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
Defense Digest
A Tale of Two Departments: Can a Motor Vehicle Defendant Assert Counterclaims Sounding in Fraud in Actions Involving Staged Accidents in Matters Venued in the Second and First Departments of the New York Appellate Division?
June 30, 2026
Key Points: The Second and First Departments of the New York Appellate Division have recently issued divergent decisions affecting a defendant’s entitlement to leave to amend its answer to assert counterclaims sounding in fraud where it appears that the accident at issue was staged/intentionally caused by the plaintiff depending on where the matter is venued. Based on these recent decisions, a defendant in a matter venued in a court in the Second Department is entitled to leave to amend its answer to assert counterclaims sounding in fraud based on mere allegations that the accident at issue was staged/intentionally caused by the plaintiff, the plaintiff knowingly made false representations to assert claims against the defendant, and that the defendant suffered damages consisting of its costs and fees incurred in investigating and litigating plaintiff’s claims. However, a defendant in a matter venued in a court in the First Department is only entitled leave to amend its answer to assert counterclaims sounding in fraud where it submits prima facie evidence that the plaintiff staged/intentionally caused the accident and made false representations, and where the defendant alleges damages beyond those associated with its costs and fees incurred in investigating and litigating plaintiff’s claims. The Second and First Department of the New York Appellate Division both recently issued decisions addressing a defendant’s entitlement for leave to amend its answer to assert counterclaims sounding in fraud arising from an accident that is apparently staged and/or intentionally caused by a plaintiff. Specifically, despite the underlying similarities between Gimenez v. Pepsi-Cola Bottling Company of New York, Inc., 225 N.Y.S.3d 691 (NY 2d Dept. 2025) and Anguisaca-Morales v. St. Paul and St. Andrew United Methodist Church, 234 N.Y.S.3d 42 (NY 1st Dept. 2025), the respective decisions of the Second Department and First Department substantially diverged. As a result of these contrasting decisions, the venue of a matter will affect a defendant’s ability to successfully obtain leave to amend its answer to assert counterclaims sounding in fraud against a plaintiff. Both Gimenez and Anguisaca-Morales involved plaintiffs whose alleged injuries resulted from accidents where liability would normally and presumably be decided against the defendants. In Gimenez, the plaintiffs allegedly were injured due to their vehicle being rear-ended by the defendants’ vehicle. In Anguisaca-Morales, the plaintiff allegedly fell from an unsecured ladder while working at a construction site. Both actions involved appeals from lower court decisions on the plaintiffs’ motions for summary judgment on liability and the defendants’ corresponding motions for leave to amend their answers to assert counterclaims for fraud against the plaintiffs based on allegations that the accident was staged/intentionally caused by the plaintiffs. With respect to the motions for summary judgment on liability, the Second and First Department both found issues of fact resulting in the plaintiffs not being entitled to summary judgment on liability. In Gimenez, the Second Department found that the defendants raised issues of fact as to the existence of a non-negligent explanation for the alleged accident and whether the plaintiffs staged the accident. In Anguisaca-Morales, the First Department found there were issues of fact as to whether the plaintiff intentionally fell and was the sole proximate cause of his alleged accident. Turning to the respective motions for leave to amend their answers filed by the defendants in Gimenez and Anguisaca-Morales, the defendants in both actions submitted proposed amended answers that asserted similar allegations of fraud in support of their respective counterclaims, including that: 1) the respective plaintiffs staged/intentionally caused the accidents; 2) that the respective plaintiffs knowingly made false representations against the respective defendants; and 3) that the respective defendants suffered damages as a result, consisting of incurring investigation and legal costs and fees. In both cases, the Second and First Department also reviewed evidence that they respectively determined had been sufficient to raise a question of fact as to whether the respective plaintiffs intentionally caused their accidents. However, despite the above similarities, the reasonings in these decisions regarding the respective defendants’ entitlement to leave to amend their answers diverged. In Gimenez, the Second Department held that the defendants were entitled to leave to amend their answer because the allegations asserted in their proposed amended answer were sufficient on their face to plead a counterclaim for fraud. However, in Anguisaca-Morales, the First Department held that the defendants were not entitled to leave to amend their answer because their proposed amended answer failed to sufficiently plead a counterclaim for fraud. In doing so, the First Department held that the counterclaim asserted in defendants’ proposed amended answer was premised on unproven allegations and the defendants failed to plead justifiable reliance or resulting damages. Thus, based on the Second Department’s decision in Gimenez, a defendant in an action venued in any of the lower courts in the ten counties that comprise the Second Department (Kings, Queens, Richmond, Nassau, Suffolk, Westchester, Dutchess, Orange, Rockland, and Putnam) is entitled to leave to amend its answer to assert a counterclaim for fraud against a plaintiff in an action based on mere allegations that the plaintiff staged and/or intentionally caused the accident at issue. Conversely, pursuant to the First Department’s decision in Anguisaca-Morales, a defendant in an action venued in any of the lower courts in the two counties that comprise the First Department (New York and Bronx) is not entitled to leave to amend its answer to assert a counterclaim for fraud against a plaintiff based on similar allegations. Even when the defendants submits evidence that that the plaintiff intentionally caused the accident that is sufficient to defeat a motion for summary judgment on liability. Instead, in order to be entitled to leave to amend its answer to assert a counterclaim for fraud against the plaintiff in a matter venued in the First Department, a defendant is effectively required to make a prima facie demonstration that the plaintiff staged/intentionally caused the accident and that the defendant sustained damages. In doing so, the damages must be in addition to what the defendant incurred in relation to investigating and litigating the plaintiff’s claims. The decisions in Gimenez and Anguisaca-Morales have not yet been cited in any subsequent decisions involving cases where the plaintiff allegedly staged/intentionally caused the accident. Instead, these decisions have only been discussed in multiple decisions by one judge in the New York Supreme Court, Kings County, in cases that do not involve allegations of staged accidents. This judge has inserted identical language in five decisions that appear to be a concerted attempt to limit the application of Gimenez to cases where there is “concrete evidence” that the accident was staged. Ian works in our Melville, NY office. He can be reached at (631) 227-6389 or ILGlick@mdwcg.com.
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.
