Auto insurers sue San Antonio physician over lots of of 'pointless' medical procedures – San Antonio Specific-InformationJuly 29, 2022
Two insurance coverage corporations are accusing a San Antonio physician of performing pointless and costly spinal surgical procedures on sufferers injured in auto accidents as a solution 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 really helpful and/or carried out spinal injections on 300 sufferers and, of these, about half had been suggested to bear spinal surgical procedure, the lawsuit alleges. The criticism was filed Tuesday in San Antonio federal courtroom.
Plaintiffs State Farm Mutual Insurance coverage Car 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 exhibits Misra has no legal historical past and no disciplinary actions towards him. He’s been a licensed doctor for nearly three many years.
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Of their causes of motion, the insurers cite a federal legislation typically related to prosecutions of mob bosses — the Racketeering Influenced and Corrupt Organizations Act, or RICO.
Submitting fraudulent payments by way 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 “had been on the very least a considerable think about inducing” them to settle bodily harm and uninsured/under-insured motorist claims they in any other case may not 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” based mostly 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 Data Institute, an business commerce group. Corporations have “particular investigative items that look into this in order to guard trustworthy policyholders from individuals who attempt to make the most of 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, based on the Texas Division of Insurance coverage.
The State Farm corporations say of their criticism 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 no less than 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 non-public 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 value greater than $50,000 — not together with anesthesia and associated gadgets that may double the fee — and are supposed 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 typically begin with “conservative care that’s not invasive,” the insurers say. That features prescribing anti-inflammatory medicines, chiropractic care or bodily remedy. If these don’t work, injections could also be acceptable, they add.
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The State Farm corporations recognized 335 sufferers handled by Misra for neck and/or again ache. They are saying his medical evaluations had been carried out as a “pretext” to carry out the injections.
“The evaluations don’t replicate the sufferers’ official examination findings or a medically mandatory therapy plan tailor-made to every affected person’s distinctive circumstances,” the swimsuit says. “Slightly, they’re boilerplate, embrace nonspecific details about the sufferers’ circumstances, and reveal noncredible patterns.”
The criticism provides, “Misra nearly all the time paperwork affected person complaints of ‘Radiating Ache” and ‘Numbness.’”
The swimsuit 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 informed Misra she didn’t like his advice 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 might obtain more cash in her insurance coverage declare, the businesses allege.
State Farm declined to remark.
Patrick Danner is a enterprise reporter for the San Antonio Specific-Information.