Auto insurers sue San Antonio physician over lots of of 'pointless' medical procedures – San Antonio Categorical-InformationJuly 29, 2022
Two insurance coverage firms are accusing a San Antonio physician of performing pointless and costly spinal surgical procedures on sufferers injured in auto accidents as a option to inflate the worth of insurance coverage claims.
A San Antonio doctor has been sued for allegedly performing pointless and costly spinal surgical procedures and procedures on sufferers injured in auto accidents to inflate the worth of their insurance coverage claims.
Dr. Sanjay Misra advisable and/or carried out spinal injections on 300 sufferers and, of these, about half have been suggested to endure spinal surgical procedure, the lawsuit alleges. The grievance was filed Tuesday in San Antonio federal court docket.
Plaintiffs State Farm Mutual Insurance coverage Vehicle Insurance coverage Co. and State Farm County Mutual Insurance coverage Co. of Texas say Misra submitted lots of of fraudulent payments and supporting documentation to the businesses.
He didn’t instantly reply to a message left with an answering service Wednesday. The Texas Medical Board web site reveals Misra has no prison historical past and no disciplinary actions in opposition to him. He’s been a licensed doctor for nearly three a long time.
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Of their causes of motion, the insurers cite a federal regulation typically related to prosecutions of mob bosses — the Racketeering Influenced and Corrupt Organizations Act, or RICO.
Submitting fraudulent payments by means of the U.S. mail quantities to a “sample of racketeering exercise” meant to defraud the insurers, the businesses allege. They are saying the fraudulent payments and supporting documentation “have been on the very least a considerable consider inducing” them to settle bodily harm and uninsured/under-insured motorist claims they in any other case won’t have settled.
The businesses say they paid greater than $6.5 million to settle the claims. They’re looking for restitution, although they don’t know exactly how a lot Misra acquired. The businesses suspect the quantity is “substantial” primarily based on Misra’s $2.5 million in expenses for the related claims.
They are saying they’re entitled to damages of greater than $1.1 million.
“Auto insurers are very vigilant” about fraudulent billing, mentioned Michael Barry, spokesman for the Insurance coverage Info Institute, an trade commerce group. Firms have “particular investigative items that look into this in order to guard sincere policyholders from individuals who attempt to benefit from the system,” he mentioned.
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Illinois-based State Farm Mutual was the state’s second largest auto insurer in 2020, with a 13.4 p.c market share, rating simply behind Progressive County Mutual Insurance coverage Co. Dallas-based State Farm County ranked thirty third with a market share of lower than one-half of 1 p.c, in response to the Texas Division of Insurance coverage.
The State Farm firms say of their grievance that “Misra falsely purports to legitimately examination people (“sufferers”) reporting neck and/or again ache and prescribe spinal injections, specifically medically pointless epidural steroid injections (“ESIs”) in at the very least one area of the backbone, for almost all such sufferers” seen by him.
He carried out the injections “with out regard as to if they’re wanted to magnify the severity and inflate the potential worth of private harm claims,” the insurers add. Every injection prices $3,300.
When the injections don’t resolve sufferers’ complaints, the insurers say, the physician recommends “costly, medically pointless surgical procedures.” The surgical procedures price greater than $50,000 — not together with anesthesia and associated gadgets that may double the price — and are meant to inflate the worth of insurance coverage claims, the insurers say.
Remedy plans for people who are suffering neck or again ache because of a automobile accident usually begin with “conservative care that isn’t invasive,” the insurers say. That features prescribing anti-inflammatory drugs, chiropractic care or bodily remedy. If these don’t work, injections could also be acceptable, they add.
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The State Farm firms recognized 335 sufferers handled by Misra for neck and/or again ache. They are saying his medical evaluations have been carried out as a “pretext” to carry out the injections.
“The evaluations don’t mirror the sufferers’ authentic examination findings or a medically essential therapy plan tailor-made to every affected person’s distinctive circumstances,” the go well with says. “Moderately, they’re boilerplate, embody nonspecific details about the sufferers’ situations, and reveal noncredible patterns.”
The grievance provides, “Misra just about at all times paperwork affected person complaints of ‘Radiating Ache” and ‘Numbness.’”
The go well with recounts numerous sufferers’ interplay with the physician. One affected person, recognized as A.M., a 16-year-old feminine who was seen by the physician in 2019, mentioned she advised Misra she didn’t like his suggestion that she obtain an injection.
“He mentioned one thing alongside the traces of, ‘Nicely, no shot, no cash’ or one thing,” she mentioned. And I used to be like, ‘Okay. That’s not what I’m right here for.’”
That was Misra’s means of telling her that she ought to obtain the injection so she may obtain extra money in her insurance coverage declare, the businesses allege.
State Farm declined to remark.
Patrick Danner is a enterprise reporter for the San Antonio Categorical-Information.