Articles Posted in Medicaid and Medicare Fraud

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

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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.

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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.

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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.

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