Florida’s Department of Investigative and Forensic Services Bureau of Insurance Fraud and the Miami Police Department raided two South Florida medical clinics accused of paying for patients and fraudulent billing. Both clinics have been under investigation since early 2017 for recruiting people for staged accidents and billing insurance companies for thousands of dollars in treatments that they were not providing.
According to Captain Emissael Díaz of Florida’s Bureau of Insurance Fraud “Just in South Florida alone, most of your rates are going to go up 20 to 25 percent just because of the insurance fraud.” The captain stated that schemes of this kind are the reason insurance rates are going in South Florida.
The suspects taken into custody are facing several charges, including patient brokering, insurance fraud and grand theft.
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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.
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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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.
A recent study by the auto insurance industry reveals that fraud costs the industry $50 billion each year. And with that much money at stake, the criminals can get pretty creative.
South Florida law enforcement used “Operation Cold Call” last year to bust up a personal insurance protection (PIP) fraud ring that used chiropractors, lawyers and clinic employees. Undercover agents infiltrated the ring over a year’s time, uncovering a network of con artists who recruited and paid people to lie about injuries and the healthcare they received after crashes. But fake injuries are pretty tame compared to two other schemes mentioned in the report:
- The Montana License Plate Scam: Montana has no sales tax or use taxes on vehicles. In this scheme, an unscrupulous attorney in Montana helps out-of-staters create a limited liability company in Montana. Then that LLC is used to buy an expensive sports car or recreational vehicle. The vehicle is taken back to the LLC owner’s home state, and technically, the owner is driving a “company car” with Montana plates. But if there is a wreck, theft or weather damage, the auto insurance company may cancel the policy or deny the claim due to violation of insurance and registration laws within the driver’s home state.
- The Hot Wheels Ruse: One insurance company had a customer make a claim for parts stolen from the customer’s vehicle. Everything appeared legit at first, until investigators took a closer look at the photos submitted with the claim. The photos were actually extreme close-ups of a toy car, but at least the toy car was the same make and model as the customer’s real car.
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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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Roxana Suarez La Rosa was arrested for PIP fraud, according to an April 28 release by the Florida Department of Financial Services’ Division of Insurance Fraud.
Suarez La Rosa owned and operated the Saint Jose Injury Center in Jacksonville that was behind a string of staged auto accidents, according to witnesses. Crash participants were asked to sign for medical services they never received, which were then billed to insurance companies. More than 50 insurance claims were generated in the alleged scam. Billing amounts were not disclosed.
If convicted, Suarez La Rosa faces up to 50 years in prison on racketeering and fraud charges. Additional cases against the medical clinic are pending.
The Office of the State Attorney in the 4th Judicial Circuit of Florida, which covers Duval, Clay and Nassau Counties, is handling the case.
Josue Pierrissaint, 30, was arrested by the Florida Division of Insurance Fraud (DIF) for charges related to operating unlicensed Orlando PIP clinics earlier this year.
A string of three PIP clinics were opened by Pierrissaint from 2010 to 2012, as listed below.
- Edgewater Chiropractic was first opened in 2010. It was based in Lockhart, Fla., located in Orange County northwest of Orlando. Chiropractor Sham Mohammed was named as the straw owner.
- Dr. Wilson’s Straight Up Chiropractic was opened several months later by Pierrissaint in association with chiropractor Koteuaisa Wilson, who also served as the straw owner. The same Lockhart, Fla. address was used in the AHCA application. Wilson later left the clinic, which reportedly did not stop Pierrissaint from using her name.
- Dr. Koteuaisa Chiropractic was next launched by Pierrissaint in 2012. The clinic was opened in Orlando without the knowledge or consent of Dr. Wilson, although her name was listed on the AHCA paperwork.
Collectively, the clinics were paid in excess of $425,000 by 16 insurance companies.
Pierrissaint, who is not a doctor, was also arrested early in 2014 on similar charges.
The FLPIPGuide previously reported that Dr. Lherisson Domond, 82, was arrested earlier this year for acting as the straw owner of Unity Pain and Injury Center in Orlando. The Florida Division of Insurance Fraud (DIF) recently revealed that Domond also fronted as the straw owner of Blesscare Chiro Center, also in Orlando.
Blesscare, an unlicensed clinic, was operated by Fortunard Dieuveillant Fonrose, 42. Medical billings totaling in excess of $86,000 were generated between May 2012 and November 2014 under Fonrose’s management, according to DIF reports.
Domond was behind the unlicensed Tamarac clinic of J.J. Health & Wellness also, according to DIF. Jonas Fils, 52, and Obinson Louis, 37, were reportedly the real owners of the clinic, which illegally billed almost $72,000 from May to September of 2013.
Keeping with the pattern of interconnections, Louis also operated the unlicensed Oakland Park clinic of Innovative Medical Rehab Center.
Overall, seven individuals were arrested for the fraudulent operation of the four unlicensed medical clinics.
The clinics were behind personal injury protection (PIP) fraud schemes responsible for more than $243,000 in illegal billings. DIF investigations are on-going, and additional arrests are expected.
An office manager who acted as a patient broker as well as her six patient recruits were recently arrested on insurance fraud charges by the Florida Department of Financial Services’ Division of Insurance Fraud (DIF) after a two-year investigation uncovered suspicious insurance claims made by the individuals.
According to a story in the Tampa Tribune, Minette St. Fleur, 50, paid individuals to pose as patients injured in car accidents. The complex scheme, which was centered at Integrated Healing Clinic in Tampa, involved these patients filing fraudulent claims to multiple insurance agencies for their bogus injuries. Prices paid for treatments, some of which never occurred, greatly exceeded actual costs and totaled more than $150,000 in fraudulent claims, DIF found.
The scam was directed at GEICO Insurance Company, 21st Century Insurance, Progressive, Safeco Insurance, State Farm Insurance and Liberty Mutual Insurance. GEICO initially noted some patients repeatedly visited the clinic for many different treatments and that some dates on clinic paperwork did not match the dates on the filing of claims. The company brought the suspicious activity to the attention of DIF who began their investigation.
St. Fleur has been charged with insurance fraud and patient brokering, and was released on $2,000 bond
The others who were arrested for their involvement in the scheme included:
- Sonthonax Ferdinand, 57
- Marie Jean Gilles Valcin, 42
- Marie Celestin, 38
- Josue Auguste, 42
- Elisena Louissaint, 48
- Joseph D Pierre, 39
Hillsborough County State Attorney Mark Ober’s office will prosecute the case.