Scott Novick, owner of pain clinics in Palm Beach, Broward and Miami, was sentenced to six and a half years in prison and forfeit almost $1.4 to Medicare. Novick pled guilty to conspiracy to commit health-care fraud resulting in Medicare losses in the amount of $2.2 million. He was sentenced to six and a half years in prison and ordered to forfeit $1.4 million to Medicare.
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Filed under Fraud, Healthcare
Washington-based policy and research group, Coalition Against Insurance Fraud, has awarded its inaugural journalism award for fraud reporting to The Palm Beach Post for its work on fraud in the sober-home industry. The award honored Post coverage dating back to 2015 when Post investigators Christine Stapleton and Pat Beall first wrote about how sober-home operators were defrauding insurers of millions of dollars for urine drug tests.
Sober homes were requiring residents to be tested every day, creating multimillion-dollar business empires. Palm Beach County treatment centers and affiliated labs were charging as much as $2,000 for urine tests that can be purchased for $25 at a drug store.
In 2016, a team of Post reporters and editors, including Stapleton, Beall, Lawrence Mower, Joe Capozzi, John Pacenti, Barbara Marshall and Mike Stuck produced “Heroin: Killer of a Generation,” a 12-page special section of stories about 216 men, women and teenagers who died of a heroin-related overdoses in Palm Beach County in 2015. One in 10 had died in a sober home.
The Post’s reporting played a role in the prosecution of sober-home operators Kenneth Chatman and Eric Snyder as well as the successful push to tighten state laws which have resulted in more than 40 people on charges related to brokering patients.
Congratulations to the Palm Beach Post on this national recognition for their work in fighting insurance fraud.
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Filed under Uncategorized
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.
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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 Uncategorized
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 Healthcare
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 Healthcare
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 Uncategorized
According to Law360, a surge in demand for product liability insurance will become a trend as advances in autonomous car technology continues to increase. These autonomous cars are removing humans from the equation, resulting in liability for accidents being shifted away from the drivers and toward the manufacturers of driverless vehicles and their hardware and software systems.
Questions regarding who would be held liable in crashes involving self-driving cars arose after a fatal accident in May involving a Tesla Model S that was equipped with partially autonomous braking and steering features. Although Tesla did state that the Model S brakes were to blame for the crash, not the autopilot feature, this event continues to attract concern from regulators and consumers.
“Experts say that as autonomous cars become more sophisticated and require less human input, the manufacturers of self-driving vehicles and their components will face more liability for accidents while individual drivers will face less.”
Subsequently, personal auto insurance pricing is expected to decrease significantly due to the decline in driver liability, while auto manufacturers and suppliers will see an increase in price for their product liability coverage.
“The entire auto insurance industry may be radically changed,” Pillsbury Winthrop Shaw Pittman LLP partner Peter Gillon said. “Drivers are the real risks these days and not the cars. The more you take driver error out of the equation, the more you are looking at an auto insurance market based on safety system performance and product liability.”
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Friday the Centers for Medicare and Medicaid Services extended a temporary ban on nonemergency ambulance and home health care agencies throughout six states, including Florida, as a continued effort to fight fraud.
In continuing the ban on nonemergency ambulance services, the ban on new emergency ambulance services was lifted. The ban, originally only implemented in Miami, Chicago and Houston, was expanded in January of 2014 to combat fraud in other metropolitan areas seen as fraud hotbeds, specifically in Michigan, Pennsylvania and New Jersey. The ban has been expanded for additional six months after being in place for three years so far.
According to CMS, Texas, Florida and Illinois are in the lower third for number of patients per home health care provider. Despite this statistic, these three states have the highest number of home health care providers according to CMS data.
Shantanu Agrawal, CMS’ deputy administrator for program integrity commented on the program:
CMS is continuing its efforts to tackle fraud, waste, abuse and protect benefits and services for those eligible for federal health care programs. . . CMS is also increasing its oversight efforts through the use of heightened screening and investigative tools for new providers in the moratoria areas.
According to the National Health Care Anti-Fraud Association, as much as $60 billion is lost due to fraud, waste and abuse of the federal health care programs.
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GEICO won a sanctions request in Florida federal court against a Mississippi auto repair shop and its law firm. U.S. Senior District Judge Gregory A. Presnell ruled that GEICO’s Motion for Attorney Fees was “meritorious” and ordered the insurance company to prepare a specific fees request.
Clinton Body Shop and its law firm, John Arthur Eaves Attorneys, lost a summary judgment in a related suit charging GEICO with unjust enrichment and tortious interference with business relations. GEICO said that the summary judgment victory in that previous case barred the body shop from reasserting those same claims. The federal judge in the Middle District of Florida agreed.
“Any reasonable attorney or claimant would have known what is one of the most fundamental principles of our legal system: that a claim or issue, once litigated to a final adjudication, cannot be relitigated,” GEICO said in its motion. “(R)efiling of the same claims they lost to GEICO three months earlier in another case is automatically bad faith, warranting sanctions.”
Clinton’s argument was that the two suits involved separate entities: the first against GEICO Insurance Co., the latter against GEICO General Insurance.
The case is part of multidistrict litigation in which repair shops in 10 states are accusing several insurance companies of violating the Sherman Antitrust Act by colluding to keep reimbursement rates low for auto body repair work.
Presnell had dismissed Clinton’s claims against GEICO in May before granting sanctions on July 19.
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