In response to the high demand for aggressive trial attorneys to defend against insurance fraud, Marshall Dennehey has significantly expanded its Fraud/Special Investigation Practice.
Insurance fraud is, understandably, no longer tolerated or in any way compromised by insurance companies and self-insureds. We work very closely with our clients in furtherance of that philosophy through relentless investigation, aggressive defense and prosecution in response to false and inflated insurance claims.
Our members supplement their litigation experience with up-to-date knowledge of the current trends in insurance fraud detection and prosecution areas by regularly attending and participating in seminars given by such educational agencies as the National Insurance Crime Bureau, International Association of Special Investigation Units and Certified Fraud Examiners. In addition, they also attend numerous local conferences and association meetings throughout Pennsylvania, New Jersey, Delaware, Ohio, Florida and New York.
Aggressive Fraud Defense
As a part of an overall aggressive fraud defense, the members of the Fraud/Special Investigation Practice believe that the "best defense is a good offense." Our trial attorneys are quite experienced in the investigation, defense and affirmative prosecution of fraudulent claims. The scope of their practice is focused on the individual claimant as well as organized groups or "rings." We routinely file suits and collect judgments against perpetrators of insurance fraud including both insureds and medical providers.
We have considerable experience with cases involving:
- Medical provider fraud
- Claimant fraud
- Insurance claim inflation
- Staged accidents
- Application/rate evasion fraud
- Workers' compensation fraud
- Vehicle "give ups"
- Suspicious jewelry losses and arsons
We maintain a centralized "fraud library" of fraud scams, investigations and perpetrators. Dissemination of this information to the group members, as well as a constant dialogue between attorneys, allows them to immediately incorporate current law and recent events in the fraud industry into defense strategies. We, in turn, enable our clients to incorporate this knowledge and experience into investigations by providing them with updates concerning recent developments in the industry. Our clients greatly appreciate the fact that we collaborate with them in the course of investigations in order to coordinate efforts and ensure that the goals of fighting fraud are met.
Results
Thought Leadership
SIU Spotlight
The Age of Automated Fraud: Defending Against Documentation Cloning and AI-Generated Claims
May 15, 2026
For years, healthcare payers have treated note cloning—the practice of copying and pasting electronic health record (EHR) text—as a primary red flag in fraud, waste, and abuse (FWA) investigations. Today, as the industry races to embrace Artificial Intelligence (AI) for documentation, the threat of "cloning" is not disappearing; it is simply evolving. For insurance carriers facing healthcare fraud costs estimated to exceed $400 billion annually in the U.S., understanding this new and evolving technological risk is paramount to effective claims denial and successful defense litigation The core issue with cloned documentation is its immediate challenge to the medical necessity of billed services. When medical records contain identical or near-identical entries across multiple dates of service, the documentation cannot support the premise that unique, individualized care was provided at each encounter. This practice undermines the credibility of the entire record. Traditional copy-and-paste charting, where clinicians simply copy-forward prior entries or borrow from templates, was quickly identified by the Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) as a priority for audit and enforcement. Its misuse often results in a form of fraud known as up-coding—the insertion of false or irrelevant details to justify a higher, more expensive level of service than was actually rendered. Simply put, manufactured records support inflated billing. Cloning 2.0: AI and the New Red Flags The rapid adoption of AI-assisted documentation tools presents carriers with a new, but strikingly familiar, compliance pitfall. Just as a keyboard shortcut once generated a suspiciously repetitive note, a sophisticated machine learning algorithm can now produce a grammatically flawless but equally generic summary. Insurance carriers must equip claims auditors with a new playbook for identifying these high-tech red flags: Repetitive and Boilerplate Phrasing: Like cut-and-paste, AI tools tend to reuse stock language verbatim—for instance, identical descriptions of a patient's presentation across many different encounters. The presence of uniform, verbose, or overly formal language that clashes with an experienced auditor's knowledge of a physician's typical "voice" should raise suspicion. These generic statements does not reflect individual patient encounters, creates the assumption that the narrative was manufactured to support, higher E/M coding and supports the appearance of a systematic inflation by a provider, not an isolated error. Overly Complete Documentation: A hallmark red flag for potential upcoding is extreme documentation thoroughness. Unlike human clinicians, who focus on relevant positives and negatives, AI systems frequently generate exhaustive, boilerplate reviews of systems. Such documentation can misrepresent the scope of the encounter, creating the appearance of higher-level services and automatically inflating the reported E/M code—despite no corresponding increase in clinical work. An example of this would be a patient presenting with a sore throat and congestion, but the note documents a 14-system Review of Symptoms (ROS), all marked negative. A routine upper respiratory complaint does not clinically justify a full multi-system ROS. This level of detail artificially supports a higher E/M level without corresponding medical necessity. Internal Inconsistencies: Because AI relies on patterns, it can fail to reconcile contradictory information or carry forward fabricated or outdated details. For instance, one section of an AI-generated note might state "no extremity pain," while another later mentions "episodes of upper extremity discomfort". These internal contradictions are destructive to a record's credibility and are prime targets for counsel in deposition. Metadata Trails: Crucially, the technology that enables AI documentation also leaves an audit trail. Carriers must leverage the power of discovery to review system logs and timestamps that reveal when AI tools were used to generate text. This metadata can prove the extent of a provider's reliance on automated shortcuts, flagging instances of potential overreliance. Fighting Fire with Fire: The Carrier's AI Defense The growing sophistication of provider fraud demands that insurance carriers evolve beyond static, rules-based fraud detection to advanced analytical models. The best defense against AI-driven fraud is often the strategic use of defensive AI. Carriers must transition to modern FWA prevention strategies by: Pre-Payment FWA Preventive Analytics: Moving beyond traditional post-pay audits, carriers are now leveraging machine learning models to score and flag claims for high-risk behavior before adjudication. This shift prevents the improper payment from ever being made. Leveraging Natural Language Processing (NLP): NLP is essential for analyzing the unstructured data in medical records, specifically clinical notes. These tools can scan millions of provider notes to detect the subtle anomalies that human auditors might miss, such as:Identification of repetitive and cloned phrases across a provider's patient roster. Flagging medical codes that do not align with the narrative diagnosis or description in the note. Predictive Behavioral Modeling: AI systems can track a provider's historical billing and documentation patterns, automatically identifying statistically significant deviations from their peers. When a provider suddenly increases their volume of complex E/M codes (a classic up-coding indicator) or exhibits unusual service combinations, the system flags the provider as a high-risk outlier for focused investigation. Network Link Analysis: Advanced analytics can uncover collusive networks of providers who might be sharing patients or services to perpetrate fraud. In conclusion, the ultimate lesson for carriers is that documentation is not merely about filling space; it is about telling the patient's distinctive and current story. Anything—whether a copy-paste command or a machine learning algorithm—that dilutes that unique story and creates repetitive or over-documented records is a pathway to claims failure and potential fraud. Insurance carriers must treat AI documentation with the same rigorous scrutiny once reserved for chart cloning, updating audit protocols to focus on individualized clinician attestation, customization, and metadata that reveals overreliance on automation.
SIU Spotlight
The "Inherent Risk" of Staged Collisions and the Limits of Sentencing Stipulations
May 15, 2026
In a significant win for law enforcement and the insurance industry, the Tenth Circuit recently affirmed a 48-month sentence for a defendant who orchestrated a sophisticated, multi-year insurance fraud scheme involving staged car wrecks. The court’s ruling in United States v. Brown, No. 25-7026 (Dec. 30, 2025) underscores a powerful legal precedent: the act of staging an automobile collision is inherently dangerous and justifies strong sentencing enhancements, regardless of whether a particular crash resulted in actual injury. A. Background Defendant Sebron Dejuan Brown operated a four-year conspiracy involving odometer tampering and staged accidents. The scheme was twofold: Vehicle Value Inflation: Brown replaced or "rolled back" odometers in high-mileage vehicles to artificially inflate their market value. Orchestrated Crashes: He and his co-conspirators then deliberately crashed these vehicles—sometimes involving unsuspecting third parties—to submit fraudulent insurance claims for vehicle repairs and bodily injuries. While the parties initially stipulated to a lower loss amount and offense level, the district court rejected the stipulated guidelines. Instead, the court applied a two-level sentencing enhancement for an offense involving the "conscious or reckless risk of death or serious bodily injury" and imposed an 11-month upward variance, resulting in a four-year prison term. B. The Tenth Circuit’s "Inherent Risk" Ruling On appeal, Brown argued that the "serious bodily injury" enhancement (U.S.S.G. § 2B1.1(b)(16)(A)) was misapplied because there was no evidence that anyone was actually at risk of grave harm during his "controlled" low-speed collisions. The Tenth Circuit rejected this "semantic and evidentiary over-demand.” The panel held that because cars are "big pieces of machinery traveling at speed," the risk of serious injury is intrinsic in any deliberately caused accident. The court clarified that sentencing judges do not need to quantify the specific degree of risk for each individual collision; the criminal method itself—staging wrecks—is enough to trigger the enhancement. Takeaways 1. The Power of "Inherent Risk" in Litigation The most important takeaway for carriers is the judicial recognition that staged accidents are inherently dangerous. Carriers can leverage this "inherent risk" logic in civil litigation—especially in RICO or fraud counterclaims—to emphasize the egregious nature of the claimant’s conduct. By framing staged accidents as acts of reckless endangerment rather than mere paperwork fraud, carriers can more effectively push for punitive measures and deter future schemes. 2. Beware of Sentencing Stipulations Brown highlights that courts are not bound by the stipulations between prosecutors and defendants regarding loss amounts or offense levels. Carriers, often acting as victims in these cases, should ensure their "actual loss" statements are strongly documented. Even if the parties agree to a lower loss figure for a plea deal, the carrier’s impact statement can lead the court to apply enhancements or adjustments that better reflect the true scope of the harm. 3. Identifying the "Sophisticated Means" Red Flags Although Brown’s scheme was simple in its execution (crashing cars), the court noted the "repetitive and consistent nature" of the fraud for over four years as a reason for the upward variance. Carriers should look for these patterns early in the Special Investigations Unit (SIU) process: Commonalities in Vehicle Acquisition: Vehicles with high mileage that have recently "lost" significant mileage on their odometers. Recruitment Patterns: Schemes involving five or more participants often share common medical providers or legal representatives. Frequency Limits: Tracking how often the same individual appears as a passenger or "witness" across different claims. 4. Proactive Defense Strategies: Beyond Affirmative Defenses Carriers should move beyond simple denials of claims. As seen in Brown, the criminal justice system is increasingly willing to treat these cases as serious threats to public safety. In civil court, carriers should consider: Declaratory Judgment Actions: Seeking an early court ruling that no coverage exists due to the fraudulent nature of the incident. Aggressive Counterclaims: Filing counterclaims for fraud or RICO violations rather than just asserting fraud as an affirmative defense. This shifts the burden and signals that the carrier will not settle "low-value" nuisance claims. Accordingly, United States v. Brown serves as a solid reminder that the "staged accident" is not viewed by the courts as a victimless white-collar crime. By affirming that these schemes pose an inherent risk of death or serious injury, the Tenth Circuit has provided insurance carriers with a potent rhetorical and legal tool to use in the ongoing fight against organized fraud rings.
