Author Archives: Fernando L. Roig, Esq.

Miami PIP Attorney Charged With Insurance Fraud

Miami attorney Anett Lopez was arrested on charges of taking part in a $1.5 million personal injury protection (PIP) fraud scheme.

Lopez is accused of filing lawsuits seeking reimbursements for the treatment of patients at Care Resources Group, a Miami healthcare clinic fraudulently operated under a straw owner.

A February investigation by the Florida Division of Investigative and Forensic Services (DIFS) uncovered that Care Resources Group was a PIP clinic illegally operating under a straw owner to avoid state licensing requirements. Lopez, straw owner Dr. Mario Torres and four others were arrested for alleged money laundering and soliciting of car accident victims in connection with the straw ownership of the clinic.

Lopez, who state authorities say was aware of the clinic’s straw ownership, filed lawsuits against at least a dozen insurance companies that resulted in payouts of nearly $1.5 million. Lopez faces seven counts each of insurance fraud and grand theft, and one count of organized scheme to fraud. She faces up to 85 years in prison if convicted of all 15 felonies.

Click here for full story.

Comments Off on Miami PIP Attorney Charged With Insurance Fraud

Filed under Fla. Stat. 627.736 (2012), Florida Agency for Health Care Administration (AHCA), Health care, Insurance Fraud, Miami-Dade County, Personal Injury Protection, PIP/No Fault

Who Is Most Likely to Die? An Unbuckled Driver on July 4

July 4 is here and with it comes a startling statistic: That’s the day Americans are most likely to die in an automobile accident.

The Auto Insurance Center compiled a year’s worth of data from the National Highway Traffic Safety Administration’s Fatality Analysis Reporting System. In that year of stats, there were 32,675 people killed in traffic accidents, a number that’s been steadily declining since 1975.

Holidays dominate the days with the most fatalities with the top three days for traffic deaths being July 4, Jan. 1 and Labor Day. The additional traveling on those days, combined with alcohol served at parties, produce a deadly combination.

August and July are the most deadly months due to summer road trips and more teens driving while school is out. In order, Saturday, Friday and Sunday are the deadliest days—again due to alcohol consumption.

The nation’s two deadliest roads have a Florida connection: I-10 (which travels from Jacksonville through Pensacola and on to California) is the worst road for fatalities, while I-95 (from Miami through Jacksonville to Maine) is second.

A few other facts compiled from the data:

  • Drivers (63%) are the most likely to be killed in an accident, followed by passengers (18%), pedestrians (15%) and cyclists (2%).
  • Not wearing a seatbelt (45% of all deaths) is the biggest risk factor, followed by driving under the influence (31%) and speeding (28%).
  • The most common blood alcohol level for alcohol-related fatal crashes was 0.22%—nearly three times the legal limit in Florida.

Click here for the full story.

Comments Off on Who Is Most Likely to Die? An Unbuckled Driver on July 4

Filed under Florida, Insurance

Auto Insurance Fraud Comes in All Shapes and Sizes

A recent study by the auto insurance industry reveals that fraud costs the industry $50 billion each year. And with that much money at stake, the criminals can get pretty creative.

South Florida law enforcement used “Operation Cold Call” last year to bust up a personal insurance protection (PIP) fraud ring that used chiropractors, lawyers and clinic employees. Undercover agents infiltrated the ring over a year’s time, uncovering a network of con artists who recruited and paid people to lie about injuries and the healthcare they received after crashes. But fake injuries are pretty tame compared to two other schemes mentioned in the report:

  • The Montana License Plate Scam: Montana has no sales tax or use taxes on vehicles. In this scheme, an unscrupulous attorney in Montana helps out-of-staters create a limited liability company in Montana. Then that LLC is used to buy an expensive sports car or recreational vehicle. The vehicle is taken back to the LLC owner’s home state, and technically, the owner is driving a “company car” with Montana plates. But if there is a wreck, theft or weather damage, the auto insurance company may cancel the policy or deny the claim due to violation of insurance and registration laws within the driver’s home state.
  • The Hot Wheels Ruse: One insurance company had a customer make a claim for parts stolen from the customer’s vehicle. Everything appeared legit at first, until investigators took a closer look at the photos submitted with the claim. The photos were actually extreme close-ups of a toy car, but at least the toy car was the same make and model as the customer’s real car.

Click here to read the entire story.

Comments Off on Auto Insurance Fraud Comes in All Shapes and Sizes

Filed under Auto Insurance Fraud, Insurance

Cyberinsurance Not A Cure-All For Data Breaches

Recent news stories have left auto insurance companies keeping a wary eye toward hackers. Cyberthieves can hack into insurance companies’ smartphone apps. Or cybercriminals can even access a car’s computer system through dongle devices used to monitor driving habits.

Unfortunately, a recent survey reveals that cyberinsurance is not a cure-all for problems created by data breaches.

But the report, which was compiled by insurance analytics company Advisen Ltd. and data response firm ID Experts from a survey of 203 risk-management professionals, offers advice for companies seeking cyberinsurance.

Cyberinsurance policies are not a one-size-fits-all solution. The report said cyberinsurance is designed to protect companies in case of “low-frequency but high-severity” attacks affecting thousands of electronic records. But the costs of most data breaches fall below deductibles in many companies’ policies. That may not be a problem for larger companies, but experts say the costs could be significant for smaller companies.

“Cyberinsurance is by no means intended to be a one-size-fits-all solution,” Greg Podolak, head of Saxe Doernberger & Vita’s cyber-risk practice, told Law360.

Companies should negotiate retroactive coverage. The report urges companies to negotiate cyberpolicies with favorable retroactive coverage. That way the company is covered in case it suffered an undetected breach before obtaining the policy.

“The report alludes to the fact that some policyholders are breached before they even know it,” Anderson Kill shareholder Joshua Gold told Law360.

Be aware of coverage gaps. Companies could still be responsible for part of the bill, even if the data breach was serious enough to trigger cyberinsurance coverage, according to the report. Company losses could follow under common exclusions included in cyberpolicies. Such exclusions may include lost business or profits as a result of bad press following a data breach.

Some insurance companies such as AIG are beginning to specialize in difference in conditions (DIC) insurance to cover policy gaps. “That type of DIC policy basically sits over traditional property insurance,” K&L Gates partner Roberta Anderson told Law360.

An even newer emerging market is insurance covering a company’s reputational harm following a data breach.

The IT department shouldn’t tackle a data breach alone. The report said 60 percent of the companies surveyed said their IT departments act alone in handling data breaches. But Podolak said a response should be multidisciplinary: “It’s not just an IT problem.”

The report urges using breach-response vendors to manage forensic analysis, notification about the data breach and public relations. “That will help the company mitigate its overall exposure and harm to their brand and reputation,” Anderson added.

Click here to view full article.

Comments Off on Cyberinsurance Not A Cure-All For Data Breaches

Filed under Insurance, Technology

Drones Used to Detect Insurance Fraud

On August 4, 2015, WFLA News Channel 8 showcased private investigator Paul Colbert’s methods of hunting down workers compensation fraud suspects through the use of the most cutting-edge technology of our time, remote robotic cameras and drones.

According to WFLA, Colbert has witnessed first hand how beneficial this technology has proven to be. These built-in “hidden cameras” have the ability to detect motion, follow targets and even zoom in without the touch of a button. Colbert showed live video clip feeds of “disabled” workers throwing footballs, doing yard work, walking around without assistance and even lifting heavy loads after claiming they were far too “disabled” to attempt such things. According to Colbert, these false claims are sheer examples of incidents that these machines are aimed at eradicating. Every year workers compensation fraud costs each of us $1,000 to promote as a deterrent to such fraudulent acts per industry statistics.

Colbert understands that his surveillance approach can seem very unconventional, but believes this breakthrough technology can have the capacity to save companies thousands of dollars on fake or exaggerated workers compensation injury claims.

Please click here for the full story.

www.roiglawyers.com

Comments Off on Drones Used to Detect Insurance Fraud

Filed under Insurance Fraud

Details Emerge on Unlicensed Clinics Behind $243K in PIP Fraud

The FLPIPGuide previously reported that Dr. Lherisson Domond, 82, was arrested earlier this year for acting as the straw owner of Unity Pain and Injury Center in Orlando. The Florida Division of Insurance Fraud (DIF) recently revealed that Domond also fronted as the straw owner of Blesscare Chiro Center, also in Orlando.

Blesscare, an unlicensed clinic, was operated by Fortunard Dieuveillant Fonrose, 42. Medical billings totaling in excess of $86,000 were generated between May 2012 and November 2014 under Fonrose’s management, according to DIF reports.

Domond was behind the unlicensed Tamarac clinic of J.J. Health & Wellness also, according to DIF. Jonas Fils, 52, and Obinson Louis, 37, were reportedly the real owners of the clinic, which illegally billed almost $72,000 from May to September of 2013.

Keeping with the pattern of interconnections, Louis also operated the unlicensed Oakland Park clinic of Innovative Medical Rehab Center.

Overall, seven individuals were arrested for the fraudulent operation of the four unlicensed medical clinics.

The clinics were behind personal injury protection (PIP) fraud schemes responsible for more than $243,000 in illegal billings. DIF investigations are on-going, and additional arrests are expected.

Comments Off on Details Emerge on Unlicensed Clinics Behind $243K in PIP Fraud

Filed under Insurance Fraud

Sales of Fraudulent Life Insurance Policies Leads to Pompano Beach Arrest

A Pompano Beach woman who sold fraudulent life insurance policies to elderly military veterans and their families has been arrested and charged with insurance fraud, according to an April 1 announcement by Florida’s Chief Financial Officer, Jeff Atwater.

Patrice Sands sold the policies to members of Make-A-Wish Veterans, Inc., a Miami company providing assistance to veterans. According to investigators, Sands sold the policies, collected premiums, and deposited those premiums into a bank account tied to her business, Universal Research Group Insurance Agency. She never actually procured the policies, however.

When her husband died, one 84-year-old victim attempted to collect the death benefits due her under the policy she had purchased from Sands. No benefits were received, however, and Sands told the widow that the insurance company had “gone under.” Sands then sought return of the life insurance certificate and allegedly destroyed it. A check written by Sands to refund the woman’s premiums bounced due to insufficient funds.

If convicted, Sands faces up to 25 years in prison and the suspension of her insurance agent license.

Since July 2014, the Division of Insurance Fraud has arrested 59 insurance agents, bail bond agents, and public adjusters for fraud that has totaled almost $4.5 million dollars.

Comments Off on Sales of Fraudulent Life Insurance Policies Leads to Pompano Beach Arrest

Filed under Insurance Fraud

Four Arrested in Medicaid Fraud Scam Targeting Orlando Homeless

The Florida Attorney General’s Office announced on March 20, 2015 that four people have been arrested for Medicaid fraud. Homeless people were allegedly recruited to pose as patients in the Orlando fraud scheme, frequently in exchange for gas cards and temporary housing.

The defendants in the case are identified as follows:

  • Christina Benson, arrested in Georgia
  • Demetrious Davis, arrested in Florida
  • Harold Harrison, arrested in North Carolina
  • Dr. Sabiha Khan, arrested in Florida

Each individual faces at least one count of Medicaid Provider Fraud and one count of Organized Scheme to Defraud.

According to the investigation, Christina Benson, owner of Tranquility Healthcare Solutions in Orlando, billed Medicaid up to $3.2 million for psychosocial rehabilitation services that were neither warranted nor provided in a period of just 18 months. The announcement cited fraudulent payments of $215,000.

The company claimed to have worked with a local doctor, Sabiha Khan, as a treating provider, but many recipients said they had never met her. Additionally, untrained personnel—including some with criminal records—were allegedly used to deliver some services.

Click on the link for the Florida Attorney General announcement.

Comments Off on Four Arrested in Medicaid Fraud Scam Targeting Orlando Homeless

Filed under Insurance Fraud

1st DCA Upholds Allstate Use of Medical Fee Schedules

In an opinion filed March 18, 2015, Florida’s First District Court of Appeal held that language in an Allstate Insurance Co. policy gave sufficient notice to an assignee of its election to use Medicare fee schedules to limit benefit reimbursements under a PIP policy. Stand-Up MRI of Tallahassee, an assignee of 14 named insureds, sued Allstate in county court, contending that Allstate’s alleged failure to give adequate notice was contrary to the Florida Supreme Court’s decision in Geico v. Virtual Imaging. The trial court agreed with Stand-Up MRI and certified a question of great public importance to the Appellate Court.

In Virtual Imaging, as here, an MRI provider had supplied services and then disputed the insurer’s authority to limit reimbursements under Medicare fee schedules. Pursuant to the Florida PIP statute, automobile insurers are required to provide PIP coverage for 80 percent of all “reasonable expenses” for medically necessary services.

The dispute here centers on whether Allstate’s policy language provided adequate notice of its election to limit reimbursements via the Medicare fee schedules or if, as Stand-Up MRI contends, the policy fails because it is ambiguous. Allstate points to the following language in the policy as having satisfied the Virtual Imaging notice requirement:

In accordance with the Florida Motor Vehicle No-Fault Law, [Allstate] will pay to or on behalf of the injured person the following benefits. . . .

Medical Expenses

Eighty percent of reasonable expenses for medically necessary … services. …

Any amounts payable under this coverage shall be subject to any and all limitations, authorized by section 627.736, or any other provisions of the Florida Motor Vehicle No-Fault Law, as enacted, amended or otherwise continued in the law, including, but not limited to, all fee schedules.

The appellate court agreed with Allstate, concluding that the policy gives sufficient notice of its election to limit reimbursements by use of the fee schedules. In making its decision, the court pointed to language in the policy stating that reimbursements “shall” be subject to the limitations of §627.736, including “all fee schedules.”

Section 627.736(5)(a) 2 refers to Medicare fee schedule-based limitations and provides that insurers “may limit reimbursement to 80 percent of the … schedule of maximum charges.” Thus, concluded the court, the notice requirement was satisfied by Allstate’s language limiting “any amounts payable” to the fee schedule-based limitations found in the statute.

Furthermore, the court also distinguished the language in Allstate’s policy from that found deficient in Virtual Imaging. There, the Florida Supreme Court concluded that Geico’s policy failed to “indicate in any way” that it intended to limit its reimbursement amounts using the fee schedules. Here, Allstate’s policy expressly limits reimbursements by “all fee schedules” in the statute, satisfying the Virtual Imaging notice requirement.

Stand-Up MRI also contended that Allstate’s use of the phrase “subject to . . . all fee schedules” fails to provide sufficient notice that reimbursements will always be limited by the fee schedules, arguing that “subject to” means only that Allstate had the option to limit reimbursements per the Medicare fee schedule , not that it would so limit reimbursements. The court, however, found no such ambiguity, stating that the language of the policy makes reimbursements subordinate to the fee schedule in “rather unmistakable terms.”

In sum, the court concluded that Allstate’s policy language gave legally sufficient notice to its insureds of its election to use the Medicare fee schedules as required by Virtual Imaging. The trial court’s decision was reversed and the case remanded for further proceedings.

The cases cited are listed below for reference.

Allstate Fire and Casualty Ins. v. Stand-Up MRI of Tallahassee, Case No. 1D14-1213, et al., 1st DCA Fla. (March 18, 2015).

Geico Gen. Ins. Co. v. Virtual Imaging Servs. Inc., 141 So. 3d 147 (Fla. 2013).

Comments Off on 1st DCA Upholds Allstate Use of Medical Fee Schedules

Filed under Fla. Stat. 627.736 (2012), The Statutory "Fee Schedules"

Miami Health Care Fraud Scheme Results in 14 Arrests

A $13.9 million fraud scheme involving a network of medical clinics resulted in the arrest of 14 Miami-Dade County residents on March 11, according to the U.S. Attorney’s Office for the Southern District of Florida.

As readers of the FLPIPGuide.com know, our coverage of medical clinics typically relates to PIP fraud. In this case, however, the named medical clinics allegedly intended to defraud health care insurers and employer-sponsored plans.

The following individuals were charged with health care fraud and conspiracy to commit health care fraud in the case of United States v. Reyna/do Castillo, et al.:

  • Reynaldo Castillo, 46, Hialeah
  • Hendris Castillo Morales, 33, Miami
  • Lisbet Castillo, 23, Hialeah
  • Maite Garcia, 40, Hialeah
  • Osvaldo Marin Medina, 48, Hialeah
  • Alejandro Biart, 40, Miami
  • Alejandro Jesus Cura, 47, Miami
  • Dania Chavez, 43, Miami
  • Ezequiel Severo Casas, 28, Hialeah
  • Humberto Martinez Rodriguez, 43, Hialeah
  • Jose Gerardo Gonzalez, 23, Miami
  • Julio Suarez, 47, Miami
  • Nelson Ramos, 56, Miami
  • Reinaldo Cinta Gonzalez, 46, Miami
  • Rudy N. Dominguez, 25, Hialeah
  • Diulys Martinez, 39, Miami

As many as 30 medical clinics based in Miami, Hialeah, Hialeah Lakes, and Doral, Fla. were owned or controlled by Reynaldo Castillo, Hendris Castillo Morales, Lisbet Castillo Batista, and Maite Garcia, according to the indictment.

Physician names and licensing information obtained through medical staffing companies was allegedly misappropriated to conceal the actual clinic ownership. Additionally, some of the individuals charged were paid fees in exchange for the use of their names as fronts for corporate ownership, bank accounts, and check cashing privileges.

Insurance companies Cigna, Blue Cross Blue Shield (BCBS), and United Health Care (UHC) were affected by the scam. Several self-insured employers whose insurance plans were managed by the three carriers were also the target of fraud, including:

  • Miami-Dade Public Schools
  • City of Miami
  • Pepsi Co.
  • BJ’s Wholesale Club
  • Macy’s
  • Nextera Energy
  • Radioshack
  • Sodexo

False and fraudulent claims totaling $125.7 million were submitted to the insurance carriers and employer plans, of which $13.85 million was paid. Many of the claims were for treatments that were not ordered by a physician or services that were never delivered.

The indictment also alleges that Reynaldo Castillo, Lisbet Castillo Batista, and Hendris Castillo incorporated an investment company to receive proceeds from the clinics and used those proceeds to purchase real estate properties. Those properties are subject to criminal forfeiture.

In a companion case, United States v. Ernesto Castillo, Osvaldo Marin Medina, Alejandro Biart, Ernesto Castillo, 43, of Hialeah, and Danny Jacomino Bordon, 50, of Miami were charged with health care fraud for causing Amazing Medical Services, Inc., Serenity Rehabilitation Center, Inc., and World of Rehabilitation Therapy, Inc. to submit false claims to Cigna totaling approximately $5.1 million, which resulted in payments to the three companies of approximately $1.1 million.

Jose Gerardo Gonzalez, Reynaldo Castillo, Ezequiel Severo Casas, and Danny Jacomino Bordon remain at large.

Click on the link to read the news release issued by the U.S. Attorney’s Office for the Southern District of Florida.

Comments Off on Miami Health Care Fraud Scheme Results in 14 Arrests

Filed under Insurance Fraud