Category Archives: Personal Injury Protection (PIP)

Florida Doctor Arrested for Allegedly Defrauding Nine Auto Insurers

According to a statement from the Florida Department of Financial Services, Dr. Celestino Santi was arrested for allegedly defrauding nine auto insurance companies our of more than $500,000 in unlicensed medical billing.

Investigators reveal that Santi was allegedly acting as a “straw owner” of Accident Care Center of Boggy Creek to disguise the identity of the unlicensed, true owner of the motor vehicle accident medical treatment center.

Click here to read the article.

Filed under Fraud, Personal Injury Protection (PIP)

Three Miami Arrests in Physical Therapy Clinic PIP Fraud Scheme

Three individuals from the Miami physical therapy clinic Professional Medical Practice have been arrested in an alleged personal injury protection (PIP) fraud scheme. The clinic owner Alean Machado, recruiter Barbarito Leyva-Claro, and physical therapist Yoandra Rodriguez-Pena were charged with Insurance Fraud, Grand Theft, Patient Brokering and Organized Scheme to Defraud.

An undercover investigation uncovered the scheme which paid $2,500 for patients that participated in the fraudulent physical therapy sessions. Two insurance companies were billed over $39,000 in fraudulent claims from the clinic. Machado, Rodriguez-Pena and Leyva-Claro could face up to 45 years in prison if proven guilty.

Click here to read the article.

Filed under Fraud, Personal Injury Protection (PIP)

Florida CFO Jimmy Patronis says a Quarter of Pedestrian Accidents in 2018 are Faked

According to Florida Chief Financial Officer Patronis, “In 2018, there were 9,300 pedestrian crashes and of those, an estimated 25 percent were staged.”

Click here to read the article.

Filed under Fraud, Personal Injury Protection (PIP)

How Billing Processes of Florida Medical Providers for PIP Claims are Affected by the Thirty Third Amendment to Regulation 83 Under New York-Based Insurance Policies

The New York State Department of Financial Services (“DFS’) has finalized the Thirty-Third Amendment to Regulation 83 (the “33rd Amendment”), which was published in the State Register on October 25, 2017 and will affect treatment rendered on or after January 23, 2018. Pursuant to the accompanying press release, the 33rd Amendment is designed to “limit the amount that insurers can reimburse for healthcare services performed outside of New York State under its no-fault insurance law.”[1] By limiting reimbursement amounts for out-of-state no-fault healthcare services, which are treating New York State (“NYS”) residents, the DFS intends to “curb costs and abuses” by out-of-state medical providers charging excessive rates.[2].

Regulation 83, governing the reimbursement of out-of-state providers, previously provided that:

“If a professional health service is performed outside New York State, the permissible charge for such service shall be the prevailing fee in the geographic location of the provider.” (11 NYCRR § 68.6).

The case of Surgicare Surgical Assoc. v National Interstate Ins. Co., 2014 WL 6610048, 2014 N.Y. Slip Op. 24362) (Anthony Cannataro, J.), provides a good example of an out-of-state provider seeking reimbursement at an exorbitant rate, diminishing the coverage available to the insured for other medically necessary services. There, the provider performed arthroscopic surgery on a covered person in New Jersey and submitted a claim for reimbursement under the applicable New York No-fault policy. Although the state of New Jersey has a fee schedule that applies to the reimbursement of medical services under the New Jersey’s No-fault law, the provider submitted a bill to the insurer for approximately $5,000 more than the amount it would have been reimbursed had the claim involved a New Jersey auto policy and as a result, was governed by the New Jersey fee schedule. The insurer reimbursed the amount permitted under the New Jersey fee schedule, essentially maintaining that, pursuant to Regulation 83, the New Jersey fee scheduled reflected the permissible amount in the geographic area. The provider sued for the difference. After discussing the applicable regulations and policy considerations behind the enactment of the New York No-fault law, including the legislative intent of cost containment, a New York City Civil Court judge held that, “when services are rendered outside of New York but in a jurisdiction which utilizes a fee schedule, the insurer complies with Section 68.6 by paying the ‘permissible’ charge for that particular medical service, that is, the amount permitted by that jurisdiction’s fee schedule.” The provider appealed and the Appellate Term affirmed. See Surgicare Surgical Assoc. v National Interstate Ins. Co., 2015 NY Slip Op 25338 (App. Term 1st Dept. 2015).

In other instances, the amount sought by out-of-state providers has been tens of thousands of dollars above the amount that would be permitted under the New York Fee Schedule. Recognizing the potential for fraud and abuse, the Amendment provides an effective solution to the exploitation of the No-fault system by out-of-state providers and, adopts, to some extent, the holding in Surgicare and, by regulation, strengthens the limits placed on reimbursement of such providers. Specifically, the Amendment states:

11 NYCRR 68.6: Health services performed outside New York State

(a)(1) If a professional health service reimbursable under [section 5102(a)(1) of the] Insurance Law section 5102(a)(1) is performed outside this State, the amount that the insurer shall reimburse for the service shall be the lower of the amount charged by the provider and the prevailing fee in the geographic location of the provider with respect to services:

(i) that constitute emergency care;

(ii) provided to an eligible injured person that is not a resident of this State; or

(iii) provided to an eligible injured person that is a resident of this State who, at the time of treatment, is residing in the jurisdiction where the treatment is being rendered for reasons unrelated to the treatment.

(2) For purposes of this subdivision, emergency care means all medically necessary treatment initiated within 48 hours of a motor vehicle accident for a traumatic injury or a medical condition resulting from the accident, which injury or condition manifests itself by acute symptoms of sufficient severity such that absence of immediate attention could reasonably be expected to result in: death; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part.  Medically necessary treatment shall include immediate pre-hospitalization care, transportation to a hospital or trauma center, emergency room care, surgery, critical and acute care.  Emergency care extends during the period of initial hospitalization until the patient is discharged from the hospital.

(b) Except as provided in subdivision (a) of this section, if a professional health service reimbursable under Insurance Law section 5102(a)(1) is performed outside this State with respect to an eligible injured person that is a resident of this State, the amount that the insurer shall reimburse for the service shall be the lowest of:

(1) the amount of the fee set forth in the region of this State that has the highest applicable amount in the fee schedule for that service;

(2) the amount charged by the provider; and

(3) the prevailing fee in the geographic location of the provider.

(c) If the jurisdiction in which the treatment is being rendered has established a fee schedule for reimbursing health services rendered in connection with claims for motor vehicle-related injuries and the fee schedule applies to the service being provided, the prevailing fee amount specified in subdivisions (a) and (b) of this section shall be the amount prescribed in that jurisdiction’s fee schedule for the respective service.

The 33rd Amendment separates treatment by out-of-state medical providers into the following two categories:

  1. Out-of-state medical services, which (a) constitute emergency care[3], (b) are provided to non-NYS residents, and (c) are provided to patients with a NYS domicile, who are currently living in the state where the treatment is being rendered, for reasons unrelated to the accident.
  2. Out-of-state medical services provided to a NYS resident, currently living in NYS.

There is one main difference between the two categories – which State’s no-fault fee schedule governs and must be utilized by the insurer when reimbursing the medical provider. Simply put, if the medical services fall into Category 1, the medical provider’s reimbursement will be capped at the No-Fault Schedule rate for the State and region wherein the services are provided. By contrast, if the medical services fall into Category 2, the medical provider’s reimbursement will be capped at the highest rate available under the New York State No-Fault Fee Schedule unless the State where the treatment is being rendered has an established fee schedule for claims related to motor vehicle-related injuries.

As such, section (c) of 11 NYCRR 68.6 would apply to medical services rendered in Florida as there is an established set of fee schedules within the Florida No-Fault Law. While the foregoing may be the general rule, there are nuances requiring attention.

The reimbursement rate for medical services is now capped at the prevailing fee in the geographical location of the provider unless the provider charges less. Thus, the 33rd Amendment now limits the prevailing geographical rate to that area’s local No-Fault Fee Schedule Rate. In other words, if x-ray services are performed in Miami, Florida the provider’s reimbursement is limited to the schedule of maximum charges as listed in the Florida No-Fault law for that geographical region (Miami) (i.e, 200% of Medicare Part B).

The medical providers and insurers also need to be familiar with the amendment’s definition of what constitutes “emergency care”’ and how it relates to reimbursement.

Example 1: If a person is transported to the Hospital as a result of a motor vehicle accident in Florida and that person lives in Florida but is covered by a New York policy, then that Hospital provider’s charges would be limited to 75% of the usual and customary charge pursuant to the Florida No-Fault Law’s schedule of maximum charges. Moreover, the emergency services doctor would be paid at its usual and customary charge which is generally the submitted charge.

Example 2: Compare to the facts that this same individual is involved in a motor vehicle accident in Florida on January 1, 2019 and is not transported to the Hospital. However, three days later they decide to go to the emergency room due to having neck and back pain related to the accident. Would these Hospital and physician services now be considered “emergency care”?  Under this amendment, it would not because the treatment was not initiated within 48 hours following the accident.

Now further compare these facts with the applicable schedule of maximum charges under Florida Statute §627.736(5) (2018) which states in pertinent part:

The insurer may limit reimbursement to 80 percent of the following schedule of maximum charges:

a. For emergency transport and treatment by providers licensed under chapter 401, 200 percent of Medicare.

b. For emergency services and care provided by a hospital licensed under chapter 395, 75 percent of the hospital’s usual and customary charges.

c. For emergency services and care as defined by s. 395.002 provided in a facility licensed under chapter 395 rendered by a physician or dentist, and related hospital inpatient services rendered by a physician or dentist, the usual and customary charges in the community.

d. For hospital inpatient services, other than emergency services and care, 200 percent of the Medicare Part A prospective payment applicable to the specific hospital providing the inpatient services.

e. For hospital outpatient services, other than emergency services and care, 200 percent of the Medicare Part A Ambulatory Payment Classification for the specific hospital providing the outpatient services.

In the situation listed in Example 2, the patient’s condition would not be considered “emergency care” and thus, payment would be made at 200 percent of the Medicare Part A prospective payment applicable to the specific hospital providing the inpatient services or 200 percent of the Medicare Part A Ambulatory Payment Classification for the specific hospital providing the outpatient services.


In order to maximize recovery without running afoul of the new fee schedule mandates of the 33rd Amendment, Florida medical providers treating patients covered by New York No-Fault policies must be cognizant of whether the service rendered meets the definition of “emergency care.” What this amendment does clarify is that if medical services are rendered in Florida under a PIP claim brought under a New York policy, then the maximum amount to be paid to the medical providers for these services would be limited to Florida’s schedule of maximum charges.

[1] Press Release, posted October 10, 2017,

[2] Id.

[3] Under the 33rd Amendment, in order to constitute emergency care, the treatment must be initiated within 48 hours of the motor vehicle accident.

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 law issues that require attention.

For additional information, please contact Stephen Mellor of Roig Lawyers at 954-354-1541 or by email at 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. 

Filed under Personal Injury Protection (PIP)

IIHS Confirmed Tesla’s Claims About Reducing Injury Liability Claims with Autopilot

The Insurance Institute for Highway Safety (IIHS) has confirmed Tesla’s claim that its Autopilot and active safety features result in ‘fewer physical damage, injury liability claims.’ However, IIHS also found that the introduction of these features could increase other kinds of claims.

The combined driver assistance features on the 2014–16 Model S lowered the frequency of claims filed under property damage liability (PDL) and bodily injury (BI) liability coverage with the 2012–14 Model S without the technology. However, IIHS didn’t find that they lowered the frequency of collision claims. They also saw increases in MedPay and PIP claims.

Highway Loss Data Institute’s senior vice president, Matt Moore, admits that they would need more data to really understand the effect of Autopilot.

Click here to read the article.

Filed under Personal Injury Protection (PIP)

Pending PIP Litigation on the East and West Coasts Could Impact States In Between

PropertyCasualty360 published a report about pending automobile personal-injury litigation in California and New York that could have a lasting impact if the decisions spread to other jurisdictions. Courts will determine allowable evidence for suits involving these insurance claims.

East Coast

In New York, insurers investigated radiologist Andrew Carothers, a suspected illegal straw owner after he filed 20,000 lawsuits against auto-insurance carriers. After insurers refused to pay Carothers, he flooded the state’s courts with more than 20,000 lawsuits seeking collection for unpaid “services.” The civil cases were consolidated, and the jury agreed Carothers was fraudulently engaged in the corporate practice of medicine. The Appellate Division affirmed, so Carothers went to the New York Court of Appeals, where the case awaits a decision.

A favorable decision can deter scams like Carothers’ in other states that forbid the corporate practice of medicine. Fraudsters who often quickly expand operations to line their pockets in other states could be deterred. A decision is expected in 2019.

West Coast

Dave Pebley was involved in a serious vehicle accident, sought medical care and filed suit. He had health coverage but decided not to submit his bills for payment. That is because, under California law, the jury would only hear about the amount paid by his health insurer as the measure of his medical expense while Pebley was billed at the top rate for medical services by refusing to use his health insurance.

The insurer cried foul, asserting that such actions mislead the jury, and are fraudulent because medical providers never expect to receive such high payments. They argued the plaintiff may present the higher medical bills but must provide expert testimony to prove the charges are fair and reasonable. Similarly, the defendant or their insurer may present counter-evidence as to what the health providers normally accept for payment of those services.

The California Second District Court of Appeal reasoned that juries should be allowed to ultimately decide the appropriate charge for the medical services. Parties are lining up to support an appeal of the case to the state Supreme Court. If Pebley succeeds in California, potentially winning the $3.6 million he seeks, the strategy of refusing to use health insurance can be expected to spread rapidly to other states.

Click here for full article.

Filed under Fraud, Personal Injury Protection (PIP)

Appeal Court Backed Air Ambulance Firm in PIP Dispute

The 11th U.S. Circuit Court of Appeals backed air-ambulance firm Air Methods Corp. in a dispute stemming from a traffic accident that resulted in the death of accident victim Lemar Bailey about whether the amount paid for helicopter services should be limited by Florida’s no-fault auto insurance law. The federal appeals court ruled that the air-ambulance firm is considered an air carrier under federal law and should be able to bill the child’s father, Lenworth Bailey, for costs that exceeded the limits in the state’s no-fault system.

Following the March 2013 accident, Air Methods Corp. billed $27,975 for its services. Bailey’s auto insurer, State Farm Mutual Automobile Insurance Co., paid $6,911 under the fee schedule. His health insurer, Aetna Life Insurance Co. paid another $3,681. However, Bailey did not pay the remaining balance of nearly $17,400. He filed a potential class-action lawsuit alleging that the air ambulance company was trying to improperly collect amounts in excess of the fee schedule. However, the judge ruled in favor of the Air Method, which led Bailey to the appeals court that also rejected such arguments.

Click here to view the full article.

Filed under Legislation, Personal Injury Protection (PIP)

UPDATE: Ringleader Pleads Guilty To His Role In $23 Million Auto Insurance Fraud Crime Ring

Andrew Rubinstein of Miami and the self-confessed ringleader, Felix Filenger of Sunny Isles pleaded guilty to a racketeering conspiracy charge last year. Rubinstein and Filenger were paying kickbacks to tow truck drivers and body shop workers who illegally steered accident victims to chiropractic clinics they owned at a rate of $1,500 to $2,000 per “patient.” Clinic workers would then have patients attend multiple visits, document exaggerated pain levels, and bill insurance providers for treatment in the amount of $10,000, the maximum allowed under Florida law.

According to Prosecutors, the clinics were located throughout south and central Florida, including Sunrise, Hollywood, Hallandale Beach, Pompano Beach, Delray Beach, West Palm Beach, Miami, Orlando and Kissimmee.

Under the terms of his plea agreement, both sides had agreed to recommend the six-year sentence for Rubinstein. Filenger’s sentencing has been postponed. Several other people who also admitted their roles in the fraud are scheduled for sentencing later this year.

Click here to view the full article. (Previous post)

Filed under Fraud, Personal Injury Protection (PIP)

Ringleader Pleads Guilty To His Role In $23 Million Auto Insurance Fraud Crime Ring

According to the Sun Sentinel, Felix Filenger of Sunny Isles, pleaded guilty this week to his role in an elaborate crime ring that operated at several South Florida chiropractor clinics. The fraud totaled at least $23 million from 10 auto insurance companies over the last seven years, per court records.

Federal prosecutors say Filenger and Andrew Rubinstein took over troubled clinics and hid their ownership by having chiropractors and other people register the practices in their names. The men told chiropractors what treatments they wanted to be performed, based on the potential revenue from the services, prosecutors said. Medical staff who refused to “play ball” were fired, they said.

Filenger admitted he, and other group leaders, paid kickbacks of $1,500 to $2,000 – per patient – to tow truck drivers and body shop workers who agreed to illegally steer accident victims to chiropractic clinics that were secretly owned by Filenger and his allies.

Filenger plead guilty to one count of racketeering conspiracy on Monday in federal court in Miami and is scheduled to go to trial on January 8.  Two co-defendants, who are still scheduled for trial that day, may plead guilty to related charges on Wednesday, court records show.

Andrew Rubinstein, 48, of Miami, is jailed on charges of racketeering and mail fraud conspiracies, wire fraud, health care fraud, and making false statements.

Olga Spivak, 59, a chiropractor from Hollywood, is free on bond. She faces the same charges.

Click here for full article.

Filed under Personal Injury Protection (PIP)

Attorney Fee Multipliers in PIP and the Search for a Guiding Lodestar

In October 2017, the Supreme Court again addressed the issue of contingency fee multipliers to awards of attorneys’ fees. Personal Injury Protection (PIP) Plaintiff attorneys felt a tinge of delight and perhaps delayed buying their lottery tickets in hopes that this new decision will help them win an attorney fee multiplier if they prevail in a PIP suit. While HB 119 in 2012 eliminated multipliers from newer PIP lawsuits, there are still many older cases that are now being resolved which face the possibility of large awards of attorney fees going to Plaintiff attorneys. Additionally, there is no penalty for a Plaintiff attorney to attempt to pursue a multiplier, thus the key question is how to best defend against this potential windfall.

To understand the new decision in Joyce v. Federated Nat’l Ins. Co., 2017 Fla. LEXIS 2070 (Fla. 2017), it is beneficial to look back at the Florida Supreme Court’s interpretation of how and when to award a multiplier. The seminal decision regarding the applicability of multipliers is still the Quanstrom decision from 1990. Specifically, the requirements under Quanstrom necessary to find a fee multiplier are:

  1. Whether the relevant market requires a contingency fee multiplier to obtain competent counsel.
  2. Whether the attorney was able to mitigate the risk of non-payment in any way.
  3. Whether any of the factors set forth in Rowe are applicable, especially, the amount involved, the results obtained, and the type of fee arrangement between the attorney and his client. Id. at 834.

Joyce re-iterates that a market inquiry as to whether a multiplier was necessary to obtain competent counsel is the primary factor under the Quanstrom[1] requirements. This is important to PIP litigation since there are few, if any, potential PIP lawsuits that cannot find a warm and welcoming PIP attorney eager and willing to take the case.

Interestingly, the Florida Supreme Court in Joyce noted that the United States Supreme Court in 1992 revisited the issue of contingency fee multipliers in Burlington v. Dague, 505 U.S. 557 (1992), concluding that “enhancements for contingency [was] not permitted under the fee-shifting statutes at issue…[and] Justice Scalia, writing for the majority, reasoned that enhancement for contingency would likely duplicate in substantial part factors already subsumed in the lodestar.” Joyce. at 17, citing Dague at 567.

Under Joyce, the Florida Supreme Court separated itself from this federal precedent and continued to allow the use of multipliers under Florida law. The fear was that without the possibility of contingency multipliers some individuals with meritorious claims would fail to obtain competent counsel and the Florida Supreme Court noted “their usefulness in helping parties secure legal representation and their importance in ensuring access to Courts.” Id. at 17-18 citing Bell v. U.S.B. Acquisition Co., Inc., 734 So.2d 403, 411 (Fla. 1999). In other words, the Florida Supreme Court was concerned that Justice Scalia failed to consider that without a potential multiplier there is a danger of never obtaining competent counsel. Id. at 25. But with the thousands of PIP lawsuits being filed every year, can a Plaintiff truly make an argument that finding a PIP attorney is difficult?

Under Joyce, it appears that contingency fee multipliers are alive and well under Florida Law, and there are some circumstances where they are certainly warranted. Paradoxically, the best argument against the applicability of multipliers to the majority of PIP lawsuits comes from the Joyce opinion itself. The majority opinion which intentionally diverged from federal precedent on multipliers in order to preserve access to courts appears to have absolutely no concern about whether prohibiting multipliers in PIP lawsuits somehow prevents individuals from obtaining fair access to courts or diminishes one’s ability to obtain competent counsel. The dissent also argues that PIP litigation suffered no decrease in volume after HB 119 and that there was no negative impact on an insured’s ability to obtain counsel in PIP cases. Id. at 40-41. The dissent even cites the Plaintiff’s own expert testimony that there is no lack of attorneys willing and able to take PIP cases and “that same fee expert begrudgingly ‘hate[d]’ to admit that plaintiffs’ attorneys throughout the entire State of Florida are abundantly motivated to take PIP cases (even though PIP cases contain no possibility of a multiplier).” Id. at 42.

The majority opinion in Joyce actually agreed with the dissent that PIP litigation is different because of the number of attorneys willing to take PIP lawsuits. The majority opinion notes that PIP should not be compared to other types of first-party litigation since, “the fact that there are attorneys who specialize in PIP claims, which can be handled with relative ease in a volume practice, does not correlate with the availability of competent attorneys who are willing to litigate other types of insurance coverage cases, where generally more complex issues are raised.” Id. at 25. Clearly, the majority opinion is willing to differentiate PIP lawsuits from other types of first-party litigation due to the ease of obtaining a competent attorney.

Ultimately, none of the Quanstrom factors changed with the recent Joyce decision. However, the new opinion does provide an excellent analysis and justification as to how multipliers developed under Florida law and why the Supreme Court continues to think multipliers are necessary to ensure fair and equal access to the courts. It is important to keep in mind that Joyce does not mean a PIP lawsuit can never justify a multiplier. In fact, the Quanstrom decision is a PIP lawsuit[2]. Understanding the best way to contest aggressive attempts to collect fee multipliers and create an appropriate record at the trial court level remains important in PIP litigation.

[1] Standard Guaranty Insurance Co. v. Quanstrom,555 So.2d 828 (Fla. 1990)
[2] Other notable PIP lawsuits have been awarded multipliers after there was substantial and competent evidence to justify that a multiplier was necessary.  See  State Farm Fire & Casualty Co. v. Palma, 555 So.2d 836 (Fla. 1990)

If you have any questions on this issue, please feel free to contact our Insurance Services Team at

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 seven 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.

Filed under Personal Injury Protection (PIP), Uncategorized