Tag Archives: Insurance Fraud

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

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

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

Miami Woman Arrested and Charged in Insurance Fraud Scheme

According to the Palm Beach Post, Carmen Montalvo-Rivera of Miami was arrested and charged in Lake Worth, FL on Thursday, October 27th after investigators say she defrauded SUNZ Insurance Company. The arrest report states that Montalvo-Rivera’s shell company, Enterprises Remodeling Group Inc., used uninsured employers to do construction work. Once the job was finished, she would then cash the checks made out to the shell company in order to pay the workers in cash and severely underreport her company’s wages to the insurance company.

Montalvo-Rivera reported Enterprise Remodeling Group’s wages at $26,665 when they were actually $4,307,092.48. Her insurance premium should have been between $327,000 and $525,000 instead of the $1,796 premium she had been paying due to her fraudulent reporting.

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

GEICO Files RICO Suit Alleging Windshield Repair Fraud

A federal lawsuit filed by GEICO on June 9 provides an inside look at an elaborate windshield repair fraud scheme.

The suit, filed in the Middle District of Florida, makes claims of fraud, unjust enrichment and RICO (Racketeer Influenced and Corrupt Organizations Act) violations against at least two companies and their owners.

The complaint explained the scheme as follows:

A company called Cornerstone Mobile paid kickbacks to car dealerships and car wash companies to work off their properties. Cornerstone would offer to fix even the slightest damage to windshields for free. It would obtain the car owner’s insurance information and, more importantly, the owner’s signature to transfer assignment of benefits. Sometimes, GEICO alleges, the Cornerstone owners would steal insurance information from glove boxes of cars and forge the owners’ signature.

Eventually, Cornerstone Network was incorporated. The two entities had separate tax identification numbers but operated in an identical manner. GEICO says the two companies were used in hopes of reducing the number of fraudulent claims from Cornerstone Network alone, and thus avoid detection. Both companies claimed to do windshield repairs, but neither had a physical address—one was just a post office box in Tavernier.

Once Cornerstone got insurance information from automobile owners, the employees used a liquid formula from a window repair kit to coat over cracks and chips. Afterward, Cornerstone charged GEICO and other insurers for a full windshield replacement. The complaint alleges that Cornerstone would wait two to four weeks to file for reimbursement. Florida law allows insurers 30 days to make windshield replacement reimbursements, meaning GEICO was rushed to pay the claims on time and didn’t have a chance to investigate them.

GEICO presented exhibits showing more than 600 fraudulent windshield claims from each Cornerstone company, costing GEICO in excess of $223,000.

The case is Government Employees Insurance Company, et al. v. Jason Fry, et. al.

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Filed under Auto Insurance Fraud, Florida, Florida Division of Insurance Fraud, Insurance, Insurance Fraud, Middle District of Florida, Windshield Damage Scam

Medicare Fraud Roundup Is Largest in U.S. History

A nationwide sweep on June 21 resulted in the largest coordinated takedown of alleged Medicare fraudsters in U.S. history.

The Medicare Fraud Strike Force led a sweep in 36 federal court districts that resulted in charges against 301 individuals, including 61 medical professionals. The schemes involved about $900 million in fraudulent billing. South Florida was home to 100 of those defendants participating in fraud schemes involving $220 million in false billings for home health care, mental health services and pharmacy fraud.

The defendants face charges of conspiracy to commit healthcare fraud, violations of anti-kickback statutes, money laundering and aggravated identity theft. More than 60 of the individuals arrested are charged with fraud related to Medicare Part D, the prescription drug plan that is the fast-growing part of Medicare.

The defendants were part of schemes to bill Medicare and Medicaid for treatments that were medically unnecessary or never performed. Medicare beneficiaries and patient recruiters were paid kickbacks for supplying beneficiary information to providers, who used that information for fraudulent billing.

In one case in the Southern District of Florida, nine defendants were charged with operating six home health companies in the Miami area that gave bribes and kickbacks to bill for services that were not medically necessary. Those six companies defrauded Medicare of more than $24 million.

In the Middle District of Florida, which includes Orlando and Tampa, 15 individuals were charged with crimes including compounding pharmacy fraud and intravenous prescription drug fraud involving $17 million in fake bills. The owner of several infusion clinics is accused of being reimbursed by Medicare for $17 million for intravenous prescription drugs that were never purchased or administered to beneficiaries.

Click here for the press release.

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Filed under Health care, Insurance Fraud, Medicare, Miami-Dade Fraud, Southern District of Florida, Uncategorized