Friday the Centers for Medicare and Medicaid Services extended a temporary ban on nonemergency ambulance and home health care agencies throughout six states, including Florida, as a continued effort to fight fraud.
In continuing the ban on nonemergency ambulance services, the ban on new emergency ambulance services was lifted. The ban, originally only implemented in Miami, Chicago and Houston, was expanded in January of 2014 to combat fraud in other metropolitan areas seen as fraud hotbeds, specifically in Michigan, Pennsylvania and New Jersey. The ban has been expanded for additional six months after being in place for three years so far.
According to CMS, Texas, Florida and Illinois are in the lower third for number of patients per home health care provider. Despite this statistic, these three states have the highest number of home health care providers according to CMS data.
Shantanu Agrawal, CMS’ deputy administrator for program integrity commented on the program:
CMS is continuing its efforts to tackle fraud, waste, abuse and protect benefits and services for those eligible for federal health care programs. . . CMS is also increasing its oversight efforts through the use of heightened screening and investigative tools for new providers in the moratoria areas.
According to the National Health Care Anti-Fraud Association, as much as $60 billion is lost due to fraud, waste and abuse of the federal health care programs.
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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 North Florida jury convicted a Gainesville doctor of 162 counts of healthcare fraud. Ona M. Colasante, who was found guilty after a five-week trial, faces up to 10 years in prison at her sentencing in July.
Colasante owned and operated medical businesses known as the Hawthorne Medical Center (from 1998-2009) in Hawthorne, Florida, and the Colasante Clinic (from 2010-2013) in Gainesville. Colasante used a false billing scheme at those businesses to defraud Medicare, Medicaid and Blue Cross Blue Shield of Florida.
The U.S. Attorney’s Office for the Northern District of Florida described Colasante’s scheme as follows: Colasante and her employees ordered non-FDA-approved drugs at drastically reduced prices and administered them to unsuspecting patients. Colasante would then bill the insurance companies for the cost of FDA-approved drugs.
Colasante also billed the insurance companies for medical tests that were unnecessary and submitted false diagnosis codes to support her claims. She also billed insurance companies for counseling, treatment and training that was never performed. One example pointed out by the U.S. Attorney’s Office was that Colasante frequently billed the insurance companies for treatments to stop smoking even though the patients were already nonsmokers.
“Healthcare programs and patients depend on ethical practices from medical providers,” U.S. Attorney Christopher P. Canova said in commending the federal investigators and prosecutors after the trial.
Click here to read full press release.
The Florida Attorney General’s Office announced on March 20, 2015 that four people have been arrested for Medicaid fraud. Homeless people were allegedly recruited to pose as patients in the Orlando fraud scheme, frequently in exchange for gas cards and temporary housing.
The defendants in the case are identified as follows:
- Christina Benson, arrested in Georgia
- Demetrious Davis, arrested in Florida
- Harold Harrison, arrested in North Carolina
- Dr. Sabiha Khan, arrested in Florida
Each individual faces at least one count of Medicaid Provider Fraud and one count of Organized Scheme to Defraud.
According to the investigation, Christina Benson, owner of Tranquility Healthcare Solutions in Orlando, billed Medicaid up to $3.2 million for psychosocial rehabilitation services that were neither warranted nor provided in a period of just 18 months. The announcement cited fraudulent payments of $215,000.
The company claimed to have worked with a local doctor, Sabiha Khan, as a treating provider, but many recipients said they had never met her. Additionally, untrained personnel—including some with criminal records—were allegedly used to deliver some services.
Click on the link for the Florida Attorney General announcement.