When the business is the target
Insurance fraud cases are not only about individual claimants. Medical practices, physical therapy clinics, pharmacies, body shops, towing companies, contractors, and public adjusters can all be accused of submitting or inflating claims. In New York, insurers sometimes bring civil lawsuits against groups of providers, alleging a pattern of fraudulent billing and seeking repayment and a ruling that pending claims need not be paid; some of these suits invoke the federal racketeering law. Questions about who actually owns and controls a medical practice can also lead insurers to refuse no-fault payments, apart from whether the treatment was provided. Insurers report suspected fraud to the Department of Financial Services, which can refer cases to prosecutors.
Records that matter
Gather patient or customer files, treatment and repair records, billing submissions, payment histories, and the corporate documents showing who owns the business and who manages its money. Management agreements, leases, and arrangements with billing companies are often at the center of these cases, because they can show who really controls the business. Keep examination under oath transcripts and correspondence with each insurer, and do not alter records after a request arrives. If employees are contacted by investigators, they are entitled to speak with counsel, and the business should not discourage them from doing so. Billing staff and office managers are often the first people investigators approach, because they know how claims were actually prepared.
Coordinating the fronts
A business may face claim denials in arbitration, an insurer's lawsuit in court, a regulator's inquiry, and a criminal investigation, sometimes all at once. Positions taken in one can affect the others, so the order of responses matters. The first step is identifying which proceedings exist, which insurers are involved, and what each has alleged, and we review ownership and management structures for the issues insurers commonly raise. We then discuss whether the business should defend, negotiate, or restructure, and whether any individual needs separate counsel.
