Proving Fraud by A Predetermined Treatment Protocol
Read the full article at https://www.linkedin.com/pulse/zalmas-insurance-fraud-letter-barry-zalma-esq-cfe-19c, see the full video at https://rumble.com/vekstj-zalmas-insurance-fraud-letter-march-15-2021.html and at https://youtu.be/tkhTUJSIa5I and at https://zalma.com/blog plus more than 3600 posts.
Articles in the March 15, 2021 Issue include the following:
RICO Action Against Medical Providers Raises Discovery Difficulties
Insurance companies who claim to be the victims of health care providers operating in a no fault auto insurance state like Florida. In Government Employees Insurance Co., et al. v. Mark A. Cereceda, et al., CASE NO. 19-22206-CIV-ALTONAGA/GOODMAN, United States District Court Southern District of Florida Miami Division (January 15, 2021) where Plaintiffs filed a 406-page Complaint asserting 43 counts and attaching more than 8,500 pages of spreadsheets as exhibits. Specifically, Government Employees Insurance Co. (“Geico”) and related Geico entities (“Geico,” collectively) sued chiropractor (Mark A. Cereceda), other healthcare providers, and myriad LLCs which purportedly provided fraudulent healthcare services. Geico alleges that Cereceda is the managing member and owner of the LLCs.
An insurer alleging fraud based on a predetermined treatment protocol should not have to prove that each claim, in a vacuum, is fraudulent. A middle-ground accepted by courts allows insurers to rely on non-credible patterns in providers’ bills and documentation to explain globally why groups of claims are fraudulent, provided the insurer sufficiently identifies the claims at issue. It can also use specific cases to prove the pattern or fraud but then it must respond in detail to discovery requests. In that regard I have seen in my practice medical billing and reporting that was identical to multiple patients except for the name of the patient. If Geico can show that type of fraud it will have no problem with the RICO action proof and will not need to answer interrogatories about the thousands of fraudulent claims.
When You Do the Crime, You Must Do the Time
Doctor Unsuccessfully Claimed He Was A “Patsy” Who Was Talked into Helping A Criminal
Insurance Fraud Should Not Be A Retirement Plan
Insurance Fraud Gets You Three Squares and a Cot
Good News From the Coalition Against Insurance Fraud
Taking Insurance Check & Cashing It Twice Is Fraud
Insurance Fraudster & Thief Appeals Conviction Requiring A 35 Page Opinion Affirming the Conviction
Health Insurance Fraud Convictions
Other Insurance Fraud Convictions
© 2021 – Barry Zalma
Barry Zalma, Esq., CFE, now limits his practice to service as an insurance consultant specializing in insurance coverage, insurance claims handling, insurance bad faith and insurance fraud almost equally for insurers and policyholders. He also serves as an arbitrator or mediator for insurance related disputes. He practiced law in California for more than 44 years as an insurance coverage and claims handling lawyer and more than 52 years in the insurance business. He is available at http://www.zalma.com and firstname.lastname@example.org.
Mr. Zalma is the first recipient of the first annual Claims Magazine/ACE Legend Award.
Over the last 53 years Barry Zalma has dedicated his life to insurance, insurance claims and the need to defeat insurance fraud. He has created the following library of books and other materials to make it possible for insurers and their claims staff to become insurance claims professionals.
Go to the podcast Zalma On Insurance at https://anchor.fm/barry-zalma; Follow Mr. Zalma on Twitter at https://twitter.com/bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/c/c-262921; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; Go to the Insurance Claims Library – https://zalma.com/blog/insurance-claims-library/ Read posts from Barry Zalma at https://parler.com/profile/Zalma/posts; and Read last two issues of ZIFL here.