Articles Posted in Medicaid and Medicare Fraud

Three Medicare fraud schemes in recent weeks have targeted a total $139.4 million, which led the Department of Justice to seek multiple convictions and a combined 33 years in prison sentences.

Each of the alleged schemes involved the use of provider kickbacks, a popular activity in healthcare, to entice healthcare professionals to inappropriately redirect clients and beneficiaries to specific healthcare businesses.

Law enforcement officials began their crackdown on Medicare fraud earlier in the year with a mix of provider convictions and settlements involving roughly $3 million dollars.

Combating healthcare fraud continues to be a top priority for law enforcement officials because of the dangers it presents to vulnerable beneficiaries in the Medicare program, as well as the potential to recover billions in Medicare spending.

A Detroit provider was sentenced to six years in prison for $10.4 kickback scheme. The case apparently involved kickbacks for unnecessary electromyogram (EMG) tests and physical therapy tests.

He was convicted of one count of conspiracy to commit healthcare fraud, one count of wire fraud, two counts of receiving healthcare kickbacks, and had to personally forfeit $1.69 million.

A 70-year-old Boca Raton man was sentenced to five years in prison for $63 million in home health care fraud. Him and eleven other co-conspirators apparently submitted false and fraudulent claims to Medicare through kickbacks that were medically unnecessary, were not eligible for Medicare reimbursement, or were never provided by his clinic.

The man was found guilty of hiding the payments by using his clinic to provide a salary through the kickbacks, and was paid a flat rate based on the number of individuals he referred. The man also admitted patients for partial hospitalization program (PHP) services even though he knew the patients didn’t qualify for PHP service.

He was convicted of one charge of conspiracy to defraud the United States and to receive healthcare kickbacks. He personally had to forfeit $9.9 million and a personal money judgement over $400,000.

The case was investigated by the FBI, HHS, and OIG with supervision from the Medicare Fraud Strike Force and the US Attorney’s Office for the Southern District of Florida.

A 52-year-old Miami owner of multiple home health agencies was sentenced to 20 years in prison for $66 million in Medicare fraud that used his network of 20 home health agencies to host an elaborate kickback scheme.

The man and other co-conspirators were found guilty of recruiting individuals to represent his home health agencies in order to hide the man’s identity as they paid illegal bribes and kickbacks to patient recruiters to refer patients to these agencies.

The man also admitted that he submitted false and fraudulent home healthcare claims for Medicare beneficiaries that did not qualify for many services.

He had to forfeit $66.4 million in restitution and is convicted of one count of conspiracy to commit healthcare fraud and wire fraud.

The case was investigated by the FBI and was brought forward by the Medicare Fraud Strike Force and the US Attorney’s Office for the Southern District of Florida.

The Federal Anti-Kickback Statute makes it a felony to knowingly and willfully offer, pay, solicit, or receive remuneration, directly or indirectly, in order to induce business that is reimbursable under any federal health care program, such as Medicare or Medicaid. If accused of this crime, you could be facing both criminal and civil penalties.

Are you under investigation for Medicare fraud? You are not alone. About 1,400 individuals are indicted in federal court for health care fraud every year and more than 2,500 individuals are currently being investigated for Medicare fraud.

Continue Reading

A 52-year-old Miami businessman has been given a 20 year prison sentence for his apparent role in a Medicare fraud scheme.

His eight homes around Miami-Dade County, at least three cars, and a meat supermarket have been seized as a part of his $66 million in restitution.

He apparently owns 19 healthcare agencies as well. According to court documents, he tried to hide his ownership of the health agencies as part of yet another massive South Florida Medicare scam.

He apparently recruited others to falsely and fraudulently represent themselves to be the owners of the agencies in order to hide his identity and ownership interest, according to the court documents. These nominee owners completed and signed Medicare enrollment applications that fraudulently misrepresented the identities of the agencies’ ownership interest and managing control of the true owners and failed to disclose the man’s ownership interest and managing control of the agency, contrary to Medicare’s requirements.

From 2007 through 2015, the man and his nominees are accused of paying patient recruiters kickbacks to refer Medicare beneficiaries to the man’s owned facilities. The facilities billed Medicare for expensive healthcare services such as physical therapy and home health. Most of the referred beneficiaries didn’t quality for home health services or the services were imaginary.

Medicare is a federal program that provides health insurance to all American citizens over the age of 65. The government treats medicare fraud quite seriously and will prosecute anyone suspected of defrauding the program.

Continue Reading

Three people have been convicted of alleged Medicare and Medicaid fraud in a $1 billion scheme in Miami.

“This is the largest single criminal healthcare fraud case ever brought against individuals by the Department of Justice,” said Leslie R. Caldwell, Assistant Attorney General the department’s criminal division, in a statement issued Friday.

A 47-year-old man allegedly led a scheme that referred Medicare and Medicaid beneficiaries who did not qualify to skilled nursing and assisted living facilities. The man owned 30 such facilities, giving him access to thousands of beneficiaries, according to reports.

Also charged in the scheme are a 49-year-old hospital administrator and a 56-year-old physician’s assistant.

The three also are accused of accepting kickbacks, disguised as charitable donations or paid in cash, for directing the beneficiaries to selected health care providers, including pharmacies, health care agencies and mental health centers, according to investigators.

Medicare or Medicaid fraud happens when a provider knowingly makes a false or misleading statement or representation for use in obtaining reimbursement from the medical assistance program. Medicare and Medicaid providers include doctors, dentists, hospitals, nursing homes, pharmacies, clinics, counselors, personal care/homemaker companies, and any other individual or company that is paid by the the programs.

Medicaid fraud includes, but is not limited to:

  • Billing for medical services that were never performed, known as phantom billing
  • Billing for a more expensive service than was actually performed, known as upcoding
  • Billing for multiple services that should be combined into one billing, known as unbundling
  • Billing several time for the same medical service
  • Dispensing generic drugs and billing for brand-name drugs
  • Giving or accepting something in return for medical services, which is known as a kickback
  • Providing unnecessary services
  • Filing false cost reports

Continue Reading

A South Florida doctor will spend more than three years in federal prison after pleading guilty to falsely diagnosing hundreds of patients in a Medicare fraud scheme.

Court records show the 57-year-old Delray Beach doctor was also ordered Wednesday by a federal judge to pay more than $2.1 million in restitution to the government. The man previously pleaded guilty to health care fraud.

Authorities claim the man falsely diagnosed 387 patients enrolled in the Medicare Advantage program with a rare spinal condition. The patients were enrolled in a Humana Inc. health plan that was reimbursed for each diagnosis by Medicare.

The federal program paid out $2.1 million in excess benefits, 80 percent of which went to the doctor. Almost none of the patients actually had the rare spinal condition, according to reports.

Medicare and Medicaid fraud is taken quite seriously on local, state and federal levels. It is important to note that these cases are heavily investigated before charges are brought forth. With that said, you will most likely know about the possibility of being charged long before an indictment is filed against you.

Continue Reading

A Miami woman plead guilty this week for her part in an $8 million South Florida medicare fraud scheme centering around a now-defunct home health care company.

According to court documents, the woman’s co-defendants were patient recruiters for the owners and operators of Flores Home Health, a Miami home health care agency that purported to provide home health and physical therapy services to Medicare beneficiaries. The defendant herself also owned and operated a Miami medical clinic that provided fraudulent prescriptions to these patient recruiters as well as to the owners and operators of Flores Home Health.

Screen Shot 2014-01-14 at 12.37.49 PM.png

Investigations by the Medicaid Fraud Strike Force revealed that the defendants would first recruit patients for Flores Home Health and then would solicit and receive kickbacks and bribes from the owners and operators of Flores Home in return for allowing the agency to bill the Medicare program on behalf of the recruited Medicare patients. These Medicare beneficiaries were billed for home health care, like expensive physical therapies, that were not medically necessary or never provided at all.

The defendant plead guilty in U.S. District Court of and for the Southern District of Florida, and is expected to be sentenced in mid-March. Conspiracy to commit health care fraud carries a maximum penalty of 10 years in federal prison.

State and Federal Agents target all players in these types of schemes, many times alleging coding irregularities, kickbacks to patients and staff, medicaid billing for services not provided, and over charging for medical services.

Continue Reading

Contact Information