Randall F. Guzik Charged in Health Care Fraud Scheme

Source-  http://www.fbi.gov/pittsburgh/press-releases/2011/monongahela-man-charged-in-health-care-fraud-scheme 

PITTSBURGH, PA—A resident of Monongahela, Pa., has been charged in Pittsburgh on a charge of health care fraud, United States Attorney David J. Hickton announced today.

The one-count indictment, unsealed today, named Randall F. Guzik, 46, as a defendant.

According to indictment, from January 2007, to May 17, 2011, in the Pittsburgh area, Guzik defrauded two health care benefit programs, that is, Highmark Blue Cross and Blue Shield, a health insurer serving western Pennsylvania (hereinafter Highmark), and Anthem Blue Cross and Blue Shield, a health insurer serving Ohio and Kentucky (hereinafter Anthem), out of approximately $550,077.22.

Guzik prepared billings to Anthem for Highmark insureds residing in Western Pennsylvania for health care services such as conventional joint x-rays that were false in that no conventional joint x-rays were provided, the dates of the services were fabricated, the services were not provided in the locations represented on the billings, and the health care providers listed on the billings did not perform the services.

The law provides for a maximum total sentence of not more than ten years in prison, a fine of $250,000, or both. Under the Federal Sentencing Guidelines, the actual sentence imposed would be based upon the seriousness of the offense and the prior criminal history, if any, of the defendant.



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Roberto Gonzalez, Olga Gonzalez and Their Son, Fabian Gonzalez Plead Guilty in $60 Million Health Care Fraud Scheme

Source-  http://www.justice.gov/opa/pr/2011/December/11-crm-1675.html 

WASHINGTON – Three operators of a Miami health care agency pleaded guilty yesterday for their participation in a $60 million home health Medicare fraud scheme, announced the Department of Justice, the FBI and the Department of Health and Human Services (HHS).

Roberto Gonzalez, 61, Olga Gonzalez, 57, and their son, Fabian Gonzalez, 39, each pleaded guilty before U.S. District Judge Ursula Ungaro in the Southern District of Florida to one count of conspiracy to commit health care fraud.

According to the court documents, Roberto Gonzalez was the president and Olga Gonzalez was the vice president of Nany Home Health Inc., a Florida home health agency that purported to provide home health care and physical therapy services to eligible Medicare beneficiaries. Their son, Fabian, was head of the Quality and Assurance Department for Nany.

According to plea documents, the Gonzalezes conspired with patient recruiters, including Miami-area “staffing agencies,” for the purpose of billing the Medicare program for unnecessary home health care and therapy services. These recruiters and “staffing agencies” recruited patients to Nany, and provided prescriptions, Plans of Care (POCs) and certifications for medically unnecessary therapy and home health services for Medicare beneficiaries. In return, the Gonzalezes and their co-conspirators paid these staffing agencies and patient recruiters kickbacks and bribes. The Gonzaleses then used these prescriptions, POCs and medical certifications to fraudulently bill the Medicare program for home health care services, knowing that their behavior violated federal criminal laws.

According to plea documents, nurses and office staff at Nany falsified patient files, including by documenting non-existent “symptoms” for Medicare beneficiaries to make it appear that the beneficiaries qualified for home health care and therapy services when, in fact, the beneficiaries did not actually qualify for such services. The fictitious symptoms, which suggested that the patients were unable to self-inject insulin and were homebound, formed the basis for the false claims for home health care benefits and medically unnecessary therapy filed under the Medicare program.

From approximately January 2006 through November 2009, Roberto, Olga and Fabian Gonzalez, and their co-conspirators submitted approximately $60 million in false and fraudulent claims to Medicare and Medicare paid approximately $40 million on those claims.



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Butler Moultrie a Halfway House Operator Pleads Guilty to Fraud and Kickback Scheme

Source-  http://www.justice.gov/opa/pr/2011/December/11-crm-1677.html 

WASHINGTON – The manager and operator of a Fort Lauderdale, Fla.-area halfway house pleaded guilty yesterday for his role in a Medicare fraud kickback scheme that funneled patients to a fraudulent mental health provider, American Therapeutic Corporation (ATC), announced the Department of Justice, FBI and the Department of Health and Human Services (HHS).

Butler Moultrie, 46, pleaded guilty before U.S. Magistrate Judge Barry L. Garber in Miami to one count of conspiracy to commit health care fraud.

According to court documents, most of the residents at Moultrie’s halfway house were recovering from drug and/or alcohol addictions. Nevertheless, Moultrie agreed to refer Medicare beneficiaries who resided at his halfway house to ATC purportedly to receive intensive mental health services called partial hospitalization program (PHP) treatment in exchange for illegal health care kickbacks. Moultrie knew that such kickbacks were illegal, and he knew that ATC fraudulently billed the Medicare program for the PHP services. Moultrie knew that no doctor had prescribed PHP treatment for his patient referrals, and he knew that his residents required drug and/or alcohol addiction treatment rather than mental health services.

According to court filings, ATC’s owners and operators paid kickbacks to owners and operators of assisted living facilities and halfway houses, including Moultrie, and to patient brokers in exchange for delivering ineligible patients to ATC and its related company, the American Sleep Institute (ASI). In some cases, the patients received a portion of those kickbacks. Throughout the course of the ATC conspiracy, millions of dollars in kickbacks were paid in exchange for Medicare beneficiaries who did not qualify for PHP services. The ineligible beneficiaries attended treatment programs that were not legitimate so that ATC and ASI could bill Medicare more than $200 million in medically unnecessary services.

According to the plea agreement, Moultrie’s participation in the fraud resulted in approximately $1.9 million in fraudulent billing to the Medicare program. At sentencing, scheduled for Feb. 21, 2012, Moultrie faces a maximum of 10 years in prison and a $250,000 fine.

Robert and Nikki Jenkins, two other managers and operators of halfway houses in Fort Lauderdale, were sentenced yesterday for referring beneficiaries to ATC in exchange for health care kickbacks. U.S. District Chief Judge Federico A. Moreno in Miami sentenced Robert Jenkins to 24 months in prison and Nikki Jenkins to 15 months in prison. Another halfway house operator, Irene Trematerra, was sentenced last week by U.S. District Judge Ursula Ungaro to 18 months in prison for her role in providing beneficiaries to ATC in exchange for kickbacks.

ATC, its management company Medlink Professional Management Group Inc., and various owners, managers, doctors, therapists, patient brokers and marketers of ATC, Medlink and ASI, were charged with various health care fraud, kickback, money laundering and other offenses in two indictments unsealed on Feb. 15, 2011. ATC, Medlink and nine of the individual defendants have pleaded guilty or have been convicted at trial. Other defendants are scheduled to begin trial on April 9, 2012, before U.S. District Judge Patricia A. Seitz.



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Licet Diaz, Fidel Castro, Ignacio Angulo and Barbara Gonzalez Sentenced to Prison in $25 Million Health Care Fraud Scheme

Source-  http://www.justice.gov/opa/pr/2011/December/11-crm-1674.html 

WASHINGTON – Two patient recruiters, a nurse and an administrator for two Miami home health care companies were sentenced 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).

The defendants were sentenced by U.S. District Judge Joan A. Lenard in the Southern District of Florida.

Licet Diaz, 49, was sentenced to 87 months in prison, three years of supervised release and ordered to pay $7.8 million in restitution.

Fidel Castro, 49, was sentenced to 30 months in prison, three years of supervised release and ordered to pay $550,000 in restitution.

Ignacio Angulo, 48, was sentenced to 18 months in prison, two years of supervised release and ordered to pay $190,000 in restitution.

Barbara Gonzalez, 38, was sentenced to six months in prison, two years of supervised release and ordered to pay $40,000 in restitution.

Castro, Gonzalez, Angulo and Diaz each pleaded guilty earlier this year to one count of conspiracy to commit health care fraud. They were each ordered to pay their restitution jointly and severally with co-defendants.

According to court documents, Castro and Gonzalez were patient recruiters for ABC Home Health Care Inc., a Miami home health care agency that purported to provide home health and physical therapy services to Medicare beneficiaries. Angulo was a nurse and patient recruiter for Florida Home Health Care Providers Inc., another related Miami home health care agency. Diaz was an administrator for ABC and Florida Home Health. According to court documents, ABC and Florida Home Health only existed to defraud Medicare.

Castro, Gonzalez and Angulo admitted that beginning in approximately January 2006 and continuing until approximately March 2009, they recruited Medicare beneficiaries who would allow ABC and Florida Home Health to bill Medicare for home health care and therapy services that were medically unnecessary and/or never provided. Castro, Gonzalez, and Angulo solicited and received kickbacks and bribes from the owners and operators of ABC and Florida Home Health in return for recruiting patients. Castro, Gonzalez and Angulo knew that the patients they recruited did not qualify for the services billed to Medicare and that the files for the recruited patients were falsified to make it appear that the patients qualified for the services.

According to court documents, Angulo, a licensed practical nurse, along with his co-defendant nurses, falsified patient files for Medicare beneficiaries to make it appear that the beneficiaries qualified for home health care and therapy services. Angulo admitted that he knew the beneficiaries did not qualify for and did not receive the services. The files were falsified so that Medicare could be billed for medically unnecessary therapy and home health related services.

According to plea documents, Diaz distributed kickback payments to the patient recruiters on behalf of the owners of ABC and Florida Home Health. Diaz worked in the offices of ABC and Florida Home Health and was aware that office staff manipulated the patient files and nursing notes for patients at ABC and Florida Home Health.

As a result of the participation of Castro, Gonzalez, Angulo and Diaz in the illegal scheme, the Medicare program was billed approximately $550,000, $40,000, $190,000 and $7.8 million, respectively, for purported home health care services that were not medically necessary and/or were not provided.



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Ollie Futrell Pleads Guilty in Health Care Fraud Conspiracy

Source-  http://www.fbi.gov/dallas/press-releases/2011/patient-recruiter-pleads-guilty-in-health-care-fraud-conspiracy 

WASHINGTON—A patient recruiter for Alliance Healthcare Services L.P., a Dallas home health care agency, pleaded guilty yesterday for her participation in a scheme to defraud Medicare and Medicaid, announced the Department of Justice, the FBI and the Department of Health and Human Services (HHS). Four co-owners of Alliance pleaded guilty last week for their roles in the fraud scheme.

Ollie Futrell, 56, of Garland, Texas, pleaded guilty yesterday before U.S. District Judge Jane J. Boyle in the Northern District of Texas to one count of conspiracy to commit health care fraud. Ernest Amadi and his wife, Edith Amadi, both of Wylie, Texas, pleaded guilty to the same charge on Dec. 6, 2011. George Opurum and his wife, Agatha Opurum, both of Richardson, Texas, also pleaded guilty to conspiracy to commit health care fraud on Dec. 8, 2011. The five defendants were indicted and arrested in February 2011. This case was the first case to be prosecuted by the Medicare Fraud Strike Force in Dallas.

According to court documents, Ernest Amadi, 53, was the chief executive officer and administrator of Alliance, and George Opurum, 60, was the chief financial officer and alternate administrator of Alliance. Edith Amadi, 49, and Agatha Opurum, 53, were both nurses at Alliance.

As part of the conspiracy, from November 2008 through mid-February 2011, Alliance submitted claims to Medicare for home health services purportedly provided to Medicare beneficiaries. According to court documents, Alliance employees, including the owners, falsified Medicare documentation and skilled nursing notes indicating that the patients were homebound and eligible for home health care services. In fact, the majority of Alliance patients were not eligible for the services because they were not homebound. According to court documents, Alliance employees and owners falsified time sheets and patient visit logs for services that were not adequately rendered or were never provided at all. Alliance then billed Medicare as if the services were adequately provided.

According to court documents, Alliance owners conspired with Futrell to recruit Medicare patients for the company so Alliance could increase its Medicare billing and revenue. Futrell was paid cash by Alliance owners. She agreed to pay patients kickbacks so that they would continue to use Alliance. Often, Futrell paid patients $100 per month to continue to receive home health care from Alliance. Alliance owners knew about, and at times facilitated, these kickbacks.

Each defendant faces a maximum sentence of 10 years in prison, a $250,000 fine and restitution. Ernest and Edith Amadi are scheduled to be sentenced on April 19, 2012. George and Agatha Opurum are scheduled to be sentenced on April 5, 2012. Ollie Futrell is scheduled to be sentenced on April 26, 2012. All sentencings will be before Judge Boyle.



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Philadelphia physician Dr. Kermit B. Gosnell Charged with Running Pill Mill

Source-  http://www.fbi.gov/philadelphia/press-releases/2011/philadelphia-doctor-charged-with-running-pill-mill 

PHILADELPHIA—A 23-count indictment was returned and four informations1 were unsealed today charging a total of eight defendants, including Philadelphia physician Dr. Kermit B. Gosnell and members of his former staff, in a drug conspiracy case. Gosnell is charged with illegally prescribing highly-addictive painkillers and sedatives outside the usual course of professional practice and not for a legitimate medical purpose, along with related charges. The charges were announced by United States Attorney Zane David Memeger, Federal Bureau of Investigation Special Agent in Charge George C. Venizelos, Drug Enforcement Administration Special Agent in Charge Vito Guarino, and Department of Health and Human Services Special Agent in Charge Nick DiGiulio.

The indictment alleges that Gosnell, with the assistance of several of his former office staff at Family and Women’s Medical Society (“WMS”), ran a prescription “pill mill” out of his office located at 3801-3805 Lancaster Avenue in Philadelphia, Pennsylvania. From June of 2008 through February 18, 2010, Gosnell allegedly engaged in a continuing criminal enterprise by writing and dispensing fraudulent prescriptions for thousands of pills of the frequently-abused tablets OxyContin, Percocet, and Xanax, and the frequently-abused syrups Phenergan and Promethazine with Codeine. The charges state that customers, often referred to as drug “seekers,” met with Gosnell briefly for a cursory exam or no exam, paid him a fee, and then were given prescriptions for controlled substances without there being any legitimate medical purpose for the prescriptions.

It is further alleged that Gosnell and his staff allowed customers to purchase multiple prescriptions under multiple names; that customers could place orders for refills in person, over the phone, or by leaving a message on a WMS office answering machine; and that WMS office staff would give the refill orders to Gosnell, who, without seeing the customer, would write the requested prescription and give it to WMS staff who would then collect cash and “tips” from customers. According to the indictment, Gosnell did not work at WMS during the day and saw these “seekers” in the evenings or after midnight. For the first office visit, Gosnell allegedly charged $115.00 but that increased around December of 2009 when he allegedly increased the initial office visit fee to $150.00.

The indictment alleges that Gosnell went from writing several hundred prescriptions for controlled substances per month filled at pharmacies in 2008 to over 2,300 filled at pharmacies in January of 2010. It is further alleged that during the conspiracy Gosnell, with the assistance of his staff, distributed and dispensed, for no legitimate medical purpose, more than 500,000 pills containing oxycodone, more than 400,000 pills containing alprazolam, and more than 19,000 ounces of cough syrup containing codeine.

Charged in the indictment with Gosnell are office staff defendants Sherry L. West, Tamirrah M. Fluellen, and Kareema N. Cross. Charged by information are office staff Latosha R. Lewis, Earlene Tina Baldwin, and Lynda Gail Williams. Gosnell employee Steven Massof is also charged by information with 30 counts of dispensing a controlled substance using a DEA registration number issued to another person.

The charges of conspiracy to distribute a controlled substance, distribution of a controlled substance, and maintaining a drug premises each carry a maximum possible sentence of 20 years in prison.

Distribution of a oxycodone in a school zone carries a maximum sentence of 40 years in prison with a mandatory minimum one year in prison.

Continuing criminal enterprise carries a maximum sentence of life imprisonment with a mandatory minimum of 20 years in prison.

Each count of unlawful use of a DEA registration number carries a maximum possible sentence of four years in prison.

Each defendant also faces possible fines, periods of supervised release, forfeiture and special assessments. See attached chart.



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B. Elise Miller Charged with Health Care Fraud in Violation of Title 18

Source-  http://www.fbi.gov/cleveland/press-releases/2011/coshocton-woman-charged-with-health-care-fraud 

A federal grand jury in Cleveland, Ohio, returned an indictment charging B. Elise Miller, age 57 of Coshocton, Ohio, with 14 counts of health care fraud in violation of Title 18, United States Code, Section 1347, said Steven M. Dettelbach, United States Attorney for the Northern District of Ohio.

Miller is currently facing charges from two earlier indictments charging her, her husband Dana Campbell, Douglas Bolden, and James Ireland, with obstruction of justice and conspiracy.

The indictment alleges that from about 1987 to November 2008, Miller owned and operated Three Rivers Infusion and Pharmacy Specialists (Three Rivers), a medical infusion and pharmacy supply company located in Coshocton, Ohio.

In 2008, Three Rivers was under investigation by federal and state agencies for suspected over-billing of medical insurance companies for services and drugs, including a drug called Synagis used to treat infants to help prevent influenza. In August 2008, the government searched Three Rivers and seized various files including some files of patients who received Synagis, according to court documents.

The current indictment charges that Miller caused Three Rivers to file false and fraudulent claims for reimbursement for services and drugs administered to patients covered by Medicaid and Medical Mutual of Ohio (MMOH). The indictment charges that Three Rivers began submitting claims to MMOH falsely under the name “Holzer Infusion Services” in order to avoid the review of Three Rivers claims by MMOH. By the time MMOH discovered that “Holzer” was in reality, Three Rivers, MMOH had paid more than $700,000 in claims to “Holzer,” according to the indictment.

The indictment also charges that Miller caused Three Rivers to file false claims with Medicaid relating to Three Rivers dispensing Synagis to Medicaid patients. It is alleged that fictitious claims were made by Three Rivers for dispensing of Synagis at times when such drug was actually never dispensed.

If convicted, the defendants’ sentences will be determined by the Court after review of factors unique to this case, including the defendants’ prior criminal records, if any, the defendants’ roles in the offense and the characteristics of the violation. In all cases, the sentence will not exceed the statutory maximum and, in most cases it will be less than the maximum.



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Valerie Jean Flores Pleads Guilty to Conspiring to Commit Health Care Fraud

Source-  http://www.fbi.gov/sanantonio/press-releases/2011/pharmacy-technician-pleads-guilty-to-conspiring-to-commit-health-care-fraud 

MCALLEN, TX—Valerie Jean Flores 38, of Mission, Texas, has been convicted of conspiracy to commit health care fraud, United States Attorney Kenneth Magidson announced today along with Texas Attorney General Greg Abbott. Flores was formerly employed a senior pharmacist technician by Sara Elicia Garza, 55, also of Mission—a pharmacist and owner and operator of Sara’s Pharmacy and Gift Corner located in Mission.

Flores pleaded guilty to conspiracy to commit health care fraud at a hearing held earlier today before U.S. District Judge Randy Crane. At that hearing, Flores admitted that she participated in the conspiracy to defraud the Texas Medicaid/Vendor Drug program by submitting false and fraudulent claims for prescription medication that was not dispensed or provided. Specifically, Flores admitted the claims were false and fraudulent for one or more of a variety of reasons—medications were never provided or dispensed, the beneficiary had never seen the physician purporting to prescribe the medication, prescription medications were written for the treatment of medical conditions that the beneficiary did not have, claims were for refills of prescription medications authorized by a physician but which the beneficiary did not request and did not receive, and/or that the prescription medications were never dispensed to beneficiaries but were billed (referred to as “running extras” by Flores and her co-conspirators) in lieu of collecting co-pays for prescriptions that were actually dispensed or in lieu of collecting money for purchases from the Sara’s Pharmacy Gift Store.

Flores also admitted that to cover up the fraud and the conspiracy she and co-defendant Garza, along with other unindicted co-conspirators, forged prescriptions, doctors’ signatures on prescriptions, customers’ signatures on logs that purportedly indicated that a customer beneficiary had received medications and altered pharmacy records.

Flores faces a maximum punishment of 10 years in prison and up to a $250,000 fine plus up to three years of post-prison supervised release at her sentencing which is scheduled for April 5, 2012. Flores was permitted to remain on bond pending sentencing, at which time the court will also decide the amount of restitution to be ordered.



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Owners of Houston Mental Health Company and Assisted Living Facility Indicted for Alleged Roles in $90 Million Medicare Fraud Scheme

Source- http://www.justice.gov/opa/pr/2011/December/11-crm-1639.html

WASHINGTON – Two owners of a Houston mental health care company, Spectrum Care P.A., and the owner of a Houston assisted living facility were arrested today on charges related to their alleged participation in a $90 million Medicare fraud scheme, announced the Department of Justice, the Department of Health and Human Services (HHS) and the FBI.

Mansour Sanjar, 78, Cyrus Sajadi, 64, and Chandra Nunn, 33, all of Houston, were arrested today in Houston and are expected to make their initial appearances in federal court today and tomorrow. An indictment filed in the Southern District of Texas charges Sanjar, Sajadi and Nunn with conspiracy to commit health care fraud and conspiracy to pay and receive illegal health care kickbacks.

“These defendants allegedly participated in a scheme to cheat the Medicare program out of more than $90 million,” said Assistant Attorney General Lanny A. Breuer of the Justice Department’s Criminal Division. “The indictment alleges that Spectrum billed Medicare for mental health services when patients were actually watching movies, playing bingo or engaging in other activities. Our efforts over the past three years to combat Medicare fraud have been unprecedented, and today’s arrests are another example.”

“This case is another excellent example of the partnership and cooperation between the U.S. Attorney’s Office, the Department of Justice and our investigating agencies,” said U.S. Attorney Kenneth Magidson of the Southern District of Texas . “We will continue to work closely with each other to ensure those who engage in such fraudulent health care practices are brought to justice.”

According to the indictment, Sanjar and Sajadi orchestrated and executed a scheme to defraud Medicare beginning in 2006 and continuing until their arrest today. Sanjar and Sajadi owned Spectrum Care P.A., a Houston mental health company that purportedly provided partial hospitalization programs (PHP). A PHP is a form of intensive outpatient treatment for severe mental illness. Sanjar and Sajadi allegedly submitted false and fraudulent claims to Medicare through Spectrum.

According to the indictment, Nunn owned a Houston assisted living facility. The indictment alleges that Sanjar and Sajadi paid kickbacks to Nunn and other owners and operators of assisted living facilities and to patient brokers in exchange for delivering ineligible Medicare beneficiaries to Spectrum. In some cases, the patients received a portion of those kickbacks.

Sanjar and Sajadi allegedly billed Medicare for treatments purportedly provided to these recruited patients. According to the indictment, the treatments were medically unnecessary or never provided at all. The indictment alleges that Spectrum billed Medicare for more than $90 million in medically unnecessary services.



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Three Patient Recruiters for Miami Home Health Companies Sentenced to Prison in $25 Million Health Care Fraud Scheme

Source- http://www.justice.gov/opa/pr/2011/December/11-atj-1641.html

WASHINGTON – Two patient recruiters for a Miami health care agency were sentenced today to 18 and 12 months in prison, respectively, 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).

U.S. District Judge Joan A. Lenard in Miami sentenced Oscar Martinez, 54, to 18 months in prison, three years of supervised release and ordered Martinez to pay $390,000 in restitution. Judge Lenard sentenced Lesder Casanova, 40, to 12 months in prison, three years of supervised release and ordered Casanova to pay $195,000 in restitution.

In addition, on Dec. 12, 2011, co-conspirator patient recruiter Raul Alvarez, 48, was sentenced by Judge Lenard to 10 months in prison for his role in the fraud scheme. Alvarez was also sentenced to three years of supervised release and ordered to pay $118,000 in restitution.

Alvarez, Martinez and Casanova each pleaded guilty earlier this year to one count of conspiracy to commit health care fraud. They were each ordered to pay their restitution jointly and severally with co-defendants.

According to court documents, Casanova was a patient recruiter for ABC Home Health Care Inc., a Miami home health care agency that purported to provide home health and physical therapy services to Medicare beneficiaries. Alvarez and Martinez were patient recruiters for Florida Home Health Care Providers Inc., another related Miami home health care agency. According to court documents, ABC and Florida Home Health only existed to defraud Medicare.

Alvarez, Martinez and Casanova admitted that beginning in approximately January 2006 and continuing until approximately March 2009, they recruited Medicare beneficiaries who would allow ABC and Florida Home Health to bill Medicare for home health care and therapy services that were medically unnecessary and/or never provided. Alvarez, Martinez and Casanova solicited and received kickbacks and bribes from the owners and operators of ABC and Florida Home Health in return for the recruited patients. According to their pleas, Alvarez, Martinez and Casanova knew that the patients they recruited did not qualify for the services billed to Medicare. In addition, the defendants knew that the patient files for their recruited patients were falsified in order to make it appear that the patients qualified for the services.

As a result of the participation of Alvarez, Martinez and Casanova in the illegal scheme, the Medicare program was billed approximately $118,000, $390,000 and $195,000, respectively, for purported home health care services that were not medically necessary and/or were not provided.

Last week, Dr. Jose Nunez was sentenced to 40 months in prison for his role in the fraud scheme and two nurses, Luisa Morciego and Eneida Fry, were each sentenced to 24 months in prison for their roles in the scheme. Another patient recruiter, Vincente Guerra-Nistal, was sentenced to 18 months in prison in October 2011.



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Little Rock Hospice Home Care to Pay $2,700,000 Settlement in Medicare Fraud Case

Source- http://www.fbi.gov/littlerock/press-releases/2011/hospice-home-care-to-pay-2-700-000-settlement-in-medicare-fraud-case
LITTLE ROCK—Christopher R. Thyer, United States Attorney for the Eastern District of Arkansas; Valerie Parlave, Special Agent in Charge of the Little Rock Field Office of the Federal Bureau of Investigation (FBI); and Mike Fields, Special Agent in Charge of Health and Human Services Office of the Inspector General (HHS-OIG) announced today that the United States has settled a federal qui tam lawsuit filed under the False Claims Act against a Little Rock hospice and its owners and operators for $2,700,000.00. The lawsuit, which was filed by Arkansas Hospice, Inc. as relator, alleges that Hospice Home Care, Inc. billed Medicare for general inpatient (acute) care in situations where only routine care was provided. The Government’s investigation revealed that in a large number of those cases general inpatient care was not required.

The False Claims Act allows private citizens or “whistleblowers” to file lawsuits as “relators” against individuals and entities committing fraud upon the federal government. As incentive for coming forward and exposing wrongdoers, the Act provides for monetary rewards to relators and for the payment of attorney’s fees on successful claims.

According to the Complaint in Intervention filed by the United States on July 17, 2009, the alleged conduct began in January of 2002 and continued through December of 2004. During that time period, Hospice Home Care, Inc. (“HHC”), which lacked an inpatient facility, contracted with Parkview Rehabilitation and Healthcare Center (“Parkview”) to provide inpatient care to HHC patients. HHC then billed the Medicare Program for each HHC patient residing at Parkview at the general inpatient level of care. The United States’ review of the medical records

established that, for a vast majority of the days billed, patients needed only routine care. During the relevant time period, general inpatient care was reimbursed by Medicare at approximately $500 per day, while routine care was reimbursed at only $115 per day.

“As I stated just over a week ago, we are committed to pursue recovery of funds to be returned to the federal treasury when through fraudulent business practices they are stolen from federal agencies and ultimately, the citizens who need the funds for payment of legitimate claims,” stated Thyer. “This is another excellent result of the dedication by our office and investigative partners to protect the people of this district. We make these cases a high priority and commit to recovery of hard-earned tax dollars for future use by citizens who need them for their medical care.”

Fields added, “Any time greed replaces medical necessity as the primary factor in billing for medical services our most vulnerable citizens, the nation’s elderly, are imperiled. Our HHS OIG agents will continue to work closely with our law enforcement partners to investigate providers who loot the Medicare Trust fund. This settlement represents a significant recovery for taxpayers and should deter similar conduct in the future.”

“The Medicare program is relied upon by millions of our citizens and the hospice benefit is intended to provide compassionate care for those who are near the end of life. The FBI will continue to investigate and prosecute those who defraud the Medicare program or take advantage of their beneficiaries for their own pecuniary gain. Today’s settlement demonstrates the government’s commitment to protect the Medicare program from fraud and abuse and ensure Medicare beneficiaries receive the quality medical care they actually need,” said Parlave.



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Sofisha Rajhane Broadway and Emir Ramic Plead Guilty to Medicaid Kickbacks

Source-  http://www.fbi.gov/kansascity/press-releases/2011/kansas-city-woman-st.-louis-man-plead-guilty-to-medicaid-kickbacks 

KANSAS CITY, MO—Beth Phillips, United States Attorney for the Western District of Missouri, announced that a Kansas City, Mo., woman and a St. Louis, Mo., man pleaded guilty in federal court today to kickbacks that were paid to refer Medicaid patients to a non-emergency medical transportation business.

Sofisha Rajhane Broadway, 30, of Kansas City, and Emir Ramic, 34, of St. Louis, each pleaded guilty in separate appearances before U.S. District Judge Gary A. Fenner to the charges contained in an Aug. 24, 2011, federal indictment.

Broadway was employed by Logisticare Solutions, Inc., which had a contract with the state of Missouri to provide non-emergency medical transportation for Medicaid patients. Broadway worked as a scheduler at Logisticare’s network operations center in Kansas City, Mo., where she helped arrange transportation services with companies that had contracted with Logisticare to provide transportation services for Missouri Medicaid patients.

Ramic owned and operated Eurotrans Services, a transportation company in St. Louis, Mo., that contracted with Logisticare.

When Ramic complained to Broadway that he wasn’t getting enough referrals, she told him that if he paid her $150 per week she would direct additional Logisticare referrals to Eurotrans. Ramic agreed to make the payments to Broadway. Ramic paid Broadway with 13 wire transfers of $150 each from April to July 2009. In return, Broadway increased the number of referrals to Ramic.

Broadway pleaded guilty today to one count of receiving illegal kickbacks and Ramic pleaded guilty to one count of paying illegal kickbacks.

Houston Federal Jury Returns Guilty Verdicts in Health Care Fraud Trial

Source- http://www.fbi.gov/houston/press-releases/2011/houston-federal-jury-returns-guilty-verdicts-in-health-care-fraud-trial

HOUSTON—Kelvin Washington, 48, of Houston, has been convicted on all counts of health care fraud, conspiracy and violations of the anti-kickback statute charged against him, United States Attorney Kenneth Magidson announced today. The verdicts were returned less than an hour ago after six days of trial and three-and-a-half hours of deliberation.

The evidence in the week-long trial showed that from 2003 to 2007, Washington received illegal payments for the referral of dialysis patients to a Houston ambulance transport service. In addition, he conspired with others to have unsuspecting doctors sign transport prescriptions for dialysis patients never admitted to a Sugar Land nursing home where he worked.

Testimony at trial showed that Washington was paid for the referral of dialysis patients to an ambulance service that was under contract with the nursing home where he worked. The evidence also showed that he would present prescriptions to doctors who worked at the nursing home. The doctors testified that they would not have signed the prescriptions if they had known the various patients were never admitted to the nursing home.

The jury also heard evidence that the ambulance service paid the Washington in checks totaling $22,200 with many tied to specific patients. Washington did not report all the income he made to the Internal Revenue Service (IRS) from the ambulance service. At trial, an undercover video and audio tape showed one of the managers of the ambulance company bribing a patient to ride with the ambulance company. The ambulance company would later bill Medicare for this patient, a paid informant whose own doctors would not sign a prescription for him. The bill to Medicare was based upon a false script from the nursing home administrator. In a search warrant executed on a co-conspirator’s home, “The List” was discovered which detailed payments made not only to Washington but also to patients who rode with the ambulance service. A computer file from that home also showed detailed records tracking payments for patients, the check numbers for those payments and the fact that payments were made to the defendant.

The false scripts alone resulted in $1.2 million billed to Medicare and Medicaid and approximately $450,000 paid.



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Local Physician Gets 11 Years in Prison…Again

Source- http://www.fbi.gov/houston/press-releases/2011/local-physician-gets-11-years-in-prison...again

HOUSTON—Dr. Ira Klein, the local physician who was sentenced in 2007 to federal prison for defrauding insurance companies of more than $10 million, has once again appeared in federal court for a resentencing hearing, United States Attorney Kenneth Magidson announced today.

A federal jury convicted Klein, 65, of Houston, in November 2006 of 18 counts of mail fraud and 26 counts of health care fraud in connection with a scheme to defraud various insurance companies of more $10 million. In August 2007, U.S. District Judge David Hittner sentenced Klein to 135 months in prison to be followed by a three-year term of supervised release and ordered Klein to pay $11,590,784 in restitution. Klein appealed his conviction and sentence to the Fifth Circuit, which upheld all of Klein’s convictions but remanded the case for re-sentencing on the narrow issues of the amount of loss and Klein’s restitution calculation.

In March 2010, Klein represented himself at his re-sentencing hearing. On his second appeal, the Fifth Circuit ruled that Klein had not knowingly and intelligently waived his right to counsel and remanded the case for a third sentencing.

At today’s sentencing hearing, Judge Hittner again sentenced Klein to the same 135-month-term of imprisonment. Specifically, Judge Hittner found that Klein’s actual loss remained in excess of $11 million even after Klein was properly credited for the value of the medication he provided to his patients. Judge Hittner reserved his ruling on the amount of restitution owed by Klein for 90 days to give the victim insurance companies time to calculate their net losses. Judge Hittner also entered a $10 million criminal forfeiure against Klein.

At his original sentencing in 2007, the court also found Klein had obstructed justice when he conspired with jailhouse inmates to murder the Assistant United States Attorney prosecuting the case as well as one of the FBI special agents investigating the case and his wife. The court found that while in federal custody Klein met three inmates to discuss his plan. Later, Klein met with an individual and discussed the payment of $250,000 to kill his wife and the payment of an undetermined amount at a later date to kill the agent. Klein wired $250,000 from a bank account to the individual. What Klein did not know at the time was that the individual he discussed and sent payment to was a federal undercover agent. Klein ultimately pleaded guilty to charges stemming from the murder-for-hire plot and was sentenced to an additional term of imprisonment for that conduct.

Originally indicted in February 2006, Klein specialized in treating patients diagnosed with Hepatitis C and billed insurance companies for services he did not provide to patients and misrepresented services that were actually provided. The fraudulent scheme involved ordering large quantities of medications used to treat Hepatitis C and providing medications to patients to self administer at home and then billing the insurance companies as if the injections had been administered by him or his staff in his office. Evidence at trial proved Klein ordered Hepatitis C treatment kits containing both interferon and ribavirin at a cost of $695 each, but would unbundle the kit and submit claims to the insurance company for more than $3,840 for the components of the kits. The majority of the claims filed for services provided were for dates when patients were not in his office.

Klein also billed insurance companies for injecting his patients with the prescription drugs epoetin and neupogen during office visit, but again the evidence proved no office visit had occurred, and his patients were, in fact, self-administering those medications at home. Klein purchased epoetin at a cost of approximately $1,246 for 10 units of medication but in turn billed insurance companies $39,500 for the same 10 units. The Nuepogen was purchased at a cost of $1,885 for 10 units of medication, yet Klein billed insurance companies $32,700 for the same 10 units.



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Dr. Jose Nunez and Two Nurses Luisa Morciego and Eneida Fry Sentenced to Prison for Roles in $25 Million Miami Health Care Fraud Scheme

Source- http://www.justice.gov/opa/pr/2011/December/11-crm-1582.html

WASHINGTON – Two nurses and a doctor were sentenced yesterday in Miami federal court 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).

The following defendants were sentenced by U.S. District Judge Joan A. Lenard in Miami:

Jose Nunez, 63, a medical doctor, was sentenced to 40 months in prison and was ordered to pay $1.1 million in restitution.

Luisa Morciego, 40, a registered nurse, was sentenced to ­­­24 months in prison and was ordered to pay $296,000 in restitution.

Eneida Fry, 46, a licensed practical nurse, was sentenced to 24 months in prison and was ordered to pay $395,000 in restitution.

Nunez, Morciego and Fry were also each sentenced to three years of supervised release. The defendants were ordered to pay restitution jointly and severally with the co-defendants in this case and in a separate but related Medicare fraud case.

Morciego, Nunez and Fry each pleaded guilty to one count of conspiracy to commit health care fraud.

According to plea documents, Nunez was a medical doctor at two Miami-area medical offices that he owned and operated. Nunez referred patients to ABC Home Health Care Inc. and Florida Home Health Care Providers Inc., Miami home health care agencies that purported to provide home health and therapy services to Medicare beneficiaries. According to court documents, ABC and Florida Home Health billed the Medicare program for expensive physical therapy and home health services that were not medically necessary and/or never provided. Prescriptions, plans of care (POCs) and medical certifications for medically unnecessary therapy and services were issued through Nunez’s offices and other doctors’ offices in return for kickbacks and bribes. Nunez falsified patient files with descriptions of non-existent medical conditions, such as hand tremors, unsteady gait and poor vision, to make it appear that beneficiaries qualified for home health and therapy services.

From approximately January 2006 through March 2009, Nunez referred approximately 43 Medicare beneficiaries for medically unnecessary services to ABC and Florida Home Health. The medically unnecessary referrals, POCs and medical certifications resulted in approximately $1.5 million in fraudulent billings to Medicare, of which approximately $1.1 million was paid.

According to court documents, Morciego and Fry worked at ABC and Florida Home Health. Morciego and Fry, along with their co-defendant nurses, falsified patient files for Medicare beneficiaries to make it appear that the beneficiaries qualified for home health care and therapy services, when, in fact, they did not. Morciego, Fry and their co-defendant nurses did so by, among other things, describing in the nursing notes and patient files symptoms that were nonexistent. Morciego and Fry knew that these files were falsified to bill Medicare for unnecessary services, which they knew was in violation of federal criminal laws.

Fry’s additional role in the scheme was to recruit Medicare beneficiaries who would allow ABC and Florida Home Health to bill Medicare for services that were medically unnecessary and/or never provided. Fry solicited and received kickbacks and bribes from the owners and operators of ABC and Florida Home Health in return for allowing the agencies to bill Medicare on behalf of the recruited patients. Fry knew that the patients she recruited did not qualify for the services billed to Medicare and that their files were falsified to make it appear that they did qualify for the services.

As a result of Morciego’s and Fry’s participation in the illegal scheme, the Medicare program was billed approximately $296,000 and $395,000, respectively, for purported home health care services that were unnecessary and/or never provided.



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Owners of Houston Health Care Company Kemmie Houston and Sharon Beal Sentenced to Prison for Medicare Fraud

Source- http://www.justice.gov/opa/pr/2011/December/11-crm-1585.html

WASHINGTON – Two owners of a Houston durable medical equipment (DME) company were each sentenced to prison today for their roles in a Medicare fraud scheme, announced the Department of Justice, the FBI and the Department of Health and Human Services (HHS).

U.S. District Judge David Hittner in the Southern District of Texas sentenced Kemmie Houston to 63 months in prison and Sharon Beal to 51 months in prison. In addition to their prison terms, Houston and Beal were sentenced to two years of supervised release and were ordered to pay $403,704 in restitution, jointly and severally.

Beal, 48, and Houston, 43, pleaded guilty in June 2011 to one count of conspiracy to commit health care fraud.

According to court documents, Beal and Houston owned and operated STK Consultants. STK maintained a Medicare provider number to submit Medicare claims for the costs of DME and purported to provide orthotics, power wheelchairs, power wheelchair accessories and other DME to Medicare beneficiaries. According to court documents, Beal and Houston caused STK to submit claims to Medicare for DME that was medically unnecessary and/or not provided, including orthotic devices that were components of “arthritis kits.” The arthritis kit generally contained a number of devices including braces for both sides of the body and related accessories such as heat pads. In total, from August 2005 through August 2010, STK submitted approximately $851,212 in fraudulent claims to Medicare.



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Judith Negron Sentenced to 35 Years in Prison for Orchestrating $205 Million Medicare Fraud Scheme

Source- http://www.justice.gov/opa/pr/2011/December/11-crm-1604.html

WASHINGTON – The owner of a fraudulent Miami-area mental health care company, American Therapeutic Corporation (ATC), was sentenced today to 35 years in prison for orchestrating a $205 million Medicare fraud scheme, announced the Department of Justice, the FBI and the Department of Health and Human Services (HHS).

Judith Negron, 40, was sentenced by U.S. District Judge James Lawrence King in the Southern District of Florida. Judge King ordered Negron to pay more than $87 million in restitution, jointly and severally with her co-defendants. Negron was also sentenced to three years of supervised release following her prison term. Two other owners of ATC, Lawrence Duran and Marianella Valera, were sentenced in September 2011 to 50 and 35 years in prison, respectively, for their roles in the scheme. These sentences are the three longest prison sentences ever imposed in a Medicare Fraud Strike Force case.

On Aug. 24, 2011, after a six-day trial, a federal jury in the Southern District of Florida found Negron guilty of 24 felony counts, including conspiracy to commit health care fraud, health care fraud, conspiracy to pay and receive illegal health care kickbacks, conspiracy to commit money laundering, money laundering and structuring to avoid reporting requirements.

Evidence at trial demonstrated that Negron, along with Duran and Valera, masterminded and executed a scheme to defraud Medicare beginning in 2002 and continuing until they were arrested in October 2010. Evidence at trial established that the three owners submitted false and fraudulent claims to Medicare through ATC, a Florida corporation headquartered in Miami that purportedly operated 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. Negron and her co-conspirators also used a related company, American Sleep Institute (ASI), to submit fraudulent Medicare claims.

According to the evidence at trial, Negron, Duran, Valera and others paid bribes and kickbacks to owners and operators of assisted living facilities and halfway houses and to patient brokers in exchange for delivering ineligible patients to ATC and ASI. In some cases, the patients received a portion of those kickbacks. Throughout the course of the 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 PHP programs, so that ATC and ASI could bill Medicare for more than $205 million in unnecessary or illegitimate services.

According to the evidence, Negron and her co-conspirators used another company they owned and operated, Medlink Professional Management Group Inc., to conceal the fraud and kickback scheme from Medicare and law enforcement. Once Medicare paid ATC and ASI for the fraudulently billed services, Duran, Valera and others transferred the money to Medlink. Evidence at trial showed that Negron and her co-conspirators used Medlink to pay millions of dollars in kickback payments by using an extensive money laundering scheme.

Evidence at trial demonstrated that Negron signed kickback checks to patient recruiters whose only jobs at ATC were to provide patients from halfway houses or assisted living facilities. Evidence at trial also established that Negron and others caused the alteration of patient files and therapist notes for the purpose of making it falsely appear that patients being treated by ATC qualified for PHP treatments and that the treatments provided were legitimate PHP treatments. For instance, evidence established that Negron would “robo-sign” patient files, meaning she would sign patient documents as a supervising therapist without having treated the patients. The evidence also showed that Negron signed files as though she had been in two places at the same time, in Boca Raton and Homestead, Fla. Evidence further revealed that Negron knew doctors were similarly signing patient files without reading them or seeing the patients. In some cases, Negron provided the doctors with the files for their signature. According to evidence presented at trial, Negron and her co-conspirators billed Medicare for PHP treatment, including group psychotherapy, provided to a patient who was in a neuro-vegetative state, who would not lift her head or respond. The evidence also showed that Negron and her co-conspirators caused doctors to refer ATC patients to ASI even though the patients did not qualify for sleep studies.

Negron has been in federal custody since her conviction.

ATC and Medlink pleaded guilty in May 2011 to conspiracy to commit health care fraud. ATC also pleaded guilty to conspiracy to defraud the United States and to pay and receive illegal health care kickbacks. The corporations were sentenced to five years of probation per count and ordered to pay restitution of $87 million. Both corporations have been defunct since their owners were arrested in October 2010. A top manager, Margarita Acevedo, was sentenced in September 2011 to 91 months in prison.



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Dora Binimelis Pleads Guilty in Connection with Medicare Fraud Scheme

Source- http://www.justice.gov/opa/pr/2011/December/11-crm-1587.html

WASHINGTON – A clinic owner pleaded guilty today for her participation in a Detroit-area Medicare fraud scheme, announced the Department of Justice, the FBI and the Department of Health and Human Services (HHS).

Dora Binimelis, 53, of Miami, pleaded guilty before U.S. District Judge Arthur J. Tarnow in the Eastern District of Michigan to one count of conspiracy to commit health care fraud. At sentencing, Binimelis faces a maximum penalty of 10 years in prison and a $250,000 fine.

According to the plea documents, Binimelis was an owner of Blessed Medical Clinic, which purported to be a medical clinic that specialized in diagnostic testing. Binimelis admitted that the clinic defrauded Medicare by billing for expensive and medically unnecessary tests. The owners and operators of Blessed paid patient recruiters, who paid cash bribes to Medicare beneficiaries. In exchange for the cash bribes, the beneficiaries agreed to attend the clinic where they provided their Medicare provider numbers and other information, which was used to bill Medicare for unnecessary tests and services. According to her plea, Binimelis knew that the purpose of the clinic was not to treat sick patients, but to make money by defrauding Medicare. Binimelis provided diagnostic testing equipment and the capital infusion to open Blessed. In exchange for her contributions, she received a share of the Medicare fraud proceeds. According to court documents, Blessed billed Medicare $2.4 million for medically unnecessary diagnostic tests.



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Sentenced to 51 Months for Defrauding Medicaid of Nearly $1 Million

Source- http://www.fbi.gov/washingtondc/press-releases/2011/woodbridge-woman-sentenced-to-51-months-for-defrauding-medicaid-of-nearly-1-million

ALEXANDRIA, VA—Yanick Pierre, 51, of Woodbridge, Va., was sentenced today to 51 months in prison, followed by a three-year term of supervised release, for fraudulently billing Medicaid nearly $1 million from August 2008 to May 2010.

Neil H. MacBride, United States Attorney for the Eastern District of Virginia; Ken Cuccinelli, Attorney General of Virginia; and James W. McJunkin, Assistant Director in Charge of the FBI’s Washington Field Office, made the announcement after sentencing by United States District Judge Leonie M. Brinkema.

Pierre was convicted by a federal jury on Sept. 8, 2011. According to court documents, Pierre was the office manager and office administrator for First Call Home Health, a home health care business that provided home health aides and private duty nursing care to individuals so they may remain at home rather than in a hospital or nursing facility. First Call received payment for its home health services provided to Medicaid-eligible individuals through the Virginia Department of Medical Assistance Services (DMAS), which is responsible for paying medical service producers for care and services received by Medicaid recipients in Virginia.

Beginning in 2008, Pierre began submitting false claims to a DMAS intermediary for home health services to Medicaid recipients when she knew the services had not been provided. To cover up the fraud, Pierre enlisted First Call Home Health employees and family members of Medicaid recipients to fabricate nursing time sheets to corroborate the fraudulent billing. In total, the attempted loss attributed to the fraudulent billing by Pierre was approximately $979,000. Of that amount, First Call received $698,434.47. The court also entered a restitution order and a forfeiture order against Pierre in that amount.



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