Allstate accuses Florida medical clinic of billing for unnecessary, life-threatening spinal surgeries [South Florida Sun-Sentinel]

Allstate Insurance Company is accusing a Florida-based medical clinic of fraudulently performing unnecessary, life-threatening spinal surgeries and billing for surgeries not performed, then justifying them on invoices with falsified medical records.

The defendant, Florida Anesthesiology & Pain Clinic, is accused of violating laws originally created to fight organized crime.

The clinic has offices in six Florida locations: Pompano Beach, Palm Beach Gardens, Miami Gardens, Tampa, Orlando and Pensacola, according to its website.

Allstate, in a lawsuit filed Thursday in U.S. District Court in West Palm Beach, accused the clinic and its owner, Dr. Ravi Xavier, of perpetrating an “insurance fraud scheme” designed to elicit payments from the insurer.

The insurer says it paid millions of dollars to resolve insurance claims “that were based on the false, fabricated, unlawful, and improper medical services” described in the lawsuit.

All of the bills submitted to Allstate named Xavier as the physician who rendered “the alleged services,” the suit states.

The suit also says that the clinic could not have safely performed all of the services that it claimed on its invoices.

“If the defendants actually performed all the procedures they billed in the manner they claimed, the lives of the patients at issue herein were placed at risk,” the suit states.

It further claimed that “Florida Anesthesiology regularly billed for alleged injections into patients’ spines using body positioning, approaches and medications that were contraindicated, physiologically impossible, and extremely and unnecessarily dangerous.”

The procedures were billed on behalf of car crash victims who were seeking “little or no medical treatment on their own” but were “steered” to the clinic by “several law firms,” the suit says. The clinic, the suit says, agreed to generate “enormous charges regardless of patients’ actual injuries (if any).”

The clinic sent patient bills and records to the attorneys, who in turn sent them to Allstate, the suit says. After the insurer sent payments to the attorneys, the attorneys compensated the clinic at rates “far less” than the charge amounts in the records and bills sent to Allstate, according to the lawsuit.

The clinic’s advertising was geared to plaintiffs attorneys rather than patients, the suit said, citing a statement on its website that reads, “We specialize in various types of on-site testing and procedures that will assist in building a strong case for your clients . . . .”

The lawsuit claims that the clinic billed for “an incredible number” of spinal injections known as automated percutaneous discectomies (PDDs) that are typically reserved to treat persistent and severe pain that has resisted all other treatments.

The clinic “frequently billed for PDDs — at a rate of $65,000 for each” before attempting any other treatment, including at patients’ initial appointments, the suit says.

Other procedures that Allstate found on multiple invoices included radiofrequency ablations (RFAs) which destroy nerves thought to cause joint pain.

Before resorting to RFAs, however, physicians “need to identify the actual suspected source of pain” by temporarily numbing nerves to confirm that a particular joint is indeed the source of the pain.

But Florida Anesthesiology “routinely skipped” that step and instead immediately billed for the more expensive RFA procedure without regard to the fact “that patients’ nerves were being unnecessarily destroyed,” the complaint states.

The clinic routinely billed for as many as five RFAs on the same day and up to 10 per patient, the suit says, “destroying nerves in large areas of patients’ spines.”

A third type of commonly billed procedure cited in the lawsuit — epidural steroid injections (ESIs) — are used to treat pain caused by compressed nerves in patients’ spinal columns.

The clinic “routinely billed” for “excessive” steroid injections that far exceeded standards for how many should be given per day and how frequently they should be used, the lawsuit says.

The suit accuses the clinic of billing for all three treatments on the same day, which, it says “can never be medically appropriate.”

“Administering multiple treatments on the same date is redundant and the diagnostic value of each is lost because it is impossible to tell which might have caused any relief experience by the patient,” the suit says.

Other items cited in the lawsuit include vital patient statistics recorded incorrectly, suggesting that those patients “were not actually ever seen or treated,” and Xavier’s claims to have performed procedures with no assistance or witnesses, using only local anesthesia that Xavier administered himself. That would be against state law requiring anyone who administers anesthesia to do nothing else, the suit states.

A chart showing billing records of 223 patients, identified only by patient number and initials, was included as an exhibit to the lawsuit. The chart showed 131 charges for automated percutaneous discectomies at $65,000 each and charges for 244 series of four lumbar RFAs, or $20,000 per billing. Billed services on the chart totaled $21.9 million.

The lawsuit accuses Florida Anesthesiology & Pain Clinic of violating the federal and state versions of the Racketeer Influenced and Corrupt Organizations (RICO) Act, Florida’s Deceptive and Unfair Trade Practices Act, and laws prohibiting fraud and unjust enrichment.

The insurer said that before it filed the lawsuit, it reached out to the defendants and negotiated a settlement agreement in early December. Allstate said it did this to stop the fraud as soon as possible because it “was so pervasive and potentially placed patients in grave danger.”

But after agreeing on Dec. 8 to pay $2.5 million to Allstate and waive all outstanding bills to the company, the clinic’s lawyer “apologized” and told Allstate on Dec. 19 that “he was instructed by the defendants to convey that the defendants will not honor their Settlement Agreement obligations.”

Because the lawsuit was filed on Thursday, no attorney was listed as representing Xavier and the clinic. Xavier did not respond to a voice mail message and text messages left on his cell phone.

According to his Linkedin profile, Xavier has been a practicing physician specializing in anesthesiology, pain management and critical care medicine for more than 30 years.

In December 2021, he purchased a $19 million home in Manalapan under the name of one his companies, RX Colorado LLC, according to the Palm Beach County Property Appraiser’s website.

In December 2022, Xavier was sued by GC Global Consulting LLC, a company he hired to negotiate a mortgage interest rate lower than the 11% he was paying on the home.

GC Global Consulting’s suit said it negotiated a reduced rate of 5.25%, which lowered Xavier’s monthly payment on the home from about $158,000 to $58,000.

In exchange for the service, the suit said, Xavier had agreed to pay GC Global Consulting a fee of 3% of the loan amount, or $345,000.

Xavier had not paid the fee, the suit states.

In response, Xavier filed a court statement saying that the two sides had no agreement and he was given no written notice of an agreement until the lawsuit was filed.

After reaching agreement with Xavier to settle the matter, GC Global Consulting parted ways with its attorney, a court filing said. The case was dismissed in September, then refiled by GC Global on Dec. 7.

Ron Hurtibise covers business and consumer issues for the South Florida Sun Sentinel. He can be reached by phone at 954-356-4071, on Twitter @ronhurtibise or by email at [email protected].

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