Proving Fraud by A Predetermined Treatment Protocol: RICO Action Against Medical Providers Raises Discovery Difficulties.

• Author: Zalma, Barry
• Position: [ON MY RADAR]

* 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.

When an insurer sues a health care provider for fraud based on the provider's submission of bills for services rendered pursuant to a predetermined protocol, the insurer is alleging that the provider purported to treat an entire patient population in a cookie-cutter manner which, in fact, makes no medical sense, in order to financially enrich the provider by maximizing collection of the patients insurance benefits. Indeed, in predetermined-protocol cases, insurers often explain that the fraudulent nature of each bill or claim is not apparent when reviewed in isolation. Proving each of thousands of false bills would be difficult and not cost effective. That is why courts allow proof by proving predetermined Treatment Protocols where everyone receives the same treatment. The Defendants' demands for discovery chill the opportunity to prove the claimed fraud.

FACTS

Geico alleges that Defendants billed it for fraudulent healthcare services as the assignees of the Geico insureds' no-fault (personal injury protection, or "PIP") insurance benefits. Geico's lawsuit is based on 456,612 invoices, reflecting purported healthcare services provided to approximately 8,000 patients.

During discovery, Defendants propounded interrogatories designed to obtain the specifics of Geico's allegations. Geico's response was that everything was improper. Specifically, Geico (which is seeking to recover $20 million) provided supplemental interrogatory answers declaring that all charges were fraudulent.

Geico contends that it need not provide any further detail because courts have permitted insurance carriers to bring these types of lawsuits by alleging an overall scheme to use...