State Farm v. 61069
In State Farm v. 61069 filed in 2021, State Farm claimed that a clinic was licensed with AHCA but it had a medical director who was “appointed in name only.”
Numerous patients reported in EUO testimony that they received therapy before being examined by a doctor (ie there was no recommendation or prescription for physical therapy). Some patients received therapy as long as four weeks before being seen by a doctor.
Also, the clinic performed x-rays on the patients, but numerous patients reported that no one ever went over the results of the x-ray with them. In fact, several patients had fractured vertebrae and still received numerous treatments including mechanical traction. After findings of a fracture, they weren’t referred for MRI, didn’t refrain from certain therapy like mechanical traction, and weren’t referred to an orthopedist for evaluation. State Farm claimed that the x-rays were conducted “for the sake of the injury case” versus for the benefit of the patient because no one went over the results or cared what the results were.
Also, the clinic was billing for therapeutic exercises- 97110- but never documented the name of the exercise, the repetitions of the exercise, the weight/resistance used, or whether/why those exercises were clinically indicated. There is also no short term or long-term goal listed in the treatment plan for the patient in regard to weight and repetition.
Also, State Farm cited testimony from Examinations Under Oath where one patient testified that she was told on her initial visit that she “needed to go to 35-40 visits” and another patient testified that they were told on the first visit that she would need 40 therapy sessions. Obviously, you can’t tell a patient they will need 35-40 visits on the first visit because their pain might go away after a couple of weeks. Also, every patient getting 35-40 visits is a pattern showing the clinic is “treating” the PIP benefits and not the patient.
State Farm claimed that if the medical director did his job as required by Florida Statute 400.9935 then he would have taken immediate corrective action and stopped it from happening.
DISCLAIMER
This is based on a real court case that was previously filed against a medical provider/doctor. The case number has been partially redacted and names have been changed to protect the Defendants’ names. This example is posted to help educate others on the laws and potential pitfalls. This posting is not intended to embarrass or defame anyone. I have limited the information and simplified some of the facts in the lawsuit to reflect key points and make a complicated case easier to understand. This “example” is directly from a complaint filed by an insurance company; therefore, I am using the facts THEY presented. There are always two sides to a story so please understand this is just one side of the story. This information was found through records available to the public.