Wednesday, November 4, 2015

Prosthetic Limb Maker CEO Charged With State Insurance Fraud For Billing Anthem For Prosthetic Arm After Patient Died and Forging Patient's Name on Delivery Slips

Peter Lira, CEO of Am-Pro Prosthetics and Orthotics in Whittier, was arrested on three felony counts of insurance fraud in Los Angeles County Superior Court for allegedly billing Anthem Blue Cross for a $170,000 prosthetic arm for a Los Angeles County Public Defender who died of cancer after Mr. Lira was notified the patient had died. Mr. Lira was released on bond pending trial on these charges.

Mr. Lira is presumed innocent unless and until he is proved guilty beyond a reasonable doubt. These are only charges at this time.

The Department of Insurance alleges that detectives found evidence that Mr. Lira allegedly submitted fraudulent invoices and forged the deceased patient's signature on the delivery receipt to collect payment for manufacturing a prosthetic arm even though the patient has died. The Department of Insurance also alleges that Mr. Lira is believed to have changed the circumstances under which the arm was needed, claiming the man was still alive and needed the limb because of an industrial accident.

Suspecting fraud, Anthem referred the claim to the Department of Insurance for investigation. This case is being prosecuted by the Los Angeles County District Attorney's Office. Mr. Lira faces a maximum exposure of five years in prison, if convicted on all counts.

Attorney Commentary: There are times where billing for medical equipment could occur if a patient has died between the time of the order and delivery. In addition, there are times when billing mistakes occur. Statistically, that is the case.

In this matter, the Prosecution needs to prove beyond a reasonable doubt that Mr. Lira personally had “intent” to defraud. This is why there are allegations that the deceased patient’s signature was “forged” and that the “reason” the arm was needed was changed.

In a case like this, only the “billing” need to have occurred and even if the prosthetic company was not paid for the prosthetic arm, the insurance fraud charge can be alleged. Insurance companies are being more aggressive in private insurance in reporting suspected fraud. It used to be that there was simply a denial of claim but now the referrals are being made even when government insurance (Medicare or Medi-Cal) are not involved. In our office, we also see more referrals for "suspicious" claims where the patients are current or former government employees.

Posted by Tracy Green, Esq.
Green and Associates, Attorneys at Law
Office: 213-233-2260


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