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Mealey's Insurance Fraud

  • 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).

  • August 28, 2019

    Judge Overrules Nonparty’s Objections To State Farm’s Document Request

    DETROIT — A federal judge in Michigan on Aug. 26 overruled a nonparty’s objections to a magistrate judge’s ruling ordering him to produce documents about his relationship with clinics and doctors accused of submitting fraudulent bills to State Farm Mutual Automobile Insurance Co., finding that the man’s arguments “did not carry the day” (State Farm Mutual Automobile Insurance Company v. Elite Health Centers Inc., et al., No. 16cv13040, E.D. Mich., 2019 U.S. Dist. LEXIS 144205).

  • August 28, 2019

    Cardiologist Convicted Of Defrauding Government Seeks Review Of Experts’ Allowance

    WASHINGTON, D.C. — A federal trial court’s improper admission of several doctors’ expert opinions in a health care fraud case against an Ohio cardiologist warrants review by the U.S. Supreme Court, the heart doctor — who was convicted by a jury — tells the high court in an Aug. 14 petition for a writ of certiorari (Harold Persaud v United States, No. 19-216, U.S. Sup., 2019 U.S. S. Ct. Briefs LEXIS 3330).

  • August 27, 2019

    Clinics’, Doctor’s Objections To Denial Of Request To Disqualify Firms Overruled

    DETROIT — A federal judge in Michigan on Aug. 26 overruled objections filed by doctors and clinics accused of submitting fraudulent bills to State Farm Mutual Automobile Insurance Co. for personal injury protection (PIP) benefits to a magistrate judge’s ruling denying their request to move to disqualify two firms representing the insurer, holding that nothing in the magistrate judge’s ruling was “clearly erroneous or contrary to law” (State Farm Mutual Automobile Insurance Company v. Elite Health Centers Inc., et al., No. 16cv13040, E.D. Mich., 2019 U.S. Dist. LEXIS 144199).

  • August 27, 2019

    Judge:  Fraud Defendant’s Ex-Wife’s Statements Can Be Disclosed

    DETROIT — An insurance fraud defendant’s objections to a magistrate judge’s ruling allowing the disclosure of statements he made to his now ex-wife that were contained in an affidavit she submitted were overruled by a federal judge in Michigan on Aug. 26, after the judge found that the statements were not privileged (State Farm Mutual Automobile Insurance Company v. Elite Health Centers Inc., et al., No. 16cv13040, E.D. Mich., 2019 U.S. Dist. LEXIS 144195).

  • August 21, 2019

    Man Sentenced For Fraudulent Billing For Durable Medical Equipment

    LOS ANGELES — A federal judge in California on Aug. 19 sentenced a man to 46 months in prison and ordered him to pay more than $1 million in restitution after he pleaded guilty to paying kickbacks for prescriptions for durable medical equipment (DME) that were not medically necessary (United States v. Ayodeji T. Fatunmbi, et al., No. 13cr, C.D. Calif.).

  • August 20, 2019

    Judge Explains Dismissal Of Breach Of Implied Covenant Claim Against Insurer

    MINNEAPOLIS — A federal judge in Minnesota on Aug. 16 explained his ruling dismissing a man’s claim for breach of the implied warranty of good faith and fair dealing against his insurer, stating that he believes the state addressed the issue of unreasonable handling of claims in insurance contracts in its legislature and that a state appeals panel’s ruling recognizing the cause of action was not persuasive (Selective Insurance Company of South Carolina v. Amit Sela, No. 16-cv-4077, D. Minn., 2019 U.S. Dist. LEXIS 138666).

  • August 20, 2019

    Man’s Community Service Sentence For Fraud Vacated By 2nd Circuit Panel

    NEW YORK — A Second Circuit U.S. Circuit Court of Appeals panel on Aug. 19 vacated a federal judge in New York’s ruling requiring a man who pleaded guilty to insurance fraud and bank fraud to perform more than 300 hours of community service per year over the course of his supervised release, holding that the sentence did not comply with a policy statement issued by the Sentencing Commission (United States v. Nikos Parkins, No. 18-1019, 2nd Cir., 2019 U.S. App. LEXIS 24563).

  • August 15, 2019

    5th Circuit Affirms Reliability Of Experts In $300M Case Over FHA Loans

    NEW ORLEANS — The Fifth Circuit U.S. Court of Appeals on July 8 affirmed the allowance of expert testimony in a mortgage fraud case that resulted in a nearly $300 million judgment against a businessman and his companies after finding that the trial judge properly vetted the experts’ opinions and sufficiently explained his rationale for doing so (United States v. Jim C. Hodge, et al., No. 17-20720, 5th Cir., 2019 U.S. App. LEXIS 23715).

  • August 15, 2019

    Man Pleads Guilty For Submitting False Claims For Prescription Medications

    ATLANTA — A man pleaded guilty on Aug. 9 in Georgia federal court to one count of health care fraud for obtaining $300,000 from the Colorado Public Employees Retirement Association (COPERA) by submitting false claims for reimbursement for prescription medications he did not receive or that were more expensive than the medications he was receiving (United States v. Michael Bang, No. 18cr433, N.D. Ga.).

  • August 13, 2019

    Judge Transfers GEICO’s Suit Over Fraudulent Billing To New Jersey

    NEW YORK — A federal judge in New York on Aug. 8 transferred to New Jersey federal court a lawsuit brought by the Government Employees Insurance Co. (GEICO) against a New Jersey-based ambulatory care center, its management company and three doctors over a fraudulent billing scheme for personal injury protection (PIP) benefits, ruling that New Jersey is a more appropriate forum because the care center submitted the bills to the insurer (Government Employees Insurance Company v. Daniel J. Yoo, M.D., et al., No. 18-cv-5735, E.D. N.Y., 2019 U.S. Dist. LEXIS 134026).

  • August 12, 2019

    5th Circuit Upholds Denial Of Fraud Defendant’s Requested Jury Instruction

    NEW ORLEANS — A Fifth Circuit U.S. Court of Appeals panel on Aug. 8 upheld a federal judge in Texas’ ruling denying an insurance fraud defendant’s request for a good faith jury instruction, holding that the defendant failed to show that the omission of a jury instruction impaired his good faith defense (United States v. David Roy Williams, No. 18-11184, 5th Cir., 2019 U.S. App. LEXIS 23848).

  • August 07, 2019

    Judge Finds Insurance Agency May Have Breached Duty To Procure Sufficient Policy

    NEW ORLEANS — A federal judge in Louisiana on Aug. 6 denied an insurance agency’s motion for summary judgment on claims brought by a couple claiming that it should indemnify them for damages from a fire that destroyed their home, finding that genuine disputes exist as to whether the agency breached its duty to procure a policy that would have covered the home (GeoVera Specialty Insurance Co. v. Mariette Joachin, et al., No. 18-7577, E.D. La., 2019 U.S. Dist. LEXIS 131033).