On August 8, 2016, police arrested a dozen people in Miami-Dade County for their involvement in medical fraud schemes. Three of those arrested were employees of Brothers Medical Clinic on West Flagler St; which included a doctor, therapist and a woman who worked at the front desk.
According to detectives, the investigation began in September when an undercover officer walked into the clinic claiming he was involved in a car accident and needed therapy. The officer only visited that clinic once, but his insurance was billed thousands of dollars for services that were never provided.
“There wasn’t any type of treatment whatsoever,” an undercover detective with the National Insurance Crime Bureau said. “They were just billing the insurance companies for services not rendered, and this is something that goes on time and time again.”
The other nine arrests took place at a clinic in West Kendall.
“South Florida has become the capital of the country for medical fraud, and these types of clinics are an epidemic in the country,” said Miami Police Officer Rene Pimentel.
These fraudulent schemes are affecting insurance rates across the United States and are costing insureds hundreds of millions of dollars, where the sole beneficiaries are the clinics and doctors who facilitate these schemes.
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Friday the Centers for Medicare and Medicaid Services extended a temporary ban on nonemergency ambulance and home health care agencies throughout six states, including Florida, as a continued effort to fight fraud.
In continuing the ban on nonemergency ambulance services, the ban on new emergency ambulance services was lifted. The ban, originally only implemented in Miami, Chicago and Houston, was expanded in January of 2014 to combat fraud in other metropolitan areas seen as fraud hotbeds, specifically in Michigan, Pennsylvania and New Jersey. The ban has been expanded for additional six months after being in place for three years so far.
According to CMS, Texas, Florida and Illinois are in the lower third for number of patients per home health care provider. Despite this statistic, these three states have the highest number of home health care providers according to CMS data.
Shantanu Agrawal, CMS’ deputy administrator for program integrity commented on the program:
CMS is continuing its efforts to tackle fraud, waste, abuse and protect benefits and services for those eligible for federal health care programs. . . CMS is also increasing its oversight efforts through the use of heightened screening and investigative tools for new providers in the moratoria areas.
According to the National Health Care Anti-Fraud Association, as much as $60 billion is lost due to fraud, waste and abuse of the federal health care programs.
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Jorge Lorenzo, Yahima Pardo and Roberto De Jesus Alonso, all of Miami, were sentenced to prison and ordered to pay more than $40 million as a result of their involvement in what is considered the Medicare fraud scheme that caused the greatest loss to the government in 2015.
In addition to the nearly $40.4 million in restitution, the government seized over $2 million in cash and personal assets including Rolex and Cartier watches and artwork by prominent Cuban artists.
The case, before U.S. District Judge William Dimitrouleas, centered around Lorenzo’s ownership or control of 8 home health agencies in Miami-Dade County that received in excess of $40 million from Medicare as a result of fraudulent claims by way shell owners at each agency funneling claim payments to other fictitious companies staffed by co-conspirators. Once indication of a Medicare fraud investigation arose, Lorenzo would close the home health agency, keeping them open for only 8 months on average.
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The Third District Court of Appeal ruled in favor of red-light camera programs, setting up a disagreement between appellate courts and likely meaning the issue will go to the Florida Supreme Court.
Red-light cameras run by municipalities have long come under fire from critics. Opponents decry the fact that traffic tickets can be given out by someone other than a police officer, especially a private company. That’s exactly what the Fourth DCA said in 2014, ruling that red-light cameras are an unlawful delegation of police power to the third parties issuing the tickets.
The Third DCA said the most recent case was a bit different though. Judges Thomas Logue, Kevin Emas and Linda Ann Wells ruled that it was legal for municipalities to hire private companies to review traffic images and decide which ones to forward to police officers. However, the Third DCA judges said a sworn police officer is required to review the evidence for a final decision and not just rubber-stamp the third-party recommendations.
The Third DCA case arose from a suit challenging red-light cameras in Aventura, while the Fourth DCA case concerned a similar program in Hollywood. Logue and Emas designated the case as one of great importance for the Florida Supreme Court to consider, while Wells asked to certify a conflict with the Fourth DCA.
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Miami attorney Anett Lopez was arrested on charges of taking part in a $1.5 million personal injury protection (PIP) fraud scheme.
Lopez is accused of filing lawsuits seeking reimbursements for the treatment of patients at Care Resources Group, a Miami healthcare clinic fraudulently operated under a straw owner.
A February investigation by the Florida Division of Investigative and Forensic Services (DIFS) uncovered that Care Resources Group was a PIP clinic illegally operating under a straw owner to avoid state licensing requirements. Lopez, straw owner Dr. Mario Torres and four others were arrested for alleged money laundering and soliciting of car accident victims in connection with the straw ownership of the clinic.
Lopez, who state authorities say was aware of the clinic’s straw ownership, filed lawsuits against at least a dozen insurance companies that resulted in payouts of nearly $1.5 million. Lopez faces seven counts each of insurance fraud and grand theft, and one count of organized scheme to fraud. She faces up to 85 years in prison if convicted of all 15 felonies.
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Three Miami-Dade County residents were charged with conspiracy, obstruction, money laundering and healthcare fraud for their alleged involvement in a $1 billion scheme.
Philip Esformes, 47; Odette Barcha, 49; and Arnaldo Carmouze, 56, were charged in an indictment July 22.
“This is the largest, single criminal healthcare fraud case ever brought against individuals by the Department of Justice,” said Assistant Attorney General Leslie R. Caldwell of the Department of Justice.
Law360 reported that Medicare paid out at least $464 million in improper reimbursements.
The U.S. Attorney’s office in the Southern District of Florida spelled out the scheme as follows:
Esformes operated the Esformes Network, a group of more than 30 skilled nursing homes and assisted-living facilities. Barcha and Carmouze worked as a hospital administrator and physician’s assistant. The network allowed Esformes to find thousands of Medicare and Medicaid beneficiaries, many who didn’t qualify for an assisted-living facility or skilled nursing home care. The government claims Esformes and his two accomplices admitted the nonqualifying beneficiaries to Esformes’ facilities, where Medicare and Medicaid were billed for unnecessary services. In addition, the three are accused of receiving kickbacks to steer the beneficiaries to medical providers, including community mental health centers and home healthcare providers. The kickbacks were hidden by being paid in cash, disguised as donations to charity or falsely labeled as lease payments.
Enformes already paid $15.4 million in 2006 to resolve fraud claims of unnecessarily admitting patients to assisted-living facilities in a Miami-area hospital. Afterward, Enformes changed his fraud scheme in an effort to prevent detection, the federal government says.
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GEICO won a sanctions request in Florida federal court against a Mississippi auto repair shop and its law firm. U.S. Senior District Judge Gregory A. Presnell ruled that GEICO’s Motion for Attorney Fees was “meritorious” and ordered the insurance company to prepare a specific fees request.
Clinton Body Shop and its law firm, John Arthur Eaves Attorneys, lost a summary judgment in a related suit charging GEICO with unjust enrichment and tortious interference with business relations. GEICO said that the summary judgment victory in that previous case barred the body shop from reasserting those same claims. The federal judge in the Middle District of Florida agreed.
“Any reasonable attorney or claimant would have known what is one of the most fundamental principles of our legal system: that a claim or issue, once litigated to a final adjudication, cannot be relitigated,” GEICO said in its motion. “(R)efiling of the same claims they lost to GEICO three months earlier in another case is automatically bad faith, warranting sanctions.”
Clinton’s argument was that the two suits involved separate entities: the first against GEICO Insurance Co., the latter against GEICO General Insurance.
The case is part of multidistrict litigation in which repair shops in 10 states are accusing several insurance companies of violating the Sherman Antitrust Act by colluding to keep reimbursement rates low for auto body repair work.
Presnell had dismissed Clinton’s claims against GEICO in May before granting sanctions on July 19.
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The Third District Court of Appeal recently ruled in favor of Allstate in a dispute over personal injury protection (PIP) reimbursements for medical services following an auto accident.
The Third DCA now agrees with two other appellate courts: the First in Tallahassee and the Second in Lakeland. However, as a result of a contrary ruling from the Fourth DCA in West Palm Beach, the dispute is set for oral argument before the Florida Supreme Court in September.
The dispute focuses on language in auto insurance policies that spells out if the insurer properly elected to pay medical bills based upon the Medicare fee schedules enumerated in the PIP statute. Florida courts have said the insurance policies must unambiguously elect the use of the statutory fee schedules in limiting reimbursement for PIP claims.
The Third DCA case came from five consolidated appeals. All five concerned a medical provider, as assignee of a person insured by Allstate, suing Allstate for payment of medical bills under the PIP statute. In each case the policy had identical policy language stating: “Any amounts payable under this coverage shall be subject to any and all limitations, authorized by section 627.736 … including but not limited to, all fee schedules.”
Third DCA Judge Thomas Logue, who wrote the opinion, agreed with the opinions in the other two appellate courts finding for Allstate and noted that he agreed with Judge Melanie May’s dissent in the Fourth DCA ruling. Logue disagreed with medical providers, who insisted the words “subject to” were ambiguous.
“A decision that the term ‘subject to’ is ambiguous would mean that the Judicial Code and many provisions of Florida Statutes were legally meaningless and in need of redrafting,” Logue wrote. “We decline to adopt such a counter-intuitive interpretation of a common and well-understood legal expression. The use of the phrase ‘subject to’ in the policy places the insured on notice of the limitations elected by Allstate.”
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A routine traffic stop uncovered the scheme of a former employee of a health insurance company who stole the identities of customers.
Quinzella J. Romer, 39, was sentenced to 32 months in prison and ordered to pay $16,264 in restitution. Romer pleaded guilty to one count of possession of 15 or more unauthorized access devices (Social Security numbers) issued to other people and one count of aggravated identity theft.
The federal prosecutor said Romer’s scam started unraveling after a traffic stop in Coral Springs in 2014. Police noticed Romer had an outstanding warrant for petit theft, and during a pat down, officers found a Florida driver’s license in another person’s name and a cellphone.
After getting a search warrant, officers found 20 screenshots on the phone containing 50 names with Social Security numbers and dates of birth. Romer had taken the shots between 2007 and 2013 during her work as a short-term disability benefit manager at a health insurance company.
An investigation revealed that 12 of the numbers in Romer’s phone were victims of tax-related identity theft in 2013. Tax returns filed on behalf of those names sought refunds of $38,196, with the Internal Revenue Service actually paying out $16,264.
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A Delray Beach doctor was sentenced to nearly four years in prison and ordered to pay more than $2.1 million after pleading guilty to healthcare fraud.
Dr. Isaac Kojo Anakwah Thompson will have two years of supervised release after he serves the sentence of three years, 10 months handed down to him July 7 by U.S. District Judge William J. Zloch.
Thompson’s scheme involved Medicare Advantage plans sponsored by Humana. Medicare Advantage allows Medicare beneficiaries to enroll in health insurance plans sponsored by private insurance companies. Medicare pays the insurance company a fixed monthly fee. Medicare, however, does not adjust the fee according to the cost of medical care; Medicare adjusts the fee according to the medical condition of the patient. So Medicare pays more for a beneficiary with a serious medical condition.
Thompson became a primary care physician (PCP) in Humana’s network. Between 2006 and 2010, Thompson falsely diagnosed 387 Medicare Advantage beneficiaries with ankylosing spondylitis, a rare chronic inflammatory spine disease. That resulted in an extra $2.1 million, of which 80 percent went to Thompson as the PCP.
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