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Pyrrhic Victory – Partial profit makes it easier to pass judgment for insurance fraud



Following a preliminary hearing, Sanjoy Banerjee, a physician, was charged with two counts of making a false or fraudulent medical claim to an insurer, one form of perjury insurance fraud and three. The Supreme Court rejected Banerjee's request to dismiss the information as it was not supported for reasonable or probable cause and he requested a restraining order to eliminate the allegations. In Sanjoy Banerjee v. The Superior Court Of Riverside County, The People, Real Party In Interest, E076291, California Court Of Appeals, Fourth District, Second Division (October 5, 2021) banned the Court of Appeal from counting and allowed insurance fraud charges to continue. .

INTRODUCTION. The People claim that the evidence supports a strong suspicion that Banerjee committed two cases of insurance fraud and three cases of perjury. two other legal entities that he owned and controlled. The insurance fraud fees are based on Banerjee's invoices 2014-2016 to the insurer through the other two units. The allegations of perjury are based on three cases in which Banerjee signed medical reports and testified under penalty of perjury that he had not violated "section 139.3."

BACKGROUND

Banerjee is charged with violating Section 550, Subsection (a) (6) of the Penal Code, a form of insurance fraud. The law makes it a crime to "[k] now make or have made a false or fraudulent claim for payment of a health care benefit." The elements of the crime are (1) the deliberate presentation of a false claim for payment of a health care benefit, (2) with the intention of deceiving the recipient. Insurance fraud is a specific breach of intent; the defendant must specifically intend to deceive a person with a false or fraudulent statement. The crime is complete in the making of the claim, regardless of whether someone has been deceived by or something of value is received or received as consideration for the claim.

A doctor who refers to or seeks consultation from an organization where the doctor has a financial interest must disclose this interest of the patient in writing at the time of referral.

Banerjee & # 39 ;s Formation of Three Service Provider Entities

Banerjee is a licensed physician specializing in pain management. He formed his professional company, Sanjoy Banerjee, M.D., Inc., in 2005, and in 2010 he began running the company under the fictitious name, PPCC. Kensington and Rochester were formed in 2014. The Articles of Association of Kensington and Rochester state that they should be managed by their members and identify Banerjee as their only member. Information statements for Kensington and Rochester, filed in 2014, identify Kensington's type of activity as a "clinical diagnostic and reference laboratory" and Rochester's as an "outpatient surgical center."

was the only witness to testify at the preliminary hearing. Oard was commissioned to investigate "suspicious" allegations and service providers for BHHC, and he began investigating Banerjee in 2017. Oard discovered that Banerjee had billed BHHC through three legal entities, namely PPCC, Kensington and Rochester, which Banerjee owned and operated from Wildomar site.

The insurance fraud charges in counts 1 and 2 are based on Banerjee's combined invoices to BHHC, through Kensington and Rochester, between 2014 and 2016. The prosecutor claimed that these invoices were false and fraudulent because they violated Baner. 139.3 (a) by referring patients to Kensington and to Rochester units where he had a financial interest – without informing the BHHC that he had a financial interest in Kensington and Rochester. In summary, the defense attorney argued that Banerjee did not violate section 139.3 (a) and therefore did not commit insurance fraud or perjury.

DISCUSSION

It is a firm principle of statutory construction that, where exceptions to a general rule are provided by law, other exceptions shall not be implied or presumed.

A physician's disclosure to a patient that the physician has a financial interest in an organization to which the doctor refers the patient or seeks consultation is completely logical as a way of informing the patient that the doctor has a conflict of interest with the organization, regardless of the services for which the patient is.

The government violates a person's right to legal action under the Fifth Addendum "by depriving someone of their life, liberty or property under a criminal law that is so vague that it does not give ordinary people justice. if the conduct it punishes, or so non-standard that it calls for arbitrary enforcement. " ( Johnson v. US . (2015) 576 US 591, 595.)

Section 139.31 (e) provides: “The prohibition in section 139.3 shall not apply to any service intended for a specific patient. performed within, or goods provided by, a medical clinic …. "Banerjee claims that section 139.31 (e) is unconstitutionally vague because it does not specify what" within … a medical clinic "means, and because other parts of section 139.31 do not provides guidance.

Our interpretation of the exemption from the doctor's surgery. in section 139.31 (e) means that the exemption applied to Banerjee's referrals of patients to Kensington and Rochester (§ 139.3 (a)), and that Banerjee did not violate section 139.3 (a) by referring patients to services listed in section 139.3 ( a)) to Kensington and Rochester. Thus, Banerjee's actions to sign three medical statements, under penalty of perjury, certifying to the BHHC that he had complied with "Section 139.3" were not false (§ 118).

Insurance Fraud

fraudulent invoices to the BHHC for services described in Labor Code Section 139.3 (a), after referring patients to Kensington and Rochester for the services, in violation of Labor Code Section 139.3 (a). Section 550 of the Penal Code, subsection (a) (6), a form of insurance fraud, is committed when the defendant knowingly makes or has made a false or fraudulent claim about a health care benefit. Insurance fraud is a specific breach of intent; the defendant must specifically intend to deceive a person with a false or fraudulent statement. The evidence presented at the preliminary hearing shows that the Supreme Court had reasonable grounds to believe that Banerjee was liable for the insurance fraud charges.

The evidence showed that between 2014 and 2016, Banerjee presented false and fraudulent claims for health care benefits. to BHHC through Kensington and Rochester, with the specific intention of deceiving BHHC. Banerjee's invoices through Kensington and Rochester were for a significantly higher amount than Banerjee had previously invoiced BHHC for the same or similar services he provided through PPCC alone, and that BHHC had been invoiced by the group activities with which Banerjee had previously practiced. Banerjee did not inform the BHHC that he owned and operated Kensington and Rochester; and in one case, Banerjee double-billed BHHC for two epidural injections given to the same patient on the same day, through PPCC and Rochester. The Rochester billing for the two epidural injections was approximately $ 9,000 higher than the total billing for the patient through the PPCC.

The documentation also supports a strong suspicion that Kensington and Rochester were sham units, and that Banerjee formed Kensington and Rochester with the specific intentions to deceive the BHHC through its Kensington and Rochester invoices.

The Kensington and Rochester invoices gave the impression that the units were not part of Banerjee's medical practice but were independent, diagnostic test and surgical centers, operating independently of any doctor's office. . But when BHHC's investigator, Oard, visited Banerjee's Wildomar site, he discovered that Banerjee operated on Kensington from "a small locker room" and that Banerjee operated on Rochester from a "remodeled treatment room." The evidence supported a strong suspicion that Banerjee had no business reason to form Kensington and Rochester, other than to use them to present high-inflated invoices for his diagnostic and surgical services to the BHHC. The information can not be disregarded about the insurance fraud charges because the evidence shows that there is some rational basis for assuming the possibility that these crimes have been committed and that the defendant is guilty of them.

INSURANCE

Additional proceedings may continue, and the court's previous decision to stay further processing of the information was revoked and the case may go to trial on charges of two insurance frauds.

The crime of insurance fraud is a simple criminal offense. , direct, crime to prove. If a fraudulent bill is sent to an insurance company, the crime can be proven. Because the evidence showed that Banerjee, by using the two additional units, could bill $ 9,000 more than if he billed it directly, may have a jury conclude that he issued the bills with the intent to defraud the insurer. The Court of Appeal, by removing the accusations of perjury, made the case simple, clean and direct instead of complicating the trial with difficult to prove and less than clear statutes. Banerjee succeeded in part, thus making it easier for the state to convict him of insurance fraud.


© 2021 – Barry Zalma

Barry Zalma, Esq., CFE, now limits his internship to the position of insurance consultant specializing in insurance coverage, insurance claims handling, bad faith and insurance fraud almost equally for insurers and policyholders.

He also acts as an arbitrator. insurance-related disputes. He practiced law in California for more than 44 years as a lawyer for insurance coverage and claims management and more than 54 years in the insurance industry.

Subscribe to Excellence in Claims Handling at https://barryzalma.substack.com/welcome.

He is available at http://www.zalma.com and zalma@zalma.com. Zalma is the first recipient of the first annual Claims Magazine / ACE Legend Award. For the past 53 years, Barry Zalma has devoted his life to insurance, insurance claims and the need to defeat insurance fraud. He has created the following library of books and other materials to enable insurers and their claimants to become professionals in insurance claims.

Go to the training available at https://claimschool.com; articles at https://zalma.substack.com, the podcast Zalma On Insurance at https://anchor.fm/barry-zalma; Follow Mr Zalma on Twitter at https://twitter.com/bzalma ; Go to Barry Zalma videos at https://www.rumble.com/zalma; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; Go to Insurance Claims Library – https://zalma.com/blog/insurance-claims-library/ T the last two issues of ZIFL are available at https://zalma.com/zalmas-insurance-fraud- letter -2 / podcast now available at https://podcasts.apple.com/us/podcast/zalma-on-insurance/id1509583809?uo=4


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