Health Care Fraud Blog

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.