Category Archives: Miami-Dade Fraud

Geico Seeks To Recover $20M in Racketeering Suit

As reported by Law360, Geico is seeking to recover at least $20 million in compensatory damages, in addition to costs, fees and punitive damages from a Florida chiropractor and his network of clinics.

On Thursday, May 30th, the insurer filed suit in Florida federal court against Mark A. Cereceda claiming civil racketeering violations and unjust enrichment as well as common law fraud and other claims.

According to the complaint, Geico says Mark A. Cereceda and his various Ceda Orthopedics clinics in Miami billed for services that were unnecessary, never provided and performed by people who were not properly licensed. Geico paid for physical therapy services performed by unsupervised massage therapists who are unqualified to perform physical therapy and who, under Florida law, cannot be reimbursed under PIP insurance. The insurer is also requesting a declaration from the court that it is not legally obligated to pay reimbursement of more than $75,000 in pending fraudulent PIP claims submitted by Cereceda’s clinics.

Cereceda has been sued by insurers at least three times over fraudulent medical billing and coding, delivering medically unnecessary chiropractic care and engaging in an unlawful referral scheme.

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Filed under Insurance Fraud, Lawsuits, Miami-Dade County, Miami-Dade Fraud, PIP, Uncategorized, Unlicensed Clinics

Two Miami Medical Clinics Raided for Staged Accidents & Insurance Fraud

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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Filed under Florida, Florida Division of Insurance Fraud, Insurance, Insurance Claims, Insurance Fraud, Miami-Dade County, Miami-Dade Fraud

Geico Sues Florida Health Clinic for ‘Unnecessary’ Massage Claims

As reported by Law360, Geico sued Medical Wellness Services Inc. of Miami, FL for allegedly making $1.2 million in claims for providing medically unnecessary treatments for automobile accident victims who were eligible for coverage under their no-fault insurance policies. According to Geico, some of the claims were for services that were not actually provided and contained billing codes that misrepresented and exaggerated the services.

“The defendants do not now have — and never had — any right to be compensated for the fraudulent services that were billed to Geico through Medical Wellness,” Geico said. Geico claims Medical Wellness Services Inc. submitted claims for massage therapist services which are not reimbursable because Florida law prohibits no-fault insurance reimbursement for massages or other similar services.

According to the suit, the scheme began no later than 2013 and continues to this day. In addition to the request for $1.2 million in damages, Geico is also requesting a declaration from the court saying it will not have to pay any pending fraudulent claims by the health clinic which totals more than $75,000.

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Filed under Auto Insurance Fraud, Florida, Insurance, Insurance Claims, Insurance Defense, Insurance Fraud, Miami-Dade County, Miami-Dade Fraud, Personal Injury Protection, PIP/No Fault

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

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

Miami Doctor Sentenced To 9 Years For Medicare Fraud

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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Filed under Florida, Health care, Insurance, Insurance Fraud, Miami-Dade Fraud

Legal Troubles Continue For Dr. Ralph Miniet

The ongoing saga of Dr. Ralph Miniet added yet another chapter last week.

Miami Police arrested Miniet and two others last week after an anonymous tip and subsequent investigation uncovered alleged Personal Injury Protection (PIP) fraud at The Fast Rehabilitation Center at 815 NW 57th Ave. in Miami, according to multiple South Florida media reports on April 6th.

Police said the arrests were an attempt to arrest individuals involved in staging accidents and conspiring with clinics, physicians, massage therapists and lawyers to steal money from insurance companies with superfluous treatment and false lawsuits.

With Miniet arrested as he was about to board a plane to Kentucky to appear at a federal court arraignment, his legal woes became even more serious. Not only did he miss his arraignment, but Miniet likely violated terms of his house arrest. Miniet was arrested in Lexington in November where he faces charges in the Eastern District of Kentucky of illegally distributing oxycodone. Miniet was given an ankle bracelet and placed under house arrest with the condition that he stay out of trouble. He may have violated those terms, depending whether the alleged instances of fraud in Miami took place after his Kentucky arrest.

Miniet has been on the radar of the South Florida legal community for years. In 2003-4, Miniet provided 569 injections of Rho D to 567 patients that were later deemed “medically unbelievable” by the Department of Health and Human Services. Records show Miniet netted $2.3 million in that case.

Miniet also was linked to a fraud at V&V Rehabilitation Center, where true owners Janio and Jharildan Vico used Dr. Jennifer Adams as a straw owner to avoid oversight by the Agency for Health Care Administration (AHCA). The Vico brothers were convicted last October of mail fraud, money laundering and two conspiracy charges. The Vicos made about $3 million for staging traffic accidents and then billing insurance companies for fake injuries treated at V&V in Lake Worth, according to court records.

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Filed under Florida, Insurance, Insurance Fraud, Miami-Dade Fraud, Personal Injury Protection, PIP/No Fault

Four Sentenced For $126 million Florida Healthcare Fraud

Four individuals were sentenced on October 29, 2015 in Florida Federal court for their roles in a large complex scheme to rip off the city of Miami, Miami-Dade County Public Schools and numerous major companies for approximately $126 million in false healthcare claims.

The four major defendants in the case were Hendris Castillo Morales, 33, of Miami; Maite Garcia, 40, of Hialeah; Osvaldo Marin Medina, 48, of Hialeah; and Alejandro Biart, 40, of Miami. They were among 15 individuals who have pled guilty, out of 18 charged in connection with the scheme, according to the U.S. Department of Justice.

U.S. District Court Judge Robert N. Scola handed down prison terms to Castillo for a total of 121 months and Garcia for 48 months. Prosecutors stated that Castillo and Garcia were among four defendants who owned and controlled 30 companies at the heart of the scheme in the Miami area. According to prosecutors, the two used medical director staging companies to misappropriate doctors’ licensing information, which they used to submit false claims to insurers.

Judge Scola set a requirement for both Castillo and Garcia of three years of supervised release. They were also ordered to pay more than $13.8 million in restitution.

In a separate case, U.S. District Judge Urusla Ungaro sentenced both Biart and Medina to 41 months in prison followed by three years of supervised release.

Biart was accused of accepting kickbacks from other defendants in return for referring Cigna, Blue Cross Blue Shield and United Healthcare beneficiaries to medical clinics controlled by Castillo, Garcia and co-defendants Rynaldo Castillo and Lizbet Castillo Batista.

Medina was accused of accepting payments in return for allowing his name to be used to incorporate clinics, open bank accounts and cash checks received from Cigna, Blue Cross Blue Shield and United Healthcare.

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Filed under Miami-Dade Fraud