Category Archives: Medicare

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

Three from Miami Sentenced in $40M Medicare Fraud

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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Filed under Florida, Insurance Fraud, Medicare, Miami-Dade County, Uncategorized

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

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

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

Mobile Ultrasound Owner Pleads Guilty in $29 Million Fraud

The owner of a mobile diagnostic ultrasound company pleaded guilty on June 21 to a nearly $29 million insurance fraud scheme.

Michelle Kobran, 68, admitted to falsifying medical bills and giving kickbacks to doctors at her chiropractic and physical therapy center in Wheeling, IL. Kobran said she altered the information on documents to get reimbursements from Blue Cross Blue Shield of Illinois, Aetna Health Insurance and other major insurance companies.

Law360 reported that for at least three years, Kobran had a deal with Vladimir Gordin Jr.

Kobran would do ultrasounds one day a week at Gordin Medical Center, and Kobran would pay Gordin one third of the bills she charged patients referred by the chiropractor. After Kobran realized insurance companies wouldn’t reimburse for multiple ultrasounds done on the same patient in the same day, she would change the dates of service on bills. Sometimes Kobran would tell her technician not to do all the ultrasounds ordered by doctors but charge for them anyway.

Kobran’s business submitted $28.8 million in fraudulent insurance bills over a six-year period ending in 2012 with insurance companies reimbursing those services for $10.8 million.

Kobran and Gordin were indicted in August 2015 along with three managers. Kobran’s plea includes her promise to testify against the others at trial in January. She faces 10 years in prison, but by testifying against the others she could end up with only two years in prison and $658,000 in restitution.

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Filed under Insurance Fraud, Medicare

Former Fugitive Sentenced to 37 Months for Healthcare Fraud

A Cuban national was sentenced to more than three years in prison after pleading guilty to a $2.6 million healthcare fraud against Medicare, according to the Department of Justice.

Ubert Guillermo Rodriguez, 47, pleaded guilty to conspiracy to commit healthcare fraud in March 2016. Rodriguez, who had been a fugitive since his indictment in 2013 until his arrest in 2015, was also ordered to pay $918,000 in restitution and forfeit another $918,000. When federal authorities served a seizure warrant on Rodriguez’s bank account, they seized more than $243,000.

Rodriguez owned G.R. Services Equipment & Supplies near St. Petersburg. The company was supposed to supply medical equipment to Medicare beneficiaries. Rodriguez admitted his company submitted nearly $2.6 million in false claims to Medicare from May 2013 to June 2013. During that period, Rodriguez was reimbursed for hundreds of thousands of dollars for sterile collagen dressings and negative pressure wound therapy electrical pumps. Yet those items were never prescribed by doctors or given to beneficiaries.

The case was part of the Medicare Fraud Strike Force by the U.S. Attorney’s Office of the Middle District of Florida.

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Filed under Florida, Insurance, Insurance Fraud, Medicare, Middle District of Florida

Miami Man Gets 5 Years for Role in $2.3 Million Medicare Fraud

A Miami man who owned a consulting and staffing company was sentenced to five years in prison for his part in a $2.3 million scheme to defraud Medicare.

Carlos Rodriguez Nerey, the 45-year-old owner of Nerey Professional Services, was sentenced by U.S. District Judge Darrin P. Gayles. The judge also ordered Nerey to pay nearly $2.4 million in restitution.

After a one-week trial that ended April 1, 2016, a jury convicted Nerey of receiving kickbacks in connection with Medicare and of conspiracy to defraud the U.S. and pay healthcare kickbacks. At the trial it was revealed that Nerey accepted kickbacks for referring Medicare beneficiaries to Mercy Home Care and D&D&D Home Health Care as patients. Some of the patients didn’t qualify for home healthcare services under Medicare rules.

The investigation was part of the U.S. Attorney’s Medicare Fraud Strike Force.

Click here for the U.S. Attorney’s press release.

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Filed under Health care, Insurance, Insurance Fraud, Medicare

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.

Click here to read full press release.

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

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