Surgical LOP Abuse

The Surgical LOP Abuse Team concentrates in strategies for attacking unnecessary procedures and unreasonable medical billing in claims involving a Letter of Protection. The majority of these cases involve unrelated or unnecessary surgeries and procedures. Team members handle a number of specialized issues for the firm, including corporate representative depositions, unreasonable CPT code billing discovery, financial bias discovery, LOP fraud/abuse discovery and trial strategy.

The ultimate objective is to develop evidence to show a jury that certain providers engage in a system of widespread medical billing fraud when it relates to personal injury litigation. Our job is to expose the relationships between the surgeons and surgical centers, the “under the table” agreements to lease surgical suites but upcharge patients in the tens of thousands and connect the dots for jurors on the all of these issues as it relates to plaintiff’s counsel. Our SIU teams carefully develop a file on each provider and surgical center. While enforcement of the revised discovery law is somewhat uneven and varies from judge to judge, we aggressively pursue and mine this evidence on every LOP billing case. Once the evidence is obtained, it can generally be used to leverage reasonable settlements again in subsequent proceedings.

The use of a Letter of Protection (LOP) to secure medical care is no longer limited to those who lack insurance or exceed their policy limits. The LOP originated to provide medical treatment to Personal Injury Claimants who did not have insurance, but needed medical care. The doctor would provide treatment, and be given ‘protection’ by the lawyer. Today many claimants turn down submitting claims to their own health insurer in favor padding their medical specials for the potential for a larger verdict or settlement with the artificially inflated sticker prices of a LOP. Unfortunately, the LOP system has become a vehicle to promote gross overbilling that goes beyond any reasonable standard of customary reimbursement for the sake of inflating claim value. We have a dedicated team that focuses solely on these issues. Let us help level the playing field:

DEPOSITIONS – “(B)(6)” Representatives

The strategy employs obtaining key depositions of corporate representatives of the owners of medical providers, clinics and surgical centers (LOP players). The LOP players are obligated to put forward a prepared and knowledgeable witness whose testimony “binds the corporation” to testimony concerning how CPT code amounts are selected, hidden deals between facilities and surgeons, ownership and control, marketing to plaintiff personal injury firms, negotiated discounts for settled cases, etc. 30 B6- depositions provide substantive evidence that is admissible. Our goal is to expose the financial bias, hidden deals, inflated charges and connect the dots.

Financial Bias Discovery

The team focuses on seeking to find financial bias and determining whether plaintiff treating doctors have an ownership of interest, unity of ownership, and/or revenue sharing agreements with facilities and surgical centers. We have been assembling our files on certain medical providers many of which would rather settle than sit for our depositions or answer these difficult questions in front of a jury.

CPT Codes and Allowable Charges

The team specializes in investigating CPT codes to establish “reasonable” care: allowable codes used in LOP. Our attorneys will explore the health care provider’s overall billing practices to establish the true value of services. They will also explore the economics of each facility and surgery center as it relates to the business of personal injury litigation. The testimony given by the health care provider, especially as to causation, can mean the difference in a jury awarding reasonable and related medical expenses.

Trial Strategies

It is necessary to expose to the jury that the surgeon’s charges under the LOP are exorbitant, exceed usual and customary charges, and are not in accordance with customary billing practices. This can be done by putting the reasonableness of the surgeon’s charges at issue and discussing the reimbursement rates of insurance carriers and Medicare rates for each item billed by the surgeon. We carefully cross-examine physicians on how they determined their fees and compare them to customary reimbursement rates in the community, such as PIP or the Medicare fee schedule.

It is also necessary to cross-examine the surgeon regarding her involvement in litigation. We successfully argued this point to the Fourth District Court of Appeal in a landmark decision that allowed us to cross examine a surgeon by showing he was not in any in-network provider list in the World. This was relevant to show the provider was primarily involved in extensive litigation and made his living in the personal injury arena. The exposé of the surgeon’s extensive litigation practice, coupled with her refusal to accept Medicare and likely exorbitant bills will help convince the jury regarding the inflatedness and unreasonableness of the charges.

For assistance, Contact Daniel Santaniello.

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