MIAMI – GEICO has filed a federal lawsuit against another group of Florida health clinics, accusing the offices and its owners of insurance fraud.
GEICO filed its lawsuit in U.S. District Court for the Southern District of Florida, Miami Division.
The complaint is similar to another lawsuit filed in December against a group of Florida chiropractic clinics.
The named defendants in last month’s filing are: DG Esthetic and Therapy Center Inc., doing business as DG Medical Center; Miami Blu Sky Medical Center Inc.; OMC Rehab Center LLC; Preferred Rehab of Miami Inc.; Dania Lima; Mercedes Ramirez Sanchez; Alexeis Gonzalez Lacosta; Omar Castaneda; Carlos Fernandez Mesa; Mailin Rivero Ortega, M.D.; and Lauren Scott McCarver, M.D.
GEICO, in its 89-page complaint, seeks more than $1.75 million. The insurer alleges the clinics wrongfully obtained the money by submitting thousands of fraudulent and unlawful no-fault or Personal Injury Protection insurance charges.
The PIP charges, GEICO alleges, were related to “medically unnecessary, illusory, unlawful, and otherwise non-reimbursable health care services.” These include patient exams, physical therapy services, and percutaneous electrical nerve stimulation, or PENS, treatments.
PIP benefits primarily cover medical costs, lost wages, and essential services – like childcare/housekeeping – after a car accident, regardless of fault.
GEICO also seeks a declaration that it is not legally obligated to pay for reimbursements of more than $75,000 in pending PIP claims that the defendants have submitted.
The fraudulent services purportedly were provided to individuals who claimed to have been involved in automobile accidents and were eligible for insurance coverage under GEICO PIP insurance policies, the insurer contends.
“The Defendants at all relevant times have known that their PIP insurance charges were fraudulent, unlawful, and ineligible for payment for the reasons set forth herein,” the complaint states. “As such, the Defendants do not now have – and never had – any right to be compensated for the Fraudulent Services that were billed through the Clinic Defendants to GEICO.”
According to the complaint, DG Esthetic was owned and controlled by Lima; Sanchez owned and controlled Miami Blu Sky between January 2022 and September 2022; Lacosta owned and controlled Miami Blu Sky between September 2022 and the present; Castaneda owned and controlled OMC Rehab; and Mesa owned and controlled Preferred Rehab.
GEICO’s lawsuit alleges Ortega falsely purported to serve as Miami Blu Sky’s medical director from November 2021 until December 2023.
The insurer also alleges McCarver falsely purported to serve as DG Esthetic’s medical director from September 2021 to the present, as Miami Blu Sky’s medical director from January 2024 to the present, as OMC Rehab’s medical director from May 2024 to the present, and as Preferred Rehab’s medical director from August 2021 to the present.
“McCarver and Ortega never ensured that all health care practitioners at the respective Clinic Defendants had active appropriate certification or licensure for the level of care being provided, and instead permitted the respective Clinic Defendants to unlawfully bill for physical therapy services that had been performed – to the extent that they were performed at all – by massage therapists and unlicensed/unsupervised individuals,” the complaint states.
GEICO contends McCarver and Ortega never legitimately served as records owners at the clinics, “inasmuch as they did not legitimately develop and implement policies, standards, and procedures to protect the confidentiality and security of patients’ medical records at the respective Clinic Defendants, and did not legitimately train the respective Clinic Defendants’ employees in such policies, standards, and procedures.”
Under the Florida Health Care Clinic Act, no health care clinic in the state may operate without the day-to-day supervision of a physician-medical director, the lawsuit points out. The law regulates entities that provide medical services and bill insurance.
McCarver and Ortega never provided legitimate supervision at any of the clinics, GEICO alleges.
“They only occasionally were present at the respective clinics during their purported tenures as ‘medical director,’ if at all,” the lawsuit states, adding that McCarver primarily resided in Arizona during her tenure.
“Had McCarver legitimately systematically reviewed the Clinic Defendants’ billings to ensure that they were neither fraudulent nor unlawful, and had Ortega legitimately systematically reviewed Miami Blu Sky’s billings to ensure that they were neither fraudulent nor unlawful, they would have noted – among other things – that each of the Clinic Defendants unlawfully engaged in the general business practice of waiving, or failing to make a good-faith effort to collect, deductibles from their patients in violation of the False and Fraudulent Insurance Claims Statute, and they would have taken immediate corrective action.”
In addition to compensatory damages, GEICO seeks punitive damages, treble damages, and attorneys’ fees
Jacksonville firm Rivkin Radler LLP is representing GEICO in the action.
