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.

BY JOSEPH MARKS 12/20/2011

Medicare officials should better evaluate whether a new system designed to spot fraudulent claims and roll back the program's roughly $50 billion in annual improper payments is living up to its potential, a bipartisan group of senators said Tuesday.

The Centers for Medicare and Medicaid Service responded that it had been measuring results from the $100 million system since soon after its July launch and would update Congress on the results soon.

"The predictive modeling program is well on its way to achieving the kind of results CMS expected," agency officials said.

CMS plans to launch the new system nationwide this summer. But without clear metrics to gauge successes and failures neither the agency nor Congress will be able to determine whether the program is doing what it's supposed to, the senators said in a letter to Peter Budetti, director of CMS' Center for Program Integrity.

"As is often said, one cannot manage what one cannot measure," Sens. Tom Carper, D-Del.; Scott Brown, R-Mass.; and Tom Coburn, R-Okla.; said. Carper is chairman of the Senate Homeland Security Subcommittee on Federal Financial Management, which oversees CMS' financial issues. Brown is that panel's ranking Republican and Coburn, a physician, is a subcommittee member.

The predictive analysis tool was designed to flag common patterns of Medicare fraud such as suspicious billing patterns or a great distance between the hospital where treatment occurred and the claimant's home address. The plan is for CMS officials to halt those payments and immediately investigate them for possible fraud.

Legislative requirements that most Medicare claims be paid within 30 days traditionally has meant that CMS paid out claims before investigating them -- what officials call the "pay and chase" model.

The senators' letter concludes with a list of 10 questions focused on how much money the tool has clawed back, what lessons CMS officials have learned from the system's implementation so far, and whether those lessons have changed how the agency pays claims and which Medicare services providers it contracts with.

The predictive analytics program is similar to several fraud detection tools used by the Recovery Accountability and Transparency Board, which tracks spending on President Obama's $840 billion stimulus bill. That program has kept stimulus money lost to fraud at below 1 percent compared with a rate of up to 7 percent for government spending generally.

Plans to roll out similar tools on a governmentwide basis are working their way through Congress and the White House.

Read more at : http://www.nextgov.com/nextgov/ng_20111220_7934.php?oref=topnews

From the Miami Herald Blog:

Medicare fraud bill reintroduced U.S. Rep. Ileana Ros-Lehtinen, R-Miami, has reintroduced legislation that would double the fines and jail time for people convicted of Medicare fraud. It also creates a new criminal offense punishable with a 10 year minimum sentence for those who knowingly sell or distribute the ID numbers of Medicare beneficiaries. The legislation also bars those who have been part of Medicare fraud in the past from billing Medicare if they switch companies. It also facilitates real-time information sharing among law enforcement agencies to aid in uncovering and dismantling Medicare scams. "South Florida has been known as the epicenter of Medicare fraud for years," she said. "It is time we took the fight to those who seek to defraud Medicare and prey on our most vulnerable citizens. This bill not only increases the penalties for those who engage in Medicare fraud, but also sets up a pro-active paradigm that will help stem the tide of abuse in South Florida and across the nation." The bill takes particular aim at Medicare theft in Miami-Dade County, widely regarded as the nation's capital of healthcare fraud. Medicare fraud in South Florida costs taxpayers between $3 billion and $4 billion every year, according to law enforcement and healthcare officials. Nationwide, Medicare and other healthcare fraud is estimated to cost $68 billion annually.

Read more here: http://miamiherald.typepad.com/nakedpolitics/2011/12/medicare-fraud-bill-reintroduced.html#storylink=cpy

Diakon agrees to pay federal government $10.5 million

Diakon Hospice Saint John, which operates hospice care at facilities in Hazleton, Allentown, and Wyomissing, has agreed to resolve its liability for violations of the False Claims Act by paying the United States $10.56 million.

The announcement was made today by the United States Attorney’s Office for the Middle District of Pennsylvania and the U.S. Department of Health and Human Services' Office of the Inspector General.

According to those offices, from Oct. 1, 2004 through Oct. 1, 2010, Diakon erroneously submitted claims to the Medicare Program for hospice care provided to Medicare beneficiaries during periods of time in which the beneficiaries were not eligible for hospice benefits under the Medicare regulations.

Earlier this year, Diakon voluntarily disclosed to federal authorities that it had received improper Medicare and Medicaid payments. By voluntarily disclosing improper billing practices, Diakon

avoided a government lawsuit under the FCA and was able to negotiate a settlement.

The FCA provides that parties who voluntarily disclose violations of the act are liable for double damages, instead of triple damages and civil penalties between $5,500 and $11,000 for each violation.

“Health care providers that make billing compliance, self policing, and self reporting a priority foster trust in the health care industry” said Nick DiGiulio, special agent in charge for the United States Department of Health and Human Services’ Office of Inspector General. “These actions demonstrate that Diakon Hospice Saint John cares about returning money, incorrectly attained, to our federal health payment programs.”

To read the complete story, see Friday's Times Leader.

Read more: http://www.timesleader.com/news/Diakon-agrees-to-pay-federal-government-105-million.html#ixzz1fWV2t82Y

Department of Justice

Office of Public Affairs

FOR IMMEDIATE RELEASE

Tuesday, November 29, 2011

Patient Recruiter Pleads Guilty in Connection with $5.4 Million Medicare Fraud Scheme in Detroit

WASHINGTON – A patient recruiter pleaded guilty today for his participation in a Medicare fraud scheme operated out of three Detroit-area health care clinics, announced the Department of Justice, the FBI and the Department of Health and Human Services (HHS).

Santiago Villa-Restrepo, 33, of Miami, pleaded guilty before U.S. District Judge Arthur J. Tarnow in the Eastern District of Michigan to one count of conspiracy to commit health care fraud.   At sentencing, Villa-Restrepo faces a maximum penalty of 10 years in prison and a $250,000 fine.

According to the plea documents, Villa-Restrepo recruited Medicare beneficiaries for three Detroit-area health care clinics owned by co-conspirators.   In exchange for cash bribes paid by Villa-Restrepo and others, the beneficiaries agreed to attend the clinics where they provided their Medicare provider numbers and other information, which allowed the clinics to bill for diagnostic tests that were medically unnecessary, and in some cases, not provided at all.  According to court documents, Medicare was billed $5.4 million for medically unnecessary diagnostic tests by the clinics associated with the scheme.

Today’s guilty plea was announced by Assistant Attorney General Lanny A. Breuer of the Criminal Division; U.S. Attorney for the Eastern District of Michigan Barbara L. McQuade; Special Agent in Charge Andrew G. Arena of the FBI’s Detroit Field Office; and Special Agent in Charge Lamont Pugh III of the HHS Office of Inspector General’s (OIG) Chicago Regional Office.

This case is being prosecuted by Assistant U.S. Attorney Philip A. Ross of the Eastern District of Michigan, with assistance from Acting Assistant Chief Benjamin D. Singer of the Criminal Division’s Fraud Section.   The case was investigated by the FBI and HHS-OIG, 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 Eastern District of Michigan.

Since their inception in March 2007, the Medicare Fraud Strike Force operations in nine districts have charged more than 1,140 individuals who collectively have falsely 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, is taking steps to increase accountability and decrease the presence of fraudulent providers.

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.

BATON ROUGE, La. — Four Louisiana physicians wrote hundreds of bogus prescriptions that powered multimillion-dollar health-care frauds in the Baton Rouge area, according to evidence amassed by the nearly two-year-old local Medicare Fraud Strike Force.

Yet all four physicians remain licensed to practice medicine, including two who pleaded guilty and a third convicted at a jury trial in August. The fourth doctor, who had previous probations of his license, is fighting the charges in his indictment.

In a similar case that dates from before creation of the Strike Force, the Advocate reports (http://bit.ly/uTiKlA ) a Louisiana physician in 2009 retained his medical license even though he was convicted of health care fraud.

Officials of the Louisiana State Board of Medical Examiners declined to comment on the targeted physicians — three of whom had their licenses suspended or placed on probation for questionable prescription practices before being charged in the Medicare fraud cases. Doctors can continue practicing medicine while their licenses are on probation, but cannot during a suspension.

The Medicare Strike Force fraud cases are not related to the medical board's previous disciplinary actions against the four physicians, court and board records show.

The license of Dr. Sofjan Lamid, 82, of Mandeville, was twice suspended in the 1990s for alleged over-prescription of painkillers.

Lamid was ordered by the Board of Medical Examiners in 1991 to surrender "for life his DEA permit for prescription and dispensation of controlled drugs," according to the board order.

But Lamid retained authority to prescribe Medicare-funded power wheelchairs for patients. In August of 2011, Lamid was convicted by a federal jury in Baton Rouge on charges he accepted kickbacks for writing unnecessary prescriptions for power wheelchairs that resulted in fraudulent Medicare costs of $2.5 million. He has not yet been sentenced.

Rita Arceneaux, the Board of Medical Examiners' executive assistant, said board officials could not talk about any physicians charged in the Medicare investigations, including those already convicted.

The medical license of Dr. Anthony S. Jase, 41, of New Orleans, was placed on probation for three years in October 2010 for his failure to control prescription pads used to obtain amphetamines, codeine, Hydrocodone and Lomotil. Jase also was ordered by the Board of Medical Examiners to cease the practice of medicine in the field of "management of non-malignant chronic or intractable pain."

Those penalties were imposed before Jase completed a prior three-year period of license probation ordered in 2008 for what the board described as his acceptance of "cash for office-visit fees calculated ... on the amount of medications prescribed."

Jase pleaded guilty this year in a federal case that alleges he and others bilked Medicare out of more than $470,000 for unnecessary equipment or services. He agreed he owes restitution of $230,963 to Medicare.

Another Louisiana physician, now waiting for his Baton Rouge trial on Medicare fraud charges, had his license placed on probation for five years by the Board of Medical Examiners in May 2010.

That physician, Dr. Michael Selwyn Hunter, 54, of New Orleans, also was stripped of his right to practice in the "management of non-malignant chronic or intractable pain or in the treatment of obesity." The board ordered Hunter not to prescribe any medications for weight control or weight reduction.

Now, Hunter is accused in a federal indictment in Baton Rouge of providing bogus prescriptions for home health care services that fueled an alleged illegal scheme that netted $14.9 million from Medicare.

Dr. Dahlia Kirkpatrick, 63, of LaPlace, remains licensed to practice medicine in Louisiana even though she is serving a 30-month prison term for providing unnecessary prescriptions to a medical equipment retailer who defrauded Medicare of $302,811. She pleaded guilty in October 2010 and was informed at sentencing that she and the retailer are jointly responsible for repayment of Medicare's loss.

Rita Arceneaux, the Board of Medical Examiners' executive assistant, said board officials could not talk about any physicians charged in the Medicare investigations, including those already convicted.

Operators of South Florida assisted-living facilities and halfway houses charged in one of the nation’s biggest Medicare fraud cases are rushing to plead guilty rather than face risky trials and long prison sentences.

Six defendants are now looking at shorter federal sentences because of their plea agreements.

And a seventh defendant, Joseph B. Williams, 41, who ran an assisted-living facility in Pompano Beach, plans to plead guilty next week to defrauding the taxpayer-funded Medicare program, court records show.

Those seven are among 10 residential operators and recruiters charged in September with supplying patients to Miami-based American Therapeutic Corp., whose owners pleaded guilty earlier this year. Lawrence Duran and Marianella Valera, are serving 50-year and 35-year prison sentences for running a racket to rip off $200 million from Medicare for purported therapy at their chain of seven mental health clinics in South Florida and Orlando.

Among their patient suppliers: Ramchand Ramrup, who ran an assisted-living facility in Palm Beach County with a recent history of state violations.

The article below illustrates why having excellent legal defense for Medicare and Healthcare Fraud is so important. If you have been accused of Medicare, Medicaid, or Healthcare Fraud, contact Robert Malove for a free consultation.

954-861-0384

From the Miami Herald, Nov 13, 2011

jweaver@MiamiHerald.com (BY JAY WEAVER AND MICHAEL SALLAH)

http://m.miamiherald.com/mh/db_42928/contentdetail.htm?contentguid=enIfTql7&full=true#display

A Miami couple sent to prison for decades could never have carried out one of the nation’s biggest healthcare scams without assisted-living facilities and halfway houses supplying them scads of residents covered by Medicare, authorities say.

Now, the Justice Department has charged 10 residential operators in a first-ever Medicare investigation into people who prosecutors say pocketed bribes for providing patients with substance abuse problems to mental-health clinics owned by Larry Duran and Marianella Valera.

Miami-based American Therapeutic Corp. — owned by Duran and partner Valera, who were recently sentenced to 50 and 35 years in prison, respectively — was at the center of an elaborate plot to fleece $200 million from the taxpayer-funded Medicare program.

Medicare paid American Therapeutic, with seven clinics in South Florida and Orlando, $83 million over the past decade for group-therapy sessions that could not have helped people with drug and alcohol addictions, Justice Department lawyers say. Patients with drug addictions received treatment for mental illnesses they didn’t have, such as bipolar disorder. In many other instances, no treatment was provided at all.

Last week, the controversy of ALF and halfway house operators suspected of taking kickbacks for Medicare patients dominated part of a state task force’s hearing in Miami-Dade County on abuse and neglect in the industry.

So far in the federal prosecution, four residential operators in the Fort Lauderdale area have pleaded guilty to healthcare fraud. Other defendants are expected to follow their example to avoid jury trials and potentially lengthy prison sentences, according to sources familiar with the case.

Those convicted in recent weeks: Natalie Maria Evans, Irene Trematerra, and Robert and Nikki Jenkins, who collectively ran seven halfway houses. Each operator was paid $15 to $30 daily for each patient they sent to American Therapeutic’s clinics, which submitted millions of dollars in false claims as a result, court records show.

The Medicare patients were pawns in the scheme, receiving little to no compensation, according to some patients interviewed by The Miami Herald.

Evans, who pleaded guilty to defrauding Medicare and faces up to 10 years in prison, was president of Vision of Hope Recovery. The company operated five halfway houses in Fort Lauderdale.

According to a statement filed with her plea, Evans admitted she “referred beneficiaries to [American Therapeutic] for mental health treatment solely on the basis of whether they were covered by Medicare and even though most of her residents were simply recovering drug addicts and/or alcoholics.”

To keep the racket going, a multimillion-dollar slush fund was tapped for bribes by American Therapeutic’s one-time marketing director, Margarita Acevedo, of West Kendall. Earlier this year, Acevedo became the first of 34 accused healthcare executives, psychiatrists, counselors, recruiters and residential operators to plead guilty in the American Therapeutic case.

The ongoing prosecution, investigated by the FBI and Health and Human Services’ Office of Inspector General, has yielded about 16 guilty pleas and one trial conviction of American Therapeutic executive Judith Negron.

As part of her plea deal, Acevedo cooperated with authorities and fingered a cast of patient recruiters and residential operators who fed hundreds of Medicare beneficiaries to American Therapeutic.

Acevedo, who kept a ledger of recruiters, patients and kickback payments, was assisted by another marketing executive for American Therapeutic, Joseph Valdes, who also pleaded guilty this year.

They collaborated with American Therapeutic’s two owners, Duran and Valera, to direct the recruitment of patients from ALF and halfway houses, according to Justice Department trial attorney Jennifer Saulino. The executives used a healthcare shell company, Medlink, to launder Medicare payments for the kickback payments, she said in court papers.

Of the 10 residential operators charged with healthcare fraud and kickback violations, one defendant has a particularly tarnished history as an ALF operator: Ramchand “Ramy” Ramrup.

Ramrup’s attorney, Bruce Lehr, declined to comment.

Ramrup ran one of the most troubled assisted-living facilities in Palm Beach County, records show. Since 2005, state inspectors have turned up nearly 100 violations at Boynton Beach Assisted Living Facility, including caretakers failing to give crucial medications to frail elders, misappropriating residents’ money, and failing to clean filthy and decrepit rooms.

In 2006, the home was warned when one of its residents turned up at a hospital covered in oozing bedsores, dirt and his own feces.

That same year, the state banned the facility from taking in new residents until it stopped repeating the same problems.

But in the ensuing five years, the home racked up dozens more violations, including sick and elderly residents roaming from the ALF and later being picked up by police.

Ramrup’s facility was hit four times with fines, including a $5,500 penalty in 2007, but inspectors continued to turn up the same violations every year.

This past week, the state task force held a hearing at Florida International University to address abuse and neglect in the ALF industry. As part of the debate, ALF owners and advocates for residents said the payment of kickbacks for Medicare patients was rampant — especially in South Florida — even though so-called patient brokering has been illegal in the state since 1996.

The task force was appointed by Gov. Rick Scott in May after a Miami Herald series, Neglected to Death, showed the state allowed dozens of facilities to stay open even after they had been caught abusing and neglecting residents, leading to scores of deaths.

The task force will recommend changes to the flawed ALF system for the upcoming Florida legislative session.

Accused of Health Care Fraud? Call Now- Free Consultation: 954-861-0384

MIAMI, FLORIDA (AUGUST 22, 2011) - Elizabet Lombera, 39, of Miami Lakes became the tenth person arrested in a large-scale scheme to defraud the Medicare system of more than $27 million.

Lombera controlled five durable medical equipment companies in Miami, but to conceal her involvement, she and fellow conspirators put nominee presidents in place. The companies: Mercy Medical Supply, Inc., JHH Group, Inc., La Numero 1 Farmacia Discount Corp., Yani's Pharmacy, Inc., and El Perimetro Farmacia Discount Corp, submitted fraudulent for more than $27 million and received $12,438,952 as reimbursement. Allegations levied against Lombera state she used the proceeds for personal gain, which included taking a trip to Japan.

LOUISVILLE, KENTUCKY (AUGUST 15, 2011) - Although their durable medical equipment company was based in Florida, Yunior Lopez, 34, of Miami, Florida and Arturo Esquivel, 39, of Hialeah, Florida, had a 13-count indictment leveled against them regarding their false billings to Medicare on behalf of Kentucky patients.

The defendants allegedly used two Kentucky doctors' names when submitting the false claims to Medicare for products never provided to the patients. Investigators found the defendants' two businesses, Universal of Work Services and Steel Quality Medical had none of the supplies they were claiming to have provided to patients.

If convicted, the defendants face a maximum sentence of 35 years imprisonment. Arraignment for both defendants is scheduled for August 23, 2011 before the U.S. Magistrate Judge in Louisville, Kentucky.

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

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

WASHINGTON D.C. (AUGUST 9, 2011) - The U.S. Department of Justice has announced it is intervening in a lawsuit filed under the qui tam provisions of the False Claims Act against Nurses' Registry and Home Health Corporation brought in the U.S. District Court for the Eastern District of Kentucky.

Under the qui tam provisions of the Act, individuals can initiate lawsuits on behalf of the United States and share in any monies received as the result of the suit. In this case, two former employees of Nurses' Registry, Alicia Robinson-Hill and David Price, accused the home health agency of exaggerating medical conditions and needs of patients in order to increase the dollar amount of claims presented to Medicare and making false claims to Medicare for unnecessary home health services.

The government has asked the court to allow 45 days in order to present its complaint against Nurses' Registry and Home Health Corporation.

DETROIT, MICHIGAN (AUGUST 5, 2011) - The United States Attorney's Office for the Eastern District of Michigan unsealed an indictment, which charges 26 individuals including 12 pharmacists, 4 doctors, an accountant and a psychologist in a massive scheme to defraud Medicare, Medicaid and private insurance companies.

The indictment, containing 34 counts, alleges that a Canton pharmacist, Babubhai Patel, owned and controlled 26 pharmacies throughout Michigan and that he hid his ownership and control by using "straw owners." It is alleged that Patel paid kickbacks, bribes and other incentives to doctors who would then write prescriptions for insured patients and direct those patients to one of Patel's pharmacies to get their medications. The medications were not medically necessary, and in some cases, never provided. Patient recruiters also paid kickbacks to patients participating in the scheme.

The indictment also contains allegations regarding the alleged illegal distribution of controlled substances, including Oxycontin, Vicodin, Xanax and cough syrup with codeine. Distribution of these drugs were part of the kickbacks paid to patients and recruiters for their cooperation.

MIAMI, FLORIDA (AUGUST 4, 2011) - A former convicted drug trafficker who served five years now stands accused of defrauding Medicare of more than $11 million through his Miami-Dade home health care agency. Luis Alejandro Sanz billed Medicare for treatment to supposed diabetics who did not suffer from the disease or need home care nurses to inject insulin.

Sanz and his wife, Elizabeth Acosta Sanz, are charged with conspiring to commit health care fraud and money laundering. The pair were also charged with paying kickbacks to recruiters who provided the couple's agency, Ideal Home Health, with Medicare patients. U.S. Magistrate Patrick White viewed their alleged crimes as so egregious that at their arraignment he denied the defendants' bids for bond stating they were a flight risk.

Investigators found evidence of 40 separate bank accounts through which the couple divided the millions they received from Medicare, and still have not been able to trace all the funds received.

CLEARWATER, FLORIDA (AUGUST 3, 2011) - The operator of a Clearwater pain clinic didn't know a doctor for whom she submitted $457,000 in Medicare claims had been banned from participating in the federally-funded insurance program, due to a prior felony conviction. Jayam Krishna Iyer had been accused of six counts of fraud and after a week-long trial was found not guilty.

The not guilty verdict does not, however, end Iyer's legal troubles. She's facing two more lawsuits in conjunction with a patient death from an accidental overdose. Court documents allege Iyer was negligent in prescribing medications, which ultimately led to the death of Theresa Ann Kincaid. Iyer's insurance company at the same time is seeking to void Iyer's malpractice insurance policy under the pretense that Iyer submitted her insurance application using false information.

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."

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

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

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

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

MIAMI, 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.

LAKEWOOD, WASHINGTON (JULY 25, 2011) - A Washington oncologist and his wife have been indicated on 20 counts of health care fraud, obstruction of justice and money laundering. Dr. Alfred Chan was additionally indicted on two counts of making false statements. Both defendants are scheduled to be arraigned on July 29 in U.S. District Court in Tacoma.

Dr. Chan and his wife, Judy Yuan Chan, allegedly billed Medicare and healthcare programs, both federal and private, for larger amounts of medications than the patients actually received. A whistleblower, a former employee of the Chans, first sued the couple using the qui tam provisions of the False Claims Act, which allows an individual to sue alleging fraud against the U.S. government.

Court documents allege that Dr. Chan would write the amount of medication to be given to a patient on a slip of paper and then pass it to his nurse. After the patient received the medication, the slip of paper was returned to the doctor for shredding. Chan allegedly then used a "Superbill" form and recorded a higher amount of medication than was actually given and more time spent giving the med, than was actually used. His wife prepared the bills and submitted them to Medicare.

Once the Chans realized they were being investigated, they attempted to hide their assets and failed to claim bank and brokerage accounts and properties owned on a financial disclosure form and allegedly transferred assets to keep them out of law enforcement's hands. These activities resulted in false statement, obstruction and money laundering charges.

DETROIT, MICHIGAN (JULY 22, 2011) - A Detroit patient recruiter, Arnaldo Rosario, received a 27-month prison term with three years of supervised release in a sentence handed down by U.S. District Judge Gerald E. Rosen. Additionally, Rosario, along with other defendants, must repay $10,765,325 to the U.S. government as restitution for their fraudulent billing of Medicare.

Back in August 2009, Rosario pleaded guilty to one count of conspiracy to commit health care fraud as a result of a fraudulent billing and kickback scheme involving Sacred Hope Medical Center, Dearborn Medical Rehabilitation Center and Xpress Center. Rosario paid kickbacks to Medicare beneficiaries who would sign false claims stating they had received services, when in fact they had not. Rosario collected the kickback cash on a daily basis from his co-conspirators in order to pay the beneficiaries for their cooperation. Every new patient brought into the scheme garnered the co-conspirator an additional cash bonus. Between March 2006 and March 2007, Rosario and his co-conspirators billed $15.3 to Medicare and received approximately $10,765,325.

MIAMI, FLORIDA (JULY 21, 2011) - A manager of a Miami health care agency, Lisandra Alonso, and a registered nurse, Luisa Morciego, pled guilty to one count of conspiracy of commit health care fraud before U.S. District Judge Joan A. Lenard.

Alonso managed and recruited patients for ABC Home Health Care, and Morciego was a nurse for ABC and Florida Home Health Care Providers. Both companies served as home health care agencies, also providing physical therapy services to Medicare beneficiaries.

Court documents alleged that ABC and Florida Home Health billed Medicare for pricey therapy and home health services that were medically unnecessary or that were never provided. Also participating, and subsequently indicted, in the scheme were physicians, Jose Nunez and Franciso Gonzalez who wrote prescriptions for medically unnecessary services.

Alonso instructed ABC owners and operators on the specifics of a fraudulent home health agency, including the roles of recruiters, doctors, beneficiaries, kickbacks and Medicare billing. Alonso also instructed nurses on how to falsify patient files in order for them to qualify for home health and therapy services through the use of specific terminology to describe non-existent assessment findings in their nursing notes. Alonso then took kickbacks from the nurses at ABC once they were assigned a patient at ABC.

Alonso's scam resulted in Medicare billings of approximately $17 million. Morciego's participation in the scheme using falsified nursing notes, netted Medicare billings of more than $296,000. Sentencing for Morceigo is scheduled for December 5, 2011; Alonso's is scheduled for October 3, 2011.

WASHINGTON D.C. (July 20, 2011) - The U.S. Departments of Justice and Health and Human Services are taking closer looks at Medicare reimbursements for motorized scooters. Given that more than 60% of the mobility aides were provided to people who did not qualify for them, the crackdown has begun.

Investigators uncovered that the average bill to Medicare for a motorized wheelchair, or scooter as they are sometimes called, is $4,018, but the device costs only $1,048 outright.

Scammers often target communities where English is not the first language, and Medicare beneficiaries may not realize that their billing info is being used to perpetrate Medicare fraud. Often the patient will turn over their information and either never receive a wheelchair or receive one worth thousands less. Unfortunately this scam can have long-lasting implications for the beneficiary. Should they later legitimately need a wheelchair, Medicare will consider only that they have already received one and will not pay for a second.

BALTIMORE, MARYLAND (JULY 19, 2011) - Larry Bernhard who ran a home-based podiatry business plead guilty to aggravated identify theft and health care fraud in his scheme to bill Medicare for $1.1 million in false claims.

Bernhard ran the Chesapeake Wound Care Center from his home and submitted 80 claims for Medicare reimbursement for services he claimed to have provided at skilled nursing facilities. The patients were, in fact, in the hospital at the time he stated the services were provided. Bernhard admitted that he had submitted false claims for services from April 1, 2002 through October 11, 2004. As part of the settlement agreement entered into on October 30, 2007 for those claims, Bernhard was excluded from billing "Medicare, Medicaid and all other federal health care programs" for three years.

Bernhard, however, continued to bill Medicare Advantage plans from October 31, 2007 to July 20, 2010, for which he received $1.1 million. Through the use of personal identity information of 200 patients at various long term care facilities, Bernhard submitted false bills for services he never performed.

As a result of his continued defrauding of the Medicare system, Bernhard faces a maximum penalty of 10 years in prison and a mandatory two-year prison term. Bernhard agreed to repay $1,122.992.08 as restitution.

NEWARK, NEW JERSEY (JULY 18, 2011) - A Franklin Park man who owned Pro Medical Equipment Supply, a provider of durable medical equipment (DME), was indicted on one count of health care fraud and one count of making false statements in false claims to Medicare.

Augustus Ejere, 50, allegedly submitted false claims to Medicare for wheelchair accessories and never provided those accessories to beneficiaries. Additionally, ProMed didn't even carry the accessories in their stock, but Ejere instructed ProMed staff to bill for items such as joysticks and batteries which were not supplied to ProMed customers until May 2010.

Ejere could face a maximum penalty of 10 years on the court of health care fraud and five years on the false statement count; each count also carries a possible fine of $250,000.

CARBONDALE, PENNSYLVANIA (JULY 15, 2011) - A physician indicated on health care fraud and false statements in health care matters has lost his ability to receive reimbursement from all federal health care programs, including Medicare and Medicaid, for a period of five years. The penalty may severely limit Dr. Gregory Salko's ability to receive payment for services rendered.

In 2005 and 2006, Salko treated two elderly Medicare participants and falsified their medical records in order to receive reimbursement. In June 2009, the defendant pled guilty and admitted he'd made false representations in a patient's progress note, while at the same time, he also committed a HIPAA Privacy Act violation (a federal offense) by falsely representing that he had authorization to obtain copies of a patient's medical records from another facility.

In October 2009, Salko was sentenced by U.S. District Court Judge A. Richard Caputo to two-years probation, 100 hours of community service and a $20,000 fine.

SOUTH FLORIDA (JULY 14, 2011) - Just when law enforcement was getting a handle on the pill mills that proliferate the Florida healthcare market, a new wave of fraudulent therapy claims have picked up where the pill mill scammers left off.

As federal agents have cracked down on Florida's pill mills and confiscated drugs from bogus pain clinics, Medicare schemers have had to devise a new plan to continue to bilk the federal health insurance plan out of the millions that fraudulent claims earn them each year. Criminals have turned their attention to Florida's mental health and rehabilitation clinics. Last year, Florida outshone both Texas and Michigan in Medicare mental health claims with a whopping $421 million. Florida's led New York and California with its rehab clinics billing more than $310 million for physical and speech therapy. Some of those claims are legitimate, but officials believe Florida's claims shouldn't dwarf those of the larger states.

Historically Medicare has paid claims quickly without verifying their validity. With recent new legislation and a new national computerized database, federal and state law enforcement expect a slowdown in the number of fraudulent claims. As Florida is the primary hotbed of Medicare fraud, this Friday, July 15 it will host the country's first healthcare fraud summit in Miami with Attorney General Eric Holder and the Secretary of Health and Human Services, Katheleen Sebelius.

WASHINGTON D.C. (JULY 13, 2011) - In an effort to prevent billions lost each year in fraudulent Medicare claims, a nationwide computer system for tracking claims was launched in South Florida. The system is designed to examine the millions of daily claims for reimbursement using "predictive modeling," which can identify suspected hot beds of suspicious activity throughout the country.

To avoid detection, business owners who intend to defraud the Medicare system will often move their business to other areas of the country and begin working the same scam in the new locale. In June, law enforcement charged 21 alleged fraudsters in a $23 million scam; 15 of which were from Michigan, the other six from Florida. Strike force investigators have located Medicare criminal fraud networks extending from Miami to Detroit and Houston to Los Angeles. Since March 2007, strike force investigators have identified that $1.85 billion in fraudulent claims originated in South Florida, which represented the largest portion of the total $2.3 billion nationwide. Officials estimate that Medicare fraud could total as much as $60 billion per year.

In the past, Medicare reimbursements paid first and then examined the claims for discrepancies, which investigators dubbed "pay and chase." The new system will screen and analyze claims first before payouts are made. If any healthcare providers are found to be submitting suspicious claims, they will first be excluded from participating in the Medicare system and then turned over to law enforcement.

CHICAGO, ILLINOIS (JULY 12, 2011) - Jacinto "John" Gabriel, Jr. was indicted on charges of two counts of wire fraud, two counts of health care fraud and 11 counts of money laundering by a federal grand jury. The defendant has been free on bond since preliminary charges were filed in February; an arraignment date has not been set.

Gabriel owned and operated the now defunct Perpetual Home Health, Inc. in Oak Forest and Legacy Home Healthcare Services on the city's north side. The defendant had no formal medical training, no medical degrees and no licenses to practice as a health care professional. Still, Perpetual submitted 14,000 Medicare claims for services provided to Medicare beneficiaries. Those claims netted Perpetual $38 million. Legacy submitted approximately 2,000 claims and received more than $5 million.

Gabriel and his co-conspirators allegedly used personal information of Medicare beneficiaries, without their knowledge and consent, to create false patient files and submit false claims. Using the false records, Gabriel instructed employees to complete forms using false diagnoses, some of which included higher reimbursed medical conditions. After the alleged schemers pocketed their share, the proceeds from the fraud were used to pay employees and others helping to perpetuate the scheme.

MIAMI, FLORIDA (JULY 11, 2011) - Dr. Alan Gumer, 64, of Tamarac, Florida said "it was the right thing to do," when asked by U.S. District Judge Patricia Seitz why he decided to plead guilty. Gumer was charged with one count of conspiracy to commit health care fraud and four counts of health care fraud.

Gumer was a psychiatrist with American Therapeutic Corporation, a Miami-based corporation with seven locations in South Florida and Orlando. Dr. Gumer admitted he signed evaluations and other documents for unnecessary mental illness treatment, and he did so without examining the patients or reading what he was signing. Gumer also admitted to signing prescriptions for patients that did not need the medications, to simply show Medicare that the patients qualified for an intensive form of treatment. As a result of Gumer's actions, ATC netted approximately $19.3 million.

Gumer will be sentenced in January 2012 and faces a maximum of 10 years and a $250,000 fine.

MIAMI, FLORIDA (JULY 8, 2011) - Rolando Cueto, one of the nation's most wanted individuals in connection with health care fraud was captured at Miami airport late last week when he returned to the U.S. Cueto was indicted in 2008, but had been hiding out in Costa Rica under an assumed name.

Cueto's former durable medical equipment company, E.O. Medical Enterprises of Hialeah, submitted $1.9 million in false claims to Medicare. The company, however, never provided the equipment to patients, nor was the equipment ever ordered by doctors. Cueto and another defendant, Juan Carlos Garcia were indicted on fraud charges in September 2008. Cueto was able to elude authorities and flee the country. Garcia pled guilty to a charge of conspiracy to commit health care fraud and is now serving a 2.5 year sentence.

MIAMI, FLORIDA (July 7, 2011) - U.S. District Judge Joan Lenard brought the hammer down on Dr. Rene de los Rios, a physician convicted of Medicare fraud, when she sentenced the doctor to 20 years in prison. Judge Lenard expressed outrage at the defendant's behavior and "blatent lying" during his testimony at trial.

de los Rios, although with others, were part of a Medicare fraud team that sought to bilk the federal fund of millions by submitting claims of $119 million for which they were received $84 million. The other defendants fled to the Dominican Republic and went on to Cuba where it is believed they are in jail for charges unrelated to the Medicare fraud.

The doctor's attorney, tried to no avail to argue that his 72-year old client is ill with diabetes and a heart condition and requested the sentence be lowered to seven years. Justice Department trial attorney Joseph Beemsterboer argued for a 30-year sentence using the fact that authorities have been unable to locate $1.2 million that the doctor received. The sentence is among the stiffest ever received by a physician convicted of fraud

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.

BUCKHEAD, GEORGIA - Dr. Lawrence Eppelbaum, 52, asserts "I will win 100 percent" against the U.S. Department of Justice's claims the doctor defrauded both Medicare and the IRS using a bogus non-profit organization to provide kickbacks to patients, fund an area Jewish day school and file false charitable deduction claims to avoid federal tax debt. The Justice Department says he also filed claims for unnecessary treatments.

An Eppelbaum patient has also filed suit claiming the doctor violated federal laws with prohibited incentives to lure patients, such as free travel, meals and entertainment, including trips to hot springs for treatment. The attorney for the client, Marlon Wilbanks, states that Eppelbaum targeted Russian-speaking U.S. residents with known back pain issues. To the non-English speaking patients, free is a wonderful opportunity. Wilbanks calls it a "fairy tale trip."

Eppelbaum was also indicted on tax evasion and abuse of charitable organizations, which doesn't simply cheat the IRS, but also the rest of the American taxpayers, says Reginael McDaniel, special agent in charge of the Atlanta Region IRS criminal investigations. The indictment alleges that Eppelbaum set up a non-profit organization, the Back Pain Fund, and arranged with the Torah Jewish Day School in Atlanta for parents to pay their children's tuition to the fund as a "donation." Eppelbaum would then donate the full amount of the tuition back to the school, plus 25 percent. A school spokesperson denies the school knew of any wrongdoing.

It also seems Eppelbaum entered similar arrangements with other organizations and encouraged patients to pay their co-pays to the Back Pain Fund in exchange for a charitable contrition receipt that they could use on their taxes. Eppelbaum states he has no idea why he was indicted and believes himself to be the victim in the case; "because we're a successful practice, and I'm a successful rich guy."

BROOKLYN, NEW YORK - The U.S. Department of Justice announced three guilty pleas in the case of the Solstice Wellness Center Medicare fraud scheme. Dmitry Shteyman, Aleksey Shteyman and Maxsim Shvedkin entered the guilty pleas, each to one count of conspiracy to commit health care fraud, before U.S. Magistrate Judge Steven M. Gold.

The three defendants concocted a scheme to pay kickbacks to Medicare beneficiaries to coax the beneficiaries into visiting Solstice. The defendants even arranged transport to and from Solstice in order for the patients to receive therapy, diagnostic tests and physicians' services; the three admitted they had billed Medicare for $3.4 in services and tests that were not medical necessities, or in some instances, not performed.

Sentencing for Dmitry Shteyman is set for October 20, 2011. Dates for the other defendants have not been scheduled. Other individuals also pleading guilty for their role in the scheme: Sara Kalantarov, an employee of Solstice and Yefim Drakhler, a Medicare beneficiary. Others charged in the scheme: Ilya Gershkovich, Evgeny Gil, Yefim Kornfeld, Valentina Mushinskaya, Shelya Pinskaya and Vladimir Rubin; trial for these individuals is set to begin October 2011.

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.

MIAMI, FLORIDA (JUNE 28, 2011) - Dr. Rene de los Rios was sentenced Monday to nearly 20 years in prison for Medicare fraud. The doctor's defense team had tried a plea bargain of seven years, but U.S. District Judge Joan Lenard quickly rejected the deal. The doctor hoped for a shorter sentence due to his age (72), heart condition and diabetes.

Sentencing came following a conviction in April of conspiracy to commit health care fraud and submission of false claims to Medicare for a total of $46 million in fraudulent claims from an HIV infusion therapy clinic. Dr. de los Rios was able to write phony prescriptions by falsifying hundreds of patient records, and some patients even received kickbacks. Judge Lenard showed her disdain for the doctor by chastising him for his fraudulent activities and stating "Dr. de los Rios does not deserve the title of doctor anymore."

ST. CLAIR COUNTY, ILLINOIS - John M. Hardimon, 41, dba Hardimon Chiropractic Clinic was sentenced to 70 months imprisonment after pleading guilty to 14 counts of health care fraud and one count of money laundering. Hardimon's sentence included payment of restitution of $1.9 million to 14 separate medical insurers, including Medicare, Medicaid, Blue Cross Blue Shield and other union welfare funds.

Also confiscated were several of Hardimon's vehicles, including a BMW convertible, a Toyota Sierra Minivan and a Chrysler Town and Country Minivan and two residences in Shiloh, Illinois. Also seized was $714,641.13 to repay Medicaid and Medicare funds. Hardimon admitted to keeping almost no financial records and creating fake documentation to bill the insurance companies.

ORLANDO, FLORIDA - The U.S. Department of Justice announced that Alberto Laborde, 48, of Miami, was sentenced to six years and nine months in prison for conspiring to commit health care fraud and committing aggravated identity theft. His sentencing included repayment of the proceeds he received from Medicare, which amount to more than $3 million.

Laborde owned three separate shell companies, which billed Medicare for medical equipment in excess of $8.3 million. The equipment was not prescribed by a doctor as is required, nor did the Medicare beneficiary ever receive the equipment. Laborde used Medicare beneficiaries and medical doctors' names and identification numbers.

Laborde used nominee owners of the shell companies in order to hide his identity. Duniesky Hurtado, 28, also of Miami, was one of those owner nominees and received a 37-month prison sentence for conspiracy to commit health care fraud.

TAMPA, FLORIDA - Angel Gonzalez and Adrian Chalarca, both of Miami pled guilty each to one count of conspiracy to commit health care fraud, before U.S. Magistrate Judge Mark Pizzo in Tampa, Florida. From 2009 to 2010, the defendants submitted claims to Medicare for more than $757,000 on behalf of their company, Dynamic Therapy Inc.

Gonzalez as owner and vice president and Chalarca as president and administrator of Dynamic bought the company from the previous owners and began running it as a fraudulent business. The defendants paid kickbacks and bribes to Medicare beneficiaries in exchange for their billing information to submit claims for physical therapy services that were never provided. In addition, Gonzalez and other co-conspirators stole the identity of a physical therapist and other Medicare beneficiaries to submit more false claims. Gonzalez and Chalarca admitted that therapy services were never provided.

Additionally, Andres Cespedes, another vice president, pled guilty in May for his part in the scheme. When sentenced, Gonzalez and Chalarca could face a maximum penalty of 10 years in prison and a $250,000 fine. No sentencing date has been set.

ATLANTA, GA - Dr. Robert Williams of Atlanta, pled guilty on two counts of health care fraud in billing Medicare and Medicaid for $2 million in group psychological therapy to deceased patients. Originally indicted on 10 counts of fraud, the doctor admitted to two.

From July 2007 through October 2009, Williams submitted over 55,000 claims for $2 million to Medicare for group psychological therapy at nursing homes scattered throughout the Atlanta area. Medicare reimbursed $750,000. During the same time period, Williams submitted more than 40,000 Medicaid claims, in which Georgia Medicaid paid out more than $225,000. Investigators uncovered that many of the beneficiaries of services were actually deceased at the time the claims were made. Claims were also made during times when other beneficiaries were hospitalized and could not have received any care at the nursing home sites.

Williams could receive a maximum sentence of ten years and fined up to $250,000 for each count. Sentencing is scheduled for August 23, 2011 in U.S. District Court.

WASHINGTON D.C. - The U.S. Departments of Justice and Health and Human Services announced that Reynel Betancourt, 51, of Miami, Florida was sentenced to 77 months in prison for his part in a scheme to defraud Medicare of $9 million. Following the prison term, Betancourt will be subject to three years supervised release. He was ordered to pay $6 million in restitution.

While living in Michigan, Betancourt recruited patients for Dearborn Medical Rehabilitation Center, a clinic providing infusion and injection therapies to Medicare patients. Betancourt admitted he asked patients to sign paperwork documenting that they had received injections and medications which they had not received.

Betancourt's indictment originated in the Eastern District of Michigan, but after his arrest in Miami, the defendant agreed to a transfer of the case to the Southern District of Florida for his plea and sentencing. Betancourt pled guilty to one count of conspiracy to commit health care fraud and one count of money laundering.

MIAMI, FLORIDA - A man charged with submitting false claims to Medicare for more than $2.5 million was apprehended at Miami International Airport after being on the lam since late last year. Luis Perez Moreira had been living in Cancun, Mexico.

Law enforcement authorities discovered the Moreira's durable medical equipment company, Rx Plus Medical Care submitted false claims to Medicare for $2.5 million from August 2008 to April 2009. Details of the indictment show that Medicare paid approximately $383,000 to the business. In order for Perez to perpetrate the fraud and go undetected himself, he and a business partner arranged for a "nominee owner" to put the business in his name, open bank accounts and sign blank checks to Perez.

Perez is charged with conspiracy to commit health care fraud and health care fraud.

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.

NASHVILLE, TENNESSEE - Renal Care Group and Fresenius thought they were done with the long-running whistle-blower case when the judge handed down a ruling stating Fresenius, who owns Renal Care, owed the government restitution in the amount of $19.3 million. But then a few more facts came to light. U.S. District Court Judge William J. Haynes Jr. reevaluated his previous ruling and handed down a new one.... to the tune of $86.2 million.

Before Fresenius bought Renal Care, a dialysis treatment center, Renal Care submitted fraudulent claims to Medicare for a higher tier of reimbursements than it was allowed. From 1999 to 2005, Renal Care filed claims for at-home equipment at the higher level while operating dialysis centers, but that reimbursement level is not available to companies who do both.

After Fresenius bought Renal Care and was later sued, Fresenius asserted that Medicare knew of the dialysis company's structure and still paid claims. Jane Kramer, Fresenius spokesperson stated that Fresenius had received word from the Department of Health and Human Services that the billing practices used by Renal Care were in accordance with Medicare's rules.

Kramer stated Fresenius will appeal the ruling to the 6th U.S. Circuit Court of Appeals and request a jury trial. "We are confident that, after a full jury trial with testimony and evidence, no liability will be imposed," Kramer stated.

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.

HOUSTON, TX - Taking advantage of a tragic situation, a Houston federal jury returned a verdict finding a patient recruiter guilty of health care fraud. Marion Beverly Metoyer was convicted of one count of conspiracy to commit health care fraud, three counts of health care fraud, one count of conspiring to receive illegal kickbacks for referring Medicare beneficiaries and two counts of receiving illegal kickbacks for those referrals.

According to the Indictment, Helen Etinfoh owned and operated Luant & Odera, Inc., a supplier of durable medical equipment, doing business as Tonni Medical Equipment & Supplies. Metoyer recruited patients for Luant and received kickbacks when she provided the company with Medicare beneficiaries who could be billed for services rendered.

Etinfoh, along with other co-conspirators, falsely billed Medicare for wheelchairs, wheelchair accessories and power scooters. Based on Metoyer's and other's representations to the company, Luant falsely billed Medicare using a special code designating that the power wheelchairs were replacements for wheelchairs lost during the 2008 hurricanes that Houston suffered.

Some Medicare beneficiaries testified that they had never even had a power wheelchair before Luant provided them with one. Hurricane damage claims for durable medical equipment can be made to Medicare without a doctor's order. Beneficiaries further testified that Metoyer and others offered them free power wheelchairs in exchange for their Medicare information.

This is not Etinfoh's first brush with health care fraud. In April 2010, she was convicted by a federal jury and sentenced to 41 months in prison. Other patient recruiters of Luant, including Paula Whitfield, Melvin Barnes, Johnnie Lee Andrews and Monica Rene Perry, also have several convictions of health care fraud.

Metoyer's convictions could result in a total of 30 years in prison. A sentencing date has not been set.

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.

WASHINGTON, D.C. - Two related sleep medicine and durable health equipment companies have agreed to repay the United States $650,000 in false claims made to Medicare. The companies, Areté Sleep Therapy LLC and Areté Holdings LLC, with facilities in Arizona and Texas, billed the claims as part of sleep diagnostic studies performed by technicians who did not hold the proper licensure or certification according to Medicare policies. The amount to be reimbursed also includes claims made for provision of durable medical equipment as a result of those tests.

In January 2011, Areté filed for Chapter 11 in the U.S. Bankruptcy Court and agreed to pay the False Claims Act settlement from monies received following the sale of its assets. The allegations came as a result of a whistleblower lawsuit, and as a result, the person reporting the fraud will receive a portion of monies repaid, which in this case total $107,250.

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.

Fort Pierce, FL - Homero Izquierdo Ruiz could have been imprisoned for a maximum of 10 years for violating Title 18, Section 1347 of the United States Code. Instead, he was sentenced to serve two 39-month incarceration terms (which will run concurrently) on two counts of health care fraud. At the conclusion of his imprisonment, Ruiz will also have three years of supervised release. As restitution, Mr. Ruiz will also pay more than $1,000,000 to Medicare. Click here to read the official court judgment.

Stipulations of Fact in the Guilty Plea

According to the Criminal Complaint filed in US District Court for the Southern District of Florida, Fort Pierce Division, after purchasing Physical Therapy and Fitness in Martin County, Homero Izquierdo Ruiz, 46, of Miami, initiated fraudulent billing practices. The physical therapy practice received reimbursement for its rehabilitation services from Medicare Part A. In eight months from January to August 2010, the practice netted more than $500,000 in reimbursements from Medicare.

Additionally, Ruiz also bought Ebenezer Medical Services, Inc., in Miami Dade, which at one time operated as a pharmacy and received reimbursements from Medicare Part D as prescription drug coverage. When Ruiz purchased Ebenezer in May 2010, it was no longer operating as a pharmacy. Records from Medicare demonstrate that Ebenezer received more than $587,000 during the period of May 14, 2010 to August 13, 2010. Further, 16 doctors attest that Ebenezer filed false claims using their names and National Provider Identification numbers. Four other Medicare beneficiaries also filed complaints that bills listed prescription drugs that they never received.

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 targeting healthcare 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.

BROOKLYN, NEW YORK - A New York therapist pled guilty to five counts of Medicare fraud for submitting false claims for physical therapy services that were either unnecessary or never performed. The Justice Department indicted Aleksandr Kharkover on charges with billing Medicare for $11.9 million in services from January 2005 to July 2010; received $7.3 million in Medicare reimbursements.

The Wall Street Journal played a part in the investigation stemming from a December 2010 profile it ran on Kharkover after mining the Medicare claims database. The Journal suspected financial abuse after discovery that Kharkover billed far more than the norm. Another allegation states that he billed for services performed during the time period in which he was actually away on vacation. Click here to read the December 2010 WSJ article.

According to Mr. Kharkover's lawyer, there was no plea deal; his client simply "pled guilty to all charges listed in the indictment," according to the Journal.

Mr. Kharkover is currently awaiting sentencing.

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 targeting healthcare 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.

Continue reading "BROOKLYN THERAPIST PLEADS GUILTY TO MEDICARE FRAUD" »

WASHINGTON D.C. - Peter Budetti, Washington's watchdog for Medicare and Medicaid fraud warns would-be program fraudsters that he's cracking down and plans to use technology and a new long-range, far-reaching strategy to do it.

The FBI estimates figures in the double- to possible triple-digit billions are lost annually to healthcare fraud, and the State of Florida, due to its high elderly population, leads the country in Medicare scams. Medicare fraud isn't limited to criminal practices by healthcare professionals, including nurses, doctors and pharmacists, but also business owners, Medicare beneficiaries, drug dealers and even organized crime groups defraud the fund.

The Crackdown

New applications to become Medicare healthcare providers will be subject to tighter screening, including fingerprinting and criminal background checks by the FBI, if the applicant demonstrates a high-risk potential. Budetti feels a new computer payment system, complete with new software and payment algorithms, will leave the Medicare/Medicaid programs far less open to fraudulent practices. Built into this new system is the capability of immediately suspending payments to providers when fraud allegations prove to be credible.

Budetti believes that smarter computers can outwit the would-be frauders of Medicare and Medicaid thereby saving the American taxpayers and the U.S. government billions of dollars per year.

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 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.

MONROE, MICHIGAN - Dr. Oscar Linares's DEA registration was suspended for illegally distributing millions of doses of Schedule II and III narcotics and for fraudulently billing Medicare for $5.7 million. Dr. Linares faces up to 20 years in prison and a $1 million fine and was arrested at his office in Monroe, Michigan following a search of the premises. Law enforcement also seized several of the physician's assets, including four bank accounts, two watercraft and seven luxury vehicles.

Dr. Linares allegedly prescribed narcotics for approximately 250 patients per day and even paid employee bonuses anytime he had more than 200 patient appointments in a single day. The Complaint alleges misconduct based on patient accounts, employee interviews and patient visits by undercover operatives. Reportedly, Dr. Linares viewed his actions as that of a man "building an empire."

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 pill mill and 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.

DETROIT, MI (May 6, 2011) - Two owners of a Dearborn HIV-infusion clinic were convicted of conspiracy to commit health care fraud, conspiracy to pay health care kickbacks, health care fraud and conspiracy to commit money laundering. Leonio Alayone, the person who helped them launder their financial gains, was convicted of conspiracy to commit money laundering and money laundering.

According to the superseding indictment, the two owners and brothers, Martin and Joaquin Tasis, paid kickbacks to patients when the brothers used the patients' Medicare accounts to bill for services never performed. Evidence showed that the Dearborn Rehabilitation and Medical Center was specifically established for the purpose of defrauding Medicare. From 2005 to 2007, Medicare was billed $9.1 million by the clinic for medically unnecessary treatments or services that were never performed.

Initially, the clinic was located in South Florida. The brothers later moved the clinic to Michigan when law enforcement became suspicious of possible fraudulent practices. So far 12 individuals involved in the case have been convicted for their part in the fraud; two others are awaiting trial.

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 HIV infusion defense 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.

MIAMI, FLORIDA (May 3, 20100) - American Therapeutic Corporation and Medlink Professional Management Group have closed their doors following guilty pleas in a $200 million Medicare fraud case. The companies could face $80 million in penalties. Both have had their assets frozen.

The companies' owners also admitted guilt to health care fraud conspiracy, illegal health care kickbacks and money laundering crimes. The perpetrators used Medicare sleep studies claims as the avenue for the fraud and falsified patient files to quality for payments.

In addition, assisted living facilities' and half-way houses' personnel, as well as patient brokers sent the company patients that were ineligible to receive Medicare reimbursement for the studies. A few patients also received kickbacks for their participation.

Sentencing for the two corporations is scheduled for this coming July, and the companies face maximum penalties of $80 million.

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 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.

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.

MIAMI, FL - Federal agents took to the streets early this morning arrested and more than 30 suspects charged with Medicare fraud as part of a nationwide operation authorities are describing as the largest healthcare fraud take-down to date.

This morning’s arrests in Miami arrests coincided with other arrests in New York, Los Angeles and Detroit. In Miami, 32 defendants, including 2 doctors and 8 nurses, were charged for their participation in various fraud schemes involving a total of $55 million in false billings for home health care, durable medical equipment and prescription drugs.

Federal authorities charged more than 100 doctors, nurses and physical therapists in nine cities with Medicare fraud Thursday, part of a massive nationwide bust that snared more suspects than any other in history. Click here to watch ABC News anchor Diane Sawyer report on this historic bust.

More than 700 law enforcement agents fanned out to arrest 111 people accused of illegally billing Medicare more than $225 million. The arrests are the latest in a string of major busts in the past two years as authorities have struggled to pare the fraud that's believed to cost the government between $60 billion and $90 billion each year. Stopping Medicare's budget from hemorrhaging that money will be key to paying for President Barack Obama's health care overhaul.

To watch Attorney General Eric Holder's press conference, click here.

Although the Indictments remain sealed, the defendants are charged with typical healthcare fraud schemes du jour, including physical therapy, mental health and home healthcare.

The defendants are accused of submitting false claims in excess of millions of dollars in to Medicare, the federal program for the elderly and disabled.

Health and Human Services (HHS) Secretary Kathleen Sebelius and Attorney General Eric Holder partnered in 2009 to allocate more money and manpower in fraud hot spots. Thursday's indictments were for suspects in Miami, Florida; Los Angeles, California; Dallas and Houston, Texas; Detroit, Michigan; Chicago, Illinois; Brooklyn, New York; Tampa, Florida, and Baton Rouge, Louisiana. To read more about HEAT, Health Care Fraud Prevention and Enforcement Action Team, click here.

Ms. Sebelius has promised more decisive action on the front end, by vigorously screening providers and stopping payment to suspicious ones, under greater authority granted by the Affordable Care Act. Also announced today was the addition of Healthcare Fraud strike forces in Chicago and Dallas.

“Over the last two years our joint efforts have more than quadrupled the number of anti-fraud Strike Force teams operating in fraud hot spots around the country from two to nine -- with the latest additions Chicago and Dallas -- bringing hundreds of charges against criminals who had billed Medicare for hundreds of millions of dollars. Last year alone, our partnership recovered a record $4 billion on behalf of taxpayers. From 2008-2010, every dollar the Federal Government spent under its Health Care Fraud and Abuse Control programs averaged a return on investment of $6.80,” said HHS Secretary Sebelius.

When it comes to serious healthcare fraud defense, call Robert Malove. He wrote the book. If you or someone you know has been accused of committing healthcare fraud anywhere in the U.S., call Attorney Robert Malove.

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

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

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

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

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

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

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

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

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

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

As 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.

Alex Carrazana was a Medical Assistant. He is currently serving 72 months in prison for Medicare Fraud. He was for a time employed by a clinic called Midway Medical. At that clinic his job was to help with the infusion of drugs to HIV patients for therapy for a condition called thrombocytopenia, a bleeding disorder. He was not an owner, operator or licensed health care professional. Nearly everyone connected to the alleged conspiracy and probably even the government would concede he was not a major participant in the crimes (by way of disclosure, we represented other parties in this matter).

According to the government and the plea proffers of the co-defendants who were physicians, physicians assistant and owner of Midway, the clinic billed Medicare for approximately $8,000,000 in false claims. The claims were for infusion of a drug, RhoGAM, which in many instances was not provided. It was somewhat fortunate the drug wasn’t provided because the blood tests, detailing the need for the infusion therapy, had false data because the blood of the patients was altered by a person hired by the owner to mix the blood to generate false results.

There were apparently some facts that indicated Mr. Carrazana was aware fraud was going on and at a certain point he quit, according to his lawyer because he discovered what was going on and wanted out. Rather than pleading guilty with a plea agreement as most of the co-defendants did, he plead openly to the court because he and his lawyer disagreed with the facts the prosecutors would have required him to agree to as well as several sentencing guidelines adjustments; and he would have given up his right to an appeal.

By pleading guilty without a plea agreement, he and his lawyer could challenge at sentencing and on appeal everything from the amount of loss alleged down to his role in the clinic and the conspiracy. They did exactly this, and it did not turn out well - he unfortunately received a higher sentence than some of the other co-defendants. He appealed and the United States District Court for the 11th Circuit rejected all of his arguments and upheld his sentence. (To read the opinion, click: here).

The court found that leaving a conspiracy is not enough to cut off responsibility for the acts of co-conspirators after he left, therefore he was responsible for the full $8 million dollars in fraud. In addition, even though Mr. Carrazana did nothing sophisticated himself to aid in the commission of the crime and may have been unaware of the blood mixing, the court held that he should have known that his co-defendants would do something by sophisticated means, so he was also responsible for their acts in that sense.

To read more, click: here.

In the 1990’s there was a system in place that seemed reasonable at the time. The government hired private companies to audit hospital cost reports on the government’s behalf and to add additional incentive, those companies, generally large insurance companies, would receive bonuses based upon funds recovered. This lead to a sort of system where there were "gotcha" games between the auditors and providers, the providers would try and maximize their reimbursement knowing that the auditors would be specifically looking for places to cut.

Making matters worse, the auditors tended to ignore “errors” that benefited the providers because those errors didn’t benefit the government contractors. So too, the providers, in analyzing and contesting the audits through the appeals process would only report “errors” that benefited the providers. This system eventually led to the prosecution of a number of hospital executives as well as one of the largest whistleblower cases ever. (Click here to read more about John W. Schilling and the case against HCA/Columbia) The government ended that incentive program in part because of the gaming of the system it produced.

Well, it is back again. The government has contractors, called recovery audit contractors, or RACs that receive between 9-12% of overpayment funds they recover on behalf of the government on Medicare audits. In just three years, they have reportedly collected over $1 billion dollars. The only problem, except that the last time it produced somewhat unseemly results, is that these contractors are required to report to law enforcement instances of criminal fraud as opposed to billing errors or overpayment.

To date, only two cases have been referred to for criminal prosecution. The motive, you might suspect, is financial. The RACs don’t get any money for cases referred for criminal prosecution, only for their own recoveries. This suggests that the RACs are erring on the side of overpayment as opposed to fraud, which still benefits the government as well as the RAC and the provider; no harm, no foul. However, the implicit or explicit threat of criminal referral may be an interesting bargaining tool to make these recoveries. Another interesting twist is that the RACs can go back and audit the same providers over and over again, collecting on overpayments (not fraud) no matter how many times the provider makes the same errors.

To read more, click here.

If a provider discovers that it may have submitted false claims to Medicare or Medicaid, either through errors or through the malfeasance of an employee, the provider is obligated to pay the program back the funds wrongfully obtained. Medicare has a self disclosure protocol that allows providers to report false or erroneous claims but the terms of the protocol does not guarantee that by so doing anyone will avoid triple times damages under the False Claims Act or criminal prosecution.

When a provider self reports, its owners and employees can hope to avoid false claims or criminal liability based upon the benefit of telling Medicare before the false claim is otherwise discovered; whether through a whistleblower or the Program itself. However, often the problem can be large enough to cause serious financial distress to the provider or put other seemingly non responsible employees or owners at risk of criminal prosecution. Once reported, providers generally lose control of what happens; the money is not owed by only the criminal, but also the apparently innocent provider itself. The overpayment cannot be paid back at the provider’s schedule and the provider cannot control who the government decides to hold liable for the fraudulent acts.

Many times when reporting the crimes, others, innocent of the crime, also face scrutiny and the criticism “how could you have not known about this” is directed at the leaders of the organization. Some providers facing these circumstances, based upon a lack of certainty of the outcome, are tempted to end the problem, not report it, and hope that no one figures it out, fearing their own disclosure could be ruinous. This, of course, is the wrong decision, if discovered, the failure to disclose certainly tends to make everyone involved both in the activity and the decision to cover it up look guilty of a crime.

Take the case of the Eye Specialty Group of Memphis . They discovered that a physician employee was diluting the drugs used on patients so he could steal the excess drugs to sell for a profit. However, the provider unknowingly submitted claims to Medicare based upon the doctor’s services as if the doctor had been providing the accurate dose, causing the submission of false claims to Medicare. The provider had purchased all of the medicine it billed for, but the crooked doctor was stealing and reselling the excess medication. So the provider reported the doctor to the authorities and the result was a bill from Medicare for hundreds of thousands of dollars, potential lawsuits by patients, and a lot of really bad publicity.

To read more, click: here.

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.

Health and Human Services Office of Inspector General released an updated fraud alert “Telemarketing by Durable Medical Equipment Suppliers” originally published in March 2003.

The Fraud Alert states in relevant part:

Section 1834(a)(17)(A) of the Social Security Act prohibits suppliers of durable medical equipment (DME) from making unsolicited telephone calls to Medicare beneficiaries regarding the furnishing of a covered item, except in three specific situations: (i) the beneficiary has given written permission to the supplier to make contact by telephone; (ii) the contact is regarding a covered item that the supplier has already furnished the beneficiary; or (iii) the supplier has furnished at least one covered item to the beneficiary during the preceding 15 months. Section 1834(a)(17)(B) specifically prohibits payment to a supplier that knowingly submits a claim generated pursuant to a prohibited telephone solicitation. Accordingly, such claims for payment are false and violators are potentially subject to criminal, civil, and administrative penalties, including exclusion from Federal health care programs.

The Office of Inspector General (OIG) has received credible information that some DME suppliers continue to use independent marketing firms to make unsolicited telephone calls to Medicare beneficiaries to market DME, notwithstanding the clear statutory prohibition. Suppliers cannot do indirectly that which they are prohibited from doing directly. OIG has also been made aware of instances when DME suppliers, notwithstanding the clear statutory prohibition, contact Medicare beneficiaries by telephone based solely on treating physicians’ preliminary written or verbal orders prescribing DME for the beneficiaries. A physician’s preliminary written or verbal order is not a substitute for the requisite written consent of a Medicare beneficiary.

To read the Fraud Alert: Click here.

All OIG Special Fraud Alerts are available on the OIG Web
site at: http://oig.hhs.gov/fraud/fraudalerts.asp

To read the Federal Register: Click here.

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

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

To read more: Click here.

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.

According to a report released this earlier this morning, hours ahead of an official announcement scheduled for later today, arrests were made in Miami, Brooklyn and Detroit. Federal agents are expected to take about 30 suspects into custody from three states on charges related to Medicare fraud totaling $61 million.

The arrests follow an investigation by the Medicare Fraud Strike Force, a partnership between the two federal agencies that started nationally in May. Click here to read an earlier blog post.

According to sources speaking on the condition of anonymity, HHS Secretary Kathleen Sebelius will hold a news conference this afternoon in New York to make the announcement of the government’s continued crackdown on Medicare fraud. A key part of President Barack Obama's proposed healthcare overhaul targets eradicating an estimated $60 billion a year lost to Medicare fraud.

Today’s raids come a week after HHS reported that in 2008 Miami-Dade County received more than $500M from Medicare in home healthcare payments intended for the sickest patients. This figure is more than the rest of the country combined. To read the OIG report, click here.

Indictments are expected to charge that Florida scammers arranged for fake patients to bill for home healthcare, including homeless patients and others fraudulently listed as blind diabetics who submitted bills for visits by nurses twice-daily to give them insulin injections. See this Miami Herald video.

In Detroit, suspects paid recruiters to find patients willing to fake symptoms in order to justify expensive testing, and in turn bill Medicare for reimbursement. Two Brooklyn suspects are alleged to have billed Medicare for medically unnecessary durable medical equipment (DME), including expensive shoe inserts reserved for diabetics.

Increasingly the manner in which the government promotes its law enforcement efforts in the Medicare arena sound more and more like military operations or even Saturday morning cartoons. The creation of the “Strike Force” known as HEAT, Health Care Fraud Prevention & Enforcement Action Team, sounds a lot more like commandos than lawyers and agents arresting doctors and white collar criminals. In the press releases you see the use of the words “combat” and “battle” and now the battle also has phases: Miami (Phase One), Los Angeles (Phase Two), Detroit (Phase Three), and Houston (Phase Four).

For more, click here.

In one of the recent pleas related to the government’s new focus on Medicare fraud in Detroit, a physical therapist and two others pleaded guilty to approximately $2.5 million in Medicare Fraud related to physical and occupational therapy services. Click here to read the plea agreement.

Baskaran Thangarasan, one of the conspirators, was paid $50 per file to falsify multiple physical therapy visits for patients who received no therapy. Mr. Thangarasan admitted to producing over 1000 such files during the course of the conspiracy. He now faces a maximum of 10 years in prison for his role although the actual sentence will be somewhat less.

To read the article click here.

A Jacksonville physician, Janet Johnson-Hunter, pleaded guilty to altering medical records to justify ambulance transportation of patients. Rather than have the case presented to a grand jury and require the government obtain an indictment, Dr. Hunter-Johnson waived that right and instead pleaded guilty to an information, available here. Physicians do not receive reimbursement for ambulance transportation, however ambulance companies do and Dr. Hunter allegedly owned a private ambulance company.

According to the plea related documents, the doctor had staff modify patient records to reflect that patients could not walk or use a wheelchair, a precondition for payment for ambulance transportation. The Stark law prohibits a physician from referring patients to pharmacies, diagnostic companies and other ancillary service providers in which the physician has an ownership interest. The law was put into effect to prevent physicians from over-ordering services due to that financial interest.

For more info, click here.

Federal officials in charge of preventing fraud in the billion-dollar Medicare program ignored dozens of warnings of criminal activity during the Bush administration, according to investigations by the Associated Press and U.S. Senator Charles Grassley’s (R-IA) office.

CMS received about 30 tips over more than three-years reporting scams, but less than half of them got any attention. Organized crime groups have realized it is much easier and less dangerous to steal millions from the Medicare without as opposed to traditional criminal enterprises like prostitution, gambling or dope dealing.

Southern California is one that has been particularly hard hit area for Medicare fraud, where Russian, Armenian and Nigerian mafias are under investigation by federal agents. Konstantin Grigoryan, a former Soviet army colonel turned crime boss, recently pled guilty to taking $20 million from Medicare. Click here to watch a CNN report including undercover surveillance video.

Budget priorities and redirection of investigations at the state level, has led to a drop off in investigations of workers compensation fraud at a time when such fraud is increasing, according to investigators. The focus on Medicare and Medicaid fraud prosecutions has led, according to insurance industry sources, to a decrease in private insurance fraud cases, including health care insurance fraud and most notably worker’s compensation fraud. Actually, the rationales are somewhat simple, legislatures looking at investigation budgets, State and Federal, are often concerned with the return on investment. Therefore, if a state agency is bring back stolen Medicaid funds, the legislator sees a direct benefit to funding those fraud investigation programs as the programs become budget neutral or even a budget positive. However, recouping funds for private companies does not share the same status. This is a phenomenon more likely in Attorney General Office or state programs directly funded by the legislature, as opposed to more local offices.

To read more, click here.

In a Sixty Miutes piece on Medicare Fraud, reviewed by the HCFBlog here, Steve Kroft claimed the government loses $60 Billion to health care fraud. The piece, otherwise quite good, then goes on to describe some of what we have been documenting here. However, the $60 Billion dollar a year health care fraud number used on Sixty Minutes and now making the rounds doesn’t seem to have roots in any actual data. The figure, first attributed to US DOJ Heathcare fraud prosecutor Kirk Ogrosky, started getting pretty mushy when a reporter tried to get to the actual source. The reporter, Pierre Tristam, soon found numbers ranging from $13 Billion to $68 Billion all using a perception that a certain percentage of health care spending must be fraud rather than some actual data on the fraud.

Tor read more click here.

Part of the Health Care Fraud Task Force initiative in Miami, Houston, Detroit and Los Angeles has met with some success, and not so coincidently some of the cases have Miami roots. The FBI press release related to a plea in a in a $10 million infusion fraud case which mirrors frauds extensively prosecuted in Miami, a Miami resident plead guilty with regard to the fraud in Detroit.

The AP does an interesting story on the influence of organized crime on Medicare Fraud, including some violence associated with the schemes. Former drug dealers and mobsters are getting more involved in the fraud due to the lower criminal penalties and larger amounts of money available than drug dealing, loan sharking or other organized crime activities. I recall one case in which a former drug trafficker explained why he moved to Medicare Fraud, “I got older, didn’t want to run around so much and no one shoots at you.”

For more, click here.

This past Sunday night, 60 Minutes ran an excellent exposé on the $60 billion Medicare Fraud crime wave sweeping the country. 60 Minutes correspondent Steve Kroft spent some time in Miami this past August with FBI Special Agent Brian Waterman getting an overview of how Medicare fraud is perpetrated by DME scammers.

South Florida is the epicenter of Medicare fraud, so there was plenty to report. DOJ prosecutor and Healthcare Fraud Strike Force leader, Kirk Ogrosky was also interviewed and said Medicare fraud is "way bigger than the drug business in Miami now." Waterman and Ogrosky agreed that the criminals perpetrating Medicare fraud are more sophisticated than before.

"They've figured out that rather than stealing $100,000 or $200,000, they can steal $100 million. We have seen cases in the last six, eight months that involve a couple of guys that if they weren't stealing from Medicare might be stealing your car," Ogrosky explained.

"You know, we were the king of the drugs in the '80s. We're king of healthcare fraud in the '90s and the 2000's," Waterman added, speaking about South Florida.

To read the transcript of the 60 Minutes segment click here.

To watch, click here.

MIAMI, FL (June 29) In the ongoing prosecutions by the joint DOJ-HHS task force, another physician, Roberto Rodriguez was sentenced to 97 months in prison and ordered to pay over $9,000,000 in restitution in connection with $20,000,000 in fraudulent claims submitted to Medicare through 4 clinics associated with the doctor. The physician had pled guilty in March. To read the plea agreement click here, and to read the factual proffer click here.

In this, as in many of the ongoing prosecutions related to this subject matter, the allegation was that expensive drugs related to the treatment of HIV symptoms were claimed to have been administered to patients, many of whom did not have HIV. Most of the drugs were not purchased by the clinics at all. To read the indictment, click here.

Click here to read more.

“Sweeps” among law enforcement are generally used in high drug crime areas to literally sweep in and arrest as many people as possible to clear out the drug dealing in that area.

In a modification of the theme, the State of Florida Agency For Health Care Administration (AHCA) decided to conduct an auditing sweep of durable medical equipment (DME) providers in Bay County, Florida. AHCA is the Florida Medicaid program administrator, and has the authority under Florida law to initiate overpayment actions or terminate a program provider, but is not a law enforcement authority, referring instances of fraud to the Attorney General’s Medicaid Fraud Control Unit. The probe was directed to supplies of oxygen to patients with COPD under the Medicaid program.

To read more click here.

Some 60 defendants charged with Medicare Fraud in the Southern District of Florida have fled pending trial since 2004. Many who have fled are of Cuban origin, leading authorities to conclude that they have returned to Cuba, which is generally out of reach of U.S. law enforcement.

Previously, defendants were able to be released on minimal restrictions. However, over the last year judges in the Southern District have been denying bond and placing significant restrictions on defendants to assure the presence of Medicare fraud defendants.

In another very good article, Jay Weaver of the Miami Herald, breaks down the fugitive life of one such defendant, Alcides Garcia, originally believed to have fled to Cuba but who had traveled to Mexico, Spain and was eventually arrested in the Canary Islands.

To read more click here.

Telemarketers in Houston are pushing “Medicare approved arthritis kits” that are really an assortment of DME and prosthetic devices billed to Medicare individually.

Barbara McGinity with the Better Business Bureau explains that the scam artists have taken something Medicare will pay for, individual items like a wrist band, like a knee brace, like a back brace, and have packaged them making it sound like it's a new thing a Medicare approved arthritis kit.

Houston's FOX 26 Investigates report that many of the Medicare patients contacted never got the kit even though their Medicare was billed hundreds of dollars.

You can click here to read the article.

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.

Florida, New York and California are generally on the cutting edge of Medicare fraud, and many hours of law enforcement time is taken to uncover the next wave of perceived schemes. However, fresh from Georgia: hyperbaric oxygen therapy fraud.

A clinic owner in Georgia plead guilty to receiving over $1,000,0000 in reimbursement for treatment, “Hyperbaric chambers have a number of legitimate medical uses, as varied as helping burn victims and even scuba divers in their recovery. This defendant, however, turned a hyperbaric chamber into a means of generating over a million dollars in fraudulent claims…” said United States Attorney David E. Nahmias. To read more about this, click here

While it appears on the surface that fraudulent claims, particularly arising out of a single clinic would be quickly discovered and it would also seem that there are not enough burn victims or senior citizen scuba divers with the bends to make such treatment viable in the Medicare context, those are not the only reimbursable services. There is a national coverage determination (NCD) NCD 20.29 that permits hyperbaric oxygen therapy (HBOT) for several uses, particularly diabetic patients who have diabetic wounds of the lower extremities after there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care. There is also a Florida local coverage determination (LCD); LCD L28887. Click here for more.

You can read the USAO Press Release about the case by clicking here.

Eight Miami-Dade County residents have been charged in a 16-count indictment for their alleged roles in a Medicare fraud scheme involving fake HIV infusion treatments.

After the arrests, the Sept. 24, 2008, indictment was unsealed charging one count of health care fraud conspiracy against Juan A. Marrero, a/k/a Tony Marrero; Orlando Pascual Jr.; Belkis Marrero; Dr. David Rothman; Luz Borrego; Dr. Keith Russell; Eda Milanes; and Jorge L. Pacheco.

In addition to the conspiracy charge, Tony Marrero is charged with six counts of health care fraud, two counts of money-laundering conspiracy and four counts of money laundering. Pascual is also charged with six counts of health care fraud, two counts of money-laundering conspiracy and four counts of money laundering. Belkis Marrero is additionally charged with six counts of health care fraud, one count of money-laundering conspiracy and one count of money laundering. In addition to the conspiracy charge, Rothman and Borrego are each charged with four counts of health care fraud, and Milanes, Russell and Pacheco are each charged with two counts of health care fraud. The indictment also seeks forfeiture from all defendants.

According to the indictment, Tony Marrero, Pascual and Belkis Marrero controlled the day-to-day operations of two Miami medical clinics: Medcore Group LLC (Medcore) and M&P Group of South Florida Inc. (M&P). As medical assistants, Borrego (at Medcore), Pacheco (at M&P) and Milanes (at M&P) provided unneeded HIV infusion treatments to paid patients. The indictment charges that Pascual, Borrego and Milanes delivered cash payments to the patients. Furthermore, the indictment charges Rothman with ordering the unnecessary treatments at Medcore, and Russell with ordering the unnecessary treatments at M&P. Rothman and Russell allegedly conducted cursory examinations of the beneficiaries and signed the required documentation, including medical and billing records, to make it appear that the injection and infusion treatments billed by Medcore and M&P were medically necessary and provided, when, in fact, they were not.

Juan Marrero, Pascual, Belkis Marrero, Rothman and Borrego allegedly caused Medcore and M&P to submit fraudulent claims to Medicare for more than $5.3 million. The indictment alleges that the defendants laundered a portion of the proceeds to acquire the cash necessary to pay the patients.

In the event of conviction, the advisory sentencing guidelines sentence range will be determined by measuring the dollar amount of the loss suffered. It is anticipated that lawyers for the government will advocate that loss is equal to the intended loss - an amount equal to the dollar amount alleged in the indictment. However, we have been successful in persuading federal judges that an obscure provision of “Special Rules” in the calculation of loss under the Federal Sentencing Guidelines is instructive and resulted in a significant exclusion of “relevant conduct” claimed by the government and a Guideline range approximately half of that requested.

As reported earlier in this blog, (click here and here) one U.S. District Court Judge has declared that he didn’t care whether the government proved the “submitted” amount as “intended loss” when the law actually requires calculation of the “allowed amount” minus 20 percent.

Continue reading "MEDICARE FRAUD STRIKE FORCE INDICTS EIGHT MIAMI-DADE RESIDENTS FOR AIDS/HIV INFUSION FRAUD" »

MIAMI, FL (September 11, 2008) - Miami physicians, Carlos Contreras, M.D., and Ramon Pichardo, M.D., each pleaded guilty today to defrauding the Medicare program in connection with a $6.8 million HIV infusion fraud scheme. To read the indictment in its entirety, click here.

Contreras, 60, pleaded guilty to conspiracy to commit healthcare fraud and admitted that he owned a Miami clinic named CNC Medical Inc. (CNC), which purported to specialize in the treatment of HIV positive patients. From November 2002 through April 2004, Contreras admitted that he conspired with others to submit approximately $6.8 million in fraudulent Medicare bills; that he knowingly signed documents containing false information about treatments purportedly given to HIV positive patients. Contreras admitted that he approved medically unnecessary treatments at CNC and that CNC received approximately $4.2 million from the Medicare program as a result of his and his co-conspirators’ criminal conduct.

Furthermore, Contreras admitted that he entered into an agreement in approximately November 2002 with Carlos Benitez, Luis Benitez, Thomas McKenzie, Pichardo and others to operate CNC as a fraudulent HIV infusion clinic.

According to a report by the Inspector General for the U.S. Department of Health and Human Services made public a year ago, for which attorney, Benson Weintraub, a frequent contributor to this blog was interviewed by the Washington Times (click here to read that blog post), health care providers in Broward, Miami-Dade and Palm Beach submitted $2.5 billion in claims to Medicare on behalf of HIV/AIDS patients in 2005.

Miami Herald investigative reporter Jay Weaver wrote a series of articles last month disclosing the intricacies often associated with Medicare fraud / money laundering conspiracies. Those articles are quite revealing and detail the underworld character of these types of criminal operations. To read those articles click here.

Continue reading "Miami Physicians Plead Guilty and Admit Ordering $6.8M Worth of Unnecessary HIV Infusion Treatments" »

MIAMI, FL (September 9, 2008) – Dilcia Marinez, 57, pleaded guilty today in U.S. District Court to her role in defrauding the Medicare program and laundering the proceeds of the crimes in connection with a $14 million HIV infusion fraud scheme. Click here to read the indictment.

According to information in plea documents, the Benitezes referred HIV-positive Medicare beneficiaries to the clinic and directed McKenzie to teach doctors how to make it appear legitimate health services were being provided.

For the past couple of months, Miami Herald reporter Jay Weaver has written a number of articles detailing how South Florida remains a hotbed for Medicare fraud, including several articles about the Benitez brothers' fraudulent HIV infusion schemes. To read those articles, click here.

Marinez pleaded guilty to conspiracy to commit health care fraud and conspiracy to commit money laundering. Marinez admitted that she was the president and director of G&S Medical Center Inc. (G&S), a Miami health care clinic. Marinez admitted that she entered into an agreement in approximately May 2003 with Carlos Benitez, Luis Benitez, Thomas McKenzie and others to operate G&S as an HIV infusion clinic. According to a report released almost one year ago, by the Inspector General for the U.S. Department of Health and Human Services, health care providers in Broward, Miami-Dade and Palm Beach submitted $2.5 billion in claims to Medicare on behalf of HIV/AIDS patients in 2005.

Continue reading "Miami Still a Hotbed for Medicare Fraud - HIV Clinic Administrator Pleads Guilty for Role in a $14 Million Medicare Fraud Scheme" »

Today, The New York Times reported that “Medicare’s top officials said in 2006 that they had reduced the number of fraudulent and improper claims paid by the agency, keeping billions of dollars out of the hands of people trying to game the system.

“But according to a confidential draft of a federal inspector general’s report, those claims of success, which earned Medicare wide praise from lawmakers, were misleading.”

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.

On August 4, 2008, U.S. Attorney for the District of Northern Georgia David Nahmias announced that Angela D. Isley, , 44, of Atlanta, Georgia, was sentenced by United States District Judge Charles A. Pannell, Jr. to serve more than 5 years in prison on charges of health care fraud, mail fraud, and money laundering.

According to United States Attorney Nahmias and the information presented in court: Between January 2001 and December 2003, ISLEY knowingly assigned incorrect “product codes” to certain wrist braces and walking boots in Orthoscript Incorporated’s inventory in order to generate higher reimbursements from Medicare. ISLEY instructed company employees, often over their objections, to file claims with Medicare listing fraudulent product codes which are to be specifically used for custom-fabricated wrist braces, when all Orthoscript actually supplied were cheaper, prefabricated, off-the-shelf items. As a result of the health care fraud scheme, ISLEY caused Orthoscript to fraudulently bill the Medicare program for more than $600,000.

Continue reading "MEDICAL SUPPLY EXECUTIVE IMPRISONED FOR DEFRAUDING MEDICARE" »

MIAMI (July 11, 2008). Yesterday the Bureau of National Affairs first reported another case rejecting the government’s methodology of computing “loss” in health fraud cases under the federal sentencing guidelines in the Southern District of Florida.

BENSON WEINTRAUB, the nationally renown federal sentencing expert National sentencing expert, a former full-time professor of law, persuaded US District Judge Cecilia Altonaga to reduce the government’s overarching figure of $14 million down to less than $400,000. The sentence of 41 months was about half of what the government claimed should be applied under the sentencing guidelines.

This ruling adopted the legal rationale of Judge Adalberto Jordan reported earlier in this blog when he declared that he didn’t care whether the government proved the “submitted” amount as “intended loss” when the law actually requires calculation of the “allowed amount” minus 80 percent.

The defendant was a physician, Ana Caos, MD who, after a mistrial and retrial, was convicted of dual conspiracies to file false Medicare claims and receive kickbacks.

Weintraub also argued that before, during, and after trial/sentencing, the defendant suffered from significantly reduced mental capacity which materially impacted her cognitive and volitional functions to mitigate the extent of her mens rea.

The case is legally significant as setting precedential loss rulings for health care fraud.

Dr. Caos was also represented by trial attorney Robert Josefsberg.

After a six day trial in Miami, a federal jury in Miami convicted Gustavo Smith, 43, the owner of a Miami pharmacy for his role in a $3 million Medicare fraud scheme and for money laundering of all 17 counts charged against him in the September 2007 Indictment.

The charges included: conspiracy to defraud the U.S. government, to commit health care fraud, and to submit false claims to the Medicare program; seven counts of health care fraud; seven counts of submitting false claims to the Medicare program; conspiracy to commit money laundering; and one count of money laundering.

Smith’s co-defendant, Friedhelm Schock, the nominee owner of Medstar, was acquitted by the jury on all charged counts.

According to Schock's defense attorney, Michael Band of Adorno & Yoss, the government argued that Schock was the "nominee" owner of the pharmacy, signed all the Medicare documents, opened all the bank accounts, formed the corporation, received monies far in excess of what reflected the work he performed at the pharmacy and lied to the government to cover up the fraud.

Continue reading "Miami Pharmacy Owner of Convicted of Medicare Fraud, Co-defendant Acquitted" »

Check this out. Usually you would think of a psychiatrist as being someone who treats patients who suffer from auditory or visual hallucinations. However, an Illinois psychiatrist is headed to federal prison for two and a half years for defrauding Medicare of $1.75 million for submitting bills to Medicare for patients he never saw.

According to the indictment, Dr. Ajit Trikha (ah-JEET' TREEK'-ah) a 55-year-old psychiatrist pleaded guilty last June in U.S. District Court in East St. Louis to two counts of health care fraud. Trikha submitted bills to Medicare for reimbursement claiming that he had therapy sessions with patients, when in truth he never met the patient and in some instances was out of the country on vacation. He also billed for group-therapy sessions that far exceeded the 12-person limit set by Medicare and Medicaid.

Additionally, the indictment specifically alleged that the doctor and his medical practice "regularly submitted claims with [erroneous] . . . codes when spending little or no time with the patient rather than approximately 20 to 30 minutes face-to-face with the patient as required by 08 17, or approximately 45 to 50 minutes face-to-face with the patient as required by 9081. TRIKHA and TRX also submitted claims with these codes for visits with patients who were not able to communicate verbally at all."

A federal judge has ordered Trikha to reimburse the government for the money he bilked.

On April 2, the same day that seven co-defendants were indicted (click here) for their roles in an $11 million Medicare fraud scheme involving HIV infusion clinics, Rita Campos Ramirez who had pleaded guilty in August 2007 to a $170 million conspiracy to commit health care fraud was sentenced to 10 years in prison. According to the U.S. Department of Justice and local federal prosecutors, the scheme represents the largest known individual case of Medicare fraud in the history of the program.

Continue reading "Miami Woman Sentenced to 10-years for Role in $170M Healthcare Fraud Consiracy" »

Seven Miami-area residents were indicted on April 2, 2008, in connection with an $11 million Medicare fraud scheme involving HIV infusion clinics. The defendants were all charged with: conspiracy to defraud the United States, to cause the submission of false claims, to pay health care kickbacks, and conspiracy to commit health care fraud.

According to a report filed early last fall, by the Inspector General for the U.S. Department of Health and Human Services, health care providers in Broward, Miami-Dade and Palm Beach submitted $2.5 billion in claims to Medicare on behalf of HIV/AIDS patients in 2005.

Continue reading "Feds Charge Seven in $11 Million Medicare Fraud Scheme" »

On April 2, 2008, U.S. District Court Judge Adalberto Jordan of the Southern District of Florida sentenced defendant Michael Labrada, 27, of Miami to a 97 month prison term and Miguel Castillo, 42, of Miami, to a 57 month prison term for their participation in a multi-million dollar health care fraud and money laundering scheme.

Labrada was convicted of conspiring with Angel Castillo, Jr. to commit health care fraud by serving as a straw owner of a medical equipment company known as JJ & D Medical Equipment, Inc. The company submitted more than $6.8 million dollars in bogus claims and received approximately $1.6 million in payments. In the second case, Labrada was convicted of money laundering charges in connection with a $2.3 million laundering scheme orchestrated by his co-defendant, Angel Castillo, Jr.

Miguel Castillo was also convicted of related health care fraud and money laundering conspiracy charges. In addition to serving as a straw owner of a medical equipment company, Miguel Castillo collected hundreds of thousands of dollars in fraud proceeds from check cashers at the direction of his cousin and co-conspirator, Angel Castillo, Jr.

Continue reading "Two Florida Men Sentenced for Healthcare Fraud & Money Laundering" »

Yeleiny Guerrero was the co-owner of Denis Medical Services, Inc. She was charged in a 6 count indictment with conspiracy to defraud the United States by causing the filing of false Medicare claims, conspiracy to commit health care fraud and 4 counts of health care fraud. Her codefendants were Ramon Oscar Soto, Araelia Nieto and Rafael Moreno. Soto was the leader of the charged conspiracy which involved three separate DME companies: P & A Medical, ROS Medical and Denis Medical Services. Nieto and Moreno were co-owners of the other two DME companies. All three of them pleaded guilty and were sentenced to time in the federal pokey: Moreno 18 months, Nieto 24 months and Soto 37 months.

The evidence at trial demonstrated that Guerrero established the corporation in her name, opened a bank account as the sole signatory, applied for all state and federal licenses and signed the Medicare Supplier Application so as to obtain a provider number. She worked at the office in a warehouse district daily from 8 am to 12 noon.

Continue reading "Defendant Acquitted of Healthcare Fraud " »

On December 13, 2007, the owners of five separate Miami-based health care corporations have were sentenced to prison. Collectively, the five defendants filed fraudulent claims with Medicare for over $28.6 million worth of unnecessary durable medical equipment (DME) and infusion therapy.

The five defendants who were sentenced in Miami are: Rodolfo Aenlle, 47, who was sentenced to 84 months in prison; Simon Seruya, 74, who was sentenced to 50 months; Alberto Gourie, 35, who was sentenced to 51 months in prison; William Garcia, 31, who was sentenced to 41 months; and Marina Ruiz, 48, who was sentenced to 24 months in prison. In total, these individuals were ordered to repay more than $13 million in restitution.

“We are continuing to seek appropriate sentences for the most serious Medicare fraud offenders,” said Assistant Attorney General Fisher. “The Strike Force in South Florida has successfully prosecuted some of the most egregious cases of Medicare fraud, and the average prison sentence for these violators is now up to almost 52 months which is above the national average of 31 months, with many Strike Force defendants receiving over 10 years.”

Continue reading "Medicare Fraud Strike Force Cases Result in Long Prison Terms for Five Health Care Company Owners" »

September 21, 2007

From The Washington Times

By Jim McElhatton - Doctors and clinics in three Southern Florida counties account for most of the billions of dollars charged to Medicare nationwide for HIV and AIDS drugs and services, billing records show.

Federal health care regulators call the lopsided billing patterns "egregious" and warn that South Florida — particularly Broward, Miami-Dade and Palm Beach counties — is a potential hotbed for health care fraud, waste and abuse.

"It"s all ultimately part of the money-driven, underground economy in Miami," said Benson B. Weintraub, a health care fraud lawyer based in Fort Lauderdale.

According to a report this week by the Inspector General for the U.S. Department of Health and Human Services, health care providers in Broward, Miami-Dade and Palm Beach submitted $2.5 billion in claims to Medicare on behalf of HIV/AIDS patients in 2005.

Continue reading "South Florida bills billions for HIV" »

On August 31, 2007, defendants Maricel Li and Marta Perez, both residents of Miami, were sentenced by United States District Court Judge James I. Cohn in Fort Lauderdale, Florida.

Li was sentenced to twenty-four (24) months' imprisonment, followed by three (3) years of supervised release. Li was also ordered to pay $556,519.85 in restitution. Perez was sentenced to five (5) months' imprisonment, to be followed by two (2) years of supervised release.

Both defendants had previously pled guilty. Defendant Li had pled guilty to an Information charging her with conspiracy to commit health care fraud violations and conspiracy to commit structuring violations. Defendant Perez had pled guilty to conspiracy to structure financial transactions.

Continue reading "Miami Defendants Sentenced on Health Care Fraud" »

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.

On August 30, 2007, the owner and operator of a Miami durable medical equipment company and an assisted living facility was convicted as charged in a five-count indictment by a federal jury in Miami of Medicare fraud in U.S. District Court for the Southern District of Florida.

After a jury trial at federal court in Miami, the jury found Marianela Smith guilty on all charged counts including conspiracy to defraud the U.S. government, to submit false claims to Medicare, and to receive kickbacks; conspiracy to commit health care fraud; and three counts of receiving kickbacks in exchange for referring patients to a co-conspirator pharmacy.

Smith faces a maximum sentence of 30 years in prison. Prior to sentencing the U.S. Probation Office will complete a pre-sentence investigation and submit a Pre-Sentence Report to the judge for consideration. The PSI will contain an advisory guideline sentence which the court must consider in determining what type and length of sentence is sufficient, but not greater than necessary, to comply with the statutory directives set forth in 18 U.S.C. § 3553(a).

Smith is scheduled to be sentenced November 9, 2007, before U.S. District Court Judge Joan A. Lenard.

On May 18, 2007, the US Attorney's Office reported that Jafet Garcia, a defendant in a massive South Florida Medicare fraud scheme, was sentenced in West Palm Beach Federal court to ten (10) years’ imprisonment.

According to the court file, the defendant and his partners purchased four medical equipment companies located in Miami-Dade and Palm Beach Counties, between February 2004 and December 2004. The defendant and his partners recruited individuals to pose as the owners of these companies. After setting up the companies, the defendant and his partners obtained patient and physician information which they used to prepare bogus prescriptions and/or certificates of medical necessity. The bogus prescriptions and certificates purported to authorize the provision of various types of medical equipment for the named Medicare beneficiaries; in truth, the prescriptions and certificates were prepared by the defendant and/or his accomplices and contained forged physicians’ signatures.

The defendant and/or his partners provided the bogus prescriptions and certificates to a Miami billing company for submission to Medicare. The billing company prepared Medicare claims which sought reimbursement for the cost of the equipment listed in the bogus prescriptions and certificates, even though such equipment was never authorized by a physician or provided to the beneficiaries. Medicare processed the fraudulent claims and issued reimbursement checks which the defendant and/or his accomplices cashed at a Miami check cashing store. The defendant and his partners would submit claims through a particular medical equipment company for only two to three months, close it and then begin billing through another company to avoid getting caught.

The four companies used by the defendant and his partners to defraud Medicare were Sunset Medical Corporation, King Medical Service and Supplies Corporation, Travelango Services Corp. and Clear Choice Home Health, Inc. During the course of the scheme, the defendant and his partners submitted more than $9 million in bogus Medicare claims.

On May 11, the US 11th Circuit Court of Appeals, issued an opinion reversing the of convictions, all convictions of one defendant for Medicare Health Care Fraud and money laundering, and vacated the sentence for incorrect loss calculations.

The scheme involved transporting patients to the defendants’ pharmacies in exchange for illegal kickbacks for patients and doctors. However, no evidence indicated that Medicare was billed for unnecessary medical procedures. A confidential informant met with the defendants to exchange, for a fee, their checks for cash, admitted on cross-examination that one defendant, Medina, a secretary, was always sent out of the room to avoid her hearing them talk about the kickback scheme.

The Court also vacated the money laundering counts which related to the fraud counts it had set aside, since money laundering involves the proceeds of activity known by the defendants to be illegal.

The Court upheld the convictions of two defendants as to the general conspiracy charge, under 18 U.S.C. § 371, but vacated the secretary’s conviction, finding that her lack of awareness of the kickback conspiracy, and of the conspiracy’s other objectives, left insufficient evidence to
convict.

The Court remanded the case for resentencing and noted that the district court failed to make a sufficient loss calculation, and instead sentenced the defendants for the entire amount Medicare was billed in the period, without explanation. However, in the absence of evidence of Medicare’s payment of unnecessary medical claims, or that the patient kickback scheme resulted in any actual loss to Medicare, this calculation was inadequate.

On May 9, investigators said the arrests of 38 people are the result of an operation conducted by a strike force made up of a team of federal, state and local investigators who have been concentrating on Medicare fraud -- ''especially prevalent'' in South Florida -- since early March.

According to remarks made by Attorney General Alberto R. Gonzales at a press conference with Michael Leavitt, Secretary of Health and Human Services, "the indictments outline various types of fraudulent schemes. Those schemes included compounded aerosol medications -- a process where a pharmacist makes medicine to meet a special medical need for a patient, rather than dispensing less expensive commercial pharmaceuticals. The indictments allege that the homemade medications were not necessary and that they were only prescribed to defraud Medicare.

"In one example, Eduardo Moreno, the owner of multiple DME companies, was arrested on April 7 after being named in a six-count indictment on fraud charges. Two of Moreno's companies - Brenda Medical Supply Inc., and Faster Medical Equipment Inc. - allegedly billed Medicare for more than $1.9 million for services that were not medically necessary. The FBI has seized of some of Moreno's assets, including a new Rolls Royce Phantom worth approximately $200,000.

Gonzales said that some of the 38 defendants allegedly paid Medicare recipients for use of their Medicare card numbers so that the defendants could submit fraudulent claims.

''We believe scores of shell companies have opened and obtained Medicare supplier numbers in Miami-Dade County alone,'' Gonzales said.

“The landscape for fraud in south Florida has changed dramatically over the past two years. CMS has taken aggressive action to curb infusion therapy fraud and other organized fraud actions,” said Leslie Norwalk, acting administrator of the Centers for Medicare and Medicaid Services. “We have opened two satellite offices that are dedicated to combating fraud in high-risk areas and we will soon be opening a third. We are sending a strong message to those who seek to defraud the programs that if they engage in fraudulent activity, they will be caught and no longer able to take advantage of the programs to their own gain.”

Federal prosecutors in Indiana have charged Dr. Jihad Kasim, a Valparaiso pediatrician with health care fraud, accusing him of submitting more than $1 million in fraudulent Medicaid claims for medical services he didn't provide.

Kasim's accused of pilfering protected information from patient files who gave birth at hospitals he worked at and then using the information to submit fraudulent bills.

Kasim claimed most of the women were treated for blood infections, though the patients denied to investigators that they were ever diagnosed or treated for such conditions.

Prosecutors say Kasim has 14 bank accounts, three cars, two homes and a 20-foot speedboat.

On April 18, 2007, U. S. District Court Judge Marcia G. Cooke sentenced Marcelo de Jesus Serrano, a laboratory owner, who previously pled guilty in connection with a $2.5 million Medicare billing fraud scheme to a 57-month term of imprisonment for his role in the health care fraud scheme.

Serrano also agreed to forfeit in excess of $2.8 million in cash and stock holdings, along with three Mercedes Benz automobiles and a motorcycle.

The case stemmed from a fraudulent medical laboratory billing scheme that netted Serrano and his co-conspirators more than $2.5 million in Medicare payments from 2003 through 2005. Serrano operated two clinical labs, Biocyte Laboratories, Inc., and Washington Medical Laboratory, Inc., formerly located in Hallandale Beach, Florida. To conceal his ownership interests in the labs, Serrano incorporated the labs with the State of Florida in the names of fake owners, including a deceased nursing home patient. Serrano then submitted in excess of $5 million in claims to the Medicare program for fraudulent clinical laboratory testing.