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A Comprehensive Guide to NJ Insurance Fraud Law Special R Special Report www.NJInsuranceFraud.org N E W J E R S E Y New Jersey Office of the Attorney General INSURANCE SpecialSpecial RReeporport:t: audaud • AA ComprehensiveComprehensive rr 2004 Annual Report Fraud Prosecutor of the New Jersey Office of the Insurance FF GuideGuide toto NJNJ InsuranceInsurance FraudFraud LawLaw OIFP Leads Nation’s Insurance Fraud War OIFP Takes on One of State’s Largest Racketeering Rings Best Practices Guide for Insurance Company Peter C. Harvey, Attorney General Referrals to OIFP Vaughn L. McKoy, Director, Division of Criminal Justice Greta Gooden Brown, Insurance Fraud Prosecutor 2004 Annual Report of the New Jersey Office of the Insurance Fraud Prosecutor Inside Front Cover Annual Report of Annual Report Staff First Assistant Insurance Fraud Prosecutor John J. Smith The New Jersey Assistant Attorney General Editor Melaine B. Campbell Supervising Deputy Attorney General Office of the Co-Editors Stephen D. Moore Supervising Deputy Attorney General Marquis D. Jones, Jr. Insurance Fraud Deputy Attorney General Michael A. Monahan Assistant Supervising Deputy Attorney General Prosecutor Copy Editor Joan Enright Administrative Analyst Feature Writers for Calendar Year 2004 Paula Carter Analyst Diane Ibrahim Submitted Intern March 1, 2005 Lewis Korngut Supervising Deputy Attorney General (Pursuant to N.J.S.A. 17:33A-24d) John Krayniak Supervising Deputy Attorney General Annie Meredith Special Investigator Scott Patterson Supervising Deputy Attorney General Christina Runkle Analyst Contributors Michelle Apgar Peter C. Harvey Supervising Civil Investigator Attorney General John Butchko Special Assistant Jennifer Fradel Vaughn L. McKoy Deputy Attorney General, DOL Director, Division of Criminal Justice Charles Janousek Special Assistant Pat Miller Greta Gooden Brown Administrative Assistant Barry T. Riley Insurance Fraud Prosecutor Supervising State Investigator Photographers Vincent A. Matulewich Managing Deputy Chief Investigator Prepared by: Carlton A. Cooper Civil Investigator Office of the Attorney General Production Department of Law and Public Safety Paul Kraml Art Director Division of Criminal Justice Sina Adl Office of the Insurance Fraud Prosecutor Graphic Designer Administrative and P.O. Box 094 Technical Support Susan Cedar Trenton, NJ 08625-0094 Technical Assistant 609-896-8888 Cynthia Ronan www.njinsurancefraud.org Administrative Assistant Contents Message From The Insurance Fraud Prosecutor 5 OIFP Leads Nation’s Insurance Fraud War 8 Special Report — A Comprehensive Guide to New Jersey Insurance Fraud Law 24 OIFP Takes on One of State’s Largest Racketeering Rings 38 $100 Million Scam Part of Growing Trend in Insurance Professional Fraud Uncovered by OIFP 44 GlaxoSmithKline to Pay $2.1 Million to NJ’s Medicaid Program in National Settlement 50 Best Practices Guide for Insurance Company Referrals to OIFP 54 OIFP Offers Rewards for Reporting Insurance Fraud 60 Leveling the Playing Field — OIFP Targets Workers’ Compensation Premium Fraud 64 Demystifying the HIPAA Privacy Rule 68 OIFP’s Medicaid Fraud Unit Protects the Elderly 72 Behind the Scenes in Law Enforcement — The Role of Analysts in Criminal Investigations and Prosecutions 76 Dennis Jay, Executive Director of the Coalition Against Insurance Fraud, Speaks Out 82 NJ Insurance Fraud Case Notes 86 OIFP Criminal Case Notes – Insurance Fraud 90 OIFP Criminal Case Notes – Medicaid Fraud 132 OIFP Civil Case Notes 136 DOL Civil Litigation Case Notes 142 County Prosecutors’ Offices Criminal Case Notes 144 Professional Licensing Proceedings 152 Closing the Loopholes on Fraud — OIFP’s Recommendations for Legislative and Regulatory Reform 156 County Prosecutor Contacts 146 OIFP Industry Contacts 148 This Page Was Intentionally Left Blank A Message from The Insurance Fraud Prosecutor Taking the War on Insurance Fraud to the Next Level We are pleased to present the sixth Annual Report of the New Jersey Office of the Insurance Fraud Prosecutor (OIFP). As with all of our programs at OIFP, we strive to improve our prior year’s efforts in every respect, and this year’s Annual Report is no exception. In this year’s Report, we not only summarize OIFP’s accomplishments in 2004, we also provide a handy reference guide for all who are interested in combating insurance fraud in New Jersey and elsewhere, be they government officials, industry executives, or concerned citizens. In addition to our usual statistical summaries, case synopses, and narrative descriptions of OIFP’s functions and programs, we have included in this year’s Annual Report a wealth of highly in- formative materials, including an article recounting the events culminating in the creation and shap- ing of OIFP, a section providing a comprehensive guide on New Jersey’s insurance fraud laws, a Greta Gooden Brown “best practices guide” for insurance company referrals to OIFP, a detailed explanation of how the Health Insurance Portability and Accountability Act (HIPAA) affects law enforcement, an interview with the Executive Director of the Coalition Against Insurance Fraud, a directory of key official con- tacts, and other useful reference materials. Unfortunately, as this year’s Annual Report demonstrates only too clearly, insurance fraud con- tinues to maintain its dubious distinction as one of the underground economy’s largest growth indus- tries. Indeed, the current pandemic of insurance fraud continues to adversely impact not only private insurance carriers, but also governmental programs that provide various forms of social insurance, in- cluding health insurance, unemployment insurance, disability insurance, workers’ compensation in- surance, and various programs administered by the Social Security Administration. Losses caused by those who loot these programs deplete the programs’ resources and diminish the benefits other- wise available to those among us who must genuinely depend upon them for their very subsistence. Whether as an opportunistic crime or an organized criminal enterprise, insurance fraud permeates our society and drains our economic vitality. The good news, however, is that OIFP continues to redefine the manner in which government at- tacks insurance fraud. As it has from the very beginning, OIFP remains committed to fight all forms of insurance fraud. From OIFP’s birth as a fraud-fighting organization six years ago, it has screened over 60,000 reports of suspected insurance fraud, imposed over 4,500 fines totaling more than $22 million, obtained orders for over $46 million in civil and criminal restitution, pursued criminal prosecu- tions resulting in the conviction of approximately 840 insurance fraudsters and sent nearly 300 of them to jail for a total of 648 years. Now, as a new day dawns, OIFP is prepared and poised to take the war against insurance fraud to the next level. While our mandate to lead New Jersey’s fight against insurance fraud is broad, our core function remains the investigation, prosecution, and imposition of criminal and civil sanctions against insur- ance cheats. To this end, 2004 was another banner year for OIFP in the number of defendants sen- tenced to jail terms for committing insurance fraud and the amount of restitution ordered on behalf of those victimized by insurance fraudsters. Indeed, In 2004, OIFP obtained more restitution and greater jail sentences than in any other year in OIFP’s history. Most notably in 2004, the number of those sentenced to jail for committing insurance fraud significantly increased over those sentenced to jail in 2003. In 2004, criminal prosecutions by OIFP resulted in the imposition of jail sentences totaling 199 years of incarceration, an increase of over 70% from the prior year. Gains in the amount of restitution ordered for victims were similarly noteworthy, more than doubling from 2003 to over $16 million in 2004. Together with County Pros- ecutor Insurance Fraud Units funded by OIFP, in 2004, New Jersey filed criminal insurance fraud- related charges against 527 defendants, 93 of whom were sentenced to a total of 258 years in jail. OIFP, alone, accounted for over 79% of the jail time meted out to those convicted of insurance fraud. In 2004, OIFP recorded an impressive 100% conviction rate. Among OIFP’s more notable trial convictions in 2004 were guilty verdicts obtained against Linda Clements-Wright, an insurance com- pany claims specialist who stole nearly $600,000 in bogus claim settlement monies, and Eliezer Martinez, a Medicaid provider who submitted nearly $140,000 in fictitious counseling claims to the Medicaid Program. Most significantly in 2004, OIFP again ratcheted up its efforts to identify, infil- trate, and dismantle organized insurance fraud conspiracies, as evidenced by the successful pros- ecution of the insurance fraud ring headed by kingpin, Anhuar Bandy, who was sentenced to spend the next 29 years of his life behind bars. This conviction represents New Jersey’s first successful prosecution of a staged accident ring as a criminal racketeering enterprise. As in years past, OIFP was recognized in 2004 by others in the international fraud-fighting com- munity as a fraud-fighting model to be admired, studied, and emulated. OIFP and its staff received awards in 2004 from the International Association of Arson Investigators, the International Associa- tion of Special Investigative Units, the United States Social Security Administration, and the New Jersey Vehicle Theft Investigators Association. OIFP’s public awareness campaign garnered awards for its creativity and effectiveness, and, once again, officials
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