Sunday, July 31, 2011

Elizabeth Acosta Sanz and Luis Alejandro Sanz, both of Miami, Charged with Home Health Care Fraud


Source- http://www.fbi.gov/miami/press-releases/2011/miami-husband-and-wife-charged-with-home-health-care-fraud

Miami Regional Office, announced the indictment of Elizabeth Acosta Sanz and Luis Alejandro Sanz, both of Miami, Florida, on charges of conspiracy to commit health care fraud, health care fraud, conspiracy to pay kickbacks, the payment of kickbacks, conspiracy to commit money laundering, and money laundering, in violation of Title 18, United States Code, Sections 1349, 1347, 371 and 1956, respectively.

According to charges, the defendants, husband and wife, owned Ideal Home Health, a Miami-Dade home health agency that purportedly provided skilled nursing services to homebound Medicare beneficiaries. The indictment alleges that the defendants used Ideal submit fraudulent claims to Medicare for home health services that were neither medically necessary nor actually provided to Medicare beneficiaries.

More specifically, the indictment alleges that from August 2006 through March 2009, the defendants offered and paid kickbacks to recruiters and others. These individuals, in turn, paid Medicare beneficiaries to induce them to agree to be serviced by Ideal. In addition, the defendants instructed nurses to falsify patient medical records to make it appear that the Medicare beneficiaries qualified for and received home health services. In fact, however, the services were not medically necessary and had not been provided.

 In total, the defendants submitted approximately $11,340,342 in false claims to Medicare, of which Medicare paid $7,317,879. According to the criminal complaint, $1.6 million in checks were written to Elizabeth Acosta Sanz and $1.6 million in checks were written to Luis Alejandro Sanz.


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Saturday, July 30, 2011

U.S. Government Intervenes in False Claims Lawsuit Against Nurses’ Registry and Home Health Corporation


Source- http://www.justice.gov/opa/pr/2011/July/11-civ-966.html

WASHINGTON – The United States has intervened in a lawsuit against Nurses’ Registry and Home Health Corporation in the U.S. District Court for the Eastern District of Kentucky, the Justice Department announced today. The lawsuit was filed in March 2008 by two former Nurses’ Registry employees, Alicia Robinson-Hill and David Price, and alleges among other things that Nurses’ Registry made false claims to Medicare for medically unnecessary home health services.

According to the complaint, Nurses’ Registry exaggerated the medical conditions and needs of its patients for home health care services, both at the start of service and for additional and continuing care, in order to qualify for, and artificially increase, its claims to Medicare. The Lexington, Ky., company, according to its website “provides a wide range of home health care services including skilled nursing, physical and occupational therapies, in-home IV therapy, homemaker aid (bathing, dressing, grooming), and private duty.”

The lawsuit was filed under the qui tam, or whistleblower, provisions of the False Claims Act, which permit private parties to sue on behalf of the United States and share in any recovery. The False Claims Act permits the government to recover three times its damages, plus civil penalties. The government has asked the court for 45 days to file its own complaint stating the United States’ allegations.

“Home health care providers furnish essential services to some of our most vulnerable citizens,” said Tony West, Assistant Attorney General for the Justice Department’s Civil Division. “Those who misstate the conditions of their patients for their own financial gain erode the integrity of the health care system, and they do it at taxpayers’ expense.”


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Thursday, July 28, 2011

Helathcare Worker Jianzhu Liang Sentenced for Medical Fraud



Las Vegas – The Office of the Nevada Attorney General reports that Las Vegan Jianzhu Liang, age 51, was sentenced for Medicaid Fraud. Liang pled guilty to a gross misdemeanor offense: Intentional Failure to Maintain Adequate Records. Liang was sentenced to 60 days in jail, suspended, 3 years of probation, performance of 40 hours of community service and payment of $9,220.00 in restitution, penalties, and costs. The case was investigated and prosecuted by the Attorney General’s Medicaid Fraud Control Unit (MFCU). 

“We benefit our neediest citizens and protect the Medicaid system when we prosecute anyone who would defraud the system and steal Medicaid dollars,” said Attorney General Catherine Cortez Masto. 

In 2010, Nevada Medicaid provided information to the MFCU that Liang was suspected of not providing personal care services to a Medicaid recipient for which she had nonetheless still received payment from Medicaid. Medicaid has a personal care assistant program to keep people living independently in their own homes by providing basic services, including bathing, dressing, cleaning and meal preparation. Liang was employed by a home care company to provide the actual day-to-day care for two recipients. It was discovered that Liang indeed failed to provide care services for the patients for whom she was employed, yet claimed that she performed the services and received payment as if she had actually performed the services.

Persons convicted of Medicaid fraud may also be excluded from future Medicaid participation.


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Wednesday, July 27, 2011

Pharmacists Luba Balyasny Charged in $3 Million Health Care Fraud Scheme


Source- http://www.justice.gov/opa/pr/2011/July/11-crm-970.html

WASHINGTON – Two defendants who co-owned and operated two Brooklyn,N.Y.,-area pharmacies were arrested today on health care fraud charges for their alleged participation in a scheme to defraud Medicare Part D that resulted in more than $3 million in fraudulent billings, announced the Department of Justice, FBI and the Department of Health and Human Services (HHS) and its Office of Inspector General (OIG).

Luba Balyasny, 46, and Alla Shrayber, 40, are each charged with conspiracy to commit health care fraud in a criminal complaint unsealed today in the Eastern District of New York. Balyasny and Shrayber, both of Brooklyn, are licensed pharmacists in New York State who co-owned and operated Monica’s Pharmacy and L & A Pharmacy.

According to court documents, from January 2007 through December 2009, Balyasny and Shrayber allegedly defrauded the Medicare Part D program by systematically submitting false claims through their pharmacies for certain prescription medications that were not purchased by their businesses and were never dispensed to Medicare beneficiaries. The complaint alleges that the inventory at both pharmacies for certain prescription medications did not match the pharmacies’ Part D reimbursement claims. According to court documents, the pharmacies submitted prescription drug claims totaling approximately 869,698 units of prescription medications without any supporting drug purchase invoices. The shortfall allegedly resulted in approximately $3 million in false and fraudulent claims paid by Medicare Part D, Part D Plans and beneficiaries for prescription drugs that were never purchased or dispensed.

If convicted, Balyasny and Shrayber face a maximum sentence of 10 years in federal prison. A complaint merely contains allegations and defendants are presumed innocent unless and until proven guilty at trial.


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Tuesday, July 26, 2011

Dr. Glen R. Justice Sentenced to 18 Months in Prison for Billing for Cancer Meds That Were Never Provided


Source- http://www.fbi.gov/losangeles/press-releases/2011/orange-county-doctor-sentenced-to-18-months-in-prison-for-billing-for-cancer-meds-that-were-never-provided


SANTA ANA, CA—An Orange County cancer doctor was sentenced this morning to 18 months in federal prison for fraudulently submitting bills for approximately $1 million worth of injectable cancer medications that never were provided.

Dr. Glen R. Justice, 66, of Corona del Mar, was sentenced by United States District Judge Cormac J. Carney. Justice pleaded guilty in May 2010 to five counts of health care fraud.

Justice, who ran the Pacific Coast Hematology/Oncology Medical Group in Fountain Valley, defrauded health insurance providers, including the Medicare program, by billing for injectable cancer medications when patients never received those medications. In some instances where patients did receive medications, Justice “upcoded” claims made to health insurance providers by falsely claiming that he administered more expensive injectable medications than were actually given to patients.

The medications involved in the scheme included Neulasta, Neupogen, Procrit/Epogen/Aranesp, and Neumega. Justice’s scheme ran from at least 2004 through October 2009, despite being advised by staff about the improper billing and the execution of a search warrant at his medical group in November 2006. In a plea agreement filed in court, Justice acknowledged that the public and private health insurance providers—including Medicare, Tricare, carriers contracted with the federal government through the Federal Employee Health Benefit Program, and Blue Cross and Blue Shield of California—suffered losses of between $400,000 and $1 million.

During today’s sentencing hearing, Justice did not contest government allegations that he had violated his plea agreement by continuing to submit fraudulent bills after he signed the agreement in March 2010.



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Monday, July 25, 2011

Vicente Guerra-Nistal a Patient Recruiter for Miami Health Care Agency Pleads Guilty in $25 Million Medicare Fraud Scheme


Source- http://www.justice.gov/opa/pr/2011/July/11-crm-952.html

WASHINGTON – A patient recruiter of a Miami health care agency pleaded guilty today for his participation in a $25 million home health Medicare fraud scheme, announced the Department of Justice, the FBI and the Department of Health and Human Services (HHS).

Vicente Guerra-Nistal, 54, pleaded guilty before U.S. District Judge Joan A. Lenard in Miami to one count of conspiracy to commit health care fraud. Guerra was charged in a February 2011 indictment. According to plea documents, Guerra was a patient recruiter for ABC Home Health Care Inc. ABC was a Miami home health care agency that purported to provide home health and physical therapy services to Medicare beneficiaries.

According to court documents, ABC was operated for the purpose of billing the Medicare program for expensive physical therapy and home health care services that were medically unnecessary and/or were never provided. Court documents allege that the medically unnecessary services were prescribed by doctors, including Jose Nunez, M.D., and Francisco Gonzalez, M.D. Nunez and Gonzalez were also charged in the February 2011 indictment along with Guerra, and 18 other co-conspirators.

According to court documents, beginning in approximately January 2006, and continuing until approximately March 2009, Guerra offered and paid kickbacks and bribes to Medicare beneficiaries in return for those beneficiaries allowing ABC to bill Medicare for home health care and therapy services that were medically unnecessary and/or never provided. Guerra was paid kickbacks and bribes by the owners of ABC in return for recruiting the Medicare beneficiaries to ABC. Guerra admitted that he knew the patients he recruited for ABC did not qualify for the services that ABC billed to Medicare. In addition, Guerra knew that the patient files for his recruited patients were falsified in order to make it appear that the patients qualified for home health care and therapy services so that Medicare could be billed for medically unnecessary services.

As a result of Guerra’s participation in the illegal scheme, the Medicare program was billed approximately $194,000 for purported home health care services that were medically unnecessary and/or were never provided.

Sentencing has been scheduled for Oct. 17, 2011. The charge of conspiracy to commit health care fraud carries a maximum prison sentence of 10 years. The defendant also face fines and terms of supervised release, as well as forfeiture of any property or proceeds derived from his criminal activities.

Co-defendants Lisandra Alonso and Luisa Morciego pleaded guilty for their roles in the fraud scheme on July 13, 2011. Drs. Nunez and Gonzalez are scheduled to begin trial on Oct. 10, 2011. An indictment is merely a charge and defendants are presumed innocent until proven guilty.


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Saturday, July 23, 2011

Jennifer A. Netter Pleads Guilty to Role in Insurance Fraud Scheme



Source- http://www.fbi.gov/newhaven/press-releases/2011/chiropractor-pleads-guilty-to-role-in-insurance-fraud-scheme

David B. Fein, United States Attorney for the District of Connecticut, announced that JENNIFER A. NETTER, 37, of Danbury, waived her right to indictment and pleaded guilty today before United States District Judge Stefan R. Underhill in Bridgeport to one count of conspiring to make false statements relating to health care matters.

According to court documents and statements made in court, NETTER is a licensed chiropractor who worked for a chiropractor who owned a practice with offices in Stamford and Bridgeport. Between approximately December 2006 and February 2010, NETTER and her employer performed unnecessary chiropractic treatments on individuals who were involved in auto accidents. As part of the scheme, NETTER, at her employer’s direction, routinely established six-month treatment regimens for patients, regardless of medical need. NETTER and her employer also falsified medical records, including initial reports of a patient’s condition that fabricated range of motion examination results to indicate injury, failed to inquire or omitted information regarding a patient’s preexisting injuries, and drew causal connections between injury and accidents suffered without inquiry of preexisting conditions. Also, NETTER and her employer prepared final reports of condition that fabricated the severity of the condition, indicated limitations of a patient’s range of motion inconsistent with the patient’s true condition, and included unsupported permanent partial disability ratings. The chiropractic practice then provided these false reports along with health insurance claims for payment to insurance companies.

The charge of conspiring to make false statements relating to health care matters carries a maximum term of imprisonment of five years and a fine of up to $250,000.



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Thursday, July 21, 2011

Admits Participating in Insurance Fraud Scheme, Distributing Prescription Narcotics


Source- http://www.fbi.gov/newhaven/press-releases/2011/unlicensed-doctor-admits-participating-in-insurance-fraud-scheme-distributing-prescription-narcotics

David B. Fein, United States Attorney for the District of Connecticut, announced that FRANCISCO R. CARBONE, 53, of Fairfield, waived his right to indictment and pleaded guilty today before United States District Judge Stefan R. Underhill in Bridgeport to multiple federal charges stemming from his participation in an insurance fraud scheme and a conspiracy to illegally distribute prescription narcotics.

According to court documents and statements made in court, CARBONE previously had been licensed to practice medicine, working as a sole practitioner in Bridgeport. In March 2005, CARBONE’s license to practice medicine was revoked by the State of Connecticut.

Between December 2006 and February 2010, CARBONE conspired with an attorney and a chiropractor to defraud several insurance companies by exaggerating the auto accident injuries of the attorney’s clients to justify a larger monetary settlement with the insurance companies. As part of the scheme, the co-conspirators fabricated medical records, prescribed unnecessary pain medication, performed unnecessary chiropractic treatment, ordered and billed for diagnostic tests of questionable medical value, and overstated injuries or permanent partial disabilities that were allegedly caused by the accidents. Typically, the attorney would instruct his clients to see CARBONE, who both the attorney and the chiropractor knew was an unlicensed doctor. CARBONE and others would then provide prescriptions for pain medication for the clients, even if it was not needed. CARBONE also fabricated medical records, including the clients’ injuries and medical condition, even though CARBONE had not done any medical examination on the vast majority of the patients. The fabricated reports were given to the attorney who provided them to the insurance carriers in support of settlements.

CARBONE, at the request of the attorney and chiropractor, also referred clients to a diagnostic testing company owned by the chiropractor to receive “nerve conduction velocity testing” (NCV), even though CARBONE had no prior knowledge of NCVs and did not rely on the test results for any medical purpose. The chiropractor’s office would submit a bill to the attorney in the amount of approximately $2000 for each NCV test that was performed, which would eventually be paid out of settlement proceeds.

CARBONE, the attorney and the chiropractor also engaged in a scheme to defraud the State of Connecticut. By law, the State of Connecticut is entitled to 50 percent of the proceeds of a personal injury case if the individual who receives a settlement has been on public assistance, or has outstanding child support obligations. Through this scheme, the attorney would provide a fraudulent settlement statement to the State that inflated the payments to the attorney, chiropractor and CARBONE, and reduced the net payout to the client.

CARBONE and the chiropractor, at the attorney’s request, regularly kicked back a portion of their medical fees to the attorney’s clients.

From November 2006 through January 2010, James W. Marshall, Jr., a licensed doctor of osteopathic medicine in Monroe, wrote prescriptions for pain medication, including oxycodone and hydrocodone, for CARBONE’s patients. On March 1, 2011, Marshall pleaded guilty to one count of conspiring to distribute controlled substances outside the scope of the usual course of professional practice, admitting that he wrote more than 145 prescriptions for more than 4400 pills to numerous patients, without personally meeting, examining, or consulting with the patients who would receive the prescriptions.

Today, CARBONE pleaded guilty to one count of conspiring to commit mail fraud to defraud insurance carriers, one count of conspiring to commit mail fraud to defraud the State of Connecticut, one count of making a false statement relating to health care matters, and one count of conspiring to distribute controlled substances outside the scope of the usual course of professional practice. The charges carry a maximum term of imprisonment of 65 years.

CARBONE’s criminal history includes federal convictions in 1999 for violating the Medicare/Medicaid anti-kickback statute and for filing a false federal tax return, for which he was sentenced to four months of imprisonment. In 2002, CARBONE was sentenced to an additional 13 months of imprisonment for violating the conditions of his supervised release.


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Wednesday, July 20, 2011

U.S. Arrests Owners of Home Health Care Business and Suspended Podiatrist on Charges Alleging Medicare and Visa Fraud



Source- http://www.fbi.gov/chicago/press-releases/2011/u.s.-arrests-owners-of-home-health-care-business-and-suspended-podiatrist-on-charges-alleging-medicare-and-visa-fraud

CHICAGO—Two owners of a south suburban home health care business and a suspended podiatrist were arrested today on federal charges relating to alleged Medicare fraud in excess of $1.5 million and an alleged attempt to illegally obtain a work visa for one of the owners. At the same time, federal agents executed a search warrant at the business, House Call Physicians LLC, in Palos Hills. The defendants, Bahir Haj Khalil, the manager and co-owner of House Call; Mohammed Khamis Rashed, also co-owner of House Call; and Paschal U. Oparah, the suspended physician, were charged in a two-count criminal complaint that was filed yesterday and unsealed today in U.S. District Court following their arrests.

Khalil, 33, of Palos Hills, a native of Syria and a Canadian citizen who is not authorized to work in the U.S., and Oparah, 46, of South Holland, were charged with one count of health care fraud. Khalil and Rashed, 45,of Chicago, were charged with one count of visa fraud. All three are scheduled to appear at 1:15 p.m. today before U.S. Magistrate Judge Jeffrey Cole in Federal Court.

The arrests and charges were announced by Patrick J. Fitzgerald, United States Attorney for the Northern District of Illinois, together with Robert D. Grant, Special Agent in Charge of the Chicago Office of Federal Bureau of Investigation; Lamont Pugh III, Special Agent in Charge of the Chicago Region of the U.S. Department of Health and Human Services Office of Inspector General; and James Vanderberg, Special Agent in Charge of the U.S. Department of Labor Office of Inspector General. The U.S. Railroad Retirement Board Office of Inspector General also participated in the investigation, which is continuing. The investigation is being conducted by the Medicare Fraud Strike Force, which expanded to Chicago earlier this year, and is part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative between the Justice Department and HHS to focus their efforts to prevent and deter fraud and enforce anti-fraud laws around the country.

According to the complaint affidavit, the health care fraud scheme involved billing for services as if they were performed by physicians, when in fact they were performed by physician assistants; billing for podiatry services as if they were performed by a particular licensed podiatrist, when in fact they were performed by Oparah, whose license was suspended; and falsely certifying that patients were eligible for home health services, when in fact they were not homebound as required by Medicare, as well as causing medically unnecessary services to be provided to beneficiaries and billed to Medicare.

The visa fraud scheme alleges an attempt by Khalil and Rashed to obtain a visa for Khalil to work in the U.S. by misrepresenting that he was not already employed by, and did not own, House Call, and that the business intended to hire him as a home health aide earning $8.50 an hour.

The charges state that House Call was established in 2006 and enrolled in the Medicare program. The manager, Khalil, is not a licensed physician, podiatrist, physician assistant, registered nurse, or licensed practical nurse in Illinois. Between 2008 and the end of May 2011, Medicare reimbursed House Call more than $3.3 million based on approximately 36,864 claims for 2,348 separate beneficiaries. The charges rely, in part, on a former House Call physician, who recorded conversations with Khalil, and a physician assistant who cooperated with the investigation. The former physician provided information about House Call falsely certifying that patients were homebound and eligible for medicare coverage, in exchange for patient referrals from corrupt home health providers; ordering medically unnecessary tests, some of which were performed by unqualified staff; ordering medically unnecessary durable medical equipment; paying physicians for pro forma and cursory review of plans of care prepared by physician assistants; and billing services provided by physician assistants as if they were provided by medical doctors.

Between April 2008 and March 2011, House Call allegedly fraudulently obtained more than $1,150,000 in Medicare reimbursement for services billed under two physicians’ provider numbers. One of those physicians told agents that he/she was hired by Khalil and paid $2,000 a month to review and sign medical records prepared by physician assistants but was never required to see patients, according to the complaint affidavit.

In addition, House Call allegedly fraudulently obtained $463,000 from Medicare between 2008 and 2011 for services actually performed by Oparah, whose license was suspended in 2008, but which were billed as if the services had been performed by a different podiatrist, using that physician’s Medicare provider number.

Khalil, Rashed, and Oparah each obtained hundreds of thousands of dollars in payments from House Call over various periods since it was established, the charges allege.

Health care fraud and visa fraud each carry a maximum penalty of 10 years in prison and a $250,000 fine, or an alternate fine totaling twice the loss or twice the gain, whichever is greater. If convicted, the court must impose a reasonable sentence under the advisory United States Sentencing Guidelines.



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Tuesday, July 19, 2011

Indictment Charges Dr. Gautam Gupta and Dr. Rakesh Wahi with Defrauding Medicaid, Insurance Companies of $24 Million in Operation of Weight-Loss Clinics


Source- http://www.fbi.gov/springfield/press-releases/2011/indictment-charges-two-doctors-with-defrauding-medicaid-insurance-companies-of-24-million-in-operation-of-weight-loss-clinics

SPRINGFIELD, IL—A federal grand jury has charged the owner of the Nutrition Clinics, based in Rockford, Illinois, as well as an associate physician with defrauding government and private insurers, as well as patients, of as much as $24 million from unwarranted medical tests and false billings for doctor visits. Dr. Gautam Gupta, 56, of Rockford, and Dr. Rakesh Wahi, 57, of Mount Prospect, Illinois, were both charged in the indictment. At its peak, Nutrition Clinic operated at locations in Rockford, South Beloit, Naperville, Arlington Heights, and Chicago, and advertised extensively for patients using television and radio.

The court has ordered Wahi to appear before U.S. Magistrate Judge Byron G. Cudmore in Springfield on Aug. 15. Gupta, previously charged in a criminal complaint filed on June 13, 2011, remains a fugitive.

Self-described as a “weight-loss clinic,” according to the indictment, the Nutrition Clinic is owned by and operated primarily by Gupta, who was most directly responsible for the treatment and billing of patient services. Wahi became formally associated with the practice in September 2003, and as a medical doctor oversaw the medical processes, staff, and procedures at the locations to which he was assigned by Gupta.

The indictment alleges that from 2003 through at least January 2010, Gupta and Wahi, both licensed to practice medicine in Illinois, implemented and enforced policies and procedures at the clinics that benefitted them financially and resulted in submission of various fraudulent claims for payment. The claims were primarily for patients with certain insurance coverage, including those enrolled in Medicaid and Blue Cross Blue Shield of Illinois (BCBS), a private insurer. The alleged fraudulent claims include payment for testing that was not medically necessary, including extensive blood screenings, echocardiograms, thyroid ultrasounds, and nuclear stress tests, and for follow-up visits billed as if a doctor examined the patient, when in fact, various unlicensed personnel actually saw and dispensed controlled substances given to patients for weight loss.

From 2003 through 2010, according to the indictment, Gupta and Wahi were paid approximately $2.28 million by the State of Illinois and the U.S. government from the Medicaid program for claims submitted for weight loss visits, tests and procedures. For the same time period, Gupta and Wahi were paid approximately $22 million for similar claims submitted to BCBS.

The indictment alleges that on multiple occasions from 2003 to 2010, Gupta and Wahi examined patients who came to the clinic seeking to lose weight. Under the doctor’s direction, a “medical assistant” would draw blood and administer a brief EKG. Gupta, Wahi, or another at their direction, allegedly performed a cursory physical examination of the patient and regardless of the results of the EKG, if the patient had insurance, would order that the patient undergo an echocardiogram. Starting in late 2006, patients were also ordered to undergo an ultrasound examination of the thyroid, even though doctors had not received or examined results of the patient’s blood tests. On multiple occasions, as alleged in the indictment, if a patient was covered by private insurance, primarily BCBS, they would also be referred for a thalium stress test, typically conducted by Wahi. If a patient did not have insurance, no additional testing, other than a basic blood test, was ordered.

According to the indictment, Medicaid does not pay for tests used for screening as part of a weight loss program, and if tests are billed with no symptoms to justify the test, there is no reimbursement. Because of this requirement, Gupta and Wahi allegedly set and enforced practices and procedures resulting in false diagnoses or symptoms reported to Medicaid to justify the various tests.

Further, on multiple occasions, Gupta and Wahi allegedly required patients to return to the clinics for “follow-up visits” to continue to receive controlled substances and for weight loss “counseling.” According to the indictment, Gupta established and Wahi oversaw policies and procedures that billed the follow-up visits as if the patient had been examined by a doctor. In fact, patients rarely, if ever, saw a doctor or physician assistant during the “follow-up” visits, and instead saw assistants who had little, if any, appropriate medical training, qualifications or licensing for counseling or to dispense controlled substances.

The indictment, which was returned late yesterday afternoon by the grand jury, charges both Gupta and Wahi with one count of conspiracy to commit fraud and seven counts of mail fraud. Each is also charged separately with one count of health care fraud. If convicted, each count of mail fraud carries a maximum statutory penalty of 20 years in prison and a $250,000 fine; the penalty for health care fraud is up to 10 years in prison and a $250,000 fine. For conspiracy to commit fraud, the penalty is up to five years in prison. The court may also order that restitution be paid to those victimized by the crime.


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Saturday, July 16, 2011

Jorge Zamora, the Owner of Fraudulent Physical Therapy Company Pleads Guilty to Medicare Fraud Scheme



Source- http://www.justice.gov/opa/pr/2011/July/11-crm-920.html

WASHINGTON – A Miami-area resident and owner of a fraudulent physical therapy company in Lakeland, Fla., pleaded guilty today for his role in a scheme to defraud Medicare, the Departments of Justice and Health and Human Services (HHS) announced.

Jorge Zamora, 48, pleaded guilty before U.S. Magistrate Judge Mark A. Pizzo in Tampa, Fla., to one count of conspiracy to commit health care fraud.

According to court documents, Zamora was an owner of Dynamic Therapy Inc. Zamora and his co-conspirators purchased Dynamic from its previous owners, and transformed it into a fraudulent enterprise. Dynamic purported to provide physical therapy services to Medicare beneficiaries, but in reality used the stolen identities of a physical therapist and scores of patients to bill Medicare for physical therapy services that were never provided.

According to court documents, from fall 2009 to summer 2010, Zamora and his co-conspirators submitted and caused the submission of $757,654 in fraudulent claims to the Medicare program by Dynamic. Zamora admitted that he and his co-conspirators submitted claims to Medicare for physical therapy services that were never provided.

Three officers of Dynamic Therapy also have pleaded guilty to conspiracy to commit health care fraud.

At sentencing, Zamora faces a maximum penalty of 10 years in prison and a $250,000 fine. A sentencing date has not been set.



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Thursday, July 14, 2011

Lisandra Alonso and Luisa Morciego Plead Guilty in $25 Million Health Care Fraud Scheme



Source- http://www.justice.gov/opa/pr/2011/July/11-crm-914.html

WASHINGTON – The manager of a Miami health care agency and a registered nurse pleaded guilty today for their participation in a $25 million home health Medicare fraud scheme, announced the Department of Justice, the FBI and the Department of Health and Human Services (HHS).

Lisandra Alonso, 33, and Luisa Morciego, 39, each pleaded guilty before U.S. District Judge Joan A. Lenard in Miami to one count of conspiracy to commit health care fraud. Alonso and Morciego were charged in a February 2011 indictment. According to plea documents, Alonso was a manager and patient recruiter for ABC Home Health Care. Morciego was a registered nurse and worked for ABC and Florida Home Health Care Providers Inc. ABC and Florida Home Health were Miami home health care agencies that purported to provide home health and physical therapy services to Medicare beneficiaries. According to court documents, ABC and Florida Home Health were operated for the purpose of billing the Medicare program for expensive physical therapy and home health care services that were medically unnecessary and/or were never provided. Court documents allege that the medically unnecessary services were prescribed by doctors, including Jose Nunez, M.D., and Francisco Gonzalez, M.D. Nunez and Gonzalez were also charged in the February 2011 indictment along with Alonso, Morciego and 17 other co-conspirators.

According to court documents, beginning in approximately January 2006 and continuing until approximately March 2009, Alonso taught the owners and operators of ABC how to operate a fraudulent home health agency. Alonso explained the structure of the corrupt scheme, specifically the importance of recruiters, kickbacks, doctors, beneficiaries and Medicare billing. Alonso negotiated kickback payment rates between patient recruiters and the ABC owners and operators, and distributed the kickback payments to patient recruiters on behalf of the ABC owners and operators. Alonso also served as a patient recruiter for ABC. She paid kickbacks and bribes to beneficiaries in return for those beneficiaries allowing ABC to bill Medicare for services that were medically unnecessary and/or never provided.

Alonso also taught nurses at ABC how to falsify patient files for Medicare beneficiaries to make it appear that such beneficiaries qualified for home health care and therapy services from ABC. Alonso taught the nurses to do so by, among other things, describing in the nursing notes and patient files non-existent symptoms such as tremors, impaired vision, weak grip and inability to walk without assistance. These symptoms were described to make it appear that the patients qualified for home health care benefits under Medicare. Alonso admitted that the files were falsified so that ABC could bill Medicare for medically unnecessary services. Nurses employed by ABC also paid kickbacks to Alonso in return for being assigned patients at ABC.

As a result of Alonso’s participation in the illegal scheme, the Medicare program was billed approximately $17 million for home health care services that were medically unnecessary and/or were never provided.

According to court documents, from January 2006 to March 2009, Morciego worked as a registered nurse for ABC and Florida Home Health. During that time, Morciego falsified patient files for Medicare beneficiaries to make it appear that the beneficiaries qualified for home health care and therapy services. Morciego knew that the beneficiaries did not actually qualify for and did not receive the services. Morciego described in nursing notes and patient files symptoms that were non-existent, such as tremors, impaired vision, weak grip and inability to walk without assistance. Morciego admitted that the files were falsified so that ABC and Florida Home Health could bill Medicare for medically unnecessary services.

As a result of Morciego’s participation in the fraud schemes at ABC and Florida Home Health, Medicare was billed approximately $296,000 for services that were medically unnecessary and/or were never provided.

Morciego is scheduled to be sentenced on Dec. 5, 2011. Alonso is scheduled to be sentenced on Oct. 3, 2011. The charge of conspiracy to commit health care fraud carries a maximum prison sentence of 10 years. The defendants also face fines and terms of supervised release, as well as forfeiture of any property or proceeds derived from their criminal activities.

Drs. Nunez and Gonzalez are scheduled to begin trial on Oct. 10, 2011. An indictment is merely a charge and defendants are presumed innocent until proven guilty.




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Wednesday, July 13, 2011

Patrick Lynch Admits Posing as a Doctor, Treating Elderly Patients in Medicare Fraud Scheme


Source- http://www.fbi.gov/newark/press-releases/2011/toms-river-new-jersey-man-admits-posing-as-a-doctor-treating-elderly-patients-in-medicare-fraud-scheme

NEWARK, NJ—A Toms River, N.J., man today admitted to unlawfully treating patients, prescribing medicine, and ordering procedures while posing as a licensed physician with an Ocean County, N.J., medical practice, U.S. Attorney Paul J. Fishman announced. Patrick Lynch, 54, pleaded guilty in connection with the scheme he orchestrated through Toms River-based Visiting Doctors of New Jersey, in which he conducted hundreds of visits with elderly, home-bound patients and billed them to Medicare. Lynch entered his guilty plea before U.S. District Judge Peter G. Sheridan in Trenton federal court to an information charging him with one count each of health care fraud and aggravated identity theft.

“Patrick Lynch defrauded a government program designed to help Americans most in need of health support,” U.S. Attorney Fishman stated. “To further his deception, he misused the identities of skilled professionals and put elderly patients at risk. Homebound individuals with pressing medical concerns should not have to worry that they are receiving substandard care from untrained hands.”

“The threat to the public well being in this case is considerable,” said Michael B. Ward, Special Agent in Charge of the FBI’s Newark field office. “Without sufficient training and lacking minimal credentials, Patrick Lynch attempted to profit by presenting himself as a licensed medical professional, conducting home healthcare visits with elderly patients, writing prescriptions, and falsely billing Medicare. His actions placed these unsuspecting patients at undeterminable risk.”

According to documents filed in this case and statements made during today’s guilty plea proceeding:

Lynch created Visiting Doctors of New Jersey in order to provide medical care for elderly home-bound patients in the Monmouth and Ocean County areas. Because he was neither a licensed physician nor a nurse practitioner, he hired licensed individuals to conduct patient visits. When Lynch failed to pay the licensed physicians and nurse practitioners, they quit working for him. Lynch then carried on the business by posing as the licensed professionals, using their names and government-issued identification numbers to write prescriptions and submit billings to Medicare, among other things.

Over the course of the scheme, hundreds of claims were billed to Medicare for hundreds of illegal visits to elderly patients.

The health care fraud charge carries a maximum penalty of 10 years in prison and a fine of $250,000, or twice the gross gain or loss from the offense; the aggravated identity theft charge carries a mandatory sentence of two years in prison, to run consecutive to any sentence imposed on the health care fraud charge. Sentencing is currently scheduled for October 17, 2011. The amount that the defendant will be required to pay in restitution is still being determined and will be decided at sentencing.


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Tuesday, July 12, 2011

Arnaldo Rosario Sentenced to 27 Months in Prison in Connection with Detroit-Area Infusion Therapy Schemes


Source- http://www.justice.gov/opa/pr/2011/July/11-crm-907.html

WASHINGTON – A patient recruiter for three Detroit-area clinics was sentenced to 27 months in prison for his role in fraud schemes that attempted to defraud the Medicare program of more than $15 million, the Departments of Justice and Health and Human Services (HHS) announced.

Arnaldo Rosario, 30, was sentenced by U.S. District Judge Gerald E. Rosen in the Eastern District of Michigan. In addition to the prison term, Rosario was sentenced to three years of supervised release and was ordered to pay, jointly and severally with other defendants in the case, $10,765,325 in restitution.

Rosario pleaded guilty to one count of conspiracy to commit health care fraud on Aug. 18, 2009. According to court documents, Arnaldo Rosario admitted that he was responsible for overseeing and facilitating the payment of cash kickbacks to Medicare beneficiaries who visited Sacred Hope Medical Center Inc., Dearborn Medical Rehabilitation Center Inc. (DMRC) and Xpress Center Inc. (XPC). In exchange for the cash kickbacks, the beneficiaries would visit the clinics and sign documents falsely indicating that they had received services that were then billed to Medicare. According to information contained in his plea documents, Rosario admitted to obtaining cash on a daily basis from his co-conspirators to pay the beneficiaries cash kickbacks. After obtaining the cash, Rosario admitted that he would then distribute the money to several other co-defendants who were responsible for recruiting and paying the kickbacks to the beneficiaries. Arnaldo Rosario admitted to being directed to pay bonuses to the co-defendants if they were able to recruit additional Medicare beneficiaries to come to Sacred Hope, DMRC or XPC.

Rosario admitted that, between approximately March 2006 and March 2007, he and his co-conspirators caused the submission of approximately $15.3 million in false and fraudulent claims to Medicare for services supposedly provided at Sacred Hope, DMRC and Xpress Center. Based on the fraudulent claims, Medicare paid approximately $10,765,325.


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Monday, July 11, 2011

Edward G. Kluj and Gurinder Kiren Mand Charged with Multiple Counts of Health Care Fraud


Source- http://www.fbi.gov/sanfrancisco/press-releases/2011/pharmacy-owner-and-his-employee-charged-with-multiple-counts-of-health-care-fraud

SAN JOSE—A federal grand jury in San Jose indicted Edward G. Kluj, of Knightsen, California, and Gurinder Kiren Mand, of San Jose, California, with conspiracy to commit health care fraud and multiple counts of health care fraud. Gurinder Kiren Mand was additionally charged with two counts of obstruction of a criminal investigation of health care fraud, United States Attorney Melinda Haag announced.

Mr. Kluj was the owner and pharmacist at EZ Step, Inc., a pharmacy and durable equipment supplier once located in San Jose, California. Ms. Mand was an employee at EZ Step, Inc. The pharmacy is no longer in business.

According to the indictment, Mr. Kluj, 50 years old, and Ms. Mand, 28 years old, defrauded Medicare, Medi-Cal, and privately sponsored health care benefit programs by submitting claims that falsely represented that EZ Step, Inc. provided pharmaceutical items and services to beneficiaries pursuant to valid orders and prescriptions by physicians and other health care providers. The 43-count indictment alleges that between 2005 and 2007, Mr. Kluj and Ms. Mand made false claims in a variety of ways, including seeking reimbursement by forging physician’s signatures, fabricating prescriptions and durable equipment orders, altering valid prescriptions, and forging patient signatures on delivery forms to misrepresent that EZ Step, Inc. had delivered prescription medications and durable equipment (such as power wheelchairs) to patients when in fact it had not.

The defendants are also alleged to have failed to maintain proper records, as required by Medicare and Medi-Cal. Mr. Kluj is further alleged to have threatened and intimidated his employees to coerce them to participate in the false billing and to prevent them from reporting the false billing to regulatory and law enforcement authorities—including verbally accusing his employees of theft and brandishing weapons in the presence of employees.

Ms. Mand was arrested on July 7, 2011, at her residence in San Jose, California. She made her initial appearance in federal district court the same day. Her next scheduled appearance is on August 24, 2011, before the Honorable Judge Lucy Koh. Mr. Kluj was arrested on July 7, 2011, in Naples, Florida. He will make his initial appearance in federal court in the Middle District of Florida on July 8, 2001, and a later status hearing for him is expected to be scheduled before the Honorable Judge Lucy Koh.


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Sunday, July 10, 2011

Evans Oniha and Camillus Ehigie Convicted on Multiple Health Care Fraud Charges


Source- http://www.justice.gov/opa/pr/2011/July/11-crm-896.html

WASHINGTON – The co-owner of two health care companies was convicted late yesterday on multiple health care fraud charges related to his participation in a scheme to defraud Medicare, announced the Departments of Justice and Health and Human Services (HHS).

A federal jury in the Central District of California found Evans Oniha, 49, guilty of one count of conspiracy to commit health care fraud, four counts of health care fraud and one count of false statements relating to health care matters. Camillus Ehigie, 50, who co-owned and operated the health care companies with Oniha, pleaded guilty on July 5, 2011, to multiple health care fraud charges in connection with his participation in the fraud scheme. Oniha and Ehigie were indicted in February 2011. The indictment also seeks forfeiture from the defendants.

Oniha and Ehigie co-owned Caravan Medical Supplies Inc., a durable medical equipment (DME) company, and Prosperity Home Health Services Inc., a purported home health agency. According to the indictment, from October 2002 to February 2011, Oniha and Ehigie conspired with others to defraud Medicare by paying “marketers” for access to Medicare beneficiary information and fraudulent prescriptions and other documents for DME and home health services. The defendants used the fraudulent documents obtained from the marketers to submit and cause the submission of false claims to Medicare for DME and home health services that were not medically necessary, and that often were not provided to Medicare beneficiaries. According to court documents, Oniha and Ehigie caused Caravan to submit approximately $5.8 million in fraudulent claims to Medicare for DME purportedly provided by Caravan. The defendants caused Prosperity to submit approximately $8 million in fraudulent claims to Medicare for home health services purportedly provided by Prosperity. According to court documents, Ehigie also owned another DME company, Osbed Medical Supply. Ehigie caused Osbed to submit $6.1 million in fraudulent claims to Medicare.

Oniha is scheduled to be sentenced on Sept. 19, 2011, and Ehigie is scheduled to be sentenced on Jan. 30, 2012.


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Saturday, July 9, 2011

Dr. Rajashakher Reddy Signed Tens of Thousands of Radiology Reports for Over a Dozen Hospitals Where Neither He Nor Any Other Radiologist Reviewed the Film


Source- http://www.fbi.gov/atlanta/press-releases/2011/atlanta-radiologist-guilty-of-fraudulently-passing-off-diagnoses-prepared-by-non-physician-employees

ATLANTA—A jury in federal district court has returned a guilty verdict late today against RAJASHAKHER P. REDDY, M.D., 41, of Atlanta, on charges of wire fraud, mail fraud, health care fraud, and obstruction of justice. REDDY, a radiologist who ran the Atlanta-based radiology practice “Reddy Solutions, Inc.,” (“RSI”), was charged with and found guilty of perpetrating a scheme to defraud various hospitals by signing and submitting tens of thousands of radiology reports without even reviewing many of the x-rays, mammograms, CT scans, and other films that were the subjects of the reports.

United States Attorney Sally Quillian Yates said of today’s verdict, “This physician fraudulently cut corners at the expense of the hospitals he worked for and the patients who were being treated. He produced tens of thousands of reports claiming to include his medical findings and diagnoses based on radiology studies that had been performed, when in fact all those interpretations had been performed by non-qualified medical assistants. We hope this case helps protect the public from such an egregious breach of trust.”

Brian Lamkin, Special Agent in Charge, FBI Atlanta said, “Medical fraud investigations are difficult, and in this case, the combination of lies and paper trails ultimately led to a doctor who simply was not serving his patients, but serving himself and his company. People who are sick deserve to have their test results seen and professionally analyzed by a doctor, and not by a machine set up to generate profits. FBI and our investigative partners will continue to take on such medical fraud cases, as the safety of our community could be at risk.”

“The health care fraud committed by Dr. Reddy is appalling because he risked the health of innocent, trusting patients and betrayed the medical community while stealing federal taxpayer dollars from the Medicare program,” said Derrick L. Jackson, Special Agent in Charge of the Atlanta Region for the Office of Inspector General of the Department of Health & Human Services. “When criminals like Raja Reddy try to cover their crimes by obstructing a federal investigation, they will be prosecuted to the fullest extent of the law.”

The jury found REDDY guilty of 20 counts of wire fraud, five counts of mail fraud, four counts of health care fraud, and one count of obstruction of justice. He was acquitted of five counts of wire fraud. The jury deliberated for one day after a six-day trial. REDDY was indicted by a federal grand jury on the charges on November 3, 2009.

According to United States Attorney Yates, the charges, and other information presented in court,: REDDY’s company, RSI, provided radiologist coverage—interpreting x-rays and other films—to various hospitals in the Southeast that otherwise typically lacked full-time radiology coverage. Generally, hospital staff would take the film, which REDDY and other RSI radiologists would access remotely via computer. The RSI radiologist was supposed to review the film, prepare and sign a report expressing his or her medical conclusions, and electronically transmit it back to the hospital. REDDY was both the president of the company as well as one of the principal radiologists supposedly interpreting film and preparing reports.

The evidence at trial showed that from May 2007 through January 2008, REDDY signed and submitted thousands of reports in his name without even reviewing the films that were the subjects of the reports. Rather, he had non-physician technicians known as Radiology Practice Assistants (“RPAs”) review the film and prepare the reports. In some cases, REDDY directed the RSI staff to simply sign for him, and transmit the report as if he had prepared it. In other cases, REDDY accessed the system solely for the purpose of signing and submitting the reports. Either way, the majority of the time he never looked at and analyzed the underlying films, and the reports signed by him therefore did not bear his medical conclusions or those of any other doctor.

The evidence at trial included computer records that showed that while the REDDY signed over 70,000 radiology reports in eight months, he only viewed digital computer images of the studies less than 5,900 times during those months. The employees who actually viewed the majority of these studies were the RPAs, who are not qualified to interpret films but who REDDY could hire at a fraction of the cost of hiring a radiologist. The proof also included dozens of reports supposedly signed by REDDY at times when he was, in fact, traveling in the air on airplanes that lacked Internet access. These reports were signed by other employees, using REDDY’s electronic password at his direction.

The evidence revealed that REDDY also fraudulently passed off these reports prepared by non-physician assistants thousands of times, to several hospitals, mainly involving x-rays, but also including some CT scans, mammograms, and ultrasounds. Some of the hospitals and other facilities that may have received these fraudulent reports include Mountain Lakes Medical Center in Clayton, Georgia; Upson Regional Medical Center in Thomaston, Georgia; Bullock County Hospital in Union Springs, Alabama; Crenshaw Community Hospital in Lucerne, Alabama; and Columbus Diagnostic Centers in Columbus, Georgia.

In addition to fraud charges stemming from his fraudulent submission of these medical reports, REDDY was also convicted of obstructing the investigation. During the investigation, a government subpoena to RSI demanded production of the computer records that were supposed to keep track of what users accessed what images and when. REDDY instructed employees to destroy those records and, instead, create for purposes of producing to the government new fabricated records, which falsely stated that REDDY had been viewing images instead of the assistants. Witnesses at the trial explained how they were instructed by REDDY to make these fabrications and to then produce the false records to the government in response to the subpoena. The evidence at trial also showed that REDDY disposed of computer equipment requested by the government and asked employees to lie to investigators.

REDDY could receive a maximum sentence of 20 years in prison and a fine of up to $250,000 for each of the 32 fraud and obstruction counts of which he was convicted. Sentencing will occur at a date to be determined before United States District Judge Orinda D. Evans. In determining the actual sentence, the court will consider the United States Sentencing Guidelines, which are not binding but provide appropriate sentencing ranges for most offenders.


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Friday, July 8, 2011

Larry Bernhard Pleads Guilty to Fraudulently Billing Medicare Over $1.1 Million


Source- http://www.fbi.gov/baltimore/press-releases/2011/gambrills-podiatrist-pleads-guilty-to-fraudulently-billing-medicare-over-1.1-million

BALTIMORE—Larry Bernhard, age 55, a podiatrist who operated his business from his home in Gambrills, Maryland, pleaded guilty to health care fraud and aggravated identity theft related to a scheme to fraudulently bill Medicare for more than $1.1 million.

The guilty plea was announced by United States Attorney for the District of Maryland Rod J. Rosenstein; Special Agent in Charge Nicholas DiGiulio, Office of Investigations, Office of Inspector General of the Department of Health and Human Services; and Special Agent in Charge Richard A. McFeely of the Federal Bureau of Investigation.

“Health insurance programs trust providers to bill honestly for medical services, so it is essential to punish doctors who betray that trust,” said U.S. Attorney Rod J. Rosenstein. “Dr. Larry Bernhard flagrantly ripped off Medicare Advantage by fabricating claims for services that he never provided, collecting more than $1 million in new false claims even after he was caught and prohibited from billing federal health care programs.”

According to Bernhard’s plea agreement, since 1981 he has been a licensed podiatrist in Maryland and operated a podiatry practice under the business name, Chesapeake Wound Care Center. Bernhard ran the Chesapeake Wound Care Center business from his home. On October 30, 2007, Bernhard entered into a Settlement Agreement with the government to resolve allegations that from April 1, 2002 through October 11, 2004, Bernhard submitted 80 claims to Medicare for podiatry services purportedly provided at skilled nursing facilities when, in fact, the patients were actually in hospitals at the time the services were allegedly provided. As part of the settlement Bernhard agreed to be excluded from “Medicare, Medicaid, and all other Federal health care programs” for a period of three years.

Bernhard admits that from October 31, 2007 to July 20, 2010, he fraudulently billed Medicare Advantage plans and was paid at least $1.1 million from these plans. All of the fraudulent billing occurred while Bernhard was excluded from billing all federal health care programs, including Medicare Advantage plans. Of the $1.1 million received by Bernhard, at least $1 million was for services that were not rendered. Bernhard admits that he used the names and personal identifying information of approximately 200 patients at various nursing homes to submit false bills for podiatry care that he never performed.

Bernhard faces a maximum penalty of 10 years in prison for health care fraud and a mandatory two years in prison, consecutive to any other sentence imposed, for aggravated identity theft. U.S. District Judge James K. Bredar has scheduled sentencing for November 21, 2011 at 10:00 a.m. As part of his plea agreement, Bernhard has agreed to pay restitution of $1,122,992.08.


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Wednesday, July 6, 2011

Dr. Anthony Francis Valdez Pleads Guilty on Federal Health Care Fraud Charges


Source- http://www.fbi.gov/elpaso/press-releases/2011/el-paso-jury-finds-texas-pain-management-physician-and-psychiatrist-guilty-on-federal-health-care-fraud-charges

United States Attorney John E. Murphy announced that in El Paso, a federal jury convicted Dr. Anthony Francis Valdez, 57, on all charges in connection with an estimated $41 million fraudulent health care benefit program billing scheme. Dr. Valdez was the owner of the Institute of Pain Management with clinics in El Paso and San Antonio.

Dr. Valdez was charged in a 16-count superseding indictment returned on April 20, 2011, with one count conspiracy to commit health care fraud, six counts of health care fraud, six counts of false statements related to health care matters, and three counts of money laundering.

Evidence during trial revealed that beginning in January 2005 and continuing through December 2009, Dr. Valdez caused fraudulent claims to be submitted to Medicare, Medicaid, and TRICARE for procedures which he did not perform or were non-reimbursable.

As a result of the guilty verdict, Dr. Valdez faces up to 10 years in federal prison for the conspiracy charge as well as each substantive health care fraud charge; up to five years in federal prison for each of the false statement charges; and up to 20 years in federal prison for each of the money laundering charges. The government is also seeking the forfeiture of more than $1.7 million in cash, the defendant’s residence in El Paso, his residence in San Antonio, and five vehicles, as well as a monetary judgement in the case for over $41.8 million. Sentencing is scheduled for November 18, 2011 before Senior United States District Judge David Briones.



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