Government Employees Insurance v. Korn

310 F.R.D. 125, 2015 U.S. Dist. LEXIS 121754, 2015 WL 5334503
CourtDistrict Court, D. New Jersey
DecidedSeptember 14, 2015
DocketCivil No. 14-5742 (JEI/KMW)
StatusPublished
Cited by7 cases

This text of 310 F.R.D. 125 (Government Employees Insurance v. Korn) is published on Counsel Stack Legal Research, covering District Court, D. New Jersey primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Government Employees Insurance v. Korn, 310 F.R.D. 125, 2015 U.S. Dist. LEXIS 121754, 2015 WL 5334503 (D.N.J. 2015).

Opinion

OPINION

IRENAS, Senior District Judge:

Plaintiffs Government Employees Insurance Co. (“GEICO”)1 claim that Defendants — (1) Mr. Edward McMenamin and Cu-ramed, LLC; (2) Dr. Russell Abrams and Neurology Pain Associates, P.C.; and (3) Dr. Alfred Tawadrous and Primary Care & Rehabilitation, P.C.2 — conspired to commit large-scale and coordinated insurance fraud by routinely billing GEICO for medically unnecessary, or nonexistent, services provided to Defendants’ patients who are GEICO’s insureds.

As the many cases cited infra will demonstrate, Defendants’ alleged fraudulent scheme is not a novel one, nor are the legal claims asserted against Defendants. Nonetheless, the Defendants all presently move, pursuant to Fed.R.Civ.P. 12(b)(6), to dismiss the federal RICO claims asserted against them.

Defendants Dr. Abrams and Neurology Pain, as well as Defendants Dr. Tawadrous and Primary Care, also raise additional arguments, including GEICO’s failure to join its insureds as “interested parties.”

For the reasons stated herein, Defendants’ Motions will be denied in their entirety.

I.

The extent of the alleged fraudulent scheme — which allegedly began “as early as 2005,” Compl. ¶ 6 — is very large. GEICO seeks to recover more than $2.5 million in paid claims, and seeks a declaration that it is not obligated to pay an additional $3.1 million in pending claims. All claims allegedly arise out of fraudulent services provided, or purportedly provided, to Defendants’ patients who have no-fault automobile insurance policies with GEICO.

Defendant McMenamin — who, significantly, is not a licensed physician — allegedly was the orehestrator of the fraud. Through his limited liability company, Curamed, McMe-namin allegedly directed the fraudulent activities of Defendants Neurology Pain, and Primary Care which were the medical practices treating or purporting to treat patients involved in automobile accidents, and submitting the fraudulent claims to GEICO.

Defendants Dr. Abrams and Dr. Tawad-rous are alleged to be the nominal or “paper owners” of Neurology Pain and Primary Care respectively, although the Complaint asserts that the true owner of both are Defendants McMenamin and Curamed. Doctors Abrams and Tawadrous are alleged to have “sold the use of [their] medical licensees],” Compl. ¶¶ 56, 78, to McMenamin and Curamed so that McMenamin and Cu-ramed could secretly and unlawfully own and [128]*128control the medical practices.3 The doctors treated — or purported to treat — the patients, and allegedly received “a salary or some other form of compensation,” Compl. ¶ 51, in return.

The scheme allegedly operated in the following manner.

Neurology Pain and Primary Care did not “advertise or market [their] services to the general public.” Compl. ¶85. Instead, patients came to them either through referrals from personal injury attorneys, or “through illegal kickback and self-referral arrangements between and among Neurology Pain and Primary Care.” Compl. ¶ 86.4 The referrals themselves are alleged to be medically unnecessary insofar as GEICO asserts that many of the insureds were involved in relatively minor accidents that did not result in “any significant injuries or health problems.” Compl. ¶ 99.

Once referred to the medical practices, the treatment insureds received is alleged to have been provided “without regard for [their] individual presentment or symptoms,” Compl. ¶ 81, but rather, “pursuant to a predetermined, fraudulent protocol designed to maximize the billing” of GEICO. Compl. ¶ 80.

The alleged misrepresentations made pursuant to the protocol include, inter alia:

• Exaggerating the severity of patients’ injuries, Compl. ¶¶ 102-03;
• Grossly overstating the amount of time doctors spent in face-to-face time with patients, Compl. ¶¶ 104-05;
• Stating that “comprehensive” and “detailed” patient histories were taken when they were not, Compl. ¶¶ 106-13;
• Stating that “comprehensive” and “detailed” examinations were performed when they were not, Compl. ¶¶ 116-22; and
• Overstating the complexity of the medical decisionmaking, Compl. ¶ 128.

The misrepresentations were then allegedly covered-up by phony medical reports containing “boilerplate ‘diagnoses’ ” such as “myofascial pain syndrome,” “tendonitis,” “occipital neuralgia,” “herniated disc,” or “bulging disc.” Compl. ¶ 135.

GEICO asserts that the falsity of these diagnoses and reports may be inferred from the alleged facts that (a) “large numbers” of the reports contain large amounts of “identical information”'that appear to be “cut-and-pasted” from one report to the next, Compl. ¶ 138-415; (b) the diagnoses were “in many cases contravened by contemporaneous hospital records, police reports, or records from other treating providers” Compl. ¶ 1426; and (c) diagnoses of sprains or strains were, “in many cases,” made “months or even years” after accidents occurred, and long after “any genuine problems ... would have resolved,” Compl. ¶ 1437.

The fake reports were then allegedly used to support further unnecessary treatment. Treatments provided by Primary Care included “follow-up examinations, trigger point injections, ‘spray and stretch’ treatments, and PENS sessions.” Comp. ¶¶ 136, 144. Treatments provided by Neurology Pain included brain-mapping, brainstem auditory evoked potential (“BAEP”) tests, and visual evoked potential (“VEP”) tests. Compl. ¶ 207.

With respect to the trigger point injections, GEICO cites testimony of four insureds who stated under oath that they did not receive trigger point injections on certain dates, or in certain places, yet GEICO asserts that Primary Care billed GEICO for those treatments. Compl. ¶ 183.

Likewise, as to the “spray and stretch” treatments, GEICO cites testimony of five [129]*129insureds who stated under oath that they did not receive spray and stretch treatments on certain dates, yet GEICO asserts that Primary Care billed GEICO for those treatments. Compl. ¶ 206.

HCFA-1500 forms are the forms Defendants used to bill GEICO. GEICO alleges that “thousands” of these forms submitted by Defendants to GEICO were false and misleading in three material respects: (1) they represented that Primary Care and Neurology Pain were in compliance will “all significant qualifying requirements of law,” Compl. ¶ 226, when they were not, because Primary Care and Neurology Pain were owned and controlled by a non-physician; (2) they billed for medically unnecessary treatments; and (3) they billed for treatments and services that were never provided.

The Complaint asserts New Jersey common law claims for fraud, aiding and abetting fraud, and unjust enrichment. It also asserts violations of the New Jersey Insurance Fraud Prevention Act, N.J.S.A. 17:33A-1 et seq., and the federal RICO statute, 18 U.S.C. §§ 1962(c) and (d).

II.

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Bluebook (online)
310 F.R.D. 125, 2015 U.S. Dist. LEXIS 121754, 2015 WL 5334503, Counsel Stack Legal Research, https://law.counselstack.com/opinion/government-employees-insurance-v-korn-njd-2015.