Source- http://www.justice.gov/usao/pam/news/2013/Easton%20Hospital_04_03_2013.htm
The United States Attorney's Office for the Middle District of Pennsylvania announced that Easton Hospital has agreed to pay the United States $454,866 to resolve allegations that it submitted improper claims to the Medicare program. Easton Hospital is a subsidiary of Community Health Systems and is located in Easton, Pennsylvania.
According to United States Attorney Peter J. Smith, Easton Hospital has agreed to pay $454,866 to resolve allegations that from January 1, 2004, through May 28, 2009, Easton Hospital improperly submitted claims to the Medicare program for payment that contained evaluation and management services that were not allowable under Medicare.
Medicare does not normally allow additional payments for such services performed by a provider on the same day as a procedure, unless the service is significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure. In such cases, an attachment to the claim, known as "Modifier 25," may be submitted to allow the additional payment.
In this matter, the government determined that Easton Hospital incorrectly attached Modifier 25 to Medicare claims that led Medicare to pay the hospital for evaluation and management services that were not significant and separately identifiable from the underlying procedure for which Medicare also paid the hospital.
The U.S. Attorney’s Office acknowledged and Easton Hospital’s cooperation and remedial action which helped to resolve the matter. After the Government contacted Easton Hospital concerning improper Modifier 25 claims, the hospital conducted an internal review to determine what caused the improper claims to be submitted to the Medicare program and took action to increase medical coding training and bolster its compliance program.
The Harrisburg Office of the U.S. Attorney’s Office had jurisdiction because Medicare provider claims are processed by Novitas Solutions, Inc., formerly Highmark Medicare Services, in Camp Hill, Pennsylvania. The U.S. Attorney’s Office for the Eastern District of Pennsylvania cooperated in this matter.
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Source- http://www.justice.gov/usao/pam/news/2013/StLukes%20University%20Health%20Network_04_03_2013.htm
The United States Attorney's Office for the Middle District of Pennsylvania announced that the St. Luke’s University Health Network has agreed to pay the United States $1,029,791 to resolve allegations that it erroneously submitted improper claims to the Medicare program. St. Luke’s University Health Network owns and operates St. Luke’s Hospital of Bethlehem, St. Luke’s Quakertown Hospital, and St. Luke’s Miners Memorial Hospital.
According to United States Attorney Peter J. Smith, St. Luke’s University Health Network has agreed to pay $1,029,791 to resolve allegations that from January 1, 2002, through June 30, 2012, its hospitals erroneously submitted claims to the Medicare program for payment that contained evaluation and management services that were not allowable under Medicare.
Medicare does not normally allow additional payments for such services performed by a provider on the same day as a procedure, unless the service is significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure. In such cases, an attachment to the claim, known as "Modifier 25," may be submitted to allow the additional payment.
In this matter, the government determined that St. Luke’s hospitals incorrectly attached Modifier 25 to Medicare claims that led Medicare to pay the hospitals for evaluation and management services that were not significant and separately identifiable from the underlying procedures for which Medicare also made payments. St. Luke’s fully cooperated in this investigation after being contacted by the government.
The Harrisburg Office of the U.S. Attorney’s Office had jurisdiction because Medicare provider claims are processed by Novitas Solutions, Inc., formerly Highmark Medicare Services, in Camp Hill, Pennsylvania. The U.S. Attorney’s Office for the Eastern District of Pennsylvania cooperated in this matter.
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A federal jury in Detroit today convicted a home health agency owner and a physical therapist for their participation in a $2.3 million Medicare fraud scheme, announced Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division; U.S. Attorney Barbara L. McQuade of the Eastern District of Michigan; Robert D. Foley III, Special Agent in Charge of the FBI Detroit Field Office; and Special Agent in Charge Lamont Pugh III of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), Office of Investigations Detroit Office.
Mehran Javidan, 52, was found guilty in U.S. District Court for the Eastern District of Michigan of one count of conspiracy to commit health care fraud, three counts of health care fraud, three counts of making false statements related to health care matters, and one count of conspiracy to solicit or pay health care kickbacks in exchange for referrals of patients to a Detroit-area home health care company, Acure Home Care Inc.
Vishnu Meda, 32, a physical therapist, was found guilty of one count of conspiracy to commit health care fraud, two counts of health care fraud and two counts of making false statements relating to health care matters.
The jury found Javidan not guilty of one count of making false statements and one count of health care fraud, and did not reach a verdict on one additional count of health care fraud. Meda was found not guilty of one count of making false statements and one count of health care fraud.
The defendants were charged in a superseding indictment returned Nov. 29, 2012. Another individual charged in the indictment remains a fugitive.
According to evidence presented at trial, Javidan owned and operated Acure Home Care Inc., a home health care company in Oak Park, Mich., and later Troy, Mich. As shown at trial, Javidan paid doctors to refer non-homebound patients for physical therapy treatment that was medically unnecessary. The evidence showed that she also paid patient recruiters to obtain Medicare information and pre-signed physical therapy documents from Medicare beneficiaries. The recruiters for Acure obtained the Medicare information and pre-signed forms by paying patients in cash and by promising that the referring doctors would prescribe them narcotic prescriptions.
Evidence presented at trial established that Meda and other physical therapists and physical therapy assistants employed by Acure created false and fraudulent physical therapy files using the blank, pre-signed forms to make it appear as if physical therapy services were actually rendered, when, in fact, the services had not been rendered.
Acure was paid over $2.3 million from Medicare between December 2008 and November 2010.
The health care fraud conspiracy count carries a maximum potential penalty of 10 years in prison; each count of health care fraud carries a maximum penalty of 10 years in prison; each count of making false statements carries a maximum penalty of five years in prison; and each count of kickback conspiracy carries a maximum penalty of five years in prison. Sentencing for both defendants is scheduled for July 8, 2013.
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Source- http://www.fbi.gov/philadelphia/press-releases/2013/ambulance-company-and-owners-plead-guilty-in-health-care-fraud-scheme
PHILADELPHIA—MedEx Ambulance Inc., located in Feasterville, Pennsylvania, and its owners, Aleksandr N. Zagrodony and Sergey Zagorodny, pleaded guilty to all counts of a 41-count indictment charging them with health care fraud, false statements in connection with health care matters, wire fraud, and conspiracy to commit health care fraud and wire fraud, announced United States Attorney Zane David Memeger.
Defendant MedEx Ambulance was incorporated in 2004, and its owners operated an ambulance company that transported patients who were able to walk and could travel safely by means other than ambulance and who, therefore, were not eligible for ambulance transportation under Medicare requirements. The Zagorodny brothers, or others acting on their behalf, falsified reports to make it appear that the patients needed to be transported by ambulance when the defendants and their employees knew that the patients could be transported safely by other means and, in fact, many of the patients were able to walk. The defendants billed for the ambulance services as if those services were medically necessary. As a result of the fraudulent billing, the Medicare program paid more than $2.5 million for this inappropriate method of transportation.
Aleksandr Zagorodny and Sergey Zagorodny face a maximum sentence of 370 years of imprisonment, three years of supervised release, a fine of $10.25 million, mandatory restitution currently estimated at in excess of $2.6 million, and a $4,100 special assessment. MedEx faces significant financial penalties, including substantial criminal fines, restitution, and forfeiture obligations. All defendants could be excluded from participating in federal health care programs if convicted.
Agents previously seized four ambulances owned by MedEx Ambulance, purchased for more than $200,000, which are subject to criminal forfeiture proceedings. Three bank accounts also were seized, and the funds contained in those accounts, as well as other assets, including the company headquarters, are subject to criminal forfeiture proceedings.
Sentencing is scheduled for July 2, 2013, before the Honorable Berle M. Schiller.
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Source- http://www.fbi.gov/charlotte/press-releases/2013/charlotte-woman-pleads-guilty-to-4.8-million-medicaid-scheme-aggravated-identity-theft-and-other-charges
CHARLOTTE, NC—A Charlotte woman pleaded guilty today in U.S. District Court for her involvement in a health care fraud scheme that attempted to defraud Medicaid of $4.8 million for sham mental and behavioral health services, announced Anne M. Tompkins, U.S. Attorney for the Western District of North Carolina. Rodnisha Sade Cannon, 26, of Charlotte, also pleaded guilty to stealing a therapist’s identity to commit the fraud, money laundering conspiracy, and attempting to sell her Mercedes-Benz in order to prevent law enforcement agents from seizing the vehicle.
U.S. Attorney Tompkins is joined in making today’s announcement by Attorney General Roy Cooper, who oversees the North Carolina Medicaid Investigations Division (MID); Roger A. Coe, Acting Special Agent in Charge of the Federal Bureau of Investigation (FBI), Charlotte Division; Jeannine A. Hammett, Special Agent in Charge of the Internal Revenue Service, Criminal Investigation Division (IRS-CI); and Derrick Jackson, Special Agent in Charge, Department of Health and Human Services, Office of the Inspector General (HHS-OIG), Office of Investigations, Atlanta Region.
Cannon appeared this morning before U.S. Magistrate Judge David Cayer and pleaded guilty to one count of health care fraud conspiracy, one count of aggravated identity theft, and one count of money laundering conspiracy. Cannon also pleaded guilty to a single count of attempting to remove property subject to seizure, namely, a 2010 Mercedes-Benz CLS550, in a related case. At today’s plea hearing, Cannon admitted that from 2010 to 2012, she and others submitted in excess of $4.8 million in false claims to Medicaid. According to filed court documents and statements made in court, Cannon and her co-conspirators operated after-school and summer childcare programs in Gastonia and Shelby, North Carolina. Although therapists initially performed some services at these programs, Cannon and others devised a scheme to defraud Medicaid by using the Medicaid provider numbers assigned to other companies and individual therapists for all therapy services supposedly provided at their programs regardless of whether those companies and individuals actually provided the claimed services. In many instances, the claimed mental and behavioral health services were never provided at all. Cannon and others accomplished this scheme by re-directing Medicaid payments away from the Medicaid providers’ bank accounts and to bank accounts controlled by Cannon and her co-conspirators.
According to the criminal bill of information and court documents, Cannon was not licensed or qualified to provide mental and behavioral health services and she was not approved by Medicaid. Instead, Cannon and others stole the identity of Medicaid-approved providers who had some relationship with the programs in order to accomplish the fraud. For example, court documents indicate that Cannon hired M.B. to work for her company in or about May 2012, and M.B. worked there for a single day. Cannon stole M.B.’s Medicaid provider information and redirected all Medicaid payments to M.B. to be deposited into a bank account controlled by Cannon and others. Cannon and others then billed claims to Medicaid in excess of $800,000 for services that M.B. never provided, including claims for dates of service before M.B. worked for Cannon and her co-conspirators. In total, from 2010 to 2012, pursuant to the scheme to defraud, Cannon and her co-conspirators submitted approximately $4.8 million in false and fraudulent claims to Medicaid, resulting in payments of over $2.5 million to Cannon and her co-conspirators.
According to documents filed in court, Cannon also worked with Victoria Brewton, who pleaded guilty in January 2013 to carrying out a similar $8 million Medicaid fraud scheme in Shelby. Cannon assisted Brewton by providing and selling Medicaid beneficiary identification numbers and information to be used in Brewton’s fraud scheme. Brewton’s sentencing date has not been set yet.
As part of her plea, Cannon also admitted that she used the proceeds of her scheme to defraud Medicaid to purchase a 2010 Mercedes-Benz CLS550 for the purchase price of $59,500. In September 2012, law enforcement agents sought and obtained a warrant to seize this vehicle as the proceeds of Cannon’s health care fraud scheme. According to court documents, when Cannon learned that agents had a seizure warrant for the vehicle, she attempted to sell the Mercedes-Benz in order to avoid seizure of the vehicle. Cannon has agreed to forfeit the Mercedes-Benz as part of her plea today.
“Stealing money from Medicaid degrades the integrity of our health care system and victimizes those who rely on this important health care program for legitimate patient care,” said U.S. Attorney Tompkins. “The money that Cannon stole through her health care fraud scheme was intended to cover patient needs, not to purchase luxury items. Cannon will be held accountable for her actions,” Tompkins added.
Attorney General Roy Cooper stated, “Cheating Medicaid hurts needy patients, wastes taxpayer money, and drives up health care costs. Our Medicaid Investigations Division attorneys and investigators will continue to work closely with federal officials to root out fraud in North Carolina and make wrongdoers pay.”
“Money gained through illegal sources, such as health care fraud, is part of the untaxed, underground economy. This untaxed underground economy poses a threat to our voluntary tax compliance system and undermines the overall public confidence in our American system of taxation,” stated Charlotte Field Office Special Agent in Charge Jeannine A. Hammett, IRS-Criminal Investigation.
At sentencing, Cannon faces a mandatory two years in prison consecutive to any other term of imprisonment and a $250,000 fine for the aggravated identity theft charge; a maximum term of 10 years in prison, and a $250,000 fine for the health care fraud charge; a maximum term of 10 years in prison and a $250,000 for the money laundering conspiracy charge and maximum term of imprisonment of five years and a $250,000 fine for the attempted removal of property to prevent seizure. In her plea agreement, Cannon has agreed to pay full restitution to Medicaid for any losses resulting from her criminal scheme. The final restitution amount will be determined by the court at Cannon’s sentencing hearing, which has not been scheduled yet.
Cannon has been in local federal custody since her arrest on the attempted removal of property to prevent seizure charge on September 28, 2012.
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Source- http://www.justice.gov/opa/pr/2013/April/13-crm-370.html
A patient recruiter for a Miami health care company was sentenced today to serve 36 months in prison for his participation in a $20 million home health Medicare fraud scheme, announced Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division; U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida; Michael B. Steinbach, Special Agent in Charge of the FBI’s Miami Field Office; and Special Agent in Charge Christopher Dennis of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), Office of Investigations Miami Office.
Vladimir Jimenez, 43, was sentenced by U.S. District Judge Joan A. Lenard in the Southern District of Florida. In addition to his prison term, Jimenez was sentenced to serve two years of supervised release and ordered to pay $950,000 in restitution, jointly and severally with co-defendants.
In January 2013, Jimenez pleaded guilty to one count of conspiracy to receive health care kickbacks.
According to court documents, Vladimir Jimenez was a patient recruiter who worked for Serendipity Home Health, a Miami home health care agency that purported to provide home health and therapy services to Medicare beneficiaries.
According to court documents, from approximately April 2007 through approximately March 2009, Jimenez recruited patients for Serendipity, and in doing so solicited and received kickbacks and bribes from the owners and operators of Serendipity in return for allowing Serendipity to bill the Medicare program on behalf of the patients Jimenez had recruited. These Medicare beneficiaries were billed for home health care and therapy services that were medically unnecessary and/or not provided.
From approximately January 2006 through March 2009, Serendipity submitted approximately $20 million in claims for home health services that were not medically necessary and/or not provided. Medicare actually paid approximately $14 million for these fraudulent claims.
As a result of Jimenez’s participation in the illegal scheme, the Medicare program was fraudulently billed more than $400,000 for purported home health care services.
In a related case, on June 21, 2012, Ariel Rodriguez and Reynaldo Navarro, the owners and operators of Serendipity, were sentenced to 73 and 74 months in prison, respectively, following guilty pleas in March 2012 to one count each of conspiracy to commit health care fraud.
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Source- http://www.justice.gov/opa/pr/2013/April/13-crm-371.html
The owner and the director of nursing of a Louisiana home health agency were each convicted late Friday for conspiring to defraud Medicare of $17.1 million announced Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division; U.S. Attorney Donald J. Cazayoux Jr. of the Middle District of Louisiana; Mike Fields, Special Agent in Charge of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) Dallas regional office; Michael Anderson, Special Agent in Charge of the FBI’s New Orleans Division; and Louisiana State Attorney General James Buddy Caldwell.
After a six-day trial, Louis T. Age, Jr., 64, and Verna S. Age, 60, both of Slidell, La., were each convicted by a federal jury in the Middle District of Louisiana of one count of conspiracy to commit health care fraud. Louis Age was also convicted of one count of conspiracy to defraud the United States and to pay and receive illegal health care kickbacks. Verna Age was previously convicted in this case of one count of conspiracy to defraud the United States and to pay and receive illegal health care kickbacks.
Louis Age owned South Louisiana Home Health Care Inc. and operated this company along with his former wife, Verna Age, who served as the company’s director of nursing. According to evidence presented at trial, Louis and Verna Age paid recruiters, including Mary L. Johnson, to obtain Medicare beneficiary information. The evidence showed that Louis Age hired and paid medical doctors, including Michael S. Hunter, to sign referrals and certifications for home health services that were not medically necessary. As a registered nurse and director of nursing for South Louisiana Home Health Care, Verna Age falsified and directed others to falsify certification evaluations and other forms to make it appear that the home health services were medically necessary.
Evidence at trial showed that South Louisiana Home Health Care fraudulently billed Medicare for home health care claims and was paid $17.1 million between 2005 and 2011.
At trial, Ayanna Age Alverez, who previously pleaded guilty in this case, testified that she was trained by her father, Louis Age, and her stepmother, Verna Age, to pay recruiters kickbacks to recruit beneficiaries, to falsify patient files and to pay doctors kickbacks for their signatures on home health certifications. Medicare beneficiaries testified that they did not need the services that South Louisiana Home Health Care billed to Medicare.
Age Alverez, Johnson and Hunter have pleaded guilty in this case and await sentencing. Co-defendant Milton L. Womack, who was also charged in the August 2011 indictment, died in July 2012.
Sentencing dates for Louis and Verna Age have not yet been scheduled. The conspiracy to commit health care fraud count carries a maximum potential penalty of 10 years in prison and a $250,000 fine, and the conspiracy to pay health care kickbacks carries a maximum penalty of five years in prison and a $250,000 fine.
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Source- http://www.justice.gov/usao/txs/1News/Releases/2013%20April/130401-%20Gibson.html
HOUSTON – Donald Gibson II, 56, of Richmond, has been convicted of conspiracy to commit health care fraud relating to medically unnecessary diagnostic testing and physical therapy, United States Attorney Kenneth Magidson announced today.
Gibson entered a plea of guilty just minutes ago, admitting he conspired to commit health care fraud along with co-defendant, Sunday Joseph Edem, 53, also of Richmond.
Gibson ordered, prescribed and authorized medically unnecessary diagnostic tests and other procedures which included allergy tests, pulmonary function tests, vestibular tests, urodynamic tests and physical therapy, among others. These services were then billed to Medicare and Medicaid for payment under Gibson’s billing number.
From January 2007 through January 2012, Gibson caused more than $19.4 million in medical claims to the Medicare and Texas Medicaid Programs. As a result, Medicare deposited approximately $8.5 million into a bank account owned and controlled by Gibson.
Edem operated medical clinics under the names of other individuals to conceal his financial interest in the businesses. Edem and Gibson conspired with one another to cause the submission of false claims to the Medicare and Medicaid programs and share in the proceeds. Gibson and Edem paid patient recruiters for referring Medicare/Medicaid beneficiaries and also paid Medicare beneficiaries for showing up at the medical clinics.
Gibson is set for sentencing on July 1, 2013, at which time he faces up to 10 years in federal prison and a possible $250,000 fine.
Edem also pleaded guilty to the same charge on Feb. 25, 2013. He is scheduled to be sentenced on May 28, 2013.
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Source- http://www.justice.gov/opa/pr/2013/March/13-crm-341.html
A registered nurse who fabricated nursing visit forms in connection with a $24 million home health care fraud conspiracy in Detroit pleaded guilty today for her role in the scheme, announced Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division, U.S. Attorney for the Eastern District of Michigan Barbara L. McQuade, Special Agent in Charge Robert D. Foley III of the FBI’s Detroit Field Office and Special Agent in Charge Lamont Pugh III of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), Chicago Regional Office.
Beverly Cooper, 59, of Detroit, pleaded guilty before U.S. District Judge Victoria A. Roberts in the Eastern District of Michigan to one count of conspiracy to commit health care fraud.
Cooper admitted that she and others conspired to defraud Medicare through home health care companies operating in the Detroit area, including Reliance Home Care LLC, First Choice Home Health Care Services Inc. and Accessible Home Care Inc. According to court documents, Cooper fabricated nursing visit notes and other documents to give Medicare the impression that she had provided home health care services, when, in fact, home health care was not needed and/or was not being provided. Cooper also admitted that while at these companies, she signed nursing visit notes for home visits made by other unlicensed individuals to give Medicare the false impression that she had provided home health care. Court documents reveal that Cooper understood that the documents she created would be used by these companies to submit claims to Medicare for home health services that were not medically necessary and/or not provided.
Court documents show that when home health companies were inspected by state regulatory agencies, Cooper and her co-conspirators participated in staged home health visits, posing as employees of these companies and treating fake patients, all to give inspectors the false impression that these companies’ operations were legitimate and that home health services were in fact being provided.
Court documents allege that between 2006 and May 2012, Cooper’s conduct caused Reliance, First Choice and Accessible to submit claims to Medicare for services that were not medically necessary and/or not provided, causing Medicare to pay these companies approximately $5,403,703.
At sentencing, scheduled for July 23, 2013, Cooper faces a maximum penalty of 10 years in prison and a $250,000 fine.
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Source- http://www.justice.gov/usao/mow/news2013/ryser.ple.html
KANSAS CITY, Mo. – Tammy Dickinson, United States Attorney for the Western District of Missouri, announced that the married owner/director and chief executive officer of a Kansas City, Mo., medical clinic pleaded guilty in federal court today to health care fraud and filing a false tax return.
Carol Ann Ryser, 76, and Michael Earl Ryser, 68, both of Mission Hills, Kan., pleaded guilty before U.S. District Judge Greg Kays to the charges contained in a June 26, 2012 federal indictment.
Carol Ryser owned Health Centers of America-Kansas City, LLC (HCA), a medical clinic in Kansas City, Mo., that was closed yesterday as part of today’s plea agreement. HCA purported to specialize in the diagnosis and treatment of chronic diseases such as Lyme disease, chronic fatigue syndrome, fibromyalgia, and other auto immune diseases.
Carol Ryser, who was a medical doctor and the clinic’s medical director, surrendered her medical license today as a condition of her plea agreement. Carol Ryser may never again seek licensing to practice medicine in the United States and she may never be involved as an owner or employee (or in any other capacity) with any medical clinic, hospital or other health care provider. Michael Ryser was the CEO, chief administrator and vice-president.
Health Care Fraud
By pleading guilty today, the Rysers admitted that they engaged in fraudulent billing by “upcoding” and falsifying claims submitted to insurers (including Blue Cross Blue Shield, Cigna, United Healthcare and others, as well as government programs such as Medicare and Tricare) in an effort to be paid more than the amount to which HCA was entitled.
The Ryser’s scheme included: (a) billing for physician office visits when Carol Ryser was out of town; (b) billing for physician office visits when Carole Ryser had little or no involvement with the patient; (c) billing for physician office visits when the patient contact was by telephone call; (d) billing for physician-supervised services when no physician was on duty at the clinic; and (e) improperly billing for consultation services.
The federal indictment describes six variations of billing fraud and includes tables of claims demonstrating each type of billing fraud. For those claims specifically included in the indictment, the total amount billed on those claims was $359,168. The total amount that was actually paid on those claims by health care benefit programs was $51,789.
False Tax Return
The Rysers also admitted that they willfully filed a false tax return for the year 2006. They understated their gross receipts and substantially overstated their expenses for 2006.
The indictment included three tax counts alleging that the Rysers operated their business as a sole proprietorship and gross receipts were deposited into two bank accounts that Michael Ryser maintained and controlled. However, they reported only the gross receipts deposited into one bank account and just part of the gross receipts deposited into the second bank account.
The Rysers understated their $10,060,012 in combined gross receipts for 2006-2008 by a total of $2,501,802 – nearly 25 percent of the gross receipts for these three years. They overstated their expenses for 2006 by $9,462,145. The total tax loss for 2006-2008 was $615,749.
Under the terms of today’s plea agreements, Michael Ryser will be sentenced within a range of 24 to 30 months in federal prison without parole. Carol Ryser will receive a sentence of three years of probation, including six months of home detention. The Rysers must pay $51,789 in restitution to the health care benefit programs that were defrauded. Sentencing hearings will be scheduled after the completion of presentence investigations by the United States Probation Office.
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Source- http://www.fbi.gov/newark/press-releases/2013/south-jersey-doctor-admits-making-half-a-million-dollars-in-fraud-scheme-involving-home-health-care-for-elderly-patients
TRENTON, NJ—A physician who was the owner and founder of Visiting Physicians of South Jersey—a Hammonton, New Jersey provider of home-based physician services for seniors—pleaded guilty today for charging lengthy visits to elderly patients that they did not receive, U.S. Attorney Paul J. Fishman announced.
Lori Reaves, 52, of Waterford Works, New Jersey, entered her guilty plea to an information charging her with one count of health care fraud before U.S. District Judge Freda L. Wolfson in Trenton federal court. During her guilty plea, Reaves admitted lying in Medicare billings about the amount of face-to-face time she spent with patients, which led to her receiving at least $511,068 in criminal profits. Reaves was the highest-billing home care provider among the more than 24,000 doctors in New Jersey from January 1, 2008 through October 14, 2011, according to court documents.
“Today, Lori Reaves, a South Jersey physician, admitted intentionally overbilling Medicare and pocketing more than half a million dollars she didn’t earn,” U.S. Attorney Fishman said. “The Medicare system depends on doctors and other medical professionals truthfully billing for services they actually provide. Here, Dr. Reaves chose to lie about the major service she was providing to her homebound, elderly patients: her time.”
According to documents filed in this case and statements made in court:
Visiting Physicians of South Jersey (VPA) provided home-based physician health care for elderly and homebound patients in New Jersey, offering services throughout South Jersey. As part of her responsibilities at VPA, Reaves was responsible for VPA’s Medicare billings as a Medicare-approved provider.
The claim submitted by the health care provider requires a physician to state a diagnosis and provide a procedure code—called a Current Procedural Technology (CPT) code—identifying services rendered. Medicare regulations require that each provider certify that the services rendered were medically necessary and were furnished by that provider. A warning at the bottom of the form specifically states that any false claims or statements in relation to the submission of a claim for reimbursement are prosecutable under federal or state law.
In most instances during the relevant time period, Reaves submitted forms that falsely claimed she had provided prolonged service visits to her patients in order to induce Medicare to make payments to her that were significantly higher than the payments she should have received.
Reaves routinely billed Medicare using codes that would have required her—under Medicare regulations and depending on the corresponding service—to spend between 60 and 150 minutes with a patient. Many of the claims Reaves submitted would have required her to spend a minimum of two-and-a-half hours of face-to-face time with her elderly clients, when she actually spent far less. As a result, Medicare reimbursed Reaves more than $511,068 for the fraudulent prolonged service visits Reaves claimed to have made.
Reaves faces a maximum potential penalty of 10 years in prison and a fine of the greatest of $250,000 or twice the gross gain or loss caused by her offense. She will also be required to forfeit the proceeds of her crime. Sentencing is currently scheduled for July 13, 2013.
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Source- http://www.justice.gov/usao/cac/Pressroom/2013/045.html
LOS ANGELES – A Carson woman has been sentenced to 156 months in federal prison in an $8 million Medicare fraud case in which she illegally paid kickbacks for referrals to patients, whose beneficiary information was used to make bogus claims to the government health care program.
Uben Ogbu Rush, 54, received the 13-year sentence yesterday afternoon from United States District Judge George H. King.
During yesterday’s hearing, Judge King said Rush was motivated by greed and the lengthy sentence was necessary, in part, to send a message of deterrence to others who might commit crimes against Medicare.
Rush owned or controlled six companies that ostensibly sold durable medical equipment, such as motorized wheelchairs and powered pressure-reducing mattresses. The companies were located in Carson, Gardena, Torrance and Paramount.
At a trial in November 2011, federal prosecutors showed a jury how Rush paid marketers to recruit Medicare beneficiaries who would allow their identities and Medicare numbers to be used for the submission of false claims. The evidence also showed how Rush paid kickbacks to marketers, who in turn paid kickbacks to doctors who fraudulently wrote prescriptions, even though the physicians had not examined the patients or an examination revealed that the medical equipment was not medically necessary.
During the course of a scheme that ran from 1999 until 2008, Rush submitted more than $15 million in fraudulent claims to Medicare seeking payment for motorized wheelchairs, hospital beds, air pressure mattresses and other items for patients who did not need the equipment. Medicare paid more than $8.1 on the bogus claims.
A co-defendant in the case, Carlos Alberto Rezabala, 60, of Downey, was sentenced by Judge King in June 2012 to 41 months in federal prison. Rezabala was a recruiter who brought Medicare beneficiaries into the scheme so their information could be used to submit fraudulent bills.
Another co-defendant, Phitsamay Syvoravong, 58, of Orange County, another recruiter who brought Medicare beneficiaries into the scheme, is scheduled to be sentenced by Judge King on May 20.
A related defendant, Dr. Alfred Glover, 57, of Playa Vista, testified at trial that he was paid for writing fraudulent prescriptions for Medicare beneficiaries, many of whom he never saw. Glover is schedule to be sentenced on May 28.
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Source- http://www.justice.gov/usao/nys/pressreleases/March13/ParkAvenueMedicalAssociatesComplaintPR.php
Preet Bharara, the United States Attorney for the Southern District of New York, announced today that the United States has filed a lawsuit against PARK AVENUE MEDICAL ASSOCIATES (“PAMA”) and PARK AVENUE MEDICAL ASSOCIATES, P.C. (“PAMA PC”), and related entities, alleging that they billed Medicare for services purportedly provided to elderly, mentally ill patients that were not medically necessary, were not documented in the medical record, and/or failed otherwise to comply with Medicare rules and regulations. The Government’s Complaint alleges that, as a consequence of the conduct of PAMA and PAMA PC, the entity that allegedly submitted claims to Medicare on behalf of PAMA, Medicare paid the defendants for thousands of claims that were not eligible for payment, resulting in over $1 million in damages.
Manhattan U.S. Attorney Preet Bharara said: “As alleged, Park Avenue Medical Associates inundated Medicare with bogus claims, including bills for unnecessary psychiatric services for vulnerable elderly patients, who did not have the ability to benefit from the services. We will continue our efforts to protect this taxpayer-funded program and the people who rely on it for care from fraud and abuse.”
According to the Complaint filed today in Manhattan federal court:
PAMA directly employs physicians, nurses, and other medical professionals who provide services to elderly patients at hospitals, including inpatient psychiatric facilities, nursing homes, assisted living facilities, and other types of long-term care facilities. The patients and residents at these facilities suffer from various chronic health conditions, including Alzheimer’s disease, dementia, schizophrenia, psychosis, depression, and anxiety. The doctors and nurses employed by PAMA receive a salary from PAMA, which contracts with the facilities. In addition to their regular salaries, psychiatrists and psychologists employed by PAMA receive bonuses based on how many services they provide and the level of reimbursement they generate for PAMA from government and other insurance providers, including Medicare.
Medicare prohibits payment for services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury. Medicare also prohibits payment for any claim without adequate documentation substantiating the reasonableness and necessity of the services provided. In particular, Medicare does not cover psychotherapy services rendered to patients with Alzheimer’s disease or dementia unless the patient’s dementia is mild, the patient has the capacity to recall what occurred at the therapy from one session to the next, and that capacity is documented in the patient’s record. Psychotherapy services are not covered when dementia has produced a severe enough cognitive deficit to prevent them from being effective. In addition, Medicare provides that psychiatric diagnostic examinations are generally covered only once for each episode of illness or suspected illness in a patient and must be medically necessary.
In violation of Medicare policies, as well as its own policies, PAMA provided psychotherapy to patients who lacked the capacity to benefit from it due to severe dementia. In addition, PAMA PC billed for psychiatric evaluations that were duplicative, failed to comply with Medicare rules, and reflected a lack of coordination of care both among PAMA’s own psychiatrists, psychologists and nurses, and between PAMA’s employees and staff at the facilities with which PAMA contracted to provide services. Moreover, PAMA PC billed for services for which it lacked any documentation whatsoever. PAMA PC billed Medicare for a far larger number of services per psychiatrist and psychologist during the period 2001 through 2012 than any other provider with a similar patient population in the New York area.
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Source- http://www.justice.gov/usao/cac/Pressroom/2013/033.html
LOS ANGELES – A federal jury has convicted a Buena Park doctor for participating in a health care fraud scheme involving unnecessary procedures and prescriptions that led to Medicare paying out nearly $3 million on fraudulent claims for durable medical equipment and nutritional supplies.
Following a five-day trial, Dr. Augustus Ohemeng, 62, was found guilty yesterday afternoon of six counts health care fraud.
While serving as medical director at Pacific Clinic in Long Beach, Ohemeng and others recruited Medicare patients and billed the national healthcare program for office visits that typically included unnecessary tests and procedures. The evidence presented at trial showed that Ohemeng also generated fraudulent prescriptions for medical equipment, power wheel chairs and enteral nutritional supplies, prescriptions that were sold to medical supply companies that used the fraudulent documents to bill Medicare for millions of dollars of unnecessary and undelivered medical supplies. “Nearly all, if not all, of the wheelchair prescriptions Ohemeng and [George Tarryk, another doctor who worked at Pacific Clinic] signed were written for people who could walk,” according to court documents.
Over the course of four years, Ohemeng signed hundreds of these fraudulent prescriptions, many of which were blank so his office manager could fill in the details.
As a result of the fraudulent conduct involving Ohemeng and his co-conspirators, which took place from February 2005 through September 2009, $5.6 million in fraudulent claims were submitted to Medicare, which paid approximately $2.97 million.
As a result of yesterday’s guilty verdicts, Ohemeng faces a maximum statutory sentence of 60 years in federal prison when he is sentenced on June 17 by United States District Judge Christina A. Snyder.
Ohemeng was among 10 defendants – including two doctors and a nurse – who were charged as a result of an investigation into Pacific Clinic, Ivy Medical Supply in Anaheim and Santos Medical Supply in South Los Angeles. All 10 defendants, including the owner of Ivy Medical Supply, have now been convicted, either as the result of guilty pleas or jury verdicts.
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HOUSTON – Children’s Physician Services of South Texas (CPSST) and Radiology Associates have agreed to pay to settle claims they violated the False Claims Act and the Texas Medicaid Fraud Prevention Act between 2002 and 2007, United States Attorney Kenneth Magidson announced today. CPSST, a part of the Driscoll Health System, has agreed to pay $1.5 million, while Radiology Associates, an independent physician group serving the Driscoll Health System, will pay $800,000 to settle claims they billed and received payment twice for the professional reading and interpretation of genetic ultrasounds.
“Improper double billing by health care providers defrauds the government funded health care programs, adds to the government’s deficit and, most importantly, reduces the funds available to meet the patients’ medical needs,” said Magidson. “In addition to yielding a substantial recovery for taxpayers, this settlement should serve notice to health care providers that taxpayers will not tolerate, much less accept, paying twice for services rendered to them.”
The settlement announced today involved allegations that CPSST billed and received payment for Radiology Associates’ professional services and, without disclosing the payments, directed Radiology Associates to bill and receive payment for the same professional services.
There are two components for each ultrasound, a technical component and a professional component. The technical component refers to the actual taking of the ultrasound by a technician and the professional component refers to the reading and interpretation of the ultrasound images by a physician, usually a radiologist. CPSST made arrangements to have Radiology Associates read and interpret the ultrasounds taken at CPSST. From Jan. 1, 2002, to June 1, 2007, Radiology Associates read and interpreted several thousand ultrasounds for CPSST. The understanding between the two providers was that CPSST would bill and receive payment solely for the technical component and Radiology Associates would bill and receive payment solely for the professional component. In reality, CPSST billed and received payment for both the technical and professional components without informing or disclosing this fact to Radiology Associates. Upon discovery of this fact, Radiology Associates informed CPSST about the double billing for the professional component, but CPSST denied billing for the professional component except for a few accidental and isolated occasions. Instead, CPSST instructed and directed Radiology Associates to continue to bill for the professional component and reaffirmed that CPSST would only bill for the technical component. Despite additional evidence of double billing, Radiology Associates ignored the evidence, accepted CPSST’s misrepresentations without question and continued to bill and receive payment for the professional component.
Government funded health care programs such as Medicare, Medicaid, TRICARE and the Federal Employees Health Benefits program agree to pay enrolled health care providers once for the technical and professional components of each ultrasound performed on a patient covered by theses health care programs. Health care providers enrolled and servicing patients covered by these government funded health care programs are prohibited from billing and receiving payment twice for the ultrasound’s technical or professional component.
The settlement resolves allegations made against Radiology Associates, Children’s Physician Services of South Texas, Center for Genetic Services, and Raymond C. Lewandowski Jr. M.D. in a qui tam or whistleblower lawsuit filed in 2008 by a former revenue manager and coding compliance officer with Radiology Associates. Under the False Claims Act, private citizens can bring suit on behalf of the government and share in any amounts that are obtained through that legal action. In this case, the share will be between 15 - 25% of the proceeds of the overall settlement.
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Source- http://www.justice.gov/opa/pr/2013/March/13-crm-281.html
A former health care clinic director and licensed therapist pleaded guilty today in connection with a health care fraud scheme involving defunct health provider Health Care Solutions Network Inc. (HCSN), announced Acting Assistant Attorney General Mythili Raman of the Justice Department's Criminal Division; U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida; Michael B. Steinbach, Special Agent in Charge of the FBI's Miami Field Office; and Special Agent in Charge Christopher B. Dennis of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), Office of Investigations Miami office.
Paul Thomas Layman, 66, of Miami, pleaded guilty before U.S. District Judge Cecilia M. Altonaga in the Southern District of Florida to one count of conspiracy to commit health care fraud.
Layman’s co-conspirator Dana Gonzalez, 43, of Miami, a registered clinical social worker intern in Florida, pleaded guilty yesterday to one count of conspiracy to commit health care fraud for her role in the scheme.
During the course of the conspiracy, Layman was employed as a substance abuse counselor, therapist and clinical director of HCSN’s Partial Hospitalization Program (PHP). A PHP is a form of intensive treatment for severe mental illness.
In Florida, HCSN operated community mental health centers at three locations. During his employment, Layman worked full time at all HCSN locations in Florida in various capacities. According to court documents, Layman was aware that HCSN in Florida paid illegal kickbacks to owners and operators of Miami-Dade County Assisted Living Facilities (ALF) in exchange for patient referral information to be used to submit false and fraudulent claims to Medicare and Medicaid. Layman also knew that many of the ALF referral patients were ineligible for PHP services because many patients suffered from mental retardation, dementia and Alzheimer's disease.
Court documents reveal that Layman was aware that HCSN personnel in Florida were fabricating patient medical records. Many of these medical records were created weeks or months after the patients were admitted to HCSN facilities in Florida for purported PHP treatment and were utilized to support false and fraudulent billing to government sponsored health care benefit programs, including Medicare and Florida Medicaid. During his employment at HCSN in Florida, Layman signed fabricated PHP therapy notes and other medical records used to support false claims to government sponsored health care programs.
HCSN also operated one location in Hendersonville, N.C. At the Hendersonville location, Layman served as the clinical director and assisted HCSN owner Armando Gonzalez in obtaining necessary licensing, credentials and Medicare authorizations for HCSN. According to court documents, from 2008 through 2009, Layman purportedly supervised therapists at HCSN in Hendersonville, including Alexandra Haynes, who was an unlicensed therapist purportedly performing PHP therapy to HCSN patients. For their roles in the conspiracy, Gonzalez pleaded guilty to one count of conspiracy to commit health care fraud and one count of conspiracy to commit money laundering, and Haynes pleaded guilty to one count of conspiracy to commit health care fraud. On Monday, Feb. 25, 2013, Gonzalez was sentenced to serve 168 months in prison for his role in the scheme.
According to court documents, Dana Gonzalez worked at HCSN in Florida from approximately April 2005 through December 2010. At HCSN in Florida, Gonzalez fabricated patient medical records, which were used to support false and fraudulent billing to Medicare and Florida Medicaid. In 2011, Gonzalez worked at HCSN in North Carolina, where she fabricated therapy notes and medical records, and provided unlicensed therapy when licensed therapists were absent.
According to court documents, from 2004 through 2011, HCSN billed Medicare and the Florida Medicaid program approximately $63 million for purported mental health services.
Fifteen defendants have been charged for their alleged roles in the HCSN health care fraud scheme, and 12 defendants have pleaded guilty. Alleged co-conspirator Wondera Eason is scheduled for trial on April 22, 2013, before Judge Altonaga in Miami. Alleged co-conspirators Alina Feas and Lisset Palmero are scheduled for trial on June 3, 2013. Defendants are presumed innocent until proven guilty at trial.
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Source- http://www.justice.gov/opa/pr/2013/March/13-civ-270.html
New Jersey-based Par Pharmaceutical Companies Inc. pleaded guilty in federal court today and agreed to pay $45 million to resolve its criminal and civil liability in the company’s promotion of its prescription drug Megace ES for uses not approved as safe and effective by the Food and Drug Administration (FDA) and not covered by federal health care programs, the Justice Department announced.
Chief Executive Officer Paul V. Campanelli pleaded guilty on behalf of Par before U.S. Magistrate Judge Madeline Cox Arleo earlier today in Newark, N.J., federal court. Judge Arleo fined Par $18 million and ordered $4.5 million in criminal forfeiture. Par also agreed to pay $22.5 million to resolve its civil liability.
“Today’s resolution emphasizes the importance of the U.S. government’s coordinated efforts to combat health care fraud. We expect companies to make honest, lawful claims about the drugs they sell. We will be vigorous in our enforcement efforts when they break the law, to ensure that they are held accountable,” said Stuart F. Delery, Principal Deputy Assistant Attorney General for the Justice Department’s Civil Division.
“The FDA requires drug makers to go through a stringent approval process before new drugs – or new uses for existing drugs – are made available to doctors and their patients,” said Paul J. Fishman, U.S. Attorney for the District of New Jersey. “Today, Par admitted that it chose to ignore that process in pursuit of more sales and greater profits. It is paying the price for its choice.”
“Individual accountability of Par’s board and executives is required under the comprehensive five-year integrity agreement the Office of the Inspector General has with the company,” said Daniel R. Levinson, Inspector General of the U.S. Department of Health and Human Services. “For example, company executives may have to forfeit annual bonuses if they or their subordinates engage in significant misconduct, and sales representatives may not be paid incentive compensation for the drug involved in the case, or successor branded versions of that drug.”
“The public has been well served by this investigation and the FDA commends the efforts of the U.S. Attorney's Office in New Jersey, the Department of Justice and the other law enforcement agencies that worked with us to vigorously pursue this matter,” said Mark Dragonetti, Special Agent in Charge of the FDA’s Office of Criminal Investigation's New York Field Office. “Today’s settlement demonstrates the FDA’s continued commitment to target companies that disregard the safeguards of the drug approval process and promote drugs for uses before they have been proven to be safe and effective.”
Par pleaded guilty to an information charging it with a criminal misdemeanor for misbranding Megace ES in violation of the Federal Food, Drug and Cosmetic Act (FDCA). Megace ES, a megestrol acetate drug product was approved by the FDA to treat anorexia, cachexia, or other significant weight loss suffered by patients with AIDS. The Megace ES distributed nationwide by Par was criminally misbranded because its FDA-approved labeling lacked adequate directions for use in the treatment of non-AIDS-related geriatric wasting, a use that was intended by Par but never approved by the FDA. The FDCA requires companies such as Par to specify the intended uses of a product in its new drug application to the FDA. Once approved, a drug may not be distributed in interstate commerce for unapproved or “off-label” uses until the company receives FDA approval for the new intended uses. In addition to the criminal fine and forfeiture, the plea agreement mandates that Par implement several compliance measures and annually provide the U.S. Attorney’s Office with a sworn certification from its chief executive officer that the company has not unlawfully marketed any of its pharmaceutical products.
The civil settlement agreement requires Par to pay $22.5 million to the federal government and various states to resolve claims arising from its off-label marketing. The civil settlement resolves allegations that Par, by promoting the sale and use of Megace ES for uses that were not FDA-approved and not covered by Federal health care programs, caused false claims to be submitted to these programs. The United States further alleged that Par deliberately and improperly targeted sales to elderly nursing home residents with weight loss, whether or not such patients suffered from AIDS, and launched a long-term care sales force to market to this population. During this marketing campaign, Par was allegedly aware of adverse side effects associated with the use of megestrol acetate in elderly patients, including an increased risk of deep vein thrombosis, toxic reactions in elderly patients with impaired renal function, and mortality. The United States alleged that Par made unsubstantiated and misleading representations about the superiority of Megace ES over generic megestrol acetate for elderly patients to encourage providers to switch patients from generic megestrol acetate to Megace ES, despite having conducted no well-controlled studies to support a claim of greater efficacy for Megace ES. Except as admitted in the plea agreement, the claims settled by the civil settlement agreement are allegations only, and there has been no determination of liability as to those claims.
In addition to the criminal and civil resolutions, Par also agreed to enter into a five-year corporate integrity agreement with the Office of the Inspector General of the Department of Health and Human Services (HHS-OIG) that requires enhanced accountability, increased transparency and wide-ranging monitoring activities conducted by both internal and independent external reviewers.
The plea agreement and corporate integrity agreement include provisions that require Par to implement changes to the way it does business. The plea agreement and agreement prohibit Par from providing compensation to sales representatives or their managers based on the volume of sale of Megace ES, and in the corporate integrity agreement, based on the volume of Megace ES and any branded successor megestrol acetate drug. Under the agreement, Par is also required to change its executive compensation program to permit the company to recoup annual bonuses from covered executives if they, or their subordinates, engage in significant misconduct.
The settlement resolves three lawsuits filed under the whistleblower provisions of the False Claims Act, which permit private parties to file suit on behalf of the United States and obtain a portion of the government’s recovery. The civil lawsuits were filed in the District of New Jersey and are captioned U.S. ex rel. McKeen and Combs v. Par Pharma ceutical, et al., U.S. ex rel. Thompson v. Par Pha rmac eutical, et al., and U.S. ex rel. Elliott & Lundstrom v. Bristol-M yers Squibb, Par Pharma ceutical, et al. As part of today’s resolution, relators McKeen and Combs will receive $4.4 million.
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Source- http://www.justice.gov/opa/pr/2013/March/13-crm-273.html
The owner and operator of a Houston-area ambulance company was convicted by a federal jury in Houston of multiple counts of health care fraud for submitting false and fraudulent claims to Medicare, Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division, U.S. Attorney Kenneth Magidson of the Southern District of Texas, Special Agent in Charge Stephen L. Morris of the FBI’s Houston Field Office and Special Agent in Charge Mike Fields of the U.S. Health and Human Services Office of Inspector General, Office of Investigations Houston Office announced today.
Olusola Elliott, 44, of Fort Bend County, Texas, was convicted late yesterday by a federal jury in U.S. District Court in the Southern District of Texas of one count of conspiracy to commit health care fraud and six counts of health care fraud.
Elliott was the owner and operator of Double Daniels LLC, a Texas entity that purportedly provided non-emergency ambulance services to Medicare beneficiaries in the Houston area. According to evidence presented at trial, Elliott and others conspired from April 2010 through December 2011 to unlawfully enrich themselves by submitting false and fraudulent claims to Medicare for ambulance services that were medically unnecessary and not provided. Evidence showed that Elliott falsified patient records in order to fraudulently bill Medicare on behalf of beneficiaries who were not in need of ambulance services.
During the course of the scheme, Elliott submitted and caused the submission of approximately $1,713,716 in fraudulent ambulance service claims to Medicare. According to court documents, Elliot transferred the proceeds of the fraud to himself and others after Medicare payments were sent to Double Daniels.
Elliot is scheduled for sentencing on May 31, 2013, in Houston. The six health care fraud counts and the conspiracy count each carry a maximum potential penalty of 10 years in prison and a $250,000 fine
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