According to Health News Florida, there are 29 Florida doctors operating with clear medical licenses although they have at least six malpractice complaints against them that have resulted in insurance payments since 2000. These doctors are continuing to practice without discipline from the state system that oversees them, which means either insurers paid to settle the cases that had no merit or the state hasn’t always followed up.
Critics say Florida’s system is broken and it’s putting people’s lives at risk. Dr. Sidney Wolfe, founder of the Public Citizen Health Research Group, based in Washington D.C has studied medical discipline nationwide for decades and says Florida’s Board of Medicine must intervene.
Patients and their families can also file a complaint with the state’s regulatory agencies, although the odds are stacked against them. 6,713 complaints and reports were filed with the Department of Health from 2015-2016. Only about 15 percent or 1,018 of them were found “legally sufficient.” Of those, 762 were taken to a probable cause panel, and three-fourths were rejected. The 188 administrative complaints filed that year represent less than 3 percent of the number of complaints and reports that came in.
In some cases involving doctors with multiple claims, records show the Department of Health received early warnings, but took little or no action. One of those cases was that of Dr. Michael Rosin, a Sarasota dermatologist who was convicted in March 2006 of defrauding Medicare of more than $3 million in a scheme that dated back more than a decade. He was sentenced to 22 years in prison and ordered to pay millions of dollars in restitution. After his criminal conviction, the Department of Health revoked his license, according to state records. Federal records show that Rosin, now 66, is at Otisville Federal Correctional Institution in Otisville, N.Y. He is scheduled for release in 2025.
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U.S. Attorney’s Office, Middle District of Florida announced that Lemon Bay Drugs North, Inc. in North Port, FL and Brooksville Drugs, Inc. operating in Brooksville, FL have agreed to pay a total of $750,000 to the government to resolve allegations that the pharmacies violated the False Claims Act.
Both pharmacies are managed by Benzer Pharmacy Holding LLC and are owned by Alpesh Patel.
The allegations were that Lemon Bay and Brooksville Drugs provided Medicare and Medicaid patients generic versions of certain medications, but charged Medicare and Medicaid for the brand name versions of those medications. These allegations were initiated in a lawsuit filed by a whistleblower who was a former pharmacy technician who worked at Lemon Bay Drugs. The whistleblower will receive $142,500 as her share of the recovery.
This investigation was handled by Assistant U.S. Attorney Kyle S. Cohen with assistance from the Department of Health and Human Services – Office of Inspector General, the Defense Criminal Investigative Service, the FBI, the Florida Medicaid Fraud Control Unit, the North Port Police Department, and the Sarasota County Sheriff’s Office.
According to the Department of Justice, the claims resolved by the settlement are allegations only, and there has been no determination of liability.
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According to The U.S. Attorney’s Office, Middle District of Florida, Southeast Orthopedic Specialists (SOS) has agreed to pay the government $4.488 million to resolve allegations that it violated the False Claims Act.
The claims against SOS arose from the company billing federal healthcare programs for services that were not medically necessary or reasonable. Specifically, the United States contended that SOS sought reimbursement for millions of dollars of healthcare claims that were questionable.
This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative.
The claims resolved by the settlement are allegations only and there has been no determination of liability.
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On November 17, 2016, Satellite Press Releases and News reported the arrest of 21-year-old Eduardo Arango Chongo in connection with the arrests of 31-year-old Osmaro Ruiz and 25-year-old Raymel Betancourt for conspiracy to commit health care fraud.
According to the complaint, the co-conspirators had established fake medical facilities in Union County, New Jersey and were fraudulently billing insurance companies for services that were never rendered. The “phantom providers” allegedly submitted false claims for services worth more than $6 million, raking in hundreds of thousands of dollars from insurance companies. The defendants also utilized an electronic healthcare network used by medical practices to access the health insurance information of individuals who were not aware of their fraudulent activities.
The defendants could face up to 10 years in prison and a $250,000 fine if found guilty of the crimes they were accused of. U.S. Attorney Paul J. Fishman credits special agents of the U.S. Postal Inspection Service and special agents of the FBI with the investigation leading to the charges.
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Miami attorney Anett Lopez was arrested on charges of taking part in a $1.5 million personal injury protection (PIP) fraud scheme.
Lopez is accused of filing lawsuits seeking reimbursements for the treatment of patients at Care Resources Group, a Miami healthcare clinic fraudulently operated under a straw owner.
A February investigation by the Florida Division of Investigative and Forensic Services (DIFS) uncovered that Care Resources Group was a PIP clinic illegally operating under a straw owner to avoid state licensing requirements. Lopez, straw owner Dr. Mario Torres and four others were arrested for alleged money laundering and soliciting of car accident victims in connection with the straw ownership of the clinic.
Lopez, who state authorities say was aware of the clinic’s straw ownership, filed lawsuits against at least a dozen insurance companies that resulted in payouts of nearly $1.5 million. Lopez faces seven counts each of insurance fraud and grand theft, and one count of organized scheme to fraud. She faces up to 85 years in prison if convicted of all 15 felonies.
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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.
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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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 U.S. government confiscated $11 million worth of properties involved in a healthcare fraud scheme centered in Mississippi that also involved residents of Florida, Alabama and Utah, according to a report in the Clarion-Ledger of Jackson, MS.
The Internal Revenue Service described the criminal activity as a compounding pharmacy scheme. The pharmacies engaged in “price rolling,” in which a pharmacy submits a bill to an insurance company to test the amount the provider will reimburse for a specific prescription. The claim is canceled, then another claim is sent for a compounded formula to see if that is reimbursed at a higher rate. Compounding is the process of creating a prescription unique for the patient’s particular needs, such as providing the same medicine in a pill and a liquid.
The IRS also said the scheme involved split billing, where a prescription is split into smaller portions. The split prescription can include separate dispensing fees as well as automatic refills that might not have been intended by the doctor.
Search warrants were served in January during the compounding pharmacy investigation. No arrests were made, but the properties were recently confiscated by the feds because evidence showed they were purchased with dirty money. Such civil forfeiture is based on the idea that the property, not the owner, has violated the law.
Following the 12 warrants, the government interviewed hundreds of people and confiscated 24 vehicles, five planes, two boats and money from 80 bank accounts totaling $15 million, according to a Mississippi Bureau of Narcotics spokeswoman.
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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.