Mealey's Insurance Fraud

  • October 17, 2019

    Evidence Demonstrated Man’s Intent To Submit False Prescriptions, Judge Says

    NEW HAVEN, Conn.  — A federal judge in Connecticut on Oct. 16 denied a man’s motion for acquittal following his conviction on two counts of health care fraud, ruling that the evidence presented during a February trial sufficiently supported the jury’s decision that the defendant intended to defraud insurance companies when submitting prescriptions to a compounding pharmacy in Mississippi using a prescription endorsed by a photocopy of a physician’s assistant’s signature (United States v. Kwasi Gyambibi, No. 18-cr-0136, D. Conn., 2019 U.S. Dist. LEXIS 179271).

  • October 17, 2019

    Social Security Disability Beneficiaries’ Request For Attorney Fees Denied By Judge

    PIKEVILLE, Ky. — Claims for attorney fees under the Equal Access to Justice Act (EAJA) brought by individuals whose requests for Social Security disability benefits were initially obtained through an attorney’s fraudulent scheme with doctors and an administrative law judge (ALJ) were denied Oct. 15 by a federal judge in Kentucky, who found that while they were prevailing parties, the SSA had substantial justification for seeking redeterminations of their benefits requests (Timothy L. Howard v. Andrew Saul, No. 16-051-DCR, E.D. Ky., 2019 U.S. Dist. LEXIS 177923).

  • October 16, 2019

    U.S. Attorney:  Doctor To Pay $1M For Fraudulently Billed Sinus Surgeries

    CEDAR RAPIDS, Iowa — The U.S. Attorney’s Office for the Northern District of Iowa announced Oct. 15 that an ear, nose and throat doctor agreed to pay $1 million to resolve allegations that she violated the False Claims Act (FCA) when submitting claims to insurers for 115 endoscopic sinus surgeries.

  • October 16, 2019

    Pennsylvania Appeals Panel: Circumstantial Evidence Supports Fraud Verdict

    HARRISBURG, Pa. — A Pennsylvania appeals panel on Sept. 30 upheld a woman’s conviction for insurance fraud and operating a vehicle without required financial responsibility, finding that the commonwealth presented sufficient evidence to show that the defendant provided a police officer with an expired insurance card, failed to inform the officer that she did not have an active policy when she was involved in an automobile accident and did not inform her insurer that she was in an accident when she did not have coverage (Commonwealth v. Renee M. Bruder, No. 1282 WDA 2018, Pa. Super., 2019 Pa. Super. Unpub. LEXIS 3687).

  • October 16, 2019

    Altered Prescription Was Properly Admitted, Pennsylvania Panel Rules

    HARRISBURG, Pa. — A woman’s convictions for insurance fraud and securing execution of documents by deception as well as her five-year sentence of probation was affirmed Oct. 15 by a Pennsylvania appeals panel that held that the commonwealth presented sufficient evidence to show that the defendant altered a prescription that allowed her to miss work and that she submitted it to her insurance company with an intent to defraud (Commonwealth v. Alvianette A. Kennedy, No. 3612 EDA 2018, Pa. Super., 2019 Pa. Super. Unpub. LEXIS 3582).

  • October 15, 2019

    Judge Finds That Allegations That Services Constitute Kickbacks Are Insufficient

    CHICAGO — A federal judge in Illinois on Sept. 30 dismissed without prejudice a registered nurse’s lawsuit contending that the Ambassador Program implemented by AbbVie Inc. and Abbott Laboratories Inc. as part of its promotion of Humira violates the False Claims Act (FCA), finding that the plaintiff’s allegations do not establish that services provided to physicians as part of the program constitute kickbacks (United States, ex rel. Lazaro Suarez v. AbbVie Inc. et al., No. 15 C 8928, N.D. Ill., 2019 U.S. Dist. LEXIS 169090).

  • October 14, 2019

    Insurer’s Fraud Claims Against Pharmacy Are Timely, Judge Rules

    TRENTON, N.J. — A federal judge in New Jersey on Sept. 30 denied a motion to dismiss an insurance company’s amended complaint accusing a pharmacy, its owner and its employees of engaging in a scheme to submit fraudulent claims for reimbursement, stating that there is insufficient evidence at the time to show that the company’s claims are barred by the state’s six-year statute of limitations (Horizon Blue Cross Blue Shield of New Jersey v. Focus Express Mail Pharmacy Inc., et al., No. 17-0571, D. N.J., 2019 U.S. Dist. LEXIS 171594).

  • October 11, 2019

    Judge Did Not Err When Imposing Sentence Above Guidelines, 11th Circuit Says

    ATLANTA — A federal judge in Florida did not err when ordering a man to a prison term that was 35 months above U.S. Sentencing Guidelines, an 11th Circuit U.S. Court of Appeals panel ruled Oct. 8, finding that the judge properly considered the defendant’s earlier conviction for health care fraud and that the subsequent scheme that led to the underlying indictment occurred just two months after his supervised release period ended (United States v. Alberto Romero Cuza, No. 19-10402, 11th Cir., 2019 U.S. App. LEXIS 30263).

  • October 09, 2019

    Judge Grants Insurer’s Request For Default Judgment Against Woman, Not Children

    NASHVILLE, Tenn. — A federal judge in Tennessee on Oct. 8 granted an insurance company’s motion for default judgment against a woman accused of unlawfully obtaining structured settlement benefits on behalf of a man who died in July 2004, finding that the company sufficiently stated claims for fraud, negligence and unjust enrichment and against her, but refused to enter default judgment against her children (Allstate Life Insurance Company of New York v. Cynthia Tyler-Howard, et al., No. 19-cv-00276, M.D. Tenn., 2019 U.S. Dist. LEXIS 174591).

  • October 07, 2019

    Convicted Cardiologist Denied High Court Review Of Allowance Of Experts

    WASHINGTON, D.C. — An Ohio cardiologist convicted of health care fraud lost his bid for U.S. Supreme Court consideration of his challenge to the trial court’s admission of several doctors’ expert opinions, when the high court justices denied certiorari on Oct. 7 (Harold Persaud v. United States, No. 19-216, U.S. Sup.).

  • October 07, 2019

    Judge Allows State Farm To File Amended Suit Over Fraudulent Billing

    BALTIMORE — A federal judge in Maryland on Sept. 25 denied an insurer’s motion to reconsider an earlier ruling dismissing its claims against a chiropractic clinic and chiropractors accused of submitting fraudulent bills but found that the company can file an amended complaint that satisfies the heightened pleading requirement of Federal Rule of Civil Procedure 9(b) (State Farm Mutual Automobile Insurance Co., et al. v. Carefree Land Chiropractic LLC, et al., No. 18cv1279, D. Md., 2019 U.S. Dist. LEXIS 166448).

  • September 30, 2019

    Man Accused Of Fraud Cannot Suppress Evidence From Compensation And Pension Exam

    MISSOULA, Mont. — A federal judge in Montana on Sept. 27 denied a man’s motion to suppress evidence taken from a compensation and pension (C&P) exam he underwent in order to determine the amount of disability benefits he could obtain from the Veteran Benefits Administration (VBA), finding that the admission of the information would not violate his right to due process under the Fourth Amendment to the U.S. Constitution (United States v. John Cicero Hughes, No. 18-38, 2019 U.S. Dist. LEXIS 167127).

  • September 19, 2019

    Judge:  Clinic Vice President Liable For Unjust Enrichment From Insurance Proceeds

    ORLANDO, Fla. — A federal judge in Florida on Sept. 16 granted in part an insurance company’s motion for summary judgment, finding that while it presented sufficient evidence showing that a nonphysician vice president of a chiropractic clinic was unjustly enriched by receiving reimbursements from the insurer, genuine disputes exist as to whether he knowingly intended to submit fraudulent claims to the company (State Farm Mutual Automobile Insurance Co., et al. v. Family Practice and Rehab Inc., et al., No. 18-cv-223-Orl-28LRH, M.D. Fla., 2019 U.S. Dist. LEXIS 159122).

  • September 18, 2019

    Magistrate Judge Recommends Treble Damages Against Clinic Owners On RICO Claims

    NEW YORK — A federal magistrate judge in New York on Sept. 11 recommended imposing treble damages against two clinic owners accused of operating enterprises under the Racketeer Influenced and Corrupt Organizations Act when submitting false no-fault personal injury claims to insurance companies for reimbursement, holding that the companies presented sufficient evidence showing that the defendants submitted the claims through the mail (Allstate Insurance Co., et al. v. A&F Medical P.C., et al., No. 14-cv-6756, E.D. N.Y., 2019 U.S. Dist. LEXIS 156274).

  • September 17, 2019

    Doctor’s Conviction, Amended Restitution Amount Affirmed By 5th Circuit Panel

    NEW ORLEANS — A Fifth Circuit U.S. Court of Appeals panel on Sept. 13 upheld the conviction of a Mississippi doctor who was found guilty of billing TRICARE, the health care benefit program serving U.S. military, veterans and their respective family members, and other insurance providers for prescriptions for compounded medicines containing ketamine that were written without first meeting the patient, finding that the evidence presented to the jury was sufficient to support its conclusion (United States v. Albert Diaz M.D., No. 18-60455, 5th Cir., 2019 U.S. App. LEXIS 27803).

  • September 16, 2019

    Man Sentenced To 20 Years In Prison For $37M Health Care Fraud Scheme

    MIAMI — A federal judge in Florida on Sept. 12 sentenced a man to 20 years in prison for his role in a $37 million health care fraud scheme that began in 1998 and involved bribing physicians to have patients entered into a network of assisted living facilities and skilled nursing facilities that he owned (United States v. Philip Esformes, et al., No. 16cr20549, S.D. Fla.).

  • September 13, 2019

    Panel Affirms Early Termination Of Legal Services Owner’s Probation For Fraud

    RIVERSIDE, Calif. — A California appeals panel on Sept. 12 upheld a lower court judge’s ruling granting a motion by a legal services owner to prematurely terminate his sentence for three years of probation after he pleaded guilty for his role in a workers’ compensation fraud scheme, finding that the prosecution was not deprived of the material terms of the defendant’s plea bargain (People v. Michael Angel Tuosto Jr., No. E071136, Calif. App., 4th Dist., 2nd Div., 2019 Cal. App. Unpub. LEXIS 6088).

  • September 11, 2019

    11th Circuit: New Trial Needed In Suit Debating Terminal Illness Diagnoses

    ATLANTA — An 11th Circuit U.S. Court of Appeals panel on Sept. 9 vacated a federal judge in Alabama’s sua sponte decision to award summary judgment to a nursing facility accused of submitting claims to Medicare for the treatment of elderly patients who were falsely diagnosed as terminally ill, finding that a new trial should be held that considers all of the evidence the government has to support its claim for falsity under the False Claims Act (FCA) (United States v. AseraCare Inc., et al., No. 16-13004, 11th Cir., 2019 U.S. App. LEXIS 27074).

  • September 04, 2019

    5th Circuit Affirms Man’s 70-Month Sentence For Health Care Fraud

    NEW ORLEANS — A Fifth Circuit U.S. Court of Appeals panel on Aug. 30 affirmed a man’s 70-month prison sentence he pleaded guilty to one count of conspiracy to commit health care fraud, holding that a federal judge in Texas properly applied sentencing enhancements based on the defendant’s use of a Medicare beneficiary’s identification number to produce a Medicare claim number (United States v. Elekwachi Kalu, No. 18-20399, 5th Cir., 2019 U.S. App. LEXIS 26466).

  • August 29, 2019

    Severance Agreement Bars Retaliation Claim Against Health Care Services Provider

    TAMPA, Fla. — A federal judge in Florida on Aug. 28 dismissed with prejudice a woman’s False Claims Act (FCA) retaliation claim that she was wrongfully terminated after complaining about her employer’s billing habits to Medicare and other insurance providers, finding that a severance agreement she signed waived her claims against the company (United States, ex rel. Melissa Higgins v. HealthSouth Corp., No. 14-cv-2769-T-33AEP, M.D. Fla., 2019 U.S. Dist. LEXIS 146351).