Alleged Plot to Destroy Medical Center By Diverting Patients to Competing Medical Center Enriched Humana and Aetna, While Financially Destroying Medical Center and Former Owner of Medical Center
Lipsy Delgado-Maza used her entire life savings of nearly $1 million to purchase a 50% ownership interest in a medical center and pharmacy. The suit alleges that, because Delgado-Maza refused to sell her ownership interest in Leal Medical Center at below market price, her former partner and former employees developed a fraudulent scheme to divert patient business away from the medical center by diverting all of Leal Medical Center’s patients to Las Americas, a competing center owned by Delgado-Maza’s former partner and employees. In essence, the lawsuit alleges that her former partner and employees conspired to steal Leal Medical Center’s most precious asset, its patients, in order to destroy Delgado-Maza’s value in the company. “We are honored to have been chosen to represent Ms. Delgado-Maza in a case which will certainly be hard fought but which we will pursue on a contingent fee basis so that we are able to offer her the key to the courthouse,” says lead trial counsel Robert Zarco.
The 28-count counterclaim and third-party complaint, filed in Miami-Dade County Circuit Court on May 29, accuses Humana and Aetna of fraud, civil conspiracy, aiding and abetting breach of fiduciary duty, violation of Florida deceptive and unfair trade practices act, and tortious interference with advantageous business relationships.
Delgado-Maza’s former partner, Jhacnea Leal, and her husband, Daniel Orozco, are alleged to have engaged in fraud, civil conspiracy, and breach of fiduciary duty, among other claims. Former employees of Leal Medical Center, Maria Guiardinu and Miguel Rodriguez, are also alleged to have committed fraud, civil conspiracy, and breach of fiduciary duty, among other claims. Dr. Marta Fernandez, the former medical director and primary care physician for Leal Medical Center, is also alleged to have engaged in fraud, civil conspiracy, and breach of fiduciary duty, among other claims.
Optimus Management Services, LLC and Optimus Billing Services, Inc. are also named as defendants for engaging in alleged fraud, civil conspiracy, aiding and abetting breach of fiduciary duty, violation of Florida deceptive and unfair trade practices act, and tortious interference with advantageous business relationships. Las Americas Medical Center, LLC and Homestead Medical Center, LLC are also alleged to have committed violations of Florida deceptive and unfair trade practices act, tortious interference with advantageous business relationships, violation of Florida uniform trade secrets act, and unjust enrichment.
According to the Complaint, not even one year after Delgado-Maza became an owner, her partner, Leal, Orozco, and Dr. Fernandez developed a fraudulent scheme to divert patient business away from Leal Medical Center and Ms. Delgado-Maza. The Complaint asserts that Orozco and Dr. Fernandez then opened competing medical centers, Las Americas and Homestead Medical Center, and fraudulently diverted all of Leal Medical Center’s patients to their competing medical centers. It further alleges that while still employed by Leal Medical Center as medical director and primary care provider, Dr. Fernandez had already began operating Las Americas.
The Complaint alleges that Optimus, a management services organization approved by Humana, also became part of this elaborate scheme to defraud Leal Medical Center and Delgado-Maza. The lawsuit alleges that Optimus got Leal Medical Center a contract with Humana to allow Leal, Orozco, and Dr. Fernandez to have access to more patients to divert to their competing medical centers. Because Optimus performed the coding and billing for Leal Medical Center, they knew which patients were the most profitable, and, in turn, knew which patients to target to divert to Las Americas, according to the Complaint. It also alleges that Optimus blocked Ms. Delgado-Maza from having access to the financial information for Leal Medical Center and, most importantly, from the Humana enrollment and insurance verification portal. Ms. Delgado-Maza alleges that they did not want to give her access to the financial information for Leal Medical Center and the Humana portal because they wanted to conceal from her how many Humana patients were enrolling in Leal Medical Center and how many Humana patients were then being diverted from Leal Medical Center to Las Americas.
According to the Complaint, in furtherance of the scheme and intentionally disregarding Dr. Fernandez’s clear conflict of interest, Optimus then obtained a contract with Humana for Las Americas. The Complaint goes on to allege that as a result of Dr. Fernandez and Optimus obtaining the Humana contract for Las Americas, and Humana’s approval of same, Leal Medical Center experienced a massive diversion of its patients. The Complaint and public records even reflect that Optimus’ Accounting Manager, Carmen Vila, is a convicted felon, having been found guilty of fraud. Yet, Ms. Vila was the individual who, on behalf of Optimus, was performing all of the accounting, bookkeeping, payroll, and check writing for Leal Medical Center and Leal Pharmacy, according to the Complaint.
The Complaint sets forth that at the forefront of this elaborate scheme was Humana and Aetna. “It is unfortunate that two well-known and respected insurance companies such as Humana and Aetna would undertake to participate in such a willful scheme to defraud and hurt a woman who has worked all her life and invested her entire life savings in a business as well as the patients of her medical center which were not only very dear to her hear but the life blood to her business,” says lead counsel Robert Zarco. According to the Complaint, Humana and Aetna became part of this elaborate scheme to defraud Leal Medical Center and its owner, Delgado-Maza in order to divert patient business away from Leal Medical Center and Delgado-Maza. Despite knowing that Dr. Fernandez was the primary care provider and medical director for Leal Medical Center, Humana, through Optimus, gave Dr. Fernandez a contract for Las Americas, according to the Complaint. By giving Dr. Fernandez a Humana contract for Las Americas, Humana actively facilitated the mass diversion of patients, states the Complaint.
The Complaint states that upon receiving a request to come and enroll patients in Leal Medical Center, agents of Humana would go to Leal Medical Center and would enroll individuals in Las Americas instead of enrolling them in Leal Medical Center. According to the Complaint, as a direct result of the actions taken by Humana, Leal Medical Center lost all of its existing Humana patients, in addition to all prospective Humana patients who were diverted to Las Americas.
The Complaint asserts that Aetna also played a substantial role in carrying out the fraudulent scheme. Aetna’s insurance agents actively contacted Leal Medical Center’s patients for the sole purpose of diverting patients to Las Americas, states the Complaint. The lawsuit alleges that Aetna’s agents were able to successfully divert patients from Leal Medical Center to Las Americas by engaging in fraudulent activity, including coercion, deceit, and without even obtaining the patient’s consent to be transferred. Similar to the Humana agents, Aetna’s agents would also go to Leal Medical Center and instead enroll individuals in Las Americas, states the Complaint. The Complaint also alleges that agents of Aetna received kickbacks in exchange for soliciting and diverting patients away from Leal Medical Center to Las Americas.
“Unfortunately, in South Florida, medical and insurance fraud are prevalent and are the cause of innocent victims being damaged, not only financially, but in terms of equality of the medical care they receive,” says lead trial counsel Robert Zarco. “It does not resonate so much in the minds of many until it hits so close to home,” states Mr. Zarco. This is not the first time that Humana is alleged to have committed Medicare fraud. Unfortunately, this is just one of the many claims against Humana for gross misconduct, including Medicare fraud. As a result, Humana has been forced to pay millions in settlements and to the government. In fact, the U.S. Justice Department has recently disclosed that Humana is under investigation for defrauding Medicare. “Ms. Delgado-Maza’s enrollment fraud claims against Humana are consistent with Humana’s profits-over-people philosophy,” says Mr. Zarco. Last year, Humana, headquartered in Louisville, Kentucky, raked in roughly $29 billion in revenue and $833 million in profits. It ranked 98th on Fortune magazine’s listing of the nation’s largest corporations.
The U.S. Justice Department disclosed that is investigating Aetna to determine if they have been engaging in Medicare Fraud. Aetna is the nation’s third-largest insurance provider with roughly 23 million customers. Aetna’s internal practices have been the subject of much scrutiny lately following the deposition testimony of their formal medical director admitted in a deposition under oath that he never looked at patients’ records when deciding whether to approve or deny care.
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