AARON DURALL y NEISHA ZAFFUTO’S VS LOS CUATRO DEMONIOS DEL SEGURO DE SALUD, 1. BLUE CROSS OF FLORIDA, 2. UNITED HEALTH GROUP, 3. AETNA, 4. ANTHEM HEALTH INSURANCE: A CASE OF TULSAFICATION AND MALICIOUS PROSECUTION: A POWER STRUGGLE OF GOOD AND EVIL IN OUR LIFE TIME (PODCAST ANALYSIS & REVIEW)

Case: Aaron Durall and Neisha Zaffuto v. Blue Cross and Blue Shield of Florida, Inc., et al.

Court: United States District Court Southern District of Florida

Case No.: 0:23-cv-61557-SINGHAL

“…Four Atlanta and South Florida businesspeople accused of having roles in an alleged $1.4 billion drug-testing fraud case have been acquitted in a federal jury retrial in Florida…”

DURALL Y ZAFUTTO v. (Blue Cross) AND LOS CUANTRO DEMONIOS del seguro de salud: Malicious PROSECUTION LAWSUIT

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A SUMMARY UNDERSTANDING OF THIS CASE

This second amended complaint alleges that Blue Cross Blue Shield of Florida, Georgia Blue, UnitedHealth, Anthem, and Aetna engaged in a malicious prosecution of Aaron Durall and Neisha Zaffuto, two minority business owners, by falsely accusing them of healthcare fraud.

Christian Fletcher of Atlanta; Aaron Durall and Neisha Zaffuto, each of Broward County, Florida; and Aaron Alonzo of Miami-Dade County, Florida, were found not guilty March 21 following a four-week retrial before Chief Judge Timothy Corrigan in the U.S. District Court for the Middle District of Florida in Jacksonville.

Four Atlanta and South Florida businesspeople accused of having roles in an alleged $1.4 billion drug-testing fraud case have been acquitted in a federal jury retrial in Florida.

The complaint details how the insurance companies provided false information and testimony to the Department of Justice, leading to Durall and Zaffuto’s indictment and two criminal trials.

Christian Fletcher of Atlanta; Aaron Durall and Neisha Zaffuto, each of Broward County, Florida; and Aaron Alonzo of Miami-Dade County, Florida, were found not guilty March 21 following a four-week retrial before Chief Judge Timothy Corrigan in the U.S. District Court for the Middle District of Florida in Jacksonville.

Ultimately acquitted, Durall and Zaffuto now sue for damages, claiming the insurance companies acted to avoid paying legitimate claims and intentionally harmed their businesses and reputations.

The complaint also alleges violations of the Florida Civil Remedies for Criminal Practices Act and the federal RICO Act. Numerous exhibits, including a superseding indictment and communications data, support the plaintiffs’ claims.

Briefing Document: Durall Second Amended Complaint

Nature of the Case: This is a civil lawsuit brought by Aaron Durall and Neisha Zaffuto against multiple major health insurance companies. The lawsuit stems from a previous criminal case in which the plaintiffs were indicted on charges related to healthcare fraud.

The plaintiffs allege that the defendants maliciously prosecuted them based on false information and that their actions resulted in significant financial and reputational harm.

EL HECHO IMPORTANTE de ESTE CASO ES QUE:

• Malicious Prosecution: This is the central theme of the complaint. The plaintiffs argue that the defendants, major health insurance companies, deliberately provided false information to law enforcement agencies to instigate a criminal investigation and prosecution.
• False Testimony and Evidence: The complaint details specific instances where representatives of the defendant companies provided false testimony under oath and manipulated evidence to support their claims of fraudulent billing practices by the plaintiffs.
• Place of Service (POS) Code 22: A key piece of the alleged false evidence centers around the use of POS Code 22. The plaintiffs assert they never used this code, which signifies outpatient services provided at a hospital. Instead, they argue that the defendants’ own systems automatically added this code to their claims during processing.
• “Non-Patient” Laboratory Testing: The defendants accused the plaintiffs of fraudulently billing for laboratory tests conducted on “non-patients,” individuals not admitted to their hospitals. The plaintiffs counter that this practice is legal and that they appropriately used the Type-of-Bill code 141 to denote such testing.
• Defamation and Tortious Interference: The complaint further alleges that the defendants’ actions defamed the plaintiffs and tortiously interfered with their business relationships, causing significant financial losses.
• RICO and CRCPA Violations: The plaintiffs allege that the defendants engaged in a pattern of racketeering activity in violation of the federal Racketeer Influenced and Corrupt Organizations Act (RICO) and the Florida Civil Remedies for Criminal Practices Act (CRCPA).

Key Facts:

• Plaintiffs’ Background: Aaron Durall is an attorney, and Neisha Zaffuto is a businessperson. They owned and operated several healthcare entities, including rural hospitals and a clinical laboratory.
• Rural Hospital Contracts: The plaintiffs’ rural hospitals had contracts with the defendant insurance companies to provide healthcare services, including laboratory testing, to their members.

• Criminal Indictment: In 2020, Durall, Zaffuto, and others were indicted on charges related to a complex healthcare fraud scheme.
• Acquittal in Criminal Case: The plaintiffs were ultimately acquitted of all charges in the criminal case.
• Evidence of Falsehoods: The complaint includes excerpts from the criminal trial transcripts where witnesses from the defendant companies admitted to providing false testimony and misrepresenting data.

CITAS IMPORTANTES de la QUEJA {Important Quotes from the Complaint}:

• Regarding POS Code 22: “Therefore, according to Tobin’s testimony during the second trial, the POS Code 22 was not submitted by Plaintiffs on any of the claims but rather was generated by UnitedHealth’s own adjudication system.” (Paragraph 185)
• Regarding the nature of laboratory tests: “Confronted by UnitedHealth’s own claims data spreadsheets, Tobin was forced to admit that, contrary to her own testimony, the vast majority of the tests performed at and billed by CGH were in fact screening tests, and not confirmations.” (Paragraph 195)
• Regarding motivation of the insurance companies: “Insurance companies do not want to pay for urine testing, right? … But when they start paying for it, they’re going to find a way to stop paying for it, right? … And they are going to bleed you dry?” (Paragraph 218)
• Regarding the impact on the plaintiffs: “As a result of Defendants’ conduct, Plaintiffs have been financially ruined and their reputations in the healthcare industry have been destroyed.” (Paragraph 227)

Overall: The Durall Second Amended Complaint paints a picture of a complex and contentious legal battle between individuals who owned and operated healthcare facilities and powerful health insurance companies.

The complaint argues that the defendants leveraged their resources and influence to unjustly target the plaintiffs, leading to their indictment and significant personal and professional damage. The lawsuit seeks substantial financial damages and aims to hold the insurance companies accountable for their alleged misconduct.

Reliance Laboratory Testing Fraud Trial

Timeline of Main Events:

2014:

• June 1st: Aaron Durall starts operating Reliance Laboratory Testing, Inc. d/b/a Reliance Laboratory Testing.

2016:

• January: Florida Blue notices a significant increase in billing from Regional General Hospital for urine drug tests, raising suspicions of potential fraud.
• September 7th: Jose Ramos from Florida Blue submits a provider case to SIRIS (Special Investigations Referral Information System), outlining concerns about excessive billing for urine drug tests by Regional General Hospital and potential billing for services not rendered.

2019:

• March: Aetna employee, Brian Jackson, is interviewed about the case.
• July: Daniel Marcotte pleads guilty to conspiracy to commit money laundering.

2020:

• June 29th: Aaron Durall, Neisha Zaffuto, and others are indicted in the Middle District of Florida for charges related to healthcare fraud and money laundering.

2022:

• May 10th: Kelly Tobin from UnitedHealth testifies in a trial related to the case, claiming that most of the billing claims were for confirmatory drug tests.

2023:

• February 22nd: The second trial begins. Kelly Tobin testifies again but is confronted with UnitedHealth’s own claims data spreadsheets. She is forced to admit that the majority of tests were, in fact, screening tests, contradicting her previous testimony.
• February 23rd: Brian Jackson testifies about the Place of Service code (POS) 22 and how CPT codes were assigned descriptions. He admits that his previous statements about the POS 22 code were incorrect.
• February 24th: Daniel Marcotte testifies and clarifies the connection between patients and hospitals for urine testing. He states that if urine samples were tested at a specific hospital, then a connection exists.

2024:

• July 11th: Aaron Durall and Neisha Zaffuto file a Second Amended Complaint for Damages and Demand for Jury Trial against Blue Cross and Blue Shield of Florida, Inc., Blue Cross Blue Shield Healthcare Plan of Georgia, Inc., UnitedHealth Group Incorporated, Anthem Insurance Companies, Inc., and Aetna Life Insurance Company.

Cast of Characters:

Plaintiffs:

• Aaron Durall: A Florida attorney and resident of Broward County. Licensed to practice law since July 2002, he owned and operated multiple healthcare-related entities, including Reliance Laboratory Testing, Inc.
• Neisha Zaffuto: A resident of Broward County, Florida. Also involved in the ownership and management of Durall’s healthcare entities.

Defendants:

• Blue Cross and Blue Shield of Florida, Inc. d/b/a Florida Blue (“Florida Blue”): A Florida for-profit corporation providing health insurance. They noticed the initial suspicious billing activity from Regional General Hospital.
• Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. f/k/a Blue Cross and Blue Shield of Georgia, Inc. d/b/a Georgia Blue (“Georgia Blue”): A Georgia for-profit corporation also providing health insurance.
• UnitedHealth Group Incorporated (“UnitedHealth”): A Delaware for-profit corporation in the healthcare industry.
• Anthem Insurance Companies, Inc. (“Anthem”): An Indiana for-profit corporation, also a health insurance provider.
• Aetna Life Insurance Company (“Aetna”): A Connecticut for-profit corporation, involved in the health insurance sector.

Other Key Individuals:

• Jose Ramos: An employee of Florida Blue who initially discovered the suspicious billing activity from Regional General Hospital and filed the report with SIRIS.
• Brian Jackson: An employee of Aetna who was interviewed and testified about the case. Admitted to giving incorrect information about the POS 22 code.
• Kelly Tobin: An employee of UnitedHealth who testified about the billing codes, initially claiming they were mostly for confirmatory tests. Later, she had to admit this was incorrect when confronted with UnitedHealth’s internal data.
• Daniel Marcotte: Pleaded guilty to a conspiracy to commit money laundering charge in July 2019. Testified in the second trial and clarified the connection between patients and hospitals in relation to urine tests.

This case involves allegations of healthcare fraud and money laundering. The plaintiffs, Aaron Durall and Neisha Zaffuto, are accusing the defendant insurance companies of maliciously prosecuting them based on false information about billing codes and procedures. The case is ongoing, and a jury trial has been requested.

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REFERENCES:

Durall Second Amended Complaint Study Guide

Durall Second Amended Complaint Study Guide

Short Answer Quiz

1. Who are the plaintiffs in the case Durall, et al. v. Blue Cross and Blue Shield of Florida, Inc., et al.?
2. What is the definition of a “non-patient” in the context of this lawsuit, and how was this concept relevant to the plaintiffs’ billing practices?
3. What is the significance of the Type-of-Bill code 141 and POS Code 22 in relation to the claims submitted by the plaintiffs?
4. What is the primary allegation against the defendant insurance companies regarding their role in the initiation of the criminal case against Durall and others?
5. What did Kelly Tobin, a witness for UnitedHealth, initially testify about the nature of the majority of the tests performed? How did this testimony change when confronted with UnitedHealth’s claims data?
6. How did the testimony of Sean Jackson, an employee of Aetna, evolve regarding the POS Code 22 and its implications for the location of the patients?
7. What was revealed about the origin of the descriptions associated with CPT codes on Aetna’s spreadsheets, and what did this reveal about the nature of the tests?
8. What did the testimony of Michael Marcotte, a physician, suggest about the connection between urine samples and the hospital in cases where the samples were tested at the hospital?
9. What is the Florida Civil Remedies for Criminal Practices Act (CRCPA), and how is it being used by the plaintiffs in this case?
10. What specific criminal offenses are the plaintiffs alleging the defendants committed as part of their “pattern of criminal activity” under the CRCPA?

Answer Key

1. The plaintiffs in the case are Aaron Durall and Neisha Zaffuto.
2. A “non-patient” is an individual who is neither an inpatient nor an outpatient of the rural hospital but has a sample sent to the rural hospital for analysis. The plaintiffs’ billing practices involved submitting claims for laboratory services performed on samples from individuals who were not patients of the hospitals.
3. Type-of-Bill code 141 indicated that the laboratory services were for “non-patients.” POS Code 22 indicated that the patient was physically present at the hospital as an outpatient. The discrepancy between these codes and the actual circumstances of the testing formed the basis of allegations of fraudulent billing.
4. The plaintiffs allege that the insurance companies knowingly provided false and misleading information to the Department of Justice, leading to the initiation of the criminal case. They specifically point to the misrepresentation of the POS Code 22 as evidence of this manipulation.
5. Kelly Tobin initially testified that the majority of the tests were “confirmation tests.” However, when confronted with UnitedHealth’s own claims data, she had to admit that the vast majority were actually “screening tests.” This contradiction undermined the initial claims of fraudulent billing for more expensive confirmation tests.
6. Sean Jackson initially stated that the POS Code 22 indicated that the patients were physically at the hospital. Later, he corrected his testimony, acknowledging that this was not accurate when the POS Code 22 was used with a Type-of-Bill code 141.
7. It was revealed that Aetna attached descriptions to the CPT codes after receiving the claims from the hospital. The descriptions indicated that the tests were “drug screens,” which are generally considered screening tests and not confirmation tests.
8. Michael Marcotte testified that when urine samples from his patients were tested at the hospital, there was a clear connection between the patient and the hospital for the purpose of testing. This testimony refuted the claim that there was no connection between the non-patient individuals and the hospitals where the tests were performed.
9. The CRCPA, also known as “Florida RICO,” is a law that allows individuals to sue for damages caused by a pattern of criminal activity. The plaintiffs are using the CRCPA to allege that the defendants engaged in a pattern of criminal activity that led to their indictment and subsequent damages.
10. The plaintiffs allege that the defendants engaged in Conspiracy to Violate the Florida Communications Act, Conspiracy to Commit Insurance Fraud, and Conspiracy to Defraud the United States, among other offenses, as part of their pattern of criminal activity.

Essay Questions

1. Analyze the arguments presented by the plaintiffs in their Second Amended Complaint. What are the key elements of their claims, and what evidence do they cite to support their allegations?
2. Evaluate the role of the various witnesses whose testimonies are cited in the complaint. How do their statements contribute to the plaintiffs’ narrative of events, and what are the potential strengths and weaknesses of relying on their testimony?
3. Compare and contrast the legal theories underlying the different counts brought against the defendant insurance companies. What are the distinguishing elements of each cause of action, and how do they collectively strengthen the plaintiffs’ case?
4. Assess the potential implications of the plaintiffs’ reliance on the Florida Civil Remedies for Criminal Practices Act (CRCPA). What are the advantages and challenges of pursuing this legal strategy, and how might it impact the outcome of the case?
5. Consider the broader implications of this case for the healthcare industry. What are the potential consequences of the alleged actions of the insurance companies, and what impact could this lawsuit have on future billing practices and interactions between healthcare providers and insurers?

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Glossary of Key Terms

CLIA: Clinical Laboratory Improvement Amendments. Federal regulatory standards that apply to all clinical laboratories in the US.

CPT Codes: Current Procedural Terminology codes. Numeric codes used to identify medical services and procedures for billing purposes.

POS Code: Place of Service code. A two-digit code used on healthcare claims to specify the location where a medical service was performed.

UB-04: Uniform Billing form. A standard claim form used by institutional providers to bill for healthcare services.

CRCPA: Florida Civil Remedies for Criminal Practices Act. A Florida law that allows individuals to sue for damages caused by a pattern of criminal activity, also known as “Florida RICO.”

Malicious Prosecution: A tort that occurs when someone initiates or continues a legal proceeding against another person without probable cause and for an improper purpose.

Abuse of Process: A tort that occurs when someone uses the legal process for an ulterior motive or purpose other than its intended purpose.

Tortious Interference: A tort that occurs when someone intentionally interferes with a valid contractual relationship or business expectancy of another party, causing economic harm.

RICO: Racketeer Influenced and Corrupt Organizations Act. A federal law that provides for extended criminal penalties and a civil cause of action for acts performed as part of a criminal organization.

Association-in-Fact Enterprise: A group of individuals who come together for a common purpose, even if they have not formed a legal entity.

Pattern of Criminal Activity: A series of related criminal acts committed over a period of time, as defined under the RICO Act and the CRCPA.