Holland & Knight - Insurance Fraud and Recovery

Insurance Fraud and Recovery  Holland & Knight's nationwide Insurance Fraud and Recovery Team is distinguished by the scope of our experience and results obtained in federal and state courts, the number of attorneys devoted to this practice area and the depth of our knowledge gained from working with some of the nation's largest insurance carriers.  During the past 12 years, the attorneys on our team have helped clients recover and/or resist more than $150 million in exposure or potential loss in connection with fraudulent schemes.  Holland & Knight attorneys work closely with insurance company in-house special investigation units to develop investigative techniques and provide legal guidance as part of our extensive collaboration with client teams.

OVERVIEW Holland & Knight's Insurance Fraud and Recovery Team is built on three principles:  Our attorneys have an in-depth understanding of our clients' business operations.  We provide guidance on questions of law and investigative issues to develop appropriate resolution strategies.  When appropriate and necessary, we protect the rights of insurance carrier clients through litigation to recover the financial losses suffered as a result of unlawful acts and to stop the illegal behavior.

Healthcare fraud costs insurers anywhere between $70 billion and $234 billion each year, harming both patients and taxpayers, and property and casualty insurers lose more than $30 billion each year to fraud, according to industry data. Insurance fraud has evolved into a sophisticated, systemic enterprise with the large-scale participation of unethical providers and organized crime.

The magnitude and sophistication of the schemes to defraud requires lawyers of equal sophistication and experience. The nationwide Insurance Fraud and Recovery Team consists of experienced litigators who focus their careers on understanding the varying fraudulent schemes, the statutory and legal framework within which the schemes operate, and helping clients recover misappropriated assets and payments made for unlawful claims. Our team includes former prosecutors who have tried hundreds of cases to verdict and attorneys with decades of experience in complex commercial litigation and trials.

Based on the number of lawyers and resources we dedicate to this area and the value of our recoveries and anti-fraud efforts, we are one of the leading law firms in the insurance fraud recovery space.

We also represent self-insured retailers, investors, trusts and individuals who are victims of large-scale fraud. In all cases, our approach is to lay the groundwork for identifying and investigating unlawful claims and recovering any amounts paid in the courts, if necessary.

WHAT WE DO Our objective is to deeply understand the circumstances our insurer clients face when evaluating claims so that our team can identify fraud and unlawful efforts to obtain insurance benefits. We investigate all aspects of insurance fraud and litigate these issues in virtually all U.S. jurisdictions to recover the losses and stop the concerted actions to defraud our clients.

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Suspected fraud comes to our attention through a variety of avenues. Clients regularly uncover suspicious activity and payment patterns through the use of data analytics. Evidence often is datadriven, and we have broad experience using data analytics to quickly identify patterns and other indicators of fraud. Whistleblowers, tipsters, patients and insureds also inform clients of suspected conduct, and we frequently manage such investigations based on information obtained from these third parties. In all cases, we provide guidance to our clients, collaborating closely with clients' special investigation units (SIUs), to investigate the suspected unlawful conduct. Our attorneys immerse themselves in our clients' internal processes and procedures, and we often provide teaching or consulting on general investigative issues to our clients' SIUs.

COUNSEL TO AMERICA'S INSURERS Holland & Knight represents some of the nation's largest healthcare and property and casualty insurance companies. Healthcare now represents almost a quarter of the U.S. gross national product (GNP), and the opportunity for fraud is enormous. Our group was formed with the recognition that effective investigations and recovery require a deep understanding of the complex laws and regulations that govern healthcare reimbursement, licensing and reporting, as well as the protocols and culture of the industry and medical profession. While individuals continue to commit fraud, we have found that many schemes are large-scale criminal enterprises that mix legitimate care with illegal claims, referrals and other self-dealing. The practice of medicine grows more complex every day, and our attorneys familiarize themselves with the minutiae of diagnosis, treatment and reimbursement in order to recognize fraud. Our team has a deep understanding of the medicines involved in the claims that we are asked to review, and we have longstanding relationships with the nation's leading experts who guide the analysis of appropriate medical treatment.

Our long experience with many versions of fraudulent schemes allows us to help our clients establish prevention and detection programs and identify gaps in their protection and opportunities for exploitation. Representative successes on behalf of our property and casualty and health insurer clients include:  Obtained a ruling of first impression that it is fraudulent to present bodily injury claims to insurer where the medical bills have been sold without disclosing the details of the transaction to the carrier  Represented the nation's largest property and casualty insurance company in the first attempt by the insurance sector to sue a medical legal referral service in connection with the submission of alleged fraudulent claims in violation of Florida's self-referral laws  Obtained summary judgment in favor of the plaintiff and established law that provides a clinic license obtained by fraud is void ab initio  Prosecuted Racketeer Influenced and Corrupt Organizations Act (RICO), fraud and deceptive trade practice claims, including action on behalf of insurance carriers seeking in excess of $35 million in damages against physicians, surgery centers and medical practice managers for certain spinal procedures performed on personal injury claimants  Represented a national health insurer in federal court against a substance use disorder facility and associated laboratory, detox facility and marketing arm involving claims of fraud, violations of Florida's Deceptive and Unfair Trade Practice Act (FDUTPA) and unjust enrichment pertaining to performance of unnecessary and unlawful urine drug testing, as well as the inappropriate use of marketing entities and the unlawful brokering of patients

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 Advanced counterclaims against related substance use disorder providers in numerous states alleging schemes involving patient brokering, referrals for unnecessary and non U.S. Food and Drug Administration (FDA) approved ancillary services and violations of the federal Elimination of Kickbacks in Recovery Act (EKRA)  Secured dismissals of provider claims for failure to properly plead Employee Retirement Income Security Act (ERISA)-related causes of action, while asserting counterclaims for fraudulent conduct involving exploitation of patients through the inappropriate use of urine drug testing and failure to comply with state and federal law

STAYING CURRENT WITH INNOVATION AND ENFORCEMENT TOOLS While lawmaking in Washington, D.C., receives the most attention, there are hundreds of state laws that affect our clients, and we follow those developments closely since many of our clients operate in multiple jurisdictions. On the state level, 116 fraud-related bills were introduced in 2018, and 33 passed, according to the Insurance Journal. The new laws address nearly every aspect of insurance fraud, and most will create new tools to prevent fraud or enable recovery. However, the laws also address insurer responsibilities, particularly in the area of data privacy, and we advise clients on how to use these investigative data in compliance with all state and federal laws.

PRIMARY CONTACTS David I. Spector

Sandra L. Heller

Partner | West Palm Beach 561.650.8304 david.spector@hklaw.com

Partner | West Palm Beach 561.650.8376 sandra.heller@hklaw.com

Andrew M. Loewenstein Partner | West Palm Beach 561.650.8354 andrew.loewenstein@hklaw.com

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