Division of Insurance Fraud Presented by Senior Attorney Howard Pohl Captain Steven Smith
The Florida Bar Protecting Rights Pursuing Justice Promoting Professionalism - Insure Integrity of the Profession - Assist Attorneys in Maintaining the Highest of Ethical Standards - Protect, Educate and Assist the Public
Solicitation Florida Statute 817.234 (8) states: (8)(a) It is unlawful for any person intending to defraud any other person to solicit or cause to be solicited any business from a person involved in a motor vehicle accident for the purpose of making, adjusting, or settling motor vehicle tort claims or claims for personal injury protection benefits required by s. 627.736. Any person who violates the provisions of this paragraph commits a felony of the second degree, punishable as provided in s. 775.082, s. 775.083 or s. 775.084. A person who is convicted of a violation of this subsection shall be sentenced to a minimum term of imprisonment of 2 years
Solicitation Florida Statute 817.234 (8) states: (8)(b) A person may not solicit or cause to be solicited any business from a person involved in a motor vehicle accident by any means of communication other than advertising directed to the public for the purpose of making motor vehicle tort claims or claims for personal injury protection benefits required by s. 627.736, within 60 days after the occurrence of the motor vehicle accident. Any person who violates this paragraph commits a felony of the third degree, punishable as provided in s. 775.082, s. 775.083 or s. 775.084
Solicitation Florida Statute 817.234 (8) states: (c) A lawyer, health care practitioner as defined in s. 456.001, or owner or medical director of a clinic required to be licensed pursuant to s. 400.9905 may not, at any time after 60 days have elapsed from the occurrence of a motor vehicle accident, solicit or cause to be solicited any business from a person involved in a motor vehicle accident by means of in person or telephone contact at the person's residence, for the purpose of making motor vehicle tort claims or claims for personal injury protection benefits required by s. 627.736. Any person who violates this paragraph commits a felony of the third degree, punishable as provided in 775.082, s. 775.083 or s. 775.084 (d) Charges for any services rendered by any person who violates this subsection in regard to the person for whom such services were rendered are noncompensable and unenforceable as a matter of law
817.505 Patient Brokering Similar to solicitation with proof of payment Florida Statute 817.505 states: (1) It is unlawful for any person, including any health care provider or health care facility, to: (a) Offer or pay any commission, bonus, rebate, kickback, or bribe, directly or indirectly, in cash or in kind, or engage in any split-fee arrangement, in any form whatsoever, to induce the referral of patients or patronage to or from a health care provider or health care facility;
817.505 Patient Brokering (b) Solicit or receive any commission, bonus, rebate, kickback, or bribe, directly or indirectly, in cash or in kind, or engage in any split-fee arrangement, in any form whatsoever, in return for referring patients or patronage to or from a health care provider or health care facility; (c) Solicit or receive any commission, bonus, rebate, kickback, or bribe, directly or indirectly, in cash or in kind, or engage in any split-fee arrangement, in any form whatsoever, in return for the acceptance or acknowledgement of treatment from a health care provider or health care facility; or (d) Aid, abet, advise, or otherwise participate in the conduct prohibited under paragraph (a), paragraph (b), or paragraph (c)
The Attorneys Essential players in many PIP fraud schemes; often insulated from direct contact / involvement Some have their own runners or investigators Receive direct referrals from clinic owners; some have offices in the clinic; many meet with and sign up clients in the clinic One goal is to obstruct insurance company through representation in PIP claim represent the patient, but really acting on the behalf of the clinic Represent clinic in PIP suits; obtain legal fees that often dwarf the claim amounts
Lawyer Referral Services Prior investigations have shown that advertising is sometimes used to cover illegal solicitation The advertising costs can also be used to conceal patient brokering The type of advertising, including some of the target audiences, send a message that if you are in an accident, you are entitled to $10,000 Not always clear that the $10,000 is going to the clinic or attorney and not necessarily the person in the crash Our investigations have shown that many persons involved in accidents know that whether they are hurt or not, they can get some money
Lawyer Referral Services Attorney Attorney Clinic Clinic Lawyer Referral Service 1-800-123-OUCH MRI Facility MRI Facility Attorney Clinic
Lawyer Referral Services Attorney LRS is the advertising conduit fees are paid by each of the individuals to get referrals from the LRS Clinic Attorney MRI Facility Lawyer Referral Service 1-800-123-OUCH Clinic Attorney MRI Facility If the rates were the same each month, no matter how many referrals are involved probably okay When the monthly rate changes based on the number of referrals, for example 5 referrals @ $1,000 each in January = $5,000; 10 referrals at $1,000 each in February = $10,000 Clinic That would be patient brokering and illegal
Lawyer Referral Services Attorney Attorney Clinic Without the LRS, the clinics, attorneys and MRI facilities just send referrals back and forth for money The LRS becomes the advertiser and broker Clinic Lawyer Referral Service 1-800-123-OUCH MRI Facility MRI Facility Attorney Clinic
Case # 1 Scenario Jimmy is involved in auto accident, sees the commercial and calls to get info on medical services, so he calls 1-800-123- OUCH to go to clinic Jimmy is referred to Miami Accident Treatment Center When Jimmy arrives at clinic, Mary from attorney Jason Whiplash s office is waiting and meets him in the lobby before he is seen by a doctor Why is the lawyer there? Who contacted the lawyer to tell him about Jimmy? Why is the lawyer necessary? What interest does the lawyer have?
Case # 2 Scenario Billy is involved in auto accident, and calls 1-800-123-OUCH for referral to a clinic and medical treatment Billy is referred to Miami Accident Treatment Center When Billy arrives at clinic, he is given a packet of paperwork to sign by the clinic receptionist before he is seen by a doctor. Included in the paperwork is a retainer contract for the law firm of Jason Whiplash This contract is not explained to him, Billy signs it along with the other 30 pages in the packet, including fraudulent treatment forms Billy has no idea he has an attorney
Case # 3 Scenario Betty is involved in auto accident Betty calls 1-800-123-OUCH to go to a clinic for medical treatment Betty is referred to Miami Accident Treatment Center When Betty arrives at clinic, the receptionist tells her she needs to go to the lawyer s office and meet with Jason Whiplash in order to treat at this clinic
Case # 4 Scenario On Monday, Barney is involved in auto accident, sees the ad where he can get medical treatment and calls 1-800-123- OUCH to go to clinic Barney is referred to Miami Accident Treatment Center, and is given an appointment in two days for Wednesday However, on Monday night, an investigator shows up at Barney s house and says that the LRS sent them to sign him up with an attorney
Case # 5 Scenario Larry is involved in auto accident, sees the ad where he can get medical treatment and calls 1-800-123-OUCH to go to clinic Larry is referred to Miami Accident Treatment Center When Larry arrives at the clinic, Mary from attorney Jason Whiplash s office is waiting and meets with him before he sees a doctor Larry says he has an attorney, and he does not need the services of Jason Whiplash Mary says that Miami Accident Treatment Center only works with Jason Whiplash, and Larry must use them if he intends to treat here
Miscellaneous Issues Why would an attorney instruct his client not to answer the question at an insurance company EUO (Examination Under Oath) How did you get to your attorney? Why does the medical professional feel the need to refer a patient to an attorney? What does that have to do with the treatment of the patient, and the provider s responsibility to heal? Why does a lawyer need to work with a medical professional who will give a disability rating to the patient / client? How does the lawyer ethically represent the client / patient at the same time he represents the clinic? Is he able to represent the patient if the clinic is his client?