Author Archives: Abbi S. Freifeld, Esq.

Physicians able to keep practicing for years after they are arrested for pending felony charges

According to the Palm Beach Post, investigators with the Florida Department of Health (DOH) and Broward County Sheriff’s Office arrived at a Pompano Beach pain clinic in 2012 to search for evidence of crime. Dr. Donald Willems, the osteopathic physician admitted to signing blank prescriptions for powerful painkillers such as oxycodone, admitted to letting a clinic manager fill them out, for patients he had not seen.

Eight criminal charges were leveled against Willems, including racketeering and illegally providing oxycodone. With those felony charges still pending, Willems was arrested again on December 21, 2016, named in a federal complaint alleging insurance fraud orchestrated by a local treatment center.

Anyone checking out his background on the Florida Department of Health’s consumer website would never have known it. The site listed the doctors’ license to practice as “clear and active.”

The DOH, which participated in the 2012 clinic raid, did not file formal disciplinary charges against Willems until January 2016, three years after criminal charges were filed.

The Health Department has previously faced criticism for extensive lags between the time a physician is arrested on drug-related charges and the time the state files a disciplinary charge that could result in sanctions, which include revoking a doctor’s license.

In some ways, quick action by the DOH is hindered by law. State law does not require that a doctor tell the department when he or she is arrested; only when there is a conviction. It can be years between an arrest and a trial.

According to DOH spokesman Brad Dalton, when law enforcement agencies tell the state an investigation is underway, “there are times when the department is asked to wait until a criminal case resolves … to protect the confidentiality of an active law enforcement investigation.”

The agency does not impose sanctions. After investigating, it may file a formal disciplinary charge — an administrative complaint — seeking disciplinary sanctions.

The burden of proof needed to justify such disciplinary charges is high, said Dalton. In a civil court suit, lawyers need to prove a “preponderance” of evidence to win their case, he points out. To prove a discipline case against a doctor, the state has to prove “clear and convincing” evidence.

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Filed under Broward County, DOH, Insurance Claims, Insurance Fraud, Pain Clinics, Palm Beach County

United States Settles False Claims Act Allegations Against Orthopedic Surgery Practice For $4,488,000

According to The U.S. Attorney’s Office, Middle District of Florida, Southeast Orthopedic Specialists (SOS) has agreed to pay the government $4.488 million to resolve allegations that it violated the False Claims Act.

The claims against SOS arose from the company billing federal healthcare programs for services that were not medically necessary or reasonable. Specifically, the United States contended that SOS sought reimbursement for millions of dollars of healthcare claims that were questionable.

This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative.

The claims resolved by the settlement are allegations only and there has been no determination of liability.

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Filed under False Claims Act, Florida, Health care, Insurance, Insurance Fraud, Middle District of Florida

Miami Man Charged with Conspiracy to Commit Health Care Fraud

On November 17, 2016, Satellite Press Releases and News reported the arrest of 21-year-old Eduardo Arango Chongo in connection with the arrests of 31-year-old Osmaro Ruiz and 25-year-old Raymel Betancourt for conspiracy to commit health care fraud.

According to the complaint, the co-conspirators had established fake medical facilities in Union County, New Jersey and were fraudulently billing insurance companies for services that were never rendered. The “phantom providers” allegedly submitted false claims for services worth more than $6 million, raking in hundreds of thousands of dollars from insurance companies. The defendants also utilized an electronic healthcare network used by medical practices to access the health insurance information of individuals who were not aware of their fraudulent activities.

The defendants could face up to 10 years in prison and a $250,000 fine if found guilty of the crimes they were accused of. U.S. Attorney Paul J. Fishman credits special agents of the U.S. Postal Inspection Service and special agents of the FBI with the investigation leading to the charges.

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Filed under Florida, Health care, Insurance, Insurance Fraud

Driverless Cars Will Fuel Surge In Product Liability Coverage

According to Law360, a surge in demand for product liability insurance will become a trend as advances in autonomous car technology continues to increase. These autonomous cars are removing humans from the equation, resulting in liability for accidents being shifted away from the drivers and toward the manufacturers of driverless vehicles and their hardware and software systems.

Questions regarding who would be held liable in crashes involving self-driving cars arose after a fatal accident in May involving a Tesla Model S that was equipped with partially autonomous braking and steering features. Although Tesla did state that the Model S brakes were to blame for the crash, not the autopilot feature, this event continues to attract concern from regulators and consumers.

“Experts say that as autonomous cars become more sophisticated and require less human input, the manufacturers of self-driving vehicles and their components will face more liability for accidents while individual drivers will face less.”

Subsequently, personal auto insurance pricing is expected to decrease significantly due to the decline in driver liability, while auto manufacturers and suppliers will see an increase in price for their product liability coverage.

“The entire auto insurance industry may be radically changed,” Pillsbury Winthrop Shaw Pittman LLP partner Peter Gillon said. “Drivers are the real risks these days and not the cars. The more you take driver error out of the equation, the more you are looking at an auto insurance market based on safety system performance and product liability.”

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Filed under Insurance

Medicare Ban on Non-emergency Ambulance and Home Health Care Agencies Continues

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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Filed under Florida, Insurance, Insurance Fraud, Medicare, Uncategorized

Delray Beach Doctor Sentenced for $2.1 Million Medicare Scheme

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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Filed under Florida, Health care, Insurance Fraud, Medicare, Southern District of Florida

Five South Floridians Enter Pleas in Insurance Fraud Case

Five defendants arrested on insurance fraud charges as part of the Division of Insurance Fraud’s Operation Cold Call have been sentenced after entering guilty pleas, according to The PIP Source, a newsletter of the Florida Division of Insurance Fraud.

The crimes – which were prosecuted by the 15th Judicial Circuit (Palm Beach County) and the 19th Judicial Circuit (Martin, St. Lucie, Indian River and Okeechobee counties) – took place in 2014 and 2015. A yearlong undercover investigation turned up illegal activity at two healthcare clinics: Accident Recovery Centers and Active Recovery Centers. Patients were illegally recruited and bills were sent for services that were never rendered.

Here are the five pleas and their punishment:

  • Runner Douglas Anthony Santiago was sentenced to three years probation for patient brokering.
  • Runner Alejandro Jose Marin was sentenced to two years probation for patient solicitation and patient brokering.
  • Attorney Brian Greenspoon was sentenced to 18 months probation for patient solicitation.
  • Chiropractor Roger Toby Hughes Bell was convicted of patient brokering and surrendered his license.
  • Attorney Cory Meltzer was convicted of patient solicitation and agreed to disbarment.

Two chiropractors are scheduled for trial later this year, while the final defendant is negotiating a plea.

 

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Filed under Florida Division of Insurance Fraud

Florida Doctor Convicted of 162 Counts of Fraud

A North Florida jury convicted a Gainesville doctor of 162 counts of healthcare fraud. Ona M. Colasante, who was found guilty after a five-week trial, faces up to 10 years in prison at her sentencing in July.

Colasante owned and operated medical businesses known as the Hawthorne Medical Center (from 1998-2009) in Hawthorne, Florida, and the Colasante Clinic (from 2010-2013) in Gainesville. Colasante used a false billing scheme at those businesses to defraud Medicare, Medicaid and Blue Cross Blue Shield of Florida.

The U.S. Attorney’s Office for the Northern District of Florida described Colasante’s scheme as follows: Colasante and her employees ordered non-FDA-approved drugs at drastically reduced prices and administered them to unsuspecting patients. Colasante would then bill the insurance companies for the cost of FDA-approved drugs.

Colasante also billed the insurance companies for medical tests that were unnecessary and submitted false diagnosis codes to support her claims. She also billed insurance companies for counseling, treatment and training that was never performed. One example pointed out by the U.S. Attorney’s Office was that Colasante frequently billed the insurance companies for treatments to stop smoking even though the patients were already nonsmokers.

“Healthcare programs and patients depend on ethical practices from medical providers,” U.S. Attorney Christopher P. Canova said in commending the federal investigators and prosecutors after the trial.

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Filed under Health care, Insurance, Insurance Fraud, Medicare, Northern District of Florida

Miami Doctor Sentenced To 9 Years For Medicare Fraud

Miami doctor Henry Lora was sentenced to nine years in federal prison and ordered to pay $30.3 million in restitution for his part in a Medicare fraud ring.

U.S. District Judge Federico Moreno in Miami sentenced Lora on Monday after he pleaded guilty in February to one count of conspiracy to commit health care fraud and one count of conspiracy to defraud the U.S.

Lora, 51, was the medical director of now-defunct Merfi Corp. when he wrote prescriptions for Medicare beneficiaries that weren’t needed or were never provided, according to Law360. In exchange, Lora received kickbacks and bribes from patient recruiters and home health care operators. Lora also was accused of falsifying patient records so they would qualify for Medicare services.

Merfi’s owner, Isabel Medina, also received a nine-year sentence after pleading guilty in January 2014. Three others, German Martinez, Lerida Labrada and Mayra Flores, received sentences of 24, 37 and 24 months, respectively, for serving as patient recruiters.

The case was part of the Department of Justice’s Medicare Fraud Strike Force, which has charged more than 2,300 people with bilking Medicare out of $7 billion in fraudulent claims.

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Filed under Florida, Health care, Insurance, Insurance Fraud, Miami-Dade Fraud

Lyft Sued for Wrongful Death Over Miami Crash

On November 18,2015, a Miami widow of a car crash victim sued Lyft for alleged negligence leading to the wrongful death of a motorcyclist. The widow is alleging that the ride-hailing company failed to properly train the driver that caused the fatal accident.

Poliana Perez, whose husband Loinier Perez was killed while riding his motorcycle on October 31, believes that Lyft Florida Inc. is liable for the crash caused by driver Pirooz Pakdel. Pakdel was carrying a pair of Lyft passengers when he allegedly made an improper left-hand turn and rammed into Loinier Perez.

Perez’s attorney, Ervin Gonzalez of Colson Hicks Eidson, stated that “Lyft, which isn’t even authorized to operate in Miami-Dade County, fell far short of its obligation to act in the best interests of public safety and an innocent life was taken.” The suit alleges that Lyft knew or should have known that Pakdel was not properly trained or suited for the job. The San Franciso-based Lyft allows passengers to use a smartphone app to hail rides from drivers in their personal cars.

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Filed under Fla. Stat. 627.736 (2008)