Allstate’s Qui Tam Actions Work to Take the Profit Out of Fraud                                                                                                                    

Man Bites Dog Story – Allstate May Sue on Behalf of State for Insurance Fraud

Barry Zalma Aug 22, 2023

Read the full article at https://lnkd.in/g9-tKq7a and see the full video at https://lnkd.in/gGr83yhU and at https://lnkd.in/gdc9mPVX and at https://zalma.com/blog plus more than 4550 posts.

Allstate Insurance Company and several of its affiliates (collectively, Allstate) brought qui tam actions on behalf of the State of California alleging insurance fraud under the California Insurance Frauds Prevention Act (IFPA) (Ins. Code, § 1871 et seq.) and the Unfair Competition Law (UCL) (Bus. &Prof. Code, § 17000 et seq.) against three medical corporations, a medical management company and its parent company, four physicians, and Sattar Mir, an individual.

In the People ex rel. Allstate Insurance Company et al. v.  Discovery Radiology Physicians, P.C., et al., and v. Onesource Medical Diagnostics, LLC, et al., B315264, California Court of Appeals, Second District, Third Division (August 15, 2023) the operative complaints allege that while the medical corporations hold themselves out as providers of radiology services, they in fact act as radiology “brokers,” sending patients to radiology facilities and radiologists with which the purported medical corporations have contracted.

The trial court found the complaints failed to state causes of action under the IFPA and the UCL because they were not pled with requisite specificity.

FACTUAL BACKGROUND

Allstate’s Fraud Actions; The Initial Demurrers.

Allstate Insurance Company is an insurance company licensed to issue automobile insurance policies in California. In 2020, Allstate filed two qui tam actions alleging insurance fraud in violation of the IFPA and the UCL.

The complaints alleged that the three medical corporations were formed and controlled by Mir, who is not a physician, to broker radiology services. The resulting bills falsely identified the technical and professional services as having been provided by one of the three defendant medical corporations and grossly inflated the fees for the services provided. Allstate alleged it would not have paid the claims for services purportedly rendered by the three professional corporations had it known of the false statements and fraudulent markups.

The trial court sustained the demurrer to the first amended complaints. The trial court entered judgments of dismissal in the Discovery and OneSource actions on August 16, 2021. Allstate timely appealed.

DISCUSSION

This appeal presents four basic issues:

1  Are the business models alleged in the amended complaints unlawful? 2 If the alleged business models are unlawful, do they give rise to causes of action under the IFPA and the UCL? 3 Do the amended complaints plead fraud with sufficient particularity? 4   Does the Discovery action adequately allege delayed discovery to survive demurrer on statute of limitations grounds?

The Court of Appeals answered each question in the affirmative.

ANALYSIS

A nonlicensed individual need not examine a patient or render a medical diagnosis to engage in the unlicensed practice of medicine-to the contrary, a non-physician unlawfully practices medicine if he or she exercises undue control over a medical practice. A non-physician undoubtedly exercises undue control by owning a medical practice but may also exercise such control in a variety of other ways, including by choosing physicians to provide medical services, selecting medical equipment, determining the parameters of physicians’ employment, including case load and compensation, and making billing decisions.

Overview of the IFPA.

The IFPA was enacted to prevent automobile and workers’ compensation insurance fraud in order to, among other things, “significantly reduce the incidence or severity and automobile insurance claim payments and . . . therefore produce a commensurate reduction in automobile insurance premiums.”

A claim need not contain an express misstatement of fact to be actionable under Penal Code section 550 and Insurance Code section 1871.7, subdivision (b).  Instead, these sections require only that a person knowingly, and with intent to defraud:

1    present a claim that is false or fraudulent in some respect, 2    present, prepare, or make a statement containing false or misleading information about a material fact, or 3   conceal an event that affects a person’s right or entitlement to insurance benefits.

In other words, “[a]n insurance claim is fraudulent under [Penal Code] section 550 and [Insurance Code] section 1871.7, subdivision (b), when it is characterized in any way by deceit or results from deceit or conduct that is done with an intention to gain unfair or dishonest advantage.”

ANALYSIS.

The present case is a fraud action brought in the name of, and on behalf of, the state of California. Nor does Allstate seek to “avoid paying for” services rendered under an insurance contract, as defendants suggest; Allstate has already paid for those services and seeks through this action to recover a statutory penalty that, if recovered, will be shared by the state. For all of these reasons, the Court of Appeals concluded that the complaints allege claims under the IFPA.

The Operative Complaints State Claims Under The UCL.

The UCL prohibits “any unlawful, unfair or fraudulent business act or practice and unfair, deceptive, untrue or misleading advertising.” (§ 17200.)”  All parties agree that Allstate’s UCL claims are derivative of its IFPA claims, and thus that the UCL claims rise or fall with the IFPA claims. Because the complaints adequately plead violations of the IFPA, they also adequately plead violations of the UCL.

The Amended Complaints Were Pled With Adequate Specificity.

Because Allstate has not only pled an allegedly fraudulent practice, but also identified each of the allegedly false claims submitted as a result of that practice it has adequately pled its complaint with adequate specificity.

DISPOSITION

The judgments of dismissal were reversed with directions to the trial court to vacate the orders sustaining the demurrers, enter new orders overruling the demurrers, and reinstate the amended complaints. Allstate shall recover its appellate costs.

ZALMA OPINION

The qui tam provision of the IFPA is an effective means of reducing insurance fraud by taking the profit out of the procedure without taking on the need for proof beyond a reasonable doubt in a criminal proceeding. If there is no profit in fraud and because the IFPA can assess serious damages on the perpetrators Allstate, and all the Amici who supported it on this appeal, should be honored in the work to defeat fraud and should be emulated by other insurers who are the victims of fraud providers, whether medical, auto body shops, contractors, roofers, public insurance adjusters and lawyers.

(c) 2023 Barry Zalma & ClaimSchool, Inc.

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Bom dia pessoal, só queria dizer que é péssimo estudar de manhã e de tarde. 🥲

One of my favorite photos that I took of the Carolina Pinball Championship Series finals held last month.

Full album on Flickr: https://www.flickr.com/photos/thekog/albums/72177720306831145

Seleção busca contratar professor substituto na área de historia Concursos › Notícias › Norte EDITAL DE ABERTURA Nº 05/2023 PROVAS RELACIONADAS PCI Concursos

Final de treino de Jiu-Jítsu, no IFPA - 15/03/2023 (quarta-feira) Projeto de Extensão - Judô e Jiu-Jítsu, Como Inclusão Social #IFPA #BJJ #JiuJitsu (em Ginásio Poliesportivo IFPA) https://www.instagram.com/p/Cp1KbT-t3Ih/?igshid=NGJjMDIxMWI=

CRAZY STUCKY BALL ON WALKING DEAD PINBALL AT @sfgamingexpo in #atlantageorgia #atlanta #georgia #twd #sternpinball #art #tv #sfge #sfge2022 #lymansheats #johnborg #southenfriedgamingexpo #thewalkingdead #ifpa #ifpapinball (at Renaissance Atlanta Waverly Hotel & Convention Center) https://www.instagram.com/p/CgD1Z02OXq7/?igshid=NGJjMDIxMWI=

"Brazil is still a highly unknown export power in the avocado market"

The 7th International Fruit, Vegetable and Flower Industry Trade Fair of the International Fresh Produce Association (IFPA), The Brazil Conference, will be held in Brazil on August 22 and 23. This year will be the first in which the event will last for two days, during which there will be discussions on industry trends, Brazil's fresh food will be showcased in the exhibition area, and there will be opportunities for networking between producers, suppliers and buyers, said Valeska Oliveira, IFPA country manager in Brazil.

"The event's focus is the domestic and export markets, but also the import market, because Brazil also consumes temperate climate fruits and vegetables, such as berries, cherries, pears or plums, of which we do not have a large production in the country," said Valeska.

Brazil is one of the major players in the export of fruit, and Europe is the main destination for Brazilian exports. In 2022, the country had 2.6 billion hectares that yielded 41 million tons of fruit, generating 970 million dollars in revenue from exports. And the prospect is that shipments will increase this year compared to 2022.

"One of the objectives is to grow as exporters, both in the number of destinations, as there are many options for the opening of new markets, and in the range of products. In fact, there's plenty of potential for the development of avocado exports. We are currently working on that," said Valeska. And the export figures for 2023 confirm this.

Continue reading.

El 29 de octubre se celebra el Día Mundial de la Psoriasis.

Durante el año 2004, se reunieron diversas asociaciones de pacientes con psoriasis para crear un Comité Directivo del Día Mundial de la Psoriasis. La Federación Internacional de Asociaciones de Psoriasis (IFPA) impulsó este día con la intención de informar y concienciar a la población sobre los efectos psicológicos y físicos que sufren los pacientes afectados por la psoriasis o artritis psoriásica.

En la actualidad, más de cincuenta países participan activamente desarrollando actividades destinadas a informar, apoyar y ayudar. Entre los objetivos de este día se encuentran:

Aumentar la conciencia. En el mundo más de 125 millones de personas padecen este trastorno y se ven afectados física, emocional, social y financieramente. Es por ello importante crear conciencia sobre el efecto que tiene en las personas.

Difundir la información. Muchos desconocen esta enfermedad, por lo que es importante difundir información y romper mitos. También es necesario que los pacientes estén al tanto de su condición para poder hablar sobre ello.

Buscar mejoras en el acceso al tratamiento. Ejercer presión para que los entes gubernamentales y centros de salud, entre otros, ayuden a las personas a tener un mejor y asequible acceso al tratamiento.

Darle voz a la comunidad de psoriasis. Brindarles la oportunidad de expresar sus necesidades y padecimientos a través de una plataforma común para que el mundo escuche sus voces.

¿Qué es la psoriasis?

La psoriasis es una enfermedad crónica que causa inflamación y descamación de la piel, produciendo parches, enrojecimiento, escamas, picor, dolor, calentamiento, coloración e hinchazón. Puede afectar cualquier área del cuerpo, aunque es frecuente en las rodillas, codos, espalda, brazos, piernas y cuero cabelludo.

Las investigaciones realizadas han encontrado que este padecimiento tiene mucha relación con el componente genético, que, combinados con estrés y medio ambiente, hacen posible su desarrollo. Por eso deducen que puede ser de tipo hereditario.

Debido a la visibilidad de los síntomas, las personas tienden a creer que puede ser contagiosa y los afectados suelen sentir vergüenza y en muchos casos se aíslan, provocando en ellos daños psicológicos y sociales. De hecho, ha sido reconocida por la Organización Mundial de la Salud (OMS) como una enfermedad grave que requiere de mayor concienciación.

Aunque no es curable, es posible reducir los síntomas y brotes con tratamientos tópicos, luz ultravioleta, fototerapia u otros medicamentos o tratamientos recomendados por el especialista.

Este 29 de octubre vístete con los colores naranja y azul

También puedes compartir reflexiones en las redes sociales bajo las etiquetas #DiaMundialdelaPsoriasis #psoriasis

Mewling Glyph 090

Ves

[vɛs]

1. to go, to move

2. movement

3. future tense marker

Today's glyph is the glyph for "go". It's a gate radical, and is also used to mark the future tense. When it's used for the future tense, it's pronounced fas or fat, which comes from an older pronunciation. It's used in several words for movement such as ayovas "to walk", wachavas "to run", avefas "to swim", and ifpas "to dance".

Feirantes do Mercado de São Brás em Belém Iniciam Curso de Inglês em Preparação para a COP-30

Os feirantes do Mercado de São Brás deram o primeiro passo em direção à qualificação, participando da primeira aula de um curso oferecido pela Prefeitura de Belém, por intermédio da Secretaria Municipal de Administração (Semad), em colaboração com a Universidade Livre da Amazônia (Ulam). Um total de 67 inscritos se reuniram no auditório do Sindicato dos Trabalhadores em Saúde do Estado do Pará (Sindsaúde) para a primeira etapa do curso de língua inglesa, o qual é o primeiro de uma série de seis cursos planejados para os trabalhadores do Mercado de São Brás. Atuando há 38 anos na feira de São Brás, Sandra Monteiro, de 63 anos, que trabalha com venda de refeições, expressou sua alegria com a oportunidade de aprender uma nova língua. Ela comentou: "Para mim é uma grande oportunidade. Só tive aula de inglês no colégio, que concluí recentemente. Pelo menos, vou aprender a oferecer uma carne, frango ou água". A carga horária do curso de língua inglesa será de 30 horas no total, dividida em quatro horas por semana. As aulas abrangerão conceitos básicos de inglês, como conversação e cumprimentos, e serão adaptadas ao dia a dia dos alunos, feirantes, para que possam ser aplicadas durante o trabalho, explicou Vitor Wanzeler, professor do curso. Vitor ressaltou: "Vamos tentar colocar esse aluno no cotidiano da COP-30 e oferecer aulas que coloquem eles nessa vivência com o turista". Essa iniciativa integra as ações do executivo municipal visando preparar a capital paraense para a COP-30, prevista para novembro de 2025. Além do curso de inglês, serão oferecidos cursos de Capacitação em qualidade no atendimento em serviços turísticos, Marketing de negócios, Projeto Espanhol Pai D´égua e Libras – nível básico, todos disponíveis para os permissionários de São Brás e seus dependentes. Jurandir Novaes, titular da Semad, destacou que essa é uma oportunidade para os feirantes ampliarem suas experiências e se qualificarem. Ele disse: "Mais do que aprender a língua, é importante que vocês descubram também coisas do dia a dia. Falar das experiências com os turistas, seja do Brasil ou de outro país". O Instituto Federal do Pará (IFPA), Campus-Belém, será responsável por ministrar o curso de inglês e os demais. Daniel Palheta, representante do instituto, expressou o objetivo de capacitar os feirantes para que possam se comunicar e vender seus produtos para os visitantes durante a COP-30. Ele informou aos feirantes: "Estamos aqui para tentar direcionar, por meio de uma linguagem mundial que é o inglês, para que os senhores se comuniquem para os que vierem visitar Belém durante a COP-30". Com informações da Agência Belém. Read the full article

Mr. Roland Yeo, former IFPAS President and Advisory Board Chair, has long been dedicated to giving back to society. For over two decades, he has been actively involved in community and humanitarian work, impacting multiple generations. His altruism has reached communities across various countries, including the Philippines, through initiatives with Oikos Helping Hand. This commitment to service has been ongoing for several years, reflecting his dedication to holistic and integrated approaches to community development.

Man Bites Dog & Dog Bites Back                                                                                                                    

Read the full article at https://lnkd.in/gS5NANH3, see the full video at https://lnkd.in/ggYpQA3J and at https://lnkd.in/gvNrjEBu, and at https://zalma.com/blog plus more than 4750 posts.

Third Circuit Compels Arbitration of IFPA Qui Tam Claims

Post 4781

The Insurance Fraud Prevention Act (IFPA) allows insurers to sue health care providers pursuing insurers with assignments of benefits from personal injury protection (PIP) claims (no fault insurance) on behalf of the state. GEICO did so against multiple health care providers who asked the court to compel GEICO to arbitrate each potential fraud claim.

In Government Employees Insurance Co.; GEICO Indemnity Co.; GEICO General Insurance Company; GEICO Casualty Co. v. Mount Prospect Chiropractic Center, P.A., d/b/a Mount Prospect Health Center; et al, United States Court Of Appeals For The Third Circuit, Nos. 23-1378, 23-2019 & 23-2053, No. 23-1378 April 15, 2024) the Third Circuit required arbitration of GEICO’s claims of fraud by health care providers under the New Jersey Insurance Frauds Prevention Act (IFPA)

BACKGROUND

GEICO sued defendants-appellants (collectively, the “Practices”) in separate actions in the District of New Jersey, alleging they defrauded GEICO of more than $10 million by abusing the personal injury protection (“PIP”) benefits offered by its auto policies. It alleges the Practices filed exaggerated claims for medical services (sometimes for treatments that were never provided), billed medically unnecessary care, and engaged in illegal kickback schemes. GEICO’s suits against the Practices each included a claim under the IFPA, which gives insurers a fraud claim.

The Medical Practices sought arbitration of GEICO’s IFPA claim, arguing both that a valid arbitration agreement covered the claim and that a different New Jersey insurance law allowed them to compel arbitration. But each District Court disagreed, ruling instead that IFPA claims cannot be arbitrated.

IFPA Claims Can Be Arbitrated.

The Practices’ effort to compel arbitration under a different New Jersey law could do the same for the Practices’ FAA-based request. GEICO bears the burden of persuading the Third Circuit that the IFPA prohibits arbitration.  GEICO claims that every known decision has held IFPA claims inarbitrable. The Practices cite no case holding otherwise.

GEICO claims that the IFPA’s antifraud mission bars arbitration. But it does not explain why arbitrating IFPA claims frustrates that goal. The United States Supreme Court has made clear that claims arising from laws empowering private attorneys general can be arbitrated. The American Arbitration Association rules give the arbitrator broad discretion to “grant any remedy or relief[.]” Am. Arb. Ass’n, Commercial Arbitration Rules and Mediation Procedures 28 (2013) (Rule 47), https://perma.cc/4Y74- WZM8.

In addition, New Jersey has a strong policy in favor of arbitration. The Third Circuit, therefore, predicted that the New Jersey Supreme Court would allow arbitration of IFPA claims. Having concluded that IFPA claims are arbitrable, the Third Circuit then considered whether the IFPA claims before it should be compelled to arbitration.

New Jersey Insurance Law Compels Arbitration.

Each Practice sought arbitration of GEICO’s IFPA claim through N.J. Stat. Ann. § 39:6A-5.1(a) (the “Provision”). It allows “any party” to compel arbitration of “[a]ny dispute regarding the recovery of medical expense benefits or other benefits provided under [PIP] coverage . . . arising out of the operation, ownership, maintenance or use of an automobile”.  As these suits are GEICO’s effort to recover medical expense claims paid through auto insurance PIP benefits, they fall under the Provision’s plain text.

GEICO asserts that the Provision does not apply to IFPA claims because they deal with fraud.

First, the Provision does not have an exception for fraud, and the Third Circuit may not carve a broad exclusion from a plain statute on the Third Circuit’s our own initiative.

Second, the list of claims specifically subject to the Provision suggests fraud falls under its umbrella. That group includes whether the disputed medical treatment was actually performed and whether the treatment performed is reasonable or necessary. That is the alleged fraud underpinning GEICO’s IFPA claims: billing for fictitious or unnecessary care. Because the Provision’s plain language is broad and does not carve out fraud, but rather explicitly includes fraud-like claims, GEICO’s argument failed to persuade the Third Circuit.

GEICO’s IFPA Claims Are Subject to an Arbitration Agreement.

In the alternative, the Third Circuit also concluded that GEICO’s IFPA claims must be compelled to arbitration under the FAA. That statute compels claims to arbitration once a movant shows both that an arbitration agreement was validly formed and that it covers the claims at issue. To establish that an agreement was formed when (as here) a motion to compel arbitration is based on a complaint standing alone, a defendant must show that the complaint and the documents on which s it relies facially suggest that the parties agreed to arbitrate.

GEICO does not contest the Practices’ reliance on two documents to suggest formation of an arbitration agreement. The first is GEICO’s Precertification and Decision Point Review Plan (the “Plan”). This document, required by New Jersey law and approved by the New Jersey insurance regulator, governs GEICO’s reimbursement of PIP claims. GEICO could force the Practices to prove more than a suggestion by submitting or pointing to additional facts sufficient to place the arbitration agreement in issue.

It would not have taken much for GEICO to put contract formation in play. To compel arbitration of GEICO’s IFPA claims, the Third Circuit concluded it must hold that the arbitration agreement in the Plan covers them.

Nothing in the amended complaint precludes arbitration of GEICO’s IFPA claims. Rather the law requires it. Therefore, Third Circuit concluded the District Court abused its discretion in denying the motion and the Third Circuit ordered arbitration.

ZALMA OPINION

Since local prosecutors failed to deal with health care providers who try to defraud insurers like GEICO, it used the qui tam provisions of the IFPA to sue the medical providers and thereby take the profit out of their crime. The health care providers compelled arbitration thereby requiring GEICO to prove fraud in each individual claim which will probably cost more than the amount of the fraud. What is needed is for the state to prosecute the fraud perpetrators or allow the fraud to continue since it may become self-defeating for GEICO to go through with hundreds of individual arbitrations. Regardless of the legal basis for the Third Circuit’s decision, its practical effect is to make PIP fraud profitable and the fraudsters should sing Hosannas for the Third Circuit’s decision. The criminal doctors need to be prosecuted as DOJ is prosecuting Medicare and Medicaid fraudsters.

(c) 2024 Barry Zalma & ClaimSchool, Inc.

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6 Expert Gym Etiquette Tips to Help You Workout Smarter

<h2>6 Tips for a Successful Workout at the Gym</h2> <p>Going to the gym is a great way to stay fit. But did you know there are some important things to keep in mind to get the most out of your workouts? Here are six tips for gym newbies to have a safe and effective session.</p> <h3>1. Choose a Pro Gym</h3> <p>With so many gyms around, pick one that's properly equipped. Professional gyms usually have a good variety of machines and weights. This means you can work different muscles with less downtime waiting for equipment. Look for trainers too - they can help design programs for your goals.</p> <h3>2. Wear Proper Shoes</h3> <p>Sneakers are a must for gym workouts. Flip flops or slippers aren't safe since you could easily slip. Strong athletic shoes will support your feet, especially for lower body exercises that stress your ankles. Good support prevents injuries like rolled ankles.</p> <h3>3. Get a Custom Plan</h3> <p>A personal trainer can create a routine tailored to your body and abilities. They'll consider your strengths and weaknesses to develop a balanced program. Trainer certification from respected groups like IFPA (International Fitness Professionals Association) shows they know how to help you improve safely.</p> <h3>4. Warm Up First</h3> <p>Don't jump right into heavy lifts without loosening up first. Take 10 minutes to gently raise your heart rate and stretch muscles before a tough workout. Warming up prevents strains by getting your blood flowing and tissues limber.</p> <h3>5. Stay Hydrated</h3> <p>Cardio and weights make you sweat, so consumption lots of water - just not during exercise. Drink within an hour before and after your session to replace what you lose. Proper hydration aids recovery and prevents issues like faintness.</p> <h3>6. Cool Down Too</h3> <p>When you're done pushing hard, gradually decrease intensity over 5-10 minutes instead of stopping abruptly. This protects the cardiovascular system by slowly returning your breathing and heartbeat to resting levels. Listen to your body - walk if you feel lightheaded.</p> <p>Hopefully these gym basics help you work out productively and prevent injuries. Remember - every workout gets you closer to your fitness dreams, so stay motivated!</p>

Docentes contarão com a remuneração de até R$ 3,8 mil, além de outros benefícios; confira Concursos › Notícias › Norte EDITAL DE ABERTURA Nº 02/2023 PROVAS RELACIONADAS PCI Concursos

Final de treino de Judô no IFPA - 1303/2023 (Segunda-feira) Projeto de Extensão - Judô e Jiu-Jítsu, Como Inclusão Social #IFPA #Judo #Judô (em Ginásio Poliesportivo IFPA) https://www.instagram.com/p/Cp1J7wxt3vq/?igshid=NGJjMDIxMWI=

Pure Flavor® Unveils Tiki Tomatoes™ and Oronai™ Sweet Charentais Melons

Key Takeaways Pure Flavor® has launched Tiki Tomatoes™ and Oronai™ Sweet Charentais Melons as part of its innovation pipeline. Tiki Tomatoes™ have received the Superior Taste Award Certification from the International Taste Institute. The products will be unveiled at the upcoming IFPA Global Produce & Floral Show in Anaheim, California. Both products aim to meet consumer demand for innovative,…

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