‘US don’t want fascist takeover by Republican party’: McGovern vs Scott

Summary: A heated House hearing erupted as Rep. Jim McGovern and Rep. Austin Scott clashed over President Donald Trump's policies, the Republican agenda, and the upcoming November elections. McGovern accused Republicans of pushing a "fascist takeover," while Scott fired back in a tense exchange over the GOP's direction and voter sentiment. Watch the full confrontation and the biggest moments from this explosive congressional debate. 7/21/26
Showing posts with label Health care. Show all posts
Showing posts with label Health care. Show all posts

Medicare Fraud

 Company Owner Indicted for 

$784 Million Health Care 

Fraud Scheme

     (DOJ) - 8/16/2021 - A federal grand jury in Newark, New Jersey, returned a superseding indictment on Aug. 10 charging a Florida owner of multiple telemedicine companies with orchestrating a health care fraud and illegal kickback scheme that involved the submission of over $784 million in false and fraudulent claims to Medicare. This is one of the largest Medicare fraud schemes ever charged by the Justice Department. The superseding indictment also charges the defendant with concealing and disguising the proceeds of the scheme in order to avoid paying income taxes.  

    Creaghan Harry, 53, of Highland Beach, Florida, is charged in the superseding indictment with one count of conspiracy to commit health care fraud and wire fraud, and four counts of income tax evasion. Harry previously was charged in an indictment along with co-conspirators Lester Stockett and Elliot Loewenstern with one count of conspiracy to defraud the United States and to pay and receive kickbacks, four counts of receipt of kickbacks, and one count of conspiracy to commit money laundering. Stockett and Loewenstern previously pleaded guilty. If convicted, Harry faces a maximum penalty of 20 years’ imprisonment for the conspiracy to commit health care fraud and wire fraud, five years’ imprisonment on each count of tax evasion, five years’ imprisonment for the conspiracy to defraud the United States and pay and receive kickbacks, 10 years’ imprisonment for each count of receipt of kickbacks, and 20 years’ imprisonment on the conspiracy to commit money laundering.  

    A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

    According to allegations in the superseding indictment, Harry and his co-conspirators solicited illegal kickbacks and bribes from durable medical equipment (DME) suppliers and marketers in exchange for orders for DME braces and medications. Harry’s telemedicine companies then allegedly paid physicians to write medically unnecessary orders for these braces and medications. Harry’s telemedicine companies provided orders to DME suppliers that fraudulently billed Medicare over $784 million. Medicare ended up paying over $247 million. 

    In order to conceal and disguise the health care fraud and illegal kickback scheme, the superseding indictment alleges, Harry directed DME suppliers and marketers not to directly pay his telemedicine companies and instead to pay shell companies that had been opened in the names of straw owners in the United States and foreign countries, such as the Dominican Republic. Harry then transferred the funds from the shell companies to his telemedicine companies in order to pay physicians to write the unnecessary orders.

    The superseding indictment alleges that Harry falsely claimed to prospective investors, lawyers and others that his telemedicine companies had not received any kickbacks. Harry instead falsely represented that the telemedicine companies had been receiving revenue of “about $10 million per year” from fees paid by patients to receive telemedicine services, when in fact the revenue of the telemedicine companies was derived from illegal kickbacks and bribes.

    The superseding indictment further alleges that Harry committed income tax evasion in the calendar years between 2015 and 2018 by receiving the proceeds of the illegal scheme in the accounts of shell companies belonging to nominee owners and using those proceeds to live a lavish lifestyle. Harry did not file an income tax return or pay taxes on this income. 

    Assistant Attorney General Kenneth A. Polite of the Justice Department’s Criminal Division; Acting U.S. Attorney Rachael A. Honig for the District of New Jersey; Special Agent in Charge George M. Crouch of the FBI’s Newark Field Office; Special Agent in Charge Scott J. Lampert of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG); and Special Agent in Charge Michael Montanez of IRS-Criminal Investigations, Newark, made the announcement.

    HHS-OIG, the FBI and IRS-Criminal Investigations are investigating the case.

    Assistant Chief Jacob Foster of the Criminal Division’s Fraud Section’s National Rapid Response Strike Force and Trial Attorney Darren Halverson of the Newark Strike Force are prosecuting the case.

    The Fraud Section leads the Health Care Fraud Strike Force. Since its inception in March 2007, the Health Care Fraud Strike Force, which maintains 15 strike forces operating in 24 federal districts, has charged more than 4,600 defendants who have collectively billed federal health care programs and private insurers for approximately $23 billion. In addition, the HHS 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. 

    The Fraud Section uses the Victim Notification System (VNS) to provide victims with case information and updates related to this case. Victims with questions may contact the Fraud Section’s Victim Assistance Unit by calling the Victim Assistance phone line at 1-888-549-3945 or by emailing Victimassistance.fraud@usdoj.gov. To learn more about victims’ rights, please visit: https://www.justice.gov/criminal-vns/victim-rights-derechos-de-las-v-ctimas.  

    An indictment is merely an allegation, and the defendant is presumed innocent until proven guilty beyond a reasonable doubt in a court of law.

Medical Malpractice

Report: Medical Malpractice is Not

A 'Frivolous' Matter

Accusations of Lawsuit Abuse Fall Flat



By Steve Rensberry
RP News
--------------

    EDWARDSVILLE, Ill. - (RP NEWS) - 7/21/2021 - Nearly 10 percent of patients with symptoms caused by major vascular events, infections or cancers will be misdiagnosed in the United States, with more than half of those suffering death or permanent disability as a result. That's the conclusion of a 2020 study by John Hopkins University School of Medicine Director Professor David E. Newman-Toker, along with others involved with the analysis. (1)

    It's a sobering statistic, as are a long list of others involving medical malpractice cited in the latest report by the national consumer organization, Center for Justice and Democracy (CJ&D). See: Medical Malpractice Briefing Book.

    "Among the 15 diseases analyzed, spinal abscesses was the disease most often missed (62.1%). More than one-on-four aortic aneurysms and dissections have a critical delay in diagnosis (27.9%) and more than one in five (22.5%) lung cancer diagnoses are also meaningfully delayed," the John Hopkins study notes.

    Research by the Emergency Care Research Institute (ECRI) in 2020 points to similar results, concluding that "missed and delayed diagnosis" were a top patient safety concern. Diagnostic errors contributing to death were found in about 10 percent of autopsies, they said, leading to 40,000-80,000 deaths annually. Based on outpatient studies, approximately 1 in 20 adults experience a diagnostic error. (2)

More insights from the CJ&D's briefing book:

  • Despite the Emergency Medical Treatment and Labor Act (EMTALA), which requires emergency departments to treat emergency patients regardless of ability to pay, hundreds of violations of the Act are seen each year. An analysis of 10 years of EMTALA violations (2008-2018), showed more than 4,300 violations involving 1,682 hospitals, roughly 1/3 of the nation's hospitals. (3)
  • Approximately 1 in 12 errors involved women who were pregnant or in labor, while 1 in 7 involved people who were having a mental health crisis, including thoughts of suicide. "Yet experts say the raw numbers belie both the scope and severity of the problem they see. That's because enforcement of the law depends on someone filing a complaint. Although anyone can file a complaint, it's most often a doctor, nurse, or hospital administrator," the report notes.
  •  A study by Professor Ziad Obermeyer of Harvard Medical School, et al, of early death after discharges from emergency departments, using U.S. insurance claims data, shows a significant number of deaths from people on Medicare soon after discharge. "In this national analysis, we found over 10,000 Medicare beneficiaries each year died within seven days after being discharged from emergency departments, despite mean age of 69 and no obvious life limiting illnesses," the report stated. (4)
  •  A 2019 study by University of Michigan School of Public Health candidate Jun Li et al, looked at the amount of data available made available by the U.S. Centers for Medicare and Medicaid Services on 1 million U.S. doctors. Its conclusions: Three quarters of clinicians had no information about their quality of care, 99 percent had no data tied to individual job performance, and lax reporting requirements do not require that every outcome be considered, meaning clinicians may be selective in which cases to submit information on. (5)
  • Diagnostic errors are the most common and costly errors, according to an 2020 analysis by Coverys Inc. of data from 2010-2019, with death and high-severity injury making up approximately 52 percent of events and 74 percent of indemnity paid; emergency department-related events accounts for 66 percent of indemnity paid.

    The bottom line, as stated in Part I of the CJ&D's briefing book, is that medical malpractice litigation, and the cases that are filed on account of it, are not fundamentally "frivolous," despite the allegations.

    As stated in the book: "According to averages calculated from the most recent data release by the National Center for State Courts (2019): 1) Medical malpractice cases represented only 0.15 percent of state civil caseloads in 2019. This rate is consistent with NCSC data from the previous seven years. 2) Medical malpractice cases represented only 3.9 percent of state tort caseloads in 2019. This rate is consistent with NCSC data from the previous seven years."

    A 2014 study, "Medical Harm: Patient Perceptions and Follow-up Action," by Johns Hopkins University School of Medicine Professor of Surgery Martin A. Makary and others, showed lawsuits being filed following patient harms in just 1 out of every 5 cases, or 19.9 percent. "This is similar to the Harvard Medical Practice Study, which reported an estimated ratio of adverse event to malpractice claim of 7.6 to 1. Other studies have estimated that as few as 2% - 3 % of patients pursue litigation. These findings all suggest that the vast majority of patient harms never result in a lawsuit." (6)

    The argument that patient lawsuit increase medical and insurance costs also is weak, given the data.

    According to the group Americans for Insurance Reform, claims per physician were at their lowest level in four decades in 2016, when adjusted for medical care inflation. When adjusted according to the Consumer Price Index, claims are at their lowest since 1982. (7)

    “Even aside from COVID-19, the briefing book includes a number of new studies that undercut the medical industry’s principal argument for so-called ‘tort reform’ laws: cost savings. It is clear that health care and insurance costs fail to decrease when ‘tort reforms’ are enacted, meaning there is no reason for patients to lose their legal rights.” CJ&D Executive Director Joanne Doroshow stated in a March 2021 press release.

Citations

1) Medical Liability Monitor (Feb. 2021) "Rate of diagnostic errors and serious misdiagnosis-related harms for major vascular events, infections, and cancers: toward a national incidence estimate using the 'Big Three.'" ECRI Executive Brief, "Top 10 Patient Safety Concerns 2020 (March 2020).

2) ECRI, "Diagnostic Errors: Why Do They Matter, and What Can You Do?" (2019).

3) Brenda Goodman and Andy Miller, "Deprived of Care: When ERs Break the Law," WebMD and Georgia Health News, Nov. 29, 2018.

4) Ziad Obermeyer et al, "Early death after discharge from emergency departments: analysis of national US insurance claim data," BMJ, Feb. 2, 2017.

5) Lena M. Chen, Anup Das and Jun Li, "Assessing the Qualithy of Public Reporting of US Physician Performance," Jame Intern. Med, May 6, 2019; University of Michigan, "System Grading Doctors is Inefficient, Needs Revisions," May 7, 2019; Lisa Rapaport, "U.S. government website for comparing doctors lacks data on most MDs," Reuters, May 6, 2019.

6) Heather G. Lye et al, "Medical Harm: Patient Perceptions and Follow-up Actions," Journal of Patient Safety, November 13, 2014.

7) Americans for Insurance Reform, "Stable Losses/Unstable Rates 2016" (November 2016).

Criminal Scheme

CEO Sentenced for $150M 

Health Care Fraud and 

Money Laundering Scheme

 
 
TEXAS - (USAO-Texas Southern) - 2/7/2021 - The CEO of a Texas-based group of hospice and home health entities was sentenced Feb. 3 to 15 years in prison for falsely telling thousands of patients with long-term incurable diseases they had less than six months to live in order to enroll the patients in hospice programs for which they were otherwise unqualified, thereby increasing revenue to the company.

    Henry McInnis, 50, of Harlingen, Texas was convicted by a federal jury in Brownsville,Texas, in November 2019 of one count each of conspiracy to commit health care fraud, conspiracy to commit money laundering, obstruction of justice, as well as six counts of health care fraud.

McInnis’s co-conspirator, Rodney Mesquias, 50, the owner of the hospice and home health entities, was also convicted following the November 2019 trial. He was sentenced to 240 months in prison in December 2020. Two other co-conspirators have pleaded guilty and are awaiting sentencing.

“McInnis, as CEO of the company, directly oversaw a reprehensible criminal scheme that involved the submission of over $150 million in fraudulent bills, the falsification of patients’ medical records, and the payment of unlawful kickbacks,” said Acting Attorney General Nicholas L. McQuaid of the Justice Department’s Criminal Division. “McInnis preyed upon some of the most vulnerable members of our society, including many who suffered from diminished mental capacity and who were falsely and cruelly told by co-conspirators that they had only months to live. Today’s significant sentence demonstrates the department’s continued commitment to pursuing individuals, at all levels of corporate management, who engage in criminal schemes that prioritize profits over patient care.”

From 2009 to 2018, McInnis, Mesquias and others orchestrated a scheme that involved the submission of over $150 million in false and fraudulent claims for hospice and other health care services. McInnis served as the top corporate officer and administrator and oversaw the day-to-day operations of the Merida Group, a large health care company that operated dozens of locations throughout Texas.

McInnis had no medical training and worked previously as an electrician. However, he acted as the de facto director of nursing for the Merida Group. Witnesses at trial testified McInnis directed employees to admit unqualified patients to hospice and home health, keep unqualified patients on services for long periods of time and fired and reprimanded employees who refused to participate in the scheme.

McInnis also oversaw and enforced a company-wide practice of falsifying medical records to conceal the scheme. Multiple witnesses testified McInnis ordered employees to alter medical records to make it appear patients were terminally ill. In reality, some were employed or even participating in sporting events. The jury also heard that McInnis explained the purpose of the falsified records was to allow the Merida Group to pass insurance company audits.

As CEO, McInnis also adopted a policy that paid illegal kickbacks. They directed bribes to physicians under the guise of medical director fees to certify unqualified patients for hospice and home health. In some cases, they improperly offered payoffs to marketers in exchange for recruitment of patients who could be placed on extremely expensive hospice services.

HHS-OIG, FBI and Texas Health and Human Services Commission conducted the investigation. Assistant Chief Jacob Foster and Trial Attorney Kevin Lowell of the Criminal Division’s Fraud Section and Assistant U.S. Attorney Andrew Swartz of the Southern District of Texas are prosecuting the case.

The Fraud Section leads the Health Care Fraud Strike Force. Since its inception in March 2007, the Health Care Fraud Strike Force, which maintains 15 strike forces operating in 24 districts, has charged more than 4,200 defendants who have collectively billed the Medicare program for nearly $19 billion. In addition, HHS Centers for Medicare & Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

“McInnis and his co-conspirator’s reprehensible and deceitful actions to defraud Medicare weren’t without harm: vulnerable beneficiaries were unnecessarily enrolled in hospice care, preventing them from accessing needed curative care,” said Special Agent in Charge Miranda L. Bennett, U.S. Department of Health and Human Services Office of Inspector General’s (HHS-OIG) Dallas Region. “With our law enforcement partners, we will continue to investigate those who put ill-gotten profits above the well-being of patients in our health care system.”

Medicare fraud action involves 412 defendants

FLORIDA -- July 13, 2017 -- What is being called the largest ever health care fraud enforcement action by the Medicare Fraud Strike Force, involving 412 charged defendants across 41 federal districts, including 115 doctors, nurses and other licensed medical professionals, was announced on July 13 for their alleged participation in health care fraud schemes involving approximately $1.3 billion in false billings.
In the Southern District of Florida a total of 77 defendants were charged with offenses relating to their participation in various fraud schemes involving over $141 million in false billings for services including home health care, mental health services and pharmacy fraud.
“Health care fraud schemes have real, long-term consequences for our South Florida community. Patients are being denied the quality of care that they deserve, doctors are turning a blind eye to their oaths, and taxpayer money is being diverted into the pockets of the greedy. Today’s announcement highlights South Florida’s united and ongoing law enforcement effort, culminating in charges against more than twenty percent of the national defendants, to thwart evolving schemes and combat the unlawful distribution of opioids and prescriptions drugs,” Acting U.S. Attorney Benjamin G. Greenberg said
The following are some of the cases included in the take down:
Sober Homes Fraud
1. United States v. Eric Snyder and Christopher Fuller, Case No 17-MJ-8268-Brannon
Eric Snyder, 30, of Delray Beach, Florida, an owner of sober homes and addiction treatment facilities, and patient broker Christopher Fuller, 32, of West Palm Beach, Florida, are charged in a criminal complaint with conspiracy to commit health care fraud for their involvement in a scheme to illegally recruit patients, pay kickbacks and defraud health care benefit programs.
According to the criminal complaint, Snyder established a sober home, Halfway There Florida, LLC (HWT), also known as A Safe Place LLC, in Palm Beach County, Florida, which was purportedly in the business of providing a safe and drug-free residence for individuals suffering from drug and alcohol addiction. The defendants referred the sober home’s residents to a treatment center, Real Life Recovery Delray, LLC, (RLR), which was also owned by Eric Snyder. This treatment center purportedly offered clinical treatment services for persons suffering from alcohol and drug addiction.
According to the criminal complaint, to obtain patients for the sober home and treatment center (collectively “HWT/RLR”), Synder and other members of the conspiracy provided kickbacks and bribes, in the form of free or reduced rent, airline tickets, and other benefits, to individuals who agreed to reside at the sober homes, attend drug treatment therapy sessions, and submit to regular drug testing that members of the conspiracy could bill to the residents’ insurance plans. These patient brokers, including Fuller, were also paid kickbacks themselves by Snyder and others for referring patients to HWT/RLR for purported treatment.
According to the criminal complaint, fraudulent billings were submitted by HWT/RLR for services that were not medically necessary and/or were never provided. Licensed health professionals who used to work at HWT/RLR describe treatment conducted by unqualified and non-licensed employees, and billings for treatment that never occurred. The licensed professionals were asked to sign for and/or backdate this treatment as though they had conducted it. In addition, licensed professionals at HWT/RLR were asked to complete intake forms and other documents for patients that they had not seen. In some instances, services were billed for residents who left the sober homes and were no longer receiving treatment at the treatment centers. In other instances, patients were billed for therapy sessions they never attended, and therapy sign-in sheets and other documents fraudulently reflected that these patients attended these sessions, when they did not. The defendants provided services meant solely to maximize insurance reimbursements, such as expensive urine drug screens. HWT/RLR fraudulently used urine drug screens as a profit-machine, including splitting samples to send them to different laboratories, improper duplicate testing, and fraudulently double billing for tests for the same patients at both HWT and RLR. In addition, samples were fraudulently comingled prior to testing to prevent identical test results from exposing the scheme. After a search warrant was executed at a different treatment facility in Palm Beach County, in September 2014, Snyder and others attempted to stop or modify these illegal practices, and evidence of this wrongful conduct was removed and destroyed.
Drug and Pharmacy Fraud Schemes Medicare Part D
2. United States v. Orlando Bustabad, et al., Case No. 17-20441-CR-Moore
Orlando Bustabad, 61, Orlando Olver Bustabad, 31, Idilsis Manresa, 30, Sara Fernandez Escobar, 61, Mirtha Carrion Jimenez, 58, Alejandro Mena, 21, and Alejandro Sierra, 47, all of Miami, Florida, are charged by indictment with conspiracy to commit health care fraud and health care fraud. Orlando Bustabad and Orlando Olver Bustabad are also charged with aggravated identity theft.
According to the indictment, Orlando Bustabad and his son Orlando Olver Bustabad were the true owners of eight pharmacies located in Miami Dade County, namely, Med Solution Pharmacy, 17th Street Pharmacy, Rapid Pharmacy, Euro Pharmacy, A&B Pharmacy, Maxi Pharmacy, Mariposa Pharmacy, and 49th Street Pharmacy. Orlando Bustabad and Orlando Olver Bustabad operated these pharmacies under their own names or enlisted co-conspirators Manresa, Escobar, Jimenez, Mena, and Sierra to appear as owners. These pharmacies purportedly provided prescription drugs to Medicare beneficiaries. From February 2013 until June 2017, the defendants submitted and caused the submission of approximately $10,183,031 in claims for reimbursement to the Medicare Part D program, via interstate wires, that falsely and fraudulently represented that various health care benefits, primarily prescription drugs, were medically necessary, prescribed by a doctor, and had been provided by the pharmacies. As a result of such false and fraudulent claims, Medicare prescription drug plan sponsors made payments funded by the Medicare Part D Program to the corporate bank accounts of the eight pharmacies in the approximate amount of $4,649,743.
3.United States v. Victor Rocha, Case No. 17-20409-CR-Altonaga
Victor Rocha, 49, of Miami Lakes, Florida, was charged by indictment with six counts of health care fraud. The indictment charges Rocha with falsely and fraudulently submitting medical claims for prescription medications for reimbursement to Medicare Part D from September 2012 through May 2013, through his pharmacy, Med Express Pharmacy Discount, Inc. The Indictment charges that the claims were for prescription medications that were not provided and/or not medically necessary.
4. United States v. Alejandro Hernandez Rios, Case No. 17-20442-CR-Ungaro
Alejandro Hernandez Rios, 35, of Miami, Florida, was charged by indictment with five counts of health care fraud. The indictment charges Rios with falsely and fraudulently submitting medical claims for prescription medications for reimbursement to Medicare Part D from June through September 2014, through his pharmacy Independence Pharmacy and Discount, Inc. The indictment charges that the claims were for various prescription medications that were not provided and/or not medically necessary.
5.United States v. Pedro Mangano, Case No. 17-20408-CR-Martinez
Pedro Mangano, 52, of Miami, Florida, was charged by indictment with ten counts of Medicare fraud. The indictment alleges Mangano was the owner and operator of PVRX Pharmacy, located in Miami, Florida. Between March 2014 and June 2017, Mangano’s pharmacy submitted fraudulent claims for allegedly dispensing drugs to Medicare beneficiaries that the pharmacy never had in inventory to begin with. As part of the scheme, Mangano paid patient recruiters for fraudulent scripts used to defraud the Medicare Part D program. The fraudulent claims resulted in overpayments exceeding $1.1 million.
6.United States v. William Salazar Ortega, et al., Case No. 17-20454-CR-Gayles
On June 28, 2017, William Salazar Ortega and Oscar Alonso Gonzalez were indicted in connection with their roles at Latin Pharmacy, a pharmacy that defrauded Part D of the Medicare program of $2.38 million by billing for expensive prescription medications that were not prescribed to patients; were not necessary; and were not purchased. Salazar was the nominee owner of the pharmacy, and Gonzalez was its true owner. Each defendant was charged with one count of conspiracy to commit health care fraud and wire fraud and four counts of health care fraud. Gonzalez is also charged with one count of money laundering.
7.United States v. Yara Suarez, et al., Case No. 17-20453-CR-Moreno
On June 29, 2017,Yara Suarez, Jesus Sanchez, Anthony Moya and Yoel Concepcion were indicted in connection with their roles at Albe Pharmacy, a pharmacy that defrauded Part D of the Medicare program of $3.4 million by billing for expensive prescription medications that were not prescribed to patients; were not necessary; and were not purchased. Sanchez and Suarez were the owners of the pharmacy, and are each charged with one count of conspiracy to commit health care fraud and wire fraud, three counts of health care fraud and one count of conspiracy to commit money laundering. Moya and Concepcion owned and controlled shell corporations through which over $380,000 of the fraud proceeds were laundered. Moya and Concepcion are each charged with one count of conspiracy to commit money laundering and three counts of substantive money laundering.
8. United States v. Lisbet Cordova, Case No. 17-20450-CR-Cooke
On June 29, 2017, Lisbet Cordova, the owner of Jalvarez Pharmacy, Inc. (“Jalvarez”) was indicted on four counts of health care fraud. Through Jalvarez, Cordova billed Medicare, pursuant to Part D of the Medicare program, for prescriptions that were not medically necessary, prescribed or dispensed to Medicare beneficiaries. As part of the scheme, Jalvarez submitted approximately $730,000 in fraudulent claims to Medicare.
Prescription Drug Diversion
9. United States v. Jose De Jesus Rodriguez, Case No. 17-20486-CR-Scola
Jose De Jesus Rodriguez, 47, of Miami, Florida, was charged by indictment with one count of conspiracy to unlawfully distribute prescription drugs and three substantive counts of improperly distributing prescription drugs, also referred to as prescription drug diversion. The indictment charges Rodriguez with illegally distributing millions of dollars’ worth of prescription medications from August 2011 through March 2015.
10. United States v. Reynaldo Ocana, Case No. 17-MJ-02939-Otazo-Reyes
Reynaldo Ocana, 46, of Miami, Florida, was charged by criminal complaint with improperly distributing prescription drugs, also referred to as prescription drug diversion. The criminal complaint charges Ocana with illegally diverting prescription drugs in August 2016.
Home Health Care Fraud – Medicare Part A
11. United States v. Hector Fajardo Ramirez, Case No. 17-20301-CR-Moreno
Hector Fajardo Ramirez, 48, of Miami, Florida, was charged by indictment with six counts of health care fraud. The indictment charges that Ramirez falsely and fraudulently submitted medical claims for home health therapy for reimbursement to Medicare from February through July 2015, through his clinic Longevity Home Health Services, Inc. The indictment charges Ramirez with submitting claims for home health services that were not medically necessary and not provided.
12. United States v. Duniesky Cruz and Carlos Gomez Bravo, Case No. 17-20401-CR-Scola
Duniesky Cruz, 50, of Miami, Florida, the owner of home health agency Life & Hope Healthcare, Inc., and an employee Carlos Gomez Bravo, 33, of Miami, Florida, were charged by indictment with conspiracy to defraud the United States and pay health care kickbacks and payment of kickbacks in connection with a federal health care program. The charges stem from their involvement in a home health fraud scheme involving kickback payments to patient recruiters, patients, and clinic owners in exchange for patient referrals and prescriptions.
13. United States v. Vilma Alonso, Case No. 17-20468-CR-Ungaro
Vilma Alonso, 57, of Hialeah, Florida, an employee of South Florida Physician Care Network was charged by indictment with participating in a conspiracy to defraud the United States. Alonso was charged with conspiring with others to unlawfully enrich themselves by, among other things, submitting and causing the submission of false and fraudulent claims to Medicare and concealing the submission of false and fraudulent claims to Medicare. Alonso allegedly did this by causing the issuance of home health prescriptions that were not medical necessary and by paying recruiters for the referral of Medicare beneficiaries for home health services.
14. United States v. Maria Blanco, Case No. 17-20474-CR-Williams
Maria Blanco, 50 of Cape Coral, Florida, was charged by information with five counts of receiving kickbacks in connection with a federal health care program. The information charges Blanco with receiving approximately $8,500 in kickbacks on at least five occasions in 2014.
15. United States v. Enrique Vilarello, et al., Case No. 17-20482-CR-Williams
On July 7, 2017, Enrique Vilarello and Alberto Ordaz were each indicted on one count of conspiracy to pay and receive illegal kickbacks. Ordaz was also indicted on two counts of receipt of kickbacks in connection with a federal health care program. The charges stem from their roles as patient recruiters, paying illegal kickbacks to obtain medical prescriptions from clinics and receiving illegal bribes for referring patients to pharmacies, and home health agencies in and around Miami, Florida. Several of these entities, such as Merfi and City Center, are now defunct as a result of their owners being charged and pleading guilty to multi-million dollar fraud schemes.
16. United States v. Juan Rodriguez, Case No. 17-20347-CR-Scola
On May 25, 2017, Juan Rodriguez, President and Director of Good Home Care, Inc., a now-defunct home health agency located in Miami, Florida, was indicted on five counts of health care fraud for his role in a $4 million scheme. Good Home allegedly billed Medicare for home health services that were never prescribed by a licensed physician or provided to Medicare beneficiaries.
17. United States v. Jesus Escobar Montero, Case No. 17-20439-CR-Williams
On June 22, 2017,Jesus Escobar Montero, President and Director of Better Care Home Health Services, Inc., a now-defunct home health agency located in Sunrise, Florida, was indicted on four counts of health care fraud for his role in a nearly $1 million scheme. The charges arise from Montero’s ownership of Better Care, which billed Medicare for home health services that were never prescribed by a licensed physician or provided to Medicare beneficiaries.
18.United States v. Carlos Barroso, et al., Case No. 17-20432-CR-Martinez
On June 22, 2017, Carlos Barroso, Andres Perez, Rolando Perez and Reiniel Garcia were indicted in connection with their roles at Sweet Home Health, Inc., a home health agency that defrauded Part A of the Medicare program of $8.4 million by billing for home health services that were not prescribed to patients; were not necessary; and were not rendered. Barroso was the owner of Sweet Home Health and was charged with seven counts of health care fraud, as well as one count of conspiracy to commit money laundering. A. Perez, R. Perez and Garcia owned and controlled shell corporations through which the fraud proceeds were laundered. They are each charged with one count of conspiracy to commit money laundering, three counts of money laundering and three counts of structuring to avoid reporting requirements.
19. United States v. Jhony A. Alfau, et al, Case No. 17-20452-CR-Ungaro
On June 29, 2017, Jhony A. Alfau, Hector J. Garcia, and Sergio E. Santana were indicted on one count of conspiracy to commit health care and wire fraud, one count of conspiracy to make false statements relating to health care matters, and one count of making false statements relating to health care matters.The charges stem from the defendants’ role in a $50 million scheme to defraud Medicare where they falsely and fraudulently certified they provided home health care physical and occupational therapy services to Medicare beneficiaries, when in fact, they had not done so.
20. United States v. Ernesto Velasquez, Case No. 17-20462-CR-Martinez
On July 5, 2017, Ernesto Velasquez, was charged by information with one count of conspiracy to commit health care fraud. The charge stems from the defendant’s role as an employee of staffing agencies that sought to defraud the United States by billing Medicare for providing licensed physical and occupational therapy to home bound patients when, in fact, they had not rendered the services. As part of the scheme, these alleged services were billed to Medicare with a loss of over $3 million.
21. United States v. Suley Cao, Case No. 17-20451-CR-Martinez
On June 29, 2017, Suley Cao, the owner and operator of Good Friends Services, Inc. (“Good Friends”), a home health agency, was indicted on five counts of health care fraud; one count of conspiracy to defraud the United States and pay Health Care Kickbacks; and two counts of payment of kickbacks in connection with a federal health care benefit program. The charges stem from Cao’s role as owner and operator of Good Friends, which fraudulently billed Medicare for approximately $3,017,276.89 for home health services that involved a scheme whereby Good Friends made kickback payments to induce the referral of Medicare beneficiaries.
22. United States v. Rafael Arias et al., Case No. 17-MJ-02962-Garber
On July 13, 2017, Rafael Arias, Aylen Gonzalez, Ana Gabriela Mursuli Caballero, and Rafael Cabrera were charged by criminal complaint with conspiracy to commit health care fraud for their roles in an approximately $6 million Medicare fraud scheme involving various home health agencies in and around Miami, Florida. Arias was alleged to be the true owner of multiple home health agencies, such as Nestor’s Health Services, Inc. Arias hid the fact of his true ownership and instead directed others, like Cabrera, to fraudulently represent themselves as owners to Medicare, which allowed them to obtain Medicare provider numbers and submit claims for services purportedly provided to Medicare beneficiaries even though many of the services were medically unnecessary or were obtained as a result of illegal bribes and kickbacks. Gonzalez and Caballero were patient recruiters who facilitated kickback schemes with Arias by referring patients to home health agencies operated by Arias in exchange for bribes and kickbacks. Gonzalez and Caballero also purchased medically unnecessary prescriptions from fraudulent medical clinics. Caballero also owned and operated City of Angels Home Health Care LLC, a home health agency that she used to bill Medicare for home health services that were medically unnecessary or were obtained as a result of illegal bribes and kickbacks.
Assisted Living Facility Fraud
23. United States v. Bertha Blanco, Case No. 17-MJ-02949-Garber
On July 11, 2017, Bertha Blanco, who was employed for approximately 30 years by the State of Florida’s Agency for Health Care Administration (AHCA), was charged by complaint with bribery of a program receiving federal funds. AHCA is responsible for administering the Medicaid program in Florida, and is tasked with regulating and licensing health care facilities in Florida, including skilled nursing facilities (SNFs) and assisted living facilities (ALFs). The charge alleges that Blanco solicited and received cash bribes from Medicare and Medicaid providers in exchange for providing them with confidential, nonpublic AHCA reports and information, including patient complaints and the unannounced inspection schedules of AHCA surveyors. This information was ultimately used by the purchasers, some of whom were owners of skilled nursing facilities (SNFs) and assisted living facilities (ALFs), to fabricate and falsify medical paperwork and to temporarily remedy deficiencies so that AHCA would not discover lapses in patient care and revoke the licenses of these facilities. The owners of these SNFs and ALFs then submitted false and fraudulent claims to Medicare and Medicaid for patients named in the complaints and inspection reports sold to them by Blanco.
Clinics, Managed Care, Medicare Advantage Fraud – Medicare Part C
24. United States v. Beatriz Carrasco, Case No. 17-20464-CR-Ungaro
On July 6, 2017, Beatriz Carrasco, 49, of Hialeah, Florida was charged by information with one count of conspiracy to commit health care fraud and wire fraud. The information charges Carrasco, a Florida licensed insurance agent, with conspiring to enroll others into Medicare Advantage plans and Florida Medicaid. These individuals resided in Nicaragua, outside of the Medicare Advantage plans coverage area. As a result of Carrasco’s and her co-conspirator’s actions, Medicare and the Florida Medicaid program paid over $1,013,244 in monthly capitation payments and premiums on behalf of individuals residing in Nicaragua, who were otherwise ineligible to receive these benefits.
25. United States v. Greesy Misuraca, Case No. 17-20461-CR-Scola
On July 5, 2017, Greesy Misuraca, a licensed therapist, was charged by information with one count of conspiracy to commit health care fraud. The charge stems from the defendant’s alleged role in billing Medicare for licensed physical and occupational therapy that was given to home bound patients when, in fact, she did not provide the therapeutic services. As part of the scheme, these alleged services were billed to Medicare with a loss of over $650,000.
Private Insurance Fraud (Non-Medicare)
26. United States v. Leopoldo Becerra, Case No. 17-20470-CR-Moreno
Leopoldo Becerra, 50, of Miami, Florida was charged by indictment one count of health care fraud. The indictment charges Becerra with using Doctor Jalal Taslimi Medical Center, Inc., to falsely and fraudulently submit medical claims for reimbursement to Blue Cross Blue Shield of Florida from November 25, 2014 through May 25, 2015. The indictment charges Becerra with submitting fraudulent claims for beneficiaries purportedly receiving various injections.
27. United States v. Jorge A. Gonzalez and Lazaro La Paz Paz,
Case No. 17-20440-CR-Martinez
Jorge A. Gonzalez, 50, of Miami, Florida and Lazaro La Paz Paz, 50, of Hialeah, Florida are charged by indictment with one count of conspiracy to commit health care fraud and wire fraud. The indictment charges Gonzalez and La Paz Paz with using two companies, Xtra Health Center, Inc & Gold Medical Center, Inc, and fraudulently representing that medical services were prescribed by doctors and provided to private insurance beneficiaries by these businesses. Gonzalez and La Paz Paz then falsely and fraudulently submitted these medical claims for reimbursement to Blue Cross Blue Shield of Florida from April 2014 through February 2015.
Tricare Fraud – Military Insurance
28. United States v. Michael Shane Matthews, Case No. 17-20463-CR-Gayles
On July 6, 2017, Michael Shane Matthews, 47, of Newberry, Florida, was charged by information with causing the misbranding of drugs while held for sale.
29. United States v. Asciano Serna, Case No. 17-20484-CR-Altonaga
On July 7, 2017, Asciano Serna, owner and operator of ASC Pharmacy, Inc., was charged by information with one count of conspiracy to commit health care fraud. The charge arises from Serna’s role in a compounding pharmacy scheme at ASC Pharmacy involving the submission of at least $3.4 million of false and fraudulent claims to private insurance companies, Medicare, TRICARE, and other federal programs.
Unlicensed Money Transmitting and Money and Laundering
30. United States v. Yisel Torres, Case No. 17-20477-CR-Moreno
Yisel Torres, 31, of Cape Coral, Florida was charged by information with one count of participating as an unlicensed money transmitter. The information charges Torres with cashing several checks totaling $135,000 from on or about May 22, 2014, through on or about March 11, 2015. The proceeds that Torres cashed were used to pay cash kickbacks to Medicare beneficiaries that were enrolled in R&N Professional Services.
31. United States v. Angel Rivero, Case No. 17-20475-CR-Cooke
Angel Rivero, 43, of Miami, Florida was charged by information with one count of participating as an unlicensed money transmitter. The information charges Rivero with cashing several checks totaling $100,000 from on or about May 22, 2014, through on or about March 11, 2015. The proceeds that Rivero cashed were used to pay cash kickbacks to Medicare beneficiaries that were enrolled in Happy Heart Home Health Care.
32. United States v. Yailyn Marimon, et al., Case No. 17-20492-CR-Martinez
On July 11, 2017, Yailyn Marimon and Yamilka Echeverria were indicted in connection with their roles laundering money four Orlando-area medical clinics stole from Part C of the Medicare program. The Clinics, which were owned by Yosbel Marimon – the defendants’ brother and ex-husband, respectively – billed Medicare for $13.8 million of expensive infusion therapy drugs and physical therapy that were not medically necessary, and were never provided. On June 26, 2017, Yosbel Marimon was sentenced to 90 months’ imprisonment for his role in the scheme. The indictment alleges that Yailyn Marimon and Yamilka Echeverria laundered over $2 million of the fraud proceeds through shell companies they owned and controlled. Each defendant was charged with one count of conspiracy to commit money laundering and one count of substantive money laundering.
If convicted of a charged offense, a defendant faces a possible maximum statutory sentence of: five years in prison for participating in a conspiracy (to defraud the United States by paying and receiving health care kickbacks or by unlawfully distributing prescription drugs), in violation of Title 18, United States Code, Section 371; 20 years in prison for mail fraud, in violation of Title 18, United States Code, Section 1341; 20 years in prison for wire fraud, in violation of Title 18, United States Code, Section 1343; ten years in prison for health care fraud, in violation of Title 18, United States Code, Section 1347; twenty years for conspiracy to commit health care fraud and wire fraud, in violation of Title 18, United States Code, Section 1349; 20 years for money laundering or conspiracy to commit money laundering, in violation of Title 18, United States Code, Section 1956; and ten years in prison for money laundering, in violation of Title 18, United States Code, Section 1957; and five years in prison for conducting an unlicensed money transmitting business, in violation of Title 18, United States Code, Section 1960(b)(2). In addition, a defendant may be subject to one year in prison for misbranding a drug held for sale, in violation of Title 21, United States Code, Sections 331(t) (prescription drug marketing violations are subject to a maximum penalty of 10 years in prison, in accordance with Title 21, United States Code, Sections 333(b)(1)(D), and 353(e)(1)(A)) and five years in prison for payment and receipt of kickbacks in connection with a federal health care program, in violation of Title 42, United States Code, Section 1320a. Furthermore, if convicted of aggravated identity theft, in violation of Title 18, United States Code, Section 1028A, a defendant faces a mandatory consecutive term of two years in prison.
A criminal complaint, information or federal indictment is a charging instrument containing allegations. All defendants are presumed innocent, unless and until proven guilty in a court of law.
Related court documents and information may be found on the website of the District Court for the Southern District of Florida at www.flsd.uscourts.gov or on http://pacer.flsd.uscourts.gov.
The case was announced on July 13 by Benjamin G. Greenberg, Acting United States Attorney for the Southern District of Florida; George L. Piro, Special Agent in Charge, Federal Bureau of Investigation (FBI), Miami Field Office; Shimon R. Richmond, Special Agent in Charge, U.S. Department of Health & Human Services, Miami Regional Office, Office of Inspector General (HHS-OIG); and Pam Bondi, Florida Attorney General.
Source: United States Attorney's Office, Southern District of Florida

Report: Medical Errors Injure Upwards Of 488,900

By Steve Rensberry 
srensberry@rensberrypublishing.com
----------------------------------------------
   (RPC) - 2/19/2016 - A recent report by the Heartland Health Research Institute estimates that between 281,000 and 488,900 patients in Illinois hospitals are injured each year to do preventable medical errors or events. The estimate nationally is between 6.6 million and 11.5 million patients.
Preventable injuries occurring in Illinois hospitals.
    “If the Centers for Disease Control (CDC) were to include preventable medical errors in U.S. hospitals as a category, it would be the third leading cause of death in the United States, behind heart disease and cancer,” an HHRI press release about the report states.
   Fatalities occur in Illinois hospitals due to preventable adverse events (PAE) at an estimated rate of about 1 death for every 139 hospital admissions. By comparison, 11 patients die in hospitals from such errors for every vehicle fatality, 15 patients die for every murder committed in the state, and altogether nearly 3 percent of the state's entire population is harmed each year by PAEs. The frequency and volume translates into about one fatality every 50 minutes in the state due to such errors.
   The annual cost of such errors? The HHRI report estimates that in Illinois the annual social cost of such fatalities is about $5.2 billion. Nationally the cost is estimated between $23.1 billion and $103.4 billion. The number of injured patients annually in Illinois, based on the most common types of preventable medical errors, is as follows: adverse drug events (72,600 patients); venous thromboembolisms/, VTEs – blood clots that form within a vein (48,800); decubitus ulcers, bed soars (36,400); catheter-related urinary tract infections (17,500); falls in the hospital (16,200); nosocomial pneumonia (12,600); catheter, related bloodstream infections (6,300).  
   "Preventable medical errors in our hospitals is clearly alarming, both in the number of lives affected and in cost." Heartland Health Research Institute President David Lind stated. "Is Illinois making progress on preventable medical errors? The quick answer is, we don't really know because reporting yields a healthy dose of under-counting and under-reporting of medical errors. Without having stringently-coordinated regulations and policies that effectively hold providers accountable through transparent reporting, medical errors will continue and the public will remain in the dark. The Federal Aviation Administration has such regulations - shouldn't our safety be just as important when we enter a hospital as it is when we board an airplane? The public deserves transparency and accountability on this issue."
   A study by USA Today in 2013, using data from the National Practitioner Data Bank and other sources, point to an additional worry for potential patients – unnecessary surgeries, which the article states might account for as much as 10-20 percent of all operations in some specialties. Cites are cardiac procedures such as stents, angioplasty and pacemaker implants, spinal surgeries, hysterectomies, cesarean sections, and knee replacements.
   “Tens of thousands of times each year, patients are wheeled into the nation's operating rooms for surgery that isn't necessary,” authors Peter Eisler and Barbara Hensen write.
   What makes the size of the problem difficult to calculate is that only the worse cases are likely to become public knowledge, and if a surgery by chance takes care of a problem that could have been alleviated with lesser therapy or a non-surgical procedure, little suspicion is raised because the problem is gone.
   “Hospitals around the country do not report PAEs accurately and consistently - if at all,” the HHRI report states. “National experts acknowledge that most PAEs are either under reported or unreported. The Department of Health and Human Services Office of Inspector General issued a report in 2012 stating, 'Hospital staff did not report 86 percent of [patient harm] events to incident reporting systems, partly because of staff misperceptions about what constitutes patient harm.' This behavior reflects our culture of silence.”
   An October 27, 2015 Harvard Business Review report, written by Rebecca Wentraub, Yannis K. Valtis and Peter Bonis, claims there are many as 44,000 deaths in the Unites States each year due to preventable medical errors, with a price tag of roughly $17 billion.

U.S. Health Insurers Eye Bigger Profits In 2016

By Steve Rensberry 
srensberry@rensberrypublishing.com
----------------------------------------------
   (RPC) - 2/12/2016 - The Affordable Care Act not withstanding, health insurance companies across the United States have been seeking to raise their rates. Some companies, such as Blue Cross and Blue Shield of Minnesota, have sought increases of more than 50 percent in recent months. (1)
   In a Jan. 26 commentary written by CIGNA executive Wendell Porter and published by the Center for Public Integrity, that author notes that the nation's largest health insurer, UnitedHeathCare, posted profits of $10.3 billion in 2014, against revenues of $130.5 billion -- pushing its share price to $113.85. This is in sharp contract to a price of $30.40 in March of 2010.
   UnitedHealthCare isn't alone.
   “Every one of the big six saw their shares reach or come close to reaching historic highs. Although they haven’t done quite as well as United, the other five have seen the price of their stock more than double or triple. Health Net’s share price has increased 224 percent since March 2010. Anthem’s is up 238 percent over the same time period. Aetna’s 290 percent. Cigna’s 305 percent. And Humana’s 309 percent,” Porter writes. He cites the industry practice of purging unprofitable accounts--in particular small business accounts--as a contributing factor. (2)
   A Jan. 21 story by Paul R. La Monica, published by CNN and entitled “Thanks, Obamacare! Health insurer stocks soar,” cites the same record highs. “Many health care companies have yields that are significantly higher than the puny yields investors get from buying long-term U.S. Treasury bonds,” La Monica writes. (3)
   Kevin McCoy of USA Today suggests in a February 2 story that Aetna's fourth-quarter profits beat Wall Street forecasts, in part, because of an increase in the number of Medicare and Medicaid health plans it sells. (4)
   “The company said net income for the October -December quarter rose 38 percent to $320.8 million, or 91 cents a share,” McCoy writes. “That was up from $232 million, or 65 cents a share, for the same period last year.”
   New profits from Cigna Corp, meanwhile, were down 9 percent in the first quarter of 2015 (Mara Lee, Hartford Courant, Feb. 4), with the company citing higher costs associated with individual health insurance plans as one reason for the drop. A $48 million purchase by Anthem, announced last summer, is pending.
   Bob Herman, writing for Modern Healthcare, highlights other movements in the industry after years of uncertainty toward government programs and other types of investments, apart from traditional health plans. He cites data from Securities and Exchange Commission filings which show the percentage of UnitedHealthCare revenue from Medicare and Medicaid in 2009 at 49 percent, and it's share of commercial plan revenue at 50 percent, compared to 2014 revenues of 59 percent and 36 percent respectively. Aetna derived 24 percent of its profits from Medicare and Medicaid in 2009, and 76 percent from commercial accounts, compared to 42 percent and 58 percent in 2014 respectively. (5)
   “Federal spending on healthcare surpassed Social Security for the first time in 2015, thanks in large part to Medicaid expansion and the ACA's public exchanges, according to the Congressional Budget Office. Investor-owned HMOs that focus almost exclusively on outsourced Medicaid—such as Centene Corp. and Molina Healthcare—have thrived,” Heman states. “Medicare Advantage, perhaps more than any other federal program, has attracted the most interest because of the substantial revenue prospects from the growing numbers of baby boomers becoming Medicare-eligible. Almost 18 million people have a private Medicare Advantage plan, up from 10.5 million in 2009.”
   An analysis of 2016 premium changes and insurer participation in the Affordable Care Act's Health Insurance Marketplace, conducted by the Kaiser Family Foundation, looked at changes in the two lowest-priced Silver Plans for 11 major metropolitan areas and found an average, pre-tax credit increase of 4.4 percent. Those cities were: Portland, Oregon; Albuquerque, New Mexico; Richmond, Virginia; Burlington, Vermont; Baltimore, Maryland; Portland, Maine; Washington D.C.; Hartford, Connecticut; New York City, NY; Detroit, Michigan; and Seattle, Washington.
   “Our analysis is based on the 10 states plus the District of Columbia where we were able to find comprehensive filings or other information about the rates of the lowest-cost plans. Other states have released summary information, but not sufficient detail to identify the lowest-cost silver plans. In many cases, premiums are still under review by insurance departments and may change prior to the start of open enrollment,” the KFF report stated.

False Claims Act Reaps $3.5 Billion in FY 2015

   WASHINGTON – 1/1/2016 - The U.S. Department of Justice obtained more than $3.5 billion in settlements and judgments from civil cases involving fraud and false claims against the government in the fiscal year ending Sept. 30, Principal Deputy Assistant Attorney General Benjamin C. Mizer, head of the Justice Department’s Civil Division, announced in December, 2015. This is the fourth year in a row that the department has exceeded $3.5 billion in cases under the False Claims Act, and brings total recoveries from January 2009 to the end of the fiscal year to $26.4 billion.
    “The False Claims Act has again proven to be the government’s most effective civil tool to ferret out fraud and return billions to taxpayer-funded programs,” Mizer said. “The recoveries announced today help preserve the integrity of vital government programs that provide health care to the elderly and low income families, ensure our national security and defense, and enable countless Americans to purchase homes.”
    Of the $3.5 billion recovered last year, $1.9 billion came from companies and individuals in the health care industry for allegedly providing unnecessary or inadequate care, paying kickbacks to health care providers to induce the use of certain goods and services, or overcharging for goods and services paid for by Medicare, Medicaid, and other federal health care programs. The $1.9 billion reflects federal losses only. In many of these cases, the department was instrumental in recovering additional millions of dollars for consumers and state Medicaid programs.
   The next largest recoveries were made in connection with government contracts. The government depends on contractors to feed, clothe, and equip our troops for combat; for the military aircraft, ships, and weapons systems that keep our nation secure; as well as to provide everything that is needed to fund myriad programs at home. Settlements and judgments in cases alleging false claims for payment under government contracts totaled $1.1 billion in fiscal year 2015.
  The False Claims Act is the government’s primary civil remedy to redress false claims for government funds and property under government contracts, including national security and defense contracts, as well as under government programs as varied as Medicare, veterans’ benefits, federally insured loans and mortgages, highway funds, research grants, agricultural supports, school lunches, and disaster assistance. In 1986, Congress strengthened the Act by amending it to increase incentives for whistleblowers to file lawsuits on behalf of the government.
    Most false claims actions are filed under the Act’s whistleblower, or qui tam, provisions that allow individuals to file lawsuits alleging false claims on behalf of the government. If the government prevails in the action, the whistleblower, also known as the relator, receives up to 30 percent of the recovery. Whistleblowers filed 638 qui tam suits in fiscal year 2015 and the department recovered $2.8 billion in these and earlier filed suits this past year. Whistleblower awards during the same period totaled $597 million.
Health Care Fraud
    Including this past year’s $1.9 billion, the department has recovered nearly $16.5 billion in health care fraud since January 2009 to the end of fiscal year 2015 – more than half the health care fraud dollars recovered since the 1986 amendments to the False Claims Act. These recoveries restore valuable assets to federally funded programs such as Medicare, Medicaid, and TRICARE – the health care program for the military. But just as important, the department’s vigorous pursuit of health care fraud prevents billions more in losses by deterring others who might otherwise try to cheat the system for their own gain. The department’s success is a direct result of the high priority the Obama Administration has placed on fighting health care fraud. In 2009, the Attorney General and the Secretary of the Department of Health and Human Services, the department that administers Medicare and Medicaid, announced the creation of an interagency task force called the Health Care Fraud Prevention and Enforcement Action Team (HEAT), to increase coordination and optimize criminal and civil enforcement. Additional information on the government’s efforts in this area is available at StopMedicareFraud.gov, a webpage jointly established by the Departments of Justice and Health and Human Services.
    Two of the largest health care recoveries this past year were from DaVita Healthcare Partners, Inc., the leading provider of dialysis services in the United States. DaVita paid $450 million to resolve allegations that it knowingly generated unnecessary waste in administering the drugs Zemplar and Venofer to dialysis patients, and then billed the government for costs that could have been avoided. DaVita paid an additional $350 million to resolve claims that it violated the False Claims Act by paying kickbacks to physicians to induce patient referrals to its clinics. DaVita is headquartered in Denver, Colorado, and has dialysis clinics in 46 states and the District of Columbia.
   Hospitals were involved in nearly $330 million in settlements and judgments this past year. A cardiac nurse and a health care reimbursement consultant filed a qui tam suit against hundreds of hospitals that were allegedly implanting cardiac devices in Medicare patients contrary to criteria established by the Centers for Medicare and Medicaid Services in consultation with cardiologists, professional cardiology societies, cardiac device manufacturers, and patient advocates. The department settled with nearly 500 of these hospitals for a total of $250 million, including $216 million recovered in the past fiscal year. For details, see 500 Hospitals.
    Several settlements involved violations of the Stark Law. The Stark Statute prohibits certain financial relationships between hospitals and doctors that could improperly influence patient referrals. Services provided in violation of the Stark Statute are not reimbursable by Medicare or Medicaid. Hospitals settling false claims involving Stark violations include Adventist Health System for $115 million, an organization that operates hospitals and other health care facilities in 10 states; North Broward. Hospital District for $69.5 million, a special taxing district of Florida that operates hospitals and other health care facilities in Broward County, Florida; and Georgia hospital system Columbus Regional Healthcare System and Dr. Andrew Pippas for $25 million plus contingent payments up to an additional $10 million The Adventist settlement also involved allegations of miscoding claims to obtain higher reimbursements for services than allowed by Medicare and Medicaid
    Claims involving the pharmaceutical industry accounted for $96 million in settlements and judgments. Daiichi Sankyo Inc., a global pharmaceutical company with its U.S. headquarters in New Jersey, paid $39 million to resolve allegations of false claims against the United States and state Medicaid programs. Daiichi allegedly paid kickbacks to physicians to induce them to prescribe Daiichi drugs, including Azor, Benicar, Tribenzor and Welchol. Medicare and Medicaid prohibit reimbursement for drugs involved in kickback schemes. AstraZeneca LP and Cephalon Inc. paid the United States $26.7 million and $4.3 million, respectively, in separate settlements for allegedly underpaying rebates owed under the Medicaid Drug Rebate Program. As part of those settlements, the two drug manufacturers agreed to pay an additional $23 million to state Medicaid programs for their losses. And in another settlement, PharMerica Corp., the nation’s second largest nursing home pharmacy, agreed to pay the United States $9.25 million to resolve allegations that it solicited and received kickbacks from pharmaceutical manufacturer Abbott Laboratories in exchange for promoting the drug Depakote for nursing home patients. PharMerica is headquartered in Louisville, Kentucky.
    Skilled nursing homes and rehabilitation facilities have also been fertile ground for civil fraud and false claims actions. In the largest failure of care settlement with a skilled nursing home chain in the department’s history, Extendicare Health Services Inc. and its subsidiary, Progressive Step Corporation, agreed to pay the United States $32.3 million to resolve allegations that Extendicare billed Medicare and Medicaid for deficient nursing services and billed Medicare for medically unreasonable and unnecessary rehabilitation therapy services. Extendicare and Pro-Step paid an additional $5.7 million to eight states for their Medicaid losses. The department has ongoing litigation against additional nursing home chains and rehabilitation centers based on similar allegations of false claims for medically unreasonable or unnecessary rehabilitation therapy. For example, see HCR ManorCare.
Housing and Mortgage Fraud
    The department has recovered over $5 billion in housing and mortgage fraud from January 2009 to the end of fiscal year 2015, including this past year’s recoveries of $365 million. Notable recoveries this past year include a $212.5 million settlement with First Tennessee Bank N.A. First Tennessee admitted that from 2006 to 2008, through its subsidiary, First Horizon Home Loans Corporation, it originated and endorsed mortgages for federal insurance by the Federal Housing Administration (FHA) that did not meet eligibility requirements. First Tennessee also admitted failing to report such deficiencies to the authorities as required under the program despite widespread knowledge by its senior managers by early 2008. In August 2008, First Tennessee sold First Horizon to MetLife Bank N.A., a wholly-owned subsidiary of MetLife Inc. Metlife admitted similar misconduct regarding the loans it originated and endorsed from September 2008 to March 2012. MetLife paid the United States $123.5 million to resolve liability under the False Claims Act arising from its misconduct in endorsing mortgagees for FHA insurance.
    The department also settled claims against Walter Investment Management Corp. for $29.63 million. The government alleged that the company, through subsidiaries Reverse Mortgage Solution Inc., REO Management Solutions LLC, and RMS Asset Management Solutions LLC, caused false claims for fees and other costs in servicing reverse mortgages under the Department of Housing and Urban Development’s (HUD’s) Home Equity Conversion Mortgages (HECM) program. Reverse mortgage loans allow elderly people to access the equity in their homes. The loans provide monthly payments that enable the elderly to meet their day-to-day living expenses while remaining in their homes. To encourage these loans, HUD insures banks and other institutions that service the mortgages against loss, providing the institution complies with requirements to ensure the quality of such loans. Walter Investment allegedly failed to comply with these requirements.
    These recoveries are part of the broader enforcement efforts by President Obama’s Financial Fraud Enforcement Task Force. President Obama established the interagency task force in 2009, to wage an aggressive, coordinated, and proactive effort to investigate and prosecute financial crimes. The task force includes representatives from a broad range of federal agencies, regulatory authorities, inspectors general, and state and local law enforcement who, working together, bring to bear a powerful array of criminal and civil enforcement resources. The task force is working to improve efforts across the federal executive branch, and with state and local partners, to investigate and prosecute significant financial crimes, ensure just and effective punishment for those who perpetrate financial crimes, combat discrimination in the lending and financial markets, and recover proceeds for victims of financial crimes. For more information about the task force, visit www.stopfraud.gov.
Government Contracts
    Government contracts and federal procurement accounted for $1.1 billion in fraud settlements and judgments in fiscal year 2015, bringing procurement fraud totals to nearly $4 billion from January 2009 to the end of the fiscal year. Significant cases include a $146 million settlement with Supreme Group B.V. and several of its subsidiaries for alleged false claims to the Department of Defense (DoD) for food, water, fuel, and transportation of cargo for American soldiers in Afghanistan. Supreme Group is based in Dubai, United Arab Emirates (UAE). In addition, Supreme Group affiliates Supreme Foodservice GmbH, a privately held Swiss company, and Supreme Foodservice FZE, a privately-held UAE company, pleaded guilty to related criminal violations and paid more than $288 million in criminal fines.
    In two other defense contract settlements, Lockheed Martin Integrated Systems, a subsidiary of aerospace giant Lockheed Martin Inc., paid $27.5 million and DRS Technical Services Inc. paid $13.7 million to resolve allegations that their employees lacked required job qualifications while the companies charged for the higher level, qualified employees required under contracts with U.S. Army Communication and Electronics Command (CECOM). The CECOM contracts were designed to give the Army rapid access to products and services for operations in Iraq and Afghanistan.
In a pair of cases involving contracts with the General Services Administration, VMware Inc. and Carahsoft Technology Corporation paid the United States $75.5 million and Iron Mountain Companies paid $44.5 million to settle their respective liability under the False Claims Act. The government alleged that California-based VMware and Virginia-based Carahsoft misrepresented their commercial sales practices, which resulted in overcharging government agencies for their software products and services sold through GSA’s Multiple Award Schedule. Similarly, Iron Mountain, a records storage company headquartered in Massachusetts, misrepresented its commercial sales practices to GSA and failed to give certain discounts given to its commercial customers, as required to gain access to the vast federal marketplace available to contractors through the Multiple Award Schedule.
    The department settled allegations that private contractor U.S. Investigations Services Inc. (USIS) violated the False Claims Act in performing a contract with the Office of Personnel Management (OPM) to perform background investigations of federal employees and those applying for federal service. The government alleged that USIS took shortcuts that compromised its contractually-required quality review and that, had the government known, it would not have paid for the services. USIS agreed to forego at least $30 million in payments legitimately owed to the company to settle the government’s allegations.
Other Fraud Recoveries and Actions
    Although health care, mortgage, and government contract fraud dominated fiscal year 2015 recoveries, the U.S. Justice Department has aggressively pursued fraud wherever it is found in federal programs.The department recovered $44 million from Fireman’s Fund Insurance Company for alleged fraud under the U.S. Department of Agriculture’s federal crop insurance program. The United States alleged that Fireman’s Fund knowingly issued federally reinsured crop insurance policies that were ineligible for federal reinsurance. Specifically, Fireman’s Fund allegedly backdated policies, forged farmers’ signatures, accepted late and altered documents, whited-out dates and signatures, and signed documents after relevant deadlines. The policies were issued by Fireman’s Fund offices in California, Kansas, Mississippi, North Dakota, Texas, and Washington.
    The department also recovered $13 million from Education Affiliates, a for-profit education company based in White Marsh, Maryland, for alleged false claims to the Department of Education for student aid for students whose qualifications for admission were falsified to get them enrolled so they could receive aid which would be paid to the school. Education Affiliates operates 50 campuses throughout the United States under various trade names.
    In other actions, the department filed lawsuits to recover funds disbursed under the Troubled Asset Relief Program (TARP) and payments made under contracts awarded to benefit disadvantaged populations identified under the Small Business Administration’s set-aside programs. In one action, the department sued the estate and trusts of the late Layton P. Stuart, former owner and president of One Financial Corporation, and its operating subsidiary, One Bank & Trust N.A., both based in Arkansas, alleging that Stuart made misrepresentations to induce the Department of the Treasury to invest TARP funds in One Financial as part of Treasury’s Capital Purchase Program. The department recently settled with the Stuart estate and trusts for $4 million, but claims remain pending against One Financial Corporation.
   In a second action, the department filed suit against Florida-based Air Ideal Inc. and its owner, Kim Amkraut. The government alleged that Air Ideal and Amkraut falsely certified that the company qualified for preferences given to small businesses located in a Historically Underutilized Business Zone (HUBZone) when Air Ideal’s HUBZone location was no more than a virtual office and its principal place of business was in a non-HUBZone location. The government further alleged that Air Ideal used its fraudulently-procured HUBZone certification to obtain contracts from the Coast Guard, Army, Army Corps of Engineers, and Department of the Interior that were worth millions of dollars. The department settled with Air Ideal and Amkraut for $250,000 plus five percent of Air Ideal’s gross revenues for five years.
    In addition to those suits involving individuals described above, the department settled or filed suit against individuals in an array of cases. For example, Two Florida couples agreed to pay the United States $1.137 million collectively, to resolve allegations that they accepted kickbacks in exchange for home health care referrals to A Plus Home Health Care Inc. The United States previously settled with A Plus, its owner Tracy Nemerofsky, and five other couples that allegedly accepted payments from A Plus. Dr. Charles Denham, of Laguna Beach, California, paid the United States $1 million to settle allegations that he solicited and accepted kickbacks from CareFusion in return for promoting a CareFusion product and influencing recommendations by the National Quality Forum.
    Denham was a patient safety consultant who co-chaired a National Quality Forum Committee. After settling with two cardiovascular testing laboratories for $48.5 million - Health Diagnostics Laboratory Inc. (HDL) and Singulex Inc., the department intervened in three qui tam suits against another laboratory, Berkeley HeartLab Inc., a marketing company, BlueWave Healthcare Consultants Inc. and three individualsBlueWave’s owners, Floyd Calhoun Dent III and Robert Bradley Johnson and HDL’s co-founder and former chief executive officer, LaTonya Mallory. The department also intervened in two qui tam suits against Florida cardiologist Dr. Asad Qamar and his practice, the Institute for Cardiovascular Excellence PLLC, alleging that Qamar and his practice billed Medicare for medically unnecessary peripheral artery procedures and interventions and paid kickbacks to patients by waiving Medicare copayments irrespective of financial hardship. The department also filed a complaint against H. Ted Cain, Julie Cain, Corporate Management Inc. and Stone County Hospital Inc. for false claims for Medicare reimbursement. The government alleged that Ted and Julie Cain, the hospital and hospital management company owned and controlled by Ted Cain, claimed reimbursement for the hospital’s costs at inflated rates and for ineligible expenses. These matters are ongoing.
    Outside the health care arena, EDF Resource Capital Inc. agreed to transfer assets worth $5.8 million to the United States, and its chief executive officer, Frank Dinsmore, agreed to pay $200,000 to the United States, to settle allegations that they violated the False Claims Act in failing to remit payments to the Small Business Administration under the 504 loan program. The 504 loan program provides growing businesses with long-term, fixed-rate financing for major fixed assets, such as land and buildings. The program operates through local lenders like EDF, who reap benefits from the program in return for shouldering certain financial obligations which Dinsmore and EDF allegedly ignored. The department also entered settlements with two individuals for evasion of Customs duties owed on imports of aluminum extrusions from the People’s Republic of China (PRC). Robert Wingfield, the U.S. sales representative of a Chinese manufacturer, and Bill Ma, owner of an ostensible importer, allegedly misrepresented the country of origin of goods to avoid steep antidumping and countervailing duties imposed by the Department of Commerce and collected by U.S. Customs and Border Protection on imports of aluminum extrusions from the PRC to protect domestic manufacturers from unfair foreign pricing practices. The government previously settled related allegations with four importers, bringing total settlements in the case to $4.6 million, including the $435,000 from Wingfield and Ma.
Recoveries in Whistleblower Suits
    Of the $3.5 billion the government recovered in fiscal year 2015, more than $2.8 billion related to lawsuits filed under the qui tam provisions of the False Claims Act. During the same period, the government paid out $597 million to the individuals who exposed fraud and false claims by filing a qui tam complaint, often at great risk to their careers.
    The number of lawsuits filed under the qui tam provisions of the Act has grown significantly since 1986, with 638 qui tam suits filed this past year. The growing number of qui tam lawsuits, particularly since 2009, has led to increased recoveries. From January 2009 to the end of fiscal year 2015, the government recovered $19.4 billion in settlements and judgments related to qui tam suits and paid whistleblower awards of $3 billion during the same period.
    “Many of the recoveries obtained under the False Claims Act result from courageous men and women who come forward to blow the whistle on fraud they are often uniquely positioned to expose,” said Principal Deputy Assistant Attorney General Mizer.
    In 1986, Senator Charles Grassley and Representative Howard Berman led successful efforts in Congress to amend the False Claims Act to, among other things, encourage whistleblowers to come forward with allegations of fraud. In 2009, Senator Patrick J. Leahy, along with Senator Grassley and Representative Berman, championed the Fraud Enforcement and Recovery Act of 2009, which made additional improvements to the False Claims Act and other fraud statutes. And in 2010, the passage of the Affordable Care Act provided additional inducements and protections for whistleblowers and strengthened the provisions of the federal health care Anti-Kickback Statute.
   Principal Deputy Assistant Attorney General Mizer also expressed his deep appreciation for the many dedicated public servants who investigated and pursued these cases – the attorneys, investigators, auditors and other agency personnel throughout the Department of Justice’s Civil Division and the U.S. Attorneys’ Offices, as well as the agency Offices of Inspector General and the many federal and state agencies that contributed to the department’s recoveries this past fiscal year.
    “The department’s lawyers and staff, together with our law enforcement partners in federal and state governments, work tirelessly and often overcome daunting challenges to achieve these successes on behalf of the taxpayers,” Mizer said.
    The government’s claims in the matters described above are allegations only; except where indicated, there has been no determination of liability.
    Source: U.S. Department of Justice release of 12/19/2015