Mealey's Insurance Fraud

  • April 23, 2019

    Company’s Motion To Intervene In Aetna’s Billing Suit Against Opioid Maker Denied

    PHILADELPHIA — A federal judge in Pennsylvania on April 22 denied an insurance purchaser’s motion to intervene in a lawsuit brought by Aetna Inc. against the manufacturer of an opioid medication accused of billing the insurer for off-label prescriptions of Subsys, ruling that while the purchaser had standing, it lacked a financial interest in the litigation (Aetna Inc., et al. v. Insys Therapeutics Inc., et al., No. 17-4812, E.D. Pa., 2019 U.S. Dist. LEXIS 67648).

  • April 22, 2019

    Magistrate: Evidence Supports Inference On Statements Regarding Patient Payment

    MIAMI — A federal magistrate judge in Florida on April 18 held that a health care clinic patient’s statement in a police report can support an inference that a clinic employee accused of participating in a scheme to submit fraudulent no-fault personal injury protection claims to an insurance company paid patients to receive treatment at the facility and paid patients to refer someone else to the clinic (Government Employees Insurance Co., et al. v. Quality Diagnostic Health Care Inc., et al., No. 18-cv-20101, S.D. Fla., 2019 U.S. Dist. LEXIS 67262).

  • April 18, 2019

    Home Health Care Employees Sentenced To Probation For Roles In Billing Scheme

    PITTSBURGH — A federal judge in Pennsylvania on April 12 sentenced two home health care employees to up to five years’ probation and six months of home detention and ordered them to pay restitution for their roles in an $87 million fraudulent billing scheme that involved submitting claims to Pennsylvania’s Medicare program for services that were not rendered or contained insufficient supporting documentation (United States v. Autumn Brown, No. 18cr284, United States v. Brenda Lowry Horton, No. 18cr285, W.D. Pa.).

  • April 18, 2019

    Pennsylvania Panel Finds Fraud Defendant’s Sentence Modification Warranted

    HARRISBURG, Pa. — A Pennsylvania appeals court panel on April 10 affirmed a trial court judge’s decision to modify an insurance fraud defendant’s sentence to up to four years in prison after her probation was revoked, holding that her appeal was untimely by one day and that incarceration would prevent future crimes (Pennsylvania v. Christina Marie Famiano, No. 2626 EDA 2018, Pa. Super., 2018 Pa. Unpub. LEXIS 1326).

  • April 18, 2019

    Divided 9th Circuit Panel Vacates Man’s Sentence For Health Care Fraud

    PASADENA, Calif. — A 2-1 panel of the Ninth Circuit U.S. Court of Appeals on April 9 vacated a man’s 97-month sentence for 15 counts of health care fraud, holding that a federal court judge in California erred when calculating the defendant’s intended loss from the $8.4 million scheme (United States v. Michael Mirando, No. 17-50386, 9th Cir., 2019 U.S. App. LEXIS 10468).

  • April 18, 2019

    Government’s Suit Over Doctor’s Use Of Chelation Therapy Survives Dismissal

    ROME, Ga. — A federal judge in Georgia on March 8 denied a doctor’s motion to dismiss a False Claims Act (FCA) lawsuit brought by the government, holding that the doctor’s argument that the use of chelation therapy was medically necessary is not enough to prove that the bills submitted for the treatment were legal (United States v. Charles C. Adams, M.D., et al., No. 18-cv-191-HLM, N.D. Ga., 2019 U.S Dist. LEXIS 61147).

  • April 10, 2019

    Department Of Justice: Charges Filed In 6 States For Fraud Schemes

    WASHINGTON, D.C. — The U.S. Department of Justice announced April 9 that charges had been filed against 24 individuals in federal courts in California, Florida, New Jersey, Pennsylvania, South Carolina and Texas for their roles in health care fraud schemes that involved telemedicine companies inducing elderly patients to ask their physicians for durable medical equipment (DME) that was not medically necessary and then billing Medicare for the products, resulting in $1.2 billion in losses.

  • April 10, 2019

    Judge Enjoins Pharmacist From Dissipating Funds Derived From Fraud Scheme

    OKLAHOMA CITY — A pharmacist accused of submitting fraudulent bills to Medicare for prescriptions filled at two pharmacies he owned and operated was enjoined by a federal judge in Oklahoma March 26 from transferring or dissipating the more than $1 million he earned from the scheme (United States v. Jeffrey Scott Terry, No. 19-cv-250, W.D. Okla.).

  • April 09, 2019

    Judge Refuses To Suppress Possible Tax Fraud Evidence In Insurance Fraud Suit

    SCRANTON, Pa. — A federal judge in Pennsylvania on March 25 denied a defendant’s motion to suppress the admission of a thumb drive that contains the identifying information of more than 400 people for the purpose of filing federal income tax returns, finding that federal law applies to the charges of insurance fraud and tax fraud against the man and that the warrant that was executed to obtain the drive was not overbroad (United States v. Frank J. Capozzi, No. 16cr347, M.D. Pa., 2019 U.S. Dist. LEXIS 55075).

  • April 05, 2019

    Michigan Panel Reverses Ruling Applying Fraud Preclusion To Deny Coverage

    GRAND RAPIDS, Mich. — A Michigan appeals court panel on April 2 vacated a trial court judge’s ruling awarding summary judgment to an insurance company that denied coverage for a woman’s claim for no-fault personal injury protection (PIP) benefits for injuries she sustained in an automobile accident, holding that the judge erred when finding that the evidence supported the insurer’s claim that the woman’s injuries did not stem from the accident (Denise Gable v. Citizens Insurance Company of the Midwest, No. 341757, Mich. App., 2019 Mich. App. LEXIS 634).

  • April 02, 2019

    Former Account Representative Sentenced To 56 Months In Prison For Fraud

    MCALLEN, Texas — A federal judge in Texas sentenced a former toxicology testing company account representative to 56 months in prison for his role in a scheme to falsify patient records and submit urine specimens for testing at a medical clinic in order to receive commissions and collection fees from the testing company, according to a docket entry dated March 20 (United States v. Omar Solis, et al., No. 17cr1046, S.D. Texas).

  • March 22, 2019

    Counseling Services Center, Owners Not Liable For False Claims Act Violations

    LITTLE ROCK, Ark.— A federal judge in Arkansas awarded summary judgment to a mental health services center and its owners after finding that plaintiffs leading a qui tam action under the False Claims Act (FCA) failed to present evidence that the owners were in violation of the state’s Medical Corporation Act (MCA), and that any bills submitted by the center and its franchises were fraudulent (United States, ex rel. Jacqueline Clemente, et al. v. Lead Teach Mentor LLC, et al., No. 16CV00875, E.D. Ark., 2019 U.S. Dist. LEXIS 45786).

  • March 20, 2019

    Defendants’ Request For Court To Abstain From Fraudulent Billing Suit Denied

    DETROIT — A federal judge in Michigan on March 18 denied a motion to dismiss Allstate Insurance Co.’s claims for declaratory relief and violation of the Racketeer Influenced and Corrupt Organizations Act against four doctors and two clinics accused of submitting fraudulent bills for medical services that were unnecessary and unreasonable, holding that the defendants failed to establish why the court should abstain from jurisdiction (Allstate Insurance Co., et al. v. Orthopedic P.C., et al., No. 18-cv-10193, E.D. Mich., 2019 U.S. Dist. LEXIS 43171).

  • March 18, 2019

    High Court Will Not Address Pleading Standards In False Claims Act Suit

    WASHINGTON, D.C. — The U.S. Supreme Court on March 18 denied a nursing facility’s petition for a writ of certiorari and refused to review a Sixth Circuit U.S. Court of Appeals ruling that revived a woman’s False Claims Act (FCA) lawsuit accusing it of submitting fraudulent bills to Medicare on the ground that she sufficiently pleaded materiality and scienter (Brookdale Senior Living Communities Inc. v. United States, ex rel. Marjorie Prather, No. 18-699, U.S. Sup.).

  • March 14, 2019

    Home Health Therapy Services Owner, Worker Sentenced For Health Care Fraud

    MIAMI — The owner of a home health therapy services company and an employee who performed services despite not being licensed to do so were sentenced by a federal judge in Florida on March 6 after they pleaded guilty to charges of engaging in an $8.6 million health care fraud scheme (United States v. Alexander Ros Lazo, et al., No. 18cr20536, S.D. Fla.).

  • March 14, 2019

    Judge Sentences Woman To 20 Years In Prison For Health Care Fraud

    HOUSTON — A woman who was convicted in September 2017 on charges of conspiring to commit health care fraud and health care fraud was sentenced by a federal judge in Texas March 8 to 20 years in prison and ordered to pay $15 million in restitution (United States v. Aliksandar Bekatev, et al., No 14cr637, S.D. Texas).

  • March 14, 2019

    Woman Sentenced To 21 Months For Illegally Obtaining Disability Benefits

    TAMPA, Fla. — A federal judge in Florida on March 8 sentenced a woman to 21 months in prison and ordered her to pay restitution for illegally obtaining Social Security disability benefits while simultaneously working at a law firm as a title closer (United States v. Roselle Fitzgerald, No. 18cr227, M.D. Fla.).

  • March 13, 2019

    Woman’s Conviction For Disability Insurance Scheme Upheld By 9th Circuit

    PASADENA, Calif. — A Ninth Circuit U.S. Court of Appeals panel on March 12 affirmed a former sales associate’s conviction for mail fraud and witness tampering in connection with her role in orchestrating a scheme to submit fraudulent claims for disability insurance benefits from American Family Life Assurance Co. (AFLAC), finding that the evidence sufficiently demonstrated that she attempted to corruptly persuade witnesses to not speak with investigators (United States v. Patricia Diane Smith Sledge, No. 17-50363, 9th Cir., 2019 U.S. App. LEXIS 7116).

  • March 13, 2019

    Jury Should Hear Insurance Fraud Prevention Suit, New Jersey Panel Rules

    TRENTON, N.J. — A jury should decide if a California chiropractor and two of his clinics violated the Insurance Fraud Prevention Act (IFPA) when opening clinics in New Jersey and submitting claims for reimbursement to insurance companies, a New Jersey appeals court ruled March 11, finding that the ruling in Allstate New Jersey Ins. Co. v. Lajara can be applied retroactively (Allstate Insurance Co., et al. v. Northfield Medical Center P.C., et al., No. A-0964-12T4, N.J. Super., App. Div.,2019 N.J. Super. Unpub. LEXIS 572).

  • March 12, 2019

    New Jersey Appeals Court Vacates Portion Of Fraud Ruling Against Doctor

    TRENTON, N.J.— A New Jersey appeals court panel on March 8 vacated a trial court judge’s ruling finding that a radiologist violated two sections of the New Jersey Insurance Fraud Prevention Act (IFPA), holding that expert testimony is needed to determine if there was a relationship between a patient’s prior medical history and the reason the patient was undergoing the procedure performed by the radiologist (Allstate New Jersey Insurance Co., et al. v. Gregorio Lajara, et al., No. A-1151-16T4, N.J. Super., App. Div., 2019 N.J. Super. Unpub. LEXIS 523).

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