Author Archives: John Leinicke, Esq. HCRM

Brother Duo Accused of Massive Insurance Fraud Scheme

According to Law360, on January 3rd in a 427-page state court complaint the New Jersey Department of Banking and Insurance (DOBI) and Allstate Insurance Co. have accused brothers Anhuar and Karim Bandy of masterminding a massive personal injury insurance fraud scheme in which they recruited automobile accident victims for file claims for treatment. There were several law firms and health care providers involved in the schemes as well.

The Bandy brothers had previously pled guilty in July 2015 to organizing an insurance fraud scheme in which they recruited auto accident victims as patients for their clinics and received kickbacks from attorneys and medical professionals for patient referrals.

This recent complaint against the Bandy brothers detailed a series of alleged overlapping schemes that date back to their previous conviction. DOBI Commissioner Richard J. Badolato explained, “These and similar alleged fraudulent activities increase the cost of insurance to consumers.” While DOBI is seeking a fine against the Bandy brothers, Allstate is seeking reimbursement for paid benefits paid on behalf of its customers.

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Filed under Auto Insurance Fraud, Insurance Fraud, Personal Injury Protection

Miami Police Arrest Twelve for Medical Fraud Schemes

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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Filed under Insurance Fraud, Miami-Dade County

Three Miami-Dade Residents Charged in Billion-Dollar Scheme

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.

Click here to read press release.

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

Medicare Fraud Roundup Is Largest in U.S. History

A nationwide sweep on June 21 resulted in the largest coordinated takedown of alleged Medicare fraudsters in U.S. history.

The Medicare Fraud Strike Force led a sweep in 36 federal court districts that resulted in charges against 301 individuals, including 61 medical professionals. The schemes involved about $900 million in fraudulent billing. South Florida was home to 100 of those defendants participating in fraud schemes involving $220 million in false billings for home health care, mental health services and pharmacy fraud.

The defendants face charges of conspiracy to commit healthcare fraud, violations of anti-kickback statutes, money laundering and aggravated identity theft. More than 60 of the individuals arrested are charged with fraud related to Medicare Part D, the prescription drug plan that is the fast-growing part of Medicare.

The defendants were part of schemes to bill Medicare and Medicaid for treatments that were medically unnecessary or never performed. Medicare beneficiaries and patient recruiters were paid kickbacks for supplying beneficiary information to providers, who used that information for fraudulent billing.

In one case in the Southern District of Florida, nine defendants were charged with operating six home health companies in the Miami area that gave bribes and kickbacks to bill for services that were not medically necessary. Those six companies defrauded Medicare of more than $24 million.

In the Middle District of Florida, which includes Orlando and Tampa, 15 individuals were charged with crimes including compounding pharmacy fraud and intravenous prescription drug fraud involving $17 million in fake bills. The owner of several infusion clinics is accused of being reimbursed by Medicare for $17 million for intravenous prescription drugs that were never purchased or administered to beneficiaries.

Click here for the press release.

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Filed under Health care, Insurance Fraud, Medicare, Miami-Dade Fraud, Southern District of Florida, Uncategorized

25 Charged in $26 Million Medicare Fraud in Miami

Twenty-five people were charged in Miami federal court for alleged schemes to defraud Medicare. The three cases totaled about $26 million in false claims through the Medicare Part D program.

U.S. Attorney Wifredo A. Ferrer said the April 28 charges include conspiracy to commit health care fraud and wire fraud, health care fraud, conspiracy to defraud the United States, and paying and receiving healthcare kickbacks.

In the first indictment, 18 people were charged with filing false claims through eight separate pharmacies. Pedro Torres, 43, of North Bay Village and Antonio Hevia, 53, of Miami are accused of recruiting people to be owners of the pharmacies. Torres and Hevia then allegedly instructed the pharmacy staffs to submit fraudulent claims for $16.7 million for prescription drugs that were not medically necessary and not provided to the Medicare Part D beneficiaries.

In the second indictment, Ronald Dias, 28, of Miami used eight pharmacies that he owned and worked with two other Miami residents to defraud the Medicare Part D program of $10.4 million in fraudulently obtained claims. The indictment said the drugs were neither medically necessary nor provided to Medicare beneficiaries.

In the third indictment, four Miami residents are accused of receiving kickbacks and bribes to recruit Medicare beneficiaries to obtain prescriptions for drugs to be used through the OMG Pharmacy Discount with false claims filed to the Medicare Part D Program.

“Those who commit Medicare fraud through the filing of false claims, payment or receipt of kickbacks, or fraudulent medical practices jeopardize the integrity of the government benefit programs that countless citizens rely on for their well-being,” Ferrer said in a statement.

The various charges carry potential sentences each ranging from five years to 20 years in prison.

Since March 2007 in the Southern District of Florida, nearly 900 individuals have been charged in alleged frauds netting $2.5 billion through Medicare billings.

Part D prescription medicine coverage is the fastest-growing area of the Medicare program.  The federal government estimates as much as $10 billion of last year’s $120 billion in Medicare Part D spending may be fraudulent.

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Filed under Insurance Fraud, Medicare, Southern District of Florida

Legal Troubles Continue For Dr. Ralph Miniet

The ongoing saga of Dr. Ralph Miniet added yet another chapter last week.

Miami Police arrested Miniet and two others last week after an anonymous tip and subsequent investigation uncovered alleged Personal Injury Protection (PIP) fraud at The Fast Rehabilitation Center at 815 NW 57th Ave. in Miami, according to multiple South Florida media reports on April 6th.

Police said the arrests were an attempt to arrest individuals involved in staging accidents and conspiring with clinics, physicians, massage therapists and lawyers to steal money from insurance companies with superfluous treatment and false lawsuits.

With Miniet arrested as he was about to board a plane to Kentucky to appear at a federal court arraignment, his legal woes became even more serious. Not only did he miss his arraignment, but Miniet likely violated terms of his house arrest. Miniet was arrested in Lexington in November where he faces charges in the Eastern District of Kentucky of illegally distributing oxycodone. Miniet was given an ankle bracelet and placed under house arrest with the condition that he stay out of trouble. He may have violated those terms, depending whether the alleged instances of fraud in Miami took place after his Kentucky arrest.

Miniet has been on the radar of the South Florida legal community for years. In 2003-4, Miniet provided 569 injections of Rho D to 567 patients that were later deemed “medically unbelievable” by the Department of Health and Human Services. Records show Miniet netted $2.3 million in that case.

Miniet also was linked to a fraud at V&V Rehabilitation Center, where true owners Janio and Jharildan Vico used Dr. Jennifer Adams as a straw owner to avoid oversight by the Agency for Health Care Administration (AHCA). The Vico brothers were convicted last October of mail fraud, money laundering and two conspiracy charges. The Vicos made about $3 million for staging traffic accidents and then billing insurance companies for fake injuries treated at V&V in Lake Worth, according to court records.

Click here for full article.

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Filed under Florida, Insurance, Insurance Fraud, Miami-Dade Fraud, Personal Injury Protection, PIP/No Fault