throbber
Case 1:20-cv-06185-RRM-RER Document 1 Filed 12/21/20 Page 1 of 99 PageID #: 1
`
`
`
`Barry Levy Esq.
`Max Gershenoff, Esq.
`Michael Vanunu, Esq.
`RIVKIN RADLER LLP
`926 RXR Plaza
`Uniondale, New York 11556
`Counsel for Plaintiffs Government Employees Insurance Co.,
`GEICO Indemnity Co, GEICO General Insurance Company
`and GEICO Casualty Co.
`
`UNITED STATES DISTRICT COURT
`EASTERN DISTRICT OF NEW YORK
`--------------------------------------------------------------------------X
`GOVERNMENT EMPLOYEES INSURANCE CO.,
`GEICO INDEMNITY CO., GEICO GENERAL
`INSURANCE COMPANY and GEICO CASUALTY CO.,
`
`
`Plaintiffs,
`
`
`
`-against-
`
`
`
`
`SHAHID MIAN, M.D., SHAHID MIAN, M.D. P.C.,
`SHAHID MIAN, MD PROFESSIONAL CORPORATION,
`SURGERY CENTER OF ORADELL, LLC, PARKWAY
`AMBULATORY SURGERY CENTER, LLC, SADIA
`CHAUDHRY, and ATA CHAUDHRY a/k/a DANNY
`CHAUDHRY,
`
` Defendants.
`--------------------------------------------------------------------------X
`
`
`
`
`
`Docket No.:
`
`
`
`Plaintiff Demands a Trial by
`Jury
`
`COMPLAINT
`
`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:
`
`INTRODUCTION
`
`1.
`
`This action seeks to recover more than $12,000,000.00 that the Defendants
`
`wrongfully obtained from GEICO by submitting, and causing to be submitted:
`
`
`
`

`

`Case 1:20-cv-06185-RRM-RER Document 1 Filed 12/21/20 Page 2 of 99 PageID #: 2
`
`
`
`(i)
`
`(ii)
`
`thousands of fraudulent no-fault insurance charges through Shahid Mian, M.D. P.C.
`(“Mian NY PC”) and Shahid Mian, MD Professional Corporation (“Mian NJ PC”)
`for medically unnecessary, unlawful, and otherwise non-reimbursable patient
`examinations, physical therapy, interventional pain management procedures, and
`surgical procedures; and
`
`thousands of fraudulent no-fault insurance charges through Defendants Surgery
`Center of Oradell, LLC (“Oradell ASC”) and Parkway Ambulatory Surgery Center,
`LLC (“Parkway ASC”) for unlawful, medically unnecessary, and otherwise non-
`reimbursable surgery center facility fees.
`
` (the examinations, physical therapy, interventional pain management procedures, surgical
`
`procedures, and facility fees collectively are referred to hereinafter as the “Fraudulent Services”).
`
`2.
`
`The Fraudulent Services purportedly were provided to individuals (“Insureds”)
`
`who claimed to have been involved in automobile accidents and were eligible for insurance
`
`coverage in New York and New Jersey under GEICO’s no-fault insurance policies.
`
`3.
`
`In addition, GEICO seeks a declaration that it is not legally obligated to pay
`
`reimbursement of more than $75,000.00 in pending no-fault insurance claims under New York no-
`
`fault insurance policies that have been submitted by or on behalf of Defendants Mian NY PC,
`
`Mian NJ PC, Oradell ASC, and Parkway ASC seeking reimbursement under the New York no-
`
`fault insurance laws, because of the fraudulent and unlawful conduct described herein.
`
`4.
`
`Furthermore, GEICO seeks a declaration that – between at least 2014 and the
`
`present – Mian NJ PC, Mian NY PC, Oradell ASC, and Parkway ASC have not been in compliance
`
`with all significant laws and regulations governing healthcare services providers in New Jersey.
`
`5.
`
`The Defendants fall into the following categories:
`
`(i)
`
`
`(ii)
`
`Defendant Mian NY PC is a New York medical professional corporation through
`which many of the Fraudulent Services purportedly were provided and were billed
`to automobile insurance companies in New York, including GEICO;
`
`Defendant Mian NJ PC is a New Jersey medical professional corporation through
`which many of the Fraudulent Services purportedly were provided and were billed
`to automobile insurance companies in New York and New Jersey, including
`GEICO;
`
`
`
`2
`
`

`

`Case 1:20-cv-06185-RRM-RER Document 1 Filed 12/21/20 Page 3 of 99 PageID #: 3
`
`
`
`
`
`
`
`
`
`
`
`
`
`(iii) Defendant Shahid Mian, M.D. (“Mian”) is a physician licensed to practice medicine
`in New York and New Jersey, owned and controlled Mian NY PC and Mian NJ
`PC, and purported to provide many of the Fraudulent Services through Mian NY
`PC and Mian NJ PC;
`
`
`(iv) Defendants Oradell ASC and Parkway ASC are New Jersey limited liability
`companies that falsely purported to be properly licensed in New Jersey as
`ambulatory care facilities, through which many of the Fraudulent Services
`purportedly were provided and were billed to automobile insurance companies in
`New York and New Jersey, including GEICO; and
`
`(v)
`
`Defendants Ata Chaudhry a/k/a Danny Chaudhry (“A. Chaudhry”) and Sadia
`Chaudhry (“S. Chaudhry”) are not licensed as healthcare professionals, but owned
`and controlled Parkway ASC and Oradell ASC, paid illegal compensation in
`exchange for patient referrals to Parkway ASC and Oradell ASC, and purported to
`provide many of the Fraudulent Services through Parkway ASC and Oradell ASC.
`
`6.
`
`As discussed herein, the Defendants at all relevant times have known that:
`
`(i)
`
`(ii)
`
`
`(iii)
`
`
`(iv)
`
`the Defendants were not in compliance with all significant laws and regulations
`governing healthcare practice and/or licensing laws and, as a result, were not
`eligible to receive no-fault reimbursement in the first instance;
`
`the Fraudulent Services were not provided in compliance with all significant laws
`and regulations governing healthcare practice and/or licensing laws and, therefore,
`were not eligible for no-fault 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 purportedly were subjected to them; and
`
`the billing codes used for the Fraudulent Services misrepresented and exaggerated
`the levels and types of services that purportedly were provided in order to inflate
`the charges submitted to GEICO.
`
`7.
`
`As such, the Defendants do not now have – and never had – any right to be
`
`compensated for the Fraudulent Services that were billed to GEICO in New York and New Jersey
`
`through Mian NY PC, Mian NJ PC, Parkway ASC, Oradell ASC.
`
`
`
`3
`
`

`

`Case 1:20-cv-06185-RRM-RER Document 1 Filed 12/21/20 Page 4 of 99 PageID #: 4
`
`
`
` 8.
`
`The charts annexed hereto as Exhibits “1” - “4” set forth a large, representative
`
`sample of the fraudulent claims that have been identified to date that the Defendants have
`
`submitted, or caused to be submitted, to GEICO in New York and New Jersey.
`
`9.
`
`The Defendants’ interrelated fraudulent schemes began no later than 2014 and have
`
`continued uninterrupted since that time.
`
`10.
`
`As a result of the Defendants’ interrelated fraudulent schemes, GEICO has incurred
`
`damages of more than $12,000,000.00.
`
`THE PARTIES
`
`Plaintiffs
`
`I.
`
`
`11.
`
`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 York and New Jersey.
`
`II.
`
`Defendants
`
`12. Mian NY PC is a New York medical professional corporation with its principal place
`
`of business in New York. Mian NY PC was owned and controlled by Mian, and was used by Mian
`
`as a vehicle to submit fraudulent no-fault insurance billing to GEICO and other insurers in New
`
`York.
`
`13. Mian NJ PC is a New Jersey medical professional corporation with its principal place
`
`of business in New Jersey. Mian NJ PC was owned and controlled by Mian, and was used by Mian
`
`as a vehicle to submit fraudulent no-fault insurance billing to GEICO and other insurers in New York
`
`and New Jersey.
`
`
`
`4
`
`

`

`Case 1:20-cv-06185-RRM-RER Document 1 Filed 12/21/20 Page 5 of 99 PageID #: 5
`
`
`
`14. Mian resides in and is a citizen of New York. Mian was licensed to practice medicine
`
`in New York and in New Jersey, owned and controlled Mian NY PC and Mian NJ PC, and used
`
`Mian NY PC and Mian NJ PC as vehicles to submit fraudulent no-fault insurance billing to GEICO
`
`and other insurers in New York and New Jersey.
`
`15.
`
`Defendant Oradell ASC is a New Jersey limited liability company with its principal
`
`place of business in New Jersey. Oradell ASC falsely purported to be properly licensed in New
`
`Jersey as an ambulatory care facility. Oradell ASC was owned and controlled by A. Chaudhry and
`
`S. Chaudhry, had A. Chaudhry and S. Chaudhry as its members, and was used by A. Chaudhry
`
`and S. Chaudhry as a vehicle to submit fraudulent billing to GEICO and other insurers in New York
`
`and New Jersey.
`
`16.
`
`Parkway ASC is a New Jersey limited liability company with its principal place of
`
`business in New Jersey. Parkway ASC falsely purported to be properly licensed in New Jersey as
`
`an ambulatory care facility. Parkway ASC was owned and controlled by A. Chaudhry and S.
`
`Chaudhry, had A. Chaudhry and S. Chaudhry as its members, and was used by A. Chaudhry and
`
`S. Chaudhry as a vehicle to submit fraudulent billing to GEICO and other insurers in New York and
`
`New Jersey.
`
`17.
`
`A. Chaudhry – who is S. Chaudhry’s spouse – resides in and is a citizen of New
`
`Jersey. Together with S. Chaudhry, A. Chaudhry owned and controlled Oradell ASC and Parkway
`
`ASC, paid unlawful compensation to healthcare providers in exchange for patient referrals to Oradell
`
`ASC and Parkway ASC, and used Oradell ASC and Parkway ASC as vehicles to submit fraudulent
`
`no-fault insurance billing to GEICO and other insurers in New York and New Jersey.
`
`18.
`
`S. Chaudhry – who is A. Chaudhry’s spouse – resides in and is a citizen of New
`
`Jersey. Together with A. Chaudhry, S. Chaudhry owned and controlled Oradell ASC and Parkway
`
`
`
`5
`
`

`

`Case 1:20-cv-06185-RRM-RER Document 1 Filed 12/21/20 Page 6 of 99 PageID #: 6
`
`
`
`ASC, paid unlawful compensation to healthcare providers in exchange for patient referrals to Oradell
`
`ASC and Parkway ASC, and used Oradell ASC and Parkway ASC as vehicles to submit fraudulent
`
`no-fault insurance billing to GEICO and other insurers in New York and New Jersey.
`
`
`
`19.
`
`On November 12, 2010, the New Jersey State Board of Medical Examiners (the
`
`“State Board”) entered an Order to Cease and Desist Improper Practice and to Take Corrective
`
`Actions (the “Cease and Desist Order”) against A. Chaudhry and S. Chaudhry.
`
`
`
`20.
`
`According to the Cease and Desist Order, an investigation by the New Jersey
`
`Attorney General indicated, among other things, that A. Chaudhry and S. Chaudhry had engaged
`
`in a variety of disturbing and unlawful conduct at healthcare facilities they owned, including:
`
`(i)
`
`(ii)
`
`
`(iii)
`
`
`(iv)
`
`
`21.
`
`
`
`
`falsely representing that an imaging facility they owned was licensed as an
`ambulatory care facility, when in fact it was not;
`
`engaging in the unlicensed practice of medicine at an ambulatory care facility they
`owned;
`
`operating an ambulatory care facility they owned without appointing a legitimate
`medical director at the facility as required by the pertinent regulations; and
`
`submitting billing through another of the ambulatory care facilities they owned for
`healthcare services that they had not, in fact, provided.
`
`Pursuant to the State Board’s Cease and Desist Order, A. Chaudhry and S.
`
`Chaudhry not only were directed to cease and desist from their unlawful conduct at their various
`
`healthcare facilities, but also had to pay a $25,000.00 civil penalty and substantial restitution.
`
`
`
`22.
`
`Then, in 2016, after being arrested by the New Jersey Commercial Bribery Task
`
`Force, A. Chaudhry admitted to engaging in a massive, illegal kickback scheme.
`
`
`
`23.
`
`Specifically, A. Chaudhry admitted that he paid more than $850,000.00 in
`
`kickbacks to a network of more than 15 physicians and other healthcare professionals in exchange
`
`for patient referrals to his ambulatory care facilities.
`
`
`
`6
`
`

`

`Case 1:20-cv-06185-RRM-RER Document 1 Filed 12/21/20 Page 7 of 99 PageID #: 7
`
`
`
`
`
`24.
`
`For his part in the massive kickback scheme, A. Chaudhry pleaded guilty to various
`
`crimes, including conspiracy, money laundering, and commercial bribery.
`
`JURISDICTION AND VENUE
`
`
`
`25.
`
`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.
`
`
`
`26.
`
`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).
`
`
`
`27.
`
`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.
`
`
`
`28.
`
`Venue in this District is appropriate pursuant to 28 U.S.C. § 1391, as the Eastern
`
`District of New York is the District where a substantial amount of the activities forming the basis
`
`of the Complaint occurred.
`
`29.
`
`For example, the Defendants submitted or caused to be submitted a massive amount
`
`of fraudulent billing to GEICO under New York automobile insurance policies, for treatment that
`
`they purported to provide to GEICO’s New York-based Insureds. In reliance on the fraudulent
`
`claims, personnel at a GEICO office in the Eastern District of New York issued payment on the
`
`fraudulent claims.
`
`30. What is more, and as set forth herein, the Defendants transacted substantial business
`
`in New York, and derived a substantial amount of revenue based on their fraudulent and unlawful
`
`business activities in New York.
`
`
`
`7
`
`

`

`Case 1:20-cv-06185-RRM-RER Document 1 Filed 12/21/20 Page 8 of 99 PageID #: 8
`
`
`
`31. Moreover, and as set forth herein, the Defendants not only regularly committed
`
`tortious acts in New York, but they also committed tortious acts in New Jersey that caused injury
`
`to GEICO in New York.
`
`ALLEGATIONS COMMON TO ALL CLAIMS
`
`
`I.
`
`
`
`A.
`
`
`
`An Overview of the Pertinent Law Governing No-Fault Insurance Reimbursement
`
`32.
`
`GEICO underwrites automobile insurance in New York and New Jersey.
`
`Pertinent New York Law Governing No-Fault Insurance Reimbursement
`
`33.
`
`New York’s no-fault insurance laws are designed to ensure that injured victims of
`
`motor vehicle accidents have an efficient mechanism to pay for and receive the healthcare services
`
`that they need.
`
`
`
`34.
`
`Under New York’s Comprehensive Motor Vehicle Insurance Reparations Act (N.Y.
`
`Ins. Law §§ 5101, et seq.) and the regulations promulgated pursuant thereto (11 N.Y.C.R.R. §§ 65,
`
`et seq.), automobile insurers are required to provide no-fault insurance benefits (“Personal Injury
`
`Protection” or “PIP Benefits”) to Insureds.
`
`35.
`
`In New York, PIP Benefits include up to $50,000.00 per Insured for necessary
`
`expenses that are incurred for healthcare goods and services.
`
`36.
`
`In New York, an Insured can assign his/her right to PIP Benefits to healthcare goods
`
`and services providers in exchange for those services. Pursuant to a duly executed assignment, a
`
`healthcare provider then may submit claims directly to an insurance company and receive payment
`
`for medically necessary services, using the claim form required by the New York State Department
`
`of Insurance (known as “Verification of Treatment by Attending Physician or Other Provider of
`
`Health Service” or, more commonly, as an “NF-3”). In the alternative, in New York a healthcare
`
`
`
`8
`
`

`

`Case 1:20-cv-06185-RRM-RER Document 1 Filed 12/21/20 Page 9 of 99 PageID #: 9
`
`
`
`services provider may submit claims using the Healthcare Financing Administration insurance claim
`
`form (known as the “HCFA-1500 form”).
`
`37.
`
`Pursuant to the New York no-fault insurance laws, healthcare services providers are
`
`not eligible to bill for or to collect PIP Benefits if they fail to meet any New York State or local
`
`licensing requirements necessary to provide the underlying services, or if they fail to meet the
`
`applicable licensing requirements in any other states in which such services are performed.
`
`38.
`
`For instance, the implementing regulation adopted by the New York Superintendent
`
`of Insurance, 11 N.Y.C.R.R. § 65-3.16(a)(12) states, in pertinent part, as follows:
`
`A provider of healthcare services is not eligible for reimbursement under section 5102(a)(1)
`of the Insurance Law if the provider fails to meet any applicable New York State or local
`licensing requirement necessary to perform such service in New York or meet any applicable
`licensing requirement necessary to perform such service in any other state in which such
`service is performed.
`
`
`(Emphasis added).
`
`
`39.
`
`In State Farm Mut. Auto. Ins. Co. v. Mallela, 4 N.Y.3d 313, 320 (2005), the New
`
`York Court of Appeals confirmed that healthcare services providers that fail to comply with licensing
`
`requirements are ineligible to collect PIP Benefits, and that insurers may look beyond a facially-
`
`valid license to determine whether there was a failure to abide by state and local law.
`
`40.
`
`Pursuant to New York law, foreign medical professional entities operating in New
`
`York must apply for authority to do business in New York and must have a certificate of authority
`
`from the New York Department of Education. See, e.g., N.Y. Educ. Law §§ 6509(8), 6530(12);
`
`N.Y. Bus. Corp. Law §§ 1503, 1514, 1530.
`
`41.
`
`New York law prohibits licensed healthcare services providers, including physicians,
`
`from paying or accepting compensation in exchange for patient referrals. See, e.g., New York
`
`Education Law §§ 6530(18), 6531.
`
`
`
`9
`
`

`

`Case 1:20-cv-06185-RRM-RER Document 1 Filed 12/21/20 Page 10 of 99 PageID #: 10
`
`
`
`42. Additionally, New York law prohibits licensed healthcare services providers,
`
`including physicians, from referring patients for physical therapy services – among other things – to
`
`a healthcare practice with which the healthcare service provider has a financial relationship,
`
`including an ownership or investment interest. See New York Public Health Law § 238-a.
`
`43.
`
`Furthermore, New York law prohibits licensed healthcare services providers,
`
`including physicians, from referring patients to healthcare practices in which they have an ownership
`
`or investment interest unless: (i) the ownership or investment interest is disclosed to the patient; and
`
`(ii) the disclosure informs the patient of his or her “right to utilize a specifically identified alternative
`
`health care provider if any such alternative is reasonably available”. See New York Public Health
`
`Law § 238-d.
`
`44.
`
`In New York, claims for PIP Benefits are governed by the New York Workers’
`
`Compensation Fee Schedule (the “NY Fee Schedule”).
`
`45. When a healthcare services provider submits a claim for PIP Benefits using the
`
`current procedural terminology (“CPT”) codes set forth in the NY 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 laws and regulations; (ii) the service described by the
`
`specific CPT code that is used was reasonable and medically necessary; and (iii) the service and
`
`the attendant fee were not excessive.
`
`
`
`46.
`
`Pursuant to New York Insurance Law § 403, the NF-3 and HCFA-1500 forms
`
`submitted by a healthcare services provider to GEICO, and to all other automobile insurers, must be
`
`verified by the healthcare provider subject to the following warning:
`
`Any person who knowingly and with intent to defraud any insurance company or other
`person files an application for insurance or statement of claim containing any materially false
`information, or conceals for the purpose of misleading, information concerning any fact
`material thereto, commits a fraudulent insurance act, which is a crime.
`
`
`
`10
`
`

`

`Case 1:20-cv-06185-RRM-RER Document 1 Filed 12/21/20 Page 11 of 99 PageID #: 11
`
`
`
`B.
`
`
`Pertinent New Jersey Law Governing No-Fault Insurance Reimbursement
`
`47.
`
`Like New York, 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 Reform Act (N.J.S.A. 39:6A-1 et seq.), which require automobile insurers to provide
`
`PIP Benefits to Insureds.
`
`48.
`
`As in New York, under the New Jersey no-fault insurance 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 order to receive payment for medically necessary services,
`
`using the required claim forms, including the HCFA-1500 form.
`
`49.
`
`In order for a healthcare services provider to be eligible to receive PIP Benefits in
`
`New Jersey, it must comply with all significant laws and regulations governing healthcare practice.
`
`50.
`
`Pursuant to N.J.S.A 14A:17-5, a foreign professional corporation cannot offer
`
`medical professional services in the State of New Jersey without being properly incorporated under
`
`New Jersey law.
`
`51.
`
`Pursuant to N.J.A.C. 13:35-6.17, physicians are prohibited from paying or
`
`receiving compensation, either directly or indirectly, in exchange for patient referrals.
`
`52. Moreover, N.J.A.C. 8:43A sets various significant requirements regarding the
`
`licensure and operation of ambulatory care facilities. Among other things:
`
`(i)
`
`N.J.A.C. 8:43A-2.2 provides that “[a]ny person, organization, or corporation
`desiring to operate an ambulatory care facility shall make application to the
`Commissioner for a license on forms prescribed by the Department, which are
`available from the Office of Certificate of Need and Healthcare Facility Licensure.”
`
`
`
`
`11
`
`

`

`Case 1:20-cv-06185-RRM-RER Document 1 Filed 12/21/20 Page 12 of 99 PageID #: 12
`
`
`
`(ii)
`
`N.J.A.C. 8:43A-3.3(a) requires ambulatory care facilities to disclose their
`ownership to the New Jersey Department of Health (“NJDOH”), and to report “any
`proposed change in ownership to the Director of the Office of Certificate of Need
`and Healthcare Facility Licensing in writing at least 30 days prior to the change and
`in conformance with requirements for Certificate of Need applications.”
`
`
`(iii) N.J.A.C. 8:43A-3.3(b) precludes ambulatory care facilities from being “owned,
`managed, or operated by any person convicted of a crime relating adversely to the
`person’s capability of owning, managing, or operating the facility.”
`
`In New Jersey, physicians generally may not refer patients to a healthcare provider
`
`53.
`
`in which they have any financial interest. See N.J.S.A. 45:9-22.5 (the “Codey Law”).
`
`54.
`
`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 ….
`
`
`
`55.
`
`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 to an ambulatory care facility – such as an ambulatory
`
`surgery center – in which the referring physician has a significant beneficial interest, so long as
`
`certain conditions are met (the “ASC Exception”).
`
`56.
`
`Specifically, at all relevant times, pursuant to the ASC Exception in N.J.S.A. 45:9-
`
`22-5(c)(3), the Codey Law’s restrictions on patient self-referrals did not apply to:
`
`ambulatory surgery or procedures involving the use of any 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:
`
`
`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;
`
`(a)
`
`
`(b)
`
`
`
`
`
`12
`
`

`

`Case 1:20-cv-06185-RRM-RER Document 1 Filed 12/21/20 Page 13 of 99 PageID #: 13
`
`
`
`(c)
`
`
`(d)
`
`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
`
`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).
`
`
`57.
`
`Pursuant to N.J.S.A. 39:6A-4, an insurer such as GEICO is only required to pay
`
`PIP Benefits in New Jersey for reasonable, necessary, and appropriate treatment. Concomitantly,
`
`a healthcare services provider in New Jersey is only eligible to receive PIP Benefits for medically
`
`necessary services.
`
`58.
`
`Like New York, New Jersey has established a medical fee schedule (the “NJ Fee
`
`Schedule”) that is applicable to claims for PIP Benefits.
`
`59. When a healthcare services provider submits a claim for PIP Benefits using the
`
`CPT codes set forth in the NJ 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 is used was reasonable and
`
`medically necessary; and (iii) the service and the attendant fee were not excessive.
`
`II.
`
`The Defendants’ Interrelated Fraudulent Schemes
`
`A. Mian, Mian NY PC, and Mian NJ PC’s Fraudulent Treatment and Billing Protocol
`
`
`
`60.
`
`Virtually all of the Insureds in the claims identified in Exhibits “1” – “2” whom
`
`Mian, Mian NY PC, and Mian NJ PC purported to treat were involved in relatively minor
`
`accidents, to the extent that they were involved in any actual accidents at all.
`
`
`
`61.
`
`In keeping with the fact that virtually all of the Insureds in the claims identified in
`
`Exhibits “1” – “2” were involved in only minor accidents, in most of the claims identified in
`
`Exhibits “1” – “2” the Insureds did not seek treatment at any hospital following their accidents.
`
`
`
`13
`
`

`

`Case 1:20-cv-06185-RRM-RER Document 1 Filed 12/21/20 Page 14 of 99 PageID #: 14
`
`
`
`
`
`62.
`
`To the limited extent that the Insureds in the claims identified in Exhibits “1” – “2”
`
`did report to a hospital following their accidents, they virtually always were briefly observed on
`
`an outpatient basis and then sent on their way after a few hours with, at most, a minor sprain, strain,
`
`or similar soft tissue injury diagnosis.
`
`
`
`63.
`
`Furthermore, in most cases, contemporaneous police reports indicated that the
`
`underlying accidents involved low-speed, low-impact collisions, that the Insureds’ vehicles were
`
`drivable following the accidents, and that no one was seriously injured in the underlying accidents,
`
`or injured at all.
`
`
`
`64.
`
`At the same time, virtually none of the Insureds whom Mian, Mian NY PC, and
`
`Mian NJ PC purported to treat suffered from any significant injuries or health problems as a result
`
`of the relatively minor accidents they experienced or purported to experience.
`
`
`
`65.
`
`Even so, Mian, Mian NY PC, and Mian NJ PC subjected virtually every Insured in
`
`the claims identified in Exhibit “1” – “2” to a medically unnecessary course of “treatment” that
`
`was provided pursuant to a pre-determined, fraudulent protocol designed to maximize the billing
`
`that Mian, Mian NY PC, and/or Mian NJ PC could submit to insurers, including GEICO, rather
`
`than to treat or otherwise benefit the Insureds who were subjected to it.
`
`
`
`66. Mian, Mian NY PC, and Mian NJ PC provided their pre-determined fraudulent
`
`treatment protocol to Insureds without regard for the Insureds’ individual symptoms or
`
`presentment, or – in most cases – the total absence of any actual medical problems arising from
`
`any actual automobile accidents.
`
`
`
`67.
`
`Each step in Mian, Mian NY PC, and Mian NJ PC’s fraudulent treatment and billing
`
`protocol was designed to falsely reinforce the rationale for the previous step and provide a false
`
`
`
`14
`
`

`

`Case 1:20-cv-06185-RRM-RER Document 1 Filed 12/21/20 Page 15 of 99 PageID #: 15
`
`
`
`justification for the subsequent step, and thereby permit the Defendants to generate and falsely
`
`justify the maximum amount of fraudulent no-fault insurance billing for each Insured.
`
`
`
`68.
`
`No legitimate physician, medical practice, or ambulatory surgery center would
`
`permit the fraudulent treatment and billing protocol described below to proceed under his, her, or
`
`its auspices.
`
`
`
`69. Mian, Mian NY PC, and Mian NJ PC permitted the fraudulent treatment and billing
`
`protocol described below to proceed under their auspices because they sought to profit from their
`
`fraudulent scheme.
`
`The Fraudulent Charges for Initial Examinations at Mian NY PC and Mian NJ PC
`
`1.
`
`
`70. Mian and either Mian NY PC or Mian NJ PC purported to provide virtually every
`
`Insured in the claims identified in Exhibits “1” and “2” with an initial examination.
`
`
`
`71.
`
`The initial examinations were performed as a “gateway” in order to provide
`
`Insureds with phony, pre-determined “diagnoses” to allow the Defendants to then bill GEICO and
`
`other insurers for medically unnecessary, illusory, or otherwise non-reimbursable arthroscopic
`
`surgical procedures, pain management procedures, physical therapy services, and facility fees.
`
`
`
`72. Mian purported to perform virtually all of the initial examinations in the claims
`
`identified in Exhibits “1” and “2”.
`
`73.
`
`In the claims identified in Exhibit “1”, Mian and Mian NY PC then billed most of
`
`the putative initial examinations to GEICO under CPT code 99245, typically resulting in charges
`
`of $299.26 per examination.
`
`74.
`
`In the claims identified in Exhibit “2”, Mian and Mian NJ PC then billed most of
`
`the putative initial examinations to GEICO under CPT codes 99245 or 99205, typically resulting
`
`in charges of either $350.00 or $420.25 per examination.
`
`
`
`15
`
`

`

`Case 1:20-cv-06185-RRM-RER Document 1 Filed 12/21/20 Page 16 of 99 PageID #: 16
`
`
`
`75.
`
`Pursuant to the American Medical Association’s CPT Assistant, which is
`
`incorporated by reference into the NY Fee Schedule and NJ Fee Schedule, the use of CPT code
`
`99245 to bill for an initial patient examination typically requires – among other things – that: (i)
`
`the patient presented with problems of moderate to high severity; (ii) the physician who conducted
`
`the examination spent at least 80 minutes of face-to-face time with the patient or the patient’s
`
`family; (iii) the physician who performed the examination took a “comprehensive” patient history;
`
`(iv) the physician who performed the examination conducted a “comprehensive” physical
`
`examination; and (v) the physician who performed the examination engaged in “high complexity”
`
`medical decision-making.
`
`76.
`
`Pursuant to the CPT Assistant, the use of CPT code 99205 to bill for an initial
`
`patient examination typically requires – among other things – that: (i) the patient presented with
`
`problems of moderate to high severity; (ii) the physician who conducted the examination spent at
`
`least 60 minutes of face-to-face time with the patient or the patient’s family; (iii) the physician
`
`who performed the examination took a “comprehensive” patient history; (iv) the physician who
`
`performed the examination conducted a “comprehensive” physical examination; and (v) the
`
`physician who performed the examination engaged in “high complexity” medical decision-
`
`making.
`
`77.
`
`In the claims for initial examinations identified in Exhibits “1” – “2”, the charges
`
`for the initial examinations were fraudulent because they misrepresented that Mian NY PC and
`
`Mian NJ PC were eligible to collect

This document is available on Docket Alarm but you must sign up to view it.


Or .

Accessing this document will incur an additional charge of $.

After purchase, you can access this document again without charge.

Accept $ Charge
throbber

Still Working On It

This document is taking longer than usual to download. This can happen if we need to contact the court directly to obtain the document and their servers are running slowly.

Give it another minute or two to complete, and then try the refresh button.

throbber

A few More Minutes ... Still Working

It can take up to 5 minutes for us to download a document if the court servers are running slowly.

Thank you for your continued patience.

This document could not be displayed.

We could not find this document within its docket. Please go back to the docket page and check the link. If that does not work, go back to the docket and refresh it to pull the newest information.

Your account does not support viewing this document.

You need a Paid Account to view this document. Click here to change your account type.

Your account does not support viewing this document.

Set your membership status to view this document.

With a Docket Alarm membership, you'll get a whole lot more, including:

  • Up-to-date information for this case.
  • Email alerts whenever there is an update.
  • Full text search for other cases.
  • Get email alerts whenever a new case matches your search.

Become a Member

One Moment Please

The filing “” is large (MB) and is being downloaded.

Please refresh this page in a few minutes to see if the filing has been downloaded. The filing will also be emailed to you when the download completes.

Your document is on its way!

If you do not receive the document in five minutes, contact support at support@docketalarm.com.

Sealed Document

We are unable to display this document, it may be under a court ordered seal.

If you have proper credentials to access the file, you may proceed directly to the court's system using your government issued username and password.


Access Government Site

We are redirecting you
to a mobile optimized page.





Document Unreadable or Corrupt

Refresh this Document
Go to the Docket

We are unable to display this document.

Refresh this Document
Go to the Docket