Category Archives: Southern District of Florida

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.

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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

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