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Showing posts with label Medicare. Show all posts
Showing posts with label Medicare. Show all posts

Law and Justice


Justice Department Charges 

Dozens for $1.2 Billion 

in Health Care Fraud

 

     WASHINGTON, D.C., (DOJ) - 7/20/2022 - The Department of Justice today announced criminal charges against 36 defendants in 13 federal districts across the United States for more than $1.2 billion in alleged fraudulent telemedicine, cardiovascular and cancer genetic testing, and durable medical equipment (DME) schemes.

    The nationwide coordinated law enforcement action includes criminal charges against a telemedicine company executive, owners and executives of clinical laboratories, durable medical equipment companies, marketing organizations, and medical professionals.

    Additionally, the Centers for Medicare & Medicaid Services (CMS), Center for Program Integrity (CPI) announced today that it took adverse administrative actions against 52 providers involved in similar schemes. In connection with the enforcement action, the department seized over $8 million in cash, luxury vehicles, and other fraud proceeds.

    “The Department of Justice is committed to prosecuting people who abuse our health care system and exploit telemedicine technologies in fraud and bribery schemes,” said Assistant Attorney General Kenneth A. Polite, Jr. of the Justice Department’s Criminal Division. “This enforcement action demonstrates that the department will do everything in its power to protect the health care systems our communities rely on from people looking to defraud them for their own personal gain.”

    The coordinated federal investigations announced today primarily targeted alleged schemes involving the payment of illegal kickbacks and bribes by laboratory owners and operators in exchange for the referral of patients by medical professionals working with fraudulent telemedicine and digital medical technology companies. Telemedicine schemes account for more than $1 billion of the total alleged intended losses associated with today’s enforcement action. These charges include some of the first prosecutions in the nation related to fraudulent cardiovascular genetic testing, a burgeoning scheme. As alleged in court documents, medical professionals made referrals for expensive and medically unnecessary cardiovascular and cancer genetic tests, as well as durable medical equipment. For example, cardiovascular genetic testing was not a method of diagnosing whether an individual presently had a cardiac condition and was not approved by Medicare for use as a general screening test for indicating an increased risk of developing cardiovascular conditions in the future.

    “Protecting the American people is at the forefront of the FBI’s mission,” said Assistant Director Luis Quesada of the FBI’s Criminal Investigative Division. “Fraudsters and scammers take advantage of telemedicine and use it as a platform to orchestrate their criminal schemes. This collaborative law enforcement action shows our dedication to investigating and bringing to justice those who look to exploit our U.S. health care system at the expense of patients.”

    “Today’s enforcement action highlights our dedication to fighting health care fraud and investigating individuals who target Medicare beneficiaries and steal from taxpayers for personal gain,” said Inspector General Christi A. Grimm of the U.S. Department of Health and Human Services. “HHS-OIG is proud to work alongside our law enforcement partners to disrupt fraud schemes that use the guise of telehealth to expand the reach of kickback schemes designed to cheat federally funded health care programs.”

    One particular case charged involved the operator of several clinical laboratories, who was charged in connection with a scheme to pay over $16 million in kickbacks to marketers who, in turn, paid kickbacks to telemedicine companies and call centers in exchange for doctors’ orders. As alleged in court documents, orders for cardiovascular and cancer genetic testing were used by the defendant and others to submit over $174 million in false and fraudulent claims to Medicare—but the results of the testing were not used in treatment of patients. The defendant allegedly laundered the proceeds of the fraudulent scheme through a complex network of bank accounts and entities, including to purchase luxury vehicles, a yacht, and real estate. The indictment seeks forfeiture of over $7 million in United States currency, three properties, the yacht, and a Tesla and other vehicles.  

    Some of the defendants charged in this enforcement action allegedly controlled a telemarketing network, based both domestically and overseas, that lured thousands of elderly and/or disabled patients into a criminal scheme. The owners of marketing organizations allegedly had telemarketers use deceptive techniques to induce Medicare beneficiaries to agree to cardiovascular genetic testing, and other genetic testing and equipment.

    “The Centers for Medicare & Medicaid Services continues to aggressively investigate fraud, waste and abuse and has taken action to protect patients, critical health care resources and to prevent losses to the Medicare Trust Fund,” said CMS Administrator Chiquita Brooks-LaSure. “Work like this to combat fraud, waste, and abuse in our federal programs would not be possible without the successful partnership of CMS, the Department of Justice, and the U.S. Department of Health and Human Services Office of Inspector General.”

    The charges announced today allege that the telemedicine companies arranged for medical professionals to order these expensive genetic tests and durable medical equipment regardless of whether the patients needed them, and that they were ordered without any patient interaction or with only a brief telephonic conversation. Often, these test results or durable medical equipment were not provided to the patients or were worthless to their primary care doctors. 

    Today’s announcement builds on prior telemedicine enforcement actions involving over $8 billion in fraud, including 2019’s Operation Brace Yourself, 2019’s Operation Double Helix, 2020’s Operation Rubber Stamp, and the telemedicine component of the 2021 National Health Care Fraud Enforcement Action. Specifically, the Operation Brace Yourself Telemedicine and Durable Medical Equipment Takedown alone resulted in an estimated cost avoidance of more than $1.9 billion in the amount paid by Medicare for orthotic braces in the 20 months following that enforcement action.

    Today’s enforcement actions were led and coordinated by Acting Principal Assistant Chief Jacob Foster, Acting Assistant Chief Rebecca Yuan and Trial Attorney Catherine Wagner of the National Rapid Response Strike Force in the Criminal Division’s Fraud Section. The Fraud Section’s National Rapid Response Strike Force and the Health Care Fraud Unit’s Strike Forces (SF) in Brooklyn, Detroit, the Gulf Coast, Houston, Miami, Newark, as well as the U.S. Attorneys’ Offices for the District of New Jersey, Eastern District of Louisiana, Eastern District of Texas, Middle District of Florida, Middle District of Tennessee, Northern District of Georgia, Northern District of Mississippi, and Western District of North Carolina are prosecuting these cases.

    In addition to the FBI, HHS-OIG, and CPI/CMS, VA-OIG, DCIS, IRS, MFCU, DEA, and other federal and state law enforcement agencies participated in the operation.

    Prior to the charges announced as part of today’s nationwide enforcement action and since its inception in March 2007, the Health Care Fraud Strike Force, which maintains 16 strike forces operating in 27 districts, has charged more than 5,000 defendants who collectively billed federal health care programs and private insurers approximately $24.7 billion.

    A complaint, information or indictment is merely an allegation, and all defendants are presumed innocent until proven guilty beyond a reasonable doubt in a court of law.

    The following documents related to today’s announcement are available on the Health Care Fraud Unit website through the following links:

Telemedicine Enforcement Action (justice.gov)

Telemedicine Court Documents (justice.gov)

Telemedicine Press Releases (justice.gov)

Telemedicine Case Summaries (justice.gov)

    Any patients who believe that they have been contacted as part of a fraudulent telemedicine, clinical laboratory, or DME scheme should call to report this conduct to HHS-OIG at 1-800-HHS-TIPS.

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.

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

Medicare Fraud Case Exceeds $5 Million

   HOUSTON, TEX – 4/19/2017 - A Houston-Area registered nurse pleaded guilty on April 17 for his role in a Medicare fraud scheme that resulted in losses to Medicare of more than $5 million.
   Charles Esechie, 47, of Katy, Texas, pleaded guilty before U.S. District Judge Sim Lake of the Southern District of Texas to one count of conspiracy to commit health care fraud. Esechie is scheduled to be sentenced by Judge Lake on Aug. 17, 2017
   According to the plea, from 2008 through 2015, Esechie worked as a nurse for both Harris County, Texas, Hospital District (Harris County) and Baptist Home Care Providers Inc. (Baptist), one of five Houston-area home healthcare agencies owned by Godwin Oriakhi. Esechie admitted that while he worked at Baptist, he knew that Oriakhi obtained Medicare patients by paying illegal kickback payments to patient recruiters for referring patients to Baptist for home healthcare services that Esechie knew were medically unnecessary and often not provided. Esechie also admitted that he knew that some of patients referred by the patient recruiters were homeless, and that many patients stayed at Baptist in order to receive kickbacks from Oriakhi rather than actual healthcare.
   Additionally, Esechie admitted that he engaged in a scheme to defraud Medicare through the submission of fraudulent claims for home health care services. Esechie admitted that he completed Baptist’s Medicare documents while working full time as a Harris County nurse, often claiming that he was evaluating patients for Baptist at times when his Harris County employment records showed that he was across town working at a Harris County hospital.
   To accommodate his full-time work schedule at Harris County and to avoid actually having to travel to the homes of Baptist’s patients for evaluations, Esechie admitted that he copied patient and medical information from templates created for him by Orikahi and Baptist’s office staff onto Baptist’s Medicare documents. Esechie also admitted that he saw patients in groups at the home of one of Oriakhi’s patient recruiters and conducted perfunctory examinations that lasted approximately five to 10 minutes, but over-billed Medicare for comprehensive examinations.
   In total, Esechie admitted that he, Oriakhi and others submitted approximately $5,099,970 in fraudulent home healthcare claims to Medicare, and received approximately $4,792,199 on those claims.
   To date, Jermaine Doleman, a patient recruiter, and Idia Oriakhi, Oriakhi’s daughter and the administrator of several of his home healthcare agencies, have pleaded guilty and are awaiting sentencing for their roles in the scheme. Godwin Oriakhi is charged with conspiracy, health care fraud, paying illegal kickbacks and money laundering offenses for his alleged role in the schemes and is scheduled for trial on April 11, 2017. All defendants are presumed innocent unless and until convicted beyond a reasonable doubt in a court of law.
   The FBI, HHS-OIG, IRS-CI and MFCU investigated the case, which was brought by the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Southern District of Texas. Senior Trial Attorney Jonathan T. Baum and Trial Attorneys Aleza S. Remis and William S.W. Chang of the Fraud Section are prosecuting the case.
   Acting Assistant Attorney General Kenneth A. Blanco of the Justice Department’s Criminal Division, Acting U.S. Attorney Abe Martinez of the Southern District of Texas, Special Agent in Charge Perrye K. Turner of the FBI’s Houston Field Office, Special Agent in Charge C.J. Porter of the Department of Health and Human Services Office of the Inspector General’s (HHS-OIG) Dallas Regional Office, Special Agent in Charge D. Richard Goss of Internal Revenue Service Criminal Investigation’s (IRS-CI) Houston Field Office and the Texas Attorney General’s Medicaid Fraud Control Unit (MFCU) made the announcement.
   Source: Financial Fraud Enforcement Task Force

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

Physician Sentenced For Defrauding Medicare

  Nov. 24, 2015 -- A Detroit-area physician who led and directed a multi-million-dollar Medicare fraud scheme through his medical practice was sentenced today to 72 months in prison.
   Dr. Hicham A. Elhorr, 48, of Dearborn, Michigan, was sentenced by U.S. District Judge Nancy G. Edmunds of the Eastern District of Michigan. In addition to imposing the prison term, Judge Edmunds ordered Elhorr to pay $2,073,108.16 in restitution.
   According to admissions in his plea agreement, from approximately August 2008 through September 2012, Elhorr and his coconspirators fraudulently billed Medicare $4.2 million for purported in-home physician services. Elhorr admitted that he employed unlicensed individuals through his visiting physician practice, House Calls Physicians PLLC, who held themselves out as licensed physicians and purported to provide physician home visits and other services to Medicare beneficiaries in Michigan. The unlicensed individuals prepared medical documentation that Elhorr and other licensed physicians signed as if they had performed the visits when, in fact, no licensed physicians had treated the beneficiaries.
   The case was investigated by the FBI and HHS-OIG and brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office of the Eastern District of Michigan. The case was prosecuted by former Assistant Chief Catherine K. Dick and Trial Attorneys Matthew C. Thuesen and F. Turner Buford of the Criminal Division’s Fraud Section.
  The announcement was made by Assistant Attorney General Leslie R. Caldwell of the Justice Department’s Criminal Division, U.S. Attorney Barbara L. McQuade of the Eastern District of Michigan, Special Agent in Charge David P. Gelios of the FBI’s Detroit Field Office and Special Agent in Charge Lamont Pugh III of the U.S. Department of Health and Human Services-Office of Inspector General (HHS-OIG) made the announcement.
  The Medicare Fraud Strike Force  operates in nine cities across the country and has charged approximately 2,300 defendants who have collectively billed the Medicare program for more than $7 billion since its inception in 2007.


Authorities Charge 90 with Medicare Fraud

   WASHINGTON - (FBI) - 5/14/2014 - Attorney General Eric Holder and Department of Health and Human Services (HHS) Secretary Kathleen Sebelius announced on May 13 that a nationwide takedown by Medicare Fraud Strike Force operations in six cities has resulted in charges against 90 individuals, including 27 doctors, nurses, and other medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $260 million in false billings.
   Holder and Sebelius were joined in the announcement by Acting Assistant Attorney General David O’Neil of the Justice Department’s Criminal Division, FBI Assistant Director Joseph Campbell, U.S. Department of Health and Human Services (HHS) Inspector General Daniel Levinson, and Deputy Administrator and Director of the Centers for Medicare & Medicaid Services (CMS) Center for Program Integrity Shantanu Agrawal.
   The coordinated takedown was the seventh national Medicare fraud takedown in Strike Force history. The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative announced in May 2009 between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country.
   Since their inception in March 2007, strike force operations in nine locations have charged almost 1,900 defendants who collectively have falsely billed the Medicare program for almost $6 billion. In addition, CMS, working in conjunction with HHS-OIG, has suspended enrollments of high-risk providers in five strike force locations and has removed over 17,000 providers from the Medicare program since 2011.
   The joint Department of Justice and HHS Medicare Fraud Strike Force is a multi-agency team of federal, state, and local investigators designed to combat Medicare fraud through the use of Medicare data analysis techniques and an increased focus on community policing. Almost 400 law enforcement agents from the FBI, HHS-OIG, multiple Medicaid Fraud Control Units, and other federal, state, and local law enforcement agencies participated in the takedown.
   “Medicare is a sacred compact with our nation’s seniors, and to protect it, we must remain aggressive in combating fraud,” Holder said. “This nationwide Medicare Strike Force takedown represents another important step forward in our ongoing fight to safeguard taxpayer resources and to ensure the integrity of essential health care programs. Department of Justice will not tolerate these activities. And we will continue working alongside the Department of Health and Human Services—as well as federal, state, and local partners—to use every appropriate tool and available resource to find, stop, and punish those who seek to take advantage of their fellow citizens.”
   The defendants charged are accused of various health care fraud-related crimes, including conspiracy to commit health care fraud, violations of the anti-kickback statutes, and money laundering. The charges are based on a variety of alleged fraud schemes involving various medical treatments and services, including home health care, mental health services, psychotherapy, physical and occupational therapy, durable medical equipment, and pharmacy fraud.
   According to court documents, the defendants allegedly participated in schemes to submit claims to Medicare for treatments that were medically unnecessary and often never provided. In many cases, court documents allege that patient recruiters, Medicare beneficiaries, and other co-conspirators were paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could then submit fraudulent bills to Medicare for services that were medically unnecessary or never performed. Collectively, the doctors, nurses, licensed medical professionals, health care company owners, and others charged are accused of conspiring to submit approximately $260 million in fraudulent billings.
  “Today, across the nation, scores of defendants were arrested for engaging in hundreds of millions of dollars in health care fraud,” O’Neil said. “Among the defendants charged were 27 medical professionals, including 16 doctors. The crimes charged represent the face of health care fraud today—doctors billing for services that were never rendered, supply companies providing motorized wheelchairs that were never needed, recruiters paying kickbacks to get Medicare billing numbers of patients. The fraud was rampant, it was brazen, and it permeated every part of the Medicare system. But law enforcement continues to strike back. Using cutting-edge, data-driven investigative techniques, we are bringing fraudsters to justice and saving the American taxpayers billions of dollars. Overall, since its inception, the Department of Justice’s Medicare Fraud Strike Force has charged nearly 1,900 individuals involved in approximately $6 billion of fraud. We are committed to using every tool at our disposal to prevent, deter, and prosecute health care fraud.”
   In Miami, a total of 50 defendants were charged for their alleged participation in various fraud schemes involving approximately $65.5 million in false billings for home health care and mental health services and pharmacy fraud. In one case, two defendants were charged in connection with a $23 million pharmacy kickback and laundering scheme. Court documents allege that the defendants solicited kickbacks from a pharmacy owner for Medicare beneficiary information, which was used to bill for drugs that were never dispensed. The kickbacks were concealed as bi-weekly payments under a sham services contract and were laundered through shell entities owned by the defendants.
   Eleven individuals were charged by the Houston Medicare Strike Force. Five Houston-area physicians were charged with conspiring to bill Medicare for medically unnecessary home health services. According to court documents, the defendant doctors were paid by two co-conspirators to sign off on home health care services that were not necessary and often never provided.
   Eight defendants were charged in Los Angeles for their roles in schemes to defraud Medicare of approximately $32 million. In one case, a doctor was charged for causing almost $24 million in losses to Medicare through his own fraudulent billing and referrals for durable medical equipment, including over 1,000 expensive power wheelchairs and home health services that were not medically necessary and frequently not provided.
   In Detroit, seven defendants were charged for their roles in fraud schemes involving approximately $30 million in false claims for medically unnecessary services, including home health services, psychotherapy, and infusion therapy. In one case, four individuals, including a doctor, were charged in a sophisticated $28 million fraud scheme in which the physician billed for expensive tests, physical therapy, and injections that were not necessary and not provided. Court documents allege that when the physician’s billings raised red flags, he was put on payment review by Medicare. He was allegedly able to continue his scheme and evade detection by continuing to bill using the billing information of other Medicare providers, sometimes without their knowledge.
   In Tampa, Florida, seven individuals were charged in a variety of schemes, ranging from fraudulent physical therapy billings to a scheme involving millions of dollars in physician services and tests that never occurred. In one case, five individuals were charged for their alleged roles in a $12 million health care fraud and money laundering scheme that involved billing Medicare using names of beneficiaries from Miami-Dade County for services purportedly provided in Tampa area clinics, 280 miles away. The defendants then allegedly laundered the proceeds through a number of transactions involving several shell entities.
   In Brooklyn, New York, the strike force announced an indictment against Syed Imran Ahmed, M.D., in connection with his alleged $85 million scheme involving billings for surgeries that never occurred; Dr. Ahmed had been arrested last month and charged by complaint. Dr. Ahmed has charged with health care fraud and making false statements. In addition, the Brooklyn Strike Force charged six other individuals, including a physician and two billers who allegedly concocted a $14.4 million scheme in which they recruited elderly Medicare beneficiaries and billed Medicare for medically unnecessary vitamin infusions, diagnostic tests and physical and occupational therapy supposedly provided to these patients.
   The cases are being prosecuted and investigated by Medicare Fraud Strike Force teams composed of attorneys from the Fraud Section of the Justice Department’s Criminal Division and from the U.S. Attorney’s Offices for the Southern District of Florida, the Eastern District of Michigan, the Eastern District of New York, the Southern District of Texas, the Central District of California, the Middle District of Louisiana, the Northern District of Illinois, and the Middle District of Florida; and agents from the FBI, HHS-OIG, and state Medicaid Fraud Control Units.
   Source: U.S. Federal Bureau of Investigation