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