Tag Archives: insurance

Florida Doctors With Multiple Malpractice Settlements Face Little Discipline

According to Health News Florida, there are 29 Florida doctors operating with clear medical licenses although they have at least six malpractice complaints against them that have resulted in insurance payments since 2000. These doctors are continuing to practice without discipline from the state system that oversees them, which means either insurers paid to settle the cases that had no merit or the state hasn’t always followed up.

Critics say Florida’s system is broken and it’s putting people’s lives at risk. Dr. Sidney Wolfe, founder of the Public Citizen Health Research Group, based in Washington D.C has studied medical discipline nationwide for decades and says Florida’s Board of Medicine must intervene.

Patients and their families can also file a complaint with the state’s regulatory agencies, although the odds are stacked against them. 6,713 complaints and reports were filed with the Department of Health from 2015-2016. Only about 15 percent or 1,018 of them were found “legally sufficient.” Of those, 762 were taken to a probable cause panel, and three-fourths were rejected. The 188 administrative complaints filed that year represent less than 3 percent of the number of complaints and reports that came in.

In some cases involving doctors with multiple claims, records show the Department of Health received early warnings, but took little or no action. One of those cases was that of Dr. Michael Rosin, a Sarasota dermatologist who was convicted in March 2006 of defrauding Medicare of more than $3 million in a scheme that dated back more than a decade. He was sentenced to 22 years in prison and ordered to pay millions of dollars in restitution. After his criminal conviction, the Department of Health revoked his license, according to state records. Federal records show that Rosin, now 66, is at Otisville Federal Correctional Institution in Otisville, N.Y. He is scheduled for release in 2025.

Click here to read the full article.

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Filed under Department of Health, DOH, Florida, Florida Healthcare, Health care, Insurance, Malpractice

Discount Plan Organization (DPO): What is it and why should we know?

A “Discount Medical Plan Organization” was created in 2004 and is now simply called a “Discount Plan Organization (DPO).”

What is it and why should we know?

It is like a concierge medical agreement where a patient pays a fee, for example, $1,500/year to get quick access to a specific doctor.  Usually, the DPO is the only way to access specific practitioners.  It does little more than grant access, some prophylactic treatment, and the practitioners are usually the patients’ primary care physician.  You may see these organizations providing post-accident services.

Let’s make sure we are not also paying for the DPO in disguise through administrative CPT’s. Click here for the Bill Analysis.

Summary:

Discount Medical Plan Organizations (DMPOs) offer discount medical plans, in exchange for fees, dues, charges, or other consideration, which provide access for plan members to providers of medical services and the right to receive medical services from those providers at a discount. The Legislature established the regulatory scheme for DMPOs in 2004, which includes licensure, forms and rate filings and approval, disclosure requirements, and penalties.

CS/HB 577 renames a “Discount Medical Plan” and a “Discount Medical Plan Organization” as a “Discount Plan” and a “Discount Plan Organization” (DPO), and makes extensive conforming changes to part II of ch. 636, F.S., to reflect the new names. The bill clarifies the definition of a “Discount Plan” to exclude any plan that does not charge a fee to members. The bill removes all rate and form filing and approval requirements for DPOs. To increase flexibility in marketing and reduce administrative barriers for DPOs, the bill:

  • Defines “first page”, upon which certain disclosures must appear, to mean the first page of any marketing material that first includes information describing benefits;
  • Allows DPOs to delegate functions to marketers and binds DPOs to the actions of those marketers within the scope of the delegation; and
  • Allows marketers and DPOs to commingle certain information on forms, advertisements, marketing materials, or brochures.

To maintain consumer protections for members and potential members of Discount Plans, the bill:

  • Changes the disclosure requirements by requiring acknowledgement and acceptance of the disclosures before enrollment and creating visibility and follow up requirements for disclosures made by electronic means or telephone;
  • Establishes new cancellation and reimbursement requirements for DPOs to disallow any charges beyond the effective cancellation date;
  • Requires pro rata reimbursement of charges paid by a member for the months beyond the effective cancellation date; and
  • Requires pro rata reimbursement for members who cancel during an open enrollment period, upon return of his or her discount card.

The bill does not have a fiscal impact on state or local government.

The bill became law on June 14, 2017, and is now Chapter 2017-112, Laws of Florida.

If you have any questions or would like to discuss this issue in greater detail, please feel free to contact Dennis LaRosa (dlarosa@roiglawyers.com/850-264-6389) or any ROIG Lawyers attorney of your choice.

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Filed under FL Legislation, Florida, Insurance, Insurance Defense

New Opinion Released Regarding Examinations Under Oath (EUOs)

A new opinion was recently released by the Florida 9th Circuit Court in its appellate capacity interpreting Fla. Stat. § 627.736(6)(g) and the timely scheduling of Examinations Under Oath (EUOs). This case reaffirms that as a general rule, an insurer ought to schedule the initial EUO in any claim under investigation to occur within 30 days of receipt of the first bill to ensure that the investigation is being conducted well within the time limits set forth in the PIP statute without obliging the insurer to issue a payment of the subject bill prior to investigation.

In Geico Indemnity Co. v. Central Florida Chiropractic Care a/a/o David Cherry (2016-CV-000038-A-O), Central Florida Chiropractic sued Geico for breach of contract for failure to pay overdue PIP benefits. Geico asserted as an affirmative defense that coverage was appropriately denied because the assignor failed to appear for two EUOs.

Central Florida Chiropractic contested Geico’s above-described defense because the EUOs were scheduled to occur more than 30 days after the date on which Central Florida Chiropractic had submitted the bills for the alleged charges at issue and, thus, the EUOs were unreasonably set to occur beyond the 30-day statutory period for payment of said bills. In fact, the Court noted, the first EUO request was not even sent until after 30 days had lapsed. Further, Geico had not informed the claimant pursuant to Fla. Stat. § 627.736(4)(i) that his claim was pending investigation.

The 9th Circuit ruled that even though attendance at an EUO is a condition precedent to receiving PIP benefits under Fla. Stat. § 627.736(6)(g), this provision “cannot be read in a vacuum.” The Court specifically looked to section (4)(b), which requires provider bills to be processed within 30 days of receipt, and to section (4)(i), which states that the claimant should be notified in writing within 30 days of filing the claim that an investigation is under way. Geico argued that section (4)(i) permits a 60-day extension of time for investigation beyond 30 days, but the Court pointed out that Geico failed to send any letter notifying the claimant of the investigation in this case, so the 30-day window was not extended.

The Court also explained that timely payment of the provider bills does not foreclose the insurer from investigating the claim. Nonetheless, “nothing in the statute additionally excuses the insurer’s potential breach for failure to pay a PIP claim within 30 days as contemplated by section 627.736(4)(b).”

Therefore, Geico could not enforce the EUO as condition precedent to receiving PIP benefits because by the time it had scheduled the EUOs, it was already in breach of the policy as the provider’s bills were not timely paid within 30 days. “[B]ecause Geico was already in breach of the insurance contract before the EUOs were scheduled to take place, [the assignor] was not obliged to submit to them.”

The Geico case is the latest in a long line of opinions and trial court orders, starting with Amador v. United Auto. Ins. Co., 748 So. 2d 307 (Fla. 3d DCA 1999), which holds that an EUO does not toll or extend the 30-day period within which an insurer must pay otherwise timely, compensable charges pursuant to Fla. Stat. § 627.736(4)(b). Courts have also ruled that the insurer does not comply with the 30-day requirement if it coordinates the EUO within 30 days, but the EUO is nonetheless scheduled to occur beyond the 30-day window. (See Micro-Diagnostics & South Florida Inst. of Medicina a/a/o Luz Solarte v. United Auto. Ins. Co., 12 Fla. L. Weekly Supp. 248a (Fla. 11th Cir. Ct. App. 2004). In general, an insurer cannot defend claims on the basis of a claimant’s failure to attend an EUO if said EUO is scheduled to occur outside the 30-day period after submission of the medical bills. (See Humanitary Health Care, Inc. a/a/o Juan Esquivel v. United Auto. Ins. Co., 12 Fla. L. Weekly Supp. 531b (Fla. 11th Cir. Ct. 2005).

However, a Miami-Dade appellate court did find that an insurer may still benefit from the claimant’s failure to appear for an EUO if said EUO is initially scheduled to occur within 30 days, but then rescheduled for a later date at the claimant’s request. (See West Dixie Rehab. & Medical Ctr. v. State Farm Fire & Casualty Co., 10 Fla. L. Weekly Supp. 16a (Fla. 11th Cir. Ct. App. 2002)).

The above cases make clear that any communications regarding the re-scheduling of an EUO ought to be done in writing, with language that clearly communicates that the change in date was done to accommodate the request of the insured or insured’s attorney. When appropriate, the insurer may send a letter to the claimant or claimant’s attorney pursuant to section (4)(i) advising that a claim is under investigation within 30 days of the claim filing. This will extend the time period within which an investigation may be conducted up to 90days after the submission of the claim, and thus allows additional time before any provider bills must be processed.

If you have any questions or would like to discuss this issue in greater detail, please feel free to contact us.

ROIG Lawyers is a minority-owned litigation firm with a primary focus on Insurance Defense Litigation. We serve as primary counsel for numerous national and regional carriers and corporations related to all aspects of insurance litigation from 7 offices throughout the state of Florida. ROIG Lawyers does not intend to create an attorney-client relationship by offering this information, and anyone’s review of the information shall not be deemed to create such a relationship. E-mail list/s from ROIG Lawyers are intended to provide information of general interest to the public and are not intended to offer legal advice about specific situations or problems. You should consult a lawyer with regard to specific legal issues that require attention.

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Filed under auto insurance, Case Law, Claims Handling, Examinations Under Oath (EUO), FL Legislation, Insurance, Insurance Claims, Insurance Defense, Personal Injury Protection, PIP, PIP/No Fault

New Amendments Affecting Anti-Fraud Investigative Units

The Legislature has passed some amendments that are likely to affect your SIUs. We have reviewed the new law and would like to provide you with a summary of some of the most important points.

Chapter 2017-178, Laws of Florida, primarily amended § 626.9891, Florida Statutes and went into effect June 26, 2017, when the Governor signed the bill. These amendments deal with insurer “anti-fraud investigative units.” There is very little, if anything, that must be done now other than learn the law and know what your responsibilities and timelines are.

Although you have an SIU to cover the main features of the law, some new reporting requirements and designation of an anti-fraud unit with at least 2 hours of initial anti-fraud education and 1 hour per year after that, will require all insurers “to investigate and report possible fraudulent insurance acts” to Florida government. The amendments to § 626.9891 [insurer anti-fraud investigative units; penalties for noncompliance], Florida Statutes, provide the who, what, how, when and where.

SUMMARY

*There is no legislative staff analysis of this law

By December 18, 2018, DIFS shall create best practices for the detection, investigation, prevention, and reporting of insurance fraud and other fraudulent insurance acts. The report must be updated as necessary but at least every 2 years. The report must contain specified criteria set forth in the section.

The Department of Financial Services is authorized to create rules for the administration this section. This is neither the Office of Insurance Regulation nor the Financial Services Commission (Governor and selected cabinet).

While there are compliance dates for insurers and agencies, the bill became effective upon becoming a law on June 26, 2017. By December 31, 2017, each insurer must:

  • If not in-house, contract with others to provide anti-fraud services
  • Adopt anti-fraud plan (discussed below)
  • Designate at least one employee to provide these services
  • Electronically submit reports of anti-fraud plan with the name and contact information of designated person to DIFS
  • The additional cost to the insurer for compliance may be added as an administrative expense in rate requests

Each anti-fraud plan shall include:

  • Procedures for mandatory reporting of insurance fraud
  • Acknowledgement that the insurer provides education and training required by section
  • Description of anti-fraud education and training
  • Description or flow chart of anti-fraud unit
  • Rationale and justification for level of staffing and resources used by anti-fraud unit based upon specified criteria

By December 31, 2018, each insurer shall provide staff of the anti-fraud investigative unit at least 2 hours of initial anti-fraud training that is designed to assist in identifying and evaluating instances of suspected fraudulent insurance acts in underwriting or claims activities.

Annually, after the initial training, an insurer must provide such employees a 1-hour course that addresses detection, referral, investigation, and reporting of possible fraudulent insurance acts for the types of insurance lines written by the insurer.

The insurer shall report to DIFS specified information by December 19, 2019, and annually thereafter for each line carried:

  • Number of policies in effect
  • Amount of premiums written
  • Number of claims received
  • Number of claims referred to anti-fraud unit
  • Number of fraud related matters referred to anti-fraud unit that were not claim related
  • Number of cases referred to DIFS
  • Number of case referred to other LE agencies
  • Number of cases referred to other agencies
  • Estimated dollar exposure submitted to DIFS or other agencies

In addition to reporting for all lines, workers compensation lines shall also report by December 19, 2019, the following information:

*This is a decrease in the amount of information currently required for workers compensation fraud before the amendment

  • Estimated dollar amount lost due to workers comp fraud]
  • Estimated dollar amount recovered attributed to workers comp fraud for several designated criteria
  • Number of workers comp fraud cases referred to DIFS for several designated criteria

Creating § 626.9896 Dedicated insurance fraud prosecutors:

  • DFS shall collect specified data from each state attorney who has designated attorneys and paralegals exclusively for the prosecution of insurance fraud.  [criteria omitted]
  • DIFS shall report the data to the house and senate leaders by September 1, 2018, and annually after that.

Other provisions not discussed; viatical contracts; HMO anti-fraud unit requirements; stranger-originated insurance policies are now statutorily considered void and unenforceable; an insurer may opt out of preinsurance inspection of private motor vehicles.  Preinsurance inspection reports of DIFS are eliminated.

 

These are the highlights of the bill as it applies to automobile insurance.  It does affect other lines as mentioned and we would be happy to explain the law in greater detail should you request it. If you have any questions, suggestions or reservations, please do not hesitate to contact us so that we may assist you in not only understanding the new law but how it ought to be implemented and when.

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Filed under FL Legislation, Florida, Florida Division of Insurance Fraud, Insurance, Insurance Claims, Insurance Defense, Insurance Fraud

Casselberry Residents Being Targeted by Windshield Replacement Scammers

Casselberry, Florida residents are victims of windshield replacement scammers. As reported by News 6, a Casselberry resident recently told police that two men came to her door claiming to work for the state government, insisting that a new law had been enacted that requires Floridians to replace their windshields every six months. As a result, the residents become victims, often times being exposed to an increased risk of a cheap windshield popping out and breaking during an accident. In turn, the scammers will contact the victim’s auto insurer and submit an inflated invoice for a service that was not necessary or properly done; potentially resulting in an increase in the victim’s auto insurance premium.

An increased premium is not the only risk insureds face with these scams, according to the Coalition Against Insurance Fraud, insureds could face possible fines and, even worse, jail time. Making a repair claim for a windshield you know is undamaged could get you convicted of insurance fraud.

Red flags should go up if someone shows up at your door or chases you down in a parking lot offering to fix your windshield for free. If you believe your windshield has sustained damage and needs to be repaired or replaced, call your insurance company for a list of rebuttable windshield repair/replacement companies.

For more information regarding the windshield repair scams and what you can do to fight back, visit http://www.insurancefraud.org/scam-alerts-windshield.htm.

Click here to read full article.

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Filed under Florida, Insurance, Insurance Claims, Insurance Defense, Insurance Fraud, Uncategorized, Windshield, Windshield Damage Scam

Relocation For Military Personnel Might Be An Order, But What About Vehicle Registration and Insurance?

During holidays such as Memorial Day and Independence Day, our nation pays tribute to all of our men and women, both past and present, serving in the Armed Forces. We look forward to celebrating with family and friends as we honor our military personnel and their service to this Country.

One of the things military personnel are likely to endure is moving their homes and bouncing around the Country or overseas to do their duty. These individuals often own motor vehicles and drive them across state lines to where they are newly stationed. Others are overseas for months, if not years, and have motor vehicles back at home that are not being used and are often garaged until their owners return.

So is a member of the military who is a Florida resident responsible for maintaining the registration and minimal automobile insurance on their vehicle when they are stationed out of the Country?

The answer to that is no, but be careful. Florida law makes an owner or registrant of a motor vehicle exempt from such registration and insurance requirements if a member of the United State Armed Forces is called to or on active duty outside the United States in an emergency situation. The exemption applies only as long as the member of the Armed Forces is on active duty outside the United States and applies only while the vehicle covered by the security required under Florida law is not operated by any person. However, the military insured must make a written request for this exemption and the insurer shall cancel the coverages and return any unearned premium or suspend the security required.

What does this mean? Well, the subject motor vehicle cannot be driven on the roads and highways of Florida during the time this exemption is in place. As such, if that military insured has leave and comes back to Florida, then they cannot operate that vehicle unless they renew the minimum insurance and their registration, if expired. Additionally, other individuals cannot drive that vehicle when that military insured is deployed. This can get tricky due to the fact that the worst thing that can happen to a motor vehicle is letting it sit idle for a long period of time. This can cause condensation in the fuel, carburetor issues, flat tires and other mechanical problems.

To be safe, advise everyone you know that may have access to the vehicle that it cannot be operated on the streets or highways of Florida until it is re-registered and insured. Putting a lock on the vehicle’s steering wheel or a note in the window as a reminder may also be a good practice. This does not mean you cannot start the vehicle and let it idle, it just means you cannot take it out for a drive. If you do, the driver/owner of the vehicle would become self-insured and could possibly be cited for failure to have the required insurance on the vehicle. Sorry neighbors, no favors to borrow the car for a quick trip to the market… That run for milk can leave the vehicle owner in a stale situation.

Now Florida residents are generally required every year to renew the registration on their vehicles.

However, is a member of the Armed Forces, who is a resident of another State and is ordered to be stationed in Florida, required to register their personal vehicle in Florida and maintain the minimum Florida insurance on that vehicle if they want to drive that vehicle on the roads and highways of Florida?

The answer is no. Any motor vehicle or mobile home owned by, and operated exclusively for the personal use of, any member of the United States Armed Forces who is not a resident of Florida and who is stationed in Florida while in compliance with military or naval orders, are exempt from registering and insuring their personal vehicle in Florida during that time as long as it is registered and insured in accordance with the laws of their home State.

Now the military insured may want to renew their registration and obtain the minimum Florida insurance if they know that they will be stationed in Florida for a long period of time. However, they are not required to do so as long as they have military orders keeping them stationed in Florida. Consequently, this means that the military insured will only get the benefit of the coverage’s that are available under their insurance policy and would not qualify for additional Florida Personal Injury Protection coverage benefits if they are in a motor vehicle accident in the State.

There are certain insurers that cater to the Armed Forces personnel. However, there are other insurance options for these individuals based on the competition between insurers. Thus, insurance agents and adjusters should become knowledgeable about the insurance exemptions provided to the Armed Forces personnel so to better service these special clients.

This article is not intended to create an attorney-client relationship by offering this information, and anyone’s review of the information shall not be deemed to create such a relationship. The content provided is intended to provide information of general interest to the public and is not intended to offer legal advice about specific situations or problems. You should consult a lawyer with regard to specific legal issues that require attention.

For additional information, please contact Stephen Mellor of Roig Lawyers at 954-354-1541 or by email at smellor@roiglawyers.com. Stephen G. Mellor is a partner in the Deerfield Beach office of Roig Lawyers who primarily focuses on out-of-state policy claims for insurance carriers. 

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Filed under auto insurance, FL Legislation, Florida, Insurance, Insurance Claims, Insurance Defense

Geico Claims Fraud By Plaintiff Seeking Class Action Lawsuit In Florida

As reported by Law360, in its efforts to have class certification denied, GEICO has asserted that VIP Auto Glass Inc. may lack standing to bring any claims against GEICO and maintain its lawsuit.  “Since VIP actually has no valid assignment, it has no standing to bring any claims, much less any class claims. Class certification must be denied on this ground alone,” GEICO added, also noting that it reserves the right to seek sanctions or other appropriate remedies based on the alleged improper conduct.

According to the Complaint, VIP Auto Glass Inc. is seeking damages on behalf of GEICO policyholders, alleging that GEICO’s prices violate Florida laws and “have absolutely nothing to do” with the amount most shops charge for a windshield replacement.  VIP Auto Glass has asked a federal court in Tampa to certify a class of similarly situated windshield repair facilities in the state that were hired to perform repairs by Florida GEICO policyholders, obtained an assignment of benefits and submitted bills for reimbursement, but did not receive full payment from the insurer.  However, in its response opposing that motion, GEICO has advised the court that it has recently discovered that VIP’s repeated assertions that Mr. Jones assigned it his benefits have been false.  GEICO says that Jones recently confirmed the forgery during a deposition and in a sworn affidavit, testifying that the signature and initials on the filed assignment of benefits are not his. In his affidavit, Jones also says that his first name is spelled Derryl, with two “Rs.”

GEICO has stated that the court’s analysis should end with a finding that VIP lacks standing, but also argues that class certification should be denied because class members cannot be easily ascertained since each proposed member’s assignment of benefits would have to be verified through individual factual inquiries.

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Filed under Class Action, Florida, Insurance, Insurance Defense, Windshield

Four North Carolina Men Charged in Insurance Scam

As reported by The-Dispatch.com, four North Carolina men have been charged by the N.C. Department of Insurance with charges including insurance fraud, felony conspiracy, injury to real property and attempting to obtain property by false pretense. Phillip Brandon Edwards, Mark William Madison, Joel Jayson Smith and Brandon Richard Turner are being accused of deliberately damaging roofs in at least two homes to obtain insurance payment from United Services Automobile Association under false pretense.

The National Insurance Crime Bureau, Thomasville Police Department, Davidson County Sheriff’s Office and Concord Police Department are the agencies that assisted with the investigation.

“According to the FBI, insurance fraud costs the average family between $400 and $700 per year in the form of increased premiums,” North Carolina Insurance Commissioner Mike Causey said in a news release. National Insurance Crime Bureau has seen a rise in potential fraudulent roofing claims and complaints with over 150 referral complaints in 2014 and 2015.

Click here to read full article.

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Filed under Insurance, Insurance Claims, Insurance Defense, Insurance Fraud

Florida’s Third District Court of Appeal Retroactively Applies Allstate PIP Decision

According to Law360, on Wednesday, April 19th Florida’s Third District Court of Appeal retroactively applied a state Supreme Court decision involving Allstate Insurance Co.’s personal injury protection policy language regarding the use of the Medicare fee schedules, overriding a lower court’s ruling and handing Allstate the win. After denying the insurer’s request for review of a circuit court appellate division’s ruling in favor of medical provider Hallandale Open MRI LLC last September, the court reversed course, applying the Supreme Court’s January decision in Allstate v. Orthopedic Specialists.

Click here to read the full article (subscription required).

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Filed under auto insurance, Case Law, FL Legislation, Florida, Insurance, PIP, 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.

Click here for full story.

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