida residents who filed the complaint received emergency radiological services after motor vehicle accidents. They said they were billed more than other patients who received the same services. “In fact, these fees are up to 65 times higher than the usual and customary fees charged to non-PIP patients for similar radiological services,” according to the complaint.
In one example, the court’s opinion said the hospitals charged between $5,900 and $6,965 for spinal CT scans on the plaintiffs. The ruling said Medicare rates for spinal CT scans are between $213 and $220, and rates for uninsured patients go up to $3,454.
The complaint said the exorbitant rates caused the residents’ $10,000 PIP coverage to be exhausted prematurely. The complaint also accuses HCA of breach of contract as the four Floridians entered into a Condition of Admission contract that required their accounts to be paid at the hospitals’ price lists. All four plaintiffs said they weren’t provided such a price list at the time of their treatments.
Only one of the four plaintiffs was allowed to go forward with a suit against a single hospital in the 2015 ruling by U.S. District Judge James Moody in the Middle District of Florida. Moody’s ruling was overturned by a unanimous Eleventh Circuit panel consisting of Judges Beverly B. Martin, Julie E. Carnes and Senior Judge R. Lanier Anderson III. The suit was originally filed July 2014 in the Southern District of Florida.
The Miami Herald reported on March 14, 2016, that Dr. Richard Day and wife Jean Day filed a lawsuit against Uber after being involved in a car accident. Back in December, the couple traveled to Miami from South Carolina for a medical conference when they ordered an Uber. According to a police report and the lawsuit, the driver, Ingrid Parra, crashed when leaving the Eden Roc hotel in South Beach after failing to yield to oncoming traffic. While Dr. Day’s injuries included a broken leg, his wife received massive brain injuries that will require multiple surgeries.
This is the latest lawsuit against ride- sharing services involved in Miami Dade that points to drivers paying more attention to their smartphones than the road. This comes at a time when the county commission is considering legislation to regulate businesses such as Uber and Lyft.
The popularity of these ride-sharing services has skyrocketed in South Florida and across the country in recent years, but not without controversy. Back in November, Lyft was hit with a lawsuit by a family of a 29 year old woman after being thrown off her motorcycle when colliding with a ride share driver in Wynwood. Also, in January, Uber was sued by the relatives of a Miami Dade College student who was killed in a fiery crash in Kendall. The Uber driver was not faulted in this incident.
The predominance of ride- sharing services such as Uber and Lyft have given rise to fierce resistance from taxi drivers as well as local governments who struggle to legalize their procedures. Opposition to ride sharing services, claim Uber drivers violate vehicle for-hire rules, but the popularity has put enormous pressure on the commissioners. Broward County initially required fingerprinting the drivers but backed down when Uber threatened to leave the market last summer. After a Michigan Uber driver was arrested and charged with fatally shooting six people, Miami Dade commissioners have threatened to impose the fingerprinting requirement, which they will be voting on in May.
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On August 13, 2015, The Florida Department of Financial Services Division of Insurance Fraud (DIF) announced multiple arrests related to a large scale personal injury protection fraud scheme across the Central Florida region.
According to the Orlando Business Journal, DIF and the Federal Bureau of Investigation (FBI) partnered to investigate two clinics, First Medical Rehab of Bradenton and Kirkman Family Chiropractic Care in Orlando. Their investigation led to the arrest of five people, arrest warrants issued for three additional people, and three related arrests in the Fort Myers area. Insurance carriers and former patients raised allegations of possible illegal activity happening at these two personal injury clinics.
The Kirkman Family Chiropractic investigation disclosed their plot of bypassing clinic licensure requirements set by the Agency for Health Care Administration. Co-conspirators solicited licensed chiropractors to serve as straw owners, or owners on paper only because licensed health care professionals can operate clinics without the necessity of an additional clinic license. To date, more than $100,000 in fraudulent claims have been paid by multiple insurance carriers.
The charges varied depending on each individual’s alleged role which included: patient brokering, conspiracy to commit patient brokering, false and fraudulent insurance claims, solicitation, grand theft, organized scheme to defraud and conspiracy to commit insurance fraud. All individuals arrested, if convicted can face anywhere from five to 30 years in prison as well as face fines as large as $10,000.
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The Florida Department of Financial Services Insurance Fraud Division charged Trisha Michelle Milstead a resident of Century, FL with one felony count of insurance fraud. Assistant State Attorney Greg Marcille stated that on September 8, 2014 Milstead was involved in a vehicle accident, but at the time her vehicle policy had lapsed for non-payment. She then reinstated her insurance policy on September 9, signing a statement that there had been no previous damage during the lapsed time period. Two days after the policy was reinstated she filed a claim for the accident and damage associated.
Trisha Milstead remains in the Escambia County Jail with bond set at $10,000 and is scheduled for an arraignment hearing next month.
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Roig Lawyers attorneys and healthcare policy advisor will speak at 23rd annual Florida Insurance Fraud Education Committee (FIFEC) Conference on June 12, 2015 in Orlando, FL. Nelson C. Bellido, Dennis La Rosa, Miguel Roura, and Diego Arredondo will present “Mechanisms Available to Adjusters During Review for Regulatory and Compliance Issues”. The presentation will focus on recent developments in the law, insurance adjuster review process for regulatory compliance issues, administrative regulation and the relationship to PIP under §627.732(11), and PIP amendments and licensing issues.
FIFEC is a non-profit corporation comprised of special investigative unit investigators, law enforcement personnel and dedicated individuals whose purpose is to organize and present an annual statewide educational seminar related to deterring, detecting, investigating and prosecuting insurance fraud. FIFEC is proud of its mission to provide insurance fraud education and training by giving grants to the law enforcement and criminal justice community that attend what is now known as the annual FIFEC Conference.
About Roig Lawyers
Roig Lawyers is a multi-practice Florida Litigation firm with an unfaltering growing presence in the legal market celebrating 15 years of service, with more than 100 attorneys in 6 offices in Deerfield Beach, Miami, Orlando, West Palm Beach, Tampa, and Tallahassee. Roig Lawyers offers unparalleled legal representation in the areas of commercial litigation, construction, corporate law, real estate, banking and finance, labor and employment, and all phases of insurance defense litigation.
For more information about Roig Lawyers, visit www.roiglawyers.com.