The owner of a mobile diagnostic ultrasound company pleaded guilty on June 21 to a nearly $29 million insurance fraud scheme.
Michelle Kobran, 68, admitted to falsifying medical bills and giving kickbacks to doctors at her chiropractic and physical therapy center in Wheeling, IL. Kobran said she altered the information on documents to get reimbursements from Blue Cross Blue Shield of Illinois, Aetna Health Insurance and other major insurance companies.
Law360 reported that for at least three years, Kobran had a deal with Vladimir Gordin Jr.
Kobran would do ultrasounds one day a week at Gordin Medical Center, and Kobran would pay Gordin one third of the bills she charged patients referred by the chiropractor. After Kobran realized insurance companies wouldn’t reimburse for multiple ultrasounds done on the same patient in the same day, she would change the dates of service on bills. Sometimes Kobran would tell her technician not to do all the ultrasounds ordered by doctors but charge for them anyway.
Kobran’s business submitted $28.8 million in fraudulent insurance bills over a six-year period ending in 2012 with insurance companies reimbursing those services for $10.8 million.
Kobran and Gordin were indicted in August 2015 along with three managers. Kobran’s plea includes her promise to testify against the others at trial in January. She faces 10 years in prison, but by testifying against the others she could end up with only two years in prison and $658,000 in restitution.
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Five defendants arrested on insurance fraud charges as part of the Division of Insurance Fraud’s Operation Cold Call have been sentenced after entering guilty pleas, according to The PIP Source, a newsletter of the Florida Division of Insurance Fraud.
The crimes – which were prosecuted by the 15th Judicial Circuit (Palm Beach County) and the 19th Judicial Circuit (Martin, St. Lucie, Indian River and Okeechobee counties) – took place in 2014 and 2015. A yearlong undercover investigation turned up illegal activity at two healthcare clinics: Accident Recovery Centers and Active Recovery Centers. Patients were illegally recruited and bills were sent for services that were never rendered.
Here are the five pleas and their punishment:
- Runner Douglas Anthony Santiago was sentenced to three years probation for patient brokering.
- Runner Alejandro Jose Marin was sentenced to two years probation for patient solicitation and patient brokering.
- Attorney Brian Greenspoon was sentenced to 18 months probation for patient solicitation.
- Chiropractor Roger Toby Hughes Bell was convicted of patient brokering and surrendered his license.
- Attorney Cory Meltzer was convicted of patient solicitation and agreed to disbarment.
Two chiropractors are scheduled for trial later this year, while the final defendant is negotiating a plea.
The Florida Division of Insurance Fraud arrested a man in Orlando who was charged with orchestrating automobile accidents for the purpose of defrauding insurance companies.
Alma Germain was accused of buying used junk cars to intentionally cause wrecks. Channel 9 in Orlando said one car was in such bad shape, Germain had to stop several times to add water to the radiator on the way to a staged crash.
Germain was charged with using cash to recruit people to get into crashes with him, then telling them to seek treatment at a local healthcare clinic. The clinic would then bill the insurance company.
In one particular case, Germain had three people in the car with him during a crash. He ran from the wreck site but told the three passengers to go to Family Practice and Rehab in Orlando for treatment. Family Practice billed the insurance company for nearly $25,000.
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A North Florida jury convicted a Gainesville doctor of 162 counts of healthcare fraud. Ona M. Colasante, who was found guilty after a five-week trial, faces up to 10 years in prison at her sentencing in July.
Colasante owned and operated medical businesses known as the Hawthorne Medical Center (from 1998-2009) in Hawthorne, Florida, and the Colasante Clinic (from 2010-2013) in Gainesville. Colasante used a false billing scheme at those businesses to defraud Medicare, Medicaid and Blue Cross Blue Shield of Florida.
The U.S. Attorney’s Office for the Northern District of Florida described Colasante’s scheme as follows: Colasante and her employees ordered non-FDA-approved drugs at drastically reduced prices and administered them to unsuspecting patients. Colasante would then bill the insurance companies for the cost of FDA-approved drugs.
Colasante also billed the insurance companies for medical tests that were unnecessary and submitted false diagnosis codes to support her claims. She also billed insurance companies for counseling, treatment and training that was never performed. One example pointed out by the U.S. Attorney’s Office was that Colasante frequently billed the insurance companies for treatments to stop smoking even though the patients were already nonsmokers.
“Healthcare programs and patients depend on ethical practices from medical providers,” U.S. Attorney Christopher P. Canova said in commending the federal investigators and prosecutors after the trial.
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Miami doctor Henry Lora was sentenced to nine years in federal prison and ordered to pay $30.3 million in restitution for his part in a Medicare fraud ring.
U.S. District Judge Federico Moreno in Miami sentenced Lora on Monday after he pleaded guilty in February to one count of conspiracy to commit health care fraud and one count of conspiracy to defraud the U.S.
Lora, 51, was the medical director of now-defunct Merfi Corp. when he wrote prescriptions for Medicare beneficiaries that weren’t needed or were never provided, according to Law360. In exchange, Lora received kickbacks and bribes from patient recruiters and home health care operators. Lora also was accused of falsifying patient records so they would qualify for Medicare services.
Merfi’s owner, Isabel Medina, also received a nine-year sentence after pleading guilty in January 2014. Three others, German Martinez, Lerida Labrada and Mayra Flores, received sentences of 24, 37 and 24 months, respectively, for serving as patient recruiters.
The case was part of the Department of Justice’s Medicare Fraud Strike Force, which has charged more than 2,300 people with bilking Medicare out of $7 billion in fraudulent claims.
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In Bayfront Health Education & Research Organization Inc. v. Progressive American Insurance Co., the Plaintiff billed the Defendant for services. The Defendant reduced the bills, subtracted the insured’s deductible, and paid eighty percent of the difference. Under Florida Statute § 627.736, the Defendant pled that only reasonable, related, and necessary “medical expenses are reimbursable and likewise applicable to any deductible.” The Plaintiff moved for summary judgment claiming that the Defendant misapplied the deductible. The Plaintiff claimed that the deductible should be applied to the amount billed.
The Court held that Florida Statute § 627.739(2) “requires the deductible be applied to 100 percent of the reasonable expenses.”
The Court construed Florida Statute § 627.739(2) and Florida Statute § 627.736. Under Florida Statute § 627.739(2), “[t]he deductible amount must be applied to 100 percent of the expenses and losses described in s. 627.736.” The Court looked to Florida Statute § 627.736 “to determine the expenses and losses described.” The Court said that Florida Statute § 627.736 “describes the payable expenses as ‘reasonable expenses.’”
The Court also found that “the deductible is applied to 100% of all reasonable expenses” under the insurance contract.
The Court interpreted the insurance contract. Under the insurance contract, “the deductible will be applied to 100% of the expenses and losses covered under Personal Injury Protection Coverage.” The Court said that “[m]edical benefits are part of the Personal Injury Protection Coverage and defined as 80% of all reasonable expenses.”
In sum, under Florida Statute § 627.739(2), Florida Statute § 627.736, and the insurance contract, the Court held that “the deductible is applied to 100% of the provider’s reasonable expenses.”
Order Denying Plaintiff’s Motion for Summary Judgment, in Part, and Granting, in Part, Bayfront Health Educ. & Research Org. Inc. v. Progressive Am. Ins. Co., No. 12-5556-SC (Fla. Pinellas Cty. Ct. 2015).
On November 18,2015, a Miami widow of a car crash victim sued Lyft for alleged negligence leading to the wrongful death of a motorcyclist. The widow is alleging that the ride-hailing company failed to properly train the driver that caused the fatal accident.
Poliana Perez, whose husband Loinier Perez was killed while riding his motorcycle on October 31, believes that Lyft Florida Inc. is liable for the crash caused by driver Pirooz Pakdel. Pakdel was carrying a pair of Lyft passengers when he allegedly made an improper left-hand turn and rammed into Loinier Perez.
Perez’s attorney, Ervin Gonzalez of Colson Hicks Eidson, stated that “Lyft, which isn’t even authorized to operate in Miami-Dade County, fell far short of its obligation to act in the best interests of public safety and an innocent life was taken.” The suit alleges that Lyft knew or should have known that Pakdel was not properly trained or suited for the job. The San Franciso-based Lyft allows passengers to use a smartphone app to hail rides from drivers in their personal cars.
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Zian Scott Snyder, 29, and Alicia Maria Hill, 26, of Cantonment, Florida have been charged with scheme to defraud, insurance fraud, grand theft, and conspiracy to commit insurance fraud by the Florida Division of Insurance Fraud (DIF) for alleged false claims over a custom-made engagement ring.
According to an article on NorthEscambia.com, the couple filed a false claim on a $15,000 ring that Hill claimed she lost swimming in the Gulf. She was also recorded claiming she lost the ring on a boat in the Gulf. Four days after filing the claim with her insurance company, Hill took the ring to Marks and Morgan Jewelry store in Ft. Walton Beach to have the ring repaired.. The custom-made ring was identified by photographs taken at the Ft. Walton Beach jewelry store.
Around the same time the couple filed the insurance claim, the store manager of the Jewelry store told authorities she witnessed the ring for sale on Craigslist and that she was positive that it was the same ring in question because she was the one who custom made the ring. The couple told her that the ring had not been stolen, but was eaten by a dog and was later recovered.
A month after the couple filed the insurance claim, Hill called the insurance company to report that the ring had been recovered. The insurance company then advised that the ring or the check must be returned. Three days after Hill informed the insurance company of the recovery, she changed her story once again, stating that it was actually a different ring that was recovered.
The insurance company told state investigators that neither the ring nor the insurance proceeds were ever returned by the couple.
On October 13th, Janio and Jharildan “Harold” Vico were convicted of a total of 16 charges including 12 counts of mail fraud, two counts of money-laundering, conspiracy to commit money-laundering, and conspiracy to commit wire fraud. A federal jury deliberated for approximately two hours before finding the brothers guilty, according to a palmbeachpost.com article. The conviction arises out of the brothers’ ownership and operation of the V&V Rehabilitation Center, located on 10th Avenue North, Lake Worth, Florida, from 2009 until 2011. Janio and Jharildan Vico staged traffic accidents and then billed insurance companies for fake injuries, which were treated at their Lake Worth clinic. The scheme brought in approximately $3 million for the two brothers.
Assistant U.S. Attorney Ellen Cohen is seeking for the brothers to forfeit nearly $400,000 and homes they purchased with proceeds received from the fraud. The brothers can face up to a maximum sentence of 20-years for the most serious charges. The sentencing hearing is set for January 8, 2016.
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On October 8th, Plaintiffs in two putative class actions against insurers in Florida argued before the Eleventh Circuit Court that the 2013 amendments to the State’s No-Fault Personal Injury Protection Statute created ambiguities in determining caps and that the lower courts erred in attempts to resolve those ambiguities
The contested issue is the interpretation of two sections lawmakers added to the law intended to maintain the existing $10,000 PIP benefit cap but only for claimants who have an emergency medical condition while reducing the maximum cap to $2,500 for those who did not.
Judge Carnes acknowledged that he was not satisfied with the Plaintiffs’ arguments and questioned why there was a need for certification in order to receive the $10,000 maximum for an emergency if a lack of certification would also default to a $10,000 maximum based on the prior law. However, the Judge allowed the Plaintiff’s attorney seven days to identify and submit two best examples of decisions from the Florida Supreme Court, which show a conflicting inconsistency in a state law, where the proper step is not to turn to the legislative history but to revert to prior law instead.
The Judge also challenged the Plaintiff’s argument against relying on legislative history before the defense. Counsel for the defense, Thomas E. Scott stated that “If the court were to rule this way, it would serve to defeat all that lawmakers were trying to accomplish.” The Defendant’s argument in the case is that the Legislature wanted some form of security to establish the two-tier benefit system and placed a burden on the claimant to prove their medical condition.
A decision has not yet been rendered in this case.
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