Health Care Fraud Blog

MIAMI, FLORIDA (AUGUST 10, 2011) - A Miami nurse, Armando Santos, 46, received 10 years imprisonment from his role in a scheme that saw $11 million in fraudulent claims made to Medicare.

Between 2007 and 2009, as an employee of Ideal Home Health company, Santos billed Medicare for services given to Medicare beneficiaries that were either not medically necessary or that were never given, including giving insulin injections to two patients that did not need insulin. Santos worked with the owners of the home health company, Elizabeth Acosta Sanz and Luis Alejandro Sanz in perpetrating the fraud. Of the $11 million in bogus claims filed, $7 million was received.

MIAMI, FLORIDA (JULY 27, 2011) - A Miami-based patient recruiter, Vicente Guerra-Nistal, has pled guilty to one count of conspiracy to commit health care fraud before U.S. District Court Judge Joan A. Lenard.

Guerra was part of a 20-member team that scammed Medicare out of more than $25 million. The company for which Guerra worked, ABC Home Health, provided home health services and physical therapy, but the company billed for medically unnecessary services or for services that were never provided. Two physicians, Jose Nunez, M.D. and Francisco Gonzalez, M.D. were also charged in the original February 2011 indictment for prescribing the services.

For his part in the scheme, Guerra recruited participation of Medicare beneficiaries by paying kickbacks and bribes for use of Medicare billing information. As a result of Guerra's actions, Medicare was billed $194,000. Guerra said he knew that the patients didn't qualify for the services and that patient records had been altered in order to appear as though they did qualify.

Guerra's sentencing is scheduled for October 27, 2011, and he faces a maximum of 10 years imprisonment.

MIAMI, FL – Yudel Cayro, the owner and operator of Courtesy Medical Group, was sentenced to 5 years behind bars for his role in a wide-ranging Medicare fraud scheme.

U.S. District Judge Adalberto Jordan also ordered Cayro to serve two years of supervised release following his prison term and ordered him to pay $9.8 million in restitution with his co-defendants and co-conspirators in a related case to the Centers for Medicare and Medicaid Services (CMS.)

Factual Proffer signed by Caryo at the time that he pleaded guilty, he admitted that Courtesy Medical Group operated in part to provide unnecessary prescriptions, plans of care (POC’s) and medical certifications, among other things, to Miami-area home health agencies in return for kickbacks and bribes. Courtesy supplied the fraudulent medical documents so that the home health agencies could bill the CMS for expensive home health services and therapy purportedly for insulin dependent diabetic Medicare beneficiaries. However, the services were not medically necessary and in some cases the beneficiaries did not receive the services.

In the Factual Proffer, Caryo also admits that approximately 344 prescriptions for these unnecessary services were issued through Courtesy and signed by Cayro’s co-defendant, Dr. Fred Dweck, who is scheduled to be sentenced early next year. As a result, Medicare was fraudulently billed approximately $16.6 million for home health services. Medicare paid almost $10 million of the fraudulent claims. Another owner and operator of Courtesy, co-defendant Arturo Fonseca, was sentenced in November 2010, by Judge Jordan to 5 years in prison and two years of supervised release. Fonseca’s Factual Proffer is available for viewing by clicking here.

Three of Cayro’s co-defendants, Miami-area nurses Armando Sanchez, Marlenys Fernandez and Silvio Ruiz were sentenced last week to prison for their roles in the scheme. Sanchez and Fernandez were each sentenced to two and a half years in prison. Ruiz was sentenced to four months in prison. Judge Jordan also ordered Fernandez to pay $331,622, Sanchez to pay $602,585, and Ruiz to pay $79,230 in restitution to CMS, jointly and severally with their co-defendants and co-conspirators in a related case.

Two weeks ago, another co-defendant, registered nurse Sheillah Rotta, was sentenced by Judge Jordan to two months in prison, followed by two years of supervised release, for her participation in the scheme. Rotta was also ordered to pay $74,164 in restitution to CMS, jointly and severally with her co-defendants and co-conspirators in a related case.

According to the Factual Proffers submitted at the time they pleaded guilty, the nurses were engaged in the fraudulent scheme at ABC Home Health and Florida Home Health Care Providers Inc., two Miami home health agencies that were engaged in billing the Medicare program for unnecessary home health services for Medicare beneficiaries. Specifically, the nurses admitted to falsifying patient files to make it appear that these Medicare beneficiaries qualified for two to three times daily skilled nursing visits to purportedly administer diabetic insulin injections. However, these Medicare beneficiaries did not need nor qualify for these services.

According to court documents, Sanchez admitted that as a result of his actions, more than $900,000 was falsely billed to the Medicare program (click to read his Plea Agreement and here to read his Factual Proffer; Fernandez admitted to causing approximately $500,000 in fraudulent billings to Medicare (click here to read her Plea Agreement and here to read the Factual Proffer); Rotta admitted to causing more than $100,000 in fraudulent billing (click here to read her Factual Proffer); and Ruiz admitted to causing approximately $115,000 in fraudulent billing.

The cases were brought as part of the Medicare Fraud Strike Force, supervised by the U.S. Attorney’s Office for the Southern District of Florida and the Criminal Division’s Fraud Section. Since their inception in March 2007, Strike Force operations in seven districts have obtained indictments of more than 825 individuals who collectively have falsely billed the Medicare program for more than $2 billion. In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

To learn more about the Health Care Fraud Prevention and Enforcement Action Team (HEAT), go to: http://www.stopmedicarefraud.gov/

As the federal government’s Medicare Fraud Task Force called HEAT (Health Care Fraud Prevention and Enforcement Action Team), left Miami and deployed out across the country in six phases to Houston, Los Angeles, Detroit, Tampa, Baton Rouge and Brooklyn, it seemed many of the initial arrests, particularly out of the Detroit area, had a Miami connection as if the frauds were Miami transplant operations.

Well, finally, a sizeable operation with it seems nary a link to Miami. More importantly, this arrest out of Detroit of 13 people and many of the latest arrests are all pointing towards home health as the priority. Several home health operators and several doctors were arrested in an alleged scheme involving paid patients, false plans of care, and services never performed.

To read more: Click here.

MIAMI, FL (June 26) - Gladys Zambrana, Javier Zambrana, Enrique Perez, Alejandro Hernandez Quiros aka Alex Hernandez, Vanessa Estrada, Vicenta Tellechea, Modesto Hidalgo and Carlos Castaneda were indicted in connection with an alleged $22 million Medicare fraud scheme operated out of Miami businesses purporting to specialize in home health care services.

Gladys Zambrana was also charged with four counts of health care fraud. Gladys Zambrana and Hernandez Quiros were charged with three counts each of paying health care kickbacks, while Perez, Hidalgo and Tellechea were charged with one count each of paying health care kickbacks. Gladys Zambrana, Perez, Alejandro Quiros, Tellechea and Castaneda were also charged with conspiracy to launder health care fraud proceeds.

According to the indictment, Gladys Zambrana, Perez and Hernandez Quiros operated ABC Home Health Care Inc. (ABC), listing Javier Zambrana as the owner; and Gladys Zambrana and Castaneda operated Florida Home Health Care Providers Inc. (Florida Home Health), listing Tellechea as the owner. Both ABC and Florida Home Health purported to be home health agencies that catered to Medicare beneficiaries. The indictment alleges that at both agencies, beneficiaries were recruited and paid kickbacks and bribes to arrange for their Medicare beneficiary numbers to be used by their co-conspirators to file claims with Medicare for purported home health care services. The indictment alleges that the services were not provided and were not medically necessary.

The indictment alleges that in addition to exerting ownership and control of the home health agencies, Hernandez Quiros and Castaneda acted as Medicare beneficiary recruiters for ABC and Florida Home Health, respectively; and Hidalgo, a medical assistant, falsified medical tests and records to make it appear that the services were needed. The indictment alleges that ABC billed more than $17 million to the Medicare program for services provided from January 2006 through December 2008 that were medically unnecessary and were not actually provided. During that time frame, Medicare paid more than $11 million on those fraudulent claims submitted by ABC. The indictment also alleges that from October 2007 through March 2009, Florida Home Health billed more than $5 million to the Medicare program for services that were medically unnecessary and not actually provided. During that time frame, Medicare paid more than $4 million on those fraudulent claims submitted by Florida Home Health.

The charge of conspiracy to commit health care fraud carries a maximum prison sentence of 10 years. Each charged count of health care fraud carries a maximum prison sentence of 10 years and each count of paying health care kickbacks carries a maximum prison sentence of five years. Conspiracy to launder health care fraud proceeds carries a maximum prison sentence of 10 years per count.

In conjunction with the criminal case, on June 24, 2009, the U.S. Attorney’s Office also filed a civil complaint for injunctive relief under the fraud injunction statute and obtained a temporary restraining order freezing the assets of ABC, Florida Home Health, Gladys Zambrana, Javier Zambrana, Perez, Hernandez Quiros, Castaneda and Tellechea. In addition, that temporary restraining order also freezes certain financial assets of four other companies the defendants owned or controlled and allegedly used to launder money fraudulently obtained from Medicare. The temporary restraining order is intended to preserve the remaining proceeds of the fraud for recovery by the United States as part of the criminal case and any related civil proceedings.

According to Acting U.S. Attorney Jeffrey H. Sloman, the “[c]oordinated criminal and civil action delivers an effective one-two punch to health care fraudsters: they were not only caught and criminally charged, but they are also being stripped of their illegal proceeds.”

On March 5, 2009 the Miami Herald reported that “State investigators began sweeps this week targeting fraud and abuse in the home healthcare industry in Miami-Dade, aiming to potentially save millions of dollars in questionable payments by Medicaid.

“They launched a mission to inspect up to 125 home healthcare agencies, about one-third of all Medicaid providers in the county. The providers bill for unskilled workers who are supposed to help homebound patients with bathing, skin care, medication, wound dressing and other basic needs.”

For more: click here.