Category Archives: Insurance Fraud

Geico Sues Florida Health Clinic for ‘Unnecessary’ Massage Claims

As reported by Law360, Geico sued Medical Wellness Services Inc. of Miami, FL for allegedly making $1.2 million in claims for providing medically unnecessary treatments for automobile accident victims who were eligible for coverage under their no-fault insurance policies. According to Geico, some of the claims were for services that were not actually provided and contained billing codes that misrepresented and exaggerated the services.

“The defendants do not now have — and never had — any right to be compensated for the fraudulent services that were billed to Geico through Medical Wellness,” Geico said. Geico claims Medical Wellness Services Inc. submitted claims for massage therapist services which are not reimbursable because Florida law prohibits no-fault insurance reimbursement for massages or other similar services.

According to the suit, the scheme began no later than 2013 and continues to this day. In addition to the request for $1.2 million in damages, Geico is also requesting a declaration from the court saying it will not have to pay any pending fraudulent claims by the health clinic which totals more than $75,000.

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Filed under Auto Insurance Fraud, Florida, Insurance, Insurance Claims, Insurance Defense, Insurance Fraud, Miami-Dade County, Miami-Dade Fraud, Personal Injury Protection, PIP/No Fault

Undercover Investigation Led to Arrests of Bradenton Area Chiropractors

According to ABC Action News, an undercover investigation led to the arrests of two Bradenton area chiropractors and other staff. Detectives say chiropractors Richard Tambe and Yusef Barnes, along with chiropractic assistant Johncina Harrell, performed a fraction of the treatments listed on insurance claims and were billing for treatment never rendered to patients.

The arrests and undercover investigation took place at the Back on Track clinic in Bradenton, Florida. According to the arrest report, all three were booked at the Manatee County Jail on insurance fraud, a third degree felony. Tambe faces 12 counts. Barnes is charged with 8 and Harrell is charged with 13 counts. If convicted each suspect faces as much as 5 years in prison.

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Filed under Florida, Insurance, Insurance Claims, Insurance Fraud, Uncategorized

UPDATE: Sixth Person Found Guilty in Unlicensed Chiropractic Clinics Scam

A Naples man convicted of committing mail fraud back in September of 2016 has been sentenced to 14 years in prison. According to the Naples Daily News, Nesly Loute, was also ordered to pay restitution of almost $2.15 million to the insurance companies.

Loute and five others plead guilty and were convicted of operating five unlicensed chiropractic clinics and fraudulently billing auto insurers for Personal Injury Protection benefits.

Click here to view the full article. (Previous post)

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Filed under auto insurance, Auto Insurance Fraud, Florida, Insurance Fraud, Personal Injury Protection, PIP, PIP/No Fault, Unlicensed Clinics

Trooper Fired and Arrested for Helping Friend Cover Up Crash

Florida Highway Patrol Trooper David Casillas was arrested on Tuesday, February 28th and charged with organized fraud, filing a false insurance claim and official misconduct after trying to help a friend cover up a traffic crash that occurred in June of 2015. FHP fired Casillas in January as a result of the investigation which lasted over a year.

During the investigation, it was discovered that Casillas had written a false report for a bogus insurance claim submitted by his friend, dentist Jesus Del Valle. The insurance claim was submitted as a result of damage the dentist had done to his vehicle when he sideswiped a landscaping crew and kept driving.

Del Valle’s crash left Yoel Montero, a gardener with Lewis Tree Service, with a traumatic head injury and severe injuries to his right leg. The false insurance claim alleges that the accident happened a week later than it actually happened and that he had crashed the SUV into a palm tree instead of a landscaping crew.

The key to breaking the case was the fact that Del Valle’s 2015 Land Rover needed a new passenger-side mirror which could only be ordered from Range Rover manufacturers. Only one such had been sold in that time period and it was to Del Valle’s mechanic (and friend) Ariel Perera who performed the repair on his vehicle. Perera also allegedly submitted inflated invoices to Del Valle’s insurance company as well as charged the company for replacement parts that were never actually replaced. He is also facing charges with Del Valle and Casilla.

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Filed under Auto Insurance Fraud, Florida, Insurance, Insurance Fraud, Miami-Dade County

Physicians able to keep practicing for years after they are arrested for pending felony charges

According to the Palm Beach Post, investigators with the Florida Department of Health (DOH) and Broward County Sheriff’s Office arrived at a Pompano Beach pain clinic in 2012 to search for evidence of crime. Dr. Donald Willems, the osteopathic physician admitted to signing blank prescriptions for powerful painkillers such as oxycodone, admitted to letting a clinic manager fill them out, for patients he had not seen.

Eight criminal charges were leveled against Willems, including racketeering and illegally providing oxycodone. With those felony charges still pending, Willems was arrested again on December 21, 2016, named in a federal complaint alleging insurance fraud orchestrated by a local treatment center.

Anyone checking out his background on the Florida Department of Health’s consumer website would never have known it. The site listed the doctors’ license to practice as “clear and active.”

The DOH, which participated in the 2012 clinic raid, did not file formal disciplinary charges against Willems until January 2016, three years after criminal charges were filed.

The Health Department has previously faced criticism for extensive lags between the time a physician is arrested on drug-related charges and the time the state files a disciplinary charge that could result in sanctions, which include revoking a doctor’s license.

In some ways, quick action by the DOH is hindered by law. State law does not require that a doctor tell the department when he or she is arrested; only when there is a conviction. It can be years between an arrest and a trial.

According to DOH spokesman Brad Dalton, when law enforcement agencies tell the state an investigation is underway, “there are times when the department is asked to wait until a criminal case resolves … to protect the confidentiality of an active law enforcement investigation.”

The agency does not impose sanctions. After investigating, it may file a formal disciplinary charge — an administrative complaint — seeking disciplinary sanctions.

The burden of proof needed to justify such disciplinary charges is high, said Dalton. In a civil court suit, lawyers need to prove a “preponderance” of evidence to win their case, he points out. To prove a discipline case against a doctor, the state has to prove “clear and convincing” evidence.

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Filed under Broward County, DOH, Insurance Claims, Insurance Fraud, Pain Clinics, Palm Beach County

Brother Duo Accused of Massive Insurance Fraud Scheme

According to Law360, on January 3rd in a 427-page state court complaint the New Jersey Department of Banking and Insurance (DOBI) and Allstate Insurance Co. have accused brothers Anhuar and Karim Bandy of masterminding a massive personal injury insurance fraud scheme in which they recruited automobile accident victims for file claims for treatment. There were several law firms and health care providers involved in the schemes as well.

The Bandy brothers had previously pled guilty in July 2015 to organizing an insurance fraud scheme in which they recruited auto accident victims as patients for their clinics and received kickbacks from attorneys and medical professionals for patient referrals.

This recent complaint against the Bandy brothers detailed a series of alleged overlapping schemes that date back to their previous conviction. DOBI Commissioner Richard J. Badolato explained, “These and similar alleged fraudulent activities increase the cost of insurance to consumers.” While DOBI is seeking a fine against the Bandy brothers, Allstate is seeking reimbursement for paid benefits paid on behalf of its customers.

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Filed under Auto Insurance Fraud, Insurance Fraud, Personal Injury Protection

Two Pharmacies in Florida to Pay $750k for False Billing

U.S. Attorney’s Office, Middle District of Florida announced that Lemon Bay Drugs North, Inc. in North Port, FL and Brooksville Drugs, Inc. operating in Brooksville, FL have agreed to pay a total of $750,000 to the government to resolve allegations that the pharmacies violated the False Claims Act.

Both pharmacies are managed by Benzer Pharmacy Holding LLC and are owned by Alpesh Patel.

The allegations were that Lemon Bay and Brooksville Drugs provided Medicare and Medicaid patients generic versions of certain medications, but charged Medicare and Medicaid for the brand name versions of those medications. These allegations were initiated in a lawsuit filed by a whistleblower who was a former pharmacy technician who worked at Lemon Bay Drugs. The whistleblower will receive $142,500 as her share of the recovery.
This investigation was handled by Assistant U.S. Attorney Kyle S. Cohen with assistance from the Department of Health and Human Services – Office of Inspector General, the Defense Criminal Investigative Service, the FBI, the Florida Medicaid Fraud Control Unit, the North Port Police Department, and the Sarasota County Sheriff’s Office.

According to the Department of Justice, the claims resolved by the settlement are allegations only, and there has been no determination of liability.

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Filed under Florida, Health care, Insurance, Insurance Fraud

United States Settles False Claims Act Allegations Against Orthopedic Surgery Practice For $4,488,000

According to The U.S. Attorney’s Office, Middle District of Florida, Southeast Orthopedic Specialists (SOS) has agreed to pay the government $4.488 million to resolve allegations that it violated the False Claims Act.

The claims against SOS arose from the company billing federal healthcare programs for services that were not medically necessary or reasonable. Specifically, the United States contended that SOS sought reimbursement for millions of dollars of healthcare claims that were questionable.

This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative.

The claims resolved by the settlement are allegations only and there has been no determination of liability.

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Filed under False Claims Act, Florida, Health care, Insurance, Insurance Fraud, Middle District of Florida

Miami Man Charged with Conspiracy to Commit Health Care Fraud

On November 17, 2016, Satellite Press Releases and News reported the arrest of 21-year-old Eduardo Arango Chongo in connection with the arrests of 31-year-old Osmaro Ruiz and 25-year-old Raymel Betancourt for conspiracy to commit health care fraud.

According to the complaint, the co-conspirators had established fake medical facilities in Union County, New Jersey and were fraudulently billing insurance companies for services that were never rendered. The “phantom providers” allegedly submitted false claims for services worth more than $6 million, raking in hundreds of thousands of dollars from insurance companies. The defendants also utilized an electronic healthcare network used by medical practices to access the health insurance information of individuals who were not aware of their fraudulent activities.

The defendants could face up to 10 years in prison and a $250,000 fine if found guilty of the crimes they were accused of. U.S. Attorney Paul J. Fishman credits special agents of the U.S. Postal Inspection Service and special agents of the FBI with the investigation leading to the charges.

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Filed under Florida, Health care, Insurance, Insurance Fraud

Former Mayor of Tavares, FL Admits to Committing Insurance Fraud

According to WFTV Action 9 News, Robert Wolfe, former Tavares Mayor admitted to committing insurance fraud as part of a plea deal he made with the state. Wolfe was arrested in July after investigators found that Wolfe had reported to the insurance company that he had rented a home for $2,350 a month and had to board his dogs for $1,800 a month due to a leak in his home that needed to be repaired. However, investigators found that Wolfe never moved into the rental.

Wolfe will be placed on probation for 18 months and has been ordered to pay all investigative and court costs. He was also removed from his mayoral seat in July and has since resigned. Once Wolfe completes the 18 month pretrial intervention program, charges will be dismissed.

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Filed under Florida, Insurance, Insurance Fraud