Case 2:21-cv-19408 Document 1 Filed 10/28/21 Page 1 of 125 PageID: 1
`
`
`
`Gene Y. Kang, Esq.
`Barry I. Levy, Esq. (to be admitted pro hac vice)
`Max Gershenoff, Esq. (to be admitted pro hac vice)
`Christina Bezas, Esq. (to be admitted pro hac vice)
`RIVKIN RADLER LLP
`25 Main Street, Suite 501
`Court Plaza North
`Hackensack, New Jersey 07601
`(201) 287–2460
`gene.kang@rivkin.com
`
`Counsel for Plaintiffs Government Employees Insurance
`Co., GEICO Indemnity Co., GEICO General Insurance
`Company and GEICO Casualty Co.
`
`
`
`
`UNITED STATES DISTRICT COURT
`DISTRICT OF NEW JERSEY
`
`
`
`GOVERNMENT EMPLOYEES INSURANCE CO., GEICO
`INDEMNITY CO., GEICO GENERAL INSURANCE COMPANY,
`and GEICO CASUALTY CO.,
`
`
`
`
`Case No.:
`
`
`
`
`COMPLAINT
`
`Plaintiffs Demand
`a Trial by Jury
`
`Plaintiffs,
`
`
`
`
`–against–
`
`
`
`EAST COAST SPINE, JOINT AND SPORTS MEDICINE
`PROFESSIONAL ASSOCIATION d/b/a THE SPINE AND
`SPORTS HEALTH CENTER, ALEXANDER VISCO, M.D.,
`MICHAEL KELLY, D.C., RON BEN-MEIR, D.O., FERDINAND
`IANNACCONE, D.O., BASIL KURDALI, M.D., NEIL
`TROPIANO, D.C., PRISCILLA AMPONSAH, P.T., JOHN DE
`HOYOS, P.T., TORAL DOSHI, P.T., NIDHI MADHANI, P.T.,
`ADITI MEHTA, P.T., and JUAN C. NUNEZ, P.T.,
`
`
`Defendants.
`
`
`Plaintiffs Government Employees Insurance Co., GEICO Indemnity Co., GEICO General
`
`Insurance Company and GEICO Casualty Co. (collectively “GEICO” or “Plaintiffs”), as and for
`
`their Complaint against the Defendants, hereby allege as follows:
`
`
`
`
`
`

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`
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`
`
`INTRODUCTION
`
`1.
`
`This action seeks to recover more than $1,900,000.00 that the Defendants
`
`wrongfully have obtained from GEICO by submitting, and causing to be submitted, thousands of
`
`fraudulent no-fault insurance charges through East Coast Spine, Joint and Sports Medicine
`
`Professional Association d/b/a The Spine and Sports Health Center (“East Coast Spine”) for
`
`purported
`
`initial examinations,
`
`follow-up examinations, pain management
`
`injections,
`
`electrodiagnostic testing services, and chiropractic services/physical therapy services (the
`
`purported
`
`initial examinations,
`
`follow-up examinations, pain management
`
`injections,
`
`electrodiagnostic testing services, and chiropractic/physical therapy services are referred to
`
`hereinafter as the “Fraudulent Services”).
`
`2.
`
`The Fraudulent Services purportedly were provided, to the extent that they were
`
`provided at all, to individuals (“Insureds”) who claimed to have been involved in automobile
`
`accidents and were eligible for insurance coverage under GEICO no-fault insurance policies.
`
`3.
`
`In addition, GEICO seeks a declaration that, between at least 2013 and the present,
`
`East Coast Spine and its owners, Defendants Michael Kelly, D.C. (“Kelly”) and Alexander Visco,
`
`M.D. (“Visco”), were not in compliance with the relevant laws and regulations governing
`
`healthcare practice in New Jersey, because they had an unlawful corporate structure, engaged in
`
`an unlawful self-referral scheme, billed for medically unnecessary Fraudulent Services, and
`
`misrepresented and exaggerated the level of services that purportedly were provided in order to
`
`inflate the charges submitted to GEICO.
`
`4.
`
`The Defendants fall into the following categories:
`
`
`
`2
`
`

`

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`(i)
`
`(ii)
`
`Defendant East Coast Spine is a New Jersey medical professional association
`through which many of the Fraudulent Services purportedly were provided and
`billed to insurance companies, including GEICO.
`
`Defendant Kelly is a chiropractor licensed to practice chiropractic in New Jersey,
`was the controlling member of East Coast Spine, and purported to perform many
`of the Fraudulent Services on behalf of East Coast Spine.
`
`(iii) Defendant Visco is a physician licensed to practice medicine in New Jersey,
`purported to be a member of East Coast Spine, and purported to perform many of
`the Fraudulent Services on behalf of East Coast Spine.
`
`
`(iv) Defendants Ron Ben-Meir, D.O. (“Ben-Meir”), Ferdinand Iannaccone, D.O.
`(“Iannaccone”), and Basil Kurdali, M.D. (“Kurdali”) are physicians licensed to
`practice medicine in New Jersey, and purported to perform many of the Fraudulent
`Services on behalf of East Coast Spine.
`
`
`(v)
`
`Defendant Neil Tropiano, D.C. (“Tropiano”) is a chiropractor licensed to practice
`chiropractic in New Jersey, and purported to perform many of the Fraudulent
`Services on behalf of East Coast Spine.
`
`
`(vi) Defendants Priscilla Amponsah, P.T. (“Amponsah”), John De Hoyos, P.T. (“De
`Hoyos”), Toral Doshi, P.T. (“Doshi”), Nidhi Madhani, P.T. (“Madhani”), Aditi
`Mehta, P.T. (“Mehta”), and Juan C. Nunez, P.T. (“Nunez”) are physical therapists
`licensed to practice physical therapy in New Jersey, and purported to perform many
`of the Fraudulent Services on behalf of East Coast Spine.
`
`As discussed below, the Defendants at all relevant times have known that:
`
`the Defendants were not in compliance with significant laws and regulations
`governing healthcare practice in New Jersey and as a result, were not eligible to
`receive no-fault insurance reimbursement in the first instance;
`
`the Fraudulent Services were not provided in compliance with significant laws and
`regulations governing healthcare practice in New Jersey and, as a result, were not
`eligible for no-fault insurance reimbursement in the first instance;
`
`the Fraudulent Services were not medically necessary, and were provided – to the
`extent that they were provided at all – pursuant to pre-determined fraudulent
`protocols designed solely to financially enrich the Defendants, rather than to treat
`or otherwise benefit the Insureds who were subjected to them;
`
`in many cases, the Fraudulent Services were never provided in the first instance;
`and
`
`5.
`
`(i)
`
`(ii)
`
`
`(iii)
`
`
`(iv)
`
`
`
`3
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`

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`
`
`
`
`(v)
`
`the billing codes used for the Fraudulent Services misrepresented and exaggerated
`the level of services that purportedly were provided in order to inflate the charges
`submitted to GEICO.
`
`6.
`
`As such, Defendants East Coast Spine, Kelly, Visco, Ben-Meir, Iannaccone,
`
`Kurdali, Tropiano, Amponsah, De Hoyos, Doshi, Madhani, Mehta, and Nunez do not now have –
`
`and never had – any right to be compensated for the Fraudulent Services that were billed to GEICO
`
`through East Coast Spine.
`
`7.
`
`The chart annexed hereto as Exhibit “1” sets forth a representative sample of the
`
`fraudulent claims that have been identified to date that the Defendants submitted, or caused to be
`
`submitted, to GEICO.
`
`8.
`
`The Defendants’ fraudulent scheme began as early as 2013 and has continued
`
`uninterrupted since that time. As a result of the Defendants’ scheme, GEICO has incurred damages
`
`of more than $1,900,000.00.
`
`I.
`
`Plaintiffs
`
`THE PARTIES
`
`9.
`
`Plaintiffs Government Employees Insurance Co., GEICO Indemnity Co., GEICO
`
`General Insurance Company, and GEICO Casualty Co. are Maryland corporations with their
`
`principal places of business in Chevy Chase, Maryland. GEICO is authorized to conduct business
`
`and to issue automobile insurance policies in New Jersey.
`
`II.
`
`Defendants
`
`10.
`
`Defendant East Coast Spine is a New Jersey medical professional association with
`
`its principal place of business in New Jersey. East Coast Spine was incorporated on or about
`
`October 9, 2007, and since late 2011, has been doing business as “The Spine and Sports Health
`
`Center”. What is more, since 2015, East Coast Spine has also been doing business as “The
`
`
`
`4
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`

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`
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`Orthopedic Health Center”. East Coast Spine has Kelly and Visco as its sole members, and was
`
`used by the Defendants as a vehicle to submit fraudulent billing to GEICO.
`
`11.
`
`Defendant Kelly resides in and is a citizen of New Jersey. Kelly was licensed to
`
`practice chiropractic in New Jersey in 1999, was the controlling member of East Coast Spine, and
`
`purported to perform many of the Fraudulent Services on behalf of East Coast Spine.
`
`12.
`
`Defendant Visco resides in and is a citizen of New Jersey. Visco was licensed to
`
`practice medicine in New Jersey in 2004, purported to be a member of East Coast Spine, and
`
`purported to perform many of the Fraudulent Services on behalf of East Coast Spine.
`
`13.
`
`Defendant Ben-Meir resides in and is a citizen of New Jersey. Ben-Meir was
`
`licensed to practice medicine in New Jersey in 2012, and purported to perform many of the
`
`Fraudulent Services on behalf of East Coast Spine.
`
`14.
`
`Defendant Iannaccone resides in and is a citizen of New Jersey. Iannaccone was
`
`licensed to practice medicine in New Jersey in 2017, and purported to perform many of the
`
`Fraudulent Services on behalf of East Coast Spine.
`
`15.
`
`Defendant Kurdali resides in and is a citizen of New Jersey. Kurdali was licensed
`
`to practice medicine in New Jersey in 2011, and purported to perform many of the Fraudulent
`
`Services on behalf of East Coast Spine.
`
`16.
`
`Defendant Tropiano resides in and is a citizen of New Jersey. Tropiano was
`
`licensed to practice chiropractic in New Jersey in 2013, and purported to perform many of the
`
`Fraudulent Services on behalf of East Coast Spine.
`
`17.
`
`Defendant Amponsah resides in and is a citizen of New Jersey. Amponsah was
`
`licensed to practice physical therapy in New Jersey in 2012, and purported to perform many of the
`
`Fraudulent Services on behalf of East Coast Spine.
`
`
`
`5
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`

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`18.
`
`Defendant De Hoyos resides in and is a citizen of New Jersey. De Hoyos was
`
`licensed to practice physical therapy in New Jersey in 2007, and purported to perform many of the
`
`Fraudulent Services on behalf of East Coast Spine.
`
`19.
`
`Defendant Doshi resides in and is a citizen of New Jersey. Doshi was licensed to
`
`practice physical therapy in New Jersey in 2019, and purported to perform many of the Fraudulent
`
`Services on behalf of East Coast Spine.
`
`20.
`
`Defendant Madhani resides in and is a citizen of New Hampshire. Madhani was
`
`licensed to practice physical therapy in New Jersey in 2017, and purported to perform many of the
`
`Fraudulent Services on behalf of East Coast Spine.
`
`21.
`
`Defendant Mehta resides in and is a citizen of New Jersey. Madhani was licensed
`
`to practice physical therapy in New Jersey in 2012, and purported to perform many of the
`
`Fraudulent Services on behalf of East Coast Spine.
`
`22.
`
`Defendant Nunez resides in and is a citizen of New Jersey. Nunez was licensed to
`
`practice physical therapy in New Jersey in 2003, and purported to perform many of the Fraudulent
`
`Services on behalf of East Coast Spine.
`
`II.
`
`Pleasantdale Ambulatory Care, LLC
`
`23.
`
`Although it has not been named as a Defendant in this action, Pleasantdale
`
`Ambulatory Care, LLC (“Pleasantdale ASC”), a New Jersey ambulatory surgery center, is relevant
`
`to understanding the Defendants’ fraudulent scheme and the claims brought in this action.
`
`24.
`
`Pleasantdale ASC is a New Jersey limited liability company with its principal place
`
`of business in New Jersey. Pleasantdale ASC is licensed in New Jersey as an ambulatory care
`
`facility and was initially licensed as an ambulatory care facility on or about October 12, 2013.
`
`
`
`6
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`

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`
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`Pleasantdale ASC was organized on or about December 12, 2012, and has Visco as one of its
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`members.
`
`25.
`
`At all relevant times, Visco was a significant shareholder of Pleasantdale ASC. In
`
`fact, based on Department of Health filings, Visco has owned between 9.5% and 13.5% of
`
`Pleasantdale ASC on a consistent basis since at least 2014. What is more, since January 2020,
`
`Kurdali was also a shareholder of Pleasantdale ASC.
`
`26.
`
`As set forth below, many of the Defendants’ fraudulent interventional pain
`
`management procedures that were billed through East Coast Spine were performed at Pleasantdale
`
`ASC pursuant to unlawful self-referrals.
`
`JURISDICTION AND VENUE
`
`27.
`
`This Court has jurisdiction over the subject matter of this action under 28 U.S.C. §
`
`1332(a)(1) because the total matter in controversy, exclusive of interest and costs, exceeds the
`
`jurisdictional threshold of $75,000.00, and is between citizens of different states.
`
`28.
`
`This Court also has original jurisdiction pursuant to 28 U.S.C. § 1331 over claims
`
`brought under 18 U.S.C. §§ 1961 et seq. (the Racketeer Influenced and Corrupt Organizations
`
`(“RICO”) Act).
`
`29.
`
`In addition, this Court has supplemental jurisdiction over the subject matter of the
`
`claims asserted in this action pursuant to 28 U.S.C. § 1367.
`
`30.
`
`Venue in this District is appropriate pursuant to 28 U.S.C. § 1391, as the District of
`
`New Jersey is the District where one or more of the Defendants reside and because this is the
`
`District where a substantial amount of the activities forming the basis of the Complaint occurred.
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`
`
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`7
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`

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`
`
`I.
`
`A.
`
`ALLEGATIONS COMMON TO ALL CLAIMS
`
`An Overview of the Pertinent Law Governing No-Fault Insurance Reimbursement
`
`The New Jersey No-Fault Laws
`
`31.
`
`New Jersey has a comprehensive statutory system designed to ensure that motor
`
`vehicle accident victims are compensated for their injuries. The statutory system is embodied
`
`within the Compulsory Insurance Law (N.J.S.A. 39:6B–1 to 3) and the Automobile Reparation
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`Reform Act (N.J.S.A. 39:6A–1 et seq.)(collectively referred to as the “No Fault Laws”), which
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`require automobile insurers to provide Personal Injury Protection Benefits (“PIP Benefits”) to
`
`Insureds.
`
`32.
`
`Under the No Fault Laws, an Insured can assign his or her right to PIP Benefits to
`
`healthcare services providers in exchange for those services. Pursuant to a duly executed
`
`assignment, a healthcare services provider may submit claims directly to an insurance company in
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`order to receive payment for medically necessary services, using the required claim forms,
`
`including the Healthcare Financing Administration insurance claim form (known as the “HCFA–
`
`1500 form”).
`
`B.
`
`
`
`No-Fault Reimbursement and Compliance With New Jersey Law Governing
`Healthcare Practice
`
`33.
`
`In order for a healthcare services provider to be eligible to receive PIP Benefits, it
`
`must comply with all significant laws and regulations governing healthcare practice in New Jersey.
`
`34.
`
`Thus, a healthcare services provider is not entitled to receive PIP Benefits where it
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`has failed to comply with significant statutory and regulatory requirements governing healthcare
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`practice in New Jersey, whether or not the underlying services were medically necessary.
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`8
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`35. Moreover, in order for a specific healthcare service to be eligible for PIP
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`reimbursement, the service itself must be provided in compliance with significant laws and
`
`regulations governing healthcare practice in New Jersey.
`
`36.
`
`By extension, insurers such as GEICO are not obligated to make any payments of
`
`PIP Benefits to healthcare services providers that are not in compliance with significant statutory
`
`and regulatory requirements governing healthcare practice in New Jersey.
`
`37.
`
`Furthermore, insurers such as GEICO are not obligated to make any payments of
`
`PIP Benefits for healthcare services that are not rendered in compliance with significant statutory
`
`and regulatory requirements governing healthcare practice in New Jersey.
`
`C.
`
`
`
`No-Fault Reimbursement, Medical Necessity, and the New Jersey No-Fault Care
`Paths
`
`38.
`
`Pursuant to N.J.S.A. 39:6A–4, an insurer such as GEICO is only required to pay
`
`PIP Benefits for reasonable, necessary, and appropriate treatment. Concomitantly, a healthcare
`
`services provider is only eligible to receive PIP Benefits for medically necessary services.
`
`39.
`
`Pursuant to N.J.S.A. 39:6A–2(m):
`
`(i)
`
`(ii)
`
`“Medically necessary” means that the treatment is consistent with the symptoms or
`diagnosis, and treatment of the injury
`
`is not primarily for the convenience of the injured person or provider;
`
`is the most appropriate standard or level of service which is in accordance with
`standards of good practice and standard professional treatment protocols, as such
`protocols may be recognized or designated by the Commissioner of Banking and
`Insurance, in consultation with the Commissioner of Health and Senior Services or
`with a professional licensing or certifying board in the Division of Consumer
`Affairs in the Department of Law and Public Safety, or by a nationally recognized
`professional organization; and
`
`
`(iii)
`
`
`does not involve unnecessary diagnostic testing.
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`9
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`40.
`
`Pursuant to the No-Fault Laws, the New Jersey Commissioner of Banking and
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`Insurance (the “Commissioner”) has designated specific care paths (the “Care Paths”) as the
`
`standard course of medically necessary treatment for certain types of neck and back soft tissue
`
`injuries that commonly are sustained in automobile accidents. See N.J.A.C. 11:3–4.6.
`
`41.
`
`Specifically, the Commissioner has promulgated Care Paths for the following types
`
`of injuries:
`
`(i)
`
`(ii)
`
`(iii)
`
`(iv)
`
`(v)
`
`cervical spine strains, sprains, and contusions;
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`cervical herniated disks or radiculopathies;
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`thoracic spine strains, sprains, and contusions;
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`thoracic herniated disks or radiculopathies;
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`lumbar–sacral spine strains, sprains, and contusions; and
`
`(vi)
`
`lumbar–sacral herniated disks or radiculopathies.
`
`42.
`
`The Care Paths generally provide for an initial, four–week course of conservative
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`treatment including chiropractic services, physical therapy, medication, and exercise.
`
`43.
`
`Should a healthcare services provider wish to provide additional treatment to an
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`Insured beyond the initial four weeks of conservative treatment, the Care Paths require the provider
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`to demonstrate at the four–week mark, the eight–week mark, and the 13–week mark that continued
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`treatment is warranted based on the Insured’s individual circumstances. See New Jersey
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`Department of Banking and Insurance Comments, 30 N.J.R. 4401(a).
`
`44.
`
`The guidelines established by the Commissioner in the Care Paths are designed to
`
`avoid the continuation of treatment and therapy, week after week, over many months and years,
`
`without any observable improvement. See 30 N.J.R. 4401(a).
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`
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`10
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`D.
`
`Relevant New Jersey Law Regarding the Ownership of Medical Practices
`
`45.
`
`Prior to 2018, in New Jersey, chiropractors could not own – in whole or in part –
`
`healthcare practices that provided medical diagnostic tests such as electromyography tests
`
`(“EMGs”) and nerve conduction velocity studies (“NCVs”).
`
`46.
`
`In particular, pursuant to N.J.A.C. § 13:35-2.6 (2011), which was effective to
`
`January 1, 2018:
`
`(i)
`
`(ii)
`
`N.J.A.C. § 13:35-2.6(a)(3) defined “diagnostic office” as “a practice location,
`whether stationary or mobile, not licensed by the State Department of Health and
`Senior Services, which provides equipment and staff necessary for the offering or
`performance of diagnostic tests and related services to any branch of the medical
`profession or to the public.”
`
`N.J.A.C. § 13:35-2.6(a)(3) defined “diagnostic test” as “a medical service utilizing
`biomechanical, neurological, neurodiagnostic, radiological, vascular or any means,
`other than bioanalysis, intended to assist in establishing a medical diagnosis, for the
`purpose of recommending a course of treatment for the tested patient to be
`implemented by the treating practitioner or by the consultant.”
`
`
`(iii) N.J.A.C. § 13:35-2.6(c)(2) specifically identified NCVs and EMGs as “diagnostic
`tests”.
`
`
`(iv) N.J.A.C. § 13:35-2.6(d) provided – in relevant part – that:
`
`Any diagnostic … office offering diagnostic … tests for a fee shall:
`
`1. Be solely owned and under the responsibility of one or more physicians (or
`practitioners, in the case of an office offering only tests within the scope of that
`practitioner's practice);
`
`2. Ensure that all test results are interpreted by a practitioner licensed by the Board
`and acting within the scope of licensed practice, documented in a written report
`and maintained in accordance with the requirements of N.J.A.C. 13:35-6.5; and
`
`
`
`
`(v)
`
`
`
`
`
`3. Designate a physician owner or employee (or practitioner owner or employee,
`in the case of an office offering only tests within the scope of that practitioner’s
`practice) to be responsible for the management of the office and the specific
`obligations set forth in this section.
`
`N.J.A.C. § 13:35-2.6 excluded chiropractors from the definition of “practitioners”.
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`11
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`47.
`
`Healthcare practices that provide medical diagnostic tests and are owned in
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`violation of N.J.A.C. 13:35-2.6 are ineligible to bill for or to collect PIP Benefits.
`
`E.
`
`New Jersey Law Prohibiting Self-Referrals
`
`48.
`
`In New Jersey, physicians and other “practitioners” generally may not refer patients
`
`to a “healthcare service” in which they have a “significant beneficial interest”.
`
`49.
`
`Specifically, N.J.S.A. 45:9-22.5 (the “Codey Law”) provides – in pertinent part –
`
`that:
`
`
`
`A practitioner shall not refer a patient or direct an employee of the practitioner to refer a
`patient to a healthcare service in which the practitioner, or the practitioner's immediate
`family, or the practitioner in combination with the practitioner's immediate family has a
`significant beneficial interest . . . .
`
`50.
`
`Pursuant to N.J.S.A. 45:9-22.4:
`
`“Healthcare service” means a business entity which provides on an inpatient or outpatient
`basis: testing for or diagnosis or treatment of human disease or dysfunction; or dispensing
`of drugs or medical devices for the treatment of human disease or dysfunction. Healthcare
`service includes, but is not limited to, a bioanalytical laboratory, pharmacy, home
`healthcare agency, rehabilitation facility, nursing home, hospital, or a facility which
`provides radiological or other diagnostic imagery services, physical therapy, ambulatory
`surgery, or ophthalmic services.
`
`“Practitioner” means a physician, chiropractor or podiatrist licensed pursuant to Title 45 of
`the Revised Statutes.
`
`“Significant beneficial interest” means any financial interest; but does not include
`ownership of a building wherein the space is leased to a person at the prevailing rate under
`a straight lease agreement, or any interest held in publicly traded securities.
`
`51.
`
`However, pursuant to N.J.S.A. 45:9-22-5(c)(1), the Codey Law’s restrictions on
`
`patient referrals do not apply to:
`
`medical treatment or a procedure that is provided at the practitioner’s medical office and
`for which a bill is issued directly in the name of the practitioner or the practitioner’s medical
`office … .
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`52.
`
`Pursuant to N.J.S.A. 45:9–22–5(c)(3), the Codey Law’s restrictions on patient
`
`referrals also do not apply to referrals for certain procedures performed at an ambulatory care
`
`facility, such as an ambulatory surgery center, so long as certain conditions are met (the “ASC
`
`Exception”).
`
`53.
`
`In particular, at all relevant times, the Codey Law’s restrictions did not apply to:
`
`ambulatory surgery or procedures requiring anesthesia performed at a surgical practice
`registered with the Department of Health . . . or at an ambulatory care facility licensed by
`the Department of Health to perform surgical and related services or lithotripsy services, if
`the following conditions are met:
`
`
`(a)
`
`the practitioner who provided the referral personally performs the
`procedure;
`
`the practitioner’s remuneration as an owner of or investor in the practice or
`facility is directly proportional to the practitioner’s ownership interest and
`not to the volume of patients the practitioner refers to the practice or facility;
`
`all clinically–related decisions at a facility owned in part by non–
`practitioners are made by practitioners and are in the best interests of the
`patient; and
`
`
`
`(b)
`
`
`(c)
`
`
`(d)
`
`disclosure of the referring practitioner’s significant beneficial interest in the
`practice or facility is made to the patient in writing, at or prior to the time
`that the referral is made, consistent with the provisions of section 3 of P.L.
`1989, c. 19 (C.45:9–22.6).
`
`
`Thus, if a physician refers patients to a healthcare service she owns, or directs one
`
`54.
`
`of her employees to make such referrals, for procedures performed at an ambulatory surgical
`
`center, the referrals will not qualify for the ASC Exception and therefore will violate the Codey
`
`Law unless – among other things – the physician who makes the referral personally performs the
`
`resulting procedure.
`
`55.
`
`Physicians and entities in New Jersey that engage in self-referral arrangements that
`
`violate the Codey Law are not eligible to receive PIP Benefits.
`
`
`
`
`
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`

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`
`
`F.
`
`Accurate Patient Record-Keeping
`
`56.
`
`New Jersey requires chiropractors to maintain – for at least seven years – patient
`
`records that accurately reflect the care or services rendered, including but not limited to accurate
`
`reports of examination results and diagnoses. See N.J.A.C. § 13:44E-2.2.
`
`57.
`
`Accuracy and completeness in chiropractic recordkeeping is a vital element of the
`
`standard of care, whether for soft tissue injury patients or any other type of patient.
`
`58.
`
`Precise, thorough examination, diagnostic testing, and treatment reports are
`
`critically important because important clinical decisions depend on their integrity and quality.
`
`Other chiropractors, medical doctors, and healthcare providers commonly rely on medical records
`
`maintained by a chiropractor because they reasonably presume that:
`
`(i)
`
`(ii)
`
`(iii)
`
`
`59.
`
`the chiropractor who generated the records performed the services reflected in the
`records in a manner consistent with the standard of care;
`
`the information and data contained within the records were legitimately obtained
`by the chiropractor and were not altered or contrived; and
`
`the chiropractor analyzed and interpreted the data in a manner consistent with the
`standard of care.
`
`Chiropractors and chiropractic practices that fail to maintain accurate patient
`
`
`
`records, or that falsify patient records, are not entitled to receive PIP Benefits.
`
`G.
`
`The Fee Schedule and Current Procedural Terminology Codes
`
`60.
`
`New Jersey has established a medical fee schedule (the “Fee Schedule”) that is
`
`applicable to claims for PIP Benefits.
`
`61. When a healthcare services provider submits a claim for PIP Benefits using the
`
`current procedural terminology (“CPT”) codes set forth in the Fee Schedule, it represents that: (i)
`
`the service described by the specific CPT code that is used was performed in a competent manner
`
`in accordance with applicable regulations; (ii) the service described by the specific CPT code that
`
`
`
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`

`

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`
`
`
`is used was reasonable and medically necessary; and (iii) the service and the attendant fee were
`
`not excessive.
`
`62.
`
`The No-Fault Laws specifically prohibit healthcare services providers from
`
`charging for services in amounts exceeding the amounts set forth in the Fee Schedule. See N.J.S.A.
`
`§ 39:6A–4.6; N.J.A.C. 11:3–29.6.
`
`63.
`
`The New Jersey Administrative Code provides that the Fee Schedule shall be
`
`interpreted in accordance with the Medicare Claims Processing Manual (“MCPM”), the National
`
`Correct Coding Initiative (“NCCI”) Policy Manual, and the American Medical Association’s CPT
`
`Assistant (the “CPT Assistant”).
`
`
`
`64.
`
`Additionally, No-Fault providers and insurers are directed to use the NCCI “Edits”
`
`in determining whether or not CPT codes must be bundled or can be billed separately, i.e.,
`
`unbundled. The NCCI Edits define when two CPT codes should not be reported together either in
`
`all situations or most situations.
`
`65.
`
`The MCPM, NCCI Policy Manual, NCCI Edits, and CPT Assistant are all
`
`incorporated by reference into the New Jersey No-Fault insurance regulations. See N.J.A.C. 11:3–
`
`29.4.
`
`66. With respect to unbundling, N.J.A.C. 11:3-29.4 provides that:
`
`Artificially separating or partitioning what is inherently one total Procedure into subparts
`that are integral to the whole for the purpose of increasing medical fees is prohibited.
`
`Chapter 1 of the NCCI Policy manual provides that:
`
`67.
`
`Procedures should be reported with the most comprehensive CPT code that describes the
`services performed. Physicians must not unbundle the services described by a HCPCS/CPT
`code.
`
`
`Chapter 12 of the MCPM provides that:
`
`68.
`
`
`
`15
`
`

`

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`
`
`
`H.
`
`The narrative for many CPT codes includes a parenthetical statement that the Procedure
`represents a ‘separate Procedure.’ The inclusion of this statement indicates that the
`Procedure, while possible to perform separately, is generally included in a more
`comprehensive Procedure, and the service is not to be billed when a related, more
`comprehensive, service is performed.
`
`The New Jersey Insurance Fraud Prevention Act
`
`69.
`
`New Jersey has a strong public policy against insurance fraud. This policy is
`
`manifested in a series of statutes, including the Insurance Fraud Prevention Act (“IFPA”), N.J.S.A.
`
`17:33A–1 et seq. A healthcare services provider violates the Insurance Fraud Prevention Act if,
`
`among other things, it:
`
`Presents or causes to be presented any written or oral statement as part of, or in support of
`or opposition to a claim for payment or other benefit pursuant to an insurance policy,
`knowing that the statement contains any false or misleading information concerning any
`fact or thing material to the claim; or
`
`Prepares or makes any written or oral statement that is intended to be presented to any
`insurance company or any insurance claimant in connection with, or in support of or in
`opposition to any claims for payment or other benefit pursuant to an insurance policy,
`knowing that the statement contains any false or misleading information concerning any
`fact or thing material to the claim; or
`
`Conceals or knowing fails to disclose the occurrence of an event which affects a person’s
`initial or continued right or entitlement to (a) any insurance benefits or payment or (b) the
`amount of any benefit or payment to which the person is entitled.
`
`
`See N.J.S.A. 17:33A–4.
`
`
`70.
`
`A healthcare services provider also violates the Insurance Fraud Prevention Act if
`
`it either: (i) “knowingly assists, conspires with or urges any person or practitioner to violate any
`
`of provisions of this act”; or (ii) “knowingly benefits, directly or indirectly, from the proceeds
`
`derived from a violation of this act.” Id.
`
`71.
`
`Violators of the IFPA are liable to the insurer for restitution, attorney’s fees, and
`
`the reasonable costs of the insurer’s investigation. See N.J.S.A 17:33A–7(a).
`
`
`
`16
`
`

`

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`
`
`
`72.
`
`A person that engages in a pattern of fraudulent behavior under the IFPA is liable
`
`to the insurer for treble damages. See N.J.S.A. 17:33A–7(b).
`
`73.
`
`The IFPA defines a pattern as five or more “related violations”. See N.J.S.A.
`
`17:33A–3. Violations are related if they involve either the same victim, or same or similar actions
`
`on the part of the person or practitioner charged with violating the IFPA. See N.J.S.A.17:33A–3.
`
`II.
`
`
`The Defendants’ Fraudulent Scheme
`
`74.
`
`Beginning no later than 2013, and continuing through the present date, the
`
`Defendants masterminded and implemented a massive fraudulent scheme in which they billed
`
`GEICO millions of dollars, or caused GEICO to be billed millions of dollars, for unlawful,
`
`medically unnecessa