Discovery Attempt by Alleged Fraudulent Health Care Provider Fails
Post 5232
Read the full article at https://www.linkedin.com/pulse/party-seeking-discovery-entitled-anything-relevant-zalma-esq-cfe-ce7kc, see the video at https://rumble.com/v7204g8-discovery-is-entitled-to-anything-relevant-to-partys-claim-or-defense.html and at https://youtu.be/Nuet_er3qXU, and https://zalma.com/blog plus more than 5200 posts.
Upcoding and Health Care Fraud
In UnitedHealthcare Services, Inc., et al. v. Team Health Holdings, Inc., et al., No. 3:21-cv-00364-DCLC-DCP, United States District Court for the Eastern District of Tennessee, District Judge Clifton L. Corker (November 18, 2025) This is a discovery ruling, not a final merits decision.
The Disputes
This is a fraud/RICO lawsuit brought by UnitedHealthcare (and affiliates, collectively “United”) aganst TeamHealth (a large physician staffing company focused on emergency medicine). The companies have a history of mutual litigation over billing practices, including prior suits where TeamHealth accused United of underpaying claims (“downcoding”) and won substantial judgments/arbitrations against United.
Key Facts and Allegations
Plaintiffs’ Claims
TeamHealth allegedly engaged in systematic upcoding by submitting claims with inflated billing codes (CPT codes) that misrepresent the acuity/level of emergency services provided, leading to overpayments with simple cases (e.g., indigestion) billed as high-complexity critical care.
United Health estimated overpayments of more than $100 million since 2016.
Causes of action:
1. Common-law fraud and negligent misrepresentation.
2. Violations of Tennessee insurance fraud statutes (Tenn. Code Ann. §§ 56-53-102, -103, -107).
3. Tennessee Consumer Protection Act and similar state laws.
4. Federal civil RICO (18 U.S.C. § 1962(c) – substantive) and RICO conspiracy (§ 1962(d)): Alleging TeamHealth operated an “association-in-fact” enterprise to conduct patterned fraud via mail/wire.
Defendants’ Position (TeamHealth):
Denies fraud; claims its coding is standard and appropriate. Argues United’s allegations rely on comparisons to other providers’ coding rates, making comparator data relevant for defense (e.g., to show TeamHealth’s practices are industry-normal, not fraudulent or indicative of a distinct RICO enterprise).
During fact discovery, TeamHealth served Requests for Production:
1. “Coding acuity data” (billing code distributions by severity level) from Sound Physicians (an emergency medicine group) and other United-affiliated or Optum-related EM providers.
2. Documents showing the corporate structure of Sound Physicians and those other entities.
TeamHealth’s Relevance Argument:
Sound Physicians is partially owned by Optum (a UnitedHealth Group affiliate since a 2018 investment). If Sound (allegedly “United-affiliated”) uses similar high-acuity coding or similar decentralized corporate structures, it undermines United’s claims that TeamHealth’s practices are outlier, fraudulent, or evidence of a nefarious RICO “enterprise” (vs. normal business). Rebuts intent, “distinctness” of enterprise, and non-standard coding allegations.
United’s Counterargument:
Optum’s stake in Sound is a passive minority investment; United does not control Sound’s coding policies, billing, or operations. Data from an uncontrolled third-party entity has no probative value on whether TeamHealth defrauded United.
Magistrate Judge Poplin’s Ruling
Granted compulsion for United’s own corporate structure. Denied as to RFPs 48, 50, and 51 insofar as they sought Sound/other affiliated groups’ data: “does not make it more or less likely that Defendants violated RICO or upcoded.”
TeamHealth’s Objection:
Argued Magistrate applied overly strict relevance standard; comparator evidence is discoverable under broad Fed. R. Civ. P. 26(b)(1),
District Judge Corker’s Ruling
Broad: Anything “relevant to any party’s claim or defense” and proportional. Even broader historical view ecompasses info that “bears on, or that reasonably could lead to other matter that could bear on” issues. But not unlimited: No “fishing expeditions”; courts may limit overly broad/irrelevant requests.
Holding: Denied TeamHealth’s objection; upheld Magistrate in full.
Magistrate’s conclusion (data from Sound not relevant) was not clearly erroneous or contrary to law. Ruling found to be sound is an entity United “does not control.” Its coding data or structure would not reasonably lead to admissible evidence on TeamHealth’s alleged upcoding or RICO enterprise.
For the Parties:
The ruling limits TeamHealth’s ability to obtain comparator evidence from United-affiliated (but not controlled) providers. Discovery continues on other issues; trial date not yet set (dispositive motions were due ~March 2025 per earlier orders). Upcoding allegations are common defenses by payers against high-billing EM providers.
The case remains active; this is purely a procedural win for United on one discovery front. This ruling is narrow and deferential—typical for objections to magistrate discovery orders, which are overturned only rarely.
ZALMA OPINION
When dealing with attempted health insurance provider fraud resolution of discovery issues often resolves the entire case seeking damages for fraud or alleging RICO violations. The District Judge affirmed the Magistrate Judge’s ruling and limited the use of comparator billing as a defense to the claim of fraud.
(c) 2025 Barry Zalma & ClaimSchool, Inc.
Please tell your friends and colleagues about this blog and the videos and let them subscribe to the blog and the videos.
Subscribe to my substack at https://barryzalma.substack.com/subscribe
Go to X @bzalma; Go to Barry Zalma videos at Rumble.com at https://rumble.com/account/content?type=all; Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysiZklEtxZsSF9DfC0Expg; Go to the InsuranceClaims Library – https://lnkd.in/gwEYk.
The Largest Residential Burglary of All Time
Post 5407
Fraud & the Fear of Bad Faith Suits
Posted on July 22, 2026 by Barry Zalma
See the full video at https://lnkd.in/gWQQEySW and at https://lnkd.in/gyhdK6wv
This is a Fictionalized True Crime Story of Insurance Fraud explaining why Insurance Fraud is a “Heads I Win, Tails You Lose” situation for Insurers. The story is one of a collection designed to help to Understand How Insurance Fraud in America is Costing Everyone who Buys Insurance Thousands of Dollars Every year and Why Insurance Fraud is Safer and More Profitable for the Perpetrators than any Other Crime.
This is a Fictionalized True Crime Story of Insurance Fraud explaining why Insurance Fraud is a “Heads I Win, Tails You Lose” situation for Insurers. The story is one of a collection designed to help to Understand How Insurance Fraud in America is Costing Everyone who Buys Insurance Thousands of Dollars Every year and Why Insurance Fraud is Safer and More Profitable for the Perpetrators than any Other Crime.
After ...
Chutzpah is not Enough
Post 5397
Posted on July 20, 2026 by Barry Zalma
See the video and at https://lnkd.in/gNUs2XzT and at https://lnkd.in/g2MawyzX
Magistrate Issues a Search Warrant if there is a Fair Probability that Contraband or Evidence of a Crime will be Found in a Particular Place.
In United States Of America v. Frank Suess, et al., CRIMINAL No. 3:24-308, United States District Court, M.D. Pennsylvania (July 16, 2026) a federal grand jury indicted Frank Suess, Melissa Driscoll, and others in a 55-count health care fraud and anti-kickback prosecution arising from an alleged scheme involving medically unnecessary prescription “foot baths.”
As part of the investigation, the FBI obtained an August 19, 2022 warrant to search Driscoll’s Sterling Pharmacy Yahoo email account for emails from January 1, 2018 through December 31, 2020. Driscoll moved to suppress the resulting evidence, arguing that the warrant lacked probable cause, was overbroad, and rested on material misstatements and omissions.
LAW:
The ...
Fraud Shouldn’t Pay
Post 5396
See the video and at https://rumble.com/v7ctgmq-the-great-jewel-theft.html at https://youtu.be/aRbQ2sJfGwA
This is a Fictionalized True Crime Story of Insurance Fraud explaining why Insurance Fraud is a “Heads I Win, Tails You Lose” situation for Insurers. The story is one of a collection designed to help to Understand How Insurance Fraud in America is Costing Everyone who Buys Insurance Thousands of Dollars Every year and Why Insurance Fraud is Safer and More Profitable for the ¬¬¬Perpetrators than any Other Crime.
The Insured purchased, for the first time in his life, a policy of Personal Articles Floater Insurance (PAF) scheduling $125,000 worth of ladies jewelry. He advised the insurer that the jewelry was always kept in a class E safe at his residence. He also told the insurer that he was employed full time as the owner of a gasoline service station and that he had never been canceled or suffered a previous loss.
One month after the policy was ...
Day Care Owner Loses Subsidies Because She Criticized State
Post 5421
Posted on August 11, 2026 by Barry Zalma
First Amendment Right Will be Allowed to Go to Trial
In Betsey J. Grant v. Maine State Department Of Heath And Human Services, No. 1:25-cv-00490-JAW, United States District Court, D. Maine (August 6, 2026), Betsey J. Grant, a licensed childcare provider and operator of Tiny Tikes Daycare in Trenton, Maine, sued Maine DHHS and several employees after she publicly criticized DHHS before Maine’s Government Oversight Committee and alleged that officials retaliated against her.
She claimed DHHS imposed and extended a conditional license, published stigmatizing information, interfered with subsidies and program funding, removed her from a food program, rescinded an expansion grant, and used biased or falsified evidence in licensing proceedings. Following the March 10, 2023, GOC testimony, Ms. Grant alleges that foster children's subsidies (approximately $30,000) were withheld; she was removed from the ...
Rescission for Material Misrepresentation
Post 5418
Posted on August 5, 2026 by Barry Zalma
An Insurer May Rescind An Insurance Policy Where The Applicant Made A Material Misrepresentation In The Application.
In Union Mutual Fire Insurance Company v. 844 Knickerbocker, LLC, et al. No. 2024-10359, Index No. 602824/22, 2026 NY Slip Op 04789, Supreme Court of New York, Second Department (July 29, 2026) Union Mutual Fire Insurance Company issued commercial insurance policies to 844 Knickerbocker, LLC, and Sanjaya Mallick based on applications stating that the insured property contained two apartment units. After an underlying personal injury action was filed, Union Mutual determined that the property actually contained three apartment units and rescinded the policies on the ground that the defendants had made a material misrepresentation in the applications.
LAW:
A misrepresentation is material if the insurer would not have issued the same policy, or would have issued it only on different terms, had the true ...
Rescission for Material Misrepresentation
Post 5418
Posted on August 5, 2026 by Barry Zalma
An Insurer May Rescind An Insurance Policy Where The Applicant Made A Material Misrepresentation In The Application.
In Union Mutual Fire Insurance Company v. 844 Knickerbocker, LLC, et al. No. 2024-10359, Index No. 602824/22, 2026 NY Slip Op 04789, Supreme Court of New York, Second Department (July 29, 2026) Union Mutual Fire Insurance Company issued commercial insurance policies to 844 Knickerbocker, LLC, and Sanjaya Mallick based on applications stating that the insured property contained two apartment units.
LAW:
A misrepresentation is material if the insurer would not have issued the same policy, or would have issued it only on different terms, had the true facts been disclosed. To establish materiality as a matter of law, the insurer must submit documentation of its underwriting practices, such as manuals, guidelines, bulletins, or rules addressing similar risks.
DISCUSSION/ANALYSIS:
As a result, the...
