Wifredo A. Ferrer, United States Attorney for the Southern District of Florida; John V. Gillies, Special Agent in Charge, Federal Bureau of Investigation (FBI), Miami Field Office; and Christopher B. Dennis, Special Agent in Charge, U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG), Office of Investigation, announced the arrest and indictment of Gilbert Sanabria, Jr., of Hollywood, Florida, on charges of conspiracy to commit health care fraud, conspiracy to commit bribery, and bribery, in violation of Title 18, United States Code, Sections 1349, 371, and 201(b), respectively.
According to charges, defendant, Sanabria, Jr., operated and controlled South Florida Health Care Connection Inc., a Broward corporation that was in the business of, among other things, opening and purchasing corporations that purportedly provided medical services and equipment to Medicare beneficiaries; selling and/or brokering the sale of such corporations to others; and assisting corporations with Medicare enrollment paperwork. The indictment alleges that the defendant, through South Florida Health Care Connection sold and/or brokered the sale of medical clinics to others, who would in turn submit false claims to Medicare. In addition, the indictment alleges that the defendant provided money and items of value to an employee of Medicare contractor First Coast Service Options in exchange for expedited approvals for Medicare enrollment applications and other paperwork for the fraudulent clinics.
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Wednesday, August 10, 2011
Gilbert Sanabria, Jr. Charged with Conspiracy to Commit Health Care Fraud and Bribery
Tuesday, August 9, 2011
Five Plead Guilty to Health Care Insurance Fraud
Michael J. Moore, United States Attorney for the Middle District of Georgia, announced that five defendants entered pleas of guilty to one count of health care insurance fraud against American Family Life Assurance Company, also known as Aflac, in violation of Title 18 United States Code, Section 1347(2) and 18 United States Code Section 2, before the Honorable Clay Land, United States District Court, Columbus, Georgia. Sentencing has been set for December 8, 2011.
Defendant Case Number
Derrick Jones, age 43, Columbus, GA 4:11-CR-11-CDL
Steven Lester, age 28, Marietta, GA 4:11-CR-12-CDL
Camille Toney, age 23, Phenix City, AL 4:11-CR-15-CDL
Ronnie Moore, age 47, Columbus, GA 4:11-CR-13-CDL
Aflac is engaged in business both within and outside the state of Georgia. While Aflac engages in various types of businesses, its primary function is to provide supplemental insurance (health care benefit program) to policyholders who are ill or injured, or both, and are unable to work. Each defendant submitted fraudulent claims against their supplemental insurance policies with Aflac to fraudulently obtain funds ranging in various amounts from $243.75 to $67,105.00. AFLAC’s actual loss was more than $500,000.00. Each defendant faces a possible maximum sentence of 10 years’ imprisonment, a $250,000.00 fine, or both, and three years of supervised release. “These types of cases have a far-reaching effect and are a priority of the Department of Justice,” Moore said.
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Monday, August 8, 2011
Birdie Leroy Revis in Multi-Million-Dollar Health Care Fraud Scheme Pleads Guilty to Conspiracy to Violate the Anti-Kickback Statute
HOUSTON—An accused recruiter in a multi-million-dollar health care fraud scheme scheduled for trial on Monday has instead pleaded guilty to conspiracy to violate the Anti-Kickback Statute, United States Attorney José Angel Moreno announced today. Birdie Leroy Revis, 60, of Houston, pleaded guilty before United States District Judge David Hittner this morning to conspiracy to violate the Anti-Kickback Statute. Trial had been scheduled to begin with jury selection on Monday, Aug. 8, 2011.
Revis was a recruiter for Sefan Medical Supply (Sefan), a durable medical equipment provider, located in Houston. Based upon the joint investigative efforts of the agencies comprising the Medicare Fraud Strike Force into a $2.8 million scheme to defraud Medicare by Sefan, evidence was obtained proving that Revis’ role in the scheme was to provide Medicare beneficiary information to Sefan. Sefan, in turn, then billed Medicare for medically unnecessary durable medical equipment and supplies which were either not provided to Medicare beneficiaries or a lesser product from what was billed to Medicare was provided. The information was provided on a prescription form for arthritis kits. All the kits included a knee adjustment with air chamber, rigid frame back brace, elbow with joint, ankle gauntlet, flex glove with elastic finger, heat lamp with stand, and a wrist brace. Sefan would order these items for both the left and right side. If the beneficiaries received any items, they did not receive the rigid brace items billed to Medicare—instead they would receive neoprene sleeves, which was not covered by Medicare.
Revis provided to Sefan information for more than 686 beneficiaries for which Sefan paid Revis approximately $400 per beneficiary for a total of more than $353,000. With the information provided by Revis, Sefan billed Medicare for more than $2.8 million worth of claims for arthritis kits and was paid more than $1.7 million for those fraudulent claims.
Revis remains on bond pending sentencing, which is set on Nov. 2, 2011. Revis faces a maximum of up to five years in prison, to be followed by up to a three-year term of supervised release and a fine of up to $250,000 for the kickback conspiracy conviction.
The owner of Sefan and the physician whose signature was on the prescriptions have also been convicted following their respective pleas of guilty to conspiracy to commit health care fraud. Kate Ose Olear, the owner of Sefan, was sentenced to 57 months in prison on Feb. 10, 2011, by United States District Judge David Hittner. John Edward Perry III, the physician, pleaded guilty in June 2010. He remains on bond pending his sentencing on Oct. 21, 2011, before United States District Judge Gray H. Miller.
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Sunday, August 7, 2011
Guillermina Bressler Was Sentenced to One Count of Health Care Insurance Fraud Against American Family Life Assurance Company
Michael J. Moore, United States Attorney for the Middle District of Georgia, announced that Guillermina Bressler, age 56, a resident of Columbus, Georgia was sentenced August 3, 2011, on one count of health care insurance fraud against American Family Life Assurance Company, also known as Aflac, in violation of Title 18 United States Code, Section 1347(2) and 18 United States Code Section 2, before the Honorable Clay Land, United States District Court, Columbus, Georgia.
Bressler was sentenced to seven months’ imprisonment, three years supervised release, a mandatory assessment fee of $100.00, and ordered to pay restitution in the amount of $109,451.25 to the victims.
Bressler devised a scheme to embezzle $109,451.25 from Aflac, a company engaged in business both within and outside the state of Georgia. Bressler submitted fraudulent claims against her supplemental insurance policy with Aflac to fraudulently obtain funds ranging in various amounts. While Aflac engages in various types of businesses, its primary function is to provide supplemental insurance (health care benefit program) to policyholders who are ill or injured, or both, and are unable to work.
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Friday, August 5, 2011
Kelvin Washington Arrested for Health Care Fraud and Taking Kickbacks
HOUSTON—An employee of a Houston-area nursing home has been arrested as a result of the return of a sealed indictment by a Houston grand jury chaging him with conspiracy, health care fraud, and violations of the anti‐kickback statute arising from a scheme to unlawfully bill federal health care programs for ambulance transport, United States Attorney José Angel Moreno along with Texas Attorney General Greg Abbott announced today.
Kelvin Washington, 47, of Houston, was arrested at his Houston home this morning by investigating agents with the Department of Health and Human Services‐Office of the Inspector General, Office of Investigations (HHS‐OIG‐OI) and the Texas Medicaid Fraud Control Unit. The indictment was unsealed upon Washington’s arrest. He is expected to make an initial appearance before a U.S. Magistrate Judge in Houston today at 2 p.m., at which time the issue of his release on bond is expected to be raised.
Washington, employed as an administrator at a Sugar Land-area nursing home, is accused in the 10‐count indictment of having received payments for the referral of dialysis patients to a Houston ambulance transport service between 2003 and 2007. Additionally, Washington is accused of conspiring with others to have unsuspecting doctors sign transport prescriptions for dialysis patients allegedly admitted to the Sugar Land nursing home where Washington works. The indictment alleges, among other matters, that the patients for whom Washington sought the prescriptions were never admitted to the nursing home.
According to the indictment, Medicare and Medicaid were billed almost a $1 million in false claims as a result of Washington’s alleged conduct. For his part in the scheme, Washington allegedly received approximately $20,000.
The statutory maximum penalties for a violation of the health care fraud statute is imprisonment for not more than 10 years. The maximum sentence for a violation of the conspiracy statute or the anti‐kickback statute is a maximum of five years. Each of the 10 counts charged also carry a maximum fine of $250,000 as punishment upon conviction.
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Wednesday, August 3, 2011
Twenty-Six Indicted in Drug Distribution Investigation That Led to Uncovering of Massive Health Care Fraud
An indictment returned by a federal grand jury in Detroit was unsealed today, charging 26 individuals for their participation in a large-scale health care fraud and drug distribution scheme, United States Attorney Barbara L. McQuade announced today. McQuade was joined in her announcement by Special Agent in Charge Robert L. Corso of the Drug Enforcement Administration, Special Agent in Charge Andrew G. Arena of the Federal Bureau of Investigation, and Lamont Pugh, Special Agent in Charge of the Inspector General of the Department of Health and Human Services.
“Health care fraud steals funds from programs designed to benefit patients, and we all pay for it,” U.S. Attorney McQuade said. “Federal and state investigators have teamed up in recent months to detect and prosecute those who commit health care fraud, and we hope that the strength of our efforts will have a deterrent effect.”
Robert L. Corso, Special Agent in Charge of DEA’s Detroit Field Division stated, “Confronting the illegal diversion and abuse of controlled pharmaceuticals is a top priority of DEA and our law enforcement partners. Today’s arrests and the allegations in the indictment bring to light one of the largest diversion conspiracies ever uncovered in the state of Michigan. The allegations against these 26 individuals, particularly of the medical professionals, are significant. These individuals abused their positions of trust and endangered the lives of countless people by illegally distributing more than 6 million doses of opiate painkillers and depressants throughout southeast Michigan and beyond. This indictment makes it clear that the DEA and our partners in law enforcement will continue to investigate and bring to justice those individuals that are responsible for the illegal distribution of prescription medicines.”
FBI Special Agent in Charge Arena stated, “Health care fraud and the abuse/diversion of prescription medications are increasing criminal threats to the United States. Dishonest health care providers involved in fraudulent activities frequently exploit Medicare and Medicaid through fraudulent billing schemes which abuse tax payer’s dollars. The FBI remains committed to investigating this type of fraud and bringing these individuals to justice.”
“The diversion of prescription medications coupled with the fraudulent billing of Medicare creates a toxic scenario that can place a individual’s health and safety at risk as well as taxpayers dollars,” said Lamont Pugh III, Special Agent in Charge of the Chicago Region for the U.S. Department of Health and Human Services, Office of Inspector General. “The OIG will continue to work with our law enforcement partners to hold those who seek to harm the Medicare program accountable.”
The 34-count indictment alleges that Babubhai “Bob” Patel, 49, a Canton pharmacist, was the beneficial owner and controller of some 26 pharmacies statewide (referred to in the indictment as “the Patel Pharmacies“). Babubhai Patel concealed his ownership and control over many of the Patel Pharmacies through the use of straw owners. The indictment alleges that Babubhai Patel would offer and pay kickbacks, bribes, and other inducements to physicians, in order to induce those physicians to write prescriptions for patients with Medicare, Medicaid, and private insurance, and to direct that those prescriptions be presented to one of the Patel Pharmacies for billing. In exchange for their kickbacks and inducements, the medical professionals would write prescriptions for the patients, and bill the relevant insurers for services supposedly provided to the patients, without regard to the medical necessity of those prescriptions and services. The physicians would direct the patients to fill their prescriptions at one of the Patel Pharmacies. There, according to the indictment, Babubhai Patel and his pharmacists would bill insurers, including Medicare, Medicaid, and private insurers, for dispensing the medications, despite the fact that the medications were medically unnecessary and/or never provided. Patients were recruited into the scheme by patient recruiters, who would pay kickbacks and bribes to patients in exchange for the patients’ permitting the Patel Pharmacies (and the physicians associated with Patel) to bill their insurance for medications and services that were medically unnecessary and/or never provided.
The indictment further alleges a conspiracy to distribute controlled substances at the Patel pharmacies, a purpose of which was to facilitate the submission of false and fraudulent claims to Medicare, Medicaid, and private insurers in accordance with the scheme outlined above. According to the indictment, Babubhai Patel and his associates paid physicians and podiatrists associated with the scheme kickbacks and other inducements in exchange for the medical professionals writing prescriptions for controlled substances for their patients, and directing those patients to fill the prescriptions at a Patel Pharmacy. The controlled substances involved included the Schedule II drug OxyContin, the Schedule III drug Vicodin, the Schedule IV drug Xanax, and the Schedule V drug cough syrup with codeine. According to the indictment, prescriptions for these drugs were written outside the course of legitimate medical practice. Babubhai Patel and his pharmacists would then dispense the controlled drugs to patients without medical necessity. The distribution of controlled substances in this manner was intended, in part, as a kickback to the patients for agreeing to enable their insurance cards to be billed for medications purportedly dispensed at the Patel Pharmacies. The indictment also alleges that Babubhai Patel and his pharmacists dispensed controlled substances outside the scope of legitimate medical practice to patient recruiters, as a kickback for their efforts to recruit patients into the scheme.
According to the indictment, the Patel Pharmacies billed the Medicare program not less than $37.7 million for medications purportedly provided to Medicare beneficiaries over the course of the scheme (since January 2006), and not less than $20.8 million for medications purportedly provided to Medicaid beneficiaries over the course of the scheme. The indictment further alleges that since January of 2009, the Patel Pharmacies have dispensed not less than 250,000 doses of Oxycontin, not less than 4.6 million doses of Vicodin, not less than 1.5 million doses of Xanax, and not less than 6,100 pint bottles of codeine cough syrup.
In addition to Babubhai Patel, those named in the 34-count indictment were physician Paul Petre, 43, of Rochester Hills; pharmacist Dineshkmar Patel, 33, of Canton; pharmacist Anish Bhavsar, 35, of Canton; pharmacist Ashwini Sharma, 33, of Novi; pharmacist Pinakeen Patel, 32, of Sterling Heights; pharmacist Kartik Shah, 34, of Canton, pharmacist Viral Thaker, 30, of Findlay, Ohio; pharmacist Hiren Patel, 31, of Novi; pharmacist Miteshkumar Patel, 37, of Troy; pharmacist Lokeh Tayal, 35, of Canton; pharmacist Narendera Cheraku, 33, of Farmington Hills; accountant Chetan Gujarathi, 38, of Canton; business associate Arpitkumar Patel, 26, of Romulus; business associate Sumanray Raval, 54, of Farmington Hills; business associate Harpreet Sachdeva, 38, of Canton; business associate Ramesh patel, 50, of Canton; business associate Rana Naeem, 60, of Rochester Hills; podiatrist Anmy Tran, 40, of Macomb; physician Mark Greenbain, 69, of Farmington Hills; physician Mustak Vaid, 38, of Brownstown Township; psychologist and patient recruiter Sanyani Edwards, 32, of Ferndale; business associate Komal Acharya, 27, of Farmington Hills; patient recruiter Leodis Elliott, 41, of West Bloomfield; and patient recruiter LaVar Carter, 34, of Macomb.
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Tuesday, August 2, 2011
Nelson Fernandez Pleads Guilty to Participating in $200 Million Medicare Fraud Scheme
WASHINGTON – A Miami-area resident pleaded guilty today in U.S. District Court in Miami for his role in two separate fraud schemes that resulted in the submission of more than $200 million in fraudulent claims to Medicare, announced the Department of Justice, the FBI and the Department of Health and Human Services (HHS).
Nelson Fernandez, 42, admitted to participating in a fraud scheme that was orchestrated by the owners and operators of American Therapeutic Corporation (ATC); its management company, Medlink Professional Management Group Inc.; and the American Sleep Institute (ASI). ATC, Medlink and ASI were all Florida corporations headquartered in Miami. ATC operated purported partial hospitalization programs (PHPs) in seven different locations throughout South Florida and Orlando. A PHP is a form of intensive treatment for severe mental illness. ASI purported to provide diagnostic sleep disorder testing.
Fernandez pleaded guilty to one count of conspiracy to commit health care fraud and one count of conspiracy to defraud the United States and to pay and receive illegal health care kickbacks. Fernandez was charged in an indictment unsealed on Feb. 15, 2011, in the Southern District of Florida.
According to court filings, ATC’s owners and operators paid kickbacks to owners and operators of assisted living facilities (ALFs) and halfway houses and to patient brokers in exchange for delivering ineligible patients to ATC and ASI. In some cases, the patients received a portion of those kickbacks. Throughout the course of the ATC and ASI conspiracy, millions of dollars in kickbacks were paid in exchange for Medicare beneficiaries who did not qualify for PHP services to attend treatment programs that were not legitimate PHPs so that ATC and ASI could bill Medicare for the medically unnecessary services. According to court filings, to obtain the cash required to support the kickbacks, the co-conspirators laundered millions of dollars of payments from Medicare.
In pleading guilty, Fernandez admitted to serving as a patient broker and providing patients to ATC and ASI in exchange for kickbacks in the form of checks and cash. The amount of the kickback was based on the number of days each patient spent at ATC.
According to court documents, Fernandez also conspired to commit health care fraud through Priority Home Health. Fernandez admitted that Priority Home Health submitted more than $14.7 million in fraudulent billings to Medicare. Fernandez and his co-conspirators recruited Medicare beneficiaries to Priority Home Health who did not qualify for home health services. According to court documents, Fernandez recruited some of the same beneficiaries to attend ATC.
According to the plea agreement, Fernandez’s participation in the ATC fraud resulted in $8 million in fraudulent billings to the Medicare program. His participation in the Priority Home Health fraud resulted in $14.7 million in fraudulent billings to the Medicare program.
Sentencing for Fernandez is scheduled for Jan. 17, 2012, at 8:30 a.m. Fernandez faces a maximum penalty of 15 years in prison and a $250,000 fine.
ATC, Medlink and the owners and the lead manager of ATC, Medlink and ASI were each charged with multiple health care fraud-related and money laundering counts in a superseding indictment unsealed on Feb. 15, 2011. Lawrence Duran and Marianella Valera, two of the three owners, and Margarita Acevedo, the lead manager of ATC and Medlink, have pleaded guilty for their roles in the scheme, admitting that more than $200 million in billings were submitted to the Medicare program as a part of the scheme. They are scheduled to be sentenced on Sept. 14, 2011, by U.S. District Judge James Lawrence King in the Southern District of Florida. In addition, Medlink and ATC have pleaded guilty. Trial against the third owner charged in the superseding indictment, Judith Negron, is scheduled to begin Aug. 15, 2011. A defendant is presumed innocent unless proven guilty beyond a reasonable doubt in a court of law.
The indictment charging Fernandez also charges 17 other individuals for their roles in the fraud scheme. Co-defendants Dr. Alan Gumer, Joseph Valdes, James Edwards and Adrianna Mejia have all pleaded guilty for their roles in the scheme. Trial against the remaining 13 co-defendants is scheduled to begin on Nov. 7, 2011, before U.S. District Judge Judge Patricia A. Seitz.
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Monday, August 1, 2011
Dr. Gwendolyn Washington, Pleads Guilty to Illegal Prescription Drug Trafficking and Health Care Fraud
Dr. Gwendolyn Washington, M.D., age 67, pleaded guilty today to four felony counts involving drug trafficking and health care fraud, United States Attorney Barbara L. McQuade announced. McQuade was joined in the announcement by Andrew G. Arena, Special Agent in Charge, Federal Bureau of Investigation, Detroit Field Division and Lamont Pugh, III, Special Agent in Charge, Department of Health and Human Services, Office of Inspector General.
United States Attorney Barbara L. McQuade stated, “These crimes not only harm all of us who pay to support Medicare, but create potential harm to patients by submitting patients to unnecessary testing and by putting prescription drugs on the streets. The number of fatal overdoses from prescription drugs in the United States last year was more than six times the number of fatal overdoses from all other illegal drugs combined.”
Today, Washington pleaded guilty to committing health care fraud, accepting illegal kickbacks, and committing drug distribution offenses.
First, Washington admitted that between 2004 and 2010, she performed unnecessary ultrasounds, nuclear cardiac stress tests, balance tests, sleep tests, and nerve conduction tests on patients, who were urged to return to the Washington’s office every few months for repeat tests, even though initial results were normal. Washington billed Medicare and Blue Cross and Blue Shield more than $5 million for these tests, some of which were potentially harmful to patients. Nuclear stress tests, for example, involve the intravenous injection of radionuclide, which emits radiation.
Second, Washington also admitted that she solicited and received kickbacks from home health care agencies and diagnostic testing facilities in return for referring patients to them for medical services. Washington referred patients to home health agencies, falsely certifying them as being confined to the home, in return for payments from home health care agencies of $200 to $500 per patient. In total, Washington received $350,000 in total kickback payments. Medicare paid approximately $2.8 million to agencies receiving the fraudulent referrals. Washington received another $250,000 directly from Medicare for false certifications of patients for home health services.
Third, Washington admitted to committing two counts of controlled substances offenses. In February 2010, when Medicare suspended payments to Washington, resulting in a drastic reduction in her income, she began writing prescriptions for tens of thousands of doses of OxyContin, Opana ER, and Roxicodone, highly addictive pain medications that have a significant “street value” on the illicit market. Washington sometimes wrote prescriptions for individuals who were not her patients, without an examination or determination of medical necessity, and without an appropriate diagnosis or entry in a patient chart. Washington then provided these illegal prescriptions to Virginia Dillard, a co-defendant. Dillard filled the prescriptions at various pharmacies in Highland Park, Warren, and Detroit. After filling the illegal prescriptions, Virginia Dillard delivered the controlled substances to prescription drug dealers in exchange for money. Dillard sold each filled prescription in amounts ranging from $1,000 to $2,200, and shared the proceeds with Washington. Dillard pleaded guilty earlier this week.
The maximum penalties are up to 20 years’ imprisonment. A sentencing hearing was set by Judge Borman for October 5, 2011 at 3:00 p.m.
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Sunday, July 31, 2011
Elizabeth Acosta Sanz and Luis Alejandro Sanz, both of Miami, 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
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
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Wednesday, July 27, 2011
Pharmacists Luba Balyasny Charged in $3 Million Health Care Fraud Scheme
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
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
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
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
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
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
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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