2008 Insurance Fraud Fighting Resolutions

The Barry Zalma’s Insurance Fraud Letter has started 2008 off with a bang, an opening shot at combating insurance fraud.  You can read the entire article here.

He writes:

  “As the US economy slows and the value of the dollar drops people turn to insurance fraud as a “safe” crime where their financial problems can be cured. Arson for profit, fake thefts, fake injuries all grow logarithmically as it becomes more difficult to earn an honest living.” 

 Zalma puts forth a ten point plan to fight this growth. Zalma also talks about Cardozo law professor, Lester Brickman’s, 12/16/07 Wall Street Journal editorial in which Brickman takes issue with the DOJ, as follows:

“The defects of the U.S. Department of Justice have been the subject of much commentary. But the allegations of incompetence or worse pale when compared to the free pass it has given to doctors and lawyers to commit mass tort fraud, exceeding $30 billion in the past 15 years.”“A comparative handful of doctors and technicians are responsible for the vast majority of bogus medical tests and diagnoses.” “To indict and prosecute those responsible would require testimony from other doctors that the mass-produced diagnoses cannot have been rendered in good faith.”

From the Zalma Insurance Fraud Letter:

“The lawyers sponsoring these screenings have paid over $100 million for medical reports to support the 700,000 or more claims generated by these screenings. There is compelling evidence, that the vast majority of these medical reports, including chest X-ray readings, echocardiograms, pulmonary function tests and diagnoses were bogus.”

I wrote a blog entry recently about CXS Railroad asbestosis cases which illustrates the type of fraud Zalma and Brickman are talking about.  In it the doctor would sometimes see patients at the rate of one per minute, he admitted to not physically examining patients, and first he diagnosed 1807 patients with asbestosis only and then later re-diagnosed the same 1807 for silicosis as well.  As if having a doctor rubber stamp the diagnosis weren’t easy enough, one case completely fabricated a diagnosing doctor that didn’t even exist.

Zalma theorizes the reason that nothing is being done is that “insurance companies are just not sufficiently likeable victims.”

For my plaintiff clients and readers, the Esoteric Appeal blog offers the following commentary on the subject:

“My question, though, is in an adversarial system, where these diagnoses aren’t submitted to insurance companies, or medicare, can it really be fraud? The idea is to prove if there really is asbestosis, and if there is to prove who caused it. How can one party trying to prove their case be fraudulent?”

“Now, if it were fraudulent, and as a result, false claims were made to governmental entities, or other groups which can result in prosecution, then I say go for it, but you still have the problem of dueling experts. In short, I don’t think you can prosecute fraud that’s wholly contained in the adversarial process.”

S.P.I. is a full service investigation firm specializing in insurance fraud detection via medical record canvasses and provides medical record reviews for both plaintiff and defense clients.