Health Care Fraud Blog

Medicare Fraud Cases on The Rise

http://gooznews.com/?p=3453

By GoozNews

Federal prosecutors brought a record number of cases of health care fraud in fiscal 2011, a new report said, with Florida and its huge Medicare-dependent population remaining the epicenter of fraudulent claims.

The latest data, drawn from federal records by the Transactional Records Access Records database at Syracuse University, showed total prosecutions jumped 68.9 percent to 1,235 cases compared to 2010, a record increase.

The huge increase was fueled largely by a sharp jump in cases brought in Puerto Rico, where prosecutors charged 548 defendants with health care fraud last year, up from just 119 the previous year. Most of those were minor cases. But even without the Puerto Rican cases, fraud prosecutions nationwide were up sharply and reached the highest level since 2000.

Miami led the nation in activity, accounting for nearly one out of every nine health care fraud prosecutions, followed by Houston. Together, federal prosecutors in those two districts accounted for over one out of every five health care fraud prosecutions.

The Obama administration stepped up its enforcement activity in late 2009 with the creation of tasks forces in nine cities to root out Medicare and Medicaid fraud. “They’re really going after these cases very aggressively, and I think you’ll see prosecutions increase even more over the next few years,” said Louis Saccoccio, chief executive officer of the National Health Care Anti-Fraud Association, which was launched in 1985 by insurers to help root out both private and public sector fraud in the industry.

“The good news is there’s lots of prosecutions,” he said. “The bad news is there’s lots of prosecutions. The real question is what will CMS (the Center for Medicare and Medicare Services) do to prevent these frauds from taking place in the first place.”

A typical case concluded in Trenton last week when a federal judge sentenced a former senior manager of Columbia, Md.-based Maxim Health Care Services, one of the nation’s leading home health care providers, to five months in prison for setting up a phony office that billed Medicaid and the Veterans Administration nearly a million dollars. The criminal charges were part of a nationwide investigation of Maxim that led in September to an out-of-court settlement where the firm – to avoid a conviction that might have disqualified it from the programs – agreed to pay the government $150 million in criminal and civil penalties.

Experts and even defense attorneys say health care fraud, estimated to cost the government $70 billion a year, won’t be curbed until the government figures out how to short-circuit schemes through better monitoring of claims before they are paid and better screening of firms before they are allowed to sell services to the programs. Last June, CMS launched a data-mining program that will review Medicare claims before payment to identify individual providers that show huge spikes in activity. “CMS is on the right track,” Saccoccio said.

“They have to blow up the bill now, investigate later system,” agreed Andrew Ittleman, a white collar criminal defense attorney at Fuerst Ittleman in Miami. While he says that many cases involve companies in legitimate billing disputes with the government, he agreed “it’s not at all misguided given the size of the problem and the magnitude of the fraud.”

“The more sinister cases down here involve people who set up broom closets without an address and bill Medicare as long as they can before they high-tail it to Cuba or wherever in Latin America,” he said. “Magistrates aren’t even giving pre-trial release to some of these defendants because we don’t have an extradition treaty with Cuba.”

This story appeared first in The Fiscal Times.

Eight Others, Including Senior Managers, Previously Sentenced for

Felony Charges Arising out of Maxim’s Activities

TRENTON, N.J. – A former senior manager and 13-year employee of Maxim Healthcare Services, Inc. (“Maxim”), was sentenced today to five months in prison and five months of home confinement with electronic monitoring for his involvement in the unlicensed operation of Maxim office that billed nearly a million dollars to government health care programs, J. Gilmore Childers, First Assistant U.S. Attorney announced.

Bryan Lee Shipman, 38, of Athens, Ga., pleaded guilty in Trenton federal court on June 17, 2010, to an Information charging him with one count of health care fraud. Shipman was charged in connection with his role as a regional account manager supervising Maxim’s decision to open and operate Maxim’s Gainesville, Ga., office without a license from 2008 through 2009, when he and others directed billings from that office to be submitted for reimbursement by the Medicaid program as if they were from another, licensed office. Shipman entered his guilty plea before U.S. District Judge Anne E. Thompson, who also imposed the sentence today in Trenton federal court.

On Sept. 12, 2011, Maxim – one of the nation’s leading providers of home healthcare services – entered into a settlement agreement to resolve criminal and civil charges relating to a nationwide scheme to defraud Medicaid programs and the Veterans Affairs program of more than $61 million. Maxim was charged in a criminal Complaint with conspiracy to commit health care fraud, and entered into a Deferred Prosecution Agreement (“DPA”) with the Department of Justice. The agreement allows Maxim to avoid a health care fraud conviction on the charges if it complies with the DPA’s requirements. As required by the DPA, Maxim agreed to pay approximately $150 million – a criminal penalty of $20 million and approximately $130 million in civil settlements in the matter, including to settle federal False Claims Act claims.

Shipman is one of nine individuals – eight former Maxim employees, including three senior managers, and the parent of a former Maxim patient – to have pleaded guilty to and been sentenced on felony charges arising out of the submission of fraudulent billings to government health care programs, the creation of fraudulent documentation associated with government program billings, or false statements to government health care program officials regarding Maxim’s activities.

According to documents filed in this and related cases and statements made in court:

Shipman had been employed by Maxim for 13 years, the last eight as a regional account manager. As a regional account manager, Shipman reported directly to one of two nationwide vice presidents, who in turn reported to Maxim’s president. He also managed 13 offices in 2008 with hundreds of employees and total annual sales of more than $42 million, much of which derived from government programs. In his last full year of employment, Shipman earned more than $325,000, and was among the top 25 individuals at Maxim in terms of compensation out of the more than 80,000 individuals employed by Maxim in that year.

Shipman’s annual compensation – which ranked him within the top .03% of the Company – was based to a significant degree on meeting sales goals. Shipman said his superiors demanded levels of growth based “not on any market analysis, but simply on a belief that dramatic growth was necessary regardless of market conditions.” It was in response to that pressure, Shipman said, that he authorized and supervised the unlicensed operation of the Gainesville office.

At one point, when Maxim employees believed a state regulator would be visiting the office, lower-level employees were directed by Shipman and others to provide false information to the state regulator in an effort to prevent the Medicaid program from learning about the unlicensed operation of the office.

In addition to the prison term, Judge Thompson sentenced Shipman to two years of supervised release and ordered him to pay a $10,000 fine.

The other eight individuals who pleaded guilty were sentenced by Judge Thompson as follows:

Gregory Munzel, 35, of Charleston, S.C., was employed as a regional account manager, reporting directly to a vice president, responsible for Maxim offices throughout the southeastern United States. He pleaded guilty on Dec. 4, 2009, to one count of making false statements relating to health care fraud matters. During his plea hearing, Munzel admitted that he was aware individuals he supervised were submitting time cards for work that had not actually been done – a practice Munzel said was in response to pressure from Maxim superiors to increase revenue. Munzel also acknowledged forging caregiver credentials such as CPR cards throughout his time at Maxim, in order to make it appear that the caregivers were properly credentialed, when they were not. Munzel indicated he learned the practice from his supervisors when he first joined Maxim, and that those under him engaged in the practice when he took on a leadership role with the company. Munzel was sentenced on Sept. 29, 2011, to three months of home confinement as part of a two-year term of probation. Munzel was also ordered to pay a $1,000 fine.

Matthew Skaggs, 39, was employed as a regional account manager, reporting directly to a vice president, responsible for Maxim’s offices in Texas. He pleaded guilty on Sept. 23, 2010, to making false statements relating to health care fraud matters. During his plea hearing, Skaggs acknowledged having knowingly made false statements to a surveyor from Texas’ Medicaid Program, who was investigating the operation of an unlicensed Maxim office in Houston. Skaggs was sentenced on June 10, 2011, to a three-year term of probation and ordered to pay a $4,000 fine.

Andrew Sabbaghzadeh, 30, of Clay, N.Y., was employed as an account manager; and Jason Bouche, 27, of Paradise Valley, Ariz., was employed as a recruiter at Maxim’s Tempe, Ariz. office. They pleaded guilty to health care fraud on Nov. 4, 2009, and April 23, 2010, respectively. During their plea hearings, Sabbaghzadeh and Bouche acknowledged creating fraudulent time cards in order to bill government programs. They acknowledged that in some instances, Maxim employees cut signatures from legitimate time cards and pasted them onto forged time cards in order to submit them for reimbursement. Sabbaghzadeh was sentenced on Sept. 26, 2011, to six months of home confinement as part of a three-year term of probation. Sabbaghzadeh was also ordered to pay a $2,000 fine. Bouche was sentenced on Nov. 17, 2011, to a two-year term of probation and ordered to pay a $500 fine.

Donna Ocansey, 49, of Medford, N.J., was employed as a director of clinical services (supervising nurse) in Maxim’s Cherry Hill, N.J., office. She pleaded guilty on May 28, 2010, to making false statements relating to health care fraud matters. Ocansey, a registered nurse (RN), had responsibility for, among other things, ensuring that Medicaid-required supervisory visits of patients were conducted periodically – meaning that an RN periodically visited each patient to check each patient’s condition and the care the patient was receiving from Maxim Home Health Aides, who lack the skills and training of RNs. During her plea hearing, Ocansey acknowledged that she fabricated documentation in order to make it appear that other nurses had conducted Medicaid-mandated supervisory visits, when in fact they had not. Ocansey stated that she fabricated documentation in response to pressure from her superiors at Maxim, who expected her to make sure that all supervisory visits were completed without providing adequate resources for her to do so. Ocansey was sentenced on Oct. 18, 2011, to four months of home confinement as part of a a three-year term of probation. Ocansey was also ordered to pay a $2,000 fine.

Mary Shelly Janvier-Pierre, 43, of Lake Worth, Fla., and Sandy Cave, 39, of West Palm Beach, Fla., pleaded guilty to health care fraud on Feb. 1, 2010, and June 21, 2010, respectively. During their plea hearings, Janvier-Pierre, who had been employed by Maxim’s West Palm Beach office as a licensed practical nurse; and Cave, the mother of a former pediatric patient of Maxim, admitted to their roles in a scheme to fraudulently bill Medicaid, through Maxim, for services that were not rendered. Janvier-Pierre and Cave acknowledged that they agreed to submit billings as if Janvier-Pierre was taking care of Cave’s child, when she was not. Janvier-Pierre and Cave then split the money Janvier-Pierre received for purportedly providing the care. As a result of the scheme, Maxim was paid more than $70,000 by Florida’s Medicaid program. Janvier-Pierre was sentenced on Sept. 21, 2011, to six months of home confinement as part of a three-year term of probation. Cave was sentenced on Nov. 17, 2011, to five months of home confinement as part of a three-year term of probation. Cave was also ordered to pay a $1,000 fine.

Marion Morton, 45, of North Charleston, S.C., was employed as a home health aide and personal care assistant by Maxim’s Charleston, S.C., office. He pleaded guilty on May 3, 2010, to one count of making false statements relating to health care fraud matters. During his plea hearing, Morton acknowledged that, at the instruction of Maxim employees, he fabricated timecards reflecting work he had not done. On multiple occasions, Maxim submitted bills to Medicaid based on timecards which showed he worked more than 24 hours on certain days. Morton was sentenced on May 24, 2011, to a three-year term of probation and ordered to pay a $5,000 fine.

First Assistant U.S. Attorney Childers credited special agents and investigators from HHS/OIG, under the direction of Special Agent in Charge Thomas ODonnell; the FBI, under the direction of Special Agent in Charge Michael B. Ward; and VA OIG, under the direction of Special Agent in Charge Jeffrey Hughes for conducting the multi-year investigation.

The government is represented by Assistant U.S. Attorney Jacob T. Elberg of the U.S. Attorney’s Office Health Care and Government Fraud Unit.

11-471

Defense counsel:

Maxim: Laura Laemmle-Weidenfeld Esq.; Robert Luskin Esq., Washington

Gregory Munzel: John Lacey Esq., Roseland, N.J.

Bryan Lee Shipman: Peter Bennett Esq., Middletown, N.J.

Matthew Skaggs: David Sellinger Esq., Florham Park, N.J.

Andrew Sabbaghzadeh: James Hopkins Esq., Syracuse, N.Y.

Jason Bouche: Chester Keller Esq., Assistant Federal Public Defender, Newark

Donna Ocansey: Jeffrey Carney Esq., Hackensack, N.J.

Mary Shelly Janvier Pierre: Michael Salnick Esq., West Palm Beach, Fla.

Sandy Cave: Chester Keller Esq., Assistant Federal Public Defender, Newark

Marion Morton: John Renner Esq., Marlton, N.J.

Department of Justice

Office of Public Affairs

FOR IMMEDIATE RELEASE

Wednesday, November 30, 2011

Pompano Beach, Fla.-Area Assisted Living Facility Owner Pleads Guilty to Fraud and Kickback Scheme

WASHINGTON – The owner and operator of a Pompano Beach, Fla.-area assisted living facility pleaded guilty today for his role in a Medicare fraud kickback scheme that funneled patients through a fraudulent mental health company and a Medicaid fraud scheme that billed for assisted living services that were never provided, announced the Department of Justice, the FBI, the Department of Health and Human Services (HHS) and the Medicaid Fraud Control Unit (MFCU) of the Florida Office of the Attorney General.

Joseph B. Williams, 41, pleaded guilty before U.S. District Judge Jose E. Martinez in Miami to two counts of conspiracy to commit health care fraud.  Williams was the owner and operator of Avondale Manors Retirement Home, an assisted living facility operating in Pompano Beach, and a company called Diversified Marketing Group Inc.

Williams admitted that in exchange for illegal health care kickbacks, he agreed to provide Medicare beneficiaries who resided at Avondale to American Therapeutic Corporation (ATC) for intensive mental health treatment called partial hospitalization program services.  ATC purported to operate partial hospitalization programs in seven different locations throughout south Florida and Orlando.  According to court documents, Williams was paid approximately $30 per beneficiary per day the beneficiary attended ATC.  ATC paid the kickbacks mostly by check made out to Diversified.

According to his plea, Williams knew that ATC fraudulently billed Medicare for the partial hospitalization program treatment that his referrals purportedly received.

According to court documents, ATC’s principals paid kickbacks to owners and operators of assisted living facilities and halfway houses and to patient brokers in exchange for delivering ineligible patients to ATC and its related company, the American Sleep Institute (ASI).  In some cases, the patients received a portion of those kickbacks.  Throughout the course of the ATC conspiracy, millions of dollars in kickbacks were paid in exchange for Medicare beneficiaries who did not qualify for partial hospitalization program services.  Ultimately, ATC and ASI billed Medicare for more than $200 million in medically unnecessary services.

Williams also admitted that he billed Medicaid for assisted living services purportedly provided at Avondale when, in fact, those services were never provided.   Williams paid owners and operators of halfway houses to obtain the personal identifiers of Medicaid enrollees who resided in those halfway houses and used that information to bill Medicaid fraudulently.   Williams also billed Medicaid for assisted living services provided to residents of Avondale at times when they were not receiving any services.

According to the plea agreement, Williams’s participation in the fraud resulted in more than $2 million in fraudulent billing to the Medicare and Medicaid programs.  At sentencing, scheduled for Feb. 8, 2012, Williams faces a maximum of 10 years in prison and a $250,000 fine for each count.

ATC, its management company Medlink Professional Management Group Inc., and various owners, managers, doctors, therapists, patient brokers and marketers of ATC, Medlink and ASI, were charged with various health care fraud, kickback, money laundering and other offenses in two indictments unsealed on Feb. 15, 2011.  ATC, Medlink and nine of the individual defendants have pleaded guilty or have been convicted at trial.  Other defendants are scheduled for trial April 9, 2012, before U.S. District Judge Patricia A. Seitz.

Today’s guilty plea was announced by Assistant Attorney General Lanny A. Breuer of the Justice Department’s Criminal Division; U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida; John V. Gillies, Special Agent-in-Charge of the FBI’s Miami field office; and Special Agent-in-Charge Christopher B. Dennis of the HHS Office of Inspector General (HHS-OIG), Office of Investigations Miami office.

The case is being prosecuted by Trial Attorneys Steven Kim and Jennifer L. Saulino of the Criminal Division’s Fraud Section.  The case was investigated by the FBI, HHS-OIG and MFCU and was brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Southern District of Florida.

Since its inception in March 2007, the Medicare Fraud Strike Force operations in nine locations have charged more than 1,140 defendants that collectively have billed the Medicare program for more than $2.9 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.

TAMPA (October 21) Last week, Gregory Bane, the Vice President for Operations and I.T. manager of Bane Medical Services and Oxygen and Respiratory Therapy was sentenced to three years in federal prison for conspiracy to commit health care fraud, health care fraud, and submitting false claims. Tracy Bane, the billing supervisor, was sentenced to six months in federal prison, and 18 months of house arrest for conspiracy to commit health care fraud, health care fraud and submitting false claims. In September, Ben Bane was sentenced to twelve years and six months in federal prison for conspiracy to commit health care fraud, health care fraud, and submitting false claims.

Late last year, the Banes a federal jury returned a guilty verdict for conspiracy to commit health care fraud, health care fraud and submitting false claims. During the trial, testimony and evidence presented showed the Banes knowingly violated Medicare rules prohibiting durable medical equipment (DME) companies who sell equipment from performing their own qualification testing.

Over the course of four years, Bane Medical Services and Oxygen and Respiratory Therapy, Inc., performed incorrect tests, deliberately misled doctors about it, faked test results to make it look like patients qualified for Medicare-reimbursed oxygen even though they did not, and forged doctors signatures on Certificates of Medical Necessity.

Before being arrested, Ben Bane sold Bane Medical Services to another DME company for $21 million. Bane made it appear that an independent lab had done the necessary tests. Bags full of records were burned at Ben Bane's house. The government showed that Bane Medical obtained more than $6.8 million from Medicare through the submission of false claims. The defendants were each also ordered to pay $7 million in restitution, a $3 million fine, a $1,000 special assessment, and the Court also entered a money judgment in the amount of $5,800,000, representing the proceeds of the health care fraud.

In order to satisfy the $5.8 million money judgment, the Court also ordered Ben Bane to forfeit a number of assets, including $1.425 million in cash, 2 mortgages, 17 real properties (homes and buildings) and 4 vehicles and vessels. In addition, the Court has entered three writs of execution to enforce the restitution order against properties owned by Bane, or which were held for his benefit.

Among those arrested are: mental health clinic owners, healthcare employees, patient recruiters and assisted living facility owners.

Stand by for further info.

BOSTON, MASSACHUSETTS (AUGUST 29, 2011) - Massachusetts State Attorney General Martha Coakley’s office released information that it had recovered $69 million in Medicaid fraud during the fiscal year 2011. The previous record was $14 million in 2009.

Since she took office in 2007, AG Coakley’s office has added $200 million in Medicaid fraud back to the state fund’s coffers. The $69 million figure alone represents more than the total previously collected in the ten years prior to Coakley’s tenure. For every dollar the AG’s Medicaid Fraud Division has allocated to its budget, $18 is recovered to the taxpayer.

HOUSTON, TEXAS (AUGUST 16, 2011) - A Houston area nursing home administrator was arrested in connection with an indictment handed down by a grand jury in which he was charged with conspiracy, health care fraud and violations of the anti-kickback statute.

Kelvin Washington, 47, ran a Sugar land area nursing home and was purported to have received payments for referring dialysis patients to a specific ambulance transport service between 2003 and 2007. Washington also conspired to have doctors sign transport orders for dialysis patients. The patients whose names he used, however, were never admitted to that nursing home. By the time investigators compiled their case, Washington had helped amass over $1 million in false claims to Medicare. For his part in the scheme, Washington received over $20,000.

WASHINGTON (AUGUST 12, 2011) - The Office of the Inspector General of the Department of Health and Human Services says more than 60 percent of all power wheelchairs, which are usually covered 100 percent by Medicare or private insurance, are not necessary for patients. The high cost of these chairs make them an attractive sales product for slick salesmen eager to make a buck.

Past investigations show that Medicare has paid close to four times the average $1,048 cost, making Medicare responsible for more than $4,000 for each chair. In many cases, the chairs won't work in the patient's home because doorways are too narrow or there is simply not enough room in the house to maneuver the chair. In Marvin Rosen's Coral Springs home it's become something he sits in occasionally to watch television because the chair isn't supposed to be used outside, and his home is too small to use it inside. The company who provided him with the chair failed to measure his home, which is a requirement before a patient can receive one.

NEWARK, NEW JERSEY (AUGUST 2, 2011) - The FBI wants the public's help in preventing health care fraud and they're putting up advertisements in malls and on highways to bring attention to their campaign. Digital ads went up in malls in Paramus, Wayne, Hackensack and Atlantic City, as well as on the Jersey Turnpike near the Lincoln Tunnel and several major highway systems.

The Newark office of the FBI is credited with the idea for the program. For the next two months that the ads are up, the Bureau hopes to see an increase in the number of tips reporting health care fraud. If the New Jersey campaign is successful, the Bureau will turn it into a national program with the help of Clear Channel, who also assists on the "Most Wanted" digital billboards.

Health care fraud costs the American taxpayer approximately $60 billion a year, and in New Jersey the loss was $8 million in 2010. As the number of reported health care fraud cases has fallen off in recent years, the FBI hopes to educate the public on how much they're losing by not reporting fraud. Agent Sean Keyes says "all of the best criminal investigations are human-source driven."

JERSEY CITY, NEW JERSEY (JULY 28, 2011) - Arrested for a second time in connection with fraud, Dr. Madgy Elamir was charged with health care claims fraud, Medicaid fraud and practicing medicine without a license. Elamir continued to write prescriptions despite his license having been suspended in connection with a previous arrest.

The defendant also has a trial date scheduled in September in an earlier case for his alleged role in a major narcotics trafficking and Medicaid fraud ring with connections in Hudson, Bergen, Ocean, Morris and Monmouth counties. Elamir allegedly wrote prescriptions for medically unnecessary prescriptions and illegally distributed the controlled drugs, Xanex and Percocet, in exchange for cash.

Elamir's bail on the new charges has been set at $1 million.

MIAMI, FLORIDA (JULY 26, 2011) - The Government Accountability Office recently issued a report stating the federal government's analysis systems for Medicare and Medicaid are "inadequate and underused." The report further reveals that the systems don't even analyze Medicaid data, and of the 639 analysts targeted for training with the system, only 41 have received it. The technology slated to save $21 million in Medicare and Medicaid lacks the formal planning for implementation, even though $150 million has been invested in the technology.

When the new system went live in 2009, it was intended for use by the Center for Medicare and Medicaid Services (CMS), contractors, law enforcement and state agencies, with access to the information shared across all states. Because funding for the software was delayed, the rollout date has been pushed to November 2011.

In the meantime, CMS has another fraud prevention technology program in the works, similar to the system that screens for credit card fraud. That contract came with a $77 million price tag. With approximately 4.5 million claims processed on a daily basis, rollout of these programs can't come fast enough for the taxpayer's wallet.

HOUSTON, TEXAS - The Departments of Justice and Health and Human Services announced that Ekpedeme Obot, 34, pled guilty to health care fraud and making false statements relating to health care matters in a $1.3 million Medicare fraud scheme. Obot was owner and operator of Praise DME, a durable medical equipment company that collected $945,637 in false claims.

From March 2007 to August 2008, Obot submitted claims for durable medical equipment, including orthotic devices such as braces, and accessories such as heating pads, for the treatment of arthritis that were not medically necessary. In addition to the false claims, Obot failed to provide information about his prior conviction on felony theft from 2007, which is required in the supplemental Medicare Enrollment Application. He reported only that he had been under a recoupment action by Texas Medicaid and had entered into a payment arrangement.

Sentencing is scheduled for October 12, 2011. For the count of health care fraud, Obot faces a maximum penalty of 10 years in prison and five years on the false statements charge.

TROY, MICHIGAN - Charged with conspiracy to commit health care fraud and money laundering, a Michigan couple, Surya and Srinivas Nallani, ran a $9 million physicians home visit business.

From 2005 until February 2010, the company, Allied Geriatric Services, submitted fraudulent bills through its billing manager, Srinivas Nallani. His wife, Dr. Surya Nallani billed for home visits for times while she was out of the country or for time when the distance between two locations would have made same-day travel impossible.

The maximum sentence the charges carry is 10 years in prison and a $250,000 fine, however, attorneys for the U.S. are seeking forfeiture of the Nallanis' assets in the amount of $825,000 and two of their vehicles.

MINNEAPOLIS, MINNESOTA - The owner of a home health care company bilked Medicaid out of more than $400,000 by submitting reimbursement claims for personal care services that were never performed. Joseph Vah Lavien, 57, of Brooklyn Park was charged with one count of health care fraud. He faces up to ten years in prison.

Lavien owned and operated Palm Healthcare Services, Inc. which provided in-home personal care. Between 2008 and 2009, Lavien submitted reimbursement claims for $412,227.17 to the Minnesota Department of Human Services. Lavien made claims for services that were not provided, billed for services not authorized and for more services than could be performed in a day or month, and submitted false records. Lavien may also have defrauded MinnesotaCare insurance program in the amount of $83,939. The investigation is ongoing.

The investigation resulted from a cooperative effort by the Minnesota Attorney General’s Office -Medicaid Fraud Control Unit, the Federal Bureau of Investigation, and the United States Department of Health and Human Services-Office of Inspector General.

JEFFERSON CITY, MISSOURI - Lorraine Kusior a licensed professional counselor from Mountain Grove, pled guilty to two counts of making false statements to receive Medicaid payments (Class C felonies), one count of obstruction of a Medicaid investigation (Class D) and one count of stealing by deceit (Class D). Kusior falsely made reimbursement claims to Medicaid for counseling services she never performed and used false patient records with the intent to defraud. Kusior was originally charged with 13 total felony counts.

Missouri Attorney General Chris Koster said the Medicaid Fraud Unit's review of Kusior's progress notes and Medicaid claims found incidences of inflated billing. The Class C felonies each carry the possibility of up to 7 years imprisonment; each Class D carries a possible 4 years. Kusior's sentencing is scheduled for August 3 in Waynesville, Missouri.

WASHINGTON D.C. - Health care fraud task forces are turning their attention to the executive level of health care enterprises. In an effort to crackdown on those who would perpetrate health care fraud, investigators have begun aiming their efforts at the owners and operators of drug companies, medical device manufacturers, nursing home chains and any health care business involved with Medicare and Medicaid. Senior executives could find themselves facing criminal charges even if they had no knowledge of their company's activities, but were in a position to stop it.

Prosecutors have become fed up with repeated violations, which cost taxpayers more than $60 billion per year and have decided to use enforcement tools that have long been in place, but simply not used. A simple writing of a check to repay the federal funds and a promise not to repeat the offense have been used too often, so now corporate executives must pay closer attention to how their company is billing Medicare and Medicaid lest they find themselves in hot water with the feds.

The crackdown may result in a company's ban from participating in Medicare and Medicaid reimbursements, but the power to ban lies solely with the inspector general, not a judge. The FDA has also begun using the "Park Doctrine" which allows prosecutors to bring criminal charges against executives. Any corporate officer in the chain of command could charged with a criminal misdemeanor if found to have the ability within their power to prevent the fraud.

Federal Healthcare Fraud Strike Force teams are currently operating in 9 locations: Miami, Los Angeles, Houston, Detroit, Brooklyn, Tampa, Baton Rouge, Dallas and Chicago.

If you, or someone you know is facing prosecution as a result of aggressive law enforcement activity in the area of health care fraud, make sure you contact attorney Robert Malove, co-author of the noted treatise, WHITE COLLAR CRIME: HEALTH CARE FRAUD (West)(2010-2011 ed.) to arrange an immediate consultation.

WASHINGTON D.C. - The Office of the Inspector General of the Department of Health & Human Services has been working hard. In its semi-annual report for October 2010 through March 2011, the OIG's office reported that it expected to recover approximately $222 million from audits and another $3.2 billion from criminal and civil actions. As a result of investigations during that time period the OIG also doled out 883 new exclusions to persons and entities, barring them from participating in Federal health care programs.

The OIG's report continued by revealing more than 100 perpetrators of health care fraud had been arrested, and in February 2011, Medicare Strike Force teams with more than 300 agents fanned out across the country and arrested more than 100 suspects in nine cities. Owners and executives of health care service companies, doctors and nurses, among others found themselves accused of fraudulent billing practices, money laundering, receipt of kickbacks and identity theft.

The OIG's success resulted from a collaborative effort with the Department of Justice, the Centers for Medicare & Medicaid Services, State Medicaid Fraud Control Units, other OIGs offices, State agencies and local law enforcement.

Federal Healthcare Fraud Strike Force teams are currently operating in 9 locations: Miami, Los Angeles, Houston, Detroit, Brooklyn, Tampa, Baton Rouge, Dallas and Chicago.

If you, or someone you know is facing prosecution as a result of aggressive law enforcement activity in the area of health care fraud, make sure you contact attorney Robert Malove, co-author of the noted treatise, WHITE COLLAR CRIME: HEALTH CARE FRAUD (West)(2010-2011 ed.) to arrange an immediate consultation.

HARTFORD, CONNECTICUT - Dr. Mark Izard, 78, decided to end his medical career after 50 years of practice and settle a lawsuit brought by the U.S. Department of Health and Human Services for $2.2 million. Under the terms of the settlement the doctor did not have to admit any wrongdoing.

Investigators alleged that Izard submitted claims to Medicare and Medicaid for services he never performed. The investigation uncovered claims where Izard billed for care provided to nursing home patients that had been transferred to hospitals. At Hartford Hospital the doctor filed claims for services that were actually performed by residents and hospital staff. A detailed analysis of the billing records also indicated that Izard sometimes billed for more than 24 hours of medical services in a day.

Along with the financial arrangement, the settlement, deemed a "civil billing dispute", includes a ban on Dr. Izard and his practice from participating in federal health care programs for the next seven years. Dr. Izard, although not barred from practicing medicine, has chosen instead to retire after a 50-year career.

Federal Healthcare Fraud Strike Force teams are currently operating in 9 locations: Miami, Los Angeles, Houston, Detroit, Brooklyn, Tampa, Baton Rouge, Dallas and Chicago.

If you, or someone you know is facing prosecution as a result of aggressive law enforcement activity in the area of health care fraud, make sure you contact attorney Robert Malove, co-author of the noted treatise, WHITE COLLAR CRIME: HEALTH CARE FRAUD (West)(2010-2011 ed.) to arrange an immediate consultation.

MIAMI, FL - The Departments of Justice and Health and Human Services announced that Obel Martinez and Damaris Gil, a married couple, entered into plea agreements and admitted to committing health care fraud. According to the factual proffer filed in court at the the of the guilty plea, Martinez and Gil agreed that it was their scheme to bilk Medicare of $1,089,234 in fraudulent claims. The defendants owned and operated a durable medical equipment company, OM Best Help Corp., which provided equipment as well as prescription drugs to Medicare beneficiaries.

The defendants also used Medicare provider numbers of licensed medical doctors without prior authorization and represented to Medicare that the doctors had written prescriptions for the durable medical equipment, when in fact, they did not. The pair also never provided the equipment to the Medicare beneficiaries after filing the false claims.

Sentencing is scheduled for August 23, 2011, and each defendant could receive up to a maximum of 10 years in prison.

Federal Healthcare Fraud Strike Force teams are currently operating in 9 locations: Miami, Los Angeles, Houston, Detroit, Brooklyn, Tampa, Baton Rouge, Dallas and Chicago.

If you, or someone you know is facing prosecution as a result of aggressive law enforcement in the area of health care fraud, make sure you contact attorney Robert Malove, co-author of the noted treatise, WHITE COLLAR CRIME: HEALTH CARE FRAUD (West)(2010-2011 ed.) to arrange an immediate consultation.

MIAMI-DADE, FLORIDA (May 19, 2011) - A fraudulent billing scam masterminded by Gregory Campbell, the 28-year-old son of State Rep. Daphne Campbell, has brought first-degree felony charges of grand theft, organized fraud and Medicaid fraud down on Mr. Campbell's head. He stands accused of billing the joint state and federally funded Medicaid program for $299,000 for services he never provided.

It appears Campbell billed for the same patients at two separate adult care facilities. Investigators also found Campbell billed for patients that did not live at either facility, and he offered kickbacks to the owner of one of the care sites.

Campbell was being held in the Miami-Dade county jail following his arrest on May 12. When contact by the press regarding her son's arrest, Rep. Campbell had no comment.

Healthcare Fraud Blog Publisher, Attorney Robert Malove, is an expert criminal trial lawyer as recognized by The Florida Bar. Mr. Malove has extensive experience in the area of health care fraud defense.

If you or someone you know is a healthcare provider and in need of serious pill mills, doctor shopping or any healthcare fraud defense, please contact attorney Robert Malove, co-author of the noted treatise, WHITE COLLAR CRIME: HEALTH CARE FRAUD (West)(2010-2011 ed.) to arrange an immediate consultation.

JACKSONVILLE, FLORIDA (May 9, 2011) - A Jacksonville doctor will be spending 28 months behind bars following her conviction of Medicare and Medicaid fraud. Janet Johnson-Hunter pled guilty to "conspiracy to conceal material facts in connection with the delivery of and payment for health care benefits, items and services."

Johnson-Hunter owns a private ambulance service which receives reimbursement for Medicare and Medicaid in accordance with the non-ambulatory condition of its patients. If a patient is able to walk or ride in a wheelchair, Medicare and Medicaid is less likely to reimburse the company for the patient's transportation. Johnson-Hunter told her employees to change patients' medical records to reflect a non-ambulatory condition.

Johnson-Hunter was fined $10,000 and ordered to pay $428,929 to Medicare and $46,165 to Medicaid as restitution for the fraud.

Healthcare Fraud Blog Publisher, Attorney Robert Malove, is an expert criminal trial lawyer as recognized by The Florida Bar. Mr. Malove has extensive experience in the area of health care fraud defense.

If you or someone you know is a healthcare provider and in need of serious pill mills, doctor shopping or any healthcare fraud defense, please contact attorney Robert Malove, co-author of the noted treatise, WHITE COLLAR CRIME: HEALTH CARE FRAUD (West)(2010-2011 ed.) to arrange an immediate consultation.

WASHINGTON D.C. (May 15, 2011) - A District of Columbia health care provider was indicted by a federal grand jury on "one count of health care fraud and 39 counts of false statements in a health care matter." Jacqueline Wheeler faces a possible maximum sentence of 10 years incarceration and $250,000 in fines. Wheeler, a registered naturopath with the District of Columbia Department of Health, Health Professional Licensing Administration is not a medical doctor licensed to practice medicine.

Wheeler acted as CEO of Health Advocacy Center, Inc., which is a registered Medicaid provider. She also owns Sheridan Rehabilitative and Wellness Centers, Inc, which is not a registered Medicaid provider. Wheeler did all the billing for Health Advocacy and controlled the finances of both facilities. At Health Advocacy, Wheeler worked with a licensed medical doctor and billed D.C. Medicaid for $6.2 million as reimbursement of therapy services. Wheeler claimed 22 patients each received 20 continuous hours of therapy in one 24-hour period. There are 1,440 minutes in a day and sometimes Wheeler would bill for as many as 2,910 minutes (equal to more than 48 hours) for a single patient, for a single visit.

Wheeler used the proceeds from the fraud to buy property in Florida, North Carolina and the D.C. area. The United States Attorney's Office is prosecuting the case, and the investigation is ongoing at this time.

Healthcare Fraud Blog Publisher, Attorney Robert Malove, is an expert criminal trial lawyer as recognized by The Florida Bar. Mr. Malove has extensive experience in the area of health care fraud defense.

If you or someone you know is a healthcare provider and in need of serious healthcare fraud defense, please contact attorney Robert Malove, co-author of the noted treatise, WHITE COLLAR CRIME: HEALTH CARE FRAUD (West)(2010-2011 ed.) to arrange an immediate consultation.

MONROE, NORTH CAROLINA (May 7, 2011) - A gynecologist accused of billing Medicaid for services that patients never received, settled her case for double of what she billed the insurance provider. From 2003 to 2008, Dr. Latika Patel filed false claims for more than 1,000 patients.

The doctor admitted that mistakes were made and accepted responsibility for the errors. Dr. Patel contends her staff made the errors and she had been focusing more on patient care and less on the office management side of the business. Investigators believe the doctor knowingly "upcoded" for more involved and more expensive services that were not performed.

Investigators also found the doctor had billed for services performed at one clinic when she was not at that clinic on the day billed. The terms of the settlement include that Dr. Patel does not have to admit liability, and the government does not agree that its claims were not "well-founded." No criminal charges were brought in the matter. Dr. Patel will now also be subject to audits, at her expense, of her practice and all billing will be monitored for five years.

Healthcare Fraud Blog Publisher, Attorney Robert Malove, is an expert criminal trial lawyer as recognized by The Florida Bar. Mr. Malove has extensive experience in the area of health care fraud defense.

If you or someone you know is a healthcare provider and in need of serious billing practices, doctor shopping or any healthcare fraud defense, please contact attorney Robert Malove, co-author of the noted treatise, WHITE COLLAR CRIME: HEALTH CARE FRAUD (West)(2010-2011 ed.) to arrange an immediate consultation.

TAMPA, FLORIDA - Wellness Health Plans saw five of its former executives indicted in a triple-digit million dollar fraud perpetrated on the Florida state Medicaid program. The former executives include Wellcare's CEO, general counsel and CFO. Wellcare allegedly provided false documentation that claimed costs greater than those incurred for behavioral health services.

In October 2007, federal agents descended on the company's Tampa headquarters and confiscated evidence of the alleged fraud. In 2010, Wellcare and the Justice Department reached a "preliminary settlement" of $137 million. A former financial analyst of the company and a company whistleblower, contends the settlement is too low when damages of $400 million are possible.

Healthcare Fraud Blog Publisher, Attorney Robert Malove, is an expert criminal trial lawyer as recognized by The Florida Bar. Mr. Malove has extensive experience in the area of health care fraud defense.

If you or someone you know is a healthcare provider and in need of serious billing practices, doctor shopping or any healthcare fraud defense, please contact attorney Robert Malove, co-author of the noted treatise, WHITE COLLAR CRIME: HEALTH CARE FRAUD (West)(2010-2011 ed.) to arrange an immediate consultation.

NEW ORLEANS, LOUISIANA - Thirty-one counts of Medicare and Medicaid fraud, totaling $12.5 million, were returned by a New Orleans Federal Grand Jury. Health Plus Consulting, Saturn Medical Group, New Millennium Medical Group, plus nine individuals were indicted on counts of health care fraud.

The individuals recruited patients to visit to the clinics for tests that were never performed or necessary. The patients also moved from clinic to clinic, receiving the same unnecessary tests. In exchange for their participation in the scam, the patients received prescription drugs.

Investigators seized two residences deemed "proceeds" from the crimes as well as bank accounts of some of the defendants. Depending on the extent of their individual involvement, defendants face anywhere from 10 years to 230 years imprisonment and fines. The corporations, if found guilty, could be fined as well.

Healthcare Fraud Blog Publisher, Attorney Robert Malove, is an expert criminal trial lawyer as recognized by The Florida Bar. Mr. Malove has extensive experience in the area of health care fraud defense.

If you or someone you know is a healthcare provider and in need of serious pill mills, doctor shopping or any healthcare fraud defense, please contact attorney Robert Malove, co-author of the noted treatise, WHITE COLLAR CRIME: HEALTH CARE FRAUD (West)(2010-2011 ed.) to arrange an immediate consultation.

NEW BERN, NORTH CAROLINA - Dr. Michael K. Nunn pled guilty to health care fraud and money laundering in U.S. District Court on April 25. Nunn received four years of probation and was ordered to pay $297,215 as restitution to the U.S. Department of Health & Human Services and the Veteran's Administration in connection with Medicare fraud. His medical corporation was also fined $700,000.

Nunn's company, Community Wellness Center, located in New Bern, North Carolina, fraudulently billed Medicare for diagnostic and therapy services that were never performed. If performed services were not among those that would receive reimbursement from Medicare, they were coded as services that Medicare would pay. The Veteran's Administration was often billed twice for the same services to the same patients.

Four government agencies participated in the investigation, including the Internal Revenue Service.

Healthcare Fraud Blog Publisher, Attorney Robert Malove, is an expert criminal trial lawyer as recognized by The Florida Bar. Mr. Malove has extensive experience in the area of Medicare fraud and money laundering defense.

If you or someone you know is a healthcare provider and in need of serious pill mills, doctor shopping or any healthcare fraud defense, please contact attorney Robert Malove, co-author of the noted treatise, WHITE COLLAR CRIME: HEALTH CARE FRAUD (West)(2010-2011 ed.) to arrange an immediate consultation.

WARREN, NEW JERSEY - The FBI uncovered a scam by a New Jersey physician, Yousef Massod and his office manager wife, Maruk Masood, to bilk Medicare and Medicaid out of millions. The Massods hired persons posing as licensed physicians to conduct more than 20,000 patient visits which were then billed to the government provided insurance funds.

The non-doctor defendants had graduated from medical schools in the Dominican Republic and West Indies, but had not passed their state boards and were not licensed physicians in New Jersey. The Massods paid the non-doctors $10 an hour and found two of the individuals on Craigslist.

The investigation also uncovered that Dr. Masood leads the pack in Medicaid drug billing for the State of New Jersey at $9 million for 2009. The next ranked physician only billed $6 million that year. Dr. Masood enabled the non-doctor hires to prescribe medications by providing them with pre-signed, blank prescription forms to use in their "practice."

Dr. Masood agreed to pay $1.8 million as restitution and forfeiture for the fraudulent billings. Sentencing for the Masoods will take place on July 27 in U.S. District Court. The charges to which they pled guilty carry a possible 10 years in prison and $250,000 fine.

Healthcare Fraud Blog Publisher, Attorney Robert Malove, is an expert criminal trial lawyer as recognized by The Florida Bar. Mr. Malove has extensive experience in the area of health care fraud defense.

If you or someone you know is a healthcare provider and in need of serious pill mills, doctor shopping or any healthcare fraud defense, please contact attorney Robert Malove, co-author of the noted treatise, WHITE COLLAR CRIME: HEALTH CARE FRAUD (West)(2010-2011 ed.) to arrange an immediate consultation.

As reported previously here, a central feature of the Obama administration’s health care reform has been the HEAT (Health Care Fraud Prevention and Enforcement Action Team) initiative is the use of Strike Force teams. Strike Forces are multi-agency units of Federal and State law enforcement personnel designed to identify, investigate, and prosecute Medicare fraud. Strike Forces are supported by a CMS data analysis team and CMS program experts.

Since May 2009, this Administration has expanded Strike Force cities from Miami and Los Angeles, when Strike Force teams were launched in Houston and Detroit in May 2009 and in Brooklyn, Baton Rouge, and Tampa in December 2009. (To read more, click: here).

Building on the momentum started last May, U.S. Department of Health and Human Services Deputy Secretary William Corr and U.S. Department of Justice Acting Deputy Attorney General Gary Grindler, testified earlier this month before the United States House of Representatives Subcommittee on Labor, Health and Human Services, Education, and Related Agencies Committee on Appropriations and stated that the entire $250 million increase in the President’s Budget advances the goals of the HEAT initiative.

Strike Force defendants are also more likely to receive prison sentences and longer terms of imprisonment than more traditional criminal health care fraud defendants. Since the Strike Force’s inception, over 94% of all Strike Force defendants were convicted and sentenced to terms of imprisonment compared to 64% of all criminal health care fraud defendants. The average prison term for Strike Force defendants was 45 months, which was about 10% longer than the overall national average for federal health care fraud defendants over this same period.

New Strike Force locations are chosen based on thorough analysis of Medicare claims data, which helps identify hot spots of unexplained high-billing levels in concentrated areas, and a review of the most effective allocation of investigative and prosecutorial resources. The cost associated with Strike Forces expansion resulting in 20 locations by end-of-year FY 2011 is an estimated $46 million.

U.S. Senator Tom Coburn of Oklahoma, who is also a medical doctor, is proposing that the United States root out Medicare Fraud through the use of undercover patients. Actually this is not new a new idea, government agents have in the past used undercover activities for precisely this purpose; recently, undercover agents posing as patients have been used extensively for investigations of pain management clinics.

Part of the problem is that often the undercover agent has to come up with a malady that would be the pretense of the visit. Generally, undercover agents posing as patients generate a false identity as well as a false medical history; sometimes going as far as to use test results, x-rays or the like from other, real patients. Sometimes, for example with pain clinics, the condition could be somewhat subjective; “My back hurts.” Such investigations can have good, bad and sometimes even funny results. In one undercover investigation, a Medicaid fraud agent, posing as a patient going to physician’s offices where it was alleged patients were paid, learned that one of the physicians he went to see diagnosed him with, among other things, erectile dysfunction. On the not so funny side, one department of insurance agent investigating chiropractors posed as a patient and wound up receiving an adjustment that injured his back.

In the Medicare arena, since the program is for persons over 65, the challenge would be to use retired or near retired agents and then address the same quandary; do you falsify conditions or symptoms? This can be more difficult to do with an older agent/patient; some conditions or diagnoses that might lend to potential fraudulent activity by physicians such as cancer and cardiac conditions are difficult to fake. Although scenarios can always be found to avoid a circumstance where a patient will receive certain treatments or injections, sometimes the outcomes are hard to determine.

To read more, click here.

According to a Department of Justice press release, Miami-Dade County resident Dulce Briceño was sentenced on February 4th to 63 months in prison for her role in a $2.3 million Medicare fraud scheme.

Miami based U.S. District Judge Ursula Ungaro also ordered Briceño to pay $1.8 million in restitution. Originally, Briceño was indicted in the Eastern District of Michigan, but after her arrest in Miami, she consented to have her case transferred to the Southern District of Florida for her plea and sentencing.

Briceño pleaded guilty on Oct. 9, 2009, at which time she admitted that in approximately September 2006, she agreed with the owners of X-Press Center to manage the clinic on a day-to-day basis in exchange for a percentage of the profits the clinic generated. Briceño also admitted that during the time the clinic was open, the clinic routinely billed the Medicare program for services that were medically unnecessary or were never provided. Briceño admitted that she and her co-conspirators at the clinic had purchased only a small fraction of the medications that the clinic billed the Medicare program for providing.

Briceño admitted that Medicare beneficiaries were not referred to X-Press Center by their primary care physicians, or for any other legitimate medical purpose, but rather were recruited to come to the clinic through the payment of kickbacks. In exchange for those kickbacks, Briceño admitted that the Medicare beneficiaries would visit the clinic and sign documents indicating that they had received the services billed to Medicare. Kickbacks paid to Medicare beneficiaries at the clinic, according to plea documents, came in the form of cash and prescriptions for narcotic drugs.

Briceño also admitted that between approximately September 2006 and March 2007, she and her co-conspirators at X-Press Center caused the submission of approximately $2.3 million in false and fraudulent claims to the Medicare program for services purportedly provided at X-Press Center. Medicare paid approximately $1.8 million on those claims.

As part of the recent focus of a task force in the Tampa area, a physician and a physician’s assistant who owned and operated 8 clinics were arrested for health care fraud and drug trafficking charges.

The clinics, Neurology & Pain Centers, operated in Tampa , Lakeland , Sarasota , Orlando and Jacksonville . State officials say that prescription drug overdose deaths are now more prevalent than overdose deaths for street drugs such as heroin and cocaine. The Tampa area, according to State officials, is responsible for 25% of those deaths. The allegations contained in the indictment include that the PA, Troy Wubbenna, offered free drugs to a 17 year old to recruit other high school students and that the physician, Dr. Jeffrey Friedlander, signed blank prescription pads so that drugs, particularly Oxycodone and Oxycontin, could be dispensed when he was not around.

To read more, click here.

Recently state and federal authorities announced a regional health care fraud strike force in the Tampa and Orlando region. In what may be one of the first operations of that strike force, a Lakeland, Florida couple, Lilian Pagkaliwangan, 40, and Raymundo P. Arellano, 42, operators of Lakeland Therapy Providers Inc. and Optimum Therapy Inc., were arrested for health care fraud with respect to the operation of those businesses. The charges include alleged fraudulent billing for services not provided.

According to the indictment the couple submitted claims for reimbursement for medical services not rendered, including services that were claimed to have been provided on days when the patients were not present at the clinic and couldn't receive services.

Click here to read more.

Medicare is not supposed to be free medical care. Medicare rules require an annual deductible and a 20% co-payment by patients for services under Medicare Part B. The co-payment is in part to defray costs and to hold down costs under the theory that if patients are paying some part of the fee out-of-pocket they are more inclined to scrutinize and object to excessive or unnecessary services or procedures.

In many instances however, in sort of a wink and a nod, providers either do not charge a co-payment due to “financial hardship” or bill patients for co-payments but fail to aggressively collect the payment.

The Office of Inspector General (OIG) has previously issued guidance stating that the routine waiver of co-payments is a kickback and leads to fraud: Routine waiver of deductibles and copayments by charge-based providers, practitioners or suppliers is unlawful because it results in (1) false claims, (2) violations of the anti-kickback statute, and (3)excessive utilization of items and services paid for by Medicare.

A provider, practitioner or supplier who routinely waives Medicare co-payments or deductibles is misstating its actual charge. For example, if a supplier claims that its charge for a piece of equipment is $100, but routinely waives the co-payment, the actual charge is $80. Medicare should be paying 80% of $80 (or $64), rather than 80 percent of $100 (or $80). As a consequence of the provider's misrepresentation, Medicare program is paying $16 more than it otherwise should for this item.

In certain cases, a provider, practitioner or supplier who routinely waives Medicare co-payments or deductibles also could be held liable under the Medicare and Medicaid anti-kickback statute, 42 U.S.C. 1320a-7b(b), which makes it illegal to offer, pay, solicit or receive anything of value as an inducement to generate business payable by Medicare or Medicaid. When providers, practitioners or suppliers forgive financial obligations for reasons other than genuine financial hardship of the particular patient, they may be unlawfully inducing that patient to purchase items or services from them. Check out this HHS OIG Fraud Alert regarding this practice.

The routine waiver of co-payments is difficult to prove if the provider makes some effort, however nominal, to collect those fees. The failure to collect co-payments is rarely charged as a crime, but has been the subject of whistleblower actions. Nevertheless, it is substantially easier to prove a crime if, like nine Podiatrists in the New York area, a provider specifically advertises in subways, billboards and on flyers that Medicare beneficiaries can get free services. Three of those nine providers were convicted and sentenced to prison recently for Health Care Fraud in part due to the failure to collect overpayments. To read more, click here.

According to Senator LeMieux of Florida, Florida is the health care fraud capital of the world and instead of reforming health care, the government should be focusing on fixing the current system, particularly targeting fraud waste and abuse.

Meanwhile, federal authorities are using South Florida as the testing site for the health care fraud initiatives given the prevalence of health care fraud in Dade, Broward and Palm Beach counties. The Obama administration has asked for $300 million to combat health care fraud in 2010.

To view his speech on the Senate floor in this video.

To read more, click here.

Proposals to increase the criminal penalties for health care fraud are making their way into the Senate’s health care reform bill. The proposal, The Health Care Fraud Enforcement Act, involves significant increases in potential jail time through modifications of the Federal Sentencing Guidelines to increase sentencing levels predicated upon the “amount of loss” if the offenses involve health care fraud. Also, the proposal would lessen the proof requirements in kickback cases to no longer require willful conduct for a conviction. The proposal, S.B. 1959, by Senator Kaufman is co-sponsored by other fairly powerful Senators including Schumer, Specter and Leahy.

To lear more, click here.

The health care fraud bill past last year by the Florida Legislature had a number of “get tough” provisions; including an extended list of disqualifying offenses for licensure, including some misdemeanors or other minor offenses. The law includes that a drug or fraud conviction within the last 15 years would disqualify some professionals from licensure.

This article talks about the fact that the statute will likely result in the denial of the renewal of licenses for a number of professionals for minor indiscretions in their distant past. Often when you see numbers in statutes, such as the 15 year figure here, you might believe the number is tied to some study, policy or criteria; but often the number is just pulled out of thin air. Here, for example, those professionals aren’t trustworthy enough to engage in a profession for conduct fifteen years prior. However, in court proceedings, a conviction, actually the completion of a sentence, greater than 10 years old is generally inadmissible to impeach a person and is considered too remote to have application to the person’s credibility. So to work a distant conviction would be relevant, but to testify under oath, not.

The 15 year provision seems somewhat harsh and really it doesn’t make any sense. Most careers for health care professions requiring advanced degrees start after college and graduate school, so people are generally in their twenties before they actually start their profession. However, if you were arrested for having marijuana at 18, you could not apply to the state of Florida to be a pharmacist until you were at least 33. It seems that if you are giving a time limitation at all, 15 years seems somewhat arbitrary. Perhaps there should have just been a ban, the result is the same.

For more, click here.

TALLAHASSEE, FL (September 16, 2009) Attorney General Bill McCollum announced that three people have been arrested and accused of conspiring to defraud the Florida Medicaid program out of at least $112,000.

Larry Hill is charged with Medicaid provider fraud and conspiracy to commit Medicaid provider fraud. If convicted, he faces up to 10 years in prison and $10,000 in fines. Frederica Hill is charged with Medicaid provider fraud, organized fraud, communications fraud, grand theft, neglect of a disabled adult, and conspiracy to commit Medicaid provider fraud. She faces up to 80 years in prison and up to $40,000 in fines. Cathy Summerlin is charged with Medicaid provider fraud, organized fraud, communications fraud, neglect of a disabled adult, and conspiracy to commit Medicaid provider fraud. If convicted, Summerlin faces up to 50 years in prison and up to $30,000 in fines. The case is being prosecuted by the State Attorney’s Office for the 14th Judicial Circuit. For more: Click here

The recent arrests of by the DOJ-HHS health care fraud task force, HEAT, of 52 individuals related to Medicare Fraud in Detroit, and the allegation that the crimes were somewhat commuter crimes, brought to Detroit from Miami has also raised an issue of the involvement of certain ethnic groups, and particularly recent Cuban immigrants, in the offenses. The history of the United States has certainly involved the rise of organized crime through immigrant groups, generally criminal activity becoming much easier to organize among insular communities who are suspicious of the larger communities or government to protect them.

While it is unfair to brand entire nationalities for the crimes of extreme minorities of those groups, certain ethnic groups come to be associated with certain crimes. Much has been made in lore about the Italian Mafia’s association with organized crime generally, others include Jamaican drug gangs in the 1980s, Chinese gangs in the slave trade, Nigerian credit card frauds. One other is the Miami-Cuban connection to Medicare Fraud schemes.

Such is the perception that the recent Florida Anti-Health Care Fraud legislation created a provision requiring immigrants to obtain a bond prior to obtaining a clinic license. A Miami Herald article addresses the issue of the Cuban connection to Medicare Fraud, with an interesting aside thrown in, an often raised but not yet proven allegation as to whether the Cuban government itself is involved in Medicare fraud. To read the Herald article and comments posted there, click here.

The Miami Herald received 17 Sunshine State Awards Saturday, including top honors for coverage of deadly storms in Haiti, Medicare scandals, failed transit projects and rogue mortgage brokers.

The South Florida chapter of the Society of Professional Journalists awarded The Herald nine first-place honors among large newspapers, including two of the organization's most coveted citations.

Special congratulations go out to Herald reporter Jay Weaver, who won the Sunshine State Award in the category of Medical/Health Care/Science Reporting for his exposé: ''South Florida's Medicare Racket,'' detailing massive fraud among recipients of Medicare dollars.

WellCare Health Plans, Inc., Florida ’s largest managed care provider, has agreed to pay $80 million in forfeiture and restitution to Florida’s Medicaid program. WellCare also entered into an agreement for compliance and monitoring in a deferred prosecution agreement with the United States. Under a deferred prosecution agreement, the company would not be prosecuted for fraud if it complies with all the provisions of the agreement.

WellCare was charged in a scheme to defraud the Florida Medicaid program and the Florida Healthy Kids Corp., the U.S. Attorney’s office said in a press release. The scheme alleged by the government was that Wellcare charged the Medicaid program for services it claimed were paid to another entity, Harmony Behavioral Health, Inc. Harmony was wholly owned by Wellcare and did not provide the services claimed.

To read more, click here.

Attorney General Andrew Cuomo announced that the State of New York has recovered $263 million in Medicaid funds in 2008, the most in any year and up from $114 million in 2007. $35 million came from one managed care provider, Healthfirst, and $28 million from civil settlements with home health care companies. There were also 150 convictions for Medicaid fraud in the State of NY last year, 35 related to fraudulent home health care claims.

To read the press release click here.

In a move targeted to increase health care fraud enforcement by the State of Florida, the Florida legislature has recently passed legislation containing a number of new fraud provisions, including:

* elevating Medicaid fraud from a third degree felony to first, second and third degree felonies based upon dollar amounts of fraud and increasing fines to five times the amount of the fraud;

* designating Miami-Dade County as a “health care fraud crisis area” and increasing the monitoring of home health care in Miami-Dade County requirements that owners of home health agencies to be residents of the United States for at least five years or to post a $500,000.00 bond to own a health care clinic, a home health agency or a DME company;

* increasing the number of disqualifying prior criminal offenses for home health care business ownership;

* an increase in funding for rewards for people who report health care fraud and awarding 25% or $500,000 as a reward for successful actions based upon information received;

* limits a defendant’s ability to collect attorney’s fees if successful in defending a false claims action;

* prohibits alteration of records after the commencement of an investigation or audit; and

* provides that Medicaid program terminated provider’s names will be placed on a website and physician practitioner profiles will indicate if a practitioner was terminated from the Medicaid Program.

To read the new law, click here.

The term “medically necessary” in the context of Medicare and Medicaid reimbursement has been under some scrutiny lately. Medicare defines "medical necessity" as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Medicaid has a similar definition. For items or services where there is no specific limitation based upon a coverage policy, medical necessity has often been left to the good faith determination of a physician. However, in several prosecutions of physicians for infusion of HIV drugs, the government has relied on fraudulent diagnosis or unnecessary prescribing of medications as a basis of prosecution, citing to the physician motive of profit over appropriate patient care. In addition, the 11th Circuit Court of Appeals in Atlanta has recently held that the Medicaid program in Georgia can overrule a physician’s determination of medical necessity.

The case involved a young girl whose physician ordered additional nursing care than was available under a Medicaid policy. A Federal District Court Judge found that the state could not override the physician’s order and that "the state's discretion is limited to a review of the request for fraud, abuse of the Medicaid system, and whether the service is within the reasonable standards of medical care." The Eleventh Circuit disagreed, saying both the state and the treating physician have roles in determining what is medically necessary. It cited a federal regulation that says a Medicaid agency "may place appropriate limits on a service based on such criteria as medical necessity or utilization control procedures." The Court concluded that "A private physician's word on medical necessity is not dispositive."

The case is Moore v. Medows, No. 08-13926. To read the case, click here. To read more, click here.

Reprinted from Caribbean Net News
caribbeannetnews.com

Federal grand jury in Puerto Rico hands down indictments in Medicaid fraud

Published on Thursday, March 5, 2009

By María Miranda Sierra
Caribbean Net News Puerto Rico Correspondent
Email: miranda@caribbeannetnews.com

SAN JUAN, Puerto Rico: A federal grand jury in Puerto Rico has returned a 30-count indictment, charging four individuals with conspiracy to commit health care fraud, soliciting and receiving kickbacks in relation to the Medicare Program and making false statements.

The indictment also contains forfeiture allegations for $513,108.35, including two real estate properties, US Attorney for the District of Puerto Rico Rosa Emilia Rodríguez-Vélez, said in a news conference.

Continue reading "Four Indicted in Puerto Rico on Medicare Fraud Charges" »

On January 14, 2009, the owners and operators of two Miami medical clinics, along with a phlebotomist at one of the clinics, have pleaded guilty to defrauding the Medicare program in connection with a $5.3 million HIV and cancer infusion fraud scheme.

For more: http://www.usdoj.gov/opa/pr/2009/January/09-ag-042.html

According to the L.A. Times, the owner of a Los Angeles-area hospital and a man who acted as a recruiter were arrested August 6 on federal charges of defrauding Medicare and Medi-Cal by providing unnecessary health services to homeless people who were recruited from “Skid Row” with promises of payments.

Rudra Sabaratnam, 64, of Brentwood, an owner and top executive of a hospital; and Estill Mitts, 64, who resides near the Miracle Mile section of Los Angeles, the operator of a Skid Row “Assessment Center,” were arrested without incident.

Sabaratnam and Mitts were indicted under seal by a federal grand jury last week. The 21-count indictment, which was unsealed this morning following their arrests, alleges that Sabaratnam and Mills conspired to recruit homeless people to receive unnecessary health services for the purpose of committing health care fraud.

Sabaratnam and Mitts are jointly charged with conspiring to receive and pay kickbacks for patient referrals and to commit health care fraud. Sabaratnam is charged with eight counts of paying kickbacks for patient referrals. Mitts is charged with four counts of receiving kickbacks for patient referrals. Mitts is additionally charged with six counts of money laundering and two counts of tax evasion for allegedly failing to report more than $479,000 in income in 2005 and more than $620,000 in income in 2006.

If convicted of all counts, Sabaratnam faces a statutory maximum penalty of 50 years in federal prison, and Mitts faces a maximum possible sentence of 140 years in prison. Click here to read the complete text of the US Attorney's press release.

Professor Benson Weintraub, Esquire, a Ft. Lauderdale-based global health care attorney and counselor with an international practice and clientele, and a distinguished academic authority on the Federal sentencing of corporations and individuals, has been invited to present "Defense of a Criminal Healthcare Fraud Case" at Health Care Compliance Association's (HCCA) 12th Annual Compliance Institute to be held in New Orleans April 13-16, 2008.

Weintraub has served as a full-time Professor of Law. During his legal career, Porf. Weintraub has successfully represented complex white collar targets, corporations, business entities, executives, defendants, and witnesses as a tenacious, exclusively federal white collar criminal defense lawyer for more than 25 years.

Among his credits has defended more than 60 Physicians, Health Care Delivery Corporations & Organizations, DME Distributors, Internet Pharmacies, Pharmacists, Pharmaceutical Manufacturers, and public officials on hospital regulatory boards throughout the nation.

He also represented David Paul in the failed CenTrust Bank case as well as reputed drug lords, Willie Falcon and Salvador Magluta.

Weintraub recently represented Arne Soreide, a high profile telecom executive convicted after trial (by other counsel) in Fort Lauderdale of a $22m fraud, successfully convincing the U.S. Court of Appeals for the Eleventh Circuit in Atlanta that his 25 year sentence of imprisonment must be reversed, which the appellate court conceded was improper.

Weintraub was appointed by the first Chairman of the US Sentencing Commission to assist the fledgling agency in drafting its initial sentencing guidelines for organizations and individuals.

His extensive academic writing has been widely published or cited in Yale L.J., Harvard Law Review, Federal Sentencing Reporter, Stanford Journal of Law & Policy, Notre Dame Law Review, Federal Probation (US Courts), etc., and health care blogs.

Florida Board Certified Criminal Trial Lawyer Robert David Malove is Of Counsel to Benson Weintraub, LLC, upon whom a Masters Degree in Forensic Science, was conferred on Malove by the distinguished George Washington University in Washington DC. Malove received his JD from Pepperdine University School of Law. He has completed the Graduate Certificate Program in Healthcare Corporate Compliance at George Washington University and is Certified in Healthcare Compliance (CHC) by the Compliance Certification Board of HCCA. For more information visit www.healthcarefraudblog.com.

On January 10, Cesar Romero was sentenced by U.S. District Court Judge Patricia A. Seitz to forty-six months in jail and remanded into immediate custody for his role in a multi-million dollar Medicare billing fraud scheme on which Romero previously had pled guilty. Romero faced a potential sentence range of 46 to 57 months in prison, but was sentenced to the low-end of the advisory guidelines' sentencing range called for under an Adjusted Offense Level of 23. Romero's counsel disputed the 2-level upward departure from the base offense level of 21 with a lower advisory sentencing range of 37 to 46 months incarceration.

Romero took part in a scheme in which a phantom health clinic, named “The Real Group & Associates, Inc.,” was incorporated in South Florida and subsequently billed Medicare for reimbursement for non-existent drug infusion and injection therapies typically prescribed to AIDS and chemotherapy patients. Nearly $17 million of false claims were submitted to Medicare for reimbursement, resulting in payments of more than $2.5 million on the false claims. To date, law enforcement has recovered more than $1.6 million of the fraud proceeds. At sentencing, Romero was held responsible, in part, for recruiting and managing the straw owner of the clinic, and for the creation and control of the clinic’s corporate bank accounts that were used to transfer and disburse the Medicare fraud proceeds through a series of fraudulent financial transactions.

If you or someone you know has been charged with healthcare fraud or is under investigation, call attorney Robert Malove.

On September 6, 2007, Gianni Suarez Vazquez, a participant in a massive Medicare fraud scheme, pled guilty in federal court in West palm Beach, Florida, to mail fraud and money laundering charges. He is scheduled to be sentenced before U.S. District Judge Donald M. Middlebrooks on November 15, 2007.

According to the court records, between November 2003 and August 2004, Suarez Vazquez incorporated or set up two medical equipment companies, GK Medical, Inc. and Suplident International Corporation, in Palm Beach County. Thereafter, he obtained Medicare provider numbers for both companies to enable the companies to submit claims directly to Medicare. To conceal his ownership and control of the companies, Suarez Vazquez designated "strawmen" as company owners, including his mother, on the corporate documents and Medicare Provider Agreements.

Continue reading "Palm Beach Medicare Fraudster Pleads Guilty to Mail Fraud & Money Laundering" »

On August 28, 2007, a federal grand jury indicted the former operations director of A-Care EMS Inc. on charges that he sent fraudulent claims to the Centers for Medicare and Medicaid Services to pull in more money.

The indictment, filed Tuesday in the U.S. District Court for the Southern District of Texas, claims Rodney Lee Ramos, 34, of Weslaco, instructed emergency medical technicians to transport patients for dialysis who were not confined to bed."

According to the indictment, Ramos worked as an EMT coordinator for A-Stat Ambulance Services Inc., which was owned by Guadalupe Garces Jr. and Araceli Garces. Medicaid and Medicare placed a vendor hold on that ambulance provider -- withholding payment to the company -- after federal agents determined that the owners were defrauding the federal and state health insurance programs.

The Centers for Medicare & Medicaid Services Program Integrity Group at recently opened a field office in Santa Ana, California, aimed at preventing and prosecuting health care fraud.

"In the two years since the office has been up and running, we have been able to stop almost $2billion in inappropriate or improper payments from going out the door," program director Kimberly Brandt said.

Like the Medicare Fraud Strike Force office in South Florida that arrested 38 people for defrauding the federal program out of more than $142million, the Santa Ana office uses "data mining" technology to target fraudulent Medicare and Medicaid billings.

According to Assistant U.S. Attorney Consuelo Woodhead, who coordinates federal health care fraud prosecutions in Los Angeles, officials could double the number of law enforcement personnel fighting the problem and still fall short of having enough people to make a significant difference.

Woodhead thinks, that "to really effectively deal with the problem, we're going to have to take a multidisciplinary approach where you look at licensing and certification, how claims are processed, as well as strong criminal and civil enforcement after claims are paid."

The Florida House and Senate have passed an important piece of legislation which, when signed into law by Governor Charlie Crist, will mirror the Federal False Claims Act. The False Claims Act allows the Attorney General's Medicaid Fraud Control Unit to recover triple damages in civil lawsuits against those who commit Medicaid Fraud.

Under Federal law, all states that participate in the Medicaid program must also have a Medicaid Fraud Control Unit. Florida’s Medicaid Fraud Control Unit is operated by the Office of the Attorney General and is a joint Federal-State funded law enforcement agency. The unit, working with the Agency of Health Care Administration’s (AHCA) Bureau of Medicaid Program Integrity, investigates and seeks prosecution for criminal fraud and is empowered to “seek any civil remedy provided by law.”

This legislation will increase the recovery for Florida by 10 percent on all civil actions. In 2005, the Medicaid Fraud Control Unit secured over $76 million in settlements for Florida’s consumers. Nearly the entire amount was recovered through the use of the False Claims Act.

"Those who exploit and defraud our Medicaid program steal critical health care dollars from those who desperately need these services. Once signed into law, this legislation will not only strengthen our enforcement tools but more importantly, will return millions of dollars in Medicaid resources to the elderly, the disadvantaged and others in need," said Attorney General Bill McCollum. "I commend the Legislature for passing this important legislation which will assist our state combat Medicaid fraud and punish those who selfishly cheat the system."

A Miami-Dade husband and wife, both licensed occupational therapists, were arrested on charges they defrauded the Florida Medicaid program out of more than $200,000.

Investigators with the Attorney General’s Medicaid Fraud Control Unit after receiving information from the Agency for Health Care Administration.

The investigation discovered that the Sanfords allegedly billed Medicaid for providing two or three different types of services during the same 15 minutes of face-to-face therapy, although Medicaid can only reimburse for one treatment. A number of the children who were subjected to these therapies were under the age of ten and several of them are disabled. The Sanfords’ facility, also known as Fit for Kids, is located in North Miami Beach.

The Sanfords are each charged with grand theft and organized scheme to defraud, both first-degree felonies. The charges each carry a maximum penalty of 30 years in prison and a $10,000 fine. Additionally, the Attorney General’s Medicaid Fraud Control Unit seized funds from several bank accounts controlled by the Sanfords pursuant to the Florida Contraband Forfeiture Act. The Miami-Dade County State Attorney’s Office will prosecute the case.