Tag Archives: Healthcare fraud

Telemedicine Business Owner Pleads Guilty to Fraud

Scott Gregory Roix, owner of the telemedicine company HealthRight, pleaded guilty to conspiracy to commit health care and wire fraud. Roix and his four alleged conspirators, Florida and Texas pharmacists and pharmacy owners are accused of submitting fraudulent insurance claims for more than $930 million.

Healthright made a lot of money illegally selling suspect, inexpensive drugs like weight-loss pills, skin creams and testosterone supplements at inflated prices. Roix’s company also obstructed doctor-patient relationships with telemarketers posing as “medical personnel.” HealthRight hid drug sales to the partner pharmacies by accounting for the payments as “marketing services.”

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Filed under Healthcare Fraud

Tampa Bay Businessmen Indicted in Billion Dollar Insurance Fraud Scheme

Four Pinellas County businessmen, Andrew Assad, Peter Bolos, Michael Palso and Larry Everett Smith have been indicted on charges of conspiracy to commit health care fraud, mail fraud and introducing misbranded drugs into interstate commerce. The conspiracy involved using their telemedicine business called HealthRight and compounding pharmacy companies to deceive patients, doctors, insurance carriers by fraudulently soliciting insurance coverage information and prescriptions, mark up the prices of the invalidly prescribed drugs, and bill insurance carriers. One of the compounding pharmacies, Alpha-Omega in Clearwater, allegedly charged $374 for $35-worth of lidocaine – a 969-percent markup.

According to the indictment, the men defrauded Blue Cross Blue Shield of Tennessee out of approximately $174,000,000. Another Bay area man, Scott Roix, already please guilty to felony conspiracy in this case and another case involving wire fraud. Assad, Bolos, Palso, and Smith could face prison terms of over 30 years, fines up to $250,000 and probation for their charges.

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Filed under Healthcare Fraud

Vero Beach Acupuncturist Charged with Insurance Fraud and Racketeering

Jill Jaynes of Absolute Integrated Medicine in Vero Beach has been arrested and charged with insurance fraud totaling nearly $1.5 million, racketeering and more. If Jaynes is convicted, she could face up to 135 years in prison and millions of dollars in fines.

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Filed under Healthcare Fraud, Insurance, Insurance Fraud

Owner of Medical Billing Company Pleads Guilty to Healthcare Fraud Scheme

According to the report, Billings USA received or created fabricated bills for its clinic customers. The clinics would then bill insurance companies for allowable amounts and create records to back up the charges.  Billings USA collected a 6% fee on the reimbursement from insurers. Palma’s company filed $5.7 million in fraudulent claims to Blue Cross Blue Shield with one clinic and then an additional $5.9 million in fraudulent claims to Blue Cross and Cigna with another clinic.

Mauricio Palma, the owner of medical billing office Billing USA in Miami, pleaded guilty to conspiracy to commit healthcare fraud and was sentenced to eight years in prison. Palma faces $2.1 million in restitution lost $1.8 million in forfeiture.

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Filed under Fraud, Healthcare Fraud, Healthcare Fraud

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.

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

Miami Couple Sentenced For Operating Clinic to Defraud Medicare

On June 29, 2015, U.S. District Judge Susan C. Bucklew sentenced Gladys Fuertes, 41, and Mario Fuertes, 41, of Miami for operating a sham clinic. Gladys Fuertes was sentenced to 19 years and 6 months in federal prison for conspiracy to commit healthcare fraud, healthcare fraud, aggravated identity theft, and obstruction of healthcare fraud investigation. Mario Fuertes was sentenced to 11 years and 3 months in federal prison for conspiracy to commit healthcare fraud, healthcare fraud, and obstruction of a healthcare fraud investigation. The couple was ordered to forfeit $1,036,759.72. A federal jury convicted the Fuerteses on March 24, 2015.

According to a Department of Justice release, the couple established and operated Gables Medical and Therapy Center for the purpose of committing healthcare fraud by employing unlicensed medical professionals. The Fuerteses misused the Medicare billing numbers of other medical professionals, without their knowledge, in order to claim medical treatments.

Prosecutors say Gladys and Mario Fuertes paid a co-conspirator to recruit Medicare beneficiaries and to drive patients to the Gables Medical for basic and sham medical services. The couple fraudulently billed Universal Medicare in excess of $900,000 for treatments not rendered and for treatments requiring a physician’s presence.

Gladys and Mario Fuertes also facilitated the provision of fraudulent prescriptions for controlled substances to Gables patients and allowed a co-conspirator to assist patients in filling prescriptions for controlled substances such as oxycodone, according to the Department of Justice. The co-conspirator also purchased the controlled substances from Gables patients and sold them on the street.

Gladys and Mario Fuertes also obstructed the federal investigation by instructing Gables Medical patients to lie to law enforcement agents. The couple provided federal agents with altered Medicare documentation.

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 2,300 defendants who collectively billed the Medicare program for over $7 billion, according to a Department of Justice report.

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Filed under Insurance Fraud

“Operation Never Ends” Leads to Closure of Two Clinics, Multiple Arrests

“Operation Never Ends,” the multi-organizational investigation organized by Miami police, the Secret Service, local and state agencies and insurance companies, has led to the closure of two clinics involved in staging accidents and making fraudulent insurance claims.

The more than one year long operation led to the arrest of, among others, Jorge Felix Felipe Pupo, 49, accused of being the ringleader, and Yanaris Ramirez Paneque, 36, a receptionist at one health clinic, according to authorities.  According to the report from NBC 6:

Police say they went undercover inside a medical building in the 700 block of Northwest 23rd Avenue and at another location near Flagler and the Palmetto Expressway.

Detectives said recruiters would find those willing to participate in the staged accidents, then bring them to medical clinics where paperwork was done to get money back from insurance companies.

Police Sgt. Luis Taborda explained the scheme.

“The clinics are the main,” he said. “They provide the money to a runner and the runner puts together the crash — orchestrates the crash.”

Police said the ring was making big money on the claims.

“I could tell you that in one investigation that we did at the beginning, they were up to $80,000 before we shut them down — in just one crash,” Taborda said.

The article from NBC 6 South Florida is available here.

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Filed under Fla. Stat. 627.736 (2008), Fla. Stat. 627.736 (2012), Insurance Fraud, Licensing